The clinical practice guideline (CPG) is the implementation of a depression screening tool to be used in the early perinatal period. The practice change occurred in a rural Obstetrical and Gynecological (OBGYN) practice in the southern United States. The CPG change has been guided by recommendations from both the American Congress of Obstetrics and Gynecology and the American College of Nurse Midwives. Implementation of this CPG change addresses the gap in practice of not doing depression screening during the perinatal period, and only screening during the postpartum period, which was being done at the OBGYN office. Theorist Lewin’s ‘change theory’ guided the implementation of the project. In order to apply this project, a process of changing practice guidelines was needed at the OBGYN office. The DNP project presented the practice change guideline of implementing the Edinburgh Postpartum Depression Screening (EPDS) tool. The need for the CPG development was evaluated by 3 nurse leaders using the AGREE II tool and was recommended 100% without modifications by all 3 evaluators. The CPG, with the results, was presented and discussed with the practice site’s practitioners. The practitioners implemented the EPDS to be given at the 12- week checkup appointment versus the confirmation of pregnancy appointment, which was suggested through the DNP project’s CPG. The implementation of this CPG has the potential to provide a safer environment for pregnant women, their newborns, and their families.

Postpartum depression (PPD) remains a serious mood disorder without a known etiology. PPD has a prevalence of 7-15% in the general population. Women with a history of a mood disorder are at an even higher risk for the development of PPD. Work over the last few decades has established a strong association between circadian rhythm and sleep disturbances and mood disorders, such as Major Depressive Disorder (MDD) and Bipolar Disorder (BD). Despite the breadth of evidence associating circadian rhythm disruption and depressive mood episodes, literature establishing a connection between circadian rhythms and changes in mood across the perinatal period is lacking. The work outlined in this thesis aimed to address this gap by examining the association between circadian rhythm and sleep disturbances across the perinatal period and their association with changes in mood in women at high and low risk of PPD development. A total of 87 women were studied, 45 healthy controls and 42 women with a mood history. Women were interviewed during the third trimester of pregnancy and between six to twelve weeks postpartum. Sleep and circadian rhythms were measured using both subjectively with self-reported questionnaires and objectively with actigraphy. Our results show that women at high and low risk showed higher disruption differ in subjective circadian rhythmicity, as well as in both subjective and objective parameters of sleep. Specifically, women at high risk for postpartum were found to have lower sleep efficiency, as measured by actigraphy, in the postpartum. In addition, subjective and objective parameters of sleep and circadian rhythms are associated with changes in depressive symptoms across the perinatal period. Our findings suggest that stabilizing circadian rhythms and improving sleep quality throughout the perinatal period can prevent postpartum mood worsening, particularly for those women at greatest risk. / Thesis / Master of Science (MSc)

The perinatal period is increasingly recognized as a vulnerable time for the development and exacerbation of psychopathology symptoms. Research has often focused on perinatal depression, with limited information on perinatal anxiety. This study examined the psychometric structure of all anxiety and depressive disorder symptoms as well as explored the relation between perinatal internalizing symptoms and sociodemographic, obstetric, and psychological risk factors. Obsessive-Compulsive Disorder (OCD) is a common perinatal anxiety disorder that is now classified with the Obsessive-Compulsive Spectrum (OCS) (hoarding, body dysmorphic, trichotillomania, and excoriation disorders). This study also aimed to determine the prevalence of clinically significant OCS symptoms and their association with postpartum adjustment. Participants recruited from the University of Iowa Hospitals and Clinics (N =246) completed an online questionnaire and a structured clinical interview during pregnancy (28-32 weeks gestation) and the postpartum (6-8 weeks). Questionnaires assessed demographics, pregnancy complications, anxiety sensitivity, coping strategies, maternal attitudes and experiential avoidance. Clinical interviews dimensionally assessed all anxiety and depressive symptoms as well as past psychiatric diagnoses. Confirmatory factor analyses identified three factors: Distress (depression, GAD, irritability, and panic); Fear (social anxiety, agoraphobia, specfic phobia, and OCD); and Bipolar (mania and OCD) during pregnancy and the postpartum. During pregnancy, structural equation modeling demonstrated that past psychiatric history predicted Distress and Fear symptoms. Experiential avoidance mediated the relation between negative coping strategies and Fear symptoms. In the postpartum, negative maternal attitudes predicted Distress symptoms. Experiential avoidance mediated the relation between negative coping strategies and Fear symptoms as well as between anxiety sensitivity and Fear symptoms. There were low rates of clinically significant OCS symptoms, except for body dysmorphic disorder symptoms. Elevations in all OCS disorder symptoms were significantly associated with more difficulty adjusting to the postpartum. Past psychiatric history, negative maternal attitudes, and experiential avoidance are particularly important risk factors for perinatal anxiety. Future clinical research should be aimed at identifying at-risk women and modifying experiential avoidance during the perinatal period. Elevated OCS symptoms, particularly body dysmorphic disorder symptoms, affect postpartum adjustment. Future intervention work should focus on assessing and treating perinatal body dysmorphic disorder symptoms.

BACKGROUND: Both mood and anxiety disorders are more prevalent in women than men with the onset typically occurring during adolescence or early childbearing years. These disorders are particularly prevalent during pregnancy and the postpartum period. While depression during the perinatal period has received significant attention recently, anxiety has not received the same amount of attention. METHODS: The current study was a secondary analysis of a prospective cohort study that followed 91 women with mood disorders through pregnancy and the postpartum period. Our objective was to determine if a correlation existed between anxiety and suicidality. We hypothesized that pregnant women with a history of a mood disorder and comorbid anxiety are more likely to be suicidal than those without comorbid anxiety. The presence of anxiety was determined using the anxiety subscale of the Edinburgh Postnatal Depression Scale, EPDS; a cut off score of six or greater was used to indicate significant anxiety. Suicidality was determined using three separate measures: question ten on the EPDS, question eighteen on the Inventory of Depressive Symptomatology, and question ten on the Montgomery-Asberg Depression Rating Scale. ANALYSIS: Chi square tests were used to compare the demographics of the anxious and non-anxious women based on both diagnosis of anxiety disorders and symptoms of anxiety. Z proportion tests were then used to compare the proportion women with anxiety versus those without anxiety who were suicidal. Lastly, binary logistic regression was used to determine if patients with anxiety were more likely to be suicidal. RESULTS: Among the women in this study, 62 (68.1%) had a diagnosis of major depressive disorder and 29 (31.9%) had a diagnosis of bipolar disorder based on DSM-IV-TR diagnostic criteria. In addition, 45 (49.5%) had a lifetime history of an anxiety disorder. The prevalence of significant anxiety symptoms, as determined by the anxiety subscale on the EPDS, ranged from 9.1-37.5% depending on the time point. Suicidality prevalence also varied depending on both the time point and the scale used: 0-17.5% using the MADRS, 6.7-24.7% using the EPDS, and 2.4-14.7% using the IDS. Using a binary logistic regression, we determined that anxiety was a risk factor for suicidality at time T3 (OR 2.106; 95% CI 1.274-3.481) and M1 (OR 2.057; 95% CI 1.179-3.586) on the MADRS and at T3 (OR1.758; 95% CI 1.219-2.535) on the EPDS.

Background: Perinatal depression affects 1 in 7 childbearing individuals and remains underdiagnosed and undertreated. Individuals with a psychiatric history are at increased risk of perinatal depression, and little is known about how experiences with the mental health care pathway may differ between these individuals and those without a psychiatric history. Methods: This was a secondary analysis of data from the PRISM (PRogram in Support of Moms) study, a cluster randomized controlled trial of two interventions for perinatal depression. Care access and barriers to care were evaluated in perinatal individuals who screened positive for depression using the EPDS (N=280). Results: Individuals with no psychiatric history prior to pregnancy (N=113), compared to those with such history (N=267), were less likely to be screened for perinatal depression, and less likely to be offered a therapy referral, though equally likely to attend when referred. In adjusted models, those without a psychiatric history had 0.59 times the odds of attending therapy (95% CI 0.28-1.25), 0.23 times the odds of utilizing medication (95% CI 0.11-0.47), and overall, 0.22 times the odds of receiving any depression care (95% CI 0.11-0.43). Participants reported on average 3 barriers as preventing them from receiving care “a lot” or “quite a lot”. The proportion of individuals endorsing each barrier was similar between groups, excepting “concerns about treatments available” and “thinking the problem would get better by itself”, which were more prevalent in those without a prior psychiatric history. Conclusions: There exist meaningful differences in the way perinatal individuals access care for depression based on psychiatric history. An understanding of these differences is crucial in addressing gaps between mental health care need and care receipt.

No description available.

The purpose of this study was to gain a better understanding of the paternal experience of perinatal loss. Perinatal loss is a significant life experience for childbearing families and this study helped to reveal the meaning of the paternal experience, how meaning was constructed and what factors both contributed and/or hindered coping following the loss. Although extensive research in grief and loss has been conducted there existed a significant knowledge gap related to the experience of perinatal loss and even more of a paucity concerning the understanding of the paternal experience. A qualitative study with a phenomenological approach was conducted with a purposeful sample of seven fathers who had experienced a perinatal loss. These fathers helped provide a basis for understanding through partaking in interviews conducted in a venue chosen by fathers. Data analysis involved procedures with roots in Heideggerian traditions of phenomenology, to allow for meaning interpretation of the father's narratives. The analysis resulted in four shared meanings 1) Perinatal Loss - Unexpected Reality, 2) Acknowledgment and Remembrance, 3) Significance and Strength and 4) Crisis, which consisted of 12 themes (World Falling Apart, Absolute Shock, Stoicism, Wishing for Answers, Silent Shelter, Concern for Wife, Communication, Time Heals - Though Never Forgotten, Continued Support and Understanding, Life Changing Moment, Opportunity of Growth and Avoidable Choice). Results indicated that fathers felt ill prepared for this unexpected life event and that they needed to remain strong or to live up to perceived expectations. Although the loss was never forgotten, through reflection, communication and continued support and understanding healing transpired over time and crisis was an avoidable choice. Further exploration of the paternal experience of perinatal loss with varying socio-cultural backgrounds, younger aged population group as well as different religious and cultural backgrounds is recommended. Research is also indicated to explore: 1) educational interventions focusing on both short and long term supportive care to bereaved families, 2) the impact of substantive bereavement programs on healing and meaning-making, 3) the impact of a perinatal loss experience on other members of the family unit, and 4) the impact of recurrent perinatal loss to a family.

Inflammation has modulatory effects on the brain, particularly during development. These plastic changes can hold severe functional consequences. Perinatal hypoxia-ischemia (HI)-induced inflammation can result in cerebral palsy and cognitive impairment. In an attempt to reduce inflammation in the brain, we assessed the probiotic Bifidobacterium (B.) infantis as an HI intervention, using a rat model. Rat pups, developmentally equivalent to preterm infants, were exposed to chronic hypoxia from postnatal (PND) 3 –PND 10. Inflammation was assessed through hippocampal concentrations of the cytokine interleukin-6 (IL-6). Tissue was collected from pups on PND 10 and analyzed via enzyme-linked immunosorbent assay (ELISA). Results showed lower IL-6 concentrations in hypoxic groups , regardless of B. infantis administration. Qualitative observations suggested poor gut health in association with hypoxia and probiotic exposure. These preliminary findings support the chronic hypoxia exposure model of HI and suggest the association with IL-6 and HI events is less straightforward than expected. / October 2016

Autism spectrum disorder (ASD) has been attributed to genetic and non-genetic risk factors. Of the non-genetic factors, prenatal and perinatal complications have been extensively investigated, though few associations have been replicated consistently. We selected 2,562 families with at least one individual with ASD and one unaffected sibling. We investigated the relationships between 29 prenatal and perinatal complications and ASD, while considering the influences of confounding factors, comorbid conditions, and different ASD definitions. Although many complications were associated with ASD in the pairwise comparisons, only haematological disorders of the newborn and lower Apgar scores remained significant after adjusting for the effects of the confounders. After removing individuals with congenital anomalies, only 5-minute Apgar scores were associated with ASD. In conclusion, after considering confounding effects and four ASD definitions, several perinatal complications were associated with ASD with moderate effect sizes. Furthermore, comorbid conditions with ASD appear to be intertwined in these relationships. / October 2016

El presente estudio de tipo retrospectivo, descriptivo se efectuó con el objeto de determinar la morbimortalidad y además describir el desempeño de la escala predictiva de mortalidad denominada Índice de Mortalidad Pediátrica – PIM 2. El estudio se realizó en la Unidad de Cuidados Intensivos Pediátricos del Hospital Nacional Daniel Alcides Carrión de Callao – Perú, durante el periodo comprendido entre el 1 de enero al 31 de diciembre del año 2003 siendo atendidos 171 niños. De este grupo fallecieron 33 dando una tasa de mortalidad de 19.3%. El grupo de estudio quedó conformado por 126 niños de los que fallecieron 19 siendo la mortalidad de 15.1%. La estancia hospitalaria en la unidad fue 5 ±5.4 días. En base a su mortalidad predicha calculada mediante la escala PIM 2, la población en estudio fue asignada en los siguientes grupos: Muy Bajo Riesgo, Riesgo Bajo, Riesgo Moderado, Riesgo Alto y Muy Alto Riesgo. La mayoría de la población quedó asignada al grupo de Riesgo Bajo. La tasa de mortalidad esperada durante el año 2003 fue 11.4% y la tasa de mortalidad observada fue de 15.1%. Las patologías más frecuentes fueron hipertensión endocraneana y bronconeumonía-SOBA. Las patologías con mayor porcentaje de fallecidos fueron Shock séptico e hipertensión endocraneana. La mayoría de ingresos a la UCIP vinieron procedentes de Emergencia Pediátrica. De ellos, el mayor riesgo de morir lo tuvieron los niños procedentes de su casa (14.7%) frente al grupo que vino referido de otro centro asistencial (8.1%). Se halló asociación significativa entre el estado nutricional y mortalidad observándose que sólo el 7% de los eutróficos fallecen frente al 20% de fallecidos de los niños desnutridos. Con respecto al PIM 2, los 19 niños que fallecieron tuvieron los más altos índices de riesgo de morir con un promedio de 28,8% de riesgo de mortalidad frente al 8.1% del grupo de niños que sobrevivió mostrando diferencia significativa. El PIM 2 tiene alta especificidad (95.6%) y al evaluar su desempeño se encontró que el área bajo la curva ROC fue de 0.797 considerada como aceptable. / -- The present retrospective descriptive study was performed with the aim to determine the morbimortality and describe the performance of the Paediatric Index of Mortality – PIM 2. The study was undertaken at the Pediatric Intensive Care Unit of the Hospital Nacional Daniel Alcides Carrión of Callao – Perú. During the period between January 1 to December 31 of 2003 with 171 children attended. Of this group, 33 children died and its mortality rate was 19.3%. The study group was conformed for 126 children and 19 of them died showing a mortality rate of 15.1% The hospital stay in the Unit was 5 + 5.4 days. With the predicted mortality calculed with the PIM 2, the study group was divided in the following groups: Very Low Risk, Low Risk, High and Very High Risk. The majority of the study group was assigned to the Low Risk group. The expected mortality rate in 2003 was 11.4% and the observed mortality rate was 15.1%. The most frequently pathologies were endocranean hypertension and pneumonia-SBO. The pathologies with the highest percentage of died children were septic shock and endocranean hypertension. The majority of patients admitted came from Emergency Pediatric. The most risk of mortality was obtained for the group of children who came from their home (14.7%) in comparison with the group that arrived from another hospital (8.11%). A significative association was found between malnutrition and mortality. Only 7% of eutrofic children died in comparison with the 20% of the malnourished children. In relation to PIM 2, the dead children group obtained the highest risk for die (28.8%) in comparison with the survivor children group (8.1%). The PIM 2 had a high specificity (95.6%) and the area under the ROC curve was 0.797.