Regulatory T cells (TRegs) are stable markers of immune functioning, acting to suppress inflammation. TRegs are important during implantation and early pregnancy where they suppress immune-mediated rejection of the embryo. Given the role of TRegs in the maintenance of pregnancy, their depletion can be associated with obstetric complications. Through the completion of two studies, this thesis seeks to identify the role of TRegs in two forms of perinatal pathology: depression and arterial thickening. The first study examines whether decreased TReg levels during pregnancy are associated with an increase in depressive symptoms, and if this relationship is mediated by maternal stress. We predicted that the TReg-depression relationship would be unique to pregnancy, and not occur in the postpartum. In the second study we assessed if decreased TRegs were inversely correlated with carotid arterial thickness. TReg samples were obtained from women between 24 and 32 weeks gestation (N=16), and at 12 weeks postpartum (N=19). Depression was assessed using the Edinburgh Perinatal Depression Scale (EPDS) and the Mongomery-Asberg Depression Rating Scale (MADRS) , and stress with the Perceived Stress Scale (PSS). TRegs were measured using flow cytometry. In the first study, we showed that lower TRegs were associated with increased levels of depression in pregnancy, and that this association was mediated by perceived stress. In the postpartum period, TRegs were not associated with changes in mood. In the second study, we found no relationship between TRegs and carotid arterial thickness. Our results suggest that TReg changes in pregnancy may be associated with maternal mood in pregnancy, but not in the postpartum period. Despite the fact that we failed to find a correlation between TRegs and carotid arterial thickness during pregnancy, our limited sample size leads us to recommend that the presence of an inverse correlation between these two markers not be ruled out, but suggest that these links be further examined using a larger sample and more precise imaging. Together, these two studies may provide very early insights into the role of TRegs in perinatal mood disorders and cardiovascular health and highlight the need for further research. / Thesis / Master of Science (MSc)

Yes / Purpose Perinatal depression is one of the most commonly diagnosed mental health conditions in the general maternity population but whilst the prevalence is thought to be much higher in asylum seeking and refugee (AS&R) women, it is less frequently identified and diagnosed by health care professionals. Method A systematic review was undertaken to address ‘what factors influence help-seeking behaviours in asylum seeking and refugee women with symptoms of perinatal depression’. The review focussed on women accessing care in high income countries. 12 studies met the eligibility criteria and a narrative synthesis was undertaken resulting in two main themes: women's perceptions of depression and access to healthcare and support services. Results Findings indicated that many of the influences on help-seeking were also present in the general population and women from ethnic minority populations, with the exception of migration experiences; but that women from a AS&R may experience more of these barriers, exacerbating inequality in access to and engagement with healthcare. Conclusion Further research is needed to provide more detailed insight into the experiences of asylum seeking and refugee women to identify ways that barriers in help-seeking can be addressed.

Submitted by PPG Medicina e Ci?ncias da Sa?de (medicina-pg@pucrs.br) on 2018-12-04T18:22:09Z No. of bitstreams: 1 CAMILA_DOS_SANTOS_EL_HALAL.pdf: 6036562 bytes, checksum: 43db97c52dcd3d105fd3916ba1d0f0cd (MD5) / Approved for entry into archive by Sheila Dias (sheila.dias@pucrs.br) on 2018-12-06T10:22:40Z (GMT) No. of bitstreams: 1 CAMILA_DOS_SANTOS_EL_HALAL.pdf: 6036562 bytes, checksum: 43db97c52dcd3d105fd3916ba1d0f0cd (MD5) / Made available in DSpace on 2018-12-06T10:35:35Z (GMT). No. of bitstreams: 1 CAMILA_DOS_SANTOS_EL_HALAL.pdf: 6036562 bytes, checksum: 43db97c52dcd3d105fd3916ba1d0f0cd (MD5) Previous issue date: 2018-08-17 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior - CAPES / The period extending from pregnancy to the months following delivery, although usually associated to positive feelings, represents a moment of great vulnerability to the development of major depressive disorders. Perinatal depression is a frequent pathology, and its consequences extend beyond the mother, potentially affecting the relationship with her partner and family functioning. Early exposure to maternal depression is associated to lower breastfeeding rates, impairment of mother-infant bonding, and consequences over child growth and development. Perinatal depression has been linked to infant sleep disturbances as early as in the neonatal period, with description of more night wakings, shorter sleep duration and more fragmented sleep. Sleep plays a fundamental role in child cognitive, social, and emotional development, and its disturbances, in a crucial moment of brain development, may facilitate significant and persistent dysfunctions. Studies associating maternal depression to child sleep disturbances show important heterogeneity in terms of design as in moment of sleep assessment. Sleep patterns go through important changes throughout the first twelve months of life, rendering impaired the association?s precise evaluation, as well as that of its potential long-term consequences. This study aimed to investigate the association between perinatal depression and altered infant sleep macrostructure at one year of life among participants in a birth cohort. In this population-based study, recruitment was carried out from pregnancy to soon after delivery, aiming to include all livebirths in the municipality of Pelotas throughout the year of 2015. Participants to one or both cohort-nested trials and those lacking information on maternal depression were excluded from these analyses. For the diagnosis of perinatal depression, the Edinburgh Postnatal Depression Scale (EPDS) was completed during pregnancy and 3 months after delivery, having been considered perinatally depressed mothers who scored ?13 points in one or both follow-ups. Infant sleep was assessed at 3 months through the Brief Infant Sleep Questionnaire (BISQ) and, at 12 months, through the same subjective questionnaire added to objective data derived from continuous 24-hour actigraphy. Main sleep outcomes were number of night time wakings, night vigil time and total sleep duration in 24 hours. The sample consisted of 2222 mothers/infants, in which prevalence of perinatal depression was of 22.3% (CI 95% 20.5-24). Adjusted analyses using Poisson?s regression from BISQ-derived data showed greater risk of >3 night time wakings at 12 months among infants of depressed mothers (RR 1.52; CI 95% 1.06-2.18; p=0.02). Actigraphic data did not, however, confirm those findings (adjusted RR=1.24; CI 95% 0.85-1.81; p=0.26). No association was found between perinatal depression and the other investigated sleep variables. This study suggests a potential defining role of dysfunctional cognition among mothers with a history of perinatal depression on infant sleep characteristics at the end of the first year of life. / O per?odo que se estende da gesta??o at? os meses seguintes ao parto, apesar de normalmente associado a sentimentos positivos, representa um momento de grande vulnerabilidade ao desenvolvimento de quadros depressivos maiores. A depress?o perinatal ? um dist?rbio frequente, cujas consequ?ncias se estendem para al?m da mulher acometida, potencialmente exercendo efeito sobre a rela??o com o parceiro e o funcionamento familiar. Exposi??o precoce a depress?o materna associa-se a menores taxas de amamenta??o, preju?zo do v?nculo com o beb?, e consequentes efeitos sobre o crescimento e desenvolvimento infantis. Evid?ncias associam a depress?o perinatal a dist?rbios do sono da crian?a desde o per?odo neonatal, sob a forma de maior n?mero de despertares noturnos, menor dura??o de sono e maior fragmenta??o. O sono, por sua vez, exerce papel primordial no desenvolvimento cognitivo, social e emocional da crian?a, e seus dist?rbios, em um per?odo crucial do desenvolvimento cerebral, podem favorecer disfun??es significativas e permanentes. Existe uma importante heterogeneidade em rela??o tanto ao delineamento dos estudos que associam depress?o materna a dist?rbios do sono na crian?a, quanto ao momento de avalia??o do sono, que sofre mudan?as significativas no decorrer dos primeiros doze meses de vida. Com isso, a avalia??o dessa poss?vel associa??o fica prejudicada, assim como a mensura??o de suas consequ?ncias a longo prazo. Este estudo objetivou investigar a presen?a de associa??o entre depress?o perinatal e altera??es da macroarquitetura do sono de lactentes com um ano de vida, participantes de uma coorte de nascimentos. Neste estudo de base populacional, o recrutamento ocorreu desde a gesta??o at? logo ap?s o parto, visando incluir todos os nascidos vivos na cidade de Pelotas no transcorrer de 2015. Participantes de uma das interven??es aninhadas ? coorte e aqueles sem informa??es referentes ? depress?o materna foram exclu?dos desta an?lise. Para diagn?stico de depress?o perinatal, foi aplicada a Escala de Depress?o P?s-natal de Edimburgo (EPDS) na gesta??o e 3 meses ap?s o parto, tendo sido consideradas deprimidas as m?es com pontua??o ?13 em um ou ambos os acompanhamentos. O sono dos lactentes foi avaliado aos 3 meses atrav?s do Brief Infant Sleep Questionnaire (BISQ) e, aos 12 meses, a partir dos mesmos dados subjetivos somados a informa??es objetivas obtidas a partir de 24 horas cont?nuas de actigrafia. Os principais desfechos de sono analisados foram o n?mero de despertares noturnos, dura??o da vig?lia noturna, e tempo total de sono em 24 horas. A amostra constituiu-se de 2.222 m?es e lactentes, na qual a preval?ncia de depress?o perinatal foi de 22,3% (IC95% 20,5-24). Pelo BISQ, as an?lises ajustadas atrav?s de regress?o de Poisson mostraram maior risco para >3 despertares noturnos aos 12 meses entre filhos de m?es deprimidas (RR 1,52; IC95% 1,06-2,18; p=0,02). No entanto, a avalia??o dos dados actigr?ficos n?o confirmou este achado (RR ajustado=1,24; IC95% 0,85-1,81; p=0,26). N?o houve associa??o entre depress?o perinatal e as demais vari?veis do sono. Este estudo sugere um potencial papel definidor da impress?o disfuncional entre m?es com hist?ria de depress?o perinatal sobre as caracter?sticas do sono dos lactentes ao final do primeiro ano de vida.

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.

<b>Background:</b> Perinatal depression is a significant contributor to maternal morbidity and mortality worldwide. Left untreated, perinatal depression has severe and far-reaching consequences for women, their families and wider society. Migrant women, including labour migrants and refugees, may be particularly prone to developing perinatal depression as a result of multiple stressors associated with displacement. Despite the vast majority of global migration flows occurring within low- and middle-income countries, evidence from these regions is severely lacking. This research addresses this imbalance by examining perinatal depression in migrant women living on the Thai-Myanmar border: a resource-poor setting of political tension and socio-economic disadvantage. <b>Aims:</b> This research aims to review the existing evidence around perinatal depression among migrant women from low- and middle-income settings; identify an appropriate tool to detect perinatal depression in migrant women on the Thai-Myanmar border; determine the prevalence of, and risk factors for, perinatal depression in this setting; explore women's experiences of perinatal depression; and develop recommendations for policy and practice. <b>Methods:</b> A sequential-exploratory mixed-methods design was used. The research included the following five study components: a systematic literature review; a validation study to identify a culturally-acceptable and appropriate assessment tool; a prospective cohort study of migrant women on the Thai-Myanmar border followed-up from the first trimester of pregnancy to one month post-partum; in-depth interviews with a subgroup of women with severe perinatal depression; and an informal exploration of stakeholder views. <b>Findings:</b> The systematic review found a wide range in prevalence of perinatal depression among migrant women and confirmed the absence of studies conducted in low-and middle-income destination countries. A total of 568 migrant women on the Thai-Myanmar border participated in the prospective cohort study, of whom 18.5% experienced moderate-severe depression and 39.8% experienced depression of any severity during the perinatal period. Almost a third (29%) of women reported suicidal ideation. Interpersonal violence (OR 4.5), experience of trauma (OR 2.4), a self-reported history of depression (OR 2.3) and perceived insufficiency of social support (OR 2.1) were significantly associated with perinatal depression. Lives of women with severe perinatal depression were characterised by difficult partner relationships, alcohol use among partners and interpersonal violence. A lack of mental health services currently limits the effective management of perinatal depression in this setting. Alongside training of health staff, primary, secondary and tertiary prevention efforts are required to effectively address perinatal depression on the Thai-Myanmar border.

Background: Young childbearing women have an increased risk of experiencing perinatal depression when compared to adult childbearing women. Perinatal depression has been associated with adverse life events in the literature and conceptually, in frameworks such as the Lifecycle Approach to Risk Factors for Mental Disorders Model. Purpose: The purpose of this manuscript-based thesis was to (1) determine the prevalence of: (i) adverse life events that have been associated with depression and (ii) depressive symptoms among the young pregnant and parenting women who access specialized services in an urban centre in Ontario, Canada; (2) determine which adverse life events are predictive of depression during the perinatal period, in this population; and (3) examine the psychometric properties of the Edinburgh Postnatal Depression Scale (EPDS) for use in a population of young childbearing women who access specialized services in an urban centre in Ontario, Canada. Methods: A survey was conducted with 102 young women from two agencies that provide specialized services to young parents. The interviewer-administered questionnaire included demographic questions, the Edinburgh Postnatal Depression Scale, the Antenatal Psychosocial Health Assessment, the Centers for Epidemologic Studies Depression Scale, Brown’s Support Behaviour Inventory. Results: 31.4% of the sample screened positive for perinatal depression. The only adverse life events found to predict perinatal depression were satisfaction with support from ‘others’ and intimate partner violence. Another predictor was very young maternal age (14 – 17 years). The EPDS was found to be psychometrically sound when used in this population of young childbearing women. Conclusion: In this study of young childbearing women in Ontario, Canada, we found a high prevalence rate of perinatal depression and adverse life events. Furthermore, we identified specific factors that predict the development of perinatal depression in this group. Nurses can use these findings to help prioritize perinatal screening efforts to identify this condition early on in order to lessen the adversities related to perinatal depression.

Background: In Pakistan, the prevalence of perinatal depression is high and is associated with adverse outcomes in both the mothers and their infant. Although effective psychosocial interventions have been developed for such settings, the scarcity of trained mental health professionals means that the majority of such women do not receive any intervention. The aim of this study was to explore the acceptability of peer volunteers (PVs) - volunteer lay women from the community with shared socio-demographic and life experiences with the target population – as delivery agents of a psychosocial intervention for perinatal depression in a rural area of Pakistan. Methods: This qualitative study was embedded in the pilot phase of a cluster randomised control trial. Participants included the entire sample of the pilot study: mothers (n=21), PVs (n=8), primary health care staff (n=5), husbands (n=5) and mothers-in-law (n=10). Data were collected, from these key stakeholders, through in-depth interviews and focus group discussions. Data analysis was underpinned by Framework Analysis involving five key stages: familiarisation, development of thematic framework, indexing, charting and interpretation. Results: All stakeholders viewed the PVs as acceptable delivery agents of a psychosocial intervention for perinatal depression. The PV’s personal attributes such as being local, empathic, trustworthy, approachable and of good reputation within their communities contributed to their acceptability. Their linkage with the primary health care system was vital to their legitimacy and credibility. Factors such as appropriateness of the intervention, effective training and supervision, perception of personal gain from the programme, and endorsement from their families and the community were motivational for them. Likely barriers to their work were women’s lack of autonomy, cultural beliefs around the perinatal period, stigma of depression, lack of some mothers’ engagement and resistance from some families. Conclusion: PVs are a potential human resource for the delivery of a psychosocial intervention for perinatal depression in this rural area of Pakistan. The use of such delivery agents could be considered for other under-resourced settings globally, and for other mental health conditions.

Background: According to the World Health Organization (WHO), perinatal depression (PD) is the most common childbirth complication. About 10% of pregnant women and about 13% of postpartum women experience a mental health disorder, primarily depression (WHO, 2016). One of the WHO (2015 a) goals for maternal mental health includes providing strategies for the promotion of psychosocial well-being and prevention of mental disorders of mothers during and after delivery. Purpose: The purpose of this performance improvement project was to establish a perinatal depression risk screening protocol and improve nursing knowledge on PD at a community-based hospital in Miami. Theoretical Framework: Beck’s postpartum depression theory Method: The project gained support and buy-in from the administration and management team of the healthcare institution. It included a comprehensive literature review used as a guide to establishing a perinatal depression screening protocol. Finally, staff nurses received education on PD, followed by an assessment for improved knowledge and retention of information. Result: A paired-samples t-test was conducted to compare pretest and posttest results for Registered nurses after receiving education on perinatal depression, N = 70. The results suggested improved knowledge and retention of new information. Conclusion: The perinatal depression screening protocol provided a framework for the assessment and first-line management for perinatal depression. There was evidence of improved nursing knowledge and retention of information on maternal mood disorders, especially perinatal depression.

Gestational diabetes (GDM) occurs in up to 9% of pregnancies. Perinatal depression affects up to 20% of women during pregnancy, and can extend into the postpartum period. A number of studies have linked depression and diabetes, however, whether this applies to GDM or which might come first is less understood. The purpose of this study was to examine the potential relationship between depression identified in the first trimester of pregnancy and the subsequent development of GDM. Women without pre-existing Type I/II diabetes (n = 1021) were evaluated for depression during the first trimester of pregnancy, and medical records were reviewed to identify a positive history of diabetes. Women identified as depressed during the first trimester were more likely to have GDM compared to those not depressed. After controlling for demographic factors and weight-related variables level of depression in the first trimester still predicted later GDM development. Depression identified in early pregnancy may predict increased risk of subsequent GDM development. Due to the numerous maternal, fetal and neonatal complications associated with GDM, early recognition is essential to promote the best possible outcomes for mother and infant. Recognizing depression as a possible risk factor for GDM development could lead to earlier screening and preventative measures.

Bakgrund: Under de första månaderna efter en förlossning diagnostiseras 8–15% av alla nyblivna mödrar i Sverige med depression. Syfte: Att beskriva kvinnors erfarenheter av att drabbas av förlossningsdepression. Metod: En litteraturstudie genomfördes med nio kvalitativa artiklar. Databassökning genomfördes i Cinahl, Pubmed och Psycinfo. Resultatet analyserades med inspiration av Popenoe et al., (2021) analysmodell. Resultat: Analysen resulterade i ett övergripande tema, tre huvudkategorier och nio underkategorier. Temat var “Inte kunna leva upp till egna och andras förväntningar”. De tre huvudkategorierna var: Tappa kontrollen över sitt liv, Vilja vara ensam men ändå känna sig övergiven och Vara rädd för att bli dömd som en dålig mamma. Slutsats: Kvinnorna behöver mer stöd från vårdpersonalen när de drabbats av förlossningsdepression. Kvinnorna behöver hjälp att initiera samtal om psykisk ohälsa &amp; förlossningsdepression eftersom det är ett tabubelagt ämne. Det krävs att kvinnorna känner förtroende för vårdpersonalen för att våga berätta om sin ohälsa. / Background: 8-15% of all women in Sweden get diagnosed with perinatal depression during the first month postpartum. Aim: Describe women's experiences of suffering from perinatal depression. Method: A literature study was conducted based on nine qualitative studies. Searches in databases Cinahl, Pubmed and Psycinfo were conducted. The result was analyzed with the Popenoe et al., (2021) model for analyzing literature studies. Result: The analysis resulted in one theme, three main categories and nine subcategories. The theme was “Not being able to live up to one's own and expectations of others”. The three main categories were: Losing control over one's life, Wanting to be alone but still feeling abandoned, Fear of being judged as an unsuitable mother. Conclusion: The results showed that women who suffer from postnatal depression need more support from healthcare professionals. They need help to initiate conversation about mental illness and perinatal depression since it's taboo to talk about. There's a need for women to feel comfortable with healthcare professionals to have the courage to open up about their mental illness.