Tag Archive for: postpartum

The Brain’s Journey during Pregnancy and Menopause: A Spotlight on Estradiol and the Immune System

Authors: Hannah Oppenheimer, PhD student, Arielle Crestol, PhD student, Claudia Barth, Senior Researcher/PI FemHealth Project, Division of Mental Health and Substance Abuse, Diakonhjemmet Hospital, Oslo, Norway  | Editors:  Romina Garcia de leon Reviewer: Magdalena Martínez-Garcia

Published: June 21st, 2024

There are clear sex and gender differences in several brain-related disorders. For example, relative to men, the lifetime risk for depression is twice as high in women*, and twice as many women develop late-onset Alzheimer’s disease. But what’s  causing these differences?

While the underlying reasons are not yet fully understood, sex hormones and inflammatory processes (i.e., the immune system’s response to irritants such as pathogens), are thought to play important roles. Women’s lifespans are marked by major hormonal and immune-related changes, particularly during pregnancy and menopause. Research suggests that these phases are important for brain health and mental health, both in the short-term and long-term.

What happens during pregnancy that affects brain health and mental health?

During pregnancy, the immune system fluctuates between three immunological stages with unique inflammatory profiles, each corresponding to a trimester. The first is a pro-inflammatory stage, where inflammation is enhanced to allow for the implantation of the embryo and the formation of the placenta. This is followed by an anti-inflammatory stage, namely a reduction in inflammation to support the growth of the fetus. The final stage is again pro-inflammatory and helps initiate birth. A successful pregnancy depends on the adaptation of the maternal immune system to each of these stages. The stages are also linked to hormonal changes such as rises in estradiol — the most abundant form of estrogen in women — which play a vital role in creating an anti-inflammatory immune environment.

Alongside the hormonal and immunological changes, pregnancy and the postpartum period also impact the mother’s neuroplasticity, that is, the brain’s ability to change. Changes in brain volume during pregnancy and postpartum have been associated with fluctuating estradiol levels. These changes can be beneficial! A recent study showed that cortical brain volume changes follow a U-shaped trajectory whereby volume decreases during pregnancy and increases again postpartum. Both the reduction and the increase in volume throughout this trajectory have been linked to a higher mother-to-infant attachment later on, thereby potentially helping women transitioning to motherhood. However, some of these brain changes may also lead to increased vulnerability to mental disorders such as depression, which affect almost one in five women during and after pregnancy.

Do all changes revert postpartum?

While some of the maternal brain changes revert shortly after giving birth, other changes may sustain for years or even decades. Possible long-term impacts of pregnancy on the brain have been shown in studies that found younger-looking brains in middle-aged women with biological children compared to those without (see image). This effect may be linked to the exposure to hormones and inflammatory markers during pregnancy. Furthermore,  regulatory T cells — cells that play a critical role in stopping immune responses when no longer needed and show an increase during pregnancy which persists postpartum  — may reduce risk for Alzheimer’s disease later in life. Another mechanism which may be involved in the relationship between pregnancy and long-term brain health through its effects on the maternal immune system is fetal microchimerism — the lasting presence of fetal cells in the mother’s body long after giving birth.

What happens during menopause?

Hormonal and immune-related changes during the menopause transition are thought to be the basis for menopausal symptoms which are largely neurological in nature, such as hot flashes and night sweats, mood and sleep disturbances, and trouble with memory and cognition. The transition to menopause has also been linked to changes in the brain and a heightened risk of depression. For some women, symptoms and brain changes may stabilize, or even revert after menopause. However, the presence and severity of these symptoms may increase the likelihood of developing Alzheimer’s disease in older age.

With the transition to menopause, estradiol levels decline and again influence the immune system. A balance between pro-inflammatory and anti-inflammatory responses during the reproductive years can shift to an imbalance leaning towards more pro-inflammatory responses during the transition to menopause. This process can get exacerbated in a subset of women, leading to negative health outcomes. Research suggests that the anti-inflammatory processes associated with pregnancy may shape the emerging inflammatory processes during menopause, and thereby influence later brain health.

Overall, pregnancy and menopause are transition phases encompassing hormonal and immune-related changes, which can have short-term and long-term effects on women’s brain health and mental health. Scientists are still working to better understand the implications of these relationships, including their role in disorders with large sex differences. Once that is better understood, this knowledge may help pave the way for better treatments, disease prevention, and individualized care.

Potential Effects of Pregnancy on Brain Health Through Hormonal and Immune-Related Changes

Research has found differences in brain health between women with biological children (parous) and women without (nulliparous).

*Although we acknowledge that individuals who are biologically female (i.e., XX) do not always identify as women, we used the gendered term “women” to align with common language usage.

 

Perinatal Anxiety 101: An Introduction

Authors: Brynn Stagg, MSc Student, University of British Columbia; Claudia Cargnelli, MSc Student, University of British Columbia; Nichole Fairbrother, Ph.D., RPsych, Clinical Associate Professor & MSFHR Health Professional-Investigator, University of British Columbia | Editors: Romina Garcia de leon, Shayda Swann (Blog Coordinators) 

Published: February 24th, 2023

Are you pregnant, recently given birth, or know someone who has? If so, chances are you or someone you know has experienced anxiety during or after their pregnancy.

Anxiety is a normal human experience.

We all feel anxious, worried, or afraid some of the time. Often, anxiety serves a useful purpose. For example, when heights make us anxious, this feeling serves as a warning to be careful in this potentially dangerous situation. Because of this fear, we take precautions to protect ourselves.

When does anxiety become a problem? 

Sometimes, however, we become fearful of something that is not dangerous, or more fearful than we need to be. If anxiety becomes severe enough to cause significant distress or interference in a person’s life, it may have developed into an anxiety or anxiety-related disorder (AD). 

There are several different ADs, including panic disorder, generalized anxiety disorder, social anxiety disorder, and anxiety-related disorders like obsessive-compulsive disorder and posttraumatic stress disorder. Given the diversity of ADs, it is no surprise that these are important to diagnose – especially when you add in the everyday stress that comes with parenting! 

What about anxiety during pregnancy and the postpartum? 

Anxiety is especially common (and normal) among pregnant and postpartum people. Often, the anxiety experienced during this time is related to one’s pregnancy (will my baby be healthy?), the childbirth (will childbirth be painful?), and one’s newborn (what if something happens to my baby?). 

Although anxiety during the perinatal period is common, and in many cases, a normal and healthy part of becoming a parent, sometimes perinatal anxiety becomes a problem. If you are experiencing substantial anxiety and fear, and these feelings are making you upset or affecting your ability to parent and live your life, you may be experiencing symptoms that meet criteria for an AD. 

Most importantly, we want you to know that you are not alone! There are things you can do (like talking to your healthcare providers, for starters).

Why does perinatal anxiety matter?

Over one in five (21%) pregnant and postpartum people suffer from at least one AD during the perinatal period. Believe it or not, this number is more than postpartum depression – which, at most, 10-16% of birthing people experience. 

ADs, when they occur during pregnancy, have been associated with adverse obstetrical and neonatal outcomes, such as increased risks for pre-eclampsia, preterm birth, and low birth weight. These can have consequences for the infant and developing child.

What can be done?

It’s important to ask for help. You are not alone. Some treatments really work, including self-help materials, group or individualized therapy, and/or medication. 

Cognitive Behavioural Therapy (CBT) is the recommended first-line treatment for most ADs. It is the talk therapy for anxiety with the most scientific support. It’s safe, effective, and is often the treatment of choice for pregnant or postpartum parents as it works as well or better than medication does. 

CBT works to reframe thinking patterns and behaviour. In other words, CBT focuses on how you are thinking (cognitive), what you do about those thoughts (behavioural), and then works on changing these to help your feelings. Lots of research has been done on the effectiveness of CBT in general populations, and we hope to see even more studies focused on perinatal people in the future!

If talk therapy is not helping, individuals may benefit from medication instead of, or in combination with, talk therapy. Selective serotonin and selective norepinephrine reuptake inhibitors (SSRIs and SNRIs), also known as antidepressants, are used to treat anxiety. While many are hesitant and fearful of using medications while pregnant or breastfeeding, not treating more severe perinatal anxiety greatly overshadows the risks associated with using medication, so it’s important to weigh the pros and cons. 

If you think your anxiety has become a problem, you may want to speak to your primary healthcare provider. You can also seek the services of a psychologist. 

What’s next for this area?

The team at the Perinatal Anxiety Research Lab hopes that by spreading knowledge of anxiety during pregnancy and the postpartum, we can work to make sure that perinatal anxiety becomes easily recognized so everyone can get the support they need during such a stressful time. 

Coming up, we will teach you about some important steps that are crucial in making sure parents are getting the support and resources they need. Stay tuned for our next feature on Screening for Perinatal Anxiety Disorders. 

Reflecting & Resources

If you are pregnant or have been pregnant, what has your experience been like? Did you know anxiety is this common during the perinatal period? Is there someone that could benefit from this knowledge? 

Let us know your thoughts, questions, or ideas for future posts in our Perinatal Anxiety 101 feature at womenshealth.blog@ubc.ca.

Click here for resources and additional support!

 

Behind the Science: Postpartum Care in China and Canada

 

Authors: Alex Lukey, Arrthy Thayaparan and Negin Nia (blog coordinators) | Interviewing: Kejia Wang, BSc, University of Pennsylvania, MA, University of British Columbia

Published: September 24th, 2021

For the next post in our Behind the Science series, we speak to Kejia Wang on her masters work at the University of British Columbia and career journey. In our discussion, Wang takes us through her work in women’s health research, and defines what postpartum confinement care is in China and how that differs from western systems of care.

How did you become interested in women’s health research?

I earned my undergraduate degree in the United States, where I was a bioengineering major. After that, I came to UBC to do a master’s in English, specifically rhetoric. My focus at UBC were rhetoric and Science and Technology Studies. Combining the two topics allowed me to make use of my existing knowledge from STEM while learning more about how scientific ideas are debated and disseminated in the public sphere.

After coming to UBC, I met Professor Judy Segal, who became my supervisor and mentor. She is an expert on the rhetoric of health and medicine. In Judy’s classes, we talked a lot about women’s health research. As a woman myself, I am interested in how women’s health is talked about and understood, and wanted to study women’s health from an intercultural and multidisciplinary lens.

How did you decide to make the leap from bioengineering to english?

It was very interesting! I was always interested in both science and english as a child. I went into science thinking that was what I wanted to do. But after a few years of working in science, I realized that I preferred talking about science rather than actually doing science. I want to be that person who can take an engineer’s work and explain to the lay public what it actually means. I am interested in the perception of scientific (or pseudoscientific and science-adjacent) ideas by the public and how different communities use these ideas to improve their lives.

How did that journey lead you to where you currently are in your career?

The engineering degree gave me a solid STEM foundation. The rhetoric at UBC gave me the foundation to understand how STEM and STEM-adjacent ideas are talked about in a public sphere. Now I’m doing work at the Resident Doctors of BC, where I am able to combine my abilities.

So now I’m looking at both in considering policy. How do we take the data and concerns that people have and use that to draft policies that make sense from the scientific perspective, but also benefit the patient and the provider?

Regarding your thesis work, could you explain what you did in simple terms?

When I started my master’s at UBC, I decided to do a thesis. We settled on postpartum care in China, because it ticked a lot of boxes in terms of what I was interested in.

I was interested in confinement because it’s sort of a peripheral health practice. As a practice and framework for postpartum care, it has not been validated by a randomized clinical trial (RCT), generally considered to be the gold standard of health research in the West. But since it’s still ubiquitous in Asia, it’s very much in the public consciousness. So I wanted to look at what it does, why it may be important to Chinese women as well as the Chinese nation. Which, from​​ my research, has a vested interest in supporting this practice to support a particular conceptualization of motherhood. The “ideal Chinese woman,” so to speak. I was also interested in how this Chinese practice might inform a more global and holistic perspective on what is good for our health and wellness.

For those that don’t know, could you describe what postpartum confinement is?

The Chinese practice of postpartum confinement is an umbrella term for several different practices that Chinese women do right in the period after they give birth, usually for about one month.

There is a whole spectrum of possible practices, some more and some less popular, that women choose from. Usually, a woman will pick about three or four different practices with the advice and suggestions of her family and health care providers.

Some of these practices include consuming specialized meals intended to restore her vitality or avoiding certain environmental triggers. This can include anything, such as washing your hair to the overuse of electronic gadgets. In some cases, there are movement restrictions, such as not leaving the house for the first few days or longer.  There is also the sense that the woman is supposed to be taken care of by others, either by the family and partner or by peripheral health professionals, such as a doula, postpartum nanny, or workers at postpartum centers.

What are some common misconceptions of postpartum confinement?

A big one is that since the English term calls it ‘confinement,’ there is a sense that women are locked up in their houses. This obviously sounds oppressive and knowing Chinese practices, like the one-child policy, you may think that is true.

In some cases, there is an element of coercion to it if the family members or centre has too much power dictating what the women should or shouldn’t do. Generally speaking though, the woman has a lot of power in choosing what she wants to do. All these things are still woman-centred and these practices are supposed to help the woman recover.

What do you think is the most important impact of your research?

I think one finding that I wasn’t expecting was the Chinese state’s investment in these practices and women’s health. In a way, that seems to run counter to how people might usually conceptualize the Chinese government. You hear about things like the one-child policy or the forced IUDs. That is considered to be quite invasive.

The state, in supporting this practice, positions itself more benevolently. This practice is framed as something that helps the woman recover, and even become a better woman. You are expected to not only recover the vitality and health that you had before, but there are these messages that encourage you to become an even more successful worker in your field, mother, and contributing female citizen.

Another thing was that I came to understand the practice of postpartum care in China as filling a niche for what the western medicine model is not providing to women who are going through childbirth and the postpartum. Western medicine provides many guarantees around health outcomes measured by quantitative parameters. But there are other measures of wellness and health, such as bonding with the infant and bonding with the family, and a return to the “normal” that is also very valued. So that’s why I think the practice has the reach and support that it has.

The other thing to add to what’s interesting is the western model seems to be more infant-centred in the postpartum. While the Chinese model is very much mother-centred, which really shifts the whole paradigm around which practices are prioritized.

Based on your work, what would you like to see adopted in the healthcare system?

So from a different culture’s, and dare I say EDI (equity, diversity and inclusion) point of view, especially in a city as ethnically diverse as Vancouver, it would be very helpful if a Chinese Canadian mother giving birth would have these kinds of support from her home culture.

Obviously, this is not unique to Chinese people. If it’s possible to have that kind of support, not in the sense that you would be offered the full Chinese postpartum experience in Canada, but if there is more familiarity with these ways of thinking and providing care.

The other thing, which is much more difficult, is for the health system to start considering other parameters in the outcomes when we talk about improving patient outcomes. This would mean incorporating other indicators, such as the time required for the mother’s general fitness level to return to her pre-childbirth baseline.

Why do you think we need to focus on women’s health in research?

If we have a very child-focused postpartum system, that means that the mother’s health is likely being overlooked. This is unfortunate, because the postpartum is a very important moment in a woman’s life – she is adjusting to her new role as a mother physically and mentally, both at home and in broader society. I think it’s important and good for there to be more attention brought to the mother during this developmental period in her life.

 

Pregnancy and Mental Health: New Research Paves the Way for Better Treatment

Authors: Wansu Qiu (Ph.D. candidate), Liisa A.M. Galea (PhD, Graduate Program in Neuroscience, Department of Psychology. Djavad Mowafaghian Centre for Brain Health, University of British Columbia) & Katherine Moore (Adv. Dip., BA)

Pregnancy and postpartum are two periods in a person’s lifetime that cause major changes to the body and brain. Anyone who has been pregnant will no doubt be fully aware of the dramatic changes to their bodies. But what is perhaps less well known is that there are also changes that occur in the brain. Indeed, you may be familiar with the term “baby brain” or “maternal amnesia”. These terms are often used in a derogatory way towards new parents, but people need to be aware that changes to the brain do occur and can have a significant impact on mental health.

Unfortunately, many of the natural brain changes that occur during pregnancy and the postpartum period are similar to what we see in people with major depression. These changes include, but are not limited to, reductions in brain volume, increased inflammation, hormonal profile changes, and metabolism changes. So, it is natural to wonder whether and how these natural changes contribute to greater susceptibility to depression during pregnancy or the postpartum.

It turns out that the perinatal period (pregnancy and the postpartum) is a particular time of risk to develop depression. Perinatal depression is defined as depression that occurs during pregnancy or in the first few months following childbirth and affects approximately 15% of new parents. However, not all people that experience perinatal depression develop symptoms at the same time or have the same symptoms. For example, the majority of people with perinatal depression experienced depression at least once before their pregnancy. However, 40% of people with perinatal depression experienced depression for the first time in their lives in the early postpartum period. Unfortunately, research has typically not separated findings according to when depression starts. This is problematic because knowing when depressive symptoms begin can help us determine the cause of depression (etiology), as well as how to properly treat it. In fact, studies that separate findings by depression onset (e.g. during pregnancy versus postpartum) and include whether there was a previous history of depression, show that the success of antidepressants vary depending on these factors. Thus, the distinct biological changes between pregnancy and postpartum may be the reason why drug effectiveness changes during these periods.

Yet, very little research exists on the connection between these biological mechanisms, depression that starts during the perinatal period and treatment efficacy. Our lack of understanding is partially due to the misidentification of perinatal depression as just another form of major depression. This issue stems from the fact that current diagnostic manuals, such as the DSM-V, do not distinguish between depression onset during pregnancy versus depression onset during postpartum. Furthermore, they only consider depression occurring in the first four weeks after birth as the postpartum period, when in fact many distinct physiological changes occur well into the first year of motherhood that may impact depression susceptibility. Considering the large number of people that live with postpartum depression, but whom have never experienced depression before, it is pertinent to determine why this period has such a high risk for depression onset. Even more troubling, antidepressant treatments may be less effective when treating perinatal depression compared to treating depression at other times. Indeed, the effectiveness of antidepressants is even worse in the postpartum period compared to other periods of pregnancy such as preconception.

 

Sadly, pregnant and postpartum people are not often studied and are left out of clinical trials. The lack of females in research is troubling enough given the greater number of pharmaceutical side effects they experience and misdiagnosis they receive compared to men. This is compounded by the lack of data on the safety and efficacy of drugs during the perinatal period. Interestingly, there has been a surge in preclinical animal models of perinatal depression over the last 20 years. These studies have also shown that antidepressants are less effective when depression onset is during the postpartum. Specifically, using a preclinical model of first-time postpartum depression onset, researchers found that high stress hormone levels cause depressive-like symptoms including passive coping, reduced maternal care (e.g. more time spent away from the nest) and decreased plasticity in the hippocampus. Interestingly, the hippocampus is an area of the brain that is affected by depression in human populations too. In a series of studies, researchers also found that a common antidepressant, fluoxetine (Prozac), shows limited effectiveness in treating these symptoms in the postpartum. This mirrors previous findings in humans on antidepressant use during postpartum. Astonishingly, they found that fluoxetine reversed the decrease in maternal care behaviour in the early postpartum but did not reverse depressive symptoms (e.g. brain changes, passive coping) in the later postpartum, suggesting that fluoxetine may lose its effectiveness over time.

In a recent article, cluster member (Wansu Qiu: @WQiuPhoenix) wanted to understand what mechanisms or biomarkers may be limiting the efficacy of fluoxetine in the postpartum.  Using this same preclinical model, Qiu and colleagues discovered that inflammation and metabolism may play a role in the lack of antidepressant efficacy during the postpartum in females. Inflammation is important to examine because depression has been linked to increase inflammatory signalling and antidepressant effectiveness has been linked to decreased inflammatory signalling. Fluoxetine treatment in the postpartum increased a proinflammatory signal, IL-1β (a cytokine), in the hippocampus and decreased tryptophan concentrations. This is notable as fluoxetine usually decreases cytokines when it reverses symptoms, and decreased tryptophan is often found in depression in females. More alarmingly, they found that the effects of fluoxetine were still present when rat moms were given a high dose. Thus, the authors suggest that the lack of treatment efficacy is not due to how antidepressants are metabolized in the maternal body, but due to changes in drug action on inflammation and metabolism. Overall, these new findings suggest that the lack of effectiveness of fluoxetine to reverse symptoms in the postpartum may be related to tryptophan metabolism, possibly acting via inflammation in rodent moms. This new research can lead to a better understanding of postpartum depression and antidepressant efficacy, possibly paving new ways for better treatment options.

The bottom line: scientists need more research funding to study the distinct presentations of perinatal depression (pregnancy onset versus postpartum onset) and we need more researchers to take on these kinds of projects. Clinicians need to be on the lookout for perinatal mood disorders, and we need governments to develop a national strategy for perinatal mental health. As a society, we all need to support people not just during pregnancy but also in the postpartum—as they say, it takes a village.