UNBEARABLE TRAUMA AND IRREPARABLE DAMAGE: MATERNAL DEATH BY SUICIDE RAISES SERIOUS PERPLEXITIES

INTRODUCTION: Maternal death by suicide raises serious perplexities. The ICD-10 classifies maternal suicide as an indirect form of maternal death. Due to this current misclassification, a classificatory consensus of maternal suicide as a direct form of maternal death is urgent. OBJECTIVE: Analyze the psychological that permeate the phenomenon of maternal suicide, to define the profile of mothers in the postpartum period and pregnant women who commit suicide, with the purpose of elucidating ways of preventing maternal suicide. METHOD: A systematic review was made following the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta-Analysis). RESULTS: Twenty-one studies reported the urgent need to implement interventions in order to prevent or reduce mental health problems caused by mothers and pregnant women who commit suicide. Twenty studies demonstrate the need for interventions to organizational adjustments, especially related to the emotional conflicts involved suicide and maternity. CONCLUSION: Maternal suicide is mainly caused by severe psychiatric disorders, however, higher suicide rates are seen due to psychosocial factors, such as poor familial support and domestic violence, illegal substance abuse and alcoholism, history of sexual or physical violence, racial oppression, economic instability, unwanted pregnancy, difficulty in accessing intentional abortion, and trauma related to past maternity experiences.

Cerebral diffusion kurtosis imaging to assess the pathophysiology of postpartum depression

Postpartum depression (PPD), a main cause of maternal suicide, is an important issue in perinatal mental health. Recently, cerebral diffusion tensor imaging (DTI) studies have shown reduced fractional anisotropy (FA) in major depressive disorder (MDD) patients. There are, however, no reports using diffusion kurtosis imaging (DKI) for evaluation of PPD. This was a Japanese single-institutional prospective study from 2016 to 2019 to examine the pathophysiological changes in the brain of PPD patients using DKI. The DKI data from 3.0 T MRI of patients one month after delivery were analyzed; the patients were examined for PPD by a psychiatrist. The mean kurtosis (MK), FA and mean diffusivity (MD) were calculated from the DKI data and compared between PPD and non-PPD groups using tract-based spatial statistics analysis. Of the 75 patients analyzed, eight patients (10.7%) were diagnosed as having PPD. In the PPD group, FA values in the white matter and thalamus were significantly lower and MD values in the white matter and putamen were significantly higher. The area with significant differences in MD value was more extensive (40.8%) than the area with significant differences in FA value (6.5%). These findings may reflect pathophysiological differences of PPD compared with MDD.

Towards safe motherhood to - are we moving in the right direction?: experience from an urban health facility in South India

Background: This study was designed to evaluate the institutional Maternal Mortality Ratio (iMMR) in our institution, a tertiary private medical college hospital and to suggest recommendations and possible interventions to reduce it.Methods: This retrospective descriptive study was conducted by reviewing the hospital records over a period of ten years from January 2009-December 2018. The case records were reviewed for maternal demographic characteristics and complications.Results: The total number of deaths during the study period was 21, giving an iMMR of 85.268 per 100000 live births. Most of the maternal deaths (>80%) occurred postpartum. Obstetric causes contributed to 57% of the deaths with hypertension and hemorrhage topping the list. Other causes were sepsis and non obstetric causes including one case of maternal suicide. 52.38% of the women died more than 48 hours after admission to the hospital, while 28.57% succumbed in less than six hours. Secondary complications noted were ICU admission, extended intubation, massive transfusion, operative intervention and multi organ dysfunction.Conclusions: The classical triad of Hypertension, Hemorrhage and Sepsis continues to be the major determinant of maternal mortality and are potentially preventable by promoting universal access to quality health care, strengthening of health services and ensuring accountability.

Perinatal Depression

Perinatal depression includes major and minor depression occurring in pregnancy and one year postpartum. Affecting one in seven women, it is one of the most common pregnancy complications; however, it is often under recognized and undertreated. A personal history of perinatal or non-perinatal depression significantly increases risk. Screening using a validated instrument is recommended in the context of systems to ensure effective diagnosis, treatment, and follow-up. Evidence-based treatment includes psychotherapy and pharmacotherapy. Selective serotonin reuptake inhibitors are well-studied in pregnancy, are associated with low overall absolute risk, and are differentially secreted into breast milk. If left untreated, perinatal depression is associated with significant short- and long-term negative maternal-child consequences including, among many others things, poor bonding. Of note, maternal suicide exceeds hemorrhage and hypertensive disorders as a cause of maternal mortality. It is critical to recognize that one in five women who screen positive for perinatal depression will have bipolar disorder and are at highest risk for postpartum psychosis, suicide, and infanticide, especially if prescribed unopposed anti-depressant monotherapy. Women who screen positive for having bipolar disorder should be referred for psychiatric evaluation. This review contains 6 figures, 13 tables and 54 references Keywords: Pregnancy, Postpartum, Perinatal, depression, Mood disorder, Baby blues, Bipolar disorder, Psychosis, Psychotherapy, Psychopharmacology

Perinatal Depression

Perinatal depression includes major and minor depression occurring in pregnancy and one year postpartum. Affecting one in seven women, it is one of the most common pregnancy complications; however, it is often under recognized and undertreated. A personal history of perinatal or non-perinatal depression significantly increases risk. Screening using a validated instrument is recommended in the context of systems to ensure effective diagnosis, treatment, and follow-up. Evidence-based treatment includes psychotherapy and pharmacotherapy. Selective serotonin reuptake inhibitors are well-studied in pregnancy, are associated with low overall absolute risk, and are differentially secreted into breast milk. If left untreated, perinatal depression is associated with significant short- and long-term negative maternal-child consequences including, among many others things, poor bonding. Of note, maternal suicide exceeds hemorrhage and hypertensive disorders as a cause of maternal mortality. It is critical to recognize that one in five women who screen positive for perinatal depression will have bipolar disorder and are at highest risk for postpartum psychosis, suicide, and infanticide, especially if prescribed unopposed anti-depressant monotherapy. Women who screen positive for having bipolar disorder should be referred for psychiatric evaluation. This review contains 6 figures, 13 tables and 54 references Keywords: Pregnancy, Postpartum, Perinatal, depression, Mood disorder, Baby blues, Bipolar disorder, Psychosis, Psychotherapy, Psychopharmacology