Association between stillbirth ≥23 weeks gestation and acute psychiatric illness within 1 year of delivery
Association between stillbirth ≥23 weeks gestation and acute psychiatric illness within 1 year of delivery
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DOI：
10.1016/j.ajog.2019.06.027
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发表时间：
2019-11-01
影响因子：
9.8
通讯作者：
Cahill, Alison G.
中科院分区：
文献类型：
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作者：
Lewkowitz, Adam K.;Rosenbloom, Joshua I.;Cahill, Alison G.
背景：死产与情绪和心理症状有关。死产和诊断出的产后精神疾病之间的关联不太为人所知。 目的：本研究的目的是确定女性在死产后一年与活产相比是否有更高的风险经历临床医生诊断的精神疾病。 研究设计：这项回顾性队列研究使用国际疾病分类第 9 版、临床修改诊断和程序代码来确定佛罗里达州住院患者的参与者、暴露和结果和州急诊部数据库。 2005-2014年首次分娩的13-54岁佛罗里达州女性居民也被纳入其中；患有《国际疾病分类》第 9 版临床修订版编码的精神疾病或怀孕期间物质使用的女性被排除在外。该暴露是妊娠 >= 23 周的死产住院期间的国际疾病分类第 9 版临床修改诊断代码。主要结局是在急诊科就诊或分娩后 1 年内因精神疾病综合症状入院期间的主要或次要国际疾病分类第 9 版临床修改诊断代码：自杀未遂、抑郁、焦虑、创伤后应激障碍、精神病、急性应激反应或适应障碍。次要结果是药物或酒精使用或依赖的物质使用组合。我们使用多变量逻辑回归比较死产与活产后的结果，调整母亲的社会人口因素、医疗合并症和严重的产时发病率。我们还使用 Cox 比例风险模型并测试是否违反比例风险假设，以确定死产分娩后一年内主要结局的最高风险时间，并调整与逻辑回归模型中相同的因素和发病率。 结果：总共纳入了 8292 名死产单胎妇女和 1,194,758 名活产单胎妇女。死产后出院一年内，4.0% 的女性 (n=331) 曾因精神疾病而到急诊科就诊或住院；与活产相比，风险高出近 2.5 倍（1.6%；n=19,746）；调整后优势比，2.47； 95% 置信区间，2.20-2.77）。与活产相比，死产产后一年内，女性因吸毒、酗酒或依赖而进入急诊室或住院的风险也更高（124 [1.5%] vs 7033 [0.6%]；调整后优势比，2.41；95% 置信区间，1.99-2.90）。 Cox 比例风险模型表明，产后精神疾病的最高风险区间是死产后 4 个月内（调整后风险比，3.26；95% 置信区间，2.63-4.04），尽管在产后 4-12 个月内风险仍然很高（调整后风险比，2.42；95% 置信区间，2.13-2.76）。结论：编码活产后一年内急诊科就诊或入院时出现精神疾病或药物滥用的情况并不少见，相当于每 100 名妇女中就有近 2 人患有精神疾病或药物滥用。然而，死产与精神疾病发病率（相当于每 25 名女性中有 1 例）和药物滥用（相当于每 100 名女性中有 3 例）的风险增加相关，其中从分娩到产后 4 个月期间发生产后精神疾病的风险最高。
BACKGROUND: Stillbirth has been associated with emotional and psychologic symptoms. The association between stillbirth and diagnosed postpartum psychiatric illness is less well-known.OBJECTIVE: The purpose of this study was to determine whether women have a higher risk of experiencing clinician-diagnosed psychiatric morbidity in the year after stillbirth vs livebirth.STUDY DESIGN: This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedure codes to identify participants, exposures, and outcomes within the Florida State Inpatient and State Emergency Department databases. The first delivery of female Florida residents aged 13-54 years old from 2005-2014 was included; women with International Classification of Diseases, 9th Revision, Clinical Modification coding for psychiatric illness or substance use during pregnancy were excluded. The exposure was an International Classification of Diseases, 9th Revision, Clinical Modification diagnosis code during delivery hospitalization of a stillbirth at >= 23 weeks gestation. The primary outcome was a primary or secondary International Classification of Diseases, 9th Revision, Clinical Modification diagnosis code during an Emergency Department encounter or inpatient admission within 1 year of delivery for a composite of psychiatric morbidity: suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder. The secondary outcome was a substance use composite of drug or alcohol use or dependence. We compared outcomes after delivery of stillbirth vs livebirth using multivariable logistic regression, adjusting for maternal sociodemographic factors, medical comorbidities, and severe intrapartum morbidity. We also used Cox proportional hazard models and tested for violation of the proportional hazard assumption to identify the highest risk time within the year after stillbirth delivery for the primary outcome, adjusting for the same factors and morbidities as in the logistic regression model.RESULTS: A total of 8292 women with stillborn singletons and 1,194,758 with liveborn singletons were included. Within 1 year of hospital discharge after stillbirth, 4.0% of the women (n=331) had an Emergency Department encounter or inpatient admission that was coded for psychiatric morbidity; the risk was nearly 2.5 times higher compared with livebirth (1.6%; n=19,746); adjusted odds ratio, 2.47; 95% confidence interval, 2.20-2.77). Women also had higher risk of having an Emergency Department encounter or inpatient admission coded for drug or alcohol use or dependence in the year after delivery of stillbirth vs livebirth (124 [1.5%] vs 7033 [0.6%]; adjusted odds ratio, 2.41; 95% confidence interval, 1.99-2.90). Cox proportional hazard modeling suggested that the highest risk interval for postpartum psychiatric illness was within 4 months of stillbirth delivery (adjusted hazard ratio, 3.26; 95% confidence interval, 2.63-4.04), although the risk remained high during the 4-12 months after delivery (adjusted hazard ratio, 2.42; 95% confidence interval, 2.13-2.76).CONCLUSION: Coding for psychiatric illness or substance misuse in Emergency Department visits or hospital admissions in the year after delivery of livebirths was not uncommon, corresponding to nearly 2 per 100 women. However, having a stillbirth was associated with increased risk of both psychiatric morbidity (corresponding to 1 per 25 women) and substance misuse (corresponding to 3 in 100 women), with the highest risk of postpartum psychiatric morbidity occurring from delivery until 4 months after delivery.