Download PDF
Am J Perinatol 2021; 38(13): 1412-1419
DOI: 10.1055/s-0040-1713368
Original Article

Lifetime Psychosocial Stress Exposure Associated with Hypertensive Disorders of Pregnancy

Madeleine Caplan 
1   Department of Obstetrics and Gynecology, NorthShore University HealthSystem, School of Medicine, Duke University, Durham, North Carolina
,
Lauren S. Keenan-Devlin
2   Department of Obstetrics and Gynecology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, Illinois
,
Alexa Freedman
3   Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Institute for Policy Research, Northwestern University, University of Chicago Pritzker School of Medicine, Evanston, Illinois
,
William Grobman
4   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University, Northwestern University Feinberg School of Medicine, Chicago, Illinois
,
Pathik D. Wadhwa
5   Department of Psychiatry and Human Behavior, University of California, School of Medicine, UC Irvine Development, Health and Disease Research Program, Irvine, California
,
Claudia Buss
6   UC Irvine Development, Health and Disease Research Program, University of California Irvine, Irvine, California
7   Department of Medical Psychology, Charité, University Medicine Berlin, Berlin, Germany
,
Gregory E. Miller
8   Department of Psychology, Institute for Policy Research, Northwestern University, Evanston, Illinois
,
Ann E.B. Borders
9   Department of Obstetrics and Gynecology, NorthShore University Health System, Center for Healthcare Studies, Institute for Public Health and Medicine, University of Chicago Pritzker School of Medicine, Northwestern University, Evanston, Illinois
› Author Affiliations Funding Funding for this study was provided by HHSN275201200007I–HHSN27500005. National Children's Study: Vanguard Study–Task Order 5: Stress and Cortisol Measurement for the National Children's Study. A.E.B.B. was the principal investigator.
› Further Information
    Permissions and Reprints

Abstract

Objective Hypertensive disorders of pregnancy (HDP) complicate 5 to 10% of all pregnancies and are a major cause of pregnancy-related morbidity. Exposure to psychosocial stress has been associated with systemic inflammation and adverse birth outcomes in pregnant women. Thus, it is probable that psychosocial stress and inflammation play a role in the development of HDP. The primary objective of this analysis was to determine if a woman's lifetime psychosocial stress exposure was associated with an increased risk of HDP. Additionally, we examined whether serum inflammation was an underlying biological mediator for this relationship.

Study Design A multisite prospective study was conducted in a sociodemographically diverse cohort of 647 pregnant women. At a study visit between 12 and 206/7 weeks' gestation, maternal psychosocial stress was assessed with six validated assessments and inflammation was measured via log-transformed serum concentrations of interferon-γ, interleukin (IL)-10, IL-13, IL-6, IL-8, and tumor necrosis factor-α. A composite stress score was calculated for each participant from the six stress assessments. The diagnosis of HDP was abstracted from the medical record and was defined as the presence of gestational hypertension after 20 weeks of pregnancy and/or preeclampsia. The association between composite stress and HDP was determined using binary logistic regression. Inflammation, using the six inflammatory biomarkers, was tested as a potential mediator between stress and HDP.

Results Participants with higher composite stress scores were more likely to develop HDP (odds ratio [OR]: 1.50, 95% confidence interval [CI]: 1.06–2.12). When adjusted for known risk modifiers, including maternal age, race/ethnicity, parity, pre-pregnancy body mass index, diabetes, chronic hypertension, and smoking during pregnancy, the risk remained unchanged (OR: 1.50, 95% CI: 1.03–2.20). No mediation effect by inflammation was observed.

Conclusion Independent of known risk factors, women exposed to greater composite stress burden across the life course are at increased risk of developing HDP.

Key Points

  • This study was conducted to determine if women with high levels of psychosocial stress have differences in risk for hypertensive disorders of pregnancy (HDP).

  • Independent of known risk factors, women with increased lifetime psychosocial burden are at higher risk for HDP.

  • A model that captures multiple domains of life stress may better predict HDP than a unimodal stress assessment.

Keywords

hypertensive disorders of pregnancy - preeclampsia - gestational hypertension - inflammation - psychosocial stress


Publication History

Received: 18 November 2019

Accepted: 07 May 2020

Article published online:
02 July 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Lo JO, Mission JF, Caughey AB. Hypertensive disease of pregnancy and maternal mortality. Curr Opin Obstet Gynecol 2013; 25 (02) 124-132
    CrossrefPubMedGoogle Scholar
  • 2 Wagner SJ, Barac S, Garovic VD. Hypertensive pregnancy disorders: current concepts. J Clin Hypertens (Greenwich) 2007; 9 (07) 560-566
    CrossrefPubMedGoogle Scholar
  • 3 Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet 2006; 367 (9516): 1066-1074
    CrossrefPubMedGoogle Scholar
  • 4 Say L, Chou D, Gemmill A. et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014; 2 (06) e323-e333
    CrossrefPubMedGoogle Scholar
  • 5 Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol 2015; 125 (01) 5-12
    CrossrefPubMedGoogle Scholar
  • 6 Folk DM. Hypertensive disorders of pregnancy: overview and current recommendations. J Midwifery Womens Health 2018; 63 (03) 289-300
    CrossrefPubMedGoogle Scholar
  • 7 Harmon QE, Huang L, Umbach DM. et al. Risk of fetal death with preeclampsia. Obstet Gynecol 2015; 125 (03) 628-635
    CrossrefPubMedGoogle Scholar
  • 8 McDonald SD, Malinowski A, Zhou Q, Yusuf S, Devereaux PJ. Cardiovascular sequelae of preeclampsia/eclampsia: a systematic review and meta-analyses. Am Heart J 2008; 156 (05) 918-930
    CrossrefPubMedGoogle Scholar
  • 9 Bartsch E, Medcalf KE, Park AL, Ray JG. ;High Risk of Pre-eclampsia Identification Group. Clinical risk factors for pre-eclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies. BMJ 2016; 353: i1753
    Google Scholar
  • 10 Wright D, Syngelaki A, Akolekar R, Poon LC, Nicolaides KH. Competing risks model in screening for preeclampsia by maternal characteristics and medical history. Am J Obstet Gynecol 2015; 213 (01) 62.e1-62.e10
    CrossrefPubMedGoogle Scholar
  • 11 National Collaborating Centre for Women's and Children's Health (UK). Hypertension in Pregnancy: The Management of Hypertensive Disorders during Pregnancy. London: RCOG Press; 2010
    Google Scholar
  • 12 Fisher SJ. Why is placentation abnormal in preeclampsia?. Am J Obstet Gynecol 2015; 213 (04) S115-S122
    CrossrefPubMedGoogle Scholar
  • 13 Harmon AC, Cornelius DC, Amaral LM. et al. The role of inflammation in the pathology of preeclampsia. Clin Sci (Lond) 2016; 130 (06) 409-419
    CrossrefPubMedGoogle Scholar
  • 14 Sargent IL, Germain SJ, Sacks GP, Kumar S, Redman CW. Trophoblast deportation and the maternal inflammatory response in pre-eclampsia. J Reprod Immunol 2003; 59 (02) 153-160
    CrossrefPubMedGoogle Scholar
  • 15 Redman CW, Sargent IL. Latest advances in understanding preeclampsia. Science 2005; 308 (5728): 1592-1594
    CrossrefPubMedGoogle Scholar
  • 16 Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. JAMA 2007; 298 (14) 1685-1687
    CrossrefPubMedGoogle Scholar
  • 17 Hobel CJ, Goldstein A, Barrett ES. Psychosocial stress and pregnancy outcome. Clin Obstet Gynecol 2008; 51 (02) 333-348
    CrossrefPubMedGoogle Scholar
  • 18 Spruill TM. Chronic psychosocial stress and hypertension. Curr Hypertens Rep 2010; 12 (01) 10-16
    CrossrefPubMedGoogle Scholar
  • 19 Sparrenberger F, Cichelero FT, Ascoli AM. et al. Does psychosocial stress cause hypertension? A systematic review of observational studies. J Hum Hypertens 2009; 23 (01) 12-19
    CrossrefPubMedGoogle Scholar
  • 20 Coussons-Read ME, Okun ML, Nettles CD. Psychosocial stress increases inflammatory markers and alters cytokine production across pregnancy. Brain Behav Immun 2007; 21 (03) 343-350
    CrossrefPubMedGoogle Scholar
  • 21 Paul K, Boutain D, Agnew K, Thomas J, Hitti J. The relationship between racial identity, income, stress and C-reactive protein among parous women: implications for preterm birth disparity research. J Natl Med Assoc 2008; 100 (05) 540-546
    CrossrefPubMedGoogle Scholar
  • 22 Tosun M, Celik H, Avci B, Yavuz E, Alper T, Malatyalioğlu E. Maternal and umbilical serum levels of interleukin-6, interleukin-8, and tumor necrosis factor-alpha in normal pregnancies and in pregnancies complicated by preeclampsia. J Matern Fetal Neonatal Med 2010; 23 (08) 880-886
    CrossrefPubMedGoogle Scholar
  • 23 Aggarwal R, Jain AK, Mittal P, Kohli M, Jawanjal P, Rath G. Association of pro- and anti-inflammatory cytokines in preeclampsia. J Clin Lab Anal 2019; 33 (04) e22834
    CrossrefPubMedGoogle Scholar
  • 24 Christian LM, Glaser R, Porter K, Iams JD. Stress-induced inflammatory responses in women: effects of race and pregnancy. Psychosom Med 2013; 75 (07) 658-669
    CrossrefPubMedGoogle Scholar
  • 25 Takiuti NH, Kahhale S, Zugaib M. Stress-related preeclampsia: an evolutionary maladaptation in exaggerated stress during pregnancy?. Med Hypotheses 2003; 60 (03) 328-331
    CrossrefPubMedGoogle Scholar
  • 26 Kurki T, Hiilesmaa V, Raitasalo R, Mattila H, Ylikorkala O. Depression and anxiety in early pregnancy and risk for preeclampsia. Obstet Gynecol 2000; 95 (04) 487-490
    PubMedGoogle Scholar
  • 27 Vollebregt KC, van der Wal MF, Wolf H, Vrijkotte TG, Boer K, Bonsel GJ. Is psychosocial stress in first ongoing pregnancies associated with pre-eclampsia and gestational hypertension?. BJOG 2008; 115 (05) 607-615
    CrossrefPubMedGoogle Scholar
  • 28 Cnossen JS, Vollebregt KC, de Vrieze N. et al. Accuracy of mean arterial pressure and blood pressure measurements in predicting pre-eclampsia: systematic review and meta-analysis. BMJ 2008; 336 (7653): 1117-1120
    CrossrefPubMedGoogle Scholar
  • 29 Andersson L, Sundström-Poromaa I, Wulff M, Aström M, Bixo M. Implications of antenatal depression and anxiety for obstetric outcome. Obstet Gynecol 2004; 104 (03) 467-476
    CrossrefPubMedGoogle Scholar
  • 30 Sikkema JM, Robles de Medina PG, Schaad RR. et al. Salivary cortisol levels and anxiety are not increased in women destined to develop preeclampsia. J Psychosom Res 2001; 50 (01) 45-49
    CrossrefPubMedGoogle Scholar
  • 31 Klonoff-Cohen HS, Cross JL, Pieper CF. Job stress and preeclampsia. Epidemiology 1996; 7 (03) 245-249
    CrossrefPubMedGoogle Scholar
  • 32 Landsbergis PA, Hatch MC. Psychosocial work stress and pregnancy-induced hypertension. Epidemiology 1996; 7 (04) 346-351
    CrossrefPubMedGoogle Scholar
  • 33 Yu Y, Zhang S, Wang G. et al. The combined association of psychosocial stress and chronic hypertension with preeclampsia. Am J Obstet Gynecol 2013; 209 (05) 438.e1-438.e12
    CrossrefPubMedGoogle Scholar
  • 34 Grobman WA, Parker CB, Willinger M. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b) Network*. Racial disparities in adverse pregnancy outcomes and psychosocial stress. Obstet Gynecol 2018; 131 (02) 328-335
    CrossrefPubMedGoogle Scholar
  • 35 Miller GE, Culhane J, Grobman W. et al. Mothers' childhood hardship forecasts adverse pregnancy outcomes: role of inflammatory, lifestyle, and psychosocial pathways. Brain Behav Immun 2017; 65: 11-19
    CrossrefPubMedGoogle Scholar
  • 36 McFarlane J, Hughes RB, Nosek MA, Groff JY, Swedlend N, Dolan Mullen P. Abuse assessment screen-disability (AAS-D): measuring frequency, type, and perpetrator of abuse toward women with physical disabilities. J Womens Health Gend Based Med 2001; 10 (09) 861-866
    CrossrefPubMedGoogle Scholar
  • 37 Corney RH, Clare AW. The construction, development and testing of a self-report questionnaire to identify social problems. Psychol Med 1985; 15 (03) 637-649
    CrossrefPubMedGoogle Scholar
  • 38 Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983; 24 (04) 385-396
    CrossrefPubMedGoogle Scholar
  • 39 Alderdice F, Savage-McGlynn E, Martin C. et al. The Prenatal Distress Questionnaire: an investigation of factor structure in a high risk population. J Reprod Infant Psychol 2013; 31: 456-464
    CrossrefPubMedGoogle Scholar
  • 40 Williams DR, Neighbors HW, Jackson JS. Racial/ethnic discrimination and health: findings from community studies. Am J Public Health 2003; 93 (02) 200-208
    CrossrefPubMedGoogle Scholar
  • 41 Irwin M, Artin KH, Oxman MN. Screening for depression in the older adult: criterion validity of the 10-item Center for Epidemiological Studies Depression Scale (CES-D). Arch Intern Med 1999; 159 (15) 1701-1704
    CrossrefPubMedGoogle Scholar
  • 42 ACOG Practice Bulletin No. ACOG practice bulletin no. 202: gestational hypertension and preeclampsia. Obstet Gynecol 2019; 133 (01) e1-e25
    Google Scholar
  • 43 Ross KM, Miller G, Culhane J. et al. Patterns of peripheral cytokine expression during pregnancy in two cohorts and associations with inflammatory markers in cord blood. Am J Reprod Immunol 2016; 76 (05) 406-414
    CrossrefPubMedGoogle Scholar
  • 44 Williams DR, Yan Yu, Jackson JS, Anderson NB. Racial differences in physical and mental health: socio-economic status, stress and discrimination. J Health Psychol 1997; 2 (03) 335-351
    CrossrefPubMedGoogle Scholar
  • 45 Ritter C, Hobfoll SE, Lavin J, Cameron RP, Hulsizer MR. Stress, psychosocial resources, and depressive symptomatology during pregnancy in low-income, inner-city women. Health Psychol 2000; 19 (06) 576-585
    CrossrefPubMedGoogle Scholar
  • 46 Greenwood JP, Scott EM, Walker JJ, Stoker JB, Mary DA. The magnitude of sympathetic hyperactivity in pregnancy-induced hypertension and preeclampsia. Am J Hypertens 2003; 16 (03) 194-199
    CrossrefPubMedGoogle Scholar
  • 47 Fischer T, Schobel HP, Frank H, Andreae M, Schneider KT, Heusser K. Pregnancy-induced sympathetic overactivity: a precursor of preeclampsia. Eur J Clin Invest 2004; 34 (06) 443-448
    CrossrefPubMedGoogle Scholar
  • 48 Schobel HP, Fischer T, Heuszer K, Geiger H, Schmieder RE. Preeclampsia -- a state of sympathetic overactivity. N Engl J Med 1996; 335 (20) 1480-1485
    CrossrefPubMedGoogle Scholar
  • 49 Leung TN, Chung TK, Madsen G. et al. Analysis of mid-trimester corticotrophin-releasing hormone and alpha-fetoprotein concentrations for predicting pre-eclampsia. Hum Reprod 2000; 15 (08) 1813-1818
    CrossrefPubMedGoogle Scholar
  • 50 Perkins AV, Linton EA, Eben F, Simpson J, Wolfe CD, Redman CW. Corticotrophin-releasing hormone and corticotrophin-releasing hormone binding protein in normal and pre-eclamptic human pregnancies. Br J Obstet Gynaecol 1995; 102 (02) 118-122
    CrossrefPubMedGoogle Scholar
  • 51 Austin MP, Leader L. Maternal stress and obstetric and infant outcomes: epidemiological findings and neuroendocrine mechanisms. Aust N Z J Obstet Gynaecol 2000; 40 (03) 331-337
    CrossrefPubMedGoogle Scholar