Journals Watch - Pregnancy care and depression

Too busy to read all the journals? Let Dr Suzanne Hunter keep you up to date with the latest research.

Ultrasound of a mid-term pregnancy, iron supplementation in mild anaemia may not benefit the mother
Ultrasound of a mid-term pregnancy, iron supplementation in mild anaemia may not benefit the mother

Iron supplementation in mid-pregnancy Am J Obstet Gynecol 2009; 201: 158-60
I have always been wary of iron supplementation in pregnancy. This paper raises some interesting points, although I am not entirely convinved by this study.

This study started off observing that iron is a strong pro-oxidant and influences glucose metabolism. The authors compared rates of gestational diabetes and the metabolic syndrome in pregnant women taking iron supplementation with women not taking iron.

Those taking iron had higher pre-pregnancy BMIs, actual BMIs, waist circumference, BP, fasting glucose, insulin resistance and lower HDL levels.

Hypertension occurred 2.5 times more frequently in those taking iron and gestational diabetes almost twice as often. Where I have a problem is that the study does not look at causality although, interestingly, iron supplementation did give higher glucose levels on the glucose tolerance test in normoglycaemic women.

There may well be a connection and I would use this study as a shot across the bows when it comes to the almost routine prescribing of iron supplementation in mild anaemia in pregnancy.

GPs are not over-prescribing antidepressants Br J Gen Pract 2009; 59: 644-9
Antidepressant prescribing has risen steadily since the 1990s, despite a lack of evidence of increasing prevalence of depression or changes in patient behaviour.

The assumption has therefore been that GPs are over prescribing and a policy has even been made in Scotland to reduce this prescribing.

This study looked at patients coming into four practices over five days and issued each patient with a Hospital Anxiety and Depression Scale questionnaire in the waiting room.

The GPs were then asked to independently assess the patient's depression status and finally the notes were examined for antidepressant usage.

The results certainly went against the current assumed wisdom. The GPs were actually rather cautious about diagnosing depression, diagnosing it in 52 per cent of those with a clinically significant episode. There was no real evidence of antidepressant prescribing without a valid reason.

It seems to me that the increase in prescribing has come from an increase in recognition of depression, and any efforts to limit prescribing could have a deleterious effect on patient care.

GPs' views on antidepressant prescribing Br J Gen Pract 2009; 59: 658-9
This qualitative interview study put the question of why antidepressant prescribing has increased so much to a panel of Scottish GPs. GPs from 30 practices were interviewed.

The GPs were well aware of the increase in antidepressant prescribing and the negative publicity surrounding it. A number of themes arose, mostly of an external nature.

It was felt that campaigns, such as Defeat Depression, increase GPs' awareness, and also patients' willingness to seek help. The introduction of SSRIs has made treatment safer, especially in the absence of available alternatives.

The medicalisation of life's unhappiness and the expectation that GPs should do something about it have also contributed, as has previous media hounding of GPs for missing depression. The GPs seemed frustrated at this situation.

The GPs see themselves as responding to change rather than facilitating it.

Emergency contraception use and future risk Am J Obstet Gynecol 2009; 201: 146-7
It has been hypothesised that women who use emergency contraception are at higher risk of pregnancy and STIs.

However, this survey analysing a group of participants from a trial of advanced provision of emergency contraception found no association between use of emergency contraception and either pregnancy or infection.

It compared women who had used emergency contraception with a control group that had not and found them no more likely to get pregnant or have an STI in the subsequent 12 months.

The authors suggest clinical efforts should focus on improving risk communication, giving clear instructions on effective contraceptive use, and improving the identification of high-risk adolescents prior to the initiation of sexual activity.

Late recognition of pregnancy Am J Obstet Gynecol 2009; 201: 156-8
About a third of pregnancies are unplanned and thus unexpected. An unexpected pregnancy may lead to a delay in recognising the symptoms of pregnancy and risky behaviour may continue (for example, smoking and drinking) while the developing fetus is at its most vulnerable.

This study examined the proportion of pregnancies that had a delayed recognition (here defined as after six weeks gestation) and whether there were any risks associated with this. The researchers looked at birth outcomes such as premature birth, low birth weight and admission to the neonatal intensive care unit.

They found that 27 per cent of pregnancies had a delayed recognition. Late recognition of pregnancy was associated with a slightly greater risk of prematurity (odds ratio 1.09) and of the baby needing neonatal intensive care (odds ratio 1.12).

The authors conclude that these results provide an impetus for promoting early recognition of pregnancy but I am not sure how public health messages would affect this.

  • Dr Hunter is a GP in Bishops Waltham, Hampshire and a member of our team who regularly review the journals

THE QUICK STUDY

  • Iron supplementation used during pregnancy may interfere with glucose metabolism.
  • Antidepressants are not prescribed too frequently.
  • Prescribing increases for antidepressants are due to external influences, GPs believe.
  • Emergency contraception is not associated with an increased risk of future pregnancy or STI.
  • Premature births can be associated with late recognition of the pregnancy.

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