Pregnancy

Women in their late 30s to early 40s who have difficulty conceiving are often unaware that success rates of fertility treatment decline with age, most commonly due to declining ovarian function. Counseling about the high prevalence of infertility and miscarriage may be met with surprise and sadness. Reports of children born to high-profile women older than 50 years may contribute to misconceptions, but these births highlighted in the media were likely achieved with donor oocytes from a younger woman or with oocytes or embryos that were previously cryopreserved. Consistent with declining fertility rates worldwide,1 the fertility rate in the US has declined from 70.9 births per 1000 women in 1990 to 56.1 per 1000 in 2022.2 Simultaneously, the 2019 US Census reported that age at first birth had risen from 27 years in 1990 to 30 years in 2019 as more women postponed first birth.

Reasons for these trends may include lack of a partner, economic insecurity, career aspirations, and long work hours. Concerns about childbearing discrimination, including lack of pregnancy and postpartum support, and childcare challenges also likely influence decisions to delay pregnancy. Results of a questionnaire completed by 5692 US general surgery residents reported that more female than male residents delayed pregnancy because of training (46.8% vs 32.7%; P < .001) and experienced pregnancy/parenthood-based mistreatment (58.1% vs 30.5%; P < .001).3

Introduction: Existing guidelines for primary care clinicians (PCCs) on the detection and management of perinatal depression (PD) contain important gaps. This review aims to provide PCCs with a summary of clinically relevant evidence in the field.

Methods: A narrative literature review was conducted by searching PubMed and PsycINFO for articles published between 2010 to 2023. Guidelines, systematic reviews, clinical trials, and/or observational studies were all examined.

Results: Screening with the Edinburgh Postnatal Depression Scale or Patient Health Questionnaire-9 followed by a diagnostic evaluation for major depressive disorder in probable cases can enhance PD detection. At-risk individuals and mild to moderate PD should be referred for cognitive behavioral therapy or interpersonal psychotherapy when available. Selective serotonin reuptake inhibitors should be used for moderate to severe PD, with sertraline, escitalopram, or citalopram being preferred first. Using paroxetine or clomipramine in pregnancy, and fluoxetine or doxepin during lactation is generally not preferred. Gestational antidepressant use is associated with a small increase in risk of reduced gestational age at birth, low birth weight, and lower APGAR scores, though whether these links are causal is unclear. Sertraline and paroxetine have the lowest rate of adverse events during lactation. Consequences of untreated PD can include maternal and offspring mortality, perinatal complications, poor maternal-infant attachment, child morbidity and maltreatment, less breastfeeding, and offspring developmental problems.

Conclusions: These clinically relevant data can support the delivery of high-quality care by PCCs. Risks and benefits of PD treatments and the consequences of untreated PD should be discussed with patients to support informed decision making.

Importance: Anxiety disorders are commonly occurring mental health conditions. They are often unrecognized in primary care settings and substantial delays in treatment initiation occur.

Objective: The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for anxiety disorders in asymptomatic adults.

Population: Asymptomatic adults 19 years or older, including pregnant and postpartum persons. Older adults are defined as those 65 years or older.

Evidence assessment: The USPSTF concludes with moderate certainty that screening for anxiety disorders in adults, including pregnant and postpartum persons, has a moderate net benefit. The USPSTF concludes that the evidence is insufficient on screening for anxiety disorders in older adults.

Recommendation: The USPSTF recommends screening for anxiety disorders in adults, including pregnant and postpartum persons. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for anxiety disorders in older adults. (I statement).

Importance: Gestational diabetes is diabetes that develops during pregnancy. Prevalence of gestational diabetes in the US has been estimated at 5.8% to 9.2%, based on traditional diagnostic criteria, although it may be higher if more inclusive criteria are used. Pregnant persons with gestational diabetes are at increased risk for maternal and fetal complications, including preeclampsia, fetal macrosomia (which can cause shoulder dystocia and birth injury), and neonatal hypoglycemia. Gestational diabetes has also been associated with an increased risk of several long-term health outcomes in pregnant persons and intermediate outcomes in their offspring.

Objective: The USPSTF commissioned a systematic review to evaluate the accuracy, benefits, and harms of screening for gestational diabetes and the benefits and harms of treatment for the pregnant person and infant.

Population: Pregnant persons who have not been previously diagnosed with type 1 or type 2 diabetes.

Evidence assessment: The USPSTF concludes with moderate certainty that there is a moderate net benefit to screening for gestational diabetes at 24 weeks of gestation or after to improve maternal and fetal outcomes. The USPSTF concludes that the evidence on screening for gestational diabetes before 24 weeks of gestation is insufficient, and the balance of benefits and harms of screening cannot be determined.

Recommendation: The USPSTF recommends screening for gestational diabetes in asymptomatic pregnant persons at 24 weeks of gestation or after. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for gestational diabetes in asymptomatic pregnant persons before 24 weeks of gestation. (I statement).