Effect Of Perioperative Depression On Postpartum Recovery In Women Who Underwent Cesarean Section And Its Perioperative Intervention

Background and objectsCesarean is a unique surgical procedure.Puerpera experience both physical and emotional changes during long pregnancy and childbirth.When formulating the perioperative program for maternal women,in addition to their physical conditions and general surgical factors,doctors should also pay attention to their psychological factors.The most common perinatal psychological disorder that afflicts puerpera is perinatal depression,including antenatal depression(AD)and postpartum depression(PD).Perinatal depression affects maternal and infant outcomes and increases adverse perinatal events.According to the previous study,women with AD have a 7-fold higher risk of PD in postpartum than those without AD that increases the chance of cesarean section.The 10-item Edinburgh postpartum depression(EPDS-10)scales are commonly used for screening for perinatal depression but have not been used for assessment of preoperative AD and prediction of postoperative rehabilitation.Therefore,we first explored the relationship between EPDS-10 score and postoperative recovery quality of cesarean section by retrospective study,which provides psychological evidence for the prediction and evaluation of perioperative rehabilitation of cesarean section.Secondly,due to the lack of a laboratory diagnostic strategy,the identification of AD often requires a comprehensive clinical interview by a psychiatrist.Objective biomarkers that can be measured externally have been demonstrated to be good predictors of the personalized diagnosis and treatment of depression.For this purpose,metabolomics is currently a viable and widely used method for finding biomarkers for neuropsychological diseases.However,at present,studies using metabolomics to explore biomarkers of AD are lacking.Therefore,this study aimed to use metabolomics to find potential biomarkers related to AD in women who had undergone a cesarean section.Finally,the risk of postpartum depression after the cesarean section is significantly higher than that of vaginal delivery.Some studies have even found that these symptoms may continue for up to 2 years postpartum without prevention or treatment,and approximately 40% of affected women will have a relapse during their subsequent pregnancies.8 However,at present,studies regarding the prevention of postpartum depression for women patients undergoing cesarean section remain lacking.The preliminary study of our group found that tramadol PCIA can improve postpartum depression.Tramadol PCIA is an effective and well-tolerated agent for analgesia after cesarean section.Tramadol,a non-opioid central analgesic,has an inhibitory effect on the reuptake of norepinephrine and serotonin,indicating that it has the potential to reduce the risk of suffering from depression for puerperas.Postoperative analgesia using tramadol may be one of the ideal strategies for cesarean patients in the presence of analgesic and antidepressant demand.Therefore,we planned to investigate the effect of postoperative tramadol on postpartum depression in the cesarean section by randomized controlled double-blind trial.Part I: The effect of antenatal depression on the quality of postoperative recovery of cesarean women: an observational studyMethods:Following the inclusion and exclusion criteria,we retrospectively searched 300 women who underwent cesarean delivery at the second affiliated hospital of the army military medical university from September 2017 to January 2018.Data were first analyzed by multiple linear regression analysis to explore the relationship between preoperative EPDS scores and postoperative recovery quality.Then,the subjects were divided into two groups with a preoperative EPDS score of ?10.According to the factors affecting the quality of postoperative recovery,the propensity score matching(PSM)was performed between the two groups.After matching,the differences in recovery quality between the two groups after the cesarean section were compared.Results:The multiple linear regression analysis of this study showed a negative correlation between the EPDS-10 score and the QoR-15(recovery quality scale)(b'=-0.258,P<0.001).As the score of EPDS-10 increased and the degree of depression worsened,the QoR-15 score decreased.58 pairs of data being obtained after PSM,the results of the analysis showed that subjects with preoperative EPDS?10 had lower postoperative QoR-15 scores.In other words,a pregnant woman with a high risk of AD,the quality of recovery after the cesarean section will be worse than the risk of women without a high risk of AD.Conclusion:With the increase of EPDS-10 score before the cesarean section that means worsening of depression,the score of postoperative QoR-10 decreased which means decreased the quality of postoperative recovery.Part II: Biomarker Screening for Antenatal Depression in Women Who Underwent Caesarean Section: A Matched Observational Study with Plasma LipidomicsMethods:We screened single-pregnant women who were scheduled to undergo elective cesarean delivery at the second affiliated hospital of the army military medical university from May 2018 to August 2018.Qualified subjects were divided into the AD group and non-AD group according to whether had AD.Then,the two groups were matched 1:1 according to age(±1-year-old)and BMI(±1 kg/m2).Each group was eventually included in 30 subjects.Differential lipid expression between the two groups was analyzed by ultra-performance liquid chromatography-mass spectrometry(UPLC-MS)to find potential biomarkers associated with AD.Results:We screened a total of 484 pregnant women and finally recruited 66 subjects,including 33 subjects with severe prenatal depression and 33 subjects without severe antenatal depression.35 differentially expressed lipid metabolites were identified(P < 0.05).Among them,the area under ROC curve of the Cholesterol sulfate(CS)was 0.823(95% CI: 0.716-0.930),and the PC(18:2(2E,4E)/0:0)0.778(95% CI: 0.662-0.895).In conditional logistic stepwise regression analysis,CS(P = 0.009)and PC(18:2(2E,4E)/0:0)(P = 0.035)were also confirmed as effective predictors of risk factors for antenatal depression,especially CS may be a specific biomarker for AD.Conclusion:The up-regulation of CS and PC expression in plasma may be an effective and specific biomarker for predicting antenatal depression.Part III: a randomised,double-blind,placebo-controlled trial to explore the effect of tramadol in the prevention of postpartum depressionMethods:From September 2017 to June 2019,we recruited 1,230 cesarean delivery women who met the inclusion and exclusion criteria in the second affiliated hospital of the army military medical university.Considering the difference that the puerpera may have AD and no AD,we used a method of stratified block randomization according to whether the preoperative EPDS?10.Through a prospective,randomized,controlled,and double-blind study design,we randomly assigned eligible subjects to tramadol PCIA(T group),hydromorphone PCIA(H group),and ropivacaine PCEA(R group)postoperative analgesia groups at 1:1:1.Finally,the differences in the incidence of severe postpartum depression(PD)of three groups between the 4th week and the 3rd month after surgery were compared.Results:From September 27,2017 to September 5,2019,we included and followed a total of 1,230 eligible cesarean delivery cases.The incidence of major postpartum depression in the 4th week after surgery was 9.3%.Although the overall incidence of T(6.6%)was lower than H(10.2%)and R(10.5%),there was no significant difference between the T group and H group(P=0.118),the T group and the R group(P=0.092)after Bonferroni correction.In the subgroup analysis of patients with preoperative EPDS?10,the incidence of major PD in the T group was significantly lower than that in the H group(16[16.5%] vs 28[32.6%],OR 2.44;95% CI 1.21~4.93,P =0.011)and R group(16[16.5%] vs 29[30.9%],OR 2.26;95% CI 1.13~4.51,P =0.019).There is still a statistical difference after Bonferroni correction(P=0.022;P=0.038).The incidence of major PD was 7.9% in the third month after surgery,which was no significant difference for the overall and subgroup analyses in the three groups.Besides,the QoR-15 score of T-group(121.30±15.75)was significantly higher than that of the H group(118.36±17.39;Bonferroni corrected P=0.036)and R group(116.22±18.20;Bonferroni corrected P <0.001).There was no significant difference in sleep quality between the T group and the H group on the 1st and 2nd day after surgery(P =0.738;P =0.305),however,the T group was significantly better than the R group(P =0.009;P =0.002).Besides,the quality of sleep in the H group was significantly better than that in the R group(P =0.005),but there was no difference between the two groups on the 2nd day after surgery(P =0.073).Conclusions:The use of tramadol PCIA within 48 hours after surgery can effectively release the postoperative pain of the cesarean section,meanwhile can significantly improve the postpartum depression of woman who underwent a cesarean section.