Study On The Relationships Between Pregnancy Anxiety, Depression And Phthalates And Missed Abortion

Objective:1.This study aimed to estimate the mental health status of pregnant women,and analyze the effect of anxiety and depression on missed abortion during pregnancy.2.This study aimed to detect the levels of urinary phthalate metabolites in pregnant women,and explore the impact of phthalate on the risk of missed abortion.Methods:The cases included in the study were diagnosed as missed abortion and the control subjects were pregnant women with normal embryo development who were hospitalized in the obstetrical clinic at the same time.All cases and controls were collected from the First Affiliated Hospital of Shanxi Medical University in Taiyuan from June 2018 to January 2019.Every subject finished a questionnaire survey which included subject's demographics information(e.g.,age,registered permanent residence,BMI,gestational age,occupation,education level,and monthly household income,gravidity,etc.)and factors that may influence exposure to phthalate during pregnancy(e.g.,smoking,drinking,making up,plastic food containers,and decorating house,etc.).Each participant provided a spot urine sample 30ml.Self-rating anxiety scale(SAS),self-rating depression scale(SDS)and social support revalued scale(SSRS)were used to assess the psychological status and social support of pregnant women.Four urinary phthalate metabolites including monomethyl phthalate(MMP),monoethyl phthalate(MEP),monobutyl phthalate(MBP)and monobenzyl phthalate(MBzP),were determined by solid phase extraction-high performance liquid chromatography(SPE-HPLC).Urinary concentrations of phthalate metabolites were corrected for dilution by specific gravity(SG).Epi Data 3.1 was used to record questionnaire and establish database.The statistical analyses were performed using SPSS statistical software,version 23.0.In all analyses,a p-value of<0.05 was considered to be statistically significant.If the continuous data was normally distributed,the mean�standard deviation(?x�s)was used for statistical description,and the t-test was used for comparison between groups.If the continuous data was not normally distributed,the median and interquartile range(M and QR)were used for statistical description,and the Manny-Whitney U test was used for comparison between groups.Categorical data and grade data were expressed as numbers and frequencies,and?~2 test was used for comparison between groups.Logistic regression model was used to analyze the relationships between anxiety,depression,PAEs and missed abortion,and multivariate factor analysis of missed abortion was conducted.Results:1.Basic information of the subjectsA total of 271 pregnant women participated in this survey,including 123 cases,148controls.The results showed that cases were slightly older(t=-3.506,P=0.001)and had higher gravidity(?~2=14.289,P=0.001)compared to the controls.No one of 271women had smoke consumption during pregnancy.The significant differences in the occupation(?~2=16.881,P=0.005)and the use of plastic food containers(?~2=4.922,P=0.027)were observed between cases and the controls.There were no significant differences in BMI,gestational age,registered permanent residence,education level,monthly household income,drinking,drinking strong tea or coffee,making up,and decorating house between cases and controls(P all>0.05).2.Psychological state and social support of the subjects(1)The average score of anxiety in the cases was(44.27�7.95)and in the controls was(42.85�8.36).There was no statistically significant difference between the two groups(t=-1.426,P=0.155).The total detection rate of anxiety was 25.20%(31/123)in the case group and and that in the control group was 20.27%(30/148).There was no significant difference in anxiety level between the case group and the control group(?~2=1.613,P=0.453).Through factor analysis,SAS indexes were classified as anxiety-motor stress factor,anxiety-emotional disorder factor,anxiety-neurologic dysfunction factor and anxiety-physical disorder factor.The scores of each factor were analyzed,and it was found that the anxiety-motor stress factor scores in the case group were higher compared to the controls(t=-3.242,P=0.001).Furthermore,the logistic analysis adjusted by demographic factors revealed that anxiety-motor stress factor was a risk factor for missed abortion(adjusted OR=1.44,95%CI=1.09-1.89).(2)The average score of depression in the cases was(49.03�11.45)and in the controls was(46.19�11.10).There was statistically significant difference between the two groups(t=-2.069,P=0.039).The total detection rate of depression in the case group was 45.53%(56/123)and that in the control group was 29.73%(44/148).There was significant difference in depression level between the case group and the control group(?~2=9.534,P=0.014).Through factor analysis,SDS indexes were classified as depression-mental inhibition factor,depression-emotional disorder factor and depression-physical disorder factor.The scores of each factor were analyzed,and it was found that the depression-emotional disorder factor scores in the case group were higher compared to the controls(t=-3.658,P<0.001).Furthermore,the logistic analysis adjusted by demographic factors revealed that depression-emotional disorder factor was a risk factor for missed abortion(adjusted OR=1.61,95%CI=1.21-2.14).(3)The total score of social support in the cases was(40.28�6.73)and in the controls was(41.75�6.52).There was no statistically significant difference between the two groups(t=1.814,P=0.071).However,the differences of scores between the case group and the control group in the two dimensions of subjective support(t=1.997,P=0.047)and social support utilization(t=3.265,P=0.001)were statistically significant.There was no significant difference in the level of social support between the cases and the controls(?~2=0.422,P=0.516).Furthermore,the logistic analysis adjusted by demographic factors revealed that subjective support was a protection factor for missed abortion(adjusted OR=0.85,95%CI=0.74-0.98).(4)Statistically significant factors such as age,gravidity,occupation,plastic food containers,anxiety-motor stress factor,depression-emotional disorder factor,and subjective support were introduced into multivariate logistic regression model,and it was found that the older,the more susceptible to missed abortion(OR=1.09,95%CI=1.02-1.17).The risk of missed abortion when using plastic food containers was 1.85times that when not using plastic food containers(OR=1.85,95%CI=1.08-3.18).Anxiety-motor stress factor(OR=1.39,95%CI=1.05-1.84)and depression-emotional disorder factor(OR=1.47,95%CI=1.10-1.95)were risk factors for missed abortion.3.Urinary phthalate metabolite levels in subjects(1)The detection frequencies of four phthalate metabolites were in the following decreasing order:MEP>MBP>MBzP>MMP.The level of our phthalate metabolites in urine samples were in the following decreasing order:MEP>MMP>MBzP>MBP.Both unadjusted and SG-adjusted MMP(Z=-3.898,P<0.001;Z=-3.116,P=0.002)and MBP(Z=-2.198,P=0.028;Z=-2.192,P=0.028)concentrations were higher in cases than in controls.(2)The Kendall's tau-b correlation analysis found that the use of plastic food containers during pregnancy was associated with MMP(r=0.196,P<0.001)and MEP(r=0.099,P=0.046)concentrations.The consumption of drinking,drinking strong tea or coffee,making up and decorating house were not associated with the urinary phthalate metabolite concentrations(P all>0.05).(3)The logistic analysis of phthalate metabolite concentrations and missed abortion revealed that each one-unit increase of MMP adjusted for demographic factors and log-transformed,the risk of missed abortion increased by 37%(adjusted OR=1.37,95%CI=1.07-1.77).When we stratified the phthalate metabolite concentrations in urine into quartiles(Q),the third quartiles(Q3)of MMP(adjusted OR=2.74,95%CI=1.24-6.03)and MBzP(adjusted OR=2.22,95%CI=1.01-4.89)increased the possibility of missed abortion compared to the lowest quartiles(Q1).(4)The statistically significant factors of the first part and the second part were introduced into the multivariate logistic regression model,and it was found that the older,the more susceptible to missed abortion(OR=1.10,95%CI=1.04-1.17).Anxiety-motor stress factor(OR=1.40,95%CI=1.07-1.83),depression-emotional disorder factor(OR=1.54,95%CI=1.17-2.02)and MMP(OR=1.37,95%CI=1.07-1.75)were risk factors for missed abortion.(5)The results of interaction showed that there was no interaction between anxiety and MMP exposure,and the relative excess risk due to interaction(RERI)=-1.14(95%CI=-3.87-1.59),the attributable proportion due to interaction(AP)=-0.39(95%CI=-1.52-0.73),the synergy index(S)=0.62(95%CI=0.19-2.01).There was no interaction between depression and MMP exposure,and the relative excess risk due to interaction(RERI)=-0.02(95%CI=-3.25-3.20),the attributable proportion due to interaction(AP)=-0.01(95%CI=-0.68-0.67),the synergy index(S)=0.99(95%CI=0.42-2.33).Conclusions:(1)The detection rate of anxiety and depression in pregnant women was relatively high.Anxiety and depression during pregnancy may increase the risk of missed abortion.(2)Phthalate exposures were widespread in pregnant women,and MMP was an independent risk factor for missed abortion.