Psychiatric Caseness And Its Obstetric Correlates In Pregnant Population Attending Antenatal Clinic In TUTH

Background: Prevalence rates for psychiatric disorders during pregnancy have been found to range from 6-13%. Psychiatric caseness during pregnancy not only affects the mother but also affects the health and development of the child. Various factors have been found to be associated with psychiatric caseness in different cultural and social settings including obstetric history. Objective: To evaluate the relation of obstetric history in pregnant population with psychiatric caseness. Methods: This is a cross sectional study with a total of 300 sample collected within 6 months in antenatal clinic of obstetric OPD, TUTH using semi-structured proforma and SRQ-24. Results: 15% of the pregnant women could be labeled as psychiatric cases. Trimester and, complication during current pregnancy showed statistically significant association with psychiatric caseness. Conclusion: As 15% of pregnant ANC attendees were found to be having psychiatric illness, it can be recommended that pregnant females be routinely screened for the possibility of psychiatric caseness especially if it is the first trimester or complication during this pregnancy is noted.


INTRODUCTION
Prevalence rates for psychiatric disorders during pregnancy have been found to range from 6-13%. 1,2,3,4Women are consistently found to have higher rates of mental illness than men. 5 Even among females, differences between the rates of psychiatric illness between non-pregnant and pregnant population exists.Pregnancy, parturition (childbirth or delivery), and the postpartum period involve a series of tightly orchestrated hormonal events that create the potential for unique psychological states.Pregnancy is not only a biological event, but also an adaptive process as well.Hence, the psychopathology of pregnancy must be understood in terms of adjustment which all women must make when they conceive. 6Obstetric factors have been studied in relation to psychiatric caseness.It has been seen that trimester of pregnancy affects the rates of psychiatric symptoms, with some studies suggesting an exacerbation of psychiatric disorders in the first 2 trimesters of pregnancy. 7History of induced abortion was also a risk factor for psychiatric disturbance in pregnancy.Pregnancy complications were also associated with significantly higher risk of psychiatric morbidity in pregnant women. 8A higher risk was associated with adverse reproductive events including unwanted or unintended pregnancy, past pregnancy losses, coincidental illness and operative birth. 9Some studies 10,11 found higher prevalence of psychiatric illness among pregnant women who had three or more children.

MATERIAL AND METHOD
This was a cross sectional study.Samples were collected from obstetric Out Patient Department (OPD) in the antenatal clinic of Tribhuvan University Teaching Hospital (TUTH) within the duration of 6 months Original Article between 1 st Jestha, 2070 and 29 th Kartik, 2070.25% of the patient attending OPD in previous registers maintained in the OPD was calculated to be 300 which was taken as sample size.Semi-structured proforma was used to record the socio-demographic parameters.In obstetric history, number of pregnancies, last menstrual period, complications during present pregnancy, whether pregnancy was planned or not, complications during past delivery, loss of any previous pregnancies, death of a child, number of daughters was asked about.SRQ-24 was used to screen for psychiatric caseness with score of more than 10 taken as cut off as suggested in a previous study 12 .Epi While evaluating occupation, it was seen that 65 percent were housewives, 11 percent student, 9.7 percent were in service, 9.3 percent were involved in some type of business and 5 percent were in other occupation.Taking the cut off score of 11 or more to be cases, it was seen that 85 percent were noncases and 15 percent could be labeled as psychiatric caseness.19% of those who had planned their pregnancy and 13.9% of those who had not planned their pregnancy were cases.

DISCUSSION
In the total sample, 45 (15%) were cases and 255 (85%) were non-cases.This is comparable to findings from other studies 1,2,3,4 .30.8% of first trimester sample were cases whereas only 24.5% of second trimester and 8.6% of third trimester were cases.This was found to be statistically significant with p value of 0.00.So, there is higher chance of a pregnant female being a case in the first trimester.Clinical studies 7 have suggested that trimester of pregnancy affects the rates of psychiatric symptoms, with some studies suggesting an exacerbation of psychiatric disorders in the first 2 trimesters of pregnancy.The finding of this study can be justified when 21 we consider that the first trimester is a time when the pregnant mother is still adjusting to the news of her pregnancy and the subsequent responsibilities it signifies.It can be hypothesized that news of pregnancy acted as a stressor which resulted in subsequent reaction to stress that has both psychological and physical symptoms which have been picked up by the questionnaire and represented as cases.Hence, this could have resulted in the significant association found between first trimester and psychiatric caseness.Among cases, 46.7% were primi gravida, 37.8% were gravida 2, 8.9% were gravida 3 and 6.7% were gravida 4 which is comparable to sample percentages and shows no statistical significance.Some studies 10, 11 have however found higher prevalence of psychiatric illness among pregnant women who had three or more children which also reflects gravidity of a pregnant mother.Among cases, 73.3% were planned and 26.7% were unplanned which is proportionate to the sample and was not found to be statistically significant.As all the cases were married in this study, even though the pregnancy was unplanned, there is greater support and shared burden which could explain less association with psychiatric illness than shown in some studies 13,14 .6.7% of the sample had complications during this pregnancy.35% of those with complication during this pregnancy were cases whereas only 13.6% of those without complication during this pregnancy were cases.This was found to be statistically significant with p value of 0.01 which was also seen in another study where reporting pregnancy complications were associated with higher rates of psychiatric disorders in pastyear pregnant women 15 .18% of sample had abortions or stillbirths in the past pregnancies.20.4% of those with positive history of pregnancy loss were cases and 13.8% of those without history of loss of pregnancies were cases but this was not found to be statistically significant.15.4% of those with negative history and 10% of those with positive history of complication during previous delivery were cases and this was not statistically significant.A reason for this finding in this study could be that receiving care in a tertiary care hospital might have reassured the females of better care and hence less psychological upheaval.However, reason for this finding needs to be further researched.Limitation for this study is that as this is from a single centre without a control group, it is difficult to generalize the result in the general population.

CONCLUSION
Perinatal psychiatric illness carries a great deal of importance because it affects not just the mother but also the health and development of the child.Results obtained from the study showed that 15% of the sample population could be labeled as psychiatric caseness which was comparable to the results obtained from other lower and middle income countries.This study also found that those who were in the first trimester and those who had complications during the present pregnancy had statistically significant association with psychiatric caseness.As the percentage of those with psychiatric caseness is significant, it can be recommended that pregnant females be routinely screened for the possibility of psychiatric caseness and even more so if the factors that have been listed above are present in the history so that those symptoms can be addressed and worsening of these symptoms in the postpartum period prevented.

Table 1 . Age Distribution
RESULT