Stress Pathways to Spontaneous Preterm Birth: The Role of Stressors, Psychological Distress, and Stress Hormones

Abstract

The authors investigated a large number of stressors and measures of psychological distress in a multicenter, prospective cohort study of spontaneous preterm birth among 5,337 Montreal (Canada)-area women who delivered from October 1999 to April 2004. In addition, a nested case-control analysis (207 cases, 444 controls) was used to explore potential biologic pathways by analyzing maternal plasma corticotrophin-releasing hormone (CRH), placental histopathology, and (in a subset) maternal hair cortisol. Among the large number of stress and distress measures studied, only pregnancy-related anxiety was consistently and independently associated with spontaneous preterm birth (for values above the median, adjusted odds ratio = 1.8 (95% confidence interval: 1.3, 2.4)), with a dose-response relation across quartiles. The maternal plasma CRH concentration was significantly higher in cases than in controls in crude analyses but not after adjustment (for concentrations above the median, adjusted odds ratio = 1.1 (95% confidence interval: 0.8, 1.6)). In the subgroup (n = 117) of participants with a sufficient maternal hair sample, hair cortisol was positively associated with gestational age. Neither maternal plasma CRH, hair cortisol, nor placental histopathologic features of infection/inflammation, infarction, or maternal vasculopathy were significantly associated with pregnancy-related anxiety or any other stress or distress measure. The biologic pathways underlying stress-induced preterm birth remain poorly understood.

The Relationship between Prenatal Stress, Depression, Cortisol and Preterm Birth: A Review

“…Two studies examined the relationship between stress and cortisol only (Harville et al, 2009;Obel et al, 2004) while five studies only explored the relationship between cortisol and preterm birth (Campbell, Challis, DaSilva, & Bocking, 2005;Phocas, Sarandakou, & Rizos, 1990;Mazor et al, 1994Mazor et al, , 1996Sandman et al, 2006). Of the 22 articles seven determined the relationship between stress or depression, cortisol and preterm birth together at the same time (Diego et al, 2009;Erickson et al, 2001;Field et al, 2004Field et al, , 2006Hobel et al, 1999;Kramer et al, 2009;Shaikh et al, 2011).…”

“…The studies that examine the relationship between maternal stress, cortisol and preterm birth together at the same time have inconsistent findings (see Table 1) (Erickson et al, 2001;Hobel et al, 1999;Kramer et al, 2009;Ruiz et al, 2001;Shaikh et al, 2011). Few studies (Erickson et al, 2001;Hobel et al, 1999;Kramer et al, 2009) support the hypothesis that cortisol levels increase with maternal stress.…”

“…Few studies (Erickson et al, 2001;Hobel et al, 1999;Kramer et al, 2009) support the hypothesis that cortisol levels increase with maternal stress. However, the Ruiz et al (2001) study does not support the hypothesis that cortisol levels increases with stress, but it shows a significant relationship between stress and gestational age.…”

“…Hobel (1999) also conducted a prospective study in which 524 women of diverse ethnic and socioeconomic background were followed till delivery but only 18 women who delivered preterm were matched with 18 women who delivered at term. Moreover, Kramer, Lydon, et al (2009) prospectively recruited 5337 pregnant women of Montreal and conducted a nested case-control study. But, Ruiz et al (2001) conducted a prospective, longitudinal, observational study in which 78 women were recruited and followed till delivery and divided into three groups: normal term (n = 53), preterm labor (n = 17), and preterm birth groups (n = 6).…”

“…Preterm infants are also at a greater risk of serious health problems, such as cerebral palsy, blindness, breathing problems, and cognitive learning disabilities (Green et al, 2005;Latengresse, 2009;Rafati et al, 2005). Kramer et al (2009) stated that understanding the etiology of preterm birth will facilitate early identification of mothers at risk for preterm birth. Implementation of early intervention strategies for these high risk mothers will decrease preterm birth thereby reducing the burden of preterm birth (i.e., infant mortality, morbidity, postpartum depression, parental role stress, and financial stress).…”