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PubMed2001

Screening for postnatal depression: are specific instruments mandatory?

BACKGROUND: Few studies have examined the utility of rating scales developed in non-puerperal context in detecting postnatal depression. This study evaluated the utility of the General Health Questionnaire (GHQ) and the Beck Depression Inventory (BDI) in screening for depression among recently delivered women in Hong Kong. METHODS: A prospective cohort of 145 Chinese women completed the GHQ, BDI and Edinburgh Postnatal Depression Scale (EPDS) 6 weeks after delivery. They were then assessed using the non-patient version of the Structured Clinical Interview for DSM-III-R (SCID-NP) to establish psychiatric diagnosis, against which the criterion validity of the GHQ and BDI was evaluated against this clinical diagnosis. The psychometric performance of the GHQ, BDI and EPDS in detecting postnatal depression was assessed using the receiver operating characteristic (ROC) curves. RESULTS: Both Chinese GHQ and BDI had satisfactory sensitivity and positive predictive value in detecting postnatal depression. Their receiver operating characteristic (ROC) curves were comparable to that of the EPDS. LIMITATION: The study was conducted in Chinese women using translated version of the rating scales. CONCLUSIONS: The GHQ and BDI are useful for detecting postnatal depression among recently delivered Chinese women. The results of this study suggest that rating scales developed in non-puerperal context may also be applicable for postnatal depression.

Adolescent↗
PubMed2001

Infant massage improves mother-infant interaction for mothers with postnatal depression.

BACKGROUND: Postnatal depression can have long term adverse consequences for the mother-infant relationship and the infant's development. Improving a mother's depression per se has been found to have little impact on mother-infant interaction. The aims of this study were to determine whether attending regular massage classes could reduce maternal depression and also improve the quality of mother-infant interaction. METHOD: Thirty-four primiparous depressed mothers, median 9 weeks postpartum, identified as being depressed following completion of the Edinburgh Postnatal Depression Scale (EPDS) at 4 weeks postpartum, were randomly allocated either to an infant massage class and a support group (massage group) or to a support group (control group). Each group attended for five weekly sessions. Changes in maternal depression and mother-infant interaction were assessed at the beginning and the end of the study by comparing EPDS scores and ratings of videotaped mother-infant interaction. RESULTS: The EPDS scores fell in both groups. Significant improvement of mother-infant interaction was seen only in the massage group. LIMITATION: The sample size was small and had relatively high dropout. It was not possible to distinguish which aspects of the infant massage class contributed to the benefit. CONCLUSION: This study suggests that learning the practice of infant massage by mothers is an effective treatment for facilitating mother-infant interaction in mothers with postnatal depression.

Adolescent↗
PubMed1999

The glutamate and carbachol effects on the early post-denervation depolarization in rat diaphragm are directed towards furosemide-sensitive chloride transport.

The membrane potentials of denervated muscle fibres of the rat diaphragm kept in a tissue culture medium are depolarized by about 8-10 mV (10-12%) within 3 h after denervation. This early post-denervation depolarization (EPD) is substantially reduced (2-3 mV) when muscle strips are bathed with 1 mM L-glutamate (GLU) which is found in motor nerve endings, or with 5 x 10(-8) M carbachol (CCh), which mimics the effect of nonquantally released acetylcholine (ACh). The hyperpolarizing effects of GLU and CCh on EPD are not influenced by ouabain, an active sodium transport inhibitor, but are absent when Cl- transport is augmented by increased osmolarity (500 mosmol/l) produced by addition of sucrose or NaCl. The EPD and the effect of hyperosmolarity are effectively prevented by the Cl- transport inhibitor furosemide (1 x 10(-4) M) or by a chloride-free bathing medium. It is suggested that the post-denervation cessation of nonquantal ACh release, and probably also GLU release, from nerve endings leads to the activation of the furosemide-sensitive Cl- transport in the sarcolemma, which is responsible for the early post-denervation depolarization.

Animals↗
PubMed2004

Domestic violence: prevalence in pregnant women and associations with physical and psychological health.

OBJECTIVES: To examine the prevalence of domestic violence (DV) and its associations with obstetric complications and psychological health in women on antenatal and postnatal wards. STUDY DESIGN: A cross-sectional survey conducted in an inner-London teaching hospital. Two hundred English-speaking women aged 16 and over, were interviewed between July 2001 and April 2002. The Abuse Assessment Screen was used to assess for experiences of DV. Depression was assessed using the Edinburgh Postnatal Depression Scale (EPDS). The analysis of predictors of obstetric complications grouped together those known to be associated with DV. RESULTS: 23.5% of women had lifetime experience of DV, 3% during the current pregnancy. Women with a history of DV were significantly more likely to be single, separated or in non-cohabiting relationship and to have smoked in the year prior to and/or during pregnancy. Higher EPDS scores were significantly associated with DV, single, separated or non-cohabiting status, and obstetric complications. Both a history of DV and increased EPDS scores were significantly associated with obstetric complications after controlling for other known risk factors. CONCLUSIONS: Domestic violence is regarded as an important risk marker for the development of obstetric complications and depressive symptomatology. This finding of itself justifies training and education of maternity health professionals to raise awareness.

Adolescent↗
PubMed2000

Criterion validation of the Edinburgh postnatal depression scale as a screening tool for depression in patients with advanced metastatic cancer.

It is estimated that 25% of palliative care patients will have identifiable symptoms of depression. Near the end of life, the distinction between what can be called "appropriate sadness" and depression may be difficult. Many palliative care units use rating scales to help identify patients who may be depressed. It is believed that symptoms such as guilt, worthlessness, and hopelessness may be more discriminating than other symptoms for depression within this population. The Edinburgh postnatal depression scale (EPDS) was devised for use in women in the postnatal period and does not contain any somatic-type symptoms. It consists of 10 items, each rated on a four-point scale, and includes items on guilt, thoughts of self-harm, and hopelessness. It has not previously been used for screening in cancer patients. In a study of 100 inpatients receiving palliative care, a cutoff of 13 on the EPDS had a sensitivity of 81% and a specificity of 79% for detecting cases of depression. There was a low rate of misclassifications. This study suggests that the EPDS may be useful as a screening instrument for palliative care patients.

Adult↗
PubMed1999

The role of pterins and related factors in the biology of early postpartum depression.

Plasma tryptophan and other putative amino acids, cortisol, folate and vitamin B12 and urinary biopterin (B) and neopterins (N) were measured in three groups of women: 62 women in the early postpartum period, 23 pregnant and 38 non-gravid controls. Sixty-two postpartum women were screened for depression by the Edinburgh postnatal depression scale (EPDS) on day 7 after delivery. Postpartum women had significantly lower tryptophan, vitamin B12 and significantly greater levels of cortisol, folate, neopterins and biopterins than controls. Comparisons between women who were classified on the EPDS as cases and non-cases revealed only a statistically significant difference for lower N:B (P<0.01) and lower folate (P<0.01) ratio in cases than non-cases. Multiple regression analysis showed a significant contribution for low tryptophan to increased EPDS which also showed significant correlations with low methionine, low tyrosine, low N:B ratio and high vitamin B12.

Adult↗
PubMed2002

Composite electrochemical biosensors: a comparison of three different electrode matrices for the construction of amperometric tyrosinase biosensors.

A comparison of the behaviour of three different rigid composite matrices for the construction of amperometric tyrosinase biosensors, which are widely used for the detection of phenolic compounds, is reported. The composite electrode matrices were, graphite-Teflon; reticulated vitreous carbon (RVC)-epoxy resin; and graphite-ethylene/propylene/diene (EPD) terpolymer. After optimization of the experimental conditions, different aspects regarding the stability of the three composite tyrosinase electrode designs were considered and compared. A better reproducibility of the amperometric responses was found with the graphite-EPD electrodes, whereas a longer useful lifetime was observed for the graphite-Teflon electrodes. The kinetic parameters of the tyrosinase reaction were calculated for eight different phenolic compounds, as well as their corresponding calibration plots. The general trend in sensitivity was graphite-EPD>graphite-Teflon>>RVC-epoxy resin. A correlation between sensitivity and the catalytic efficiency of the enzyme reaction for each phenolic substrate was found. Furthermore, differences in the sensitivity order for the phenolic compounds were observed among the three biocomposite electrodes, which suggests that the nature of the electrode matrix influences the interactions in the tyrosinase catalytic cycle.

Biosensing Techniques↗
PubMed1986

Faecal egg counts and nematode fecundity: Heligmosomoides polygyrus and laboratory mice.

The results are presented of an experimental investigation of the relationship between faecal egg counts and worm burden in outbred MF1 mice infected with Heligmosomoides polygyrus (Nematoda). The sex-ratio of the adult parasites was found to be significantly female biased, but independent of parasite burden. Evidence was also found to suggest a significant association between parasite density and mating success. The linear logarithmic relationship (gradient of approximately 2) between the variance and mean of repeated egg counts from individual mice could not be disrupted by controlled experimental conditions, and is therefore concluded to be an inherent feature of the biology of helminth-host interactions. A significant positive association was detected between host faecal output and parasite fecundity; further investigation of the cause of this association is now required. Average faecal production was found to be inversely related to worm burden. In combination, the above two factors account partly, but not completely, for the observed density dependence in the absolute rate of parasite egg production. Two epidemiological consequences of the relationship between faecal production and parasite fecundity are discussed. First, absolute rates of egg production can only be estimated by temporal egg counts (epd). Secondly, measurements of egg production/g of faecal material (epg) are more reliable indicators of worm burden than measurements of epd. Both faecal output and worm fecundity respond as might be predicted to a period of host food deprivation; faecal egestion and measurements of epd are significantly depressed, and measurements of epg are significantly increased. The data are consistent with the hypothesis that egg production and faecal output are causally associated, but that other factors relating to parasite density also influence egg production. Of the possible causes for the high variability in parasite egg production between mice harbouring low number of worms, the most likely explanation seems to be host heterogeneity (possible genetic in origin). This is discussed in relation to similar patterns observed in data collected from human populations in areas of endemic helminth infection.

Analysis of Variance↗
PubMed1996

Post-natal depression in an urban area of Portugal: comparison of childbearing women and matched controls.

The point prevalence of depression measured on one occasion between 2 and 5 months after childbirth was estimated to be 13.1% in 352 mothers living in urban Portugal; the criterion was a score of 13 or more on a translated version of the Edinburgh Post-natal Depression Scale (EPDS). More detailed comparisons were made between a subgroup of 118 mothers and 118 matched controls who had not borne a child in the previous 2 years. Post-natal women were twice as likely as non-childbearing controls to meet the EPDS criterion for depression In comparison with controls, they were also more severely depressed as judged by their total scores on another questionnaire, the Zung Scale. Comparisons of individual symptom scores (Zung Scale) showed that childbearing women, as a whole, reported more somatic symptoms than controls, but when only those women judged to be depressed or dysphoric by the EPDS were compared, this difference disappeared. Stepwise logistic analyses of symptoms contributing to the categorization of a 'case' of post-natal versus non-post- natal depression did not reveal any very clear divergences in self-reported psychopathology. In childbearing women, two factors were found significantly to contribute to higher depression scores; women with more children and those from lower socio-economic groups were most at risk.

Adult↗
PubMed2001

CEA and CA 19-9 measurement as a monitoring parameter in metastatic colorectal cancer (CRC) under palliative first-line chemotherapy with weekly 24-hour infusion of high-dose 5-fluorouracil (5-FU) and folinic acid (FA).

BACKGROUND: There have been contradictory reports on the benefit of CEA and CA 19-9 measurements in patients with metastatic colorectal cancer using palliative chemotherapy. The object of this study was to examine the diagnostic accuracy of monitoring of palliative chemotherapy by means of CEA and CA 19-9. PATIENTS AND METHODS: The tumour markers CEA and CA 19-9 were subjected to serial measurement in patients with metastatic colorectal cancer (n = 90) using palliative first-line chemotherapy with weekly 24-hour infusion of high-dose 5-FU with FA and were compared with objective response according to WHO criteria. 85 patients could be evaluated. 43 patients (51%) initially had elevated CEA (> or = 10 ng/ml) and 33 patients (39%) elevated CA19-9 (> or = 50 IE/ml). In 24 patients (28%), both markers were initially increased. With CEA positive patients, 143 cycles of chemotherapy were carried out, which showed the following response in the various cycles: 21 episodes with progressions (ePD), 69 episodes with no change (eNC), 53 episodes with partial/complete remission (ePR/eCR). With CA 19-9 positive patients, 100 cycles of chemotherapy were carried out with the following results: 21 episodes with progressions (ePD), 48 episodes with eNC, and 31 episodes with ePR/eCR. RESULTS: A CEA rise by at least 50% differentiated between ePD versus eNC/ePR/eCR with a sensitivity of 76% and specificity of 90%. With CEA decreases of at least 30% in 99% of these patient episodes (78 of 79), a tumour progression could be excluded. Patients with an initial drop in CEA after the first cycle of chemotherapy of at least 50% of the initial level had a significantly higher probability of achieving an ePR/eCR in further therapy (relative risk 2.9; P = 0.002). With an CA 19-9 increase of at least 30%, a sensitivity progression of 62% and a specifity of 90% could be calculated. A CA 19-9 decrease of at least 60% excludes a progression in 95% of the patient episodes. CONCLUSIONS: A CEA or CA 19-9 rise is only conditionally appropriate for recording progressions. A progression however, can be excluded with falling levels with high diagnostic accuracy, in which CEA offers a greater degree of certainty than CA 19-9. With a drop in CEA 79 of 143 (= 55%) of the CT scans could be saved, in which case 78 of 79 patient episodes (99%) were correctly assessed as 'no progression'. In patients with an increased CEA and CA 19-9 the CEA determination is sufficient for the further monitoring. A confirmation of these results by multicenter trials can result in a considerable decrease of monitoring costs for palliative treatment.

Adult↗
PubMed2001

Postnatal depression: use of health services and satisfaction with health-care providers.

The objective of this study was to compare health-care use and satisfaction with health-care providers between depressed and non-depressed women in the first 4 months after childbirth. Sixteen weeks after delivery a questionnaire, which included the Edinburgh Postnatal Depression Scale (EPDS) and items about health-care use and satisfaction, was mailed to women who attended the antenatal clinic, Royal Women's Hospital, Brisbane. Completed questionnaires were returned by 574 (86.4%) of the 664 women surveyed. During the study period most women (91%) visited a general practitioner at least once and 117 (12%) saw their doctor on five or more occasions. A total of 118 (20.7%) scored above 12 on the EPDS. Depressed women were more likely to visit a psychiatrist (OR, 9.2; 95% CI, 4.3-19.6), social worker (OR, 6.1; 95% CI, 3.3-11.1), postnatal depression group (OR, 4.0; 95% CI, 1.3-12.6), paediatrician (OR, 2.5; 95% CI, 1.6-3.9), or a general practitioner (OR, 2.1; 95% CI, 1.4-3.2) than non-depressed women. Twenty-two (18.5%) of the depressed women had contact with a psychiatrist. Compared with non-depressed women, those scoring above 12 on the EPDS were less satisfied with the services of general practitioners (P=< 0.000), paediatricians (P=0.002), Nursing Mothers' Associations of Australia (P=0.043) and obstetricians (P=0.045). Postpartum depression leads to an increase use of health-care services and has a negative effect on satisfaction with some services.

Adult↗
PubMed1998

Endoscopic papillary dilation by balloon and isosorbide dinitrate drip infusion for removing bile duct stone.

BACKGROUND: Endoscopic papillary dilation (EPD) by balloon in the management of bile duct stones has recently been claimed to be effective for removing bile duct stones. METHODS: Without endoscopic sphincterotomy, we attempted to remove large or multiple bile duct stones through EPD combined with drip infusion of isosorbide dinitrate in 35 patients. Isosorbide dinitrate, at a rate of 5 mg/h, was administered intravenously, and a balloon dilator with a 10-mm diameter was inflated within 3 min across the papilla. Stones were then smashed using a mechanical lithotriptor, and the fragments were extracted with a basket or the balloon. RESULTS: Extraction of stones was successful in 33 (94%) of 35 patients by the combined therapy. Two of them (6%) developed mild pancreatitis. CONCLUSION: EPD combined with medical sphincter dilation was effective for large and multiple bile duct stones.

Adult↗
PubMed2005

Screening and treatment for depression during pregnancy: a cautionary note.

OBJECTIVE: The aim of this study was to evaluate the recruitment and retention of depressed pregnant women, identified initially through screening, to a randomized controlled psychotherapy trial. METHOD: Consecutive pregnant women presenting for routine ultrasound scan were asked to complete the Edinburgh Postnatal Depression Scale (EPDS). Women who scored greater than 12 on the EPDS and who agreed to contact were invited to attend an initial assessment to determine eligibility for the trial. Consenting, eligible women were randomized to either cognitive behaviour therapy (CBT) or routine clinical care (RCC). Follow-up assessments were conducted at mid (6 weeks following initial assessment), end (approximately 36 weeks gestation), and postpartum (approximately 4 months postdelivery) for all participants. RESULTS: 400 women were offered the EPDS, and 93% completed the questionnaire (370/400). Thirteen percent (49/370) of these women scored greater than 12, although only a minority of these women agreed to be contacted (15/49). Of those who agreed to be contacted, less than half attended initial interview (7/15 attended; 3/15 ineligible; 5/15 declined). Upon interview, all women except for one, were eligible and consenting (6/7). Three women were randomized to CBT and three to RCC. Only one woman randomized to CBT chose to commence treatment, and only one woman randomized to RCC was offered treatment for her low mood by her lead maternity provider. CONCLUSIONS: While the vast majority of pregnant women were willing to complete a depression screening questionnaire, most did not agree to additional contact or assessment, and either were not offered treatment or did not accept treatment. This was not an effective recruitment strategy for a randomized controlled psychotherapy trial.

Adult↗
PubMed2006

Evaluation of a radiation protection cabin for invasive electrophysiological procedures.

AIMS: Complex invasive electrophysiological procedures may result in high cumulative operator radiation exposure. Classical protection with lead aprons results in discomfort while radioprotection is still incomplete. This study evaluated the usefulness of a radiation protection cabin (RPC) that completely surrounds the operator. METHODS AND RESULTS: The evaluation was performed independently in two electrophysiology laboratories (E1-Leuven, Belgium; E2-Bordeaux, France), comparing operator radiation exposure using the RPC vs. a 0.5 mm lead-equivalent apron (total of 135 procedures). E1 used thermoluminiscent dosimeters (TLDs) placed at 16 positions in and out of the RPC and nine positions in and out of the apron. E2 used more sensitive electronic personal dosimeters (EPD), placed at waist and neck. The sensitivity thresholds of the TLDs and EPDs were 10-20 microSv and 1-1.5 microSv, respectively. All procedures could be performed unimpeded with the RPC. Median TLD dose values outside protected areas were in the range of 57-452 microSv, whereas doses under the apron or inside the RPC were all at the background radiation level, irrespective of procedure and fluoroscopy duration and of radiation energy delivered. In addition, the RPC was protecting the entire body (except the hands), whereas lead apron protection is incomplete. Also with the more sensitive EPDs, the radiation dose within the RPC was at the sensitivity threshold/background level (1.3+/-0.6 microSv). Again, radiation to the head was significantly lower within the RPC (1.9+/-1.2 microSv) than with the apron (102+/-23 microSv, P<0.001). CONCLUSION: The use of the RPC allows performing catheter ablation procedures without compromising catheter manipulation, and with negligible radiation exposure for the operator.

Arrhythmias, Cardiac↗
PubMed2004

Radiation dose measurements to the interventional cardiologist using an electronic personal dosemeter.

The aim of this study was to investigate the use of an electronic personal dosemeter (EPD) worn by a senior cardiologist in an Interventional Cardiology (IC) Laboratory of a busy cardiac centre and how the results could help in the evaluation of radiation protection equipment used. Patient samples consist of 28 patients (10 coronary angiographies (CAs) and 18 percutaneous transluminal coronary angioplasties (PTCAs)). Patient dose was measured with a dose-area product (DAP) meter. Cardiologist radiation dose value written on the EPD as well as the protective equipment used was collected. Between patient and cardiologist dose, a significant correlation was found in CA and a moderate correlation in PTCA. Mean cardiologist effective dose E per procedure was found to be 0.2 microSv in CA and 0.3 microSv in PTCA. EPD proved to be an easy, direct and straightforward way to measure the radiation dose that the cardiologist receives in an IC laboratory.

Angioplasty, Balloon, Coronary↗
PubMedDate not supplied

Comparative analysis of the performance of the Postpartum Depression Screening Scale with two other depression instruments.

BACKGROUND: Postpartum depression affects approximately 13% of mothers but up to 50% of all cases of this tragic illness can go undetected. OBJECTIVE: The purpose of this study was to compare the performance of a newly created instrument, the Postpartum Depression Screening Scale (PDSS), with the Edinburgh Postnatal Depression Scale (EPDS) and a general depression scale, the Beck Depression Inventory-II (BDI-II). METHOD: In this methodological design a total of 150 new mothers completed these three instruments in random order, followed immediately by a DSM-IV diagnostic interview. Using the LABROC I program, the areas under each of the instrument's Receiver Operator Characteristic (ROC) curves were compared to determine if they were significantly different. RESULTS: Eighteen (12%) of the women were diagnosed with major postpartum depression, 28 women (19%) with minor postpartum depression, and 104 women (69%) with no depression. Compared to the EPDS, the PDSS had a significantly larger area under the ROC curve when screening for major or minor postpartum depression. When using the published recommended cut-off scores for major depression for the three instruments, the PDSS achieved the highest combination of sensitivity, 94%, and specificity, 98%. When detecting women with major or minor postpartum depression, the PDSS again yielded the highest combination of sensitivity (91%) and specificity (72%) of the three instruments. The PDSS identified 17 (94%) of the women diagnosed with major postpartum depression, the EPDS identified 14 of these women (78%), and the BDI-II identified 10 of the 18 women (56%). CONCLUSION: If mothers identified as "most depressed" are substantially determined by the instrument used, the implications for both research and clinical practice are significant. Researchers and clinicians need to be aware of the differential sensitivity of depression instruments which, while supposedly measuring the same construct, are focused on different components of this mood disorder.

Adolescent↗
PubMedDate not supplied

Are stress-induced cortisol changes during pregnancy associated with postpartum depressive symptoms?

OBJECTIVE: The purpose of this study was to examine the association between psychobiological stress reactivity during healthy pregnancy and depressive symptoms in the early puerperium. METHODS: A sample of healthy nulliparous pregnant women (N = 57) between the ages of 21 and 35 years underwent a standardized psychosocial stress test during pregnancy. Within an average of 13 days after delivery, postpartum depressive symptoms were assessed using the German version of the Edinburgh postnatal depression scale (EPDS). The sample was divided into a group with probable cases (EPDS score >9, N = 16) and a group with probable noncases (EPDS score < or =9, N = 41). RESULTS: The probable case group showed significantly higher cortisol responses to the stress test compared with the probable noncase group, whereas baseline levels did not differ. Additionally, women in the probable case group showed significantly higher state anxiety and lower mood state throughout the experiment. Furthermore, the probable case group showed higher stress susceptibility, higher trait anxiety, and higher levels in the Symptom Checklist. No differences were found for prior episodes of psychiatric disorders, obstetrical complications, birth weight, or mode of delivery. CONCLUSIONS: Our data provide evidence that healthy pregnant women developing postpartum depressive symptoms might already be identified during pregnancy by means of their higher cortisol reactivity and their higher psychological reactivity in response to psychosocial stress. Further investigations are required to explore whether higher psychobiological stress responses not only precede depressive symptoms within 2 weeks after birth, but might also predict postpartum major depression.

Adult↗
PubMed2004

Does pain relief during delivery decrease the risk of postnatal depression?

BACKGROUND: To test the hypothesis that sufficient pain relief during delivery decreases the risk of postnatal depression. METHODS: As part of a prospective follow-up study of the risk factors for postnatal depression and its impact on the mother-infant interaction and child development, 185 parturients filled in the Edinburgh Postnatal Depression Scale (EPDS), first during the first postpartum week and again (n = 162) 4 months later. The incidence and the risk of high EPDS scores was calculated according to the mode of delivery and the mode of pain relief during vaginal delivery, also after adjusting for the length of labor. RESULTS: Mothers who received epidural/paracervical blockade during their delivery spent less time in the delivery room than mothers in the nitrous oxide/acupuncture group (p = 0.033) or mothers with no pain relief (p = 0.026) and had shorter length of labor than mothers without pain relief (p = 0.04). The adjusted risk of depressive scores at the first postnatal week was decreased in the epidural/paracervical group when compared with no analgesia group (OR: 0.25, 95% CI: 0.09-0.72). This difference was not shown at 4 months postpartum. Elective or emergency cesarean section did not increase the risk of high EPDS scores at the first week or at 4 months postpartum. CONCLUSION: The mode of pain relief during vaginal delivery seems to be associated with the incidence of postpartum depression, especially immediately after delivery.

Adult↗