Brown University

Perinatal mental health conditions are among the most common complications of pregnancy and the postpartum period. They are the leading preventable cause of pregnancy-related morbidity and mortality in the United States, largely through suicide, accidental drug overdose, and homicide. When untreated, they are associated with negative short- and long-term outcomes for perinatal individuals, offspring, partners, families, and society. Despite this, perinatal mental health conditions remain underdetected and undertreated. In this narrative review, we highlight resources that increase the capacity for obstetric clinicians to address perinatal mental health. These include clinical guidelines such as the American College of Obstetricians & Gynecologists' Clinical Practice Guidelines and the Alliance on Innovation in Maternal Health's Perinatal Mental Health Conditions Patient Safety Bundle. In addition, we discuss implementation and educational tools to help apply evidence-based guidance into clinical practice, including the Lifeline for Moms Perinatal Mental Health Tool Kit, Addressing Perinatal Mental Health Conditions in Obstetric Settings e-module, Guide for Integrating Mental Health Care Into Obstetric Practice, and Perinatal Mental Health Certification Programs. We also discuss consultation and expert support, including the statewide and regional Perinatal Psychiatry Access Programs. Patient-facing resources discussed include the federally funded maternal mental health hotline and Postpartum Support International's virtual support groups. Finally, opportunities to support obstetric care clinicians in addressing perinatal mental health through reimbursement approaches and policies are also discussed.

Kara Stavros: Dr. Stavros has served as a paid consultant for Springer Healthcare. Pushpa Narayanaswami: Research Support: NIH, Alexion, Argenx, Cabaletta-Bio, Dianthus. Advisory boards/Consultation: Alexion, Argenx, Amgen, CVS, Cartesian, Dianthus, EMD-Serono, GSK, Immunovant, Immune-Abs, Janssen, Novartis, UCB, Vor-Bio. Speaker honoraria: UCB, Alexion, WebMD, PeerVoice, Medscape, Academic CME, Med Learning Group. Data Safety Monitoring Boards: Alexion, NMD pharma, Sanofi. Royalties: Springer Nature. Other: Serve as Associate Editor, Muscle and Nerve and Associate Editor, Classification of Evidence, Neurology. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Left ventricular (LV) dysfunction is a potential cardioembolic source of ischemic stroke, but its role in recurrent stroke risk and treatment response remains unclear. We explore whether LV injury associates with the risk of recurrent stroke and modifies the association between anticoagulation and stroke recurrence using real-world data. We performed a multicenter, retrospective study of Cardiac Abnormalities in Stroke Prevention and Recurrence cohort across 27 US sites. Patients with LV ejection fraction ≥20% were included. LV injury, defined as LV ejection fraction 20% to 40% and wall motion abnormality, was the primary exposure and treatment effect modifier. The treatment of interest was anticoagulant versus antiplatelet therapy. The composite outcome included recurrent stroke, major bleeding, or death. Outcomes were evaluated using unadjusted and inverse probability weighting adjusted Cox proportional hazards models, with treatment effect modification tested by LV injury status. Among 2685 patients enrolled, 2328 with complete data were analyzed (median age, 65 years; 49.8% female; median follow-up, 1.6 years). LV injury was present in 310 patients (13.3%). Overall, 535 events occurred: 258 recurrent ischemic strokes, 28 hemorrhagic strokes, 67 major hemorrhages, and 256 deaths. LV injury was associated with a higher unadjusted risk of the primary outcome (hazard ratio [HR], 1.51 [95% CI, 1.21-1.87]), though nonsignificant after inverse probability weighting adjustment (adjusted HR, 1.29 [95% CI, 0.97-1.70]). In the LV injury subgroup, anticoagulation versus antiplatelet therapy was associated with a lower risk of the primary outcome (adjusted HR, 0.24 [95% CI, 0.10-0.59]), relative to the non-LV injury subgroup (adjusted HR, 1.28 [95% CI, 0.83-1.95]; p[LV-interaction], 0.001). Similar interactions were seen for EF 20% to 40% (versus >40%; adjusted HR, 0.19 [95% CI, 0.04-0.86]; p[LV-interaction], 0.001) and wall motion abnormality (versus no wall motion abnormality; adjusted HR, 0.33 [95% CI, 0.15-0.73]). After cryptogenic stroke, anticoagulation in those with LV injury was associated with lower rates of recurrent stroke, major bleeding, and death. These findings warrant confirmation in a dedicated randomized controlled trial. URL: https://www.clinicaltrials.gov; Unique identifier: NCT06398366.

Several risk factors for progression to severe COVID-19have been identified, but whether multiple concomitant risk factors (risk stacking) further increase risk remains unknown. We sought to identify outpatient populations at the highest risk for severe COVID-19 using risk factor stacking. We conducted a retrospective cohort study of Veterans Affairs (VA) outpatient adults (≥ 18years) at high risk for severe COVID-19 with a positive SARS-CoV-2 test or COVID-19 diagnosis between April 1, 2022 and August 21, 2024. Severe COVID-19 was defined as COVID-19-related hospitalization or all-cause mortality within 30days. Logistic regression models were used to quantify the impact of combinations of multiple risk factors (stacked risks) on severe COVID-19. Risk factors, selected based on prevalence and CDC criteria, included age ≥ 50years, chronic lung disease, cancer, neurological conditions/cerebrovascular disease, chronic kidney disease, chronic liver disease, diabetes mellitus, heart conditions, mental health conditions, obesity, smoking, immunosuppression, hypertension, and not being up to date on COVID-19 vaccination. Among 379,144 VA outpatients with COVID-19, 1.5% (5801) had severe outcomes within 30days. Risk increased with each additional factor from two (adjusted odds ratio [aOR] 2.10, 95% confidence interval [CI] 1.37-3.23) to 14 risk factors (aOR 43.49, 95%CI 4.94-382.66) compared to one. Overall, 239 significant risk factor combinations were identified. Hypertension appeared in 196 combinations (82.0%), not up-to-date on COVID-19 vaccination in 173 combinations (72.4%), smoking in 168 combinations (70.3%), and heart conditions in 154 combinations (64.4%). The combination with the highest risk (aOR 35.25, 95%CI 16.06-77.37) included age ≥ 50years, chronic lung disease, neurological conditions/cerebrovascular disease, diabetes mellitus, heart conditions, smoking, hypertension, and not being up-to-date on COVID-19 vaccination. In this large national cohort, severe COVID-19 risk increased with the number of risk factors present. Patients with multiple overlapping risk factors who were not vaccinated were at the highest risk for severe COVID-19. As recommendations have shifted toward risk-based clinical decision-making, identifying patients with particularly high-risk combinations of conditions is increasingly important to support targeted vaccination and timely antiviral treatment.