Problem: Depression and Fatigue in HIV Positive Pregnant Women during Repeated Pregnancies: A Single Case Analysis
Clinically relevant problem statement. Is there a change over time during repeated pregnancies in depression and fatigue symptoms in an HIV positive pregnant woman?  
Background: There is a large body of knowledge related to the presence and effects of depression during pregnancy. A substantial number of women experience their first onset of mood or anxiety disorders during pregnancy, while those with a history of psychiatric disorder are at increased risk for a recurrence or relapse of symptoms during pregnancy (Bennett et al., 2004).  Perinatal depression is a significant problem for the general population.  An estimated 20% of women are depressed during pregnancy, with even higher rates among pregnant women of low socioeconomic status (SES) (Bennett et al., 2004).  Depression is a symptom that influences the quality of life among 83% of HIV infected women (Hudson, Kirksey, & Holzemer, 2004). Fatigue, although an expectation in pregnancy, as a lingering symptom, places a woman at an increased risk for post partum depression and is the most frequent and debilitating complaint of HIV positive people (Voss, 2005).  When these symptoms are combined, a constellation of concern is created for HIV positive pregnant women.   HIV as a chronic disease during pregnancy is a time of emotional change and uncertainty. When present, women are at higher risk for exacerbation of symptoms of depression and fatigue that can affect physical and psychosocial functioning as well as infant care and well being.
Design: Longitudinal repeated measures single case analysis design.  
Conceptual Framework: The UCSF Symptom Management Model
Procedures: Women were recruited for a larger study from a convenience sample of those seeking prenatal care at a large urban northeast teaching hospital.  For single case analysis, one woman who had two pregnancies over 29 months was enrolled twice to examine the effects of pregnancy on symptoms over time. All women were approached to participate during the second trimester, consented, and data were collected pre delivery at two time intervals in person and post delivery at 1, 2, 3, 4, 6 and 8 weeks post partum over the phone. Instruments used for analysis included the CESD short form, the EPDS and the HIV-related Fatigue Scale for intensity and consequences.
Results: Measures of fatigue and depression decreased significantly from pregnancy 1 to pregnancy 2 (p <.0001). The CESD detected the presence of depression throughout the first pregnancy.  Fatigue intensity and consequences were significantly higher in pregnancy 1 than pregnancy 2. Fatigue was highest pre delivery and diminished over time in both pregnancies.
Interpretation and Nursing implications: Fatigue and depression symptoms were higher in pregnancy 1 than pregnancy 2 suggesting that symptoms may be exacerbated in the presence of HIV and could be related to uncertainty related to newborn outcomes. Evaluation of depression and fatigue during pregnancy, its intensity and support for coping and intervening are vital to emotional wellbeing in women with HIV.