Posttraumatic stress disorder 2 months after cesarean delivery: a multicenter prospective study

BACKGROUND

The prevalence and risk factors of posttraumatic stress disorder after cesarean delivery, outside high-risk contexts, remain unclear.

OBJECTIVE

This study aimed to assess posttraumatic stress disorder prevalence and risk factors at 2 months postpartum among a general population of women with cesarean delivery.

STUDY DESIGN

This was a prospective ancillary cohort study of the Tranexamic Acid for Preventing Postpartum Hemorrhage after Cesarean Delivery (TRAAP2) trial, conducted in 27 French hospitals from 2018 to 2020, enrolling women expected to undergo cesarean delivery before or during labor at ≥34 weeks of gestation. After randomization, characteristics of the cesarean delivery and postpartum blood loss were prospectively collected. Two months after childbirth, posttraumatic stress disorder profile (presence of posttraumatic stress disorder symptoms) and provisional diagnosis (positive screening for diagnosis consistent with a posttraumatic stress disorder) were assessed by 2 self-administered questionnaires (Impact of Event Scale - Revised and Traumatic Event Scale). The corrected posttraumatic stress disorder prevalence was estimated with inverse probability weighting to take nonresponse into account. Associations between potential risk factors and posttraumatic stress disorder were analyzed by multivariate logistic or linear regression modeling according to the type of dependent variable.

RESULTS

In total, 2785 of 4431 women returned the Impact of Event Scale - Revised questionnaire and 2792 the Traumatic Event Scale (response rates of 62.9% and 63.0%). The prevalence of posttraumatic stress disorder profile was 9.0% (95% confidence interval, 7.8%-10.3%) and of provisional diagnosis 1.7% (95% confidence interval, 1.2%-2.4%). Characteristics associated with a higher risk of posttraumatic stress disorder profile were prepregnancy vulnerability factors (young age, high body mass index, and African-born migrant) and cesarean delivery-related obstetrical factors (cesarean delivery after induced labor [adjusted odds ratio, 1.81; 95% confidence interval, 1.14-2.87], postpartum hemorrhage [adjusted odds ratio, 1.61; 95% confidence interval, 1.04-2.46] and high-intensity pain during the postpartum stay [adjusted odds ratio, 1.90; 95% confidence interval, 1.17-3.11]). Women who had immediate skin-to-skin contact with their newborn were at lower risk of posttraumatic stress disorder (adjusted odds ratio, 0.66; 95% confidence interval, 0.46-0.98), and women with bad memories of delivery on day 2 postpartum were at higher risk (adjusted odds ratio, 3.20; 95% confidence interval, 1.97-5.12). The Impact of Event Scale - Revised and the Traumatic Event Scale yielded consistent results.

CONCLUSION

Approximately 1 in 11 women with cesarean deliveries had posttraumatic stress disorder symptoms at 2 months postpartum. Some obstetrical interventions and components of cesarean delivery management may influence this risk.

HELLP syndrome at <23 weeks' gestation: a systematic literature review

OBJECTIVE

We performed a systematic review to evaluate the clinical presentation and maternal and fetal outcomes in pregnancies with early-onset HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.

DATA SOURCES

PubMed, Ovid MEDLINE, Scopus, CINAHL, Cochrane Library, and ClinicalTrials.gov were queried from inception through January 1, 2023 with the following terms: "HELLP syndrome," "HELLP," "hemolysis, elevated liver enzymes, low platelets," "hemolysis, elevated liver enzymes, low platelets syndrome," "pre-viable," "peri-viable," "previable," "periviable," "first trimester," "second trimester," "before 23 weeks," "<23 weeks," "<23 week gestation," and "before 23 weeks gestation." We also included an additional case from our institution.

STUDY ELIGIBILITY CRITERIA

Abstracts, unpublished studies, and review articles were excluded, yielding 46 studies that met our inclusion criteria.

METHODS

Two reviewers (N.S.I. and M.H.M.) performed the study selection and subsequent data extraction independently, after which the results were reviewed together. PRISMA guidelines were followed, and our study was registered at PROSPERO (CRD42021292692).

RESULTS

A total of 55 patients had 58 pregnancies complicated by early-onset HELLP syndrome, including 3 with recurrent HELLP. The most common presenting signs/symptoms were abdominal pain (35/45; 78%), hypertension (32/49; 65%), nausea/vomiting (16/45; 36%), headache (13/45; 29%), and edema (8/45; 18%). Lactate dehydrogenase ≥600 IU/L was observed in 21 of 31 (68%) cases, whereas liver enzyme abnormalities and thrombocytopenia were reported in 48 of 51 (94%) and 50 of 54 (93%) cases, respectively. Maternal complications were encountered in 25 of 56 (45%) cases. The most common complications were hepatic (13/56; 23%), central nervous system-related (11/56; 20%), and respiratory (11/56; 20%). In 36 of 57 (63%) cases, pregnancy was terminated. Of the 21 continued pregnancies, early fetal death (at <20 weeks' gestation) was reported in 10 (48%), stillbirth in 6 (28%), and neonatal demise in 2 (10%). Living neonates were reported in 3 of 21 (14%) cases, all delivered at 23 weeks. The perinatal mortality rate was 73% (8/11). One case (2%) reported maternal death. Antiphospholipid syndrome was diagnosed in 14 of 29 (48%) cases.

CONCLUSION

Early-onset HELLP syndrome presents with symptoms similar to those observed in later gestation. Maternal complications are life-threatening, with the most common complications being hepatic, central nervous system-related, and respiratory. Fetal outcomes are poor.

Evidence of Anxiety, Depression and Learning Impairments following Prenatal Hypertension

Background: Hypertensive disorders of pregnancy, such as Preeclampsia (PreE) and HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome, affects approximately 5–10% of pregnancies and increases the risk of women developing disorders, such as anxiety or depression, in the postpartum period. Using preclinical rodent models, we set out to determine whether rats with a history of PreE or HELLP had evidence of anxiety, depression or cognitive impairment and whether immune suppression during pregnancy prevented these changes in mood and/or cognition. Methods: Timed-pregnant rats were infused with sFlt-1 and/or sEng to induce PreE or HELLP beginning on gestational day 12. After delivery, a battery of validated behavioral assays was used to assess post-partum depression, anxiety and learning. Results: There was no negative effect on maternal pup interaction due to PreE or HELLP; however, hypertensive dams spent more time immobile in the forced swim test (p < 0.0001). Hypertensive dams also spent less time in the open area of the open field (p = 0.001). There were no significant changes in recognition memory (p = 0.08); however, spatial learning was impaired in hypertensive dams (p = 0.003). Immobility time in the forced swim test was positively correlated with increased circulating S100B (p = 0.04), while increased time spent in the outer zones of the open field was negatively correlated with BDNF levels (p < 0.0001). Conclusion: The results from this study suggest that hypertensive pregnancy disorders are associated with depression, anxiety and learning impairments in the post-partum period.

Depression, anxiety and posttraumatic stress disorder six months following preeclampsia and normotensive pregnancy: a P4 study

Background

Mental health is an integral part of overall health. Mental health disorders following childbirth are common and poor maternal mental health has consequences for both the mother and her infant. Preeclampsia is also relatively common in pregnancy but there is little known about the intersection between these two important conditions. Gaining a better understanding of the psychological consequences following preeclampsia is important, especially the link with depression, anxiety and posttraumatic stress disorder. If women who experience preeclampsia are recognised as being at increased risk of poor mental health, targeted screening in the postpartum period should be implemented.

Aims

To describe the prevalence and symptom severity of depression, anxiety and posttraumatic stress disorder at six months postpartum in women, who had a diagnosis of preeclampsia, compared to those who had normal blood pressure in pregnancy.

Methods

The mental health component of the prospective cohort study, the Postpartum, Physiology, Psychology and Paediatric follow-up study (P4 Study) was used. Women diagnosed with preeclampsia (n = 90) and those who were normotensive during pregnancy (n = 302) completed the Edinburgh Postnatal Depression Scale, General Anxiety Disorder Scale, and the Posttraumatic Stress Diagnostic Scale or Posttraumatic Stress Diagnostic Sclae-5 at six months postpartum.

Results

At six months postpartum, depressive scores were similar in both groups but a higher proportion of women from the preeclampsia group scored above the threshold for depression (2% v 7% p = 0.04). There were no differences between the groups in the prevalence or severity of anxiety or PTSD. However, more women in the preeclampsia group reported their birth experience as a traumatic event (1% vs 7%, p = 0.01). On correlation testing and modelling, booking Edinburgh Postnatal Depression Scale score, any mental health history, experiencing birth as traumatic and the General Anxiety Disorder Scale score were independent predictors of postpartum Edinburgh Postnatal Depression Scale scores.

Conclusion

The postpartum clinical care of women with preeclampsia often focusses on the immediate physical health issues, but these women may also benefit from mental health screening. Targeted screening of preeclamptic women in the postpartum period may lead to more timely referral and initiation of treatment.

Trial registration

Retrospectively registered on 18/11/2013 with the Australian and New Zealand Clinical Trials Registry. Registration Number: ACTRN12613001260718.

Severe postpartum hemorrhage increases risk of posttraumatic stress disorder: a prospective cohort study

PURPOSE

To evaluate whether severe postpartum hemorrhage (PPH) is a risk factor for posttraumatic stress disorder (PTSD). Severe PPH can be experienced as a traumatic event. PTSD leads to negative mental health effects. Knowing risk factors for PTSD during childbirth offers opportunities for early interventions, which may prevent the development of PTSD.

MATERIALS AND METHODS

In this prospective study, we compared two groups of participants; women with ≥2000 mL of blood loss (severe PPH, patients) and women with ≤500 mL of blood loss (controls). Participants were screened for PTSD using the PCL-5 four to six weeks after delivery. Positive screening was followed by the CAPS-5 to diagnose PTSD.

RESULTS

We included 187 PPH patients and 121 controls. Median PCL-5 scores were higher for PPH patients (5.0) than controls (4.0, p = 0.005). Thirteen PPH patients (7.0%) and two controls (1.7%) scored ≥32 on the PCL-5, indicative of probable PTSD (OR 4.45, 95% CI 0.99-20.06, p = 0.035). Significant more PPH patients than controls met criteria for a clinical diagnosis of PTSD on the CAPS-5 (n = 10, 5.6% vs n = 0, 0.0%; p = 0.007).

CONCLUSIONS

There is a significant and clinically relevant increased risk for developing PTSD after severe PPH. Gynecologists and midwives are advised to screen for PTSD at postpartum follow-up visits to prevent long-term negative mental health effects.

CLINICAL TRIAL REGISTRATION

NL50273.100.14.

Severe psychological impact and impaired quality of life after a spontaneous haemoperitoneum in pregnancy in women with endometriosis and their partners

Background

Spontaneous Haemoperitoneum in Pregnancy (SHiP) is a rare, but life-threatening complication of pregnancy that occurs predominantly in the third trimester of pregnancy and is associated with adverse pregnancy outcomes. Recently the largest case series in literature was published describing 11 Dutch cases of SHiP in women with endometriosis.

Purpose

To investigate experiences, psychological impact, and quality of life after SHiP.

Methods

A mixed-methods study was performed in women with a history of SHiP and their partners, including all known cases in the Netherlands between 2007 to 2015. Semi-structured in-depth interviews were organized between 2016 and 2017 and analysed thematically with a framework approach. Participants were asked to complete questionnaires investigating the impact of the event (Impact of Event Scale) and Quality of Life (RAND-36).

Results

Out of a total of 11 known cases, 7 women agreed for be individually interviewed. From these, all women described a freeze response at the moment of SHiP, combined with either an anxious reaction or a survival mode mind-set. All women received psychological help after SHiP. Still, the feeling of not being heard by the medical staff was present in all women. Other themes such as postpartum period, bonding with their child, effect on daily life, reviving the event, and future pregnancies were also identified in the interviews. In regard to their partners, 3 were interviewed, hence no saturation was achieved. Finally, the questionnaires showed lower Quality of Life and an impact score of ≥ 8/10.

Conclusion

SHiP had a profound impact on women and their partners. Dedicated psychological help should be offered to all women after experiencing SHiP.

Relationship of post-traumatic stress disorder with disrespect and abuse during childbirth in a group of Iranian postpartum women: a prospective study

BACKGROUND

Disrespect and abuse (D&A) violate the fundamental principles of ethics, human rights, and basic obligations to protect and relieve patients. This study aimed to identify the status of D&A and its relationship with the post-traumatic stress disorder (PTSD) among Iranian women.

METHODS

This prospective study was conducted on 288 mothers admitted to the maternity wards of three public and three private hospitals in Tabriz. The data collection tools were socio-demographic and obstetric questionnaires as well as D&A (6-18 h postpartum) and PTSD (one month postpartum) scales, which were completed by participants in interviews. Multivariate logistic regression was employed to determine the relationship between PTSD and D&A in adjusting the socio-demographic and obstetric variables.

RESULTS

In this study, 74.7% of mothers reported one or multiple types of D&A. According to the diagnostic criteria for PTSD, 16.3% of the participants experienced postpartum PTSD. The mean (± standard deviation) of the PTSD score was reported 7.32 (± 2.0) in the women experiencing D&A, whereas it was 1.0 (± 0.0) in the women having no experiences of D&A. According to the Mann-Whitney U test results, there was a significant relationship between the total and all subscales of PTSD score and D&A (p < 0.001). The multivariate logistic regression results indicated that the likelihood of PTSD was significantly lower in the participants without any D&A experiences than in those with D&A experiences (aOR: 0.06; 95% CI 0.01 to 0.58; p = 0.015).

CONCLUSION

Given the PTSD-D&A relationship, it is recommended to improve maternal care in maternity facilities to prevent any unintended PTSD complications.

Neurobiology of peripartum mental illness

At least one in seven pregnant or recently postpartum women will experience a mental illness such as an anxiety disorder, depressive disorder, or substance use disorder. These mental illnesses have detrimental effects on the health of the mother, child, and family, but little is known about the hypothalamic and other neural correlates of maternal mental health concerns. The transition to parenthood alone is a time of remarkable neural plasticity, so it is perhaps not surprising that current research is showing that maternal mental illness has unique neural profiles. Furthermore, the neural systems affected by peripartum mental illness overlap and interact with the systems involved in maternal caregiving behaviors, and mother-infant interactions are, therefore, highly susceptible to disruption. This review discusses what we know about the unique neural changes occurring during peripartum mental illness and the role of the hypothalamus in these illnesses. With an improved understanding of the neural correlates of maternal mental health and disease, we will be better equipped to predict risk, develop effective treatments, and ultimately prevent suffering for millions of parents during this critical time in life.

Preeclampsia as a risk factor for postpartum depression and psychosis: a systematic review and meta-analysis

Postpartum depression (PPD) and postpartum psychosis (PPP) are serious mental conditions that are usually not diagnosed early enough, leading to delayed treatment. Several studies confirmed an association between preeclampsia (PE) and psychiatric disorders during pregnancy. We conducted a systematic review of the literature aiming to investigate whether women with a history of PE are more likely to develop PPD or PPP, and whether PE is a risk factor for depression outside the perinatal period (PROSPERO protocol number CRD42018114188). We also conducted a meta-analysis to quantitatively assess the severity of depressive symptoms between women with and without a history of PE. A literature search with no year and no language restriction was conducted. The search yielded 950 articles, with 698 remaining after duplicate removal, and 13 being suitable for the systematic review. Eight of the 13 studies found an association between preeclampsia and depression. All studies assessed the impact of PE on depression, and only two studies assessed the impact of PE on PPP. Eight of the studies were included in the meta-analysis, which yielded a higher severity of depressive symptoms postpartum in women with PE. However, these results must be interpreted with caution considering the high heterogeneity of the included studies. Our meta-analysis also showed that women with a history of PE showed higher severity of depressive symptoms outside of the puerperal period. In conclusion, this systematic review and meta-analysis suggest that that PE is not only a risk factor for development of depression, but it is also associated with higher severity of depressive symptoms.

First-Trimester Prediction of Preterm Prelabour Rupture of Membranes

BACKGROUND

Preterm prelabour rupture of membranes (PPRoM) is commonly associated with preterm delivery and affects up to 3% of all pregnancies. It is associated with high rates of morbidity and mortality for the mother and the newborn.

OBJECTIVES

To identify risk factors for PPRoM and develop a model for first-trimester prediction of risk of PPRoM.

METHODS

A retrospective analysis of a series of women who had first-trimester (11-13+6 weeks) screening for aneuploidy and pre-eclampsia and delivered in the same institution was performed. Univariate and multivariate logistic regression analyses were used to identify maternal and pregnancy factors and then develop a clinical prediction model for PPRoM.

RESULTS

10,280 women were screened between April 2010 and October 2016. 144 (1.4%) had PPRoM. Maternal factors predictive of PPRoM included nulliparity (parous women, OR 0.53; 95% CI 0.4-0.8), pre-existing diabetes mellitus (DM) (Type 1 DM, OR 6.7; 95% CI 2.3-19.4, Type 2 DM, OR 5.3; 95% CI 1.6-18.3), maternal age group (p = 0.004), and BMI category (p = 0.012). Uterine artery pulsatility index (UAPI) and biochemical parameters (PAPP-A, free βHCG) did not reach statistical significance. The predictive model had moderate efficacy with an area under the ROC curve of 0.67.

CONCLUSIONS

Several maternal characteristics collected during first-trimester screening predict PPRoM. Biomarkers currently measured during first-trimester screening (PAPP-A, βHCG, and UAPI) do not predict PPRoM. Whilst a predictive model can be generated with information currently collected at 11-13+6 weeks, this has only modest screening performance. First-trimester screening provides a structured framework where other predictors could improve model performance, and future studies should focus on the addition of other risk factors and biomarkers that may improve screening efficacy.

Prenatal and Perinatal EMDR Therapy: Early Family Intervention

This article discusses the integration of eye movement desensitization and reprocessing (EMDR) therapy with a family therapy treatment, which was designed for treating mothers and their babies from conception through the first year of life. The Calming Womb Family Therapy Model (CWFTM) is a multidisciplinary, Integrative, early intervention approach. Its foundations originate from Murray Bowen's family model of understanding the individual in the context of their families as emotional interactive systems; Selma Fraiberg's psychodynamic work and psychoeducational interventions with mothers and infants to resolve maternal trauma and transference reactions to their babies followed by educational guidance in infant development through the first year of their lives; and EMDR therapy. EMDR therapy can improve internal resources for expectant mothers; monitor their levels of psychological distress; and enable them to access and process traumatic memories, other adverse life experiences, recent stressors, and pre-perinatal concerns and bring them to adaptive resolution. EMDR therapy can also help pregnant mothers develop imaginal templates of future events that incorporate in utero developmental prenatal education and deepen their bonds with their babies. The pre-perinatal psychotherapist's knowledge of infant development and capacity for interpersonal warmth, affect tolerance, somatic resourcing, reflective stance, and relational attunement can provide a fertile ground for the expectant mother and womb baby relationship and enriching life together. The ultimate goal is to conceive and rear healthy children.

Treatment of posttraumatic stress disorder following childbirth

Aim: The aim of this systematic review is to give an overview of the literature on treatment options for posttraumatic stress disorder (PTSD) following childbirth and to assess their efficacy.Method: PubMed, Embase, Web of Science, Cochrane and PsycINFO were searched using "PTSD", "childbirth" and "therapy" as terms for studies in English language published between 2000 and 2017. Additional studies were identified by checking reference lists. Studies were included when presence of PTSD was confirmed prior to treatment and childbirth was the traumatic event focused on. All studies were reviewed on sample size, study design, used instruments, sample characteristics, type of treatment and the result of treatment regarding PTSD (symptoms).Results: Six studies met the inclusion criteria. One study on debriefing, three studies on cognitive behavioral therapy (CBT) and two studies on eye movement desensitization and reprocessing (EMDR) were identified. Both EMDR and CBT appear to be promising therapies for PTSD following childbirth. Debriefing seems to be beneficial when women request it themselves.Conclusions: EMDR and CBT seem to be effective as therapy for PTSD following childbirth. However, evidence is still limited and more controlled trials are needed to draw conclusive results.

Is fear of childbirth related to the woman's preferred location for giving birth? A Dutch low-risk cohort study

BACKGROUND

In The Netherlands, women with low-risk pregnancy are routinely given the option of home birth, providing a unique opportunity to study the relationship between fear of childbirth (FOC) and preference for childbirth location, and whether women experience higher FOC when the actual location differs from their preference.

METHODS

In this prospective cohort study, 331 nulliparous and parous women completed a questionnaire at gestational week 30 (T1) and two months postpartum (T2). FOC was assessed using versions A (T1) and B (T2) of the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ).

RESULTS

At T1, women who preferred home birth had significantly lower FOC compared with women who preferred a hospital birth (mean ± SD W-DEQ scores: 55 ± 19.8 and 64 ± 18.3, respectively, P < .01). About 28% of women who responded at T2 gave birth at home. Congruence between the preferred and actual childbirth location was not predictive of FOC assessed at T2 when adjusted for obstetric and psychological variables. In an extended analysis, we found that except for prepartum FOC, the following variables also correlated with postpartum FOC: being referred because of complications and poor neonatal condition.

CONCLUSIONS

Compared to women who prefer hospital birth, women who prefer home birth have lower prepartum and postpartum FOC. Giving birth at a location other than the preferred location does not appear to affect postpartum FOC. Whether giving birth at home or in the hospital, caregivers should pay extra attention to women with high FOC because they are vulnerable to postpartum FOC, especially after a complicated birth and referral.

Impact of preventive screening and lifestyle interventions in women with a history of preeclampsia: A micro-simulation study

BACKGROUND

Preeclampsia is a female-specific risk factor for the development of future cardiovascular disease. Whether early preventive cardiovascular disease risk screenings combined with risk-based lifestyle interventions in women with previous preeclampsia are beneficial and cost-effective is unknown.

METHODS

A micro-simulation model was developed to assess the life-long impact of preventive cardiovascular screening strategies initiated after women experienced preeclampsia during pregnancy. Screening was started at the age of 30 or 40 years and repeated every five years. Data (initial and follow-up) from women with a history of preeclampsia was used to calculate 10-year cardiovascular disease risk estimates according to Framingham Risk Score. An absolute risk threshold of 2% was evaluated for treatment selection, i.e. lifestyle interventions (e.g. increasing physical activity). Screening benefits were assessed in terms of costs and quality-adjusted-life-years, and incremental cost-effectiveness ratios compared with no screening.

RESULTS

Expected health outcomes for no screening are 27.35 quality-adjusted-life-years and increase to 27.43 quality-adjusted-life-years (screening at 30 years with 2% threshold). The expected costs for no screening are €9426 and around €13,881 for screening at 30 years (for a 2% threshold). Preventive screening at 40 years with a 2% threshold has the most favourable incremental cost-effectiveness ratio, i.e. €34,996/quality-adjusted-life-year, compared with other screening scenarios and no screening.

CONCLUSIONS

Early cardiovascular disease risk screening followed by risk-based lifestyle interventions may lead to small long-term health benefits in women with a history of preeclampsia. However, the cost-effectiveness of a lifelong cardiovascular prevention programme starting early after preeclampsia with risk-based lifestyle advice alone is relatively unfavourable. A combination of risk-based lifestyle advice plus medical therapy may be more beneficial.

Sex differences in stress-related disorders: Major depressive disorder, bipolar disorder, and posttraumatic stress disorder

Stress-related disorders, such as mood disorders and posttraumatic stress disorder (PTSD), are more common in women than in men. This sex difference is at least partly due to the organizing effect of sex steroids during intrauterine development, while activating or inhibiting effects of circulating sex hormones in the postnatal period and adulthood also play a role. Such effects result in structural and functional changes in neuronal networks, neurotransmitters, and neuropeptides, which make the arousal- and stress-related brain systems more vulnerable to environmental stressful events in women. Certain brainstem nuclei, the amygdala, habenula, prefrontal cortex, and hypothalamus are important hubs in the stress-related neuronal network. Various hypothalamic nuclei play a central role in this sexually dimorphic network. This concerns not only the hypothalamus-pituitary-adrenal axis (HPA-axis), which integrates the neuro-endocrine-immune responses to stress, but also other hypothalamic nuclei and systems that play a key role in the symptoms of mood disorders, such as disordered day-night rhythm, lack of reward feelings, disturbed eating and sex, and disturbed cognitive functions. The present chapter focuses on the structural and functional sex differences that are present in the stress-related brain systems in mood disorders and PTSD, placing the HPA-axis in the center. The individual differences in the vulnerability of the discussed systems, caused by genetic and epigenetic developmental factors warrant further research to develop tailor-made therapeutic strategies.

Depression, Anxiety, and Post-traumatic Stress Disorder Following a Hypertensive Disorder of Pregnancy: A Narrative Literature Review

Introduction: Pregnancy and childbirth can be a source of anxiety and worry for women. This is probably more so for women with a complicated pregnancy. Anxiety and worry may contribute to, or exacerbate, mental health disorders including depression and post-traumatic stress disorder (PTSD). Mental health is an integral part of health and well-being and poor mental health can be detrimental to the woman's welfare and her infant's behavior and cognitive development. It may be undetected, potentially leading to a burden on the woman, her family, the health system, and society. Women with complicated pregnancies, such as those with hypertensive disorders of pregnancy (HDP), may be at greater risk of poor mental health. The aim of this review was to examine whether there is an association between depression, anxiety, and PTSD in postpartum women with a history of HDP.

Methods: A narrative literature review was undertaken. Using the key search terms: preeclampsia, gestational hypertension, hypertensive disorders, pregnancy complications, depression, anxiety, and post-traumatic stress disorder; electronic databases were searched to determine what is known about depression, anxiety, and PTSD after HDP.

Results: In total, 17 publications were included. The relationship between HDP and depression, anxiety, and PTSD was variable between studies and inconsistent. Although some studies reported no significant association, there is a trend for increased prevalence and symptom severity of depression, anxiety, and PTSD following HDP. This trend was particularly evident following the more severe presentations of HDP. It was uncertain whether this association was due to the hypertensive disorder itself, the sequelae of the HDP, such as giving birth to a preterm baby, or it predated the pregnancy.

Conclusions: Women who experience HDP may be at increased risk of developing postpartum depression, anxiety, and PTSD. Awareness of, and screening for, these mental health disorders in the postpartum period will alert clinicians to the need for additional follow-up and referral for women following HDP. More research on the benefits and risks of such an approach is needed.

A Pilot Study of Oxytocin in Low-Income Women With a Low Birth-Weight Infant: Is Oxytocin Related to Posttraumatic Stress?

BACKGROUND

Negative outcomes related to prematurity may lead to maternal distress. Mothers of premature/low birth-weight infants report increased posttraumatic stress (50%) and depressive symptoms (63%) compared with mothers of full-term infants. Low-income, minority mothers with greater posttraumatic stress and depression have an increased risk for premature/low birth-weight delivery compared with their white counterparts. Variations in the neuropeptide oxytocin are implicated in lactation, perinatal depression, and maternal behavior.

PURPOSE

To examine the associations among posttraumatic stress, depressive symptoms, and oxytocin in a pilot sample of minority mothers with premature/low birth-weight infants in the neonatal intensive care unit (NICU).

METHODS

This study employed a descriptive, correlational pilot design of 8 minority, low-income mothers with premature/low birth-weight infants. Participants answered questionnaires pertaining to posttraumatic stress, depression, lactation, and demographics and oxytocin was measured. This is a substudy that added oxytocin values.

RESULTS

Four participants had elevated depressive symptoms and 5 supplied their own milk. Women who provided their own milk had lower depressive (t = 3.03, P = .023) and posttraumatic stress (t = 3.39, P = .015) symptoms compared with women not supplying their own milk. Women with elevated posttraumatic stress had higher levels of depressive symptoms (r(8) = 0.8, P = .006) and lower levels of oxytocin (r(8) = 0.77, P = .026).

IMPLICATIONS FOR PRACTICE

These results are congruent with previous literature on providing human milk and maternal mental health. In addition, we found a possible relationship between postpartum posttraumatic stress and oxytocin in minority women with premature/low birth-weight infants. NICU nurses should encourage lactation and assess mothers for posttraumatic stress and depressive symptoms.

IMPLICATIONS FOR RESEARCH

Research is needed to identify the biologic milieu associated with posttraumatic stress and depression in at-risk mothers.

History of Preeclampsia Adds to the Deleterious Effect of Chronic Stress on the Cardiac Ability to Flexibly Adapt to Challenge

Preeclampsia, a pregnancy-specific disorder, presents a major health problem during gestation, but is also associated with increased risk for cardiovascular complications in later life. We aimed to investigate whether chronic stress experience and preeclampsia may have additive adverse effects on the cardiac ability to flexibly adapt to challenge, that is, to mount an appropriately vigorous heart rate response to an acute psychological challenge, or whether they may perhaps have synergistic effects (e.g., mutual augmentation of effects). Blunted cardiac responding to challenge has been linked to poor health outcomes in the longer term. Women previously affected by preeclampsia and women after uncomplicated pregnancies were tested 15-17 weeks post-partum in a standardized stress-reactivity protocol, while cardiovascular variables were simultaneously recorded. Changes in heart rate and blood pressure in response to the stressor were analyzed with regard to the effects of history of preeclampsia and chronic stress experience. Findings indicated blunted cardiac responses in women with higher chronic stress experience (p = 0.020) and, independently from that, in women with a history of preeclampsia (p = 0.018), pointing to an additive nature of the effects of preeclampsia and chronic stress on impaired cardiovascular functioning. Consequently, if both are present, a history of preeclampsia may add to the already deleterious effects of the experience of chronic stress. The additive nature of the effects suggests that stress-reducing interventions, albeit they will not eliminate the heightened cardiovascular risk in patients with a history of preeclampsia, may improve their overall prognosis by avoiding further accumulation of risk.

Post-traumatic stress disorder in the perinatal period: A concept analysis

AIMS AND OBJECTIVES

To report an analysis of the concept of perinatal post-traumatic stress disorder.

BACKGROUND

Prevalence of perinatal post-traumatic stress disorder is rising in the USA, with 9% of the U.S. perinatal population diagnosed with the disorder and an additional 18% being at risk for the condition. Left untreated, adverse maternal-child outcomes result in increased morbidity, mortality and healthcare costs.

DESIGN

Concept analysis via Walker and Avant's approach.

METHODS

The databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Academic Search Premier and PsychINFO were searched for articles, written in English, published between 2006-2015, containing the terms perinatal and post-traumatic stress disorder.

RESULTS

Perinatal post-traumatic stress disorder owns unique attributes, antecedents and outcomes when compared to post-traumatic stress disorder in other contexts, and may be defined as a disorder arising after a traumatic experience, diagnosed any time from conception to 6 months postpartum, lasting longer than 1 month, leading to specific negative maternal symptoms and poor maternal-infant outcomes. Attributes include a diagnostic time frame (conception to 6 months postpartum), harmful prior or current trauma and specific diagnostic symptomatology defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Antecedents were identified as trauma (perinatal complications and abuse), postpartum depression and previous psychiatric history. Consequences comprised adverse maternal-infant outcomes.

CONCLUSIONS

Further research on perinatal post-traumatic stress disorder antecedents, attributes and outcomes in ethnically diverse populations may provide clinicians a more comprehensive framework for identifying and treating perinatal post-traumatic stress disorder.

RELEVANCE TO CLINICAL PRACTICE

Nurses are encouraged to increase their awareness of perinatal post-traumatic stress disorder for early assessment and intervention, and prevention of adverse maternal-infant outcomes.

Risk factors for chronic post-traumatic stress disorder development one year after vaginal delivery: a prospective, observational study

Our study aimed to assess the prevalence of post-traumatic stress disorder (PTSD) after childbirth one year after vaginal delivery and to identify characteristics of women and deliveries associated with it. Questionnaires were mailed a year after delivery to 1103 women with prospectively collected delivery and postpartum data, including a question on day 2 assessing their experience of childbirth. PTSD was assessed a year later by the Impact of Event and Traumatic Event Scales; 22 women (4.2%, 95%CI 2.7-6.3%) met the PTSD diagnostic criteria and 30 (5.7%; 95%CI 3.9-8.0%) PTSD profile criteria. Factors associated with higher risk of PTSD profile were previous abortion (aOR 3.6, 95%CI 1.4-9.3), previous postpartum hemorrhage (Aor 5.3, 95%CI 1.3-21.4), and postpartum hemoglobin <9 g/dl (aOR 2.7, 95%CI 1.0-7.5). Among 56 women (10.3%) reporting bad childbirth memories at day 2 postpartum, 11 (21.1%) met PTSD diagnosis and 11 (21.1%) PTSD profile criteria a year later, compared with 11 (2.4%) (P < 0.001) and 18 (3.8%) (P < 0.001), respectively, of the 489 (87.7%) women with good memories. PTSD is not rare at one year after vaginal delivery in a low-risk population. A simple question at day 2 post partum may identify women most at risk of PTSD and help determine if early intervention is needed.

Preeclampsia and the brain: neural control of cardiovascular changes during pregnancy and neurological outcomes of preeclampsia

Preeclampsia (PE) is a form of gestational hypertension that complicates ∼5% of pregnancies worldwide. Over 70% of the fatal cases of PE are attributed to cerebral oedema, intracranial haemorrhage and eclampsia. The aetiology of PE originates from abnormal remodelling of the maternal spiral arteries, creating an ischaemic placenta that releases factors that drive the pathophysiology. An initial neurological outcome of PE is the absence of the autonomically regulated cardiovascular adaptations to pregnancy. PE patients exhibit sympathetic overactivation, in comparison with both normotensive pregnant and hypertensive non-pregnant females. Moreover, PE diminishes baroreceptor reflex sensitivity (BRS) beyond that observed in healthy pregnancy. The absence of the cardiovascular adaptations to pregnancy, combined with sympathovagal imbalance and a blunted BRS leads to life-threatening neurological outcomes. Behaviourally, the increased incidences of maternal depression, anxiety and post-traumatic stress disorder (PTSD) in PE are correlated to low fetal birth weight, intrauterine growth restriction (IUGR) and premature birth. This review addresses these neurological consequences of PE that present in the gravid female both during and after the index pregnancy.

The OptiMUM-study: EMDR therapy in pregnant women with posttraumatic stress disorder after previous childbirth and pregnant women with fear of childbirth: design of a multicentre randomized controlled trial

Background: Approximately 3% of women develop posttraumatic stress disorder (PTSD) after giving birth, and 7.5% of pregnant women show a pathological fear of childbirth (FoC). FoC or childbirth-related PTSD during (a subsequent) pregnancy can lead to a request for an elective caesarean section as well as adverse obstetrical and neonatal outcomes. For PTSD in general, and several subtypes of specific phobia, eye movement desensitization and reprocessing (EMDR) therapy has been proven effective, but little is known about the effects of applying EMDR during pregnancy. Objective: To describe the protocol of the OptiMUM-study. The main aim of the study is to determine whether EMDR therapy is an effective and safe treatment for pregnant women with childbirth-related PTSD or FoC. In addition, the cost-effectiveness of this approach will be analysed. Method: The single-blind OptiMUM-study consists of two two-armed randomized controlled trials (RCTs) with overlapping design. In several hospitals and community midwifery practices in Amsterdam, the Netherlands, all eligible pregnant women with a gestational age between eight and 20 weeks will be administered the Wijma delivery expectations questionnaire (WDEQ) to asses FoC. Multiparous women will also receive the PTSD checklist for DSM-5 (PCL-5) to screen for possible PTSD. The clinician administered PTSD scale (CAPS-5) will be used for assessing PTSD according to DSM-5 in women scoring above the PCL-5 cut-off value. Fifty women with childbirth-related PTSD and 120 women with FoC will be randomly allocated to either EMDR therapy carried out by a psychologist or care-as-usual. Women currently undergoing psychological treatment or women younger than 18 years will not be included. Primary outcome measures are severity of childbirth-related PTSD or FoC symptoms. Secondary outcomes are percentage of PTSD diagnoses, percentage caesarean sections, subjective childbirth experience, obstetrical and neonatal complications, and health care costs. Results: The results are meant to provide more insight about the safety and possible effectiveness of EMDR therapy during pregnancy for women with PTSD or FoC. Conclusion: This study is the first RCT studying efficacy and safety of EMDR in pregnant women with PTSD after childbirth or Fear of Childbirth.

Posttraumatic stress disorder in parents following infant death: A systematic review

Parents who have lost an infant prior to, during, or following birth often interpret the event as highly traumatic. The present systematic review included 46 articles based on 31 different studies of posttraumatic stress disorder (PTSD) in parents bereaved by infant death. The PTSD prevalence in mothers differed widely across studies with estimated rates at 0.6-39%. PTSD in fathers following infant loss has been less extensively studied but PTSD levels were generally much lower than in mothers with reported prevalence rates at 0-15.6% across studies. PTSD symptoms were not found to differ much depending on whether the death occurred prior to, during, or following birth and nor was gestational age consistently associated with PTSD severity. A number of risk and protective factors have been found to be associated with PTSD severity. Relevant focus areas for future research are presented along with considerations for future pregnancies and children. The suffering associated with PTSD following infant loss is overwhelming because of the rates at which such losses occur around the world. For this reason, it is problematic that not all types of infant loss resulting in sufficient symptoms of re-experiencing, avoidance, and arousal can elicit a DSM-5 PTSD diagnosis.

Long-term follow-up of psychosocial distress after early onset preeclampsia: the Preeclampsia Risk EValuation in FEMales cohort study

OBJECTIVE

To examine long-term psychosocial distress in women with a history of early onset preeclampsia (PE) compared to a comparison group.

METHODS

Women with and without a history of early onset PE participating in the 'Preeclampsia Risk EValuation in FEMales' (PREVFEM) study were sent questionnaires, on average 14.1 years (SD = 3.2, range 5-23 years) after the index pregnancy. In total 265 (77%) women with PE and 268 (78%) age-matched women without PE returned questionnaires (mean age 43.5, SD =4.6 years). Group differences were examined on indicators of psychosocial distress, depressive symptoms, anxiety, fatigue, loneliness, marital quality, trait optimism and Type D personality, and unadjusted and adjusted for a priori chosen and study-specific covariates. In secondary analyses, the effect of previously detected hypertension was examined, as well as pregnancy-related events within the PE group.

RESULTS

Women with a history of PE reported more subsequent depressive symptoms (B = 0.70, 95% CI 0.09-1.32, p = 0.026) and more fatigue (B = 1.12, 95% CI 0.07-2.18, p = 0.037) compared to the non-PE group, but the differences explained less than 1% of the variance. The differences remained after adjustment for age, BMI and education level, and additional adjustment for partner, being unemployed and physical activity. No significant differences were observed for anxiety, loneliness, marital quality, optimism, or Type D personality. These differences were not explained by four-year previously measured elevated blood pressure in the PE group. Having had a stillborn child or early neonatal death during the index pregnancy was associated with higher depressive symptoms, anxiety, fatigue, and loneliness in the PE group, but these factors explained only a small proportion of the variance in these psychosocial distress factors.

CONCLUSION

A history of early PE is associated with slightly higher levels of depressive symptoms and fatigue on average 14 years later, but this is unlikely to be of clinical relevance.

The aetiology of post-traumatic stress following childbirth: a meta-analysis and theoretical framework

There is evidence that 3.17% of women report post-traumatic stress disorder (PTSD) after childbirth. This meta-analysis synthesizes research on vulnerability and risk factors for birth-related PTSD and refines a diathesis-stress model of its aetiology. Systematic searches were carried out on PsycINFO, PubMed, Scopus and Web of Science using PTSD terms crossed with childbirth terms. Studies were included if they reported primary research that examined factors associated with birth-related PTSD measured at least 1 month after birth. In all, 50 studies (n = 21 429) from 15 countries fulfilled inclusion criteria. Pre-birth vulnerability factors most strongly associated with PTSD were depression in pregnancy (r = 0.51), fear of childbirth (r = 0.41), poor health or complications in pregnancy (r = 0.38), and a history of PTSD (r = 0.39) and counselling for pregnancy or birth (r = 0.32). Risk factors in birth most strongly associated with PTSD were negative subjective birth experiences (r = 0.59), having an operative birth (assisted vaginal or caesarean, r = 0.48), lack of support (r = -0.38) and dissociation (r = 0.32). After birth, PTSD was associated with poor coping and stress (r = 0.30), and was highly co-morbid with depression (r = 0.60). Moderator analyses showed that the effect of poor health or complications in pregnancy was more apparent in high-risk samples. The results of this meta-analysis are used to update a diathesis-stress model of the aetiology of postpartum PTSD and can be used to inform screening, prevention and intervention in maternity care.

Factors Associated with Post-Traumatic Symptoms in Mothers of Preterm Infants

OBJECTIVES

Symptoms of post-traumatic distress in mothers of preterm infants have been a subject of mental health research. The aim of this study was to assess the prevalence of and risk factors associated with such symptoms in mothers of preterm infants in Taiwan.

METHODS

This was a cross-sectional study performed between January 1, 2010 and June 30, 2011. One hundred and two mothers of preterm infants born at less than 37 weeks gestation and with a subsequent neonatal intensive care unit (NICU) stay between 2005 and 2009 were recruited. Participants completed a demographic questionnaire, the Impact of Event Scale-Revised (IES-R), the Center for Epidemiologic Studies Depression Scale (CES-D) and the neuroticism subscale of the Maudsley Personality Inventory (MPI). The preterm infants' data were taken from medical records.

RESULTS

The prevalence of symptoms of distress was 25.5% (26/102) in the participants. These symptoms were associated with previous miscarriages, preterm premature rupture of membranes, neurotic personality and depression.

CONCLUSIONS

The experience of preterm birth and NICU hospitalization can be traumatic to mothers. Early support for mothers during the preterm infants' NICU stay and transition to home care are recommended.

Women's experiences of symptoms of posttraumatic stress disorder (PTSD) after traumatic childbirth: a review and critical appraisal

This paper critically analyses nine studies on postnatal posttraumatic stress disorder (PTSD) following traumatic childbirth, in order to find common themes of PTSD symptoms, using the cognitive model of PTSD as a guide; it critically appraised one of the studies in depth and it attempted to explain the lived experience of women suffering from postnatal PTSD following traumatic childbirth and the suitability of cognitive behavioural therapy (CBT) for postnatal PTSD. This paper found that women following traumatic childbirth do experience postnatal PTSD; postnatal PTSD symptoms are similar to PTSD symptoms of other events and that CBT for PTSD of other events is just as effective for postnatal PTSD. Future recommendations include more qualitative studies with interpretative phenomenological approach in order to establish evidence-based CBT treatment for this client group, and more referrals need to be sent to the psychological services for CBT intervention.

The attachment of prematurely born children at school age: A pilot study

This prospective longitudinal study compared the psychological development and patterns of attachment of 20 prematurely born children and 20 full-term children at 7 years of age. The School-age Assessment of Attachment (SAA) was used, and hypotheses and interpretation of the findings were drawn from the Dynamic-Maturational Model of Attachment and Adaptation (DMM). Significant differences between prematurely born and full-term children were found: 10% versus 0% at "high" risk, 55% versus 25% at "moderate" risk, and 35% versus 75% at "low" risk. There were no differences in the percentage of psychological trauma between samples, but there was a difference in the types of experiences leading to trauma. For prematurely born children, it was most often illness, whereas for full-term children, it was family problems. We discuss the implications for clinicians.

Neurocognitive functioning following preeclampsia and eclampsia: a long-term follow-up study

OBJECTIVE

Women who suffered preeclampsia and eclampsia may report subjective cognitive difficulties in daily life, the interpretation of which is cumbersome, because these are affected by emotional factors. Previous studies only included preeclamptic women investigated shortly after pregnancy. We aimed to determine whether these subjective reports of cognitive difficulty could be interpreted as reflecting objective cognitive dysfunction. Therefore, cognitive functioning was assessed using standardized neurocognitive tests in both preeclamptic and eclamptic women several years following the index pregnancy.

STUDY DESIGN

Forty-six formerly eclamptic, 51 formerly preeclamptic, and 48 control women who had normotensive pregnancies, age-matched, participated in this study. Average elapsed time since index pregnancy was 7 years. Neurocognitive tests were divided into 6 domains; visual perception, motor functions, working memory, long-term memory, attention, and executive functioning. Subjective cognitive functioning was measured by the Cognitive Failures Questionnaire and anxiety/depression by the Hospital Anxiety and Depression Scale.

RESULTS

Both preeclamptic and eclamptic women performed worse on the motor functions domain (P < .05), without differences on the other domains. They scored worse on the Cognitive Failures Questionnaire (P < .01), the Hospital Anxiety and Depression Scale anxiety (P < .01), and depression (P < .05) subscales.

CONCLUSION

Women who suffered eclampsia and/or preeclampsia demonstrate no objective cognitive impairment as compared with controls. Contrary to the well-structured test setting, both groups do report more cognitive failures, which are thought to reflect neurocognitive dysfunction in complex, stressful daily-life situations. Such report of cognitive failures may be compounded by anxiety and depression. Future studies should focus on the relationship of neurocognitive functioning with structural cerebral abnormalities.

The relationship between severe maternal morbidity and psychological health symptoms at 6-8 weeks postpartum: a prospective cohort study in one English maternity unit

BACKGROUND

The incidence of severe maternal morbidity is increasing in high-income countries. However, little has been known about the impact on postnatal morbidity, particularly on psychological health outcomes. The objective of this study was to assess the relationship between severe maternal morbidity (ie. major obstetric haemorrhage, severe hypertensive disorders or intensive care unit/obstetric high dependency unit admission) and postnatal psychological health symptoms, focusing on post-traumatic stress disorder (PTSD) symptoms at 6-8 weeks postpartum.

METHOD

A prospective cohort study was undertaken of women who gave birth over six months in 2010 in an inner city maternity unit in England. Primary outcomes were prevalence of PTSD symptoms namely: 1) intrusion and 2) avoidance as measured using the Impact of Event Scale at 6 - 8 weeks postpartum via a self-administered postal questionnaire. Secondary outcomes included probable depression. Data on incidence of severe maternal morbidity were extracted from maternity records. Multivariable logistic regression analysis examined the relationship between severe maternal morbidity and PTSD symptoms taking into account factors that might influence the relationship.

RESULTS

Of women eligible to participate (n=3509), 52% responded. Prevalence of a clinically significant level of intrusion and avoidance were 6.4% (n=114) and 8.4% (n=150) respectively. There was a higher risk of PTSD symptoms among women who experienced severe maternal morbidity compared with women who did not (adjusted OR = 2.11, 95%CI = 1.17-3.78 for intrusion; adjusted OR = 3.28, 95%CI = 2.01-5.36 for avoidance). Higher ratings of reported sense of control during labour/birth partially mediated the risk of PTSD symptoms. There were no statistically significant differences in the prevalence or severity of symptoms of depression.

CONCLUSION

This is one of the largest studies to date of PTSD symptoms among women who had recently given birth. Findings showed that an experience of severe maternal morbidity was independently associated with symptoms of PTSD. Individually tailored care that increases women's sense of control during labour may be a protective factor with further work required to promote effective interventions to prevent these symptoms. Findings have important implications for women's health and the content and organisation of maternity services during and after the birth.

Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy

OBJECTIVE

This guideline summarizes the quality of the evidence to date and provides a reasonable approach to the diagnosis, evaluation and treatment of the hypertensive disorders of pregnancy (HDP).

EVIDENCE

The literature reviewed included the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines from 2008 and their reference lists, and an update from 2006. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT) and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2006 and March 2012. Articles were restricted to those published in French or English. Recommendations were evaluated using the criteria of the Canadian Task Force on Preventive Health Care and GRADE.

Including ethical considerations in models for first-trimester screening for pre-eclampsia

Recent efforts to develop reliable and efficient early pregnancy screening programmes for pre-eclampsia have focused on combining clinical, biochemical and biophysical markers. The same model has been used for first-trimester screening for fetal aneuploidies i.e. prenatal diagnosis (PD), which is routinely offered to all pregnant women in many developed countries. Some studies suggest combining PD and pre-eclampsia screening, so women can be offered testing for a number of conditions at the same clinical visit. A combination of these tests may be practical in terms of saving time and resources; however, the combination raises ethical issues. First-trimester PD and pre-eclampsia screening entail qualitative differences which alter the requirements for disclosure, non-directedness and consent with regard to the informed consent process. This article explores the differences related to the ethical issues raised by PD and pre-eclampsia in order to elucidate which factors are relevant to deciding the type of information and consent required in each context from the perspective of the ethical principles of beneficence and autonomy. Furthermore, it argues that ensuring respect for patient autonomy is context dependent and, consequently, pre-eclampsia screening and PD should be performed independently of one another.

Anxiety and depression following preeclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome. A systematic review

Women who suffered from pregnancy complications are at increased risk for anxiety and depression. The aim of this study was to evaluate whether having suffered from preeclampsia (PE) or HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome is associated with anxiety and depression, and whether PE/HELLP is an independent risk factor for developing anxiety and depression. Systematic search on PubMed and PsycInfo with no time limit. Studies presenting original data, including women with a history of PE/HELLP and at least one comparison group of women without PE/HELLP, reporting the results for each group separately or in a multivariate regression analysis with PE/HELLP as an independent variable. Study characteristics and outcomes were extracted using a prespecified form. If necessary, additional calculations were performed. The search yielded 267 articles, with only six being suitable for inclusion in this review. Studies on depression (six studies) showed generally positive associations between PE/HELLP and the prevalence of depression or severity of depressive symptoms. However, the results of three studies were not statistically significant. Studies addressing anxiety (two studies) did not show significant associations between PE/HELLP and anxiety scores. Associations between post-traumatic stress and PE/HELLP, investigated in four studies, were often nonsignificant. Due to heterogeneity of study methods, a meta-analysis of the results was not possible. In most studies, confounder control was poor. Evidence is mixed but generally points to positive associations between various forms of psychopathology and previous PE/HELLP. Causality of the associations can, however, not be judged adequately.

Web recruitment and internet use and preferences reported by women with postpartum depression after pregnancy complications

Nearly one million women each year have pregnancy complications that cause antepartum and postpartum anxiety and depression. This exploratory study determined 1) feasibility of using social media to recruit women with depressive symptoms following high risk pregnancy, 2) women's barriers to treatment, 3) use of online resources for assistance with PPD, and 4) preferences for internet treatment. Among a national sample of 53 women, nearly 70% had major depression. Common barriers were lack of time and stigma. Over 90% of women would use the internet to learn coping strategies for PPD. Women expressed interest in web-based PPD treatment and identified desired characteristics of an intervention.

Post-Traumatic Stress Disorder (PTSD) Following Childbirth: Prevalence and Contributing Factors

Background

Childbirth might be a traumatic event for some women.

Objectives

This study was conducted with the objective of investigating the prevalence of Post-Traumatic Stress Disorder (PTSD) following childbirth.

Patients and Methods

The study was designed using a descriptive correlation scheme. The participants were selected from the women referred to the healthcare centers affiliated with Zahedan University of Medical Sciences, Zahedan, Iran. Personal interviews were conducted with 600 women who were 6-8 weeks postpartum and had been undergone to this center for postpartum and child care.

Results

One hundred and three (17. 2%) women had symptoms of PTSD following childbirth based on the PTSD Symptom Scale (PSS). The results of logistic regression analysis revealed a significant correlation between maternal occupation (P = 0.01), depression level (P < 0.001) and anxiety level (P < 0.001) with PTSD following childbirth.

Conclusions

PTSD from childbirth occurs in some women. Early identification of risk factors should lead to early therapeutic intervention in the mothers at risk of PTSD.

Long-term child follow-up after large obstetric randomised controlled trials for the evaluation of perinatal interventions: a systematic review of the literature

BACKGROUND

Although the hope is that many perinatal interventions are performed with an ultimate aim to improve the long-term health and development of the child, long-term outcome is rarely used as a primary end-point in perinatal randomised controlled trials (RCTs).

OBJECTIVE

To evaluate how often and with which tools long-term follow-up is performed after large obstetric RCTs.

SEARCH STRATEGY

We searched the Cochrane Library for Cochrane reviews published by the Cochrane Pregnancy and Childbirth Group for reviews on interventions that aimed to improve neonatal outcome. Selection criteria  Reviews on perinatal interventions that were not performed to improve the condition of the neonate were excluded. We limited our review to RCTs with more than 350 participating women. For each included study, we checked in Web of Science as to whether the researchers had reported on follow-up in subsequent publications.

DATA COLLECTION AND ANALYSIS

Relevant information was extracted from these RCTs by two reviewers using a predefined data collection sheet. All information was analysed using SPSS 17.0 (SPSS Inc., Chicago, IL, USA).

MAIN RESULTS

We studied 212 reviews including 1837 RCTs on perinatal interventions, 249 (14%) of which included 350 participants. Only 40 of 249 RCTs (16%) followed the children after discharge from the hospital to evaluate the effect of a specific perinatal intervention. The number of RCTs with long-term follow-up remained stable, with 10 of 67 RCTs (15%) reporting follow-up before 1990, 17 of 115 (15%) between 1990 and 2000, and 13 of 67 (19%) after 2000 (P = 0.68).

CONCLUSIONS

Only a small minority of large perinatal RCTs report the long-term follow-up of the child. Future obstetric RCTs should consider performing long-term follow-up at the start of the trial.

Posttraumatic stress following childbirth in homelike- and hospital settings

OBJECTIVE

To assess the prevalence of posttraumatic stress disorder (PTSD) following childbirth in homelike versus hospital settings and to determine risk factors for the development of posttraumatic stress symptoms. METHODS.: Multi-center cross-sectional study at midwifery practices, general hospitals and a tertiary (university) referral center. An unselected population of 907 women was invited to complete questionnaires on PTSD, demographic, psychosocial, and obstetric characteristics 2 to 6 months after delivery. Prevalence of PTSD was based on women who met all criteria of the diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV), whereas risk factors were determined using the severity (sum-score) of posttraumatic stress symptoms.

RESULTS

PTSD following childbirth was found in 1.2% of the respondents (5/428 women, response rate 47%), while 9.1% of women (39/428) had experienced the delivery as traumatic. Posttraumatic stress symptoms were associated with unplanned cesarean section, low sense of coherence (coping skills), and high intensity of pain. Initial differences in posttraumatic stress symptoms between home and hospital deliveries disappeared after taking into account the (by definition) uncomplicated nature of home births.

CONCLUSION

In this Dutch study, 1 in 100 women had PTSD following childbirth, with no differences between home- and hospital deliveries after controlling for complications and interventions. Emergency cesarean section, severe labor pain, and poor coping skills were associated with more posttraumatic stress symptoms.