Posttraumatic stress disorder and pregnancy complications

doi:10.1016/S0029-7844(00)01097-8

Obstetrics & Gynecology

Volume 97, Issue 1, January 2001, Pages 17-22

https://doi.org/10.1016/S0029-7844(00)01097-8 Get rights and content

Abstract

Objective: To assess the associations between specific pregnancy complications and posttraumatic stress disorder based on neurobiologic and behavioral characteristics, using Michigan Medicaid claims data from 1994–1996.

Methods: Two thousand, two hundred nineteen female recipients of Michigan Medicaid who were of childbearing age had posttraumatic stress disorder on the basis of International Classification of Diseases, 9th Revision (ICD-9) codes. Twenty percent (n = 455) of those recipients and 30% of randomly selected comparison women with no mental health diagnostic codes (n = 638; P < .001) had ICD-9 diagnostic codes for pregnancy complications. We used multiple logistic regression to investigate associations between specific pregnancy complications and posttraumatic stress disorder, controlling for demographic and psychosocial variables. Obstetric complications were hypothesized based on high-risk behaviors and neurobiologic alterations in stress axis function in posttraumatic stress disorder.

Results: After controlling for demographic and psychosocial factors, women with posttraumatic stress disorder had higher odds ratios (ORs) for ectopic pregnancy (OR 1.7, 95% confidence interval [CI] 1.1, 2.8), spontaneous abortion (OR 1.9, 95% CI 1.3, 2.9), hyperemesis (OR 3.9, 95% CI 2.0, 7.4), preterm contractions (OR 1.4, 95% CI 1.1, 1.9), and excessive fetal growth (OR 1.5, 95% CI 1.0, 2.2). Hypothesized labor differences were not confirmed and no differences were found for complications not thought to be related to traumatic stress.

Conclusions: Pregnant women with posttraumatic stress disorder might be at higher risk for certain conditions, and assessment and treatment for undiagnosed posttraumatic stress might be warranted for women with those obstetric complications. Prospective studies are needed to confirm present findings and to determine potential biologic mechanisms. Treatment of traumatic stress symptoms might improve pregnancy morbidity and maternal mental health.

Section snippets

Materials and methods

We used a dataset with mental health and perinatal data, Michigan’s Medicaid Eligibility and Paid Claims records, to test our hypothesis. The data included the completely processed fee-for-service records beginning January 1, 1994 and ending December 31, 1996 for 526,692 women born from 1950–1983. The data had been encrypted to protect confidentiality, and The University of Michigan institutional review board approved this secondary analysis. Variables for this analysis came from International

Results

Among 526,629 female Medicaid recipients with fee-for-service data from 1994–1996, 104,287 (19.8%) had at least one mental health diagnostic code from among the ICD-9 codes 290–347. Among those women, 2219 (2.1%) had code 309.81 for posttraumatic stress disorder. That is a prevalence of 0.4%, which likely represents an underreporting of the disorder.2

Bivariate tests on demographic variables (Table 1) showed no group differences in age. There were more white women in the diagnosed group,

Discussion

Our findings suggest that women with posttraumatic stress disorder might be at higher risk for some physical pregnancy problems, which were predicted based on known behavioral and neuroendocrine sequelae of traumatic stress, including ectopic pregnancy, spontaneous abortion, hyperemesis, preterm contractions, and excessive fetal growth. Hypothesized labor differences were not confirmed in those data. No differences were found in complication rates that were not believed to be related to

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Increasing prevalence of substance use in pregnancy presents a public health crisis that is compounded by posttraumatic stress disorder (PTSD) comorbidity. We aimed to detail the clinical complexities of PTSD treatment provision among pregnant women with substance use histories.
We conducted a qualitative study using clinical case consultation field notes (N = 47 meetings) which were gathered during a hybrid effectiveness-implementation pilot study of Written Exposure Therapy (WET) for PTSD among pregnant women seen in an obstetrics-SUD clinic [2019–2021]. Patient baseline survey data (N = 25) were used to characterize the sample and contextualize engagement.
Participants were exposed to a high number of trauma/adversity event types. There was no association between number of trauma/adversity event types and treatment response or dropout. Qualitative findings revealed clinical features relevant to PTSD treatment, including multi-system involvement; parental trauma and substance use; relevance of substance use to trauma context and posttraumatic cognitions, emotions, and behaviors; impact of trauma on experiences of pregnancy, attachment, and child rearing; limited social networks placing women at risk of ongoing violence; and experiences of substance use discrimination.
PTSD treatment among pregnant women with substance use histories is highly important to maternal-child health.
Understanding the Mental Health Impact of Previous Pregnancy Loss Among Currently Pregnant Veterans
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Pregnancy loss, including miscarriage and stillbirth, is common and associated with an increased risk for prenatal and postnatal depression, as well as posttraumatic stress disorder (PTSD). Racial disparities have been observed in pregnancy loss, with Black women having higher rates of pregnancy loss and postnatal depression. However, no research to date has examined the mental health and demographic correlates of pregnancy loss within a veteran population.
The current study examined associations between pregnancy loss and mental health and demographic correlates among 1,324 pregnant veterans, of which 368 had a history of at least one stillbirth and/or miscarriage.
Veterans with a history of pregnancy loss, compared with those without, were more likely to have a diagnosis of anxiety (52.7% vs. 46.4%, p = .04), depression (62.5% vs. 50.8%, p = .0001), or PTSD (46.5% vs. 37.6%, p = .003); were more likely to report receiving mental health care during pregnancy (23.1% vs. 16.8%, p = .01); and were more likely to have experienced military sexual trauma (harassment: 56.5% vs. 49.9%, p = .04; rape: 38.9% vs. 29.3%, p = .0004). Results also indicated that Black veterans were more likely to report a history of pregnancy loss (32.1% vs. 25.3%, p = .01). Further, Black veterans were more likely to experience clinically meaningful prenatal depression symptoms (adjusted odds ratio: 1.90; 95% confidence interval: 1.42–2.54) after accounting for past loss and age in logistic regression models.
Taken together, findings from the present investigation corroborate previous research highlighting the deleterious impact of pregnancy loss and extend prior work by examining these associations among a diverse sample of pregnant veterans.
Cognitive Processing Therapy for Childbirth-Related Posttraumatic Stress Disorder: A Case Report
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Having a baby is a natural biological process and commonly considered a positive and exciting time in life. However, birth and the postpartum period also represent a vulnerable time for mental health and the development of posttraumatic stress disorder (PTSD) among women who are exposed to traumatic events during birth. Childbirth-related PTSD (CB-PTSD) is a relatively new and unique construct, associated with negative impacts to the mother, her infant, and family more broadly. Research investigating psychological interventions following traumatic births remains scant and no studies have evaluated cognitive processing therapy (CPT), a well-established and empirically supported psychological therapy, in the treatment of CB-PTSD. We conducted a case study using CPT for CB-PTSD, modifying the length of the traditional protocol to eight sessions, and tailoring the content to meet the unique needs of postpartum women. Following CPT for CB-PTSD, clinically significant and meaningful treatment outcomes were produced in both PTSD and depressive symptoms, with gains maintained at 1-month follow-up. Our modified version of CPT for CB-PTSD was also highly acceptable with the participant in our case study. These findings provide initial support for CPT as a strong psychotherapeutic intervention option for targeting CB-PTSD. Further research is necessary to examine this treatment and its acceptability with a larger sample.
Association of severe maternal morbidity and post-traumatic stress disorder
2022, AJOG Global Reports
Citation Excerpt :
Chronic psychosocial stress may indeed portend worse pregnancy outcomes. Previous studies have demonstrated that PTSD was associated with an increased risk for spontaneous abortion, gestational diabetes, preeclampsia, preterm birth, and prolonged hospitalization.21,22,29 Although the mechanism of psychological stress causing worse obstetrical outcomes is unknown, there is evidence that antenatal depression, anxiety, and stress are associated with poorer outcomes such as preterm birth, low birthweight, and cesarean delivery.30,31
Severe maternal morbidity refers to the most serious complications of pregnancy. Whether severe maternal morbidity is associated with post-traumatic stress disorder is currently under active investigation.
This study aimed to examine the association between severe maternal morbidity and post-traumatic stress disorder at delivery.
This was a retrospective cohort study querying the Healthcare Cost and Utilization Project's National Inpatient Sample, which included 12,857,721 patients for national estimates who had vaginal or cesarean deliveries between January 2016 and December 2019. Patients with mental health conditions other than post-traumatic stress disorder and substance use disorder were excluded. Severe maternal morbidity was defined according to the Centers for Disease Control and Prevention definition (a total of 21 indicators). Main outcomes were trends and characteristics related to post-traumatic stress disorder, assessed with a multivariable binary logistic regression model. Sensitivity analysis included subcohort assessment restricted to patients per clinical and obstetrical demographics.
A total of 8880 patients had a diagnosis of post-traumatic stress disorder during the hospital admission for delivery (prevalence rate, 6.9 per 10,000). The prevalence rate of post-traumatic stress disorder increased from 5.0 to 8.8 per 10,000 deliveries between 2016 and 2019. This increasing trend remained independent in multivariable analysis. The adjusted odds ratio, compared with 2016, was 1.26 (95% confidence interval, 1.19–1.35) for 2017, 1.50 (95% confidence interval, 1.41–1.60) for 2018, and 1.73 (95% confidence interval, 1.63–1.84) for 2019. Severe maternal morbidity occurred in 210,605 (1.6%) patients. Patients who had severe maternal morbidity were more likely to have a diagnosis of post-traumatic stress disorder than those without severe maternal morbidity (12.8 vs 6.8 per 10,000 deliveries; adjusted odds ratio, 1.57; 95% confidence interval, 1.39–1.78) in multivariable analysis. This association remained robust in several subcohort analyses including (1) participants aged ≤35 years (adjusted odds ratio, 1.62; 95% confidence interval, 1.41–1.86), (2) those aged ≤35 years without medical comorbidity (adjusted odds ratio, 2.01; 95% confidence interval, 1.70–2.37), and (3) those aged <35 years without medical comorbidity, cesarean delivery, and preterm delivery (adjusted odds ratio, 4.52; 95% confidence interval, 3.56–5.74).
There has been a gradual increase in the number of patients with a diagnosis of post-traumatic stress disorder at delivery in recent years among those without other mental health or substance use conditions. These data suggest that there is a possible association between severe maternal morbidity and post-traumatic stress disorder.
The associations between childhood maltreatment and pregnancy complications: A systematic review and meta-analysis
2022, Journal of Psychosomatic Research
Childhood maltreatment is associated with pregnancy complications. This study aimed to systematically review and quantitatively synthesize the strength of the associations between maternal histories of childhood maltreatment and the risk of preterm delivery, low birth weight, and gestational diabetes.
Subject Headings and keywords for childhood maltreatment and the pregnancy outcomes were searched in MEDLINE (Ovid; 1946-Present), PsycINFO (Ovid; 1806-Present), and Web of Science Core Collection. Original studies or dissertations that reported quantitative associations between childhood maltreatment and any of the pregnancy outcomes of interest were included. Two independent reviewers selected the pertinent studies, assessed the risk of bias, and extracted data. Pooled effect sizes were calculated for the three outcomes.
Twenty-eight studies were reviewed and 22 were meta-analysed. Maternal childhood maltreatment was associated with preterm birth (OR = 1.27 95% CI: 1.06–1.52, p = 0.001), low birth weight (OR = 1.42 95% CI: 1.10–1.83, p = 0.001), and gestational diabetes (RR = 1.37 95% CI: 1.02–1.83, p = 0.030), however high levels of heterogeneity were found. Findings were insignificant for studies examining gestational age and birth weight as continuous variables.
Findings confirm that under certain conditions, childhood maltreatment is associated with pregnancy outcomes. Future research should prioritize mediation and moderation models to clarify the mechanisms underlying these relationships. Trauma-informed care is needed to tailor the appropriate care for expecting mothers.
Prenatal maternal posttraumatic stress disorder as a risk factor for adverse birth weight and gestational age outcomes: A systematic review and meta-analysis
2021, Journal of Affective Disorders
Citation Excerpt :
Moreover, anxiety alone is associated with an increased risk of LBW and PTB (Ding et al., 2014), so analyzing anxiety data mixed with PTSD data may obscure PTSD effects. Thus, these summary studies, while suggesting a possible relationship, do not fill the critical gap in the literature regarding the consistency and degree of associations specifically between prenatal PTSD and these adverse birth outcomes (Engel et al., 2005; Rogal et al., 2007; Seng et al., 2001; Xiong et al., 2008). The aim of our meta-analytic study was to focus on PTSD and determine the magnitude of any association of prenatal PTSD with low birth weight (LBW), birth weight (BW), preterm birth (PTB), or gestational age (GA).
Although not routinely assessed, prenatal posttraumatic stress disorder (PTSD) is associated with poor maternal mental health and mother-infant bonding. Prenatal PTSD may also be associated with birth weight and gestational age outcomes, but this remains unclear. This systematic review and meta-analysis investigated the association of prenatal PTSD with risk of low birth weight (LBW) or preterm birth (PTB) (dichotomous medically-defined cut-offs) or with birth weight (BW) or gestational age (GA) (continuous variables).
A comprehensive literature search was conducted in Web of Science, MedLine, PubMed, and PsychInfo. Data were collected and processed according to Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Study quality was assessed with the Newcastle-Ottowa Quality Assessment Scale. Pooled effect sizes were estimated with random-effects models (correlation for continuous and odds ratios for dichotomous outcomes).
Sixteen studies with 51,470 participants (prenatal PTSD 8%) were included in 4 meta-analyses. Maternal prenatal PTSD was associated with higher risks of LBW (OR = 1.96; 95% CI, 1.26, 3.03; P = .003), PTB (OR = 1.42; 95% CI, 1.16, 1.73; P = .001), and reduced GA (r = -0.04; 95% CI, -0.06, -0.01; P = .002).
Different designs across studies, variety of PTSD assessment practices, and a small pool of studies were noted.
Findings suggest prenatal PTSD presents increased risks of LBW, PTB, and reduced GA. Evidence of physical harm to neonates from prenatal PTSD provides a powerful rationale to increase prenatal PTSD screening and identify effective prenatal interventions to improve maternal and child outcomes.

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^☆: Supported by Individual National Research Service Award NRO7301 from the National Institute of Nursing Research, Bethesda, Maryland; by a dissertation grant (315-SAP/98) from the Blue Cross and Blue Shield of Michigan Foundation, Detroit, Michigan; and by a Regents’ Fellowship from the University of Michigan, Ann Arbor, Michigan (Dr. Seng). The data for this study were made available by Health Management Associates, Inc., Lansing, Michigan.

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Posttraumatic stress disorder and pregnancy complications☆

Abstract

Section snippets

Materials and methods

Results

Discussion

Psychoneuroendocrinology

J Psychosom Res

Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women

J Consult Clin Psychol

Posttraumatic stress disorder in the National Comorbidity Survey

Arch Gen Psychiatry

Traumatic events and posttraumatic stress disorder in an urban population of young adults

Arch Gen Psychiatry

Trauma and posttraumatic stress disorder in the communityThe 1996 Detroit Area Survey of Trauma

Arch Gen Psychiatry

The scope of rapeIncidence and prevalence of sexual aggression and victimization in a national sample of higher education students

J Consult Clin Psychol

Risk factors for adolescent substance abuse and dependenceData from a national sample

J Consult Clin Psychol

Sequelae of abuseHealth effects of childhood sexual abuse, domestic battering, and rape

J Nurse Midwifery

Trauma and recoveryThe aftermath of violence—from domestic abuse to political terror