Understanding posttraumatic stress disorder (PTSD) during pregnancy is important given that PTSD is relatively common and persistent in nature. PTSD will occur in approximately 10% of women in their lifetime, with one-third of episodes lasting more than five years. Given the relatively high prevalence of PTSD in young women and the chronic nature of the illness, many women may experience PTSD symptoms during pregnancy.
PTSD is diagnosed when an individual has persistent symptoms related to a traumatic event, including re-experiencing the event (for example in the form of flashbacks or nightmares), avoiding feelings, people or places associated with the traumatic event, and having hyperarousal, or a high general level of anxiety, that can result in symptoms such as insomnia, startling easily, or irritability and outbursts of anger.
Studies have suggested that rates of PTSD are higher in pregnant women than in non-pregnant women. Some researchers have hypothesized that the unique psychological and physical aspects of pregnancy may exacerbate symptoms of PTSD. For women who have PTSD related to childhood abuse, for example, the process of preparing to become a parent can carry complex feelings and may worsen anxiety. Additionally, physical changes during pregnancy or routine prenatal care could trigger symptoms in women with a history of sexual abuse. In addition, women may stop psychotropic medications used to treat PTSD during pregnancy, thus increasing the likelihood of an increase in symptomatology.
Alternatively, sampling error in these studies may be responsible for higher reported rates of PTSD. Some symptoms of a normal pregnancy, such as insomnia, overlap with the symptoms of PTSD and could lead to a falsely elevated report of PTSD symptoms. Additionally, the majority of studies examining PTSD rates during pregnancy have studied young women from low-income community samples, a subpopulation with higher rates of PTSD at baseline.
A recent study by Seng and colleagues investigated perinatal outcomes for women with and without PTSD. In the study, 839 women were interviewed during their first pregnancy regarding a history of trauma and associated PTSD symptoms. The women fell in to three groups: women with PTSD, trauma-exposed women without PTSD and women without trauma histories. Perinatal outcomes including birth weight and gestational age were gathered from medical records at the time of delivery.
In this study, infants born to mothers with PTSD had a lower mean birth weight than infants in either the trauma-exposed group without PTSD or the group without a trauma history. This study did not address possible mechanisms for poorer perinatal outcomes in this population. It is not clear whether it is PTSD alone that leads to negative perinatal outcomes. One confounding factor is that PTSD is highly comorbid with depression and other anxiety disorders, which have also been associated with lower birth weight in infants and other adverse outcomes. Additionally, at least one study (Smith 2006) found that women with active PTSD symptoms in pregnancy were more likely to engage in poor health behaviors, including substance use, which may have a more direct impact on infant outcomes.
For women with PTSD, treatment is available. First line treatments include psychotherapy and antidepressant medication (selective serotonin reuptake inhibitors or SSRIs). Therapy targeted at PTSD symptoms during pregnancy should focus on establishing a sense of safety and coping with active symptoms. Exploration of traumatic events should only be done when a woman is not in crisis. Given the potential for worsening of symptoms, engaging in exploratory therapy would not be recommended during pregnancy or the postpartum period. Women should discuss the risks and benefits of treatment with their doctors, and medication should be used when potential benefits outweigh the risks.
Julia Wood, MD
References:
Seng JS, Low LK, Sperlich M, Ronis DL, Liberzon I. Post-traumatic stress disorder, child abuse history, birthweight and gestational age: a prospective cohort study. BJOG. 2011 Oct;118(11):1329-39.
Seng JS, Rauch SAM, Resnick H, Reed CD, King A, Low LK, McPherson, M, Muzik M, Abelson J, Liberzon I. Exploring posttraumatic stress disorder symptom profile among pregnant women. J Psychosom Obstet gynaecol. 2010 Sept; 31(3):176-187.
Smith MV, Poschman K, Cavaleri MA, Howell HB, Yonkers KA. Symptoms of Posttraumatic Stress Disorder in a Community Sample of Low-Income Pregnant Women. Am J Psychiatry 2006; 163:881-884.
2 Comments
Consider the possibility for studying the effects for prophylaxis of PTSD or depression. The study group could be women who have lost a viable pregnancy. In this situation, such as abruption , cord accident or undetected growth restriction, a day can go from seemingly normal to catastrophe.
The problem is that most people get no help after this horrible turn of events. Generally speaking, if the patient desires, clonazepam 1 -2 mg qhs for 3 weeks and .5-1 mg qd for 1 week. Additionally sertraline at 25 mg qhs. Clinically I have seen better outcomes for this group in terms of length and depth of depression.
One must consider that in these situations, the risk of post partum depression is 100% and the replay of the news that the baby is not alive will be etched into the brain for years. Pretreatment is not to avoid mourning, it is to help a mourning process to occur then a return to baseline. One could debate aggressive anxiety and depression treatment, thus a study in this group may help with ideas on immediate post trauma protocols.
Nice article, well written and informative. Thank you. Chevies Newman,MD
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MGH Center for Women's Mental Health Replied:
December 23rd, 2011 at 1:11 pm
@Chevies Newman, I think you bring up several very good points. The first is that we probably do not give enough attention to losses that occur during pregnancy. I don’t think every woman who experiences a loss will go onto have depression, but clearly this is a traumatic experience.
A significant proportion of women who experience a loss or some other catastrophic event during pregnancy later develop PTSD.
You have hypothesized that we might be able to prevent PTSD in these women. You mentioned early treatment with anxiolytics or SSRIs. To the best of my knowledge, this has not been studied in this population but these sorts of interventions are being tested in other populations experiencing trauma.
While a loss or a complication during pregnancy can be a devastating experience; however, most women recover and many will become pregnant again. It is likely that these women are more vulnerable to PTSD during a subsequent pregnancy, and it would be important to know if there are any interventions which may reduce this risk.
Thanks for your comments.
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Hi – Love these readings on pregnancy, motherhood & mental health. Just some thoughts from my clinical life…As a therapist who specializes in the perinatal period, I think there are several “categories” of PTS/PTSD in pregnancy and of course these overlap. I see many women who suffer from situational, normal grief/depression from pregnancy loss, along with situational PTS from the(necessary) medically induced/supported labor of the stillborn. There are also women with situational PTSD from traumatic births, births where there were many normal & necessary yet intrusive medical procedures. These situations are exacerbated if the mom has a pre-existing mental illness. Then, there are the women who are suffering with chronic, lifelong PTSD from abusive pasts or unmanageable present-life situations. What I hear most often from women about the medical trauma suffered, If only SOMEONE had spoken to me, if only SOMEONE had acknowledged me as a person, I would have coped much better. I see that as a request for improved maternity care on the medical side. AND I also hear much actual despair from the mom, her mom-baby attachment process after a traumatic birth may never be complete b/c she did not have skin-to-skin with her baby right after birth. So, then we need to address the feelings, the re-framing & understanding of both the medical establishment and how it runs and also educated on the true nature of the infant attachment process (a long process with room for resiliency and correction,not only dependent on the first few moments of life.) I am a great advocate of infant/mom bonding, etc…but there is room for improvement on the natural childbirth discourse as well, a responsibility to present attachment research. With respect, Kathy
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