Posttraumatic stress disorder after pre-eclampsia: an exploratory study

Abstract

Information about the psychological sequelae of pre-eclampsia (PE) is scarce. Post-traumatic stress disorder (PTSD) may develop after exposure to a stress condition. This study explored whether PE predisposes to PTSD in patients and their partners. Primiparas with a recent history of preterm PE (n=18), preterm birth (PT; n=29), term PE (n=23), or uneventful term birth (C; n=43), and most of their partners completed questionnaires measuring PTSD, depression and related psychological factors. About one-fourth of patients developed PTSD after preterm PE as well as after PT. It occurred in 17% after term PE and in none of the control subjects. A substantial minority of partners was also affected. PTSD symptoms were strongly related to individual psychological characteristics (peritraumatic dissociation, negative interpretations of symptoms, and thought suppression) rather than to objective indicators of condition-severity. The data suggest that PE predisposes to PTSD, primarily but not exclusively resulting from concomitant preterm birth.

Introduction

Pre-eclampsia (PE) is a disease that complicates 6 to 8% of all pregnancies. Although the pathogenesis dates back to the period of implantation, clinical signs rarely develop before the second half of pregnancy. Symptoms may vary widely. Particularly patients with early onset PE (<32 weeks) may develop severe symptoms, such as upper abdominal pain, headache, vision disturbances, weakness and discomfort [1]. These are often accompanied by anxiety about the condition of the unborn baby, which is often in jeopardy because of concomitant placental insufficiency. As the exact cause of PE is still obscure, management of PE is limited to blood pressure control and symptom relief in combination with close maternal/fetal surveillance [1], [2], [3]. In most cases of early onset PE, a deteriorating fetal condition necessitates preterm pregnancy termination by cesarean section, often resulting in birth of an infant at risk for mortality or morbidity. These infants usually require prolonged management in a neonatal intensive care unit, which is a typically stressful period for the parents. It is unclear to what extent the psychological sequelae of PE might be attributed to the syndrome itself or to stress associated with the birth of the jeopardized infant.

Post-traumatic Stress Disorder (PTSD) may result from exposure to extreme psychological stress. More specifically, PTSD may develop following objective threat (“actual or threatened death or serious injury, or a threat to the physical integrity of self or others”), that elicits a typical subjective response (“intense fear, helplessness or horror”) [4]. The disorder consists of persistent re-experiencing the causal stress condition (e.g., intrusive memories, flashbacks and nightmares), avoiding reminders/numbing (e.g., thoughts, activities and places), and hyperarousal (e.g., sleeping problems, irritability and difficulty concentrating). To diagnose PTSD, the occurrence of at least one re-experiencing symptom, three avoidance symptoms and two symptoms of hyperarousal is required for a period of at least one month [4]. While the incidence of PTSD is only 1.7% after uneventful pregnancy [5], it is increased after pregnancy complicated by emergency cesarean birth, preterm birth (PT), or term delivery of an infant with subsequent serious complications [6], [7], [8]. Stress-conditions predisposing to PTSD are typically unpredictable and uncontrollable [9]. Particularly early onset PE develops unexpectedly and almost always ends in the cesarean birth of an infant at risk for morbidity. Moreover, this infant has a high chance to require prolonged treatment in a neonatal intensive care unit. It follows that PE is to be considered a condition with potentially strong psychological impact, not only for the mother, but also for her partner.

This study was intended to explore the hypothesis that PE predisposes to PTSD and related morbidity in both the patient and her partner, with the associated preterm birth rather than the syndrome itself being the triggering factor. To this end, we compared the incidence of PTSD in formerly preterm and term pre-eclamptics with two “control” groups of women, matched for gestational age. That is to say, one control group consisted of women who had a preterm birth, but no other complications. The other control group consisted of women who had an uneventful pregnancy and (term) delivery. Most of the partners were also tested. It is well established that not everyone exposed to a PTSD qualifying stressor develops the disorder. We also determined whether PTSD was associated with depressive symptoms and with risk factors known from the general PTSD literature. These are objective indicators of condition severity [10] (gestational age of hospital admittance and length of hospital stay), immediate psychological reactions (peritraumatic distress and dissociation) [11], negative interpretations of initial psychological symptoms (taking them as signs of going crazy or losing control) [12], and avoidant coping (suppression of condition-related thoughts) [13].