Post-traumatic Stress Disorder (PTSD) in Pregnancy | Article

This chapter should be cited as follows:
Challacombe FL, McKenzie-McHarg K, Glob. libr. women's med.,
ISSN: 1756-2228; DOI 10.3843/GLOWM.412393

The Continuous Textbook of Women’s Medicine Series – Obstetrics Module

Volume 7

Maternal mental health in pregnancy

Volume Editor: Professor Louise Howard, King’s College, London, UK

Chapter

Post-traumatic Stress Disorder (PTSD) in Pregnancy

First published: February 2021

AUTHORS

Fiona L Challacombe, PhD, DClinPsy

NIHR Clinical Lecturer, Section of Women’s Mental Health, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK

Kirstie McKenzie-McHarg, DClinPsy, CPsychol, AFBPsS

Consultant Clinical Psychologist, Department of Clinical Health Psychology, Warwick Hospital, Warwick, UK

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INTRODUCTION

What is post-traumatic stress disorder?

Post-traumatic stress disorder (PTSD) is a condition caused by exposure to a significant traumatic event or events, that is, “a stressful event or situation (either short or long lasting) of exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone” (ICD-10¹). These events can range from single event traumas such as an accident or traumatic childbirth to repetitive traumas including childhood abuse or intimate partner violence (IPV).

Whilst the experience of trauma can lead to a range of consequences, a cardinal feature of PTSD is persistent reliving of the traumatic experience in the form of intrusive flashbacks, vivid memories, recurring dreams, or by experiencing distress when exposed to circumstances resembling or associated with the stressor. Dissociation is the experience of fully leaving the present moment due to these symptoms being too overwhelming; it can take the form of depersonalization or derealization and it is not under conscious control. Dissociation can also happen during a trauma when the mind ‘shuts off’ from the experience.

Avoidance of reminders or triggers of the trauma is another core symptom. This includes people, situations or circumstances resembling or associated with the event. People with PTSD often try to push memories of the event out of their mind and avoid thinking or talking about it in detail, particularly about its worst moments. This persistent avoidance of the trauma, combined with intrusive memories of the trauma, results in a typical presentation of intrusion – distress – avoidance – attempts to suppress and control thoughts – intrusion and so on. Some people ruminate excessively about questions that prevent them from coming to terms with the event (for example, about why the event happened to them, about how it could have been prevented, or about how they could take revenge).

PTSD sufferers also experience symptoms of hyperarousal including hypervigilance for threat, exaggerated startle responses, irritability and difficulty concentrating, and sleep problems. Others with PTSD also describe symptoms of emotional numbing. These include lack of ability to experience feelings, feeling detached from other people, giving up previously significant activities, and amnesia for significant parts of the event.

These experiences will cause significant impairment in the person’s life, for example affecting their day to day function and relationships with others.

Although the experience of some of these symptoms are common after exposure to trauma, in the majority of people they will reduce and resolve over time. Therefore, a diagnosis of PTSD cannot usually be made until at least one month after a trauma. However, for some people symptoms can arise and persist for several months or even years after the traumatic event.

Complex PTSD

Recently the notion of ‘complex PTSD’ (cPTSD) has been proposed in WHO’s ICD-11 (but not the American DSM-5 system). This is a form of PTSD that is related to repeated early traumas and is associated with significant relationship and emotional regulation difficulties in addition to the core symptoms of PTSD. ICD-11 cPTSD includes the three PTSD clusters and three additional clusters that reflect ‘disturbances in self-organization’ (DSO): (1) affective dysregulation, (2) negative self-concept, and (3) disturbances in relationships.² These disturbances are proposed to be typically associated with sustained, repeated, or multiple forms of traumatic exposure (e.g. genocide campaigns, childhood sexual abuse, child soldiering, severe domestic violence, torture, or slavery), reflecting loss of emotional, psychological, and social resources under conditions of prolonged adversity.³ Complex PTSD during pregnancy characterized by dissociation has been associated with higher maternal cortisol levels, suggesting one possible mechanism of intergenerational influence.⁴

Prevalence of PTSD in pregnancy and postpartum

Most studies have used DSM-IV criteria to assess prevalence, with variations due to sampling and research methodology. A recent systematic review established the mean prevalence of antenatal PTSD to be 3.3% (95% CI 2.44–4.54) in community samples. The majority of postpartum studies measured PTSD in relation to childbirth with a mean prevalence of 4.0% (95% CI 2.77–5.71) in community samples. Women in high-risk groups (defined by physical complications, more socio-economic risk factors) were at greater risk of PTSD with a mean prevalence of 18.95% (95% CI 10.62–31.43) in pregnancy and 18.5% (95% CI 10.6–30.38) after birth.⁵ Less research has taken place in low and middle income countries (LMIC), but studies indicate that prevalence in pregnancy may be higher (e.g. 11% in South Africa⁶ and 36% in Peru⁷), probably owing to the higher levels of social adversity faced by these women. In the Peruvian study for example, a quarter of participants had experienced four or more traumas, and 60.5% of those women had PTSD.⁷

Presentation of PTSD in pregnancy

PTSD can occur secondary to any type of trauma but those that commonly contribute to perinatal PTSD are: childhood sexual and/or physical abuse; IPV; combined exposure to abuse and witnessing abuse; previous traumatic birth, miscarriage or abortion; and obstetric procedures.⁸^,⁹ There is considerable evidence that experiences of childhood adversity are related to perinatal PTSD and depression.¹⁰ It should be remembered that exposure to a traumatic event does not inevitably lead to PTSD or any other problem.

As with PTSD at other times, PTSD during pregnancy is often comorbid with depression and anxiety disorders.¹¹ It can also overlap with pregnancy-related anxiety, that is, fears related to the outcome of the pregnancy for mother and child.

PTSD in pregnancy may be exacerbated by low social support.¹² A conflictual partner relationship has been related to higher rates of PTSD.¹³ Conversely, good partner support can be adaptive even if the woman has been previously exposed to childhood or adult interpersonal trauma.¹⁴ IPV is common during pregnancy and can often escalate or begin during pregnancy, resulting in serious consequences to mother and child. About 40% of women in this situation may report depression, with PTSD rates ranging from 19 to 84%.¹⁵^,¹⁶^,¹⁷ For these women, taking steps to ensure their safety and that of the baby is of paramount concern.

Pregnant women experiencing PTSD may present with more risky behavior such as smoking or use of alcohol and drugs; difficulties with sleep may also feature.¹⁰^,¹⁸

Fear of childbirth and PTSD

Some women may experience such severe negative anticipation of the birth that they experience many of the symptoms of PTSD, sometimes in the absence of exposure to a traumatic birth.¹⁹ For women who have never had a birth experience of their own, this is known as primary tokophobia.²⁰ For some women, future reproductive choices can be affected by a high level of fear, resulting in women delaying or avoiding pregnancy.²¹

For others, previous birth experiences up to and including stillbirth play a role in fear of childbirth and pregnancy PTSD.²² A large number of women may have some symptoms of PTSD after childbirth which will subside over time but may re-emerge in a subsequent pregnancy. Approximately 2–3% of women develop PTSD after their experience of childbirth.²³ In addition to a subjectively traumatic experience of labor, postnatal PTSD has been linked with a number of factors during pregnancy: antenatal depression, fear of childbirth, poor physical health and medical complications and pre-existing PTSD.²³ Medically complicated pregnancies are linked with an increased risk of developing postnatal PTSD.²⁴

Pre-existing PTSD may be exacerbated by pregnancy (fear of childbirth, ongoing trauma, or the impact of having to engage in intimate physical examinations for those with a trauma history). Those with the greatest increase in symptoms during pregnancy may have greatest implications for impact on mother and child.²⁵

IMPACT OF PTSD IN PREGNANCY FOR MOTHER AND CHILD

Many pregnant women have experienced adverse or traumatic events and do not develop psychological difficulties. It is PTSD rather than exposure that is associated with negative outcomes including functional impairment for the woman. Women can feel strong emotions such as anger, self-blame, suicidal ideation, loss of positive affect, isolation and dissociation from others.

There is some, but mixed, evidence that PTSD during pregnancy is related to negative obstetric outcomes including birth complications, prematurity and low birth weight.²⁶ It may have an impact on increased risky behaviors during pregnancy such as alcohol and drug use or excessive weight gain.²⁷

Perinatal PTSD may be linked with less likelihood to initiate or persist with breastfeeding.²⁸^,²⁹ However, the evidence base remains small.²⁸

The impact on mother–infant interactions and attachment is not clear cut. Women may perceive a greater impact than has been found in observational studies. Mother–infant interactions may be affected but this may be driven more by depression than PTSD symptoms.³⁰

However, there may be a differential impact on boys and children with more difficult temperament.³¹ While there remains a small body of evidence, there is some suggestion of impact on child feeding and postnatal PTSD symptoms have been linked to infant sleep problems at 2 years.³² These studies need replication.

Only one study has examined longer term cognitive development at 2 years in the children of mothers with perinatal PTSD, finding a negative impact.³³

ASSESSMENT OF PTSD

The UK National Institute for Health and Care Excellence (NICE) NG116 guidelines on trauma³⁴ recommend enquiring about all symptom areas in PTSD and giving specific examples of traumas that may have occurred. The guidelines for antenatal and postnatal mental health (CG192) state that pregnant women should be assessed for trauma history.³⁵ It should be noted that PTSD may present as depression or other anxiety disorders and can often be missed.

Key symptom areas in PTSD

Re-experiencing
Avoidance
Hyperarousal (including hypervigilance, anger and irritability)
Negative alterations in mood and thinking
Emotional numbing
Dissociation
Emotional dysregulation
Interpersonal difficulties or problems in relationships
Negative self-perception

All symptom areas described above should be covered with specific questions, as well as duration of the symptoms and functional impairment in terms of work, leisure, relationships and any other meaningful domains. Also assess feelings about the pregnancy, birth, and unborn child. Consider who else is in the family system, if they are a possible source of support or if they may have their own mental health needs. For example, partners can also develop PTSD in the context of traumatic birth.³⁶

Sensitivity is required in enquiring about PTSD symptoms and causes. Setting is important; for example, if the trauma occurred in a hospital and the assessment is planned to take place in a hospital this may trigger symptoms of PTSD for the person or may lead them to avoid attending.

As noted above, women in LMIC may have particularly high trauma exposure rates.³⁷ UK NICE guidelines on trauma also note that “For refugees and asylum seekers at high risk of PTSD, think about the routine use of a validated, brief screening instrument for PTSD as part of any comprehensive physical and mental health screen”.

Check whether the person is still under threat, for example, an ongoing victim of IPV. In this case, initiate safeguarding proceedings and provide information on services providing specific support for IPV. Suicidality and any current risk to self or others including the unborn child must also be carefully assessed. Establish a risk management and safety plan as soon as possible.

Useful questions to ask to diagnose PTSD

Have you been finding that thoughts about the trauma come into your mind even when you don’t want them? Can you stop them if you want to?
Do you ever feel like the trauma is literally happening again – it’s not a memory?
Do you have any dreams or nightmares about the trauma that make you feel upset?
Are there any places you avoid going because they remind you of the trauma?
Are there any people you avoid because they remind you of the trauma? – prompt relating to birth trauma: what about newborn babies? pregnant women? midwives?
Do you ever know in your head that you love someone, but you can’t feel it inside?
Have you been experiencing anger or irritability more than usual? If yes, do you think this is because you’re tired, or for some other reason?
Is there someone or something you blame for what happened?

In many cases people have not heard of the diagnosis of PTSD and struggle to make sense of what is happening to them, sometimes fearing that the symptoms mean they have lost their mind. It can be very helpful to explain that PTSD is a normal reaction to extraordinary circumstances and that it can be treated with evidence-based interventions by a qualified clinician.

Useful description of intrusive memories in PTSD for patients

When you’ve had a traumatic experience, your brain is trying to understand what happened to you, so it thinks about the experience a lot of the time, processing and making sense of things. When it does that, you feel distressed, because the experience was traumatic and you don’t want to think about it. So, you push all those thoughts and memories into a wardrobe in the back of your mind, and you shut the doors, and you block them by standing with your back to the doors. When you’re tired, or just sitting quietly with no distractions, your brain leaps into action and starts trying to make sense of things again. So, from your perspective, the wardrobe doors creak open, and distressing things start to fall out. Because they’re not things you want to think about, you slam the doors shut again, and then the whole process begins again. Over time the wardrobe becomes so full of all the difficult thoughts and memories that you can’t keep the doors shut any more, and they are falling out all the time.

Standardized measures of PTSD

Standardized measures can validate a diagnostic interview and provide an indication of severity.

The Post-traumatic Diagnostic Scale (PDS) is a 24-item self-report measure used for establishing PTSD diagnosis, which has been updated to DSM-5 criteria.³⁸ It has been translated into several languages.

The Impact of events scale-revised (IES-R) is a free 22-item self-report scale measuring symptoms of PTSD over the preceding 7 days.³⁹ Scores of over 24 indicate possible PTSD but it does not in itself establish a diagnosis. It is easy to administer and has been translated into a number of languages including French, Spanish, Chinese, Japanese, Arabic and German. It can be a useful measure of clinical change during treatment.

INTERVENTIONS FOR PTSD IN PREGNANCY

There is currently little pregnancy specific evidence for PTSD interventions. However, there is a general view that standard treatments should be reasonably effective. The evidence-based treatments recommended for PTSD are trauma-focused cognitive-behavioral therapy (CBT) and eye-movement desensitization and reprocessing (EMDR).³⁴ These must be delivered by trained and supervised practitioners. These treatments should normally be provided on an individual outpatient basis.

NICE guidelines recommend that prior to treatment is it important to give information about PTSD covering common reactions to traumatic events, including the symptoms of PTSD and its course, assessment, treatment and support options, and where their care will take place.

CBT refers to a range of interventions based on common principles, including trauma-focused CBT, narrative-exposure therapy and prolonged-exposure therapy. It includes psychoeducation about reactions to trauma, strategies for managing arousal and flashbacks, and safety planning. It then focuses on elaboration of trauma memories, restructuring of the trauma memory and meanings and helping the person overcome avoidance. The person is helped to build a more functional life and re-engage in meaningful activities.

EMDR is a treatment for non-combat-related PTSD, based on targeted processing of memories (often visual images) and promoting more positive beliefs about the self. Eye movements are used when targeting memories; self-soothing techniques are also outlined for use during and between sessions.

It is possible that PTSD treatment can temporarily make symptoms worse – therefore the timing and circumstances of treatment must be taken into consideration. It is not advisable to begin a treatment in the later stages of pregnancy, with 32 weeks’ gestation a reasonable cut-off to allow time to make sufficient change prior to delivery with weekly appointments.

Medication can be used and should be discussed and monitored by a qualified medical doctor. Selective serotonin reuptake inhibitors (SSRI) treatment can be used for PTSD if acceptable to the woman.

Obstetric management in collaboration with the woman and her mental health practitioner is important if PTSD has been identified. Particularly (but not only) in the case of sexual trauma there may be implications for the woman in terms of needing support with intimate physical exams and the procedure of birth, the gender of the obstetrician, who is present for the birth and many other idiosyncratic features that could trigger aspects of the trauma for her.

Prevention of birth-related PTSD

Given that birth is a predictable event that has been associated with PTSD, some attention has been given to modifiable risk factors during the experience of birth. In particular, the role of professionals during birth is important in the development of PTSD and dissatisfaction with professionals has been associated with chronic PTSD.⁴⁰

A survey of 2900 women investigated how they believed the traumatic experience could have been prevented by the caregivers or by themselves. Women perceived that lack and/or loss of control, fear for baby's health/life, and a high intensity of pain/physical discomfort were most frequently related to developing PTSD. Many felt that professionals should have communicated, listened and provided more and better emotional and practical support during the birth. First time mothers also identified that the discrepancy between their expectations and the reality of delivery was also an issue.⁴¹ There are therefore opportunities for prevention in terms of improved communication during labor, realistic and collaborative birth plans and pre-birth information and provision of clear choices for women where possible.

Some women with birth-related PTSD in pregnancy may request elective cesarean due to their previous negative experiences. The knowledge that there is a route to request a cesarean can help manage their anxiety around the birth. NICE (CG132) suggests that women requesting an elective cesarean for reasons of fear of delivery should be given the opportunity to speak to a mental health professional with appropriate perinatal knowledge to support the decision either way.⁴² While many women can be supported to have a natural delivery after a traumatic birth, not all women will wish to go down this route and this should be a valid choice.⁴³

It is clear women experience psychological distress in pregnancy after perinatal loss.⁴⁴ After a stillbirth, grief counseling may reduce symptoms of PTSD⁴⁵ which could then help mothers in a subsequent pregnancy.

Given the evidence that it can actually prevent the normal processing of traumatic events, debriefing after a traumatic birth is not recommended.³⁵^,⁴⁶

PRACTICE RECOMMENDATIONS

Implications for obstetric and psychological care

Pregnant women should be asked about a history of traumatic experiences that could impact on pregnancy and birth and women who screen positive for such experiences should be assessed for PTSD
Current safety and risks should be assessed
Women experiencing PTSD in pregnancy should be referred promptly to an appropriate mental health service with perinatal knowledge
Obstetric and psychological colleagues will need a mechanism for good communication between their services regarding specific women
Obstetric management should be trauma-informed, i.e. adjusted to take into account potential distress caused by intimate examinations, gender of practitioners, etc.
Women should be involved in the planning of their delivery as much as possible and wherever reasonable, a good care plan put in place to support their mental health
The care plan should include pragmatic interventions which can be supported/provided by the maternity service (such as who should be present, whether to exclude others from the room, warnings about the need for vaginal examinations, and making sure women understand they can refuse, the need to accept that some women do not want to breastfeed for reasons of trauma)
Care plans, once agreed, should be followed except in emergency situations
Pain control should be good in labor

CONFLICTS OF INTEREST

The author(s) of this chapter declare that they have no interests that conflict with the contents of the chapter.

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GUIDELINES

UK National Institute for Health and Care Excellence (NICE). PTSD NG116. Updated 2018 to include childbirth and neonatal death as specific triggers. https://www.nice.org.uk/guidance/ng116
UK National Institute for Health and Care Excellence (NICE). Antenatal and Postnatal mental Health CG192 (2014) https://www.nice.org.uk/guidance/cg192
UK National Institute for Health and Care Excellence (NICE). Cesarean section CG132 (2012) https://www.nice.org.uk/guidance/cg132
American Psychological Association: Clinical Practice Guideline for the Treatment of PTSD (updated 2017) https://www.apa.org/ptsd-guideline/

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