Post-traumatic stress disorder following emergency peripartum hysterectomy

Patient-Reported Outcomes and PTSD Symptoms in Emergency General Surgery

INTRODUCTION

Patient-reported outcomes (PRO) are increasingly recognized as a measure of surgical quality and long-term outcomes. There are few PRO data for patients undergoing emergency general surgery (EGS) procedures. Sudden illness and injury are associated with worse health-related quality of life, symptoms of depression, post-traumatic stress. This study aimed to evaluate PRO and post-traumatic stress disorder (PTSD) symptoms in an EGS population.

METHODS

Patients who underwent an EGS operation and had quality improvement data available from Jan 2020 to Jan 2021 were eligible for inclusion. Participants completed a survey of demographics, socio-economic status, PROMIS PRO measures for general life satisfaction (GLS), general self-efficacy (GSE), and physical function (PF), and the PCL-5 PTSD symptom screening tool.

RESULTS

One hundred forty-one patients were eligible for inclusion, 40 (28%) completed the study. Mean PRO scores were 52.5 ± 9.3 for GLS, 48.6 ± 8.0 for GSE, and 48.7 ± 9.6 for PF. 12.5% of patients had a low or very low GLS and GSE score, while 32.5% had mild, moderate, or severe PF scores. Seven patients (17.5%) scored >31 on PCL-5 indicating a positive PTSD screen. Regression analysis found American society of anesthesiology score, emergency case, and lower income associated with lower GLS scores. Age, body mass index, and lower income were associated with lower PF scores.

CONCLUSIONS

We found that following EGS most patients have average PRO. This limited study did also identify that there are patients potentially at risk for worse functional and mental health outcomes. We plan to use this data to prospectively evaluate the role that EGS plays in these outcomes and how they can be improved on.

Posttraumatic stress disorder prevalence and childbirth: update meta-analysis after the introduction of the DSM-5 and COVID-19 pandemic

PURPOSE

Meta-analyses were previously performed to estimate PTSD prevalence in the postpartum period. Significant events that could impact this outcome occurred in the last decade, such as the publication of the DSM-5 in 2013 and the COVID-19 pandemic in 2020. This systematic literature review with a meta-analysis addressed studies published after 2014 to estimate PTSD prevalence after childbirth.

METHOD

The methodological guidelines recommended by PRISMA were followed. The meta-analysis estimate was the proportion of PTSD cases. The restricted maximum likelihood (REML) was the method adopted for estimation in addition to multilevel random effect models. Subgroup analyses were performed to assess the impact of interest variables.

RESULTS

The estimated prevalence was 0.10 (95%CI: 0.8-0.13; I2 = 98.5%). No significant differences were found regarding the introduction of the DSM-5 (p = 0.73) or COVID-19 (p = 0.97), but instead, between low- and middle-income countries, e.g., the Middle East presents a higher prevalence (p < 0.01) than European countries.

CONCLUSIONS

There is a potential increase in PTSD prevalence rates after childbirth in the last decade not associated with the pandemic or the current diagnostic classification. Most studies showed a methodological fragility that must be overcome to understand this phenomenon better and support preventive actions and treatment for puerperal women.

Pre-Pandemic Predictivity of Anxious-Depressive Symptoms in Post-Surgical Traumatic Distress in Hysterectomy for Benign Disease and COVID-19 Outbreak: A Case-Control Study

Background: The severe acute respiratory syndrome coronavirus (SARS-CoV-2) pandemic led to several needed containment measures that conditioned the onset of depressive, anxiety, and post-traumatic stress symptoms in the population. These symptoms, especially if not diagnosed and treated, can also occur in patients undergoing medical care or surgery, with a high impact on people's lives and causing low adherence to treatment. The study evaluates whether the spread of the coronavirus disease 2019 (COVID-19) worsened the onset of post-surgical distress and symptoms of anxiety and depression in a population undergoing hysterectomy for benign disease during the pandemic era, comparing it with a population with the same characteristics but recruited before COVID-19. Methods: The sample was evaluated before surgery (T1), post-operatively (T2), and 3 months after surgery (T3) through a sociodemographic questionnaire and through the HADS (Hospital Anxiety and Depression Scale) to evaluate anxious-depressive symptoms and the PCL-5 (Post-traumatic Stress Disorder Checklist for DSM-5) to assess the onset of post-surgical distress. Results: Patients treated after the COVID-19 pandemic showed a higher depressive symptoms rate compared with those treated before (p-value = 0.02); conversely, pre-COVID-19 patients were more prone to develop post-traumatic stress disorder (PTSD) (p-value = 0.04). A significant association between the occurrence of PTSD and anxiety-depressive symptoms registered at T2 (p-value = 0.007) and T3 (p-value < 0.0001) emerged. In the end, the COVID-19 pandemic has exerted a detrimental influence on the mental well-being of the patients under investigation, with a notable exacerbation of their mood disturbances. Conclusions: The findings advocate for the implementation of psychometric and psychodiagnostic assessments to promptly detect high-risk scenarios that could lead to PTSD, compromising treatment compliance and exacerbating the overall outcome, resulting in substantial direct and indirect burdens.

Association of severe maternal morbidity with bonding impairment and self-harm ideation: A multicenter prospective cohort study

BACKGROUND

Evidence on the association between severe maternal morbidity (SMM) and mother-infant bonding and self-harm ideation is limited. We aimed to examine these associations and the mediating effect of Neonatal Intensive Care Unit (NICU) admission at one-month postpartum.

METHODS

This multicenter, prospective cohort study was conducted in Japan (n = 5398). SMM included preeclampsia, eclampsia, severe postpartum hemorrhage, placental abruption, and a ruptured uterus. Lack of affection (LA) and Anger and Rejection (AR) were assessed using the Mother-Infant Bonding Scale (MIBS), and self-harm ideation was assessed using the 10th item of the Edinburgh Postnatal Depression Scale (EPDS). Linear and logistic regression models were used to examine the association between SMM and MIBS score and self-harm ideation. A structural equation model (SEM) was employed to examine the mediating effect of NICU admission on the association between SMM and mother-infant bonding and postpartum depressive symptoms.

RESULTS

Women with SMM had a 0.21 (95 % confidence interval [CI]: 0.03-0.40) point higher MIBS score and a decreasing trend in the risk of self-harm ideation (odds ratio 0.28, 95 % CI: 0.07-1.14) compared to those without SMM. SEM analysis revealed that SMM was associated with MIBS partially through NICU admission.

LIMITATIONS

EPDS scores during pregnancy could be an unmeasured confounder.

CONCLUSIONS

Women with SMM had higher MIBS scores, particularly on the LA subscale, which was partially mediated by NICU admission. Psychotherapy to support parent-infant relationships is necessary for women with SMM.

Uterus-preserving surgical management of placenta accreta spectrum disorder: a large retrospective study

BACKGROUND

The two-child policy implemented in China resulted in a surge of high-risk pregnancies among advanced maternal aged women and presented a window of opportunity to identify a large number of placenta accreta spectrum (PAS) cases, which often invoke severe blood loss and hysterectomy. We thus had an opportunity to evaluate the surgical outcomes of a unique conservative PAS management strategy for uterus preservation, and the impacts of magnetic resonance imaging (MRI) in PAS surgical planning.

METHODS

Cross-sectional study, comparing the outcomes of a new uterine artery ligation combined with clover suturing technique (UAL + CST) with the existing conservative surgical approaches in a maternal public hospital with an annual birth of more than 20,000 neonates among all placenta previa cases suspecting of PAS between January 1, 2015 and December 31, 2018.

RESULTS

From a total of 89,397 live births, we identified 210 PAS cases from 400 singleton pregnancies with placenta previa. Aside from 2 self-requested natural births (low-lying placenta), all PAS cases had safe cesarean deliveries without any total hysterectomy. Compared with the existing approaches, the evaluated UAL + CST had a significant reduction in intraoperative blood loss (β=-312 ml, P < .001), RBC transfusion (β=-1.08 unit, P = .001), but required more surgery time (β = 16.43 min, P = .01). MRI-measured placenta thickness, when above 50 mm, can increase blood loss (β = 315 ml, P = .01), RBC transfusion (β = 1.28 unit, P = .01), surgery time (β = 48.84 min, P < .001) and hospital stay (β = 2.58 day, P < .001). A majority of percreta patients resumed normal menstrual cycle within 12 months with normal menstrual fluid volume, without abnormal urination or defecation.

CONCLUSIONS

A conservative surgical management approach of UAL + CST for PAS is safe and effective with a low complication rate. MRI might be useful for planning PAS surgery.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR2000035202.

Knowledge Gaps in Placenta Accreta Spectrum

Since its first description early in the 20th Century, placenta accreta and its variants have changed substantially in incidence, risk factor profile, clinical presentation, diagnosis and management. While systematic use of diagnostic tools and a multidisciplinary team care approach has begun to improve patient outcomes, the condition's pathophysiology, epidemiology, and best practices for diagnosis and management remain poorly understood. The use of large databases with broadly accepted terminology and diagnostic criteria should accelerate research in this area. Future work should focus on non-traditional phenotypes, such as those without placenta previa-preventive strategies, and long term medical and emotional support for patients facing this diagnosis. KEY POINTS: · Placenta accreta spectrum research may be improved with standardized terminology and use of large databases.. · Placenta accreta prediction should move beyond ultrasound with the addition of biomarkers, and needs to extend to those without traditional risk factors.. · Future research should identify practices that can prevent future accreta development..

Primary postpartum haemorrhage and longer-term physical, psychological, and psychosocial health outcomes for women and their partners in high income countries: A mixed-methods systematic review

OBJECTIVES

Most research about outcomes following postpartum haemorrhage (PPH) has focused on immediate outcomes. There are fewer studies investigating longer-term maternal morbidity following PPH, resulting in a significant knowledge gap. This review aimed to synthesize the evidence about the longer-term physical and psychological consequences of primary PPH for women and their partners from high income settings.

METHODS

The review was registered with PROSPERO and five electronic databases were searched. Studies were independently screened against the eligibility criteria by two reviewers and data were extracted from both quantitative and qualitative studies that reported non-immediate health outcomes of primary PPH.

RESULTS

Data were included from 24 studies, of which 16 were quantitative, five were qualitative and three used mixed-methods. The included studies were of mixed methodological quality. Of the nine studies reporting outcomes beyond five years after birth, only two quantitative studies and one qualitative study had a follow-up period longer than ten years. Seven studies reported outcomes or experiences for partners. The evidence indicated that women with PPH were more likely to have persistent physical and psychological health problems after birth compared with women who did not have a PPH. These problems, including PTSD symptoms and cardiovascular disease, may be severe and extend for many years after birth and were more pronounced after a severe PPH, as indicated by a blood transfusion or hysterectomy. There was limited evidence about outcomes for partners after PPH, but conflicting evidence of association between PTSD and PPH among partners who witnessed PPH.

CONCLUSION

This review explored existing evidence about longer-term physical and psychological health outcomes among women who had a primary PPH in high income countries, and their partners. While the evidence about health outcomes beyond five years after PPH is limited, our findings indicate that women can experience long lasting negative impacts after primary PPH, including PTSD symptoms and cardiovascular disease, extending for many years after birth.

PROSPERO REGISTRATION

PROSPERO registration number: CRD42020161144.

Emergency Peripartum Hysterectomy During COVID-19 Pandemic

Objective

To evaluate women undergoing emergency peripartum hysterectomy (EPH) during COVID-19 pandemic regarding their sociodemographic features, indications, intraoperative and postoperative complications, and assess their health problems related to a traumatic birth.

Methods

This was a retrospective review of EPH cases operated from March 2020 to March 2021 in terms of demographic characteristics, intraoperative, and postoperative outcome variables.

Results

During the specified time period, there were nine cases of EPH. All patients were young with ages ranging from 25 to 31 years; all were unbooked having unplanned pregnancies and presented at varying gestational ages. Six out of nine cases (66.67%) had previously scarred uterus with five women having morbidly adhered placenta. A total of 77.78% (seven out of nine) patients referred to our centre with high-risk factors. Five out of nine women (55.56%) needed ICU care. Seven out of nine women (77.78%) had live births and two of these infants died. The guilt of losing the baby, lethargy, worries related to feminity and sexual health, and flashbacks of ICU stay were major concerns.

Conclusion

The morbidly adhered placenta was the primary cause of EPH in our study cohort. Preventive psychological session should be an integral part of postpartum follow-up visits for any women with traumatic childbirth.

Clinical characteristics and haemodynamic state of patients undergoing interhospital transfer for postpartum haemorrhage: A study of a single-centre helicopter emergency medical service

OBJECTIVE

Uterine artery embolization is an attractive option for the management of postpartum haemorrhage, however it is not available in every hospital. We compared the clinical characteristics and haemodynamic state of patients with postpartum haemorrhage, before and after helicopter transfer to a tertiary hospital for possible uterine artery embolization. We also analysed whether the type of treatment could modify the outcome.

STUDY DESIGN

Between 1999 and 2019 in Switzerland, we retrospectively found 82 consecutive patients with postpartum haemorrhage who were transferred by a physician-staffed helicopter emergency medical service to the tertiary hospital for potential uterine artery embolization. The collected data included the type of delivery, estimated blood loss, shock index and blood lactate levels before transfer and at destination, uterine artery embolization rate and hospital mortality rate. Our primary outcome was to describe the clinical characteristics, outcomes and haemodynamic state of the patients with postpartum haemorrhage before and after helicopter transfer. Our secondary outcome was to report the treatments performed at the tertiary hospital. The collected data were analysed with Stata version 14 (Stata Corporation, College Station, TX, USA). Continuous data are compared by using the Student's t-test or the Mann-Whitney U test, as appropriate.

RESULTS

We included 69 patients. Postpartum haemorrhage occurred after vaginal delivery in 38 cases (55%). Blood loss prior to transfer exceeded 2 L in 34% of cases. The median shock index was 1 (IQR 0.8-1.1) before transfer and 0.9 (IQR 0.8-1.1) after transfer (p = 0.41). The median lactate level was 2.9 mmol/L (IQR 2.1-6.8) before, and 2.1 mmol/L (IQR 1.55-3.5) after transfer (p = 0.90). Forty-four patients underwent uterine artery embolization (64%), with an overall success rate of 93%. One patient died (1.4%), from a haemorrhagic shock of abdominal origin.

CONCLUSIONS

Interhospital helicopter transfer of patients with postpartum haemorrhage to a tertiary hospital seems to be safe in our setting, despite a significant proportion of patients exhibiting signs of haemodynamic instability. Decision criteria would be helpful to better guide choices regarding the transfer of patients with postpartum haemorrhage.

A way forward in the maternal mortality crisis: addressing maternal health disparities and mental health

Our objective was to review the role of maternal health disparities and mental health in the maternal mortality crisis in the USA, and discuss how perinatal care quality improvement in these areas is a critical lever for reducing maternal death. This paper summarizes content from a plenary talk delivered at the 2020 Biennial Meeting of the International Marcé Society for Perinatal Mental Health, in commemoration of the Society's 40th anniversary. The talk synthesized literature on two characteristics of the maternal mortality crisis in the US: (1) wide racial and ethnic disparities in maternal mortality and severe morbidity and (2) the impact of mental health and substance use disorders on maternal death, and introduced a framework for how health care quality gaps contribute to both of these issues. The US remains an outlier among similar nations in its alarmingly high rates of maternal mortality. Achieving significant progress on this measure will require confronting longstanding racial and ethnic disparities that exist throughout the pregnancy-postpartum continuum, as well as addressing the under-reported issue of maternal self-harm. Suicide and overdose are leading but under-recognized causes of death among pregnant and postpartum women in some states. Health care delivery failures, including inadequate risk assessment, care coordination, and communication, are identified in the literature on drivers of maternal health disparities and self-harm. Many of the same steps to improve quality of perinatal care can help to reduce health disparities and address the essential role of mental health in maternal well-being.

Comparison of mental burden across different types of cancer patients in Nepal: a special focus on cervical cancer patients

Purpose

The purpose of the study is to assess the differential impact of gender and cancer sites on mental burden across different types of cancer and control patients.

Design/methodology/approach

The paper is based on a primary survey undertaken in 2015–2016 of 600 cancer and 200 control patients across five hospitals of Nepal. The data was analyzed using propensity score matching methods and treatment effect weighting estimators.

Findings

The authors find that of all the types of patients covered under this study, cervical cancer patients suffered from a greater intensity of anxiety and lack of functional wellbeing. On an average, all other female, male cancer patients, and control patients experience significantly lower intensity of mental burden in the range of 1.83, 2.63 and 3.31, respectively when compared to patients of cervical cancer. The results are robust across all the four treatment effect estimators and through all the measures of mental burden. The implications of suffering from cervical cancer, as a unique gynecological cancer was studied in-depth. An effect size analysis pointed out to the dysfunctional familial relationship as additional causes of concern for cervical cancer patients.

Originality/value

An important finding that emerged is that female cancer patients especially those who have cervical cancer should be given special attention because they appear to be the most vulnerable group. Further work is needed to delineate the reasons behind a cervical cancer patient facing higher amount of stress.

The Role of Religion and Spirituality in Conceptualizing Reproductive Loss: Clinical Implications of the Narratives of Gestational Surrogates in the USA

Reproductive losses experienced by gestational surrogates, who do not share a genetic connection to the child they are carrying, may not be acknowledged or treated as compassionately as women who lose their "own" pregnancies. In-depth, semi-structured interviews were conducted with 17 gestational surrogates from diverse religious backgrounds. Grounded theory analysis of data included line-by-line coding, and emergent themes were identified. The results suggest that understanding and utilizing the religious/spiritual beliefs of a gestational surrogate may be one way for health professionals to provide implications counseling prior to surrogacy and also as a means to help process and grieve losses that may occur within surrogacy.

Placenta Accreta Spectrum

Placenta accreta spectrum is a term used to describe abnormal adherence and abnormal invasion of the placenta into the uterine wall during pregnancy. The incidence of placenta accreta spectrum has steadily increased over the last 40 years and is most notably linked to rising cesarean birth rates. This condition is associated with increased maternal morbidity and mortality because of the high risk of severe hemorrhage and likely need for hysterectomy at the time of birth. Early diagnosis of abnormal placentation is preferable in order to coordinate birth planning with a interprofessional collaborative team within a high-level perinatal care center. This article describes the case of a woman diagnosed with placenta accreta spectrum and the clinical course of her pregnancy and birth.

Women's experiences following emergency Peripartum hysterectomy at St. Francis hospital Nsambya. A qualitative study

Background

Emergency peripartum hysterectomy (EPH) is a known remedy for saving women’s lives when faced with the challenging situation of severe post partum hemorrhage not responsive to conservative management. However, EPH by its nature is also a traumatic birth event that causes serious physical, emotional and psychological harm. Unfortunately at St. Francis Hospital Nsambya nothing much is known about these experiences since no study has been undertaken and these women are not routinely followed up. The purpose of this study was to explore these emotional experiences.

Methods

This was a qualitative phenomenological study carried out between August and December 2018. All those women who had undergone EPH between January 2015 and August 2018 were eligible to participate in the study. Purposive sampling was used. 18 women were interviewed before saturation was reached. All interviews were audio-recorded and then transcribed verbatim. Thematic analysis was used to analyze the data.

Results

Three major themes were identified as the main experiences of these women in this study and they were; Loss of Womanhood, Joy for being alive and Loss of marital safety.

Conclusion

Women experience serious emotional consequences following EPH. We recommend routine follow-up to help appreciate these experiences and advise them on appropriate mitigating measures.

Synthesis of Mixed Research on Posttraumatic Stress Related to Traumatic Birth

OBJECTIVE

To synthesize mixed-research results (quantitative and qualitative) on posttraumatic stress in women who experienced traumatic births.

DATA SOURCES

PubMed, Scopus, and PsycINFO databases.

STUDY SELECTION

Quantitative and qualitative studies were included if they were published in English from January 1, 2009, through December 31, 2018, and focused on posttraumatic stress in the postpartum period related to traumatic childbirth.

DATA EXTRACTION

The final sample consisted of 59 studies: 4 qualitative and 55 quantitative. Both authors independently appraised each study using the Critical Appraisal Skills Programme. Quantitative studies were synthesized by narrative synthesis and vote counting, and qualitative studies were synthesized by content analysis.

DATA SYNTHESIS

In the included studies, prevalence rates of elevated posttraumatic stress ranged from 0.8% to 26%. Significant predictors of posttraumatic stress that occurred before childbirth and those that were birth related were identified. Reports of six intervention studies to decrease posttraumatic stress symptoms after traumatic births were included. These interventions focused on postnatal debriefing, expressive writing, online cognitive behavioral therapy, a brief cognitive intervention, and the implementation of the nine instinctive stages of the infant during the first hour after birth. We created four themes from the findings of the qualitative studies: Distressing Symptoms, Detrimental Effect of Posttraumatic Stress on Women's Relationships With Their Infants and Partners, Critical Influence ofSupport, and Debriefing.

CONCLUSION

When a woman experiences posttraumatic stress related to a traumatic birth, the entire family unit is vulnerable. Findings from quantitative predictor studies can be used to develop an instrument to screen women for risk factors for posttraumatic stress related to birth trauma. Primary interventions are needed to prevent women from experiencing traumatic births.

Antenatal Management of Placenta Accreta

Predelivery diagnosis of placenta accreta, increta, and percreta (from here referred to as placenta accreta, unless otherwise noted) has increasingly created opportunities to optimize antenatal management. Despite the increased frequency of placenta accreta today, occurring in as many as 1 in 533 to 1 in 272 deliveries, high-quality data are lacking for many aspects of antenatal management. This chapter will discuss antenatal management of, and risks faced by, women with suspected placenta accreta, a condition that most frequently requires a potentially morbid cesarean hysterectomy.

Posttraumatic stress disorder related to postpartum haemorrhage: A systematic review

In some cases childbirth leads to negative psychological responses such as posttraumatic stress disorder (PTSD). Postpartum hemorrhage (PPH) is a common and major complication of childbirth, which occasionally requires emergency hysterectomy in severe cases. Patients often describe these complications as a traumatic experience. It is unknown whether PPH is a risk factor for developing PTSD. In this systematic review we summarize the current knowledge about the association between PPH with or without emergency hysterectomy and posttraumatic stress symptoms or PTSD. If PPH is a risk factor for PTSD, this will allow adequate preventive measures with the aim to reduce the long-term effects and socioeconomic problems associated with PTSD. To conduct this review MEDLINE, EMBASE, Web of Science, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Library and PsycINFO databases were searched for publications between January 1986 and October 2017. Manuscripts evaluating the association between PPH and peripartum emergency hysterectomy and PTSD or posttraumatic stress symptoms were included. Fifty-two articles met the criteria for full-text review. Seven articles were included in this review. Five studies focused on the association between PPH and PTSD and two studies evaluated the association between emergency hysterectomy and PTSD. Three studies found no association between PPH and PTSD. Two studies reported a higher risk of developing PTSD or posttraumatic stress symptoms after PPH. Two studies reported a higher risk of developing PTSD after emergency hysterectomy. Meta-analysis was not possible due to the heterogeneity of these studies. Based on the results of these studies there may be an association between PPH and PTSD. Secondly, it seems likely that an association exists between emergency postpartum hysterectomy and PTSD, but the strength of this conclusion is limited by the small amount of studies included.