Continuing the conversation: a cross-sectional study about the effects of work-related adverse events on the mental health of Dutch (resident) obstetrician-gynaecologists (ObGyns)

BACKGROUND

Obstetrician-Gynaecologists (ObGyns) frequently face work-related adverse events such as severe obstetric complications and maternal or neonatal deaths. In 2014, the WATER-1 study showed that ObGyns are at risk of developing work-related posttraumatic stress disorder (PTSD), while many hospitals lacked a professional support system. The aim of the present study is to evaluate the current prevalence of work-related traumatic events and mental health problems among Dutch ObGyns, as well as to examine the current and desired support.

METHODS

In 2022, an online questionnaire was sent to all members of the Dutch Society of Obstetrics and Gynaecology (NVOG), including resident and attending ObGyns. The survey included questions about experienced work-related events, current and desired coping strategies, and three validated screening questionnaires for anxiety, depression, and PTSD (HADS, TSQ, and PCL-5).

RESULTS

The response rate was 18.8% and 343 questionnaires were included in the analysis. Of the respondents, 93.9% had experienced at least one work-related adverse event, 20.1% had faced a complaint from the national disciplinary board, and 49.4% had considered leaving the profession at any moment in their career. The prevalence rates of clinically relevant anxiety, depression, and psychological distress were 14.3, 4.4, and 15.7%, respectively. The prevalence of work-related PTSD was 0.9% according to DSM-IV and 1.2% according to DSM-5. More than half of the respondents (61.3%) reported the presence of a structured support protocol or approach in their department or hospital, and almost all respondents (92.6%) rated it as sufficient.

CONCLUSIONS

The percentages of anxiety, depression, psychological distress and PTSD are comparable to the similar study performed in 2014. Most Dutch ObGyns experience adverse events at work, which can be perceived as traumatic and, in certain cases, may lead to the development of PTSD. Structured support after adverse work-related events is now available in almost two-thirds of workplaces, and was mostly experienced as good. Despite substantial improvements in the availability and satisfaction of professional support after work-related adverse events, the prevalence rates of mental problems remain considerable, and it is imperative to sustain conversation about the mental well-being of ObGyns.

Effect of early postpartum EMDR on reducing psychological complaints in women with a traumatic childbirth experience

This pilot study investigated the feasibility of postpartum Eye Movement Desensitization and Reprocessing (EMDR) for improving posttraumatic stress disorder (PTSD) symptoms, and its association with work absence, relationship difficulties, and development of psychiatric disorders in women with a traumatic childbirth experience who do not meet all criteria for PTSD. A randomized controlled study was conducted among 20 women (EMDR (N=11) vs. care as usual (CAU) (N=9)) who reported a traumatic birth. Outcomes were measured by questionnaires and a semi-structured interview. The results showed improvement of trauma-related psychological complaints for all women. EMDR appears to be more effective in reducing PTSD symptoms than CAU. Moreover, EMDR showed a small positive effect on work absence due to factors related to the traumatic childbirth experience. Results from the questionnaires were substantiated by interviews. However, due to the small size of the study, no statistically significant differences were found. In addition, no differences were found for relationship difficulties and development of psychiatric disorders. In conclusion, women with a traumatic birth experience may benefit from EMDR, even if they do not qualify for a diagnosis of PTSD. This study could be a starting point for future research aimed at early treatment that reduces trauma-related psychological complaints in postpartum women.

How safe is the treatment of pregnant women with fear of childbirth using eye movement desensitization and reprocessing therapy? Obstetric outcomes of a multi-center randomized controlled trial

INTRODUCTION

Pregnant women with fear of childbirth display an elevated risk of a negative delivery experience, birth-related post-traumatic stress disorder, and adverse perinatal outcomes such as preterm birth, low birthweight, and postpartum depression. One of the therapies used to treat fear of childbirth is eye movement desensitization and reprocessing (EMDR) therapy. The purpose of the present study was to determine the obstetric safety and effectiveness of EMDR therapy applied to pregnant women with fear of childbirth.

MATERIAL AND METHODS

A randomized controlled trial (the OptiMUM-study) was conducted in two teaching hospitals and five community midwifery practices in the Netherlands (www.trialregister.nl, NTR5122). Pregnant women (n = 141) with a gestational age between 8 and 20 weeks and suffering from fear of childbirth (i.e. sum score on the Wijma Delivery Expectations Questionnaire ≥85) were randomly allocated to either EMDR therapy (n = 70) or care-as-usual (CAU) (n = 71). Outcomes were maternal and neonatal outcomes and patient satisfaction with pregnancy and childbirth.

RESULTS

A high percentage of cesarean sections (37.2%) were performed, which did not differ between groups. However, women in the EMDR therapy group proved seven times less likely to request an induction of labor without medical indication than women in the CAU group. There were no other significant differences between the groups in maternal or neonatal outcomes, satisfaction, or childbirth experience.

CONCLUSIONS

EMDR therapy during pregnancy does not adversely affect pregnancy or the fetus. Therefore, therapists should not be reluctant to treat pregnant women with fear of childbirth using EMDR therapy.

Severe postpartum hemorrhage increases risk of posttraumatic stress disorder: a prospective cohort study

PURPOSE

To evaluate whether severe postpartum hemorrhage (PPH) is a risk factor for posttraumatic stress disorder (PTSD). Severe PPH can be experienced as a traumatic event. PTSD leads to negative mental health effects. Knowing risk factors for PTSD during childbirth offers opportunities for early interventions, which may prevent the development of PTSD.

MATERIALS AND METHODS

In this prospective study, we compared two groups of participants; women with ≥2000 mL of blood loss (severe PPH, patients) and women with ≤500 mL of blood loss (controls). Participants were screened for PTSD using the PCL-5 four to six weeks after delivery. Positive screening was followed by the CAPS-5 to diagnose PTSD.

RESULTS

We included 187 PPH patients and 121 controls. Median PCL-5 scores were higher for PPH patients (5.0) than controls (4.0, p = 0.005). Thirteen PPH patients (7.0%) and two controls (1.7%) scored ≥32 on the PCL-5, indicative of probable PTSD (OR 4.45, 95% CI 0.99-20.06, p = 0.035). Significant more PPH patients than controls met criteria for a clinical diagnosis of PTSD on the CAPS-5 (n = 10, 5.6% vs n = 0, 0.0%; p = 0.007).

CONCLUSIONS

There is a significant and clinically relevant increased risk for developing PTSD after severe PPH. Gynecologists and midwives are advised to screen for PTSD at postpartum follow-up visits to prevent long-term negative mental health effects.

CLINICAL TRIAL REGISTRATION

NL50273.100.14.

Treatment of Pregnant Women With Fear of Childbirth Using EMDR Therapy: Results of a Multi-Center Randomized Controlled Trial

Fear of childbirth (FoC) occurs in 7. 5% of pregnant women and has been associated with adverse feto-maternal outcomes. Eye Movement Desensitization and Reprocessing (EMDR) therapy has proven to be effective in the treatment of posttraumatic stress disorder (PTSD) and anxiety; however, its effectiveness regarding FoC has not yet been established. The aim was to determine the safety and effectiveness of EMDR therapy for pregnant women with FoC. This single-blind RCT (the OptiMUM-study, www.trialregister.nl, NTR5122) was conducted in the Netherlands. FoC was defined as a score ≥85 on the Wijma Delivery Expectations Questionnaire (WDEQ-A). Pregnant women with FoC and a gestational age between 8 and 20 weeks were randomly assigned to EMDR therapy or care-as-usual (CAU). The severity of FoC was assessed using the WDEQ-A. Safety was indexed as worsening of FoC symptoms, dropout, serious adverse events, or increased suicide risk. We used linear mixed model analyses to compare groups. A total of 141 women were randomized (EMDR n = 70; CAU n = 71). No differences between groups were found regarding safety. Both groups showed a very large (EMDR d = 1.36) or large (CAU d = 0.89) reduction of FoC symptoms with a mean decrease of 25.6 (EMDR) and 17.4 (CAU) points in WDEQ-A sum score. No significant difference between both groups was found (p = 0.83). At posttreatment, 72.4% (EMDR) vs. 59.6% (CAU) no longer met the criteria for FoC. In conclusion, the results are supportive of EMDR therapy as a safe and effective treatment of FoC during pregnancy, albeit without significant beneficial effects of EMDR therapy over and above those of CAU. Therefore, the current study results do not justify implementation of EMDR therapy as an additional treatment in this particular setting.

Effectiveness of a guided ACT-based self-help resilience training for depressive symptoms during pregnancy: Study protocol of a randomized controlled trial embedded in a prospective cohort

Background

During pregnancy, about 10 to 20% of women experience depressive symptoms. Subclinical depression increases the risk of peripartum depression, maternal neuro-endocrine dysregulations, and adverse birth and infant outcomes. Current treatments often comprise face-to-face psychological or pharmacological treatments that may be too intensive for women with subclinical depression leading to drop-out and moderate effectiveness. Therefore, easily accessible, resilience enhancing and less stigmatizing interventions are needed to prevent the development of clinical depression. This paper describes the protocol of a prospective cohort study with an embedded randomized controlled trial (RCT) that aims to improve mental resilience in a sample of pregnant women through a self-help program based on the principles of Acceptance and Commitment Therapy (ACT). Maternal and offspring correlates of the trajectories of peripartum depressive symptoms will also be studied.

Methods

Pregnant women (≥ 18 years) receiving care in Dutch midwifery practices will participate in a prospective cohort study (n ~ 3500). Between 12 and 18 weeks of pregnancy, all women will be screened for depression with the Edinburgh Postnatal Depression Scale (EPDS). Women with an EPDS score ≥ 11 will be evaluated with a structured clinical interview. Participants with subclinical depression (n = 290) will be randomized to a 9-week guided self-help ACT-training or to care as usual (CAU). Primary outcomes (depressive symptoms and resilience) and secondary outcomes (e.g. anxiety and PTSD, bonding, infant development) will be collected via online questionnaires at four prospective assessments around 20 weeks and 30 weeks gestation and at 6 weeks and 4 months postpartum. Maternal hair cortisol concentrations will be assessed in a subsample of women with a range of depressive symptoms (n = 300). The intervention’s feasibility will be assessed through qualitative interviews in a subsample of participants (n = 20).

Discussion

This is the first study to assess the effectiveness of an easy to administer intervention strategy to prevent adverse mental health effects through enhancing resilience in pregnant women with antepartum depressive symptomatology. This longitudinal study will provide insights into trajectories of peripartum depressive symptoms in relation to resilience, maternal cortisol, psychological outcomes, and infant developmental milestones.

Trial registration

Netherlands Trial Register (NTR), NL7499. Registered 5 February 2019.

Potential traumatic events in the workplace and depression, anxiety and post-traumatic stress: a cross-sectional study among Dutch gynaecologists, paediatricians and orthopaedic surgeons

OBJECTIVE

To compare the prevalence of work-related potential traumatic events (PTEs), support protocols and mental health symptoms across Dutch gynaecologists, orthopaedic surgeons and paediatricians.

DESIGN

Cross-sectional study, supplementary analysis of combined data.

SETTING

Nationwide survey between 2014 and 2017.

PARTICIPANTS

An online questionnaire was sent to all Dutch gynaecologists, orthopaedic surgeons and paediatricians, including resident physicians (4959 physicians). 1374 questionnaires were eligible for analysis, corresponding with a response rate of 27.7%.

OUTCOME MEASURES

Primary outcome measures were the prevalence of work-related PTEs, depression, anxiety, psychological distress and traumatic stress, measured with validated screening instruments (Hospital Anxiety and Depression Scale, Trauma Screening Questionnaire). Secondary outcomes were the association of mental health and defensive practice to traumatic events and support protocols.

RESULTS

Of the respondents, 20.8% experienced a work-related PTE at least 4 weeks ago. Prevalence rates indicative of depression, anxiety or post-traumatic stress disorder (PTSD) were 6.4%, 13.6% and 1.5%, respectively. Depression (9.2% vs 5.2%, p=0.019), anxiety (18.2% vs 8.2%, p<0.001) and psychological distress (22.8% vs 12.5%, p<0.001) were significantly more prevalent in female compared with male attendings. The absence of a support protocol was significantly associated with more probable PTSD (p=0.022). Those who witnessed a PTE, reported more defensive work changes (28.0% vs 20.5%, p=0.007) and those with probable PTSD considered to quit medical work more often (60.0% vs 35.8%, p=0.032).

CONCLUSION

Physicians are frequently exposed to PTEs with high emotional impact over the course of their career. Lacking a support protocol after adverse events was associated with more post-traumatic stress. Adverse events were associated with considering to quit medical practice and a more defensive practice. More awareness must be created for the mental health of physicians as well as for the implementation of a well-organised support system after PTEs.

The effects of PTSD treatment during pregnancy: systematic review and case study

BACKGROUND

PTSD in pregnant women is associated with adverse outcomes for mothers and their children. It is unknown whether pregnant women with PTSD, or symptoms of PTSD, can receive targeted treatment that is safe and effective.

OBJECTIVE

The purpose of the present paper was to assess the effectiveness and safety of treatment for (symptoms of) PTSD in pregnant women.

METHOD

A systematic review was conducted in accordance with the PRISMA guidelines in Pubmed, Embase, PsychINFO, and Cochrane. In addition, a case is presented of a pregnant woman with PTSD who received eye-movement desensitization and reprocessing (EMDR) therapy aimed at processing the memories of a previous distressing childbirth.

RESULTS

In total, 13 studies were included, involving eight types of interventions (i.e. trauma-focused cognitive behavioural therapy, exposure therapy, EMDR therapy, interpersonal psychotherapy, explorative therapy, self-hypnosis and relaxation, Survivor Moms Companion, and Seeking Safety Intervention). In three studies, the traumatic event pertained to a previous childbirth. Five studies reported obstetrical outcomes. After requesting additional information, authors of five studies indicated an absence of serious adverse events. PTSD symptoms improved in 10 studies. However, most studies carried a high risk of bias. In our case study, a pregnant woman with a PTSD diagnosis based on DSM-5 no longer fulfilled the criteria of PTSD after three sessions of EMDR therapy. She had an uncomplicated pregnancy and delivery.

CONCLUSION

Despite the fact that case studies as the one presented here report no adverse events, and treatment is likely safe, due to the poor methodological quality of most studies it is impossible to allow inferences on the effects of any particular treatment of PTSD (symptoms) during pregnancy. Yet, given the elevated maternal stress and cortisol levels in pregnant women with PTSD, and the fact that so far no adverse effects on the unborn child have been reported associated with the application of trauma-focused therapy, treatment of PTSD during pregnancy is most likely safe.

Traumatic Experiences and the Midwifery Profession: A Cross-Sectional Study Among Dutch Midwives

Introduction

Traumatic events that occur in a clinical setting can have long‐lasting adverse effects on persons who are affected, including health care providers. This study investigated the prevalence of work‐related traumatic events, posttraumatic stress disorder (PTSD), anxiety, and depression among Dutch midwives. Additionally, differences between midwives working in primary care (independently assisting births at home and in birthing centers) and midwives working in secondary or tertiary care (hospital setting) were examined. Finally, this study investigated the support midwives would like to receive after experiencing a work‐related adverse event.

Methods

A descriptive, cross‐sectional online survey of Dutch midwives was conducted. The respondents completed a questionnaire about demographic and work‐related events, as well as the Trauma Screening Questionnaire and the Hospital Anxiety and Depression Scale.

Results

The estimated response rate was 23%, with 691 questionnaires eligible for analysis. Thirteen percent of respondents reported having experienced at least one work‐related traumatic event. Among these, 17% screened positive for PTSD, revealing an estimated PTSD prevalence of 2% among Dutch midwives. Clinically relevant anxiety symptoms were reported by 14% of the respondents, significantly more often among midwives working in primary care (P = .014). Depressive symptoms were reported by 7% of the respondents. The desired strategies to cope with an adverse event were peer support by direct colleagues (79%), professional support from a coach or psychologist (30%), multidisciplinary peer support (28%), and support from midwives who are not direct coworkers (17%).

Discussion

Dutch midwives are at risk of experiencing work‐related stressful or traumatic events that might lead to PTSD, anxiety, or depression. Midwives working in primary care reported higher levels of anxiety compared with their colleagues working in a clinical setting (secondary or tertiary care). Most midwives preferred peer support with direct colleagues after an adverse event, and some could have profited from easier access to seeking professional help. It could be speculated that midwives would benefit from increased awareness about work‐related traumatic events as well as implementation of standardized guidelines regarding support after a traumatic event.

Screening for trauma and anxiety recognition: knowledge, management and attitudes amongst gynecologists regarding women with fear of childbirth and postpartum posttraumatic stress disorder

Objective: Fear of childbirth (FoC) and postpartum posttraumatic stress disorder (PP-PTSD) are often less well recognized by healthcare professionals than other peripartum mental health disorders. This study aims to evaluate knowledge, management and attitudes of gynecologists and gynecology residents regarding women with FoC and PP-PTSD.Study design: A cross-sectional study was conducted among gynecologists and gynecology residents using an online questionnaire. An invitation was sent to all 1401 members of the Dutch Society of Obstetrics and Gynecology.Results: Two hundred forty-four respondents completed the online multiple-choice and open question survey. More respondents were able to answer the questions about risk factors, signs/symptoms and consequences of FoC in comparison with similar questions about PP-PTSD. When asked about performing a cesarean section on maternal request, 74% of respondents would grant this request if fear would persist despite adequate psychological treatment. During labor, providing good explanations and obtaining informed consent were most frequently named to reduce fear or the likelihood of a traumatic birth experience. Caregivers' attitudes towards women with FoC or suspected PP-PTSD were mainly positive.Conclusions: Further knowledge, in particular about PP-PTSD, is desirable for appropriate recognition of women with FoC and PP-PTSD. Gynecologists should be made more aware of how their communication is perceived by patients, given the discrepancy between patients' experiences and the attitudes gynecologists report themselves. For optimizing the organization of care, we would recommend the use of a clear (inter)national policy regarding maternal requests for cesarean section (CS).Brief rationaleThe objective of this study was to evaluate knowledge and awareness regarding fear of childbirth (FOC) and postpartum posttraumatic stress disorder (PP-PTSD) among gynecologists and gynecology residents, assessing their attitudes towards women suffering from these conditions, and evaluating organization of care.The main findings and recommendations of the study include that gynecologists should be better trained to appropriately recognize fear of childbirth and postpartum posttraumatic stress disorder, and they should be made more aware of how their communication is perceived by patients, given the discrepancy between patients' experiences and the attitudes gynecologists report themselves.

Work-related adverse events leaving their mark: a cross-sectional study among Dutch gynecologists

BACKGROUND

Health care professionals who are frequently coping with traumatic events have an increased risk of developing a posttraumatic stress disorder. Research among physicians is scarce, and obstetrician-gynecologists may have a higher risk. Work-related traumatic events and posttraumatic stress disorder among obstetricians-gynecologists and the (desired) type of support were studied.

METHODS

A questionnaire was emailed to all members of the Dutch Society of Obstetrics and Gynaecology, which included residents, attending, retired and non-practicing obstetricians-gynecologists. The questionnaire included questions about personal experiences and opinions concerning support after work-related events, and a validated questionnaire for posttraumatic stress disorder.

RESULTS

The response rate was 42.8% with 683 questionnaires eligible for analysis. 12.6% of the respondents have experienced a work-related traumatic event, of which 11.8% met the criteria for current posttraumatic stress disorder. This revealed an estimated prevalence of 1.5% obstetricians-gynecologists with current posttraumatic stress disorder. 12% reported to have a support protocol or strategy in their hospital after adverse events. The most common strategies to cope with emotional events were: to seek support from colleagues, to seek support from family or friends, to discuss the case in a complication meeting or audit and to find distraction. 82% would prefer peer-support with direct colleagues after an adverse event.

CONCLUSIONS

This survey implies that work-related events can be traumatic and subsequently can lead to posttraumatic stress disorder. There is a high prevalence rate of current posttraumatic stress disorder among obstetricians-gynecologists. Often there is no standardized support after adverse events. Most obstetrician-gynecologists prefer peer-support with direct colleagues after an adverse event. More awareness must be created during medical training and organized support must be implemented.

Preventing post-traumatic stress disorder following childbirth and traumatic birth experiences: a systematic review

INTRODUCTION

Between 9 and 44% of women experience giving birth as traumatic, and 3% of women develop a post-traumatic stress disorder following childbirth. Knowledge on risk factors is abundant, but studies on treatment are limited. This study aimed to present an overview of means to prevent traumatic birth experiences and childbirth-related post-traumatic stress disorder.

MATERIAL AND METHODS

Major databases [Cochrane; Embase; PsycINFO; PubMed (Medline)] were searched using combinations of the key words and their synonyms.

RESULTS

After screening titles and abstracts and reading 135 full-text articles, 13 studies were included. All evaluated secondary prevention, and none primary prevention. Interventions included debriefing, structured psychological interventions, expressive writing interventions, encouraging skin-to-skin contact with healthy newborns immediately postpartum and holding or seeing the newborn after stillbirth. The large heterogeneity of study characteristics precluded pooling of data. The writing interventions to express feelings appeared to be effective in prevention. A psychological intervention including elements of exposure and psycho-education seemed to lead to fewer post-traumatic stress disorder symptoms in women who delivered via emergency cesarean section.

CONCLUSIONS

No research has been done on primary prevention of traumatic childbirth. Research on secondary prevention of traumatic childbirth and post-traumatic stress disorder following delivery provides insufficient evidence that the described interventions are effective in unselected groups of women. In certain subgroups, results are inhomogeneous.

Psychosocial Predictors of Postpartum Posttraumatic Stress Disorder in Women With a Traumatic Childbirth Experience

Objective: To analyze the predictive value of antepartum vulnerability factors, such as social support, coping, history of psychiatric disease, and fear of childbirth, and intrapartum events on the development of symptoms of postpartum posttraumatic stress disorder (PP-PTSD) in women with a traumatic childbirth experience. Materials and methods: Women with at least one self-reported traumatic childbirth experience in or after 2005 were invited to participate through various social media platforms in March 2016. They completed a 35-item questionnaire including validated screening instruments for PTSD (PTSD Symptom Checklist, PCL-5), social support (Oslo social support scale, OSS-3), and coping (Antonovsky's sense of coherence scale, SoC). Results: Of the 1,599 women who completed the questionnaire, 17.4% met the diagnostic criteria for current PTSD according to the DSM-5, and another 26.0% recognized the symptoms from a previous period, related to giving birth. Twenty-six percent of the participating women had received one or more psychiatric diagnoses at some point in their life, and five percent of all women had been diagnosed with PTSD prior to their traumatic childbirth experience. Women with poor (OR = 15.320, CI = 8.001-29.336), or moderate (OR = 3.208, CI = 1.625-6.333) coping skills were more likely to report PP-PTSD symptoms than women with good coping skills. Low social support was significantly predictive for current PP-PTSD symptoms compared to high social support (OR = 5.557, CI = 2.967-7.785). A predictive model which could differentiate between women fulfilling vs. not fulfilling the symptom criteria for PTSD had a sensitivity of 80.8% and specificity of 62.6% with an accuracy of 66.5%. Conclusions: Low social support, poor coping, experiencing "threatened death" and experiencing "actual or threatened injury to the baby" were the four significant factors in the predictive model for women with a traumatic childbirth experience to be at risk of developing PP-PTSD. Further research should investigate the effects of interventions aimed at the prevention of PP-PTSD by strengthening coping skills and increasing social support, especially in women at increased risk of unfavorable obstetrical outcomes.

Supervisión de casos: Mujer embarazada traumatizada

Supervisión de casos es un nuevo apartado regular del Journal of EMDR Practice and Research en el que un terapeuta solicita ayuda con un caso complicado y tres expertos le responden por escrito. En este artículo, Amy Robbins, una terapeuta certificada en terapia de desensibilización y reprocesamiento por movimientos oculares (EMDR) de Atlanta, Georgia, describe brevemente un caso complicado en el que una mujer embarazada busca tratamiento por un trauma sufrido durante un tornado. La terapeuta pregunta si es recomendable hacer tratamiento con EMDR y qué precauciones debería tener en cuenta. La primera especialista, Carol Forgash, ofrece información general sobre el embarazo y la psicoterapia y señala aspectos a tener en cuenta, precauciones y contraindicaciones a la hora de proceder con EMDR. Recomienda que si se escoge este tratamiento, la terapeuta proceda con un protocolo de trauma reciente para hacer blanco específicamente sobre los recuerdos traumáticos del reciente tornado. El segundo especialista, Andrew Leeds, comenta sobre la ausencia de ensayos controlados aleatorizados (ECA) u otros informes científicos que exploren la seguridad del tratamiento EMDR con mujeres embarazadas. Señala que las mujeres embarazadas con síntomas de estrés postraumático tendrían que entender que hay grandes posibilidades de que el EMDR mejore su calidad de vida como madre y que, probablemente, los riesgos de sufrir efectos adversos en la estabilidad del embarazo son muy bajos, aunque siguen siendo desconocidos. La tercera especialista, Claire Stramrood, explica que los pocos estudios de casos que han evaluado el EMDR durante el embarazo han encontrado efectos positivos, pero estaban relacionados con mujeres con trastorno de estrés postraumático (TEPT) posterior al nacimiento del bebé. Afirma que una vez que se haya consultado al obstetra, se haya informado a las mujeres de los posibles riesgos y beneficios y hayan firmado un consentimiento informado, deberían de poder decidir si comenzar la terapia EMDR durante el embarazo.

Case Consultation: Traumatized Pregnant Woman

Case consultation is a new regular feature in the Journal of EMDR Practice and Research in which a therapist requests assistance regarding a challenging case and responses are written by three experts. In this article, Amy Robbins, a certified eye movement desensitization and reprocessing (EMDR) therapist from Atlanta, Georgia, briefly describes a challenging case in which a pregnant woman seeks treatment for trauma suffered in a tornado. The clinician asks if it is advisable to provide EMDR treatment and what concerns she should be aware of. The first expert, Carol Forgash, provides some general information about pregnancy and psychotherapy and outlines considerations, concerns, and contraindications for proceeding with EMDR. She recommends that if treatment is chosen, the therapist proceed with a recent trauma protocol to specifically target the traumatic memories of the recent tornado. The second expert, Andrew Leeds, comments on the absence of randomized controlled trials (RCTs) or other scientific reports exploring the safety of EMDR treatment of pregnant women. He states that pregnant women with symptoms of posttraumatic stress should understand that there is a high probability that EMDR will improve maternal quality of life and that the risks of adverse effects on stability of pregnancy are probably low, but that these remain unknown. The third expert, Claire Stramrood, explains that the few case studies that evaluated EMDR during pregnancy have found positive effects but pertained to women with posttraumatic stress disorder (PTSD) following childbirth. She asserts that once obstetricians have been consulted, women have been informed about possible risks and benefits, and, given their informed consent, they should be able to choose to commence EMDR therapy during pregnancy.

Posttraumatic stress disorder, anxiety and depression following pregnancies conceived through fertility treatments: the effects of medically assisted conception on postpartum well-being

OBJECTIVE

To compare the postpartum prevalence of Posttraumatic Stress Disorder (PTSD), anxiety and depression in women who conceived via medically assisted conception (MAC) and women who conceived naturally.

STUDY DESIGN

All women (n = 907) who delivered under supervision of four independent midwifery practices and three hospitals in the Netherlands during a 3-month period were asked to complete questionnaires on demographic, logistic, psychosocial and obstetric characteristics two to six months postpartum. In this cross-sectional study PTSD was measured with the Traumatic Event Scale-B; anxiety and depression were measured with the Hospital Anxiety and Depression Scale.

RESULTS

The response rate was 47% (428 participants). No significant differences were found in the prevalence of PTSD (0.0% vs. 1.3%; odds ratio [OR] = 0.0, confidence interval [CI]: 0-infinity), anxiety (28.1% vs. 22.2%; OR = 1.4, CI: 0.6-3.1) and depression (9.4% vs. 14.6%; OR = 0.6, CI: 0.8-2.0) between the 32 women who conceived via MAC and the 396 women who conceived naturally.

CONCLUSION

We did not find significant differences in the prevalence of PTSD, anxiety and depression between women who conceived via MAC and women who conceived naturally.

The patient observer: eye-movement desensitization and reprocessing for the treatment of posttraumatic stress following childbirth

BACKGROUND

No standard intervention with proved effectiveness is available for women with posttraumatic stress following childbirth because of insufficient research. The objective of this paper was to evaluate the possibility of using eye-movement desensitization and reprocessing treatment for women with symptoms of posttraumatic stress disorder following childbirth. The treatment is internationally recognized as one of the interventions of choice for the condition, but little is known about its effects in women who experienced the delivery as traumatic.

METHODS

Three women suffering from posttraumatic stress symptoms following the birth of their first child were treated with eye-movement desensitization and reprocessing during their next pregnancy. Patient A developed posttraumatic stress symptoms following the lengthy labor of her first child that ended in an emergency cesarean section after unsuccessful vacuum extraction. Patient B suffered a second degree vaginal rupture, resulting in pain and inability to engage in sexual intercourse for years. Patient C developed severe preeclampsia postpartum requiring intravenous treatment.

RESULTS

Patients received eye-movement desensitization and reprocessing treatment during their second pregnancy, using the standard protocol. The treatment resulted in fewer posttraumatic stress symptoms and more confidence about their pregnancy and upcoming delivery compared with before the treatment. Despite delivery complications in Patient A (secondary cesarean section due to insufficient engaging of the fetal head); Patient B (second degree vaginal rupture, this time without subsequent dyspareunia); and Patient C (postpartum hemorrhage, postpartum hypertension requiring intravenous treatment), all three women looked back positively at the second delivery experience.

CONCLUSIONS

Treatment with eye-movement desensitization and reprocessing reduced posttraumatic stress symptoms in these three women. They were all sufficiently confident to attempt vaginal birth rather than demanding an elective cesarean section. We advocate a large-scale, randomized controlled trial involving women with postpartum posttraumatic stress disorder to evaluate the effect of eye-movement desensitization and reprocessing in this patient group.

Posttraumatic stress following childbirth in homelike- and hospital settings

OBJECTIVE

To assess the prevalence of posttraumatic stress disorder (PTSD) following childbirth in homelike versus hospital settings and to determine risk factors for the development of posttraumatic stress symptoms. METHODS.: Multi-center cross-sectional study at midwifery practices, general hospitals and a tertiary (university) referral center. An unselected population of 907 women was invited to complete questionnaires on PTSD, demographic, psychosocial, and obstetric characteristics 2 to 6 months after delivery. Prevalence of PTSD was based on women who met all criteria of the diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV), whereas risk factors were determined using the severity (sum-score) of posttraumatic stress symptoms.

RESULTS

PTSD following childbirth was found in 1.2% of the respondents (5/428 women, response rate 47%), while 9.1% of women (39/428) had experienced the delivery as traumatic. Posttraumatic stress symptoms were associated with unplanned cesarean section, low sense of coherence (coping skills), and high intensity of pain. Initial differences in posttraumatic stress symptoms between home and hospital deliveries disappeared after taking into account the (by definition) uncomplicated nature of home births.

CONCLUSION

In this Dutch study, 1 in 100 women had PTSD following childbirth, with no differences between home- and hospital deliveries after controlling for complications and interventions. Emergency cesarean section, severe labor pain, and poor coping skills were associated with more posttraumatic stress symptoms.

Measuring posttraumatic stress following childbirth: a critical evaluation of instruments

OBJECTIVES

To evaluate instruments used to assess posttraumatic stress disorder (PTSD) following childbirth with both quantitative (reliability analysis and factor analysis) and qualitative (comparison of operationalization) techniques.

METHODS

An unselected population of 428 women completed the Traumatic Event Scale-B (TES-B) and the PTSD Symptom Scale-Self Report (PSS-SR) 2-6 months after delivery.

RESULTS

Assessment of internal consistency yielded similar results for the TES-B and PSS-SR (Cronbach's alpha = 0.87 and 0.82, respectively). Factor analysis revealed two rather than three DSM-IV symptom categories for both instruments: childbirth-related factors (re-experiencing/ avoidance) and symptoms of depression and anxiety (numbing/hyperarousal). Although the TES-B and the PSS-SR sum-scores show a strong relationship (Spearmans rho = 0.78), agreement between the instruments on the identification of PTSD cases is low (kappa = 0.24); discrepancy between TES-B and PSS-SR is largely due to differences in instruction to respondents, formulation of items, answer categories, and cut-off values.

CONCLUSIONS

Large operationalization differences between TES-B and PSS-SR have been identified, i.e., in the formulation of questions, answer categories, cut-off values and instructions to respondents. Comparison between studies using different instruments for measuring PTSD following childbirth should be done with utmost caution.

Neonatal phrenic nerve injury due to traumatic delivery

AIMS

To describe the clinical course of infants recovering spontaneously from diaphragmatic paralysis due to perinatal phrenic nerve injury as well as those that underwent plication of the diaphragm.

METHODS

Between 1990 and 2006, 14 newborns admitted to the Neonatal Intensive Care Unit (NICU) of the Wilhelmina Children's Hospital in Utrecht, The Netherlands, were diagnosed with diaphragmatic paralysis due to obstetric phrenic nerve injury. The clinical and follow-up data were studied retrospectively.

RESULTS

Four infants recovered spontaneously and could be weaned from mechanical ventilation within nine days without further treatment. Plication of the diaphragm was performed in 10 infants because of failure to wean from ventilatory support or serious persistent respiratory distress. Time between birth and plication ranged from 10 to 51 days, with a median of 19 days. Satisfactory respiratory outcome was achieved in 86% of the cases.

CONCLUSIONS

The minority of infants suffering from diaphragmatic paralysis due to perinatal phrenic nerve injury recovers spontaneously. Infants who fail to wean from ventilatory support and undergo early plication have a quick recovery and can be extubated successfully within a few days.

Cyproterone acetate- and ethinyloestradiol-containing oral contraceptive as a risk factor for upper extremity deep venous thrombosis-a case report

Deep venous thrombosis of the upper extremity (UEDVT) is a rare variety of deep venous thrombosis. Compared to lower-extremity deep venous thrombosis, less is known about the risk factors for primary UEDVT. We report on a 27-year-old woman with UEDVT extending from the jugular and subclavian veins to the elbow. The thrombosis was possibly provoked by a shoulder trauma, in combination with heterozygosity for the prothrombin G20210A mutation and a protein S-deficiency, which may have been induced by the use of a cyproterone acetate- and ethinyloestradiol (CPA/EE)-containing oral contraceptive.