Risk factors for postpartum posttraumatic stress disorder after emergency admission

Abstract

BACKGROUND:

Postpartum posttraumatic stress disorder (PTSD) can occur in women who give birth after emergency admission. The identification of risk factors for this condition is crucial for developing effective preventive measures. This retrospective study aimed to explore the incidence and risk factors for postpartum PTSD in women who give birth after emergency admission.

METHODS:

Medical records of women who gave birth after emergency admission were collected between March 2021 and April 2023. The patients’ general conditions and perinatal clinical indicators were recorded. The puerperae were divided into PTSD group and control group based on symptom occurrence at six weeks postpartum. Multivariate logistic regression analysis was performed to identify risk factors.

RESULTS:

A total of 276 puerperae were included, with a PTSD incidence of 20.3% at six weeks postpartum. Multivariate logistic regression analysis identified emergency cesarean section (odds ratio [OR]=2.102; 95% confidence interval [CI]: 1.114–3.966, P=0.022), admission to the emergency department after midnight (12:00 AM) (OR=2.245; 95%CI: 1.170–4.305, P<0.001), and cervical dilation (OR=3.203; 95%CI: 1.670–6.141, P=0.039) as independent risk factors for postpartum PTSD. Analgesia pump use (OR= 0.500; 95%CI: 0.259–0.966, P=0.015) was found to be a protective factor against postpartum PTSD.

CONCLUSION:

Emergency cesarean section, admission to the emergency department after midnight, and cervical dilation were identified as independent risk factors for postpartum PTSD, while analgesic pump use was a protective factor. These findings provide insights for developing more effective preventive measures for women who give birth after emergency admission.

INTRODUCTION

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that develops after experiencing major trauma,[1] involving a combination of recurring and distressing re-experiencing (e.g., flashbacks, intrusive thoughts), avoidance, negative alterations in mood and cognition, and hyperarousal. Similar or related stimuli may trigger symptoms that persist for years or decades, with recurrent episodes of traumatic experiences and sustained increases in vigilance and avoidance.[2-4] Childbirth, although generally viewed as a positive life event, can be a traumatic experience for many mothers due to the intense pain involved. Approximately 34%–54% of women think that childbirth is a traumatic event, and in severe cases, postpartum PTSD can occur.[5,6] The prevalence of postpartum PTSD in high-risk women can be as high as 18.5% and shows an increasing trend.[7] Studies have shown that postpartum PTSD can have a range of adverse effects on both the mother and child, including delayed intellectual development, heightened susceptibility to postpartum depression, reduced breastfeeding rates, and impaired mother-infant bonding.[8, 9]

The pathogenesis of PTSD is complex, with the formation and consolidation of fear memory playing a significant role in its development.[10] Stressful and traumatic events lead to the release of substances such as norepinephrine, which contribute to the formation of event-related fear memories and the development of PTSD.[11] Women who give birth after emergency admission may experience heightened stress and anxiety due to the suddenness and uncertainty of the event, the unfamiliarity of the emergency department, pain, and concerns for their own and their baby’s safety. These negative emotions can promote the formation of fear memories,[12,13] potentially increasing the likelihood of postpartum PTSD. However, the incidence and risk factors for postpartum PTSD in women who give birth after emergency admission remain unclear.

This study aimed to explore the incidence and risk factors for postpartum PTSD in women who give birth after emergency admission to develop more effective preventive measures for such patients.

METHODS

Study design and participants

This retrospective study included pregnant women who gave birth after emergency admission at Suzhou Xiangcheng People’s Hospital between March 2021 and April 2023. The inclusion criteria were as follows: 1) giving birth after emergency admission; 2) being aged 18 years or older; and 3) having clear consciousness with normal language expression, reading, and writing abilities. The exclusion criteria were as follows: 1) having an intellectual disability or cognitive impairment preventing completion of the assessment form and 2) having a history of trauma or psychiatric disorders.

Data collection

Retrospective data collection included general information and perinatal clinical indicators of women who gave birth after emergency admission. The collected variables included age, education level, household registration, parity, mode of delivery (vaginal or cesarean section), traumatic delivery experience (e.g., perineal tears), newborn health status (Apgar scores), full-term delivery, analgesic pump use, cervical dilation upon admission, transfer from the delivery room to the operating room for cesarean section, admission to the emergency department after midnight (12:00 AM), and pregnancy complications (e.g., hypertension, diabetes).

Evaluation scale

The occurrence of postpartum PTSD was evaluated by the Posttraumatic Stress Checklist-Civilian version[14] (PCL-C) at six weeks postpartum in the maternity clinic. A total score of ≥38 on the PCL-C indicated a diagnosis of PTSD. The scale consisted of 17 items categorized into three symptom clusters. A 5-point Likert-type scoring method was used, and the total score ranged from 17 to 85. Scores of 17–37 indicated no obvious PTSD symptoms, 38–49 indicated some PTSD symptoms, and 50–85 indicated moderate to high PTSD symptoms. Therefore, a score of 38 was used as the cut-off for a PTSD diagnosis. Accordingly, participants were divided into PTSD group and control group.

Statistical analysis

The data were analyzed using SPSS statistical software version 23.0 (IBM, USA). The Kolmogorov-Smirnov test was used to determine whether the continuous data conformed to a normal distribution. Continuous variables are presented as the mean ± standard deviation, and continuous data with a normal distribution were compared with the independent-sample t test. Categorical variables were compared by the Chi-suqare test. Logistic regression analysis was used to identify the risk factors for PTSD in puerperae who gave birth after emergency admission. A P-value <0.05 indicates a statistically significant difference.

RESULTS

The study population included 276 pregnant women, comprised 56 PTSD patients and 220 controls. There was no significant difference in the years of exposure between case patients and controls (P= 0.121). No major family or personal events (such as a car accident, serious illness, or death) occurred in either group.

Univariate analysis revealed that parity, mode of delivery, analgesic pump use, cervical dilation, admission to the emergency department after midnight, and hypertension during pregnancy were significant different between the PTSD patients and control group (Table 1).

Table 1.

Univariate analysis of risk factors for posttraumatic stress disorder (PTSD) in women who gave birth after emergency admission

Multivariate logistic regression analysis identified emergency cesarean section, admission to the emergency department after midnight, and cervical dilation as independent risk factors for postpartum PTSD. Analgesia pump use was found to be a protective factor against postpartum PTSD for women who gave birth after emergency admission (Table 2).

Table 2.

Multivariate analysis of risk factors for posttraumatic stress disorder (PTSD) in women who gave birth after emergency admission

Post hoc analysis

The numbers of different risk factors in the case patients and controls are shown in Table 3. Compared with the controls, the case patients had significantly higher numbers of risk factors (2.04±1.06 vs. 1.65±0.92, P=0.007).

Table 3.

The number of risk factors in the posttraumatic stress disorder (PTSD) patients and controls

DISCUSSION

PTSD is arguably the most common psychiatric disorder to arise after exposure to a traumatic event. Although trauma-focused cognitive behavior therapy is the best-validated treatment for PTSD, it has not improved over recent decades, and only two-thirds of PTSD patients respond adequately to this intervention. Moreover, most people with PTSD do not have access to evidence-based treatment.[15] Therefore, it is crucial to focus on preventing the occurrence of PTSD in high-risk populations, such as puerperae who give birth after emergency admission.

In our study, the postpartum PTSD incidence rate in puerperae who gave birth after emergency admission was 20.3%. This rate is consistent with a previous study conducted in high-risk populations.[7] Globally, the incidence rate of postpartum PTSD has been reported to range from 1% to 30%.[16] The incidence of 20.3% among pregnant women in this study falls within the upper middle range.

In our study, three factors were found to increase the risk of postpartum PTSD in puerperae who gave birth after emergency admission, namely emergency cesarean section, admission to the emergency department after midnight, and cervical dilation. Previous studies have also highlighted the relationship between emergency cesarean section and postpartum PTSD,[17,18] which aligns with our findings. However, the association of cervical dilation and emergency department visits after midnight with postpartum PTSD has not been extensively explored. There are possible explanations for the risk factors identified in our study. Puerperae admitted to the emergency department may experience fear, anxiety, and stress due to unexpected situation.[19,20] This, coupled with the sudden and high-risk nature of emergency cesarean section, can create a more complex and potentially life-threatening delivery process. The negative emotions, fear, and painful experiences associated with emergency cesarean section can contribute to the formation and consolidation of fear memories, potentially leading to postpartum PTSD. Childbirth pain, particularly from cervical dilation, has been shown to be highly distressing[21,22] and can stimulate the amygdala region of the limbic system, a key area involved in the formation of conditioned fear memories—a core symptom of PTSD.[23] Furthermore, puerperae admitted to the emergency department after midnight were more likely to develop PTSD. The possible reasons are as follows. First, emergency admission after midnight may occur suddenly, be extremely urgent, and involve greater pressure to ensure the health and safety of the mother and child. Second, most women admitted to the emergency department after midnight had already fallen asleep, and their sleep was interrupted by sudden pain or discomfort. Cortisol nadir levels are reached upon falling asleep, whereas levels are high upon awakening and spike by an average of 50%–60% within 30–40 min,[24,25] while the increased cortisol secretion increases the sensitivity of organisms to psychological stress.[26] Third, sudden sleep interruptions and drowsiness after midnight can increase anxiety to some extent. Anxiety shares neurobiological features with PTSD and is frequently comorbid with the disorder.[27]

In our study, analgesia pump use was a protective factor against postpartum PTSD. The release of norepinephrine during stressful and traumatic events can increase the formation of event-related fear memories, thus inducing PTSD.[11] Sedative and analgesic drugs delivered via an analgesic pump may prevent the onset and development of PTSD by lowering the important source of norepinephrine in the central nervous system and reducing the consolidation, reinforcement and formation of conditioned fear memories during the early stage of trauma.[28,29] In the post hoc analysis, PTSD patients had more risk factors, which also indicated that puerperae who gave birth after emergency admission experienced repeated stimulation due to multiple risk factors in the early stage of fear memory formation, which promoted the consolidation of fear memories. This would facilitate the development of postpartum PTSD.

Limitations

Several limitations should be considered in this study. First, this was a single-center retrospective study with a small sample size. Multicenter prospective studies with larger sample sizes are needed to validate our findings. Second, the follow-up evaluation in this study was conducted only six weeks after delivery, which may limit our understanding of the long-term prevalence and trajectory of postpartum PTSD, and a systematic review showed changes in the prevalence of PTSD after one, two, three, and six months.[30] Future studies ought to consider extending the duration of follow-up. Finally, this retrospective study focused on analyzing baseline and perinatal clinical data without gathering detailed demographic and sociological information about the participants. However, the aim of this study was to explore the clinically relevant risk factors for such high-risk pregnant women during hospitalization and to develop effective preventative measures.

CONCLUSION

Our findings suggest that emergency cesarean section, admission to the emergency department after midnight, and cervical dilation were independent risk factors for postpartum PTSD in puerperae who gave birth after emergency admission. Conversely, the use of an analgesic pump was found to be a protective factor against postpartum PTSD. These findings emphasize the importance of optimizing care and support for high-risk pregnant women after emergency admission to reduce the occurrence of postpartum PTSD. Further research is warranted to better understand the underlying mechanisms and develop targeted interventions to mitigate the risk of postpartum PTSD in this vulnerable population.