Antje Horsch

Post-traumatic stress disorder following childbirth: an update of current issues and recommendations for future research

Objective: This paper aimed to report the current status of research in the field of post-traumatic stress disorder following childbirth (PTSD FC), and to update the findings of an earlier 2008 paper. Background: A group of international researchers, clinicians and service users met in 2006 to establish the state of clinical and academic knowledge relating to PTSD FC. A paper identified four key areas of research knowledge at that time. Methods: Fourteen clinicians and researchers met in Oxford, UK to update the previously published paper relating to PTSD FC. The first part of the meeting focused on updating the four key areas identified previously, and the second part on discussing new and emerging areas of research within the field. Results: A number of advances have been made in research within the area of PTSD FC. Prevalence is well established within mothers, several intervention studies have been published, and there is growing interest in new areas: staff and pathways; prevention and early intervention; impact on families and children; special populations; and post-traumatic growth. Conclusion: Despite progress, significant gaps remain within the PTSD FC knowledge base. Further research continues to be needed across all areas identified in 2006, and five areas were identified which can be seen as ‘new and emerging’. All of these new areas require further extensive research. Relatively little is still known about PTSD FC.

Mothers’ experience of their contact with their stillborn infant: An interpretative phenomenological analysis

BackgroundGuidelines surrounding maternal contact with the stillborn infant have been contradictory over the past thirty years. Most studies have reported that seeing and holding the stillborn baby is associated with fewer anxiety and depressive symptoms among mothers of stillborn babies than not doing so. In contrast, others studies suggest that contact with the stillborn infant can lead to poorer maternal mental health outcomes. There is a lack of research focusing on the maternal experience of this contact. The present study aimed to investigate how mothers describe their experience of spending time with their stillborn baby and how they felt retrospectively about the decision they made to see and hold their baby or not.MethodIn depth interviews were conducted with twenty-one mothers three months after stillbirth. All mothers had decided to see and the majority to hold their baby. Qualitative analysis of the interview data was performed using Interpretive Phenomenological Analysis.ResultsSix superordinate themes were identified: Characteristics of Contact, Physicality; Emotional Experience; Surreal Experience; Finality; and Decision. Having contact with their stillborn infant provided mothers with time to process what had happened, to build memories, and to ‘say goodbye’, often sharing the experience with partners and other family members. The majority of mothers felt satisfied with their decision to spend time with their stillborn baby. Several mothers talked about their fear of seeing a damaged or dead body. Some mothers experienced strong disbelief and dissociation during the contact.ConclusionsResults indicate that preparation before contact with the baby, professional support during the contact, and professional follow-up are crucial in order to prevent the development of maternal mental health problems. Fears of seeing a damaged or dead body should be sensitively explored and ways of coping discussed. Even in cases where mothers experienced intense distress during the contact with their stillborn baby, they still described that having had this contact was important and that they had taken the right decision. This indicates a need for giving parents an informed choice by engaging in discussions about the possible benefits and risks of seeing their stillborn baby.

Maternal coping, appraisals and adjustment following diagnosis of fetal anomaly

So far, associations between appraisals, maternal adjustment and coping following diagnosis of fetal anomaly have not been investigated in women who continue with their pregnancy.

Reducing intrusive traumatic memories after emergency caesarean section: A proof-of-principle randomized controlled study

Preventative psychological interventions to aid women after traumatic childbirth are needed. This proof-of-principle randomized controlled study evaluated whether the number of intrusive traumatic memories mothers experience after emergency caesarean section (ECS) could be reduced by a brief cognitive intervention. 56 women after ECS were randomized to one of two parallel groups in a 1:1 ratio: intervention (usual care plus cognitive task procedure) or control (usual care). The intervention group engaged in a visuospatial task (computer-game ‘Tetris’ via a handheld gaming device) for 15 min within six hours following their ECS. The primary outcome was the number of intrusive traumatic memories related to the ECS recorded in a diary for the week post-ECS. As predicted, compared with controls, the intervention group reported fewer intrusive traumatic memories (M = 4.77, SD = 10.71 vs. M = 9.22, SD = 10.69, d = 0.647 [95% CI: 0.106, 1.182]) over 1 week (intention-to-treat analyses, primary outcome). There was a trend towards reduced acute stress re-experiencing symptoms (d = 0.503 [95% CI: −0.032, 1.033]) after 1 week (intention-to-treat analyses). Times series analysis on daily intrusions data confirmed the predicted difference between groups. 72% of women rated the intervention “rather” to “extremely” acceptable. This represents a first step in the development of an early (and potentially universal) intervention to prevent postnatal posttraumatic stress symptoms that may benefit both mother and child. Clinical trial registration ClinicalTrials.gov, www.clinicaltrials.gov, NCT02502513.

Gestational Diabetes Mellitus.

Based on the Hyperglycemia and Adverse Pregnancy Outcome study, new universal screening recommendations and cut-offs for gestational diabetes mellitus (GDM) have been proposed. In addition to the immediate perinatal risk, GDM carries an increased risk of metabolic disease in the mother and child. Maternal obesity has even been shown to be associated with increased all-cause mortality in offspring. In addition to known risk factors, excessive gestational weight gain, increased fat consumption, a low vitamin D level, psychological stress and negative mood are risk factors for GDM. Regarding therapy, the US Preventive Task Force concluded in 2013 that GDM treatment significantly reduces the risks of pre-eclampsia, macrosomia and shoulder dystocia (relative risks of 0.62, 0.5 and 0.42, respectively). Although nutrition therapy represents a cornerstone in GDM management, the results of studies are not clear regarding which types of dietary advice are the most suitable. Most physical activity interventions improve glucose control and/or reduce insulin use. Recent studies have evaluated and provided more information about treatment with metformin or glyburide. Postpartum management is essential and should focus on long-term screening and diabetes prevention strategies.

Playing the computer game Tetris prior to viewing traumatic film material and subsequent intrusive memories: Examining proactive interference.

Background and objectives Visuospatial working memory (WM) tasks performed concurrently or after an experimental trauma (traumatic film viewing) have been shown to reduce subsequent intrusive memories (concurrent or retroactive interference, respectively). This effect is thought to arise because, during the time window of memory consolidation, the film memory is labile and vulnerable to interference by the WM task. However, it is not known whether tasks before an experimental trauma (i.e. proactive interference) would also be effective. Therefore, we tested if a visuospatial WM task given before a traumatic film reduced intrusions. Findings are relevant to the development of preventative strategies to reduce intrusive memories of trauma for groups who are routinely exposed to trauma (e.g. emergency services personnel) and for whom tasks prior to trauma exposure might be beneficial. Methods Participants were randomly assigned to 1 of 2 conditions. In the Tetris condition (n = 28), participants engaged in the computer game for 11 min immediately before viewing a 12-min traumatic film, whereas those in the Control condition (n = 28) had no task during this period. Intrusive memory frequency was assessed using an intrusion diary over 1-week and an Intrusion Provocation Task at 1-week follow-up. Recognition memory for the film was also assessed at 1-week. Results Compared to the Control condition, participants in the Tetris condition did not report statistically significant difference in intrusive memories of the trauma film on either measure. There was also no statistically significant difference in recognition memory scores between conditions. Limitations The study used an experimental trauma paradigm and findings may not be generalizable to a clinical population. Conclusions Compared to control, playing Tetris before viewing a trauma film did not lead to a statistically significant reduction in the frequency of later intrusive memories of the film. It is unlikely that proactive interference, at least with this task, effectively influences intrusive memory development. WM tasks administered during or after trauma stimuli, rather than proactively, may be a better focus for intrusive memory amelioration.

Maternal posttraumatic stress disorder during the perinatal period and child outcomes: A systematic review

BACKGROUND Approximately 3.3% of women in pregnancy have posttraumatic stress disorder (PTSD) and 4% of women postpartum PTSD. The impact of maternal PTSD during the perinatal period (from conception until one year postpartum) on child outcomes has not been systematically examined. METHOD A systematic review was conducted to synthesize and critically evaluate quantitative research investigating the association between perinatal PTSD and child outcomes. Databases EMBASE, BNI, Medline, PsycInfo and CINAHL were searched using specific inclusion and exclusion criteria. RESULTS 26 papers reporting 21 studies were identified that examined associations between perinatal PTSD and postpartum birth outcomes, child development, and mother-infant relationship. Studies reviewed were heterogeneous, with poor-to-medium scores of methodological quality. Results showed that maternal postpartum PTSD is associated with low birth weight and lower rates of breastfeeding. Evidence for an association between maternal PTSD and preterm birth, fetal growth, head circumference, mother-infant interaction, the mother-infant relationship or child development is contradictory. Associations between maternal PTSD and infant salivary cortisol levels, and eating/sleeping difficulties are based on single studies, so require replication. LIMITATIONS Methodological weaknesses of the studies included insufficient sample size, use of invalidated measures, and limited external validity. CONCLUSION Findings suggest that perinatal PTSD is linked with some negative child outcomes. Early screening for PTSD during the perinatal period may be advisable and onward referral for effective treatment, if appropriate. Future research using larger sample sizes, validated and reliable clinical interviews to assess PTSD, and validated measures to assess a range of child outcomes, is needed.

The Psychological Impact of Stillbirth on Women: A Systematic Review

This systematic review explored the psychological impact of stillbirth (from 20 weeks gestation) on mothers. A search was conducted in the National Library for Health and Web of Science, Cochrane Review, and Google Scholar. A secondary search based on results from the preliminary search was undertaken. A systematic search identified 26 articles (8 qualitative, 18 quantitative studies), which met criteria and were reviewed according to guidelines. The findings revealed that stillbirth is a distressing experience that can result in high levels of psychological symptoms including anxiety, depression, distress, and negative well-being. Symptoms appear to be highest in the first few months post loss although there is evidence to suggest that for some, symptoms may persist up to 3 years. The long-lasting impact of stillbirth on women was echoed in the qualitative research. Risk factors for higher levels of anxious and depressive symptoms included higher parity at the time of loss and not being married. Social support in particular was identified to be beneficial for women post loss. Longitudinal studies utilizing designs which permit causality to be determined are required to explore the specific experience of stillbirth. Further exploration of risk and protective factors, cultural beliefs, and the impact on partner relationships is needed. Clinical implications of the findings are discussed in light of current guidance.

Cognitive Predictors and Risk Factors of PTSD Following Stillbirth: A Short‐Term Longitudinal Study

This short-term longitudinal study investigated cognitive predictors and risk factors of posttraumatic stress disorder (PTSD) in mothers following stillbirth. After a stillbirth at ≥ 24 weeks gestational age, 65 women completed structured clinical interviews and questionnaires assessing PTSD symptoms, cognitive predictors (appraisals, dysfunctional strategies), and risk factors (perceived social support, trauma history, obstetric history) at 3 and 6 months. PTSD symptoms decreased between 3 and 6 months (Cohens d ranged .34-.52). Regression analyses also revealed a specific positive relationship between Rumination and concurrent frequency of PTSD symptoms (β = .45). Negative Self-View and Negative World-View related positively and Self-Blame related negatively to concurrent number of PTSD symptoms (β = .48, .44, -.45, respectively). Suppression and Distraction predicted a decrease and Numbing predicted an increase in time-lagged number of PTSD symptoms (β = -.33, -.28, .30, respectively). Risk factors for PTSD symptoms were younger age (β = -.25), lower income (β = -.29), fewer previous pregnancies (β = -.31), and poorer perceived social support (β = -.26). Interventions addressing negative appraisals, dysfunctional strategies, and social support are recommended for mothers with PTSD following stillbirth. Knowledge of cognitive predictors and risk factors of PTSD may inform the development of a screening instrument.

Standard care practices and psychosocial interventions aimed at reducing parental distress following stillbirth: A systematic narrative review

Objective: To summarise and critically evaluate the evidence informing the provision of standard care practices and psychosocial interventions following stillbirth. Background: Stillbirth is increasingly recognised as a significant bereavement experience with the potential to cause substantial psychological distress for parents. Standard care practices and psychosocial interventions to support parents have undergone dramatic changes, with limited basis in evidence. Methods: A systematic narrative review was conducted of quantitative studies examining interventions designed to reduce psychological distress in parents following the loss of a stillborn baby. Results: Twenty-five studies met the inclusion criteria for the review. Substantial methodological weaknesses were identified among reviewed studies, including small and heterogeneous loss samples, weak study designs and lack of clarity in reported methods and outcomes. Inadequate replication of many findings substantially limits the generalisability of the evidence. Conclusion: Tentative evidence was found for the provision of mementoes of the baby and information regarding the cause of the loss, support group attendance, and cognitive behavioural interventions for parents identified with clinical levels of distress. Contradictory findings for the impact of contact with the baby prevent the formation of clear conclusions for this practice. Due to the methodological weaknesses prevalent in the research identified, the current evidence base is not considered sufficiently able to reliably inform care practices and intervention approaches. High-quality research evidence in this field is urgently required.