K. Marieke Paarlberg

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 (Cronbachs α = 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 ρ = 0.78), agreement between the instruments on the identification of PTSD cases is low (κ = 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.

Request for operative reduction of the labia minora; a proposal for a practical guideline for gynecologists.

The increase in womens request for labia reduction surgery raises medical and ethical dilemmas for the gynecological surgeon. A bio-psycho-social approach is suggested; the problem is put forward from the perspective of the medical ethical principles and a practical guideline is proposed.

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.

The role of depressive symptoms in the pathway of demographic and psychosocial risks to preterm birth and small for gestational age

OBJECTIVE depressive symptoms during pregnancy are associated with preterm birth (PTB) and small for gestational age (SGA). Depressive symptoms and PTB and SGA, however, share similar demographic and psychosocial risk factors. Therefore, we investigated whether depressive symptomatology is an independent risk factor, or a mediator in the pathway of demographic and psychosocial risks to PTB and SGA. DESIGN multicentre follow-up study. PARTICIPANTS AND SETTING pregnant women (n=1013) from midwifery practices, secondary hospitals and a tertiary hospital in three urban areas in the Netherlands. MEASUREMENTS initial risk factors and depressive symptoms were assessed with the Mind2Care instrument, including Edinburgh Depression Scale (EDS) during early pregnancy. Pregnancy outcomes were extracted from medical records. A formal mediation analysis was conducted to investigate the role of depressive symptoms in the pathway to PTB and SGA. FINDINGS a univariate association between depressive symptoms and PTB (OR:1.04; 95% CI:1.00-1.08) was observed. After adjusting for the risk factors educational level and smoking in the mediation analysis, this association disappeared. One educational aspect remained associated: low education OR: 1.06; 95%-CI:1.02-1.10. KEY CONCLUSIONS depressive symptomatology appeared no mediator in the pathway of demographic and psychosocial risks to PTB or SGA. The presumed association between depressive symptoms and PTB seems spurious and may be explained by demographic and psychosocial risk factors. IMPLICATIONS FOR PRACTICE for the prevention of PTB and SGA, interventions directed at demographic and psychosocial risk factors are likely to be of primary concern for clinicians and public health initiatives. As depressive symptoms and PTB and SGA share similar risk factors, both will profit.

Hypothesis acardiac twin pregnancies: Pathophysiology-based hypotheses suggest risk prediction by pump/acardiac umbilical venous diameter ratios.

BACKGROUND A total of 75% of monozygotic twins share 1 monochorionic placenta where placental anastomoses cause several serious complications, for example, acardiac twinning. Acardiac twins lack cardiac function but grow by perfusion of arterial blood from the pump twin. This rare pregnancy has 50% natural pump twin mortality but accurate risk prediction is currently impossible. Recent guidelines suggest prophylactic surgery before 18 weeks, suggesting 50% unnecessary interventions. We hypothesize that (1) adverse pump twin outcome relates to easy-to-measure pump/acardiac umbilical venous diameter (UVD) ratios, representing acardiac perfusion by the pumps excess cardiac output. This hypothesis suggests that (2) UVD-ratios are large, mildly varying in cases without complications but small and decreasing when complications develop, thus predicting that (3) UVD-ratios may allow risk prediction of pump twins. In this exploratory clinical pilot, we tested whether UVD-ratio measurements support these predictions. METHODS We included 7 uncomplicated (expectant management), 3 elective surgical, and 17 complicated cases (pump decompensation, emergency intervention/delivery or demise). Nine UVD-ratios were measured sonographycally and 18 by pathology. RESULTS Uncomplicated cases have larger, two serial measurements showing mildly varying UVD-ratios; elective surgical cases show larger UVD-ratios; complicated cases have smaller, two serial measurements showing decreasing UVD-ratios. There were no false-positives, no false-negatives and noncrossing linear trendlines of uncomplicated and complicated cohorts. CONCLUSION Our data provide first evidence that UVD-ratios allow risk prediction of pump twins. More early uncomplicated and late complicated cases are needed, for example, in a prospective trial, before the separation between uncomplicated and complicated cohorts is accurate enough to support a well-founded decision on (early) intervention.

Treatment of severe fear of childbirth with haptotherapy: design of a multicenter randomized controlled trial

BackgroundAbout six percent of pregnant women suffer from severe fear of childbirth. These women are at increased risk of obstetric labour and delivery interventions and pre- and postpartum complications, e.g., preterm delivery, emergency caesarean section, caesarean section at maternal request, severe postpartum fear of childbirth and trauma anxiety. During the last decade, there is increasing clinical evidence suggesting that haptotherapy might be an effective intervention to reduce fear of childbirth in pregnant women. The present study has been designed to evaluate the effects of such intervention.Methods/DesignIncluded are singleton pregnant women with severe fear of childbirth, age ≥ 18 year, randomised into three arms: (1) treatment with haptotherapy, (2) internet psycho-education or (3) care as usual. The main study outcome is fear of childbirth. Measurements are taken at baseline in gestation week 20–24, directly after the intervention is completed in gestation week 36, six weeks postpartum and six months postpartum. Secondary study outcomes are distress, general anxiety, depression, somatization, social support, mother-child bonding, pregnancy and delivery complications, traumatic anxiety symptoms, duration of delivery, birth weight, and care satisfaction.DiscussionThe treatment, a standard haptotherapeutical treatment for pregnant women with severe fear of childbirth, implies teaching a combination of skills in eight one hour sessions. The internet group follows an eight-week internet course containing information about pregnancy and childbirth comparable to childbirth classes. The control group has care as usual according to the standards of the Royal Dutch Organisation of Midwives and the Dutch Organization of Obstetrics and Gynaecology.Trial registrationThis trial was entered in the Dutch Trial Register and registered under number NTR3339 on March 4th, 2012.

Acardiac twin pregnancies part II: Fetal risk of chorangioma and sacrococcygeal teratoma predicted by pump/acardiac umbilical vein diameters.

BACKGROUND We recently published pump/acardiac umbilical venous diameter (UVD) ratios, representing the pump twins excess cardiac output fraction, of 27 acardiac twin pregnancies. There was a clear separation between the 17 pump twins that had life-threatening complications and the 10 that did not. The hypothesis of this study is that placental chorangioma and sacrococcygeal teratoma (SCT), tumors whose perfusion also causes high-output complications, have the same fetal outcome as pump twins when perfusion of the tumor requires the same excess cardiac output fraction. METHODS We compared the three fetoplacental circulations. Fetuses with a placental chorangioma and acardiac twin pregnancies both have their feeding artery and draining vein located at the placental cord insertion. In contrast, SCT lacks a prescribed feeding artery and draining vein. We, therefore, had to modify our model to assume that the diameter of the hypothetical draining vein is related to the flow difference between inferior vena cava and superior vena cava. The latter flow has been estimated sonographically and is the same as the inferior vena cava flow in the absence of an SCT. Furthermore, a simple modification accounts for the different location of the tumor with respect to the placental cord insertion. RESULTS We propose to apply the clinical pump/acardiac UVD ratios to pregnancies complicated by placental chorangiomas and the modified pump/acardiac UVD ratios for SCT. CONCLUSION Risk prediction of these rare fetal tumors may be possible based on application of data on excess cardiac output fractions from pump/acardiac UVD ratios and will require future clinical validation. Birth Defects Research (Part A) 106:733-738, 2016.

Bio-Psycho-Social Obstetrics and Gynecology: A Competency-oriented Approach

This book will assist the reader by providing individually tailored, high-quality bio-psycho-social care to patients with a wide range of problems within the fields of obstetrics, gynaecology, fertility, oncology, and sexology. Each chapter addresses a particular theme, issue, or situation in a problem-oriented and case-based manner that emphasizes the differences between routine and bio-psycho-social care. Relevant facts and figures are presented, advice is provided regarding the medical, psychological, and caring process, and contextual aspects are discussed. The book offers practical tips and actions within the bio-psycho-social approach, and highlights important do’s and don’ts. To avoid a strict somatic thinking pattern, the importance of communication, multidisciplinary collaboration, and creation of a working alliance with the patient is emphasized. The book follows a consistent format, designed to meet the needs of challenged clinicians.

A Theoretical and Empirical Study of the Core of the Psychosomatic Approach to Obstetrics and Gynecology: Meta-Competences, Clinical Roles, and POG Competency Profiles

The professional roles that are relevant for all clinicians are summarized in the CanMEDS model. Their relevance lies in the behavioral repertoire associated with the various roles; these behaviors can be used to deal with a variety of complex problems in a wide range of situations. The advantage of the clusters of knowledge, skills, and attitudes that go with these behaviors is that they are universal. Communication, collaboration, etc., transcend specialties and disciplines. They are meta-competences that can be applied in equal measure by other professionals such as midwives and even by HR staff, managers, and executives.

Resistance to fear of child birth and stability of mother-child bond

ABSTRACT In order to examine (1) the stability of the mother-child-bond and (2) associations between mother-child-bonding and aspects of maternal-well-being, pregnant women (N = 170) completed measures on well-being and mother-child-bonding at two antepartum and two postpartum time points. We found relatively weak associations between mother-child-bonding at 20 weeks of gestation and mother-child-bonding at 6 months postpartum. Fear of childbirth was weakly, but statistically significantly associated with mother-child-bonding at 6 weeks (but not at 6 months) postpartum. Correlations between antepartum general well-being and social support, on the one hand, and mother-child-bonding, on the other, failed to reach statistical significance. Women with a partner had a better mother-child-bonding at 36 weeks of gestation and 6 months postpartum, than women without a partner, and older women had better mother-child-bonding at 20 weeks of gestation, than younger women. Our findings thus suggest that mother-child-bonding is not a very stable phenomenon, but it is quite robust against potential negative influences of poor maternal mental health.