PAU, France – Post-partum post-traumatic stress disorder (PTSD) tends to worsen in the months following the birth of a child. It is therefore necessary to screen for it as soon as possible and ensure that women who are affected receive the correct treatment. This was the message delivered by Ludivine Franchitto, MD, child psychiatrist at Toulouse University Hospital in France at the Infogyn 2022 conference.  As PTSD is still not fully recognized, treatment remains inadequate and poorly documented.
Impact on caregivers too
“The situation is the same as we saw with postpartum depression. The debate went on for 20 years before its existence was officially declared,” said Franchitto. But for her, it is important not to know if post-traumatic stress could happen to a mother who had complications during pregnancy or childbirth. Instead, it’s about focusing on the consequences for the child.
In her presentation, Franchitto also noted the need to recognize that caregivers working in maternity wards may also be negatively affected as they regularly see complications that women have during pregnancy and childbirth. These workers may also develop PTSD, requiring support to perform their duties properly.
According to The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), PTSD occurs after experiencing actual (or threatened) death, serious injury, or sexual violence. Individuals who have witnessed trauma firsthand or who have experienced repeated (or extreme) exposure to aversive details of traumatic events may also develop PTSD.
Franchitto mentioned some of the criteria needed to make a diagnosis. “Intrusive memories of the event, recurrent disturbing dreams related to the event, persistent avoidance of stimuli related to the traumatic event, or negative changes in perception and mood related to the traumatic event. And the duration of the disturbance is more than 1 month .” There may also be marked changes in arousal and reactivity related to the traumatic event (eg, irritable behavior, loss of awareness of the current environment).
Prevalence in 18% of women in risk groups
According to the studies, there is a wide variation in the incidence of PTSD. If only post-traumatic symptoms (eg depressive syndrome, suicidal ideation, hyperactivity, persistent avoidance) are referred to, the rate could be as high as 40%. A 2016 meta-analysis of 59 studies found that the prevalence of PTSD was 5.9%. 
The authors distinguished between two groups of women: women with no complications during pregnancy or childbirth and those with severe pregnancy-related complications, fear of childbirth, difficult delivery, emergency caesarean section, a child born prematurely with birth defects, etc. Their analysis showed PTSD rates of 4% and 18.5%, respectively.
Surprisingly, the main risk factor for PTSD was found to be uncontrollable vomiting during pregnancy (seen in 40% of PTSD cases). Having a child with a birth defect was the second risk factor (35%) and the third was a history of violence in the mother’s childhood (34%). Women who experienced postpartum depression were also at higher risk.
Other risk factors identified were lack of communication with the healthcare team, lack of consent, lack of support from healthcare professionals and long working hours. In contrast, a sense of control and support from a partner plays a protective role.
“If PTSD symptoms are not treated after delivery, they tend to worsen between one and six months after the baby is born,” Franchitto said. Therefore, it is necessary to screen for it as soon as possible – especially by having the women fill out the City Birth Trauma Scale questionnaire – and provide appropriate treatment accordingly. When trying to limit the effects of stress, early intervention by a psychologist can be helpful.
Psychotherapy is the recommended first line of treatment for PTSD, especially cognitive behavioral therapy and eye movement desensitization and reprocessing therapy. This approach aims to limit the mental and behavioral avoidance that prevents traumatic memories from being integrated and processed as normal memories.
The effects of maternal PTSD on the child are well documented. “Babies whose mothers had PTSD during pregnancy have lower birth weights and shorter breastfeeding durations,” Franchitto said. Regarding the quality of the mother-child relationship and the long-term development of the child, “the studies have very conflicting results.”
At the end of the presentation, Professor Israël Nisand, MD, OB/GYN at the American Hospital of Paris and former president of the National College of French Gynecologists and Obstetricians, made the following comment: “I think we often underestimate the consequences of maternal post-traumatic stress on the child after birth. He added: “PTSD is a reality. Yet it is not screened for, let alone treated, even though it has serious consequences for the baby.”
Franchitto also addressed the impact on health care workers, “other victims” of the traumatic events that occurred while attending to the women in the maternity ward. “The estimated prevalence of PTSD symptoms among midwives is 22.9%,” which could lead to “a loss of confidence and a desire to leave the profession.”
To provide psychological education to health workers
Franchitto believes that it is also necessary to protect caregivers who work in maternity wards. “It is important to have the support of colleagues” – especially the team leaders – “and to share their experiences,” as long as one knows how to recognize the symptoms of post-traumatic stress through their feelings and can articulate them.
She went on to say that psychological education should be encouraged for healthcare workers, as well as “simulation-based training, to learn how to manage difficult situations.”
This content was originally published on Medscape French version.
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