Risk factors for postpartum posttraumatic stress disorder after emergency admission

doi:10.5847/wjem.j.1920-8642.2024.013

Abstract

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.

Key words: Risk factors, Posttraumatic stress disorder, Emergency, Delivery

Fengxia Du, Jun Zha, Yan Li, Lichao Fang, Shuyu Xia, Youjia Yu. Risk factors for postpartum posttraumatic stress disorder after emergency admission[J]. World Journal of Emergency Medicine, 2024, 15(2): 121-125.

Figures/Tables 3

Table 1.

Table 2.

Table 3.

References 30

1	Hori H, Kim Y. Inflammation and post-traumatic stress disorder. Psychiatry Clin Neurosci. 2019; 73(4): 143-53. doi: 10.1111/pcn.2019.73.issue-4
2	Koirala R, Søegaard EGI, Thapa SB. Updates on pharmacological treatment of post-traumatic stress disorder. JNMA J Nepal Med Assoc. 2017; 56(206): 274-80.
3	He M, Wei JX, Mao M, Zhao GY, Tang JJ, Feng S, et al. Synaptic plasticity in PTSD and associated comorbidities: the function and mechanism for diagnostics and therapy. Curr Pharm Des. 2018; 24(34): 4051-9. doi: 10.2174/1381612824666181120094749
4	Qi W, Gevonden M, Shalev A. Prevention of post-traumatic stress disorder after trauma: current evidence and future directions. Curr Psychiatry Rep. 2016; 18(2): 20. doi: 10.1007/s11920-015-0655-0
5	Asadzadeh L, Jafari E, Kharaghani R, Taremian F. Effectiveness of midwife-led brief counseling intervention on post-traumatic stress disorder, depression, and anxiety symptoms of women experiencing a traumatic childbirth: a randomized controlled trial. BMC Pregnancy Childbirth. 2020; 20(1): 142. doi: 10.1186/s12884-020-2826-1
6	Lopez U, Meyer M, Loures V, Iselin-Chaves I, Epiney M, Kern C, et al. Post-traumatic stress disorder in parturients delivering by caesarean section and the implication of anaesthesia: a prospective cohort study. Health Qual Life Outcomes. 2017; 15(1): 118. doi: 10.1186/s12955-017-0692-y
7	Yildiz PD, Ayers S, Phillips L. The prevalence of posttraumatic stress disorder in pregnancy and after birth: a systematic review and meta-analysis. J Affect Disord. 2017; 208:634-45. doi: 10.1016/j.jad.2016.10.009
8	Cook N, Ayers S, Horsch A. Maternal posttraumatic stress disorder during the perinatal period and child outcomes: a systematic review. J Affect Disord. 2018; 225: 18-31. doi: 10.1016/j.jad.2017.07.045
9	Turpin H, Urben S, Ansermet F, Borghini A, Murray MM, Müller-Nix C. The interplay between prematurity, maternal stress and children’s intelligence quotient at age 11: a longitudinal study. Sci Rep. 2019; 9(1): 450. doi: 10.1038/s41598-018-36465-2
10	Kida S. Reconsolidation/destabilization, extinction and forgetting of fear memory as therapeutic targets for PTSD. Psychopharmacology. 2019; 236(1): 49-57. doi: 10.1007/s00213-018-5086-2 pmid: 30374892
11	Soeter M, Kindt M. Noradrenergic enhancement of associative fear memory in humans. Neurobiol Learn Mem. 2011; 96(2):263-71. doi: 10.1016/j.nlm.2011.05.003 pmid: 21624479
12	Merz CJ, Wolf OT. How stress hormones shape memories of fear and anxiety in humans. Neurosci Biobehav Rev. 2022; 142: 104901. doi: 10.1016/j.neubiorev.2022.104901
13	Bender CL, Giachero M, Comas-Mutis R, Molina VA, Calfa GD. Stress influences the dynamics of hippocampal structural remodeling associated with fear memory extinction. Neurobiol Learn Mem. 2018; 155: 412-21. doi: S1074-7427(18)30223-5 pmid: 30195049
14	Gelaye B, Zheng Y, Medina-Mora ME, Rondon MB, Sánchez SE, Williams MA. Validity of the posttraumatic stress disorders (PTSD) checklist in pregnant women. BMC Psychiatry. 2017; 17(1): 179. doi: 10.1186/s12888-017-1304-4 pmid: 28494804
15	Bryant RA. Post-traumatic stress disorder: a state-of-the-art review of evidence and challenges. World Psychiatry. 2019; 18(3): 259-69. doi: 10.1002/wps.v18.3
16	Park YK, Ju HO, Na H. Reliability and validity of the Korean version of the perinatal post-traumatic stress disorder questionnaire. J Korean Acad Nurs. 2016; 46(1): 29-38. doi: 10.4040/jkan.2016.46.1.29
17	Benton M, Salter A, Tape N, Wilkinson C, Turnbull D. Women’s psychosocial outcomes following an emergency caesarean section: a systematic literature review. BMC Pregnancy Childbirth. 2019; 19(1): 535. doi: 10.1186/s12884-019-2687-7
18	Deninotti J, Denis A, Berdoulat É. Emergency C-section, maternal satisfaction and emotion regulation strategies: effects on PTSD and postpartum depression symptoms. J Reprod Infant Psychol. 2020; 38(4): 421-35. doi: 10.1080/02646838.2020.1793308 pmid: 32683885
19	Derrick K, Green T, Wand T. Assessing and responding to anxiety and panic in the emergency department. Australas Emerg Care. 2019; 22(4): 216-20. doi: S2588-994X(19)30064-8 pmid: 31530499
20	Cédric GJ, Hoareau S, Valdenaire G, Contrand B, Salmi LR, Masson F, et al. Stress and lasting symptoms following injury: results from a 4-month cohort of trauma patients recruited at the emergency department. Int Emerg Nurs. 2020; 48: 100810. doi: 10.1016/j.ienj.2019.100810
21	Rowlands S, Permezel M. Physiology of pain in labour. Baillieres Clin Obstet Gynaecol. 1998; 12(3):347-62. doi: 10.1016/S0950-3552(98)80071-0
22	Brown ST, Campbell D, Kurtz A. Characteristics of labor pain at two stages of cervical dilation. Pain. 1989; 38(3): 289-95. doi: 10.1016/0304-3959(89)90215-7 pmid: 2812840
23	Chaaya N, Battle AR, Johnson LR. An update on contextual fear memory mechanisms: transition between Amygdala and Hippocampus. Neurosci Biobehav Rev. 2018; 92: 43-54. doi: S0149-7634(17)30358-5 pmid: 29752958
24	Adam EK, Kumari M. Assessing salivary cortisol in large-scale, epidemiological research. Psychoneuroendocrinology. 2009; 34(10): 1423-36. doi: 10.1016/j.psyneuen.2009.06.011 pmid: 19647372
25	Adam EK, Quinn ME, Tavernier R, McQuillan MT, Dahlke KA, Gilbert KE. Diurnal cortisol slopes and mental and physical health outcomes: a systematic review and meta-analysis. Psychoneuroendocrinology. 2017; 83: 25-41. doi: S0306-4530(17)30265-2 pmid: 28578301
26	Yalnız Dilcen H, Aslantekin F, Aktaş N. The relationship of psychosocial well-being and social support with pregnant women’s perceptions of traumatic childbirth. Scand J Caring Sci. 2021; 35(2): 650-8. doi: 10.1111/scs.v35.2
27	Williamson JB, Jaffee MS, Jorge RE. Posttraumatic stress disorder and anxiety-related conditions. Continuum (Minneap Minn). 2021; 27(6): 1738-63. doi: 10.1212/CON.0000000000001054 pmid: 34881734
28	Wang YX, Mao XF, Li TF, Gong N, Zhang MZ. Dezocine exhibits antihypersensitivity activities in neuropathy through spinal μ-opioid receptor activation and norepinephrine reuptake inhibition. Sci Rep. 2017; 7: 43137. doi: 10.1038/srep43137
29	Weichel C, Hecht B. Tapentadol. Opioid analgesic and norepinephrine reuptake inhibitors. Med Monatsschr Pharm. 2010; 33(12): 454-60. [Article in German]
30	Taylor Miller PG, Sinclair M, Gillen P, McCullough JM, Miller PW, Farrell DP, et al. Early psychological interventions for prevention and treatment of post-traumatic stress disorder (PTSD) and post-traumatic stress symptoms in post-partum women: a systematic review and meta-analysis. PLoS One. 2021; 16(11): e0258170. doi: 10.1371/journal.pone.0258170

Risk factors	PTSD patients (n=56)	Controls (n=220)	P-value
Age			0.386
18-25 years	29 (51.8)	100 (45.5)
26-34 years	25 (44.6)	101 (45.9)
≥35 years	2 (3.6)	19 (8.6)
Education level			0.478
College degree or below	33 (58.9)	118 (53.6)
Bachelor’s degree or above	23 (41.1)	102 (46.4)
Household registration			0.283
Local	23 (41.1)	108 (49.1)
Non-local	33 (58.9)	112 (50.9)
Parity			0.041
Primipara	34 (60.7)	100 (45.5)
Multipara	22 (39.3)	120 (54.5)
Mode of delivery			0.028
Vaginal delivery	25 (44.6)	134 (60.9)
Cesarean section	31 (55.4)	86 (39.1)
Perineal tears			0.336
No	52 (92.9)	211 (95.9)
Yes	4 (7.1)	9 (4.1)
Apgar score			0.710
≥8	50 (89.3)	200 (90.9)
<8	6 (10.7)	20 (9.1)
Full-term birth			0.813
No	7 (12.5)	25 (11.4)
Yes	49 (87.5)	195 (88.6)
Used an analgesic pump			0.012
No	37 (66.1)	104 (47.3)
Yes	19 (33.9)	116 (52.7)
Cervical dilation			0.008
No	22 (39.3)	130 (59.1)
Yes	34 (60.7)	90 (40.9)
Transfer from the delivery room to the operating room for cesarean section			0.089
No	49 (87.5)	207 (94.1)
Yes	7 (12.5)	13 (5.9)
Admitted after midnight			0.002
No	26 (46.4)	151 (68.6)
Yes	30 (53.6)	69 (31.4)
Hypertension during pregnancy			0.030
No	41 (73.2)	188 (85.5)
Yes	15 (26.8)	32 (14.5)
Diabetes during pregnancy			0.508
No	50 (89.3)	189 (85.9)
Yes	6 (10.7)	31 (14.1)

Risk factors	PTSD patients (n=56)	Controls (n=220)	Adjusted OR (95% CI)	P-value
Parity			0.617 (0.324-1.172)	0.140
Primipara*	34 (60.7)	100 (45.5)
Multipara	22 (39.3)	120 (54.5)
Mode of delivery			2.102 (1.114-3.966)	0.022
Vaginal delivery*	25 (44.6)	134 (60.9)
Cesarean section	31 (55.4)	86 (39.1)
Used an analgesic pump			0.500 (0.259-0.966)	0.039
No*	37 (66.1)	104 (47.3)
Yes	19 (33.9)	116 (52.7)
Cervical dilation			2.245 (1.170-4.305)	0.015
No*	22 (39.3)	130 (59.1)
Yes	34 (60.7)	90 (40.9)
Admitted after midnight			3.203 (1.670-6.141)	<0.001
No*	26 (46.4)	151 (68.6)
Yes	30 (53.6)	69 (31.4)
Hypertension during pregnancy			1.971 (0.909-4.274)	0.086
No*	41 (73.2)	188 (85.5)
Yes	15 (26.8)	32 (14.5)

Numbers of risk factors	PTSD patients (n=56)	Controls (n=220)
0	4 (7.1)	23 (10.5)
1	13 (23.2)	72 (32.7)
2	31 (55.4)	87 (39.5)
3	13 (23.2)	35 (15.9)
4	5 (8.9)	3 (1.4)

[1]	Carlos del Pozo Vegas, Ancor Sanz-García, Antonio Dueñas-Ruiz, Pedro de Santos Castro, Ana Gil Contreras, María Blanco González, Alberto Correas Galán, Joan B. Soriano, Raúl López-Izquierdo, Francisco Martín-Rodríguez. Prehospital oxygen-therapy and mortality in patients treated by emergency medical services: a prospective, observational multicenter study [J]. World Journal of Emergency Medicine, 2025, 16(4): 357-366.
[2]	Weiming Wu, Min Li, Huilin Jiang, Min Sun, Yongcheng Zhu, Gongxu Zhu, Yanling Li, Yunmei Li, Junrong Mo, Xiaohui Chen, Haifeng Mao. Development of an emergency department length-of-stay prediction model based on machine learning [J]. World Journal of Emergency Medicine, 2025, 16(3): 220-224.
[3]	George Briassoulis, Mina Argyrakopoulou, Dafni Korela, Sotiria Labrinaki, Artemis Nikiforou, Antonios Papoutsakis, Panagiotis Briassoulis, Marianna Miliaraki, George Notas, Stavroula Ilia. Lifelong training, retraining, reskilling, upskilling and knowledge gaps in emergency medicine: a cross-sectional survey study [J]. World Journal of Emergency Medicine, 2025, 16(3): 212-219.
[4]	Qingyuan Liu, Yixin Zhang, Jian Sun, Kaipeng Wang, Yueguo Wang, Yulan Wang, Cailing Ren, Yan Wang, Jiashan Zhu, Shusheng Zhou, Mengping Zhang, Yinglei Lai, Kui Jin. Early identification of high-risk patients admitted to emergency departments using vital signs and machine learning [J]. World Journal of Emergency Medicine, 2025, 16(2): 113-120.
[5]	Ping Cui, Tingting Wen, Bingduo Wang, Shuijing Wu, Shiyu Chen, Xiangming Fang, TILP consortium. Tracheal intubation in the lateral position in emergency medicine: a narrative review and clinical protocol [J]. World Journal of Emergency Medicine, 2025, 16(2): 103-112.
[6]	Jesús Jurado-Palomo, José Luis Martín-Conty, Begoña Polonio-López, Cristina Rivera Picón, Raúl López-Izquierdo, Carlos del Pozo Vegas, Pedro Ángel de Santos Castro, Ancor Sanz-García, Francisco Martín-Rodríguez. Prehospital critical care drug-therapy and 30-day mortality in patients with acute respiratory disease [J]. World Journal of Emergency Medicine, 2025, 16(1): 43-50.
[7]	Qingliu Zheng, Changyun Liu, Lingying Le, Qiqi Wu, Zhihong Xu, Jiyan Lin, Qiuyun Chen. ICU-acquired weakness in critically ill patients at risk of malnutrition: risk factors, biomarkers, and early enteral nutrition impact [J]. World Journal of Emergency Medicine, 2025, 16(1): 51-56.
[8]	Jingyuan Xie, Jiandong Gao, Mutian Yang, Ting Zhang, Yecheng Liu, Yutong Chen, Zetong Liu, Qimin Mei, Zhimao Li, Huadong Zhu, Ji Wu. Prediction of sepsis within 24 hours at the triage stage in emergency departments using machine learning [J]. World Journal of Emergency Medicine, 2024, 15(5): 379-385.
[9]	Payush Chatta, Brian Diep, Jakrin Kewcharoen, Daniel Rossie, Cory Toomasian, Purvi Parwani, Dmitry Abramov. The diagnostic yield for computed tomography pulmonary angiography in patients with anticoagulation [J]. World Journal of Emergency Medicine, 2024, 15(4): 251-255.
[10]	Jie Er Janice Soo, Yuan Helen Zhang, Gek Hsiang Lim, Fatimah Lateef. Bicycle-related traumatic injuries: a retrospective study during COVID-19 pandemic [J]. World Journal of Emergency Medicine, 2024, 15(4): 256-262.
[11]	Rex Pui Kin Lam, Zonglin Dai, Eric Ho Yin Lau, Carrie Yuen Ting Ip, Ho Ching Chan, Lingyun Zhao, Tat Chi Tsang, Matthew Sik Hon Tsui, Timothy Hudson Rainer. Comparing 11 early warning scores and three shock indices in early sepsis prediction in the emergency department [J]. World Journal of Emergency Medicine, 2024, 15(4): 273-282.
[12]	Jonathan Chabon, Jemer Garrido, Deanna Schreiber-Gregory, Jefferson Drapkin, Sergey Motov. Trends in oxycodone and oxycodone-containing analgesics administration for back pain in emergency departments in the USA (2007-2018) [J]. World Journal of Emergency Medicine, 2024, 15(3): 169-174.
[13]	Yedalm Yoo, Shin Ahn, Bora Chae, Won Young Kim. Performance of the EDACS-ADP incorporating high-sensitivity troponin assay: Do components of major adverse cardiac events matter? [J]. World Journal of Emergency Medicine, 2024, 15(3): 175-180.
[14]	Mümin Murat Yazici, Özcan Yavaşi̇. Effect of a cervical collar on optic nerve sheath diameter in trauma patients [J]. World Journal of Emergency Medicine, 2024, 15(2): 126-130.
[15]	Rashed Alremeithi, Quincy K. Tran, Megan T. Quintana, Soroush Shahamatdar, Ali Pourmand. Approach to traumatic cardiac arrest in the emergency department: a narrative literature review for emergency providers [J]. World Journal of Emergency Medicine, 2024, 15(1): 3-9.