Chauhan AR

As obstetricians, we are only somewhat familiar with postpartum blues and depression, and when we encounter patients with severe symptoms, we usually refer them to a psychiatrist. In recent times, a more serious condition has been identified, i.e.  Postnatal or Postpartum Posttraumatic Stress Disorder (PP PTSD); this article aims to sensitize the reader to this disease entity.

Historically, from his experience with patients shocked by the events and wars of the French Revolution, Pinel wrote the first descriptions of war neuroses and described it as “cardiorespiratory neurosis” and acute stuporous posttraumatic state. Conflicts in World War I and II gave birth to terms such as “soldier's heart” and “shell shock”. However, it was the horrors of the Vietnam war and the mental anguish and “invisible wounds” that soldiers faced after returning home which made the medical profession more aware of PTSD and made this a household term. It was first mentioned in the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) of the American Psychiatric Association in 1980, and as per the DSM -IV, it is classified under anxiety disorders. Though the incidence of PTSD is only 6 – 7 % among the average population following any traumatic stress, data from the U.S. Department of Veterans Affairs state that 13.8 % veterans of Iraq and Afghanistan wars suffer from PTSD and on an average, 22 veterans commit suicide every day.

Through the understanding of PTSD in war veterans, experts have identified that a similar process occurs following birth. PP PTSD is particularly seen in those patients who may have experienced a traumatic or difficult birth or even a perception of trauma during childbirth, history of rape or sexual assault in the past, or rape or intimate partner violence in the present pregnancy, or pregnancy complicated with cord prolapse, stillbirth, unplanned cesarean section or instrumental delivery, or baby requiring NICU care. Severe physical complication or injury like PPH, unexpected hysterectomy, perineal trauma, or high levels of medical intervention are also triggers. There is a complicated mix of objective and subjective factors, including feelings of loss of control, powerlessness, lack of privacy and dignity, and/or lack of communication, support and reassurance during the delivery, and poor postnatal care. Women with lack of social support, family history of psychiatric illness especially anxiety disorders, poverty, abuse, or childhood behavioural problems are more at risk.

The diagnosis of PTSD is important as misdiagnosis is common. Though there is some symptom overlap between postnatal depression and postnatal PTSD, the two conditions are different. Women are often misdiagnosed with depression, and therefore treatments are unsuccessful. However, women with PTSD may also have depression, but the presence of one does not always imply the presence of the other. It is possible that up to 25% of women who have PTSD remain undetected. Hallmarks of PP PTSD are nightmares, poor sleep, anger, numbness or sadness and avoidance of groups.

As per DSM -IV, diagnosis of PTSD is based on a cluster of symptoms, categorized from A to F. Criterion “A” is the stressor or the traumatic event, where the patient has experienced an event that involves actual or threatened death or serious injury, and her response involves intense fear, helplessness, or horror. “B” is re-experiencing or intrusions, where the traumatic event is re-experienced in the form of recurrent images, thoughts, perceptions, or distressing dreams of the event, acting or feeling as if the event was recurring, or intense psychological distress. “C” is persistent avoidance of stimuli and numbing, indicated by avoiding thoughts, feelings, or discussion, activities, places or people that bring back recollections; inability to recall; diminished interest, or feeling detached or estranged. Criterion “D” is increased arousal manifest by difficulty in falling asleep, irritability, difficulty in concentrating, exaggerated startle response. Criterion “D” also includes negative alteration in cognition and mood, such as memory problems exclusive to the event, distorted sense of blame, horror or sadness, and feelings of isolation or detachment from other people. Criterion “E” defines that the duration of symptoms should be for more than 1 month, while criteria “F”, “G” and “H” all describe the severity of the symptoms. To clinch the diagnosis of PTSD, at least one symptom each from criterion B and C, 2 each from increased arousal (D) and negative alteration in cognition (D) should be present, along with symptoms for at least a month (E). The differential diagnosis of PTSD is other anxiety disorders, OCD, panic disorder, substance-induced disorder, borderline personality disorder or malingering.

The treatment of PTSD requires multiple modalities, including initial education and support, and referrals for psychotherapy and pharmacotherapy. The starting point may be to review and discuss the labor notes; if symptoms are of less than 4 weeks duration, 2 out of 3 patients will not require further intervention except close observation.
Psychotherapy is the mainstay of treatment, and is aimed at crisis intervention, trauma-focused psychotherapy and systematic desensitization; hospitalization may sometimes be necessary. First line psychotherapies include Cognitive Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR). CBT aims to build new cognitive skills and engage in new behaviors, or change existing ones. It includes Prolonged Exposure (PE) wherein the patient confronts situations that she has been avoiding until her distress decreases, and Cognitive Processing Therapy (CPT) wherein she examines and challenges thoughts about the trauma until she can change the way she feels. The EMDR process is based on REM sleep, where through eye movements, the brain processes disturbing images and eventually resolves them.

Evidence-based pharmacological treatments include the use of Selective Serotonin Reuptake Inhibitors (SSRIs); Paroxetine is the gold standard. Other agents like Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), benzodiazepines, antidepressants and mood stabilizers have also been used with limited efficacy. Duration of treatment is typically 8 to 12 weeks, with maintenance for at least a year. Other therapies like hypnotherapy, acupuncture, yoga, meditation, writing, running, have also been suggested, along with family support.

The long-term implications of PTSD involve greater risk of other psychiatric disorders, higher rate of unemployment, relationship problems and overall poorer quality of life. Hence as obstetricians, it is our responsibility to help prevent PTSD by offering a positive pregnancy experience. Our role is to provide education to patients about labor and delivery; offer information on best practices so as to prepare patients for pain, labor analgesia, episiotomy, instrumentation, CS; draw up and document a birth plan; document all events in labor room meticulously and be open and honest to audit/ questions postpartum. If symptoms of PTSD do occur, we should not ignore or treat them casually, but refer these cases early to appropriate facilities.