Posttraumatic stress disorder 2 months after cesarean delivery: a multicenter prospective study - 17/04/24

Doi : 10.1016/j.ajog.2024.03.011

Alizée Froeliger, MD, MPH ^a,^b,^⁎ , Catherine Deneux-Tharaux, MD, PhD ^b, Lola Loussert, MD, MPH ^b,^c, Hugo Madar, MD, MPH ^a,^b, Loïc Sentilhes, MD, PhD, FRCOG ^a
On behalf of the
Tranexamic Acid for Preventing Postpartum Hemorrhage after Cesarean Delivery (TRAAP2) trial study group
Loïc Sentilhes, MD, PhD ^d, Marie V. Senat, MD, PhD ^e, Maëla Le Lous, MD ^f, Norbert Winer, MD, PhD ^g, Patrick Rozenberg, MD, PhD ^h, Gilles Kayem, MD, PhD ^i,^r, Eric Verspyck, MD, PhD ^j, Florent Fuchs, MD, PhD ^k,^l, Elie Azria, MD, PhD ^m,^r, Denis Gallot, MD, PhD ⁿ, Diane Korb, MD, PhD ^o, Raoul Desbrière, MD ^p, Camille Le Ray, MD, PhD ^q,^r, Céline Chauleur, MD, PhD ^s, Fanny de Marcillac, MD ^t, Franck Perrotin, MD, PhD ^u, Olivier Parant, MD ^v, Laurent J. Salomon, MD, PhD ^w, Emilie Gauchotte, MD ^x, Florence Bretelle, MD, PhD ^y, Nicolas Sananès, MD, PhD ^z, Caroline Bohec, MDA ^aa, Nicolas Mottet, MD, PhD ^ab, Guillaume Legendre, MD, PhD ^ac, Vincent Letouzey, MD, PhD ^ae, Bassam Haddad, MD, PhD ^af, Delphine Vardon, MD ^ag, Hugo Madar, MD ^ah, Aurélien Mattuizzi, MD ^ah, Alizée Froeliger, MD ^ah, Valérie Daniel, PharmD ^ad,^al, Sophie Regueme, PhD ^ai, Caroline Roussillon, MD ^aj, Antoine Bénard, MD, PhD ^ak, Aurore Georget ^ak, Astrid Darsonval, PharmD ^ad,^al, Catherine Deneux-Tharaux, MD, PhD ^am
^d Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
^e Department of Obstetrics and Gynecology, Bicêtre University Hospital, Le Kremlin-Bicêtre, France
^f Department of Obstetrics and Gynecology, Rennes University Hospital, Rennes, France
^g Department of Obstetrics and Gynecology, University Medical Center of Nantes, Centre d’Investigation Clinique Mère Enfant, University Hospital, Nantes, France
^h Institut National de la Recherche Agronomique (INRA), Unité Mixte de Recherche (UMR) 1280, Physiology of Nutritional Adaptations, University of Nantes, Institut des Maladie de l’Appareil Digestif, Centre de Recherche en Nutrition Humaine–Ouest, Nantes, France (N.W.); Department of Obstetrics and Gynecology, Poissy-Saint-Germain-en-Laye Hospital, Poissy, France
ⁱ Department of Obstetrics and Gynecology, Armand-Trousseau Hospital, Paris, France
^j Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, France
^k Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier, France
^l Inserm, Centre for Research in Epidemiology and Population Health, Unité 1018, Reproduction and Child Development, Villejuif, Montpellier, France
^m Maternity Unit, Paris Saint-Joseph Hospital, Paris Descartes University, Paris, France
ⁿ Department of Obstetrics and Gynecology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
^o Department of Obstetrics and Gynecology, Robert Debré Hospital, Paris, France
^p Department of Obstetrics and Gynecology, Saint-Joseph Hospital, Marseille, France
^q Port Royal Maternity Unit, Cochin Hospital, Paris, France
^r Assistance Publique–Hôpitaux de Paris, Université de Paris, Centre for Research in Epidemiology and Statistics Sorbonne, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team (EPOPé), Inserm, Institut National de la Recherche Agronomique (INRA), University Hospital Department–Risks in Pregnancy, Paris, France
^s Department of Obstetrics and Gynecology, Saint-Etienne University Hospital, Saint Etienne, France
^t Department of Obstetrics and Gynecology, University Hospital of Strasbourg, Strasbourg, France
^u Department of Obstetrics and Gynecology, Tours University Hospital, Tours, France
^v Department of Obstetrics and Gynecology, Toulouse University Hospital, Toulouse, France
^w Department of Obstetrics and Gynecology, Necker–Enfants Malades Hospital, Paris, France
^x Department of Obstetrics and Gynecology, Nancy University Hospital, Nancy, France
^y Department of Obstetrics and Gynecology, Assistance Publique–Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
^z Department of Obstetrics and Gynecology, Centre Médico-chirurgical Obstétrique, Schiltigheim, France
^aa Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau, France
^ab Department of Obstetrics and Gynecology, Besançon University Hospital, Besançon, France
^ac Department of Obstetrics and Gynecology, Angers University Hospital, Angers, France
^ad Department of Pharmacy, Angers University Hospital, Angers, France
^ae Department of Obstetrics and Gynecology, Carémeau University Hospital, Nîmes, France
^af Department of Obstetrics and Gynecology and Reproductive Medicine, University Paris-Est Créteil, Centre Hospitalier Intercommunal de Créteil, Créteil, France
^ag Department of Obstetrics and Gynecology, Caen University Hospital, Caen, France
^ah Department of Obstetrics and Gynecology, EUropean CLInical Trials Platform & Development (EUCLID), French Clinical Research Infrastructure Network (F-CRIN), Bordeaux, France
^ai Department of Clinical Research and Innovation, EUropean CLInical Trials Platform & Development (EUCLID), French Clinical Research Infrastructure Network (F-CRIN), Bordeaux, France
^aj Department of Clinical Research and Innovation, Bordeaux University Hospital, Bordeaux, France
^ak Public Health Department, Clinical Epidemiology Unit (USMR), Bordeaux University Hospital, Bordeaux
^al PPRIGO (Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest), Brest University Hospital, Brest, France
^am Centre for Research in Epidemiology and Statistics Sorbonne, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team (EPOPé), Inserm, Paris, France

^a Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
^b Université Paris Cité, Women’s Health, Institut Hors-Murs, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Research on Epidemiology and Statistics (CRESS) U1153, Inserm, Paris, France
^c Department of Obstetrics and Gynecology, Toulouse University Hospital, Toulouse, France

^∗Corresponding author: Alizée Froeliger, MD, MPH.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Wednesday 17 April 2024

Abstract

Background

The prevalence and risk factors of posttraumatic stress disorder after cesarean delivery, outside high-risk contexts, remain unclear.

Objective

This study aimed to assess posttraumatic stress disorder prevalence and risk factors at 2 months postpartum among a general population of women with cesarean delivery.

Study Design

This was a prospective ancillary cohort study of the Tranexamic Acid for Preventing Postpartum Hemorrhage after Cesarean Delivery (TRAAP2) trial, conducted in 27 French hospitals from 2018 to 2020, enrolling women expected to undergo cesarean delivery before or during labor at ≥34 weeks of gestation. After randomization, characteristics of the cesarean delivery and postpartum blood loss were prospectively collected. Two months after childbirth, posttraumatic stress disorder profile (presence of posttraumatic stress disorder symptoms) and provisional diagnosis (positive screening for diagnosis consistent with a posttraumatic stress disorder) were assessed by 2 self-administered questionnaires (Impact of Event Scale - Revised and Traumatic Event Scale). The corrected posttraumatic stress disorder prevalence was estimated with inverse probability weighting to take nonresponse into account. Associations between potential risk factors and posttraumatic stress disorder were analyzed by multivariate logistic or linear regression modeling according to the type of dependent variable.

Results

In total, 2785 of 4431 women returned the Impact of Event Scale - Revised questionnaire and 2792 the Traumatic Event Scale (response rates of 62.9% and 63.0%). The prevalence of posttraumatic stress disorder profile was 9.0% (95% confidence interval, 7.8%–10.3%) and of provisional diagnosis 1.7% (95% confidence interval, 1.2%–2.4%). Characteristics associated with a higher risk of posttraumatic stress disorder profile were prepregnancy vulnerability factors (young age, high body mass index, and African-born migrant) and cesarean delivery–related obstetrical factors (cesarean delivery after induced labor [adjusted odds ratio, 1.81; 95% confidence interval, 1.14–2.87], postpartum hemorrhage [adjusted odds ratio, 1.61; 95% confidence interval, 1.04–2.46] and high-intensity pain during the postpartum stay [adjusted odds ratio, 1.90; 95% confidence interval, 1.17–3.11]). Women who had immediate skin-to-skin contact with their newborn were at lower risk of posttraumatic stress disorder (adjusted odds ratio, 0.66; 95% confidence interval, 0.46–0.98), and women with bad memories of delivery on day 2 postpartum were at higher risk (adjusted odds ratio, 3.20; 95% confidence interval, 1.97–5.12). The Impact of Event Scale - Revised and the Traumatic Event Scale yielded consistent results.

Conclusion

Approximately 1 in 11 women with cesarean deliveries had posttraumatic stress disorder symptoms at 2 months postpartum. Some obstetrical interventions and components of cesarean delivery management may influence this risk.

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Key words : cesarean delivery, induction of labor, maternal mental health, migrant women, pain, postpartum, postpartum hemorrhage, posttraumatic stress disorder, psychiatric disorders, skin-to-skin contact

Plan

Posttraumatic stress disorder prevalence

Risk factors for posttraumatic stress disorder

Discussion

Principal findings

Results in the context of what is known

Clinical and research implications

Strengths and limitations

Conclusion

	L.S. has carried out consultancy work and been a lecturer for Ferring Pharmaceuticals, GSK, and Bayer, and been a lecturer for Norgine in the previous 3 years. The remaining authors report no conflict of interest.
	The Tranexamic Acid for Preventing Postpartum Hemorrhage after Cesarean Delivery (TRAAP2) trial was supported by a grant from the French Ministry of Health under its Clinical Research Hospital Program (PHRC-15-0011). The funder had no role in the design and conduct of the TRAAP2 trial. This analysis has not received any specific funding.
	Cite this article as: Froeliger A, Deneux-Tharaux C, Loussert L, et al. Posttraumatic stress disorder 2 months after cesarean delivery: a multicenter prospective study. Am J Obstet Gynecol 2024;XX:x.ex–x.ex.