Fear and PTSD in obstetrics:Improving care for pregnant women and their healthcare providers

The purpose of this thesis was to increase evidence based knowledge about fear and psychological trauma in obstetrics. The main aims of this thesis were as follows:- to develop more insight into Fear of Childbirth (FoC) and childbirth-related posttraumatic stress disorder (PTSD) among pregnant women.- to determine the efficacy and safety of trauma-focused therapy, specifically EMDR therapy, in pregnant women with FoC or childbirth-related PTSD.- to determine the impact of adverse and traumatic work-related events on Dutch gynaecologists, as well as their coping mechanisms and support.To this end, we conducted a series of studies with different designs to determine the natural course of FoC (HEAR-study), to evaluate the experience of therapists with EMDR therapy during pregnancy (VIP-study), to determine the safety and efficacy of EMDR therapy for women with FoC or PTSD (OptiMUM-study) and to analyse the impact of adverse work-related events among Dutch gynaecologists (WATER 1 and WATER 2-studies)

Fear and PTSD in obstetrics:Improving care for pregnant women and their healthcare providers

The purpose of this thesis was to increase evidence based knowledge about fear and psychological trauma in obstetrics. The main aims of this thesis were as follows:- to develop more insight into Fear of Childbirth (FoC) and childbirth-related posttraumatic stress disorder (PTSD) among pregnant women.- to determine the efficacy and safety of trauma-focused therapy, specifically EMDR therapy, in pregnant women with FoC or childbirth-related PTSD.- to determine the impact of adverse and traumatic work-related events on Dutch gynaecologists, as well as their coping mechanisms and support.To this end, we conducted a series of studies with different designs to determine the natural course of FoC (HEAR-study), to evaluate the experience of therapists with EMDR therapy during pregnancy (VIP-study), to determine the safety and efficacy of EMDR therapy for women with FoC or PTSD (OptiMUM-study) and to analyse the impact of adverse work-related events among Dutch gynaecologists (WATER 1 and WATER 2-studies)

Clinical characteristics of women captured by extending the definition of severe postpartum haemorrhage with 'refractoriness to treatment': a cohort study

Background: The absence of a uniform and clinically relevant definition of severe postpartum haemorrhage hampers comparative studies and optimization of clinical management. The concept of persistent postpartum haemorrhage, based on refractoriness to initial first-line treatment, was proposed as an alternative to common definitions that are either based on estimations of blood loss or transfused units of packed red blood cells (RBC). We compared characteristics and outcomes of women with severe postpartum haemorrhage captured by these three types of definitions. Methods: In this large retrospective cohort study in 61 hospitals in the Netherlands we included 1391 consecutive women with postpartum haemorrhage who received either ≥4 units of RBC or a multicomponent transfusion. Clinical characteristics and outcomes of women with severe postpartum haemorrhage defined as persistent postpartum haemorrhage were compared to definitions based on estimated blood loss or transfused units of RBC within 24 h following birth. Adverse maternal outcome was a composite of maternal mortality, hysterectomy, arterial embolisation and intensive care unit admission. Results: One thousand two hundred sixty out of 1391 women (90.6%) with postpartum haemorrhage fulfilled the definition of persistent postpartum haemorrhage. The majority, 820/1260 (65.1%), fulfilled this definition within 1 h following birth, compared to 819/1391 (58.7%) applying the definition of ≥1 L blood loss and 37/845 (4.4%) applying the definition of ≥4 units of RBC. The definition persistent postpartum haemorrhage captured 430/471 adverse maternal outcomes (91.3%), compared to 471/471 (100%) for ≥1 L blood loss and 383/471 (81.3%) for ≥4 units of RBC. Persistent postpartum haemorrhage did not capture all adverse outcomes because of missing data on timing of initial, first-line treatment. Conclusion: The definition persistent postpartum haemo

Fear and PTSD in obstetrics:Improving care for pregnant women and their healthcare providers

The purpose of this thesis was to increase evidence based knowledge about fear and psychological trauma in obstetrics. The main aims of this thesis were as follows:- to develop more insight into Fear of Childbirth (FoC) and childbirth-related posttraumatic stress disorder (PTSD) among pregnant women.- to determine the efficacy and safety of trauma-focused therapy, specifically EMDR therapy, in pregnant women with FoC or childbirth-related PTSD.- to determine the impact of adverse and traumatic work-related events on Dutch gynaecologists, as well as their coping mechanisms and support.To this end, we conducted a series of studies with different designs to determine the natural course of FoC (HEAR-study), to evaluate the experience of therapists with EMDR therapy during pregnancy (VIP-study), to determine the safety and efficacy of EMDR therapy for women with FoC or PTSD (OptiMUM-study) and to analyse the impact of adverse work-related events among Dutch gynaecologists (WATER 1 and WATER 2-studies)

The effects of PTSD treatment during pregnancy: systematic review and case study

Background: PTSD in pregnant women is associated with adverse outcomes for mothers and their children. It is unknown whether pregnant women with PTSD, or symptoms of PTSD, can receive targeted treatment that is safe and effective. Objective: The purpose of the present paper was to assess the effectiveness and safety of treatment for (symptoms of) PTSD in pregnant women. Method: A systematic review was conducted in accordance with the PRISMA guidelines in Pubmed, Embase, PsychINFO, and Cochrane. In addition, a case is presented of a pregnant woman with PTSD who received eye-movement desensitization and reprocessing (EMDR) therapy aimed at processing the memories of a previous distressing childbirth. Results: In total, 13 studies were included, involving eight types of interventions (i.e. trauma-focused cognitive behavioural therapy, exposure therapy, EMDR therapy, interpersonal psychotherapy, explorative therapy, self-hypnosis and relaxation, Survivor Moms Companion, and Seeking Safety Intervention). In three studies, the traumatic event pertained to a previous childbirth. Five studies reported obstetrical outcomes. After requesting additional information, authors of five studies indicated an absence of serious adverse events. PTSD symptoms improved in 10 studies. However, most studies carried a high risk of bias. In our case study, a pregnant woman with a PTSD diagnosis based on DSM-5 no longer fulfilled the criteria of PTSD after three sessions of EMDR therapy. She had an uncomplicated pregnancy and delivery. Conclusion: Despite the fact that case studies as the one presented here report no adverse events, and treatment is likely safe, due to the poor methodological quality of most studies it is impossible to allow inferences on the effects of any particular treatment of PTSD (symptoms) during pregnancy. Yet, given the elevated maternal stress and cortisol levels in pregnant women with PTSD, and the fact that so far no adverse effects on the unborn child have been reported associated with the application of trauma-focused therapy, treatment of PTSD during pregnancy is most likely safe

Fluid resuscitation during persistent postpartum haemorrhage and maternal outcome: A nationwide cohort study

Clinical epidemiolog

Association of Timing of Plasma Transfusion With Adverse Maternal Outcomes in Women With Persistent Postpartum Hemorrhage

IMPORTANCE Early plasma transfusion for women with severe postpartum hemorrhage (PPH) is recommended to prevent coagulopathy. However, there is no comparative, quantitative evidence on the association of early plasma transfusion with maternal outcomes.OBJECTIVE To compare the incidence of adverse maternal outcomes among women who received plasma during the first 60 minutes of persistent PPH vs women who did not receive plasma for similarly severe persistent PPH.DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study used a consecutive sample of women with persistent PPH, defined as PPH refractory to first-line measures to control bleeding, between January 1, 2011, and January 1, 2013. Time-dependent propensity score matching was used to select women who received plasma during the first 60 minutes of persistent PPH and match each of them with a woman who had shown the same severity and received the same treatment of PPH but who had not received plasma at the moment of matching. Transfusions were not guided by coagulation tests. Statistical analysis was performed from June 2018 to June 2019.EXPOSURES Transfusion of plasma during the first 60 minutes of persistent PPH vs no or later plasma transfusion.MAIN OUTCOMES AND MEASURES Incidence of adverse maternal outcomes, defined as a composite of death, hysterectomy, or arterial embolization.RESULTS This study included 1216 women (mean [SD] age, 31.6 [5.0] years) with persistent PPH, of whom 932 (76.6%) delivered vaginally and 780 (64.1%) had PPH caused by uterine atony. Seven women (0.6%) died because of PPH, 62 women (5.1%) had a hysterectomy, and 159 women (13.1%) had arterial embolizations. Among women who received plasma during the first 60 minutes of persistent PPH, 114 women could be matched with a comparable woman who had not received plasma at the moment of matching. The incidence of adverse maternal outcomes was similar between the women, with adverse outcomes recorded in 24 women (21.2%) who received early plasma transfusion and 23 women (19.9%) who did not receive early plasma transfusion (odds ratio, 1.09; 95% CI, 0.57-2.09). Results of sensitivity analyses were comparable to the primary results.CONCLUSIONS AND RELEVANCE In this cohort study, initiation of plasma transfusion during the first 60 minutes of persistent PPH was not associated with adverse maternal outcomes compared with no or later plasma transfusion, independent of severity of PPH.Research into fetal development and medicin