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Original Investigation |

Pregnant Women With Posttraumatic Stress Disorder and Risk of Preterm Birth

Kimberly Ann Yonkers, MD1,2,3; Megan V. Smith, DrPh1,3,4; Ariadna Forray, MD1; C. Neill Epperson, MD5,6; Darce Costello, EdD1; Haiqun Lin, PhD, MD3; Kathleen Belanger, PhD†3
[+] Author Affiliations
1Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
2Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
3Yale School of Public Health, New Haven, Connecticut
4Child Study Center, Yale School of Medicine, New Haven, Connecticut
5Penn Center for the Study of Sex and Gender in Behavioral Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
6Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA Psychiatry. 2014;71(8):897-904. doi:10.1001/jamapsychiatry.2014.558.
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Importance  Posttraumatic stress disorder (PTSD) occurs in about 8% of pregnant women. Stressful conditions, including PTSD, are inconsistently linked to preterm birth. Psychotropic treatment has been frequently associated with preterm birth. Identifying whether the psychiatric illness or its treatment is independently associated with preterm birth may help clinicians and patients when making management decisions.

Objective  To determine whether a likely diagnosis of PTSD or antidepressant and benzodiazepine treatment during pregnancy is associated with risk of preterm birth. We hypothesized that pregnant women who likely had PTSD and women receiving antidepressant or anxiolytic treatment would be more likely to experience preterm birth.

Design, Setting, and Participants  Longitudinal, prospective cohort study of 2654 women who were recruited before 17 completed weeks of pregnancy from 137 obstetrical practices in Connecticut and Western Massachusetts.

Exposures  Posttraumatic stress disorder, major depressive episode, and use of antidepressant and benzodiazepine medications.

Main Outcomes and Measures  Preterm birth, operationalized as delivery prior to 37 completed weeks of pregnancy. Likely psychiatric diagnoses were generated through administration of the Composite International Diagnostic Interview and the Modified PTSD Symptom Scale. Data on medication use were gathered at each participant interview.

Results  Recursive partitioning analysis showed elevated rates of preterm birth among women with PTSD. A further split of the PTSD node showed high rates for women who met criteria for a major depressive episode, which suggests an interaction between these 2 exposures. Logistic regression analysis confirmed risk for women who likely had both conditions (odds ratio [OR], 4.08 [95% CI, 1.27-13.15]). For each point increase on the Modified PTSD Symptom Scale (range, 0-110), the risk of preterm birth increased by 1% to 2%. The odds of preterm birth are high for women who used a serotonin reuptake inhibitor (OR, 1.55 [95% CI, 1.02-2.36]) and women who used a benzodiazepine medication (OR, 1.99 [95% CI, 0.98-4.03]).

Conclusions and Relevance  Women with likely diagnoses of both PTSD and a major depressive episode are at a 4-fold increased risk of preterm birth; this risk is greater than, and independent of, antidepressant and benzodiazepine use and is not simply a function of mood or anxiety symptoms.

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Figure 1.
Patient Flowchart

PTSD indicates posttraumatic stress disorder.

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Figure 2.
Classification Tree for Risk of Preterm Birth

Ovals indicate decision nodes, and rectangles indicate terminal nodes. The number of women and the preterm birth rate (in parentheses) are displayed within each node for the women in the training sample and for the women in the testing sample. MDD indicates major depressive disorder; PTB, preterm birth; and PTSD, posttraumatic stress disorder.

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