Treatment of trauma-related symptoms and fear of childbirth in a naturalistic cohort of pregnant women

The prevalence of post-traumatic stress disorder (PTSD) during pregnancy is
approximately 3.3% and increases to 4% in the postpartum period. In the
high-risk group the prevalence is 18%. This group contains women who
experienced a traumatic childbirth in the past, underwent an emergency cesarean
section or were a victim of sexual/physical abuse in the past. The prospect of
giving birth can induce severe anxiety or PTSD symptoms during pregnancy. Both
anxiety as (subclinical) symptoms of PTSD during pregnancy are associated with
peripartum depression, obstetric complications, premature birth and impaired
cognitive development of the infant.
Eye Movement Desensitization and Reprocessing (EMDR) is a treatment, which has
initially been developed for the treatment of PTSD. EMDR aims to reduce
subjective disstress and strengthen adaptive cognitions related to the
traumatic event or (irrational) fears. This treatment is also used in clinical
practice if the memory of the trauma causes clinically distress, but the DSM-5
criteria are not fully met. A part of the pregnant women are diagnosed with
PTSD (according to the DSM-5), some pregnant women only have symptoms of PTSD.
Both groups can be treated with EMDR therapy, often as part of an integral
treatment.
Clinical practise shows that psychologists in primary care are reluctant in
treating pregnant women with EMDR, because of the worries about negative
effects on the mother and/or unborn child. However, little research is
available about EMDR during pregnancy, despite the high prevalence of PTDS
during pregnancy. Available literature focuses on EMDR therapy indicated for
PTSD after childbirth. To our knowlegde, no previous prospective study has been
published describing this specific population (pregnant women with PTSD
symptomatology and EMDR therapy) and the association with obstetric and
neonatal outcomes.
This study will give additional information to expand the knowlegde on this
specific topic and this will increase the applicability of EMDR therapy in
primary care. Furthermore, pregnant women can be informed more extensively
about the effect on the unborn child.

The primary objective of this study is to expand the knowledge about pregnant
women with PTSD (symptomatology). Pregnant women with PTSD (symptomatology)
will be described, ass wel ass the pregnant women who develop PTSD
(symptomatology) during pregnancy. In addition, an overview of EMDR therapy
will be given (type of trauma, number of targets, traumatic memory or
flashforward, considerations for not applying EMDR (despite PTSD
symptomatolgy). We examine the effect of EMDR therapy, as part of an integral
treatment, on PTSD symptomatology and fear of childbirth. The secondary object
of this study is to give a descriptive overview of obstetric and neonatal
outcomes in women with EMDR therapy during pregnancy and to give a descriptive
overview how women experienced psychological treatment and/or EMDR therapy
during pregnancy.

This is an observational study.
Participants are followed prospectively and are not assigned to a specific
treatment. EMDR therapy will be applied if it is indicated by the psychologist.

Measurements are done at intake and at amenorrhea of 37 weeks:
Self-report questionnaires are used to gain information about PTSD
symptomatology: the Life Event Checklist for DSM-5 (LEC-5) and PTSD Checklist
for DSM-5 (PCL-5). Thoughts and feelings about the upcoming childbirth are
queried by self-report questionnaire Wijma Delivery Expectancy Questionnaire
Version A (WEDQ-A).

Final follow-up takes place at 6 weeks after childbirth:
The LEC-5 and PCL-5 are again used to measure PTSD symptomatology, including a
questionnaire about the experience of the delivery (WEDQ-B). Women who do not
(anymore) receive professional care from the psychologist, will be asked if
they are able to fill out the questionnaire again.

Questionnaires are sent by e-mail.
Obstetric and neonatal outcomes are collected from patient records.

2 to 4 months postpartum, participants will be approached by telephone after
completing the study, to ask whether they would like to participate in an extra
part of the study. Nine to twelve likert scale questions will be asked.

Participation is voluntary. Participants are followed prospectively and are not
assigned to a specific treatment. EMDR therapy will be applied if indicated by
the psychologist. This represents the clinical practice in Elisabeth-Tweesteden
hospital.
Standardized questionnaire are used at three different time-points to measure
the effect of the therapy, these questionnaires can be completed online and
will take 1.5 hours in total (30minutes per time-point). No risk is associated
with participation. Standardized questionnaires can be experienced by
participants as confrontational. The psychologist will also ask the patient
about (potentional) traumatic events, this is the clinical practice. So it is
not expected that traumatic events will be discussed for the first time in the
questionnaires. To get a complete overview of all pregnant women with PTSD
during pregnancy, also women without elevated PCL-5 score at intake will be
included to this study. Clinical practice shows that women without PTSD
(symptomatology) at intake can develop symptoms of PTSD during pregnancy.
(Individual) results of the study can be provided, if requested by the
participant. To minimalize the burden of participation of the extra part of the
study (2 to 4 months postpartum), nine to twelve multiple choice questions will
be asked by phone.