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An Exploratory Analysis of Factors Associated With Spontaneous Preterm Birth Among Pregnant Veterans With Post-Traumatic Stress Disorder

  • Danielle M. Panelli
    Correspondence
    Correspondence to: Danielle M. Panelli, MD, Stanford University School of Medicine, Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Center for Academic Medicine, Obstetrics and Gynecology, MC 5317, Stanford University School of Medicine, 453 Quarry Road, Palo Alto, CA 94304. Phone: (650) 725-8623; fax: (650) 723-7737.
    Affiliations
    VA Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Menlo Park, CA, USA

    Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA
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  • Caitlin S. Chan
    Affiliations
    VA Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Menlo Park, CA, USA
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  • Jonathan G. Shaw
    Affiliations
    VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health, Care System, Menlo Park, California

    Stanford University Center for Primary Care and Outcomes Research (PCOR) and Center for Health Policy (CHP), Stanford, California

    Division of Primary Care & Population Health, Department of Medicine, Stanford University, Stanford, California
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  • Megha Shankar
    Affiliations
    Department of Internal Medicine, University of California, San Diego, San Diego, California
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  • Rachel Kimerling
    Affiliations
    VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health, Care System, Menlo Park, California

    National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health, Care System, Menlo Park, California
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  • Susan M. Frayne
    Affiliations
    VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health, Care System, Menlo Park, California

    Division of Primary Care & Population Health, Department of Medicine, Stanford University, Stanford, California
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  • Tiffany C. Herrero
    Affiliations
    Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA
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  • Deirdre J. Lyell
    Affiliations
    Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA
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  • Ciaran S. Phibbs
    Affiliations
    VA Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Menlo Park, CA, USA

    VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health, Care System, Menlo Park, California

    Stanford University Center for Primary Care and Outcomes Research (PCOR) and Center for Health Policy (CHP), Stanford, California

    Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, California
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Published:October 28, 2022DOI:https://doi.org/10.1016/j.whi.2022.09.005

      Abstract

      Introduction

      Pregnant veterans with post-traumatic stress disorder (PTSD) are at increased risk for spontaneous preterm birth, yet the underlying reasons are unclear. We examined factors associated with spontaneous preterm birth among pregnant veterans with active PTSD.

      Methods

      This was an observational study of births from administrative databases reimbursed by the Veterans Health Association between 2005 and 2015. Singleton livebirths among veterans with active PTSD within 12 months before childbirth were included. The primary outcome was spontaneous preterm birth. Maternal demographics, psychiatric history, and pregnancy complications were evaluated as exposures. Covariates significant on bivariate analysis, as well as age and race/ethnicity as a social construct, were included in multivariable logistic regression to identify factors associated with spontaneous preterm birth. Additional analyses stratified significant covariates by the presence of active concurrent depression and explored interactions between antidepressant use and preeclampsia.

      Results

      Of 3,242 eligible births to veterans with active PTSD, 249 (7.7%) were spontaneous preterm births. The majority of veterans with active PTSD (79.1%) received some type of mental health treatment, and active concurrent depression was prevalent (61.4%). Preeclampsia/eclampsia (adjusted odds ratio, 3.30; 95% confidence interval, 1.67–6.54) and ≥6 antidepressant medication dispensations within 12 months before childbirth (adjusted odds ratio, 1.89; 95% confidence interval, 1.29–2.77) were associated with spontaneous preterm birth. No evidence of interaction was seen between antidepressant use and preeclampsia on spontaneous preterm birth (p = .39). Findings were similar when stratified by active concurrent depression.

      Conclusions

      Among veterans with active PTSD, preeclampsia/eclampsia and ≥6 antidepressant dispensations were associated with spontaneous preterm birth. Although the results do not imply that people should discontinue needed antidepressants during pregnancy in veterans with PTSD, research into these factors might inform preterm birth prevention strategies for this high-risk population.
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      References

        • American College of Obstetricians and Gynecologists (ACOG)
        Committee opinion 743: Low-dose aspirin use during pregnancy.
        Obstetrics and Gynecology. 2018; 132: 44-52
        • American College of Obstetricians and Gynecologists (ACOG)
        Practice bulletin 202: Gestational hypertension and preeclampsia.
        Obstetrics and Gynecology. 2019; 133: 211-214
        • American College of Obstetricians and Gynecologists (ACOG)
        Practice bulletin 204: Fetal growth restriction.
        Obstetrics and Gynecology. 2019; 133: 1063-1066
        • American College of Obstetricians and Gynecologists (ACOG)
        Prediction and prevention of spontaneous preterm birth.
        Obstetrics and Gynecology. 2021; 138: e65-e90
        • Ananth C.V.
        • Savitz D.A.
        • Luther E.R.
        • Bowes W.A.
        Preeclampsia and preterm birth subtypes in Nova Scotia, 1986 to 1992.
        American Journal of Perinatology. 1997; 14: 17-23
        • Ananth C.V.
        • Vintzileos A.M.
        Medically indicated preterm birth: Recognizing the importance of the problem.
        Clinics in Perinatology. 2008; 35: 53-67
        • Cook N.
        • Ayers S.
        • Horsch A.
        Maternal posttraumatic stress disorder during the perinatal period and child outcomes: A systematic review.
        Journal of Affective Disorders. 2018; 225: 18-31
        • Department of Veterans Affairs Office of Research and Development
        (Available:)
        www.research.va.gov/mvp/
        Date: 2022
        Date accessed: May 10, 2022
        • Eke A.C.
        • Saccone G.
        • Berghella V.
        Selective serotonin reuptake inhibitor (SSRI) use during pregnancy and risk of preterm birth: A systematic review and meta-analysis.
        BJOG: An International Journal of Obstetrics and Gynaecology. 2016; 123: 1900-1907
        • Ekeke P.
        • Mendez D.D.
        • Yanowitz T.D.
        • Catov J.M.
        Racial differences in the biochemical effects of stress in pregnancy.
        Environmental Research and Public Health. 2020; 17: 6941
        • Frayne S.
        • Phibbs C.
        • Saechao F.
        • Friedman S.
        • Shaw J.
        • Romodan Y.
        • Haskell S.
        Sourcebook: Women veterans in the Veterans Health Administration.
        Longitudinal trends in sociodemographics, utilization, health profile, and geographic distribution. 4. Women’s Health Evaluation Initiative, Women’s Health Services, Veterans Health Administration, Washington, DC2018: 4
        • Goldenberg R.L.
        • Culhane J.F.
        • Iams J.D.
        • Romero R.
        Epidemiology and causes of preterm birth.
        Lancet. 2008; 371: 75-84
        • Gravely A.A.
        • Cutting A.
        • Nugent S.
        • Grill J.
        • Carlson K.
        • Spoont M.
        Validity of PTSD diagnoses in VA administrative data: Comparison of VA administrative PTSD diagnoses to self-reported PTSD Checklist scores.
        Journal of Rehabilitation Research and Development. 2011; 48: 21-30
        • Huybrechts K.F.
        • Sanghani R.S.
        • Avorn J.
        • Urato A.C.
        Preterm birth and antidepressant medication use during pregnancy: A systematic review and meta-analysis.
        PLoS One. 2014; 9: e92778
        • Kroll-Desrosiers A.R.
        • Crawford S.L.
        • Moore Simas T.A.
        • Clark M.A.
        • Mattocks K.M.
        Treatment and management of depression symptoms in pregnant veterans: Varying experiences of mental health care in the prenatal period.
        Psychiatric Quarterly. 2020; 91: 475-493
        • Leonard B.
        • Maes M.
        Mechanistic explanations how cell-mediated immune activation, inflammation and oxidative and nitrosative stress pathways and their sequels and concomitants play a role in the pathophysiology of unipolar depression.
        Neuroscience and Biobehavioral Reviews. 2012; 36: 764-785
        • March of Dimes
        March of Dimes preterm birth report card (p. 1–144).
        (Available:)
        • Osborne L.M.
        • Monk C.
        Perinatal depression-the fourth inflammatory morbidity of pregnancy? Theory and literature review.
        Psychoneuroendocrinology. 2013; 38: 1929-1952
        • Palmsten K.
        • Hernández-díaz S.
        Commentary: Can nonrandomized studies on the safety of antidepressants duringpregnancy convincingly beat confounding, chance, and prior beliefs?.
        Epidemiology. 2012; 23: 686-688
        • Quinn D.A.
        • Mor M.K.
        • Sileanu F.E.
        • Zhao X.
        • Callegari L.S.
        • Zephyrin L.C.
        • Borrero S.
        Measuring female veterans’ prepregnancy wellness using Department of Veterans Affairs’ health record data.
        Obstetrics and Gynecology. 2021; 137: 471-480
        • Rasmussen S.
        • Ebbing C.
        • Irgens L.M.
        Predicting preeclampsia from a history of preterm birth.
        PLoS One. 2017; 12: 1-10
        • Rogal S.S.
        • Poschman K.
        • Belanger K.
        • Howell H.B.
        • Smith M.V.
        • Medina J.
        • Yonkers K.A.
        Effects of posttraumatic stress disorder on pregnancy outcomes.
        Journal of Affective Disorders. 2007; 102: 137-143
        • Sanjuan P.M.
        • Fokas K.
        • Tonigan J.S.
        • Henry M.C.
        • Christian K.
        • Rodriguez A.
        • Leeman L.
        Prenatal maternal posttraumatic stress disorder as a risk factor for adverse birth weight and gestational age outcomes: A systematic review and meta-analysis.
        Journal of Affective Disorders. 2021; 295: 530-540
        • Seng J.S.
        • Low L.K.
        • Sperlich M.
        • Ronis D.L.
        • Liberzon I.
        Prevalence, trauma history, and risk for posttraumatic stress disorder among nulliparous women in maternity care.
        Obstetrics and Gynecology. 2009; 114: 839-847
        • Shaw J.G.
        • Asch S.M.
        • Katon J.G.
        • Shaw K.A.
        • Kimerling R.
        • Frayne S.M.
        • Phibbs C.S.
        Post-traumatic stress disorder and antepartum complications: A novel risk factor for gestational diabetes and preeclampsia.
        Paediatric and Perinatal Epidemiology. 2017; 31: 185-194
        • Shaw J.G.
        • Asch S.M.
        • Kimerling R.
        • Frayne S.M.
        • Shaw K.A.
        • Phibbs C.S.
        Posttraumatic stress disorder and risk of spontaneous preterm birth.
        Obstetrics and Gynecology. 2014; 124: 1111-1119
        • Shaw J.G.
        • Joyce V.R.
        • Schmitt S.K.
        • Frayne S.M.
        • Shaw K.A.
        • Danielsen B.
        • Phibbs C.S.
        Selection of higher risk pregnancies into Veterans Health Administration programs: Discoveries from linked Department of Veterans Affairs and California Birth data.
        Health Services Research. 2018; 53: 5260-5284
        • Shaw J.G.
        • Nelson D.A.
        • Shaw K.A.
        • Woolaway-bickel K.
        • Phibbs C.S.
        • Kurina L.M.
        Deployment and preterm birth among US Army soldiers.
        American Journal of Epidemiology. 2018; 187: 687-695
        • Shivakumar G.
        • Kroll-Desrosiers A.R.
        • Copeland L.
        • Anderson E.H.
        • Maydon A.
        • Mattocks K.
        Patterns of treatment utilization across the perinatal period in the Center for Maternal and Infant Outcomes and Research in Translation (COMFORT) veterans study.
        Journal of Women’s Health. 2020; 30: 882-890
        • Sujan A.C.
        • Rickert M.E.
        • Öberg A.S.
        • Quinn P.D.
        • Hernández-Díaz S.
        • Almqvist C.
        • D’Onofrio B.M.
        Associations of maternal antidepressant use during the first trimester of pregnancy with preterm birth, small for gestational age, autism spectrum disorder, and attention-deficit/hyperactivity disorder in offspring.
        The Journal of the American Medical Association. 2017; 317: 1553-1562
        • Venkatesh K.K.
        • Riley L.
        • Castro V.M.
        • Perlis R.H.
        • Kaimal A.J.
        Association of antenatal depression symptoms and antidepressant treatment with preterm birth.
        Obstetrics and Gynecology. 2016; 127: 926-933
        • Yonkers K.A.
        • Smith M.V.
        • Forray A.
        • Epperson C.N.
        • Costello D.
        • Lin H.
        • Belanger K.
        Pregnant women with posttraumatic stress disorder and risk of preterm birth.
        The Journal of the American Medical Association Psychiatry. 2014; 71: 897-904
        • Yonkers K.A.
        • Vigod S.
        • Ross L.E.
        Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women.
        Obstetrics & Gynecology. 2011; 117: 961-977

      Biography

      Danielle M. Panelli, MD, Maternal-Fetal Medicine physician in Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University. Research interests include maternal mental health and adverse pregnancy outcomes.

      Biography

      Caitlin S. Chan, SM, Biostatistician affiliated with the VA Health Economics Resource Center at VA Palo Alto Health Care System. Research interests include reproductive health outcomes for Veterans.

      Biography

      Jonathan G. Shaw, MD, MS, Family Medicine physician in the Division of Primary Care & Population Health, Department of Medicine, Stanford University, and health research affiliate with VA HSR&D Center for Innovation to Implementation, VA Palo Alto.

      Biography

      Megha Shankar, MD, Internal Medicine physician affiliated with the UC San Diego Division of General Internal Medicine; graduate of Advanced Fellowship in Health Services Research and Development at the VA Palo Alto. Research interests include women's health and health equity.

      Biography

      Rachel Kimerling, PhD, Clinical psychologist affiliated with the National Center for PTSD. Research interests include health services research that addresses women's health and gender issues in the detection, treatment, and impacts of traumatic stress.

      Biography

      Susan M. Frayne, MD, MPH, Internal Medicine physician, Director of Women's Health Evaluation Initiative, VA Palo Alto, affiliated with the Division of Primary Care & Population Health, Department of Medicine, Stanford University. Research interests include primary care for women with mental illness.

      Biography

      Tiffany C. Herrero, MD, Maternal-Fetal Medicine physician in Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University. Research interests include maternal morbidity and high-risk pregnancy conditions.

      Biography

      Deirdre J. Lyell, MD, Maternal-Fetal Medicine physician in Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University. Research interests include severe maternal morbidity, population health, obstetric outcomes and placenta accreta spectrum.

      Biography

      Ciaran S. Phibbs, PhD, Associate Director of VA Women's Health Evaluation Initiative, VA Palo Alto and Associate Professor of Pediatrics. Research interests include pregnancy outcomes and disparities for veterans, particularly those with mental health conditions.