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Psychosomatics 49:413-419, September-October 2008
doi: 10.1176/appi.psy.49.5.413
© 2008 Academy of Psychosomatic Medicine
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Psychosocial Distress Associated With Treatment of Hypertensive Diseases in Pregnancy

Brigitte Leeners, M.D., Ruth Stiller, M.D., Peruka Neumaier-Wagner, M.D., Sabine Kuse, M.D., Alexander Schmitt, M.D., and Werner Rath, M.D.

Received September 29, 2006; revised February 8, 2007; accepted February 9, 2007. From the Dept. of Gynecology and Obstetrics, University Hospital Zürich; the Dept. of Gynecology and Obstetrics, University Hospital Aachen; the Dept. of Gynecology and Obstetrics, University Hospital, München, Rechts der Isar; Preeclampsia Self-Help Group (Gestosefrauen e.V.). Send correspondence and reprint requests to Brigitte Leeners, M.D., Dept. of Gynecology and Obstetrics, Clinic for Endocrinology Frauenklinikstr. 10 CH 8091, Zürich, Switzerland. e-mail: Brigitte.Leeners{at}usz.ch
© 2008 The Academy of Psychosomatic Medicine


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
BACKGROUND: Hypertensive diseases in pregnancy (HDP) are a great challenge for healthcare providers. OBJECTIVE: The study aimed to investigate the experience of women developing HDP with different stressors associated with healthcare after a diagnosis of HDP. METHOD: A self- administered questionnaire referring to stress associated with general aspects, hospital stay, and mode of delivery was given to a convenience sample of 738 women with one pregnancy complicated by HDP. RESULTS: The three main aspects causing stress after diagnosis of HDP were the duration of hospital stay for women having to stay at least 7 days in the hospital, the infant’s prematurity, and uncertainty about the child’s health. Most stress factors did not vary among women showing different types of HDP, but with infants’ gestational age at delivery. CONCLUSION: The diagnosis of HDP leads to important stress during pregnancy. In addition to stressors caused by other obstetrical complications, women developing HDP have to deal with a sudden and dramatic change in fetal health risk as well as their own sometimes life-threatening situation. Because stress may have an unfavorable effect on the clinical course of the disease, these aspects should be considered when treating women with HDP.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Women developing hypertensive diseases in pregnancy (HDP) are exposed to considerable stress. Despite intense efforts, maternal mortality and morbidity from HDP remain high worldwide.1–3 HDP are known to be associated with increased rates of adverse fetal outcome, such as prematurity and/or small-for-gestational age children, with all the known potential long-term consequences.4–8 The worst clinical outcomes are associated with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. At present, other than elective delivery, there is no effective management strategy for early-onset and severe preeclampsia. Moreover, pharmacological interventions have generally proven ineffective in preventing or reducing the adverse effects of the disorder.9

After a normal pregnancy with a delivery by caesarean section, 2.4% of women develop symptoms of posttraumatic stress disorder (PTSD), and 0.9% develop full-blown PTSD.10 In HDP, not only a traumatic delivery, but numerous other factors, such as the greater risk of prematurity, the sudden diagnosis, the often-rapid aggravation of the disease, and the life-threatening situation of the mother might add to psychosocial strain and represent a risk factor for long-term maternal and fetal consequences.11 Therefore, they represent major challenges for somatic as well as psychological support from healthcare providers.

In addition to reduced well-being, psychosocial strain can add to an unfavorable course of HDP. In human12,13 as well as in animal research,14,15 increased sympathicotonus may lead to symptoms of HDP. Furthermore, psychological factors may increase the risk for long-term consequences of HDP, such as chronic hypertension, diabetes mellitus, and cardiovascular diseases, including later heart attacks and strokes.16,17 Current counseling models for HDP focus on somatic aspects and often do not meet the psychosomatic needs of women suffering from HDP.18 However, these psychosocial risk factors could also provide prophylactic options. Last, but not least, adequate coping strategies of the parents are associated with better child development; that is, if parents receive psychosocial support, the risk of long-term consequences in children after HDP can be reduced.19–21 Given that healthy nulliparas seem to develop gestational hypertension or preeclampsia in 24.9% of their pregnancies,8 improvement of psychosocial support is of great clinical importance. At present, quantitative data on psychological strain after the diagnosis and during the treatment of different types of HDP are missing. Therefore, the aims of the present study were to assess 1) which aspects of medical care in HDP cause psychosocial strain; 2) whether there are any differences among women who develop gestational hypertension, preeclampsia, or HELLP syndrome; and 3) which factors might help to reduce strain.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Study Design
The study investigated a convenience sample of women with at least one HDP. The design is exploratory and descriptive. The data were collected within a nationwide research project studying the role of epidemiological as well as psychosocial factors in the etiology and course of HDP.

Recruitment of Study Participants
Questionnaires were sent to 2,600 women who had contacted the German Preeclampsia Self-Help Group for information on HDP; 423 women had to be excluded because they had not developed HDP, and 176 were excluded because of insufficient knowledge of the German language. A total of 1,067 women with HDP, that is, 53.3% of the eligible study group, completed and returned the questionnaire.

HDP were defined according to the definition criteria of the International Society for the Study of Hypertension in Pregnancy (ISSHP).22,23 Gestational Hypertension (GH) and Chronic Hypertension (CH): Blood pressure ≥140/90 mmHg after/before 20 weeks of gestation on two occasions ≥6 hour apart; Preeclampsia: GH/CH + proteinuria (≥0.3g in a 24-hour urine specimen, or dipstick proteinuria score ≥1+ in a random urine collection); HELLP syndrome: hemolysis (lactic dehydrogenase ≥600 U/liter, aspartate aminotransferase ≥70 U/liter, alanine aminotransferase ≥90 U/liter, platelet count ≤100,000/mm3).

Each diagnosis and clinical history was confirmed by reviewing medical records. Only women with a pregnancy complicated by HDP and followed beyond the 24th week of gestation within 2 years before the study period were considered for evaluation. Patients were only included into the study when all relevant data on main outcome measures and potential confounders were available. Consequently, a further 65 questionnaires had to be excluded, leaving 50.1% of the eligible study group for statistical evaluation. We evaluated results from 738 women with a single pregnancy complicated by HDP. Results on dealing with older children when HDP was diagnosed in a later pregnancy were drawn from a group of 264 women who experienced HDP in the presence of older children.

All participants signed informed consent. The study was performed according to the recommendations of the declaration of Helsinki and was approved by our Institution’s Medical Ethics Committee.

Instruments
A standardized questionnaire comprising basic obstetrical and psychosocial questions was based on current literature24–28 and the clinical experience of the investigators. Details of methods have been described elsewhere.18,29–31 The questionnaire was pilot-tested for aspects of understanding and ambiguity in 50 women with HDP. To evaluate psychological strain, women were asked to mark the intensity of perceived stress from a list of predefined potential stressors on a 5-point Likert scale. The questionnaire offered 5 predefined answers on general aspects, 11 aspects associated with a hospital stay, and 4 aspects associated with caesarean section. Factors reducing stress associated with HDP were investigated with six predefined answers, and a free-text answer choice was offered for respondents to mention additional factors.

Investigation of Potential Confounders
Maternal age was defined as the age at the beginning of the pregnancy. Women’s nationalities were categorized as German, non-German but Caucasian, and non-Caucasian. To evaluate educational level, the authors differentiated between primary school, extended primary school, high school, and college-level education. Women were categorized according to the highest-level final exam they had passed.

The actual health status of the child was considered as the most important factor causing recall bias. To control for the effect of the children’s health status, answers from women with healthy children were compared with answers from women whose children suffered from long-term consequences of HDP. The actual health status of the child at the time of the study period was used for comparison. Women were asked to specify whether their child showed any of seven pre-given complications (epilepsy, hyperactivity, minor and major motor disorders, dysgnosia, developmental delays in age-appropriate ability to sit and walk) or to mention any other complications in a free-text answer.

Statistical Analysis
Participants’ free-text answers were analyzed by content analysis (conceptual analysis). For each question, responses were systematically reviewed for typical aspects by two members of the research team (BL and PN-W). There was agreement on classification in 98.2% of all cases. In turn, specific aspects were coded in the database to prepare statistical evaluations. Only when both investigators had agreed on the classification was a given aspect used for analysis.

The Student t-test and Wilcoxon tests were used to compare group differences in continuous variables. Differences between proportions were analyzed with the Fisher’s exact and the chi-square test. Data analysis was performed with the statistical package of the Social Sciences Advanced Statistics 4.0 (SAS Institute Inc., Cary, NC, U.S.).


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
A total of 738 women had experienced a single HDP, 91 (12.3%) of whom developed gestational hypertension (GH); 307 (41.6%), preeclampsia (PE); and 340 (46.1%), HELLP syndrome (H). The age of the children in the sample resulting from these pregnancies varied between 10 months and 23 months, with an average age of 13.6 months. Sociodemographic characteristics, that is, maternal age, nationality, educational status, marital status, and profession did not differ between women presenting with gestational hypertension, preeclampsia, or HELLP syndrome. The socioepidemiological characteristics of the 264 women who experienced HDP in the presence of an older child were not significantly different from the 738 primiparae, except in maternal age (29.0 versus 30.8; p≤0.05). Of the 738 women, 78.6 had to deliver by caesarean section (GH: 61.5%, PE: 74.3%, H: 87.1%), and 76.8% had to stay in the hospital at least 6 days (GH: 42.9%, PE: 74.3%, H: 53.5%). Table 1 summarizes gestational age and data on hospital stays in women with different types of HDP. Hospital stays before delivery did not vary significantly between women presenting with gestational hypertension, preeclampsia, and HELLP syndrome.


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TABLE 1. Gestational Age at Delivery and Hospital Stay in Women With Various Forms of HDP (N=738)



The five main stressors in women with HDP were the duration of hospital stay (57.1%), premature birth (53.7%), caesarean section (49.5%), uncertainty regarding the child’s health (41.6%), and being separated from the partner during hospitalization (40.6%). Women with gestational hypertension more often felt uncertain regarding the child’s health (53.9% versus 35.3%; p<0.005) and were less often stressed by blood samples being drawn (3.6% versus 29.1; p<0.05) than were women with HELLP syndrome. Women developing HELLP syndrome significantly less often reported uncertainty regarding the child’s health (35.3% versus 45%; p<0.05) and stress caused by the dysfunction of their own body (28.5% versus 40.4%; p<0.005) than did women presenting with preeclampsia. There were no further differences regarding factors causing psychosocial strain between women showing different types of HDP, that is, uncertainty regarding their own health, physical changes/lack of attractiveness, or an increased number of consultations. In the case of a hospital stay of more than 6 days, in all three types of HDP, the duration of the hospital stay and the separation from the husband were main stressors. Other important factors causing psychological strain were the necessity of bed-rest (38.8%) and boredom (30%). Women suffering from HELLP syndrome (43.6%), but also those developing preeclampsia (37.1%), felt especially stressed by lack of privacy. Also, women felt stressed by other patients with whom they shared a room (14.1%). In 12.4% of women, stress resulted from contact with their doctors, which was most often attributed to lack of sufficient information on the disease, on their actual situation, and on medical decisions. Of the 264 women with older children, 40.9% of the 44 with gestational hypertension, 33.6% of the 131 with preeclampsia, and 37.8% of the 90 with HELLP syndrome regretted being separated from their older children (NS); 11.4% of the women with gestational hypertension, 19.9% of the women with preeclampsia, and 13.3% of those with HELLP syndrome had difficulty with having others take care of their children (NS).

Of the women who underwent delivery by caesarean section, around 50% experienced the caesarean section, itself, as the main stressor (GH: 58.0%; PE: 48.3%; H: 48.7%; NS). The second main stressor was infants’ prematurity (GH: 42.3%, PE: 58%, H: 52.1%; NS). Further stressors were pain (HDP: 23.3%) and the atmosphere in the operating theater (HDP: 20.9%). In cases with less than 24 hours between diagnosis of HDP and delivery, 50% of the women with gestational hypertension, 67.6% of the women with preeclampsia, and 61.5% of the women with HELLP syndrome had difficulties with the sudden dramatic situation (NS). Not being able to see their child soon after delivery was perceived as a very severe stressor (10%).

Psychological strain in women whose child had normal health status, as compared with those whose child had impaired health status, varied only with regard to stress of blood samples being taken (women whose child had normal-health-status child: 35.6%, versus women whose child had reduced health status: 15.3%; p<0.01), control of infants’ intake and elimination (35.6% versus 16%; p<0.01), and infants’ prematurity (19.6% versus 51.1%; p<0.0001). Table 2 lists an overview of factors that helped women to cope with HDP.


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TABLE 2. Factors Reducing Stress Associated With HDP (N=738)




  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
Psychological strain associated with HDP is determined by three main factors: 1) the clinical course of the disease; 2) intrapsychic factors of both parents, such as personality, coping strategies, or experiences with critical life events; and 3) the support that parents receive.11,32,33 Although stress influences the development and course of HDP,12,13 and although it is evident that a sudden change from a normal to a high-risk pregnancy will cause psychological strain, the integration of psychosomatic support in current concepts of obstetrical care is only in its early stages. The study undertaken presents factors causing psychological strain in order to base such concepts on the actual needs of women being treated for HDP. It shows that women with HDP experience a high level of stress associated especially with fear about the child’s health, as well as factors related to hospitalization.

Parents of prematurely-born infants may experience an increased emotional burden, increased fear, depression, and trauma symptoms,34–37 which is in line with our results showing that prematurity is a main stressor in women with HDP. Given that several effective psychosocial support models have already been developed for parents confronted with infant prematurity,32,38 these models might be adapted and started when prematurity may be anticipated. In accordance with results from studies on other obstetrical complications, another main stressor was uncertainty about the child’s health.38 Interestingly, women developing gestational hypertension worried the most about the child’s health, followed by women developing preeclampsia, and women with HELLP syndrome. It seems likely that women with HELLP syndrome and, to a lesser degree, those with preeclampsia, were either concerned with their own situation and/or felt more confident about the medical support they received.

More than 50% of hospitalized women suffering from HDP experience the duration of the hospital stay as stressful, regardless of the type of disease. The specific factors causing stress during a hospital stay are assumed to be relatively similar in all three types of HDP. Interestingly, factors such as boredom or having to stay in bed rank quite high on the list of stressors, whereas other factors, such as having blood samples drawn or changing doctors, which are often discussed as stressors in the clinical setting, seem to be less relevant. Women suffering from HELLP syndrome had the fewest problems with the dysfunction of their own body, although they had the most somatic problems. However, dissatisfaction with the functioning of the body, feelings of guilt, and so forth, may not be the problem in the acute situation, but may be an important factor in dealing with the disease later (personal communication with members of the German Preeclampsia Self-Help Group). Another stress factor was feeling inadequately informed by the medical team39 or feeling a lack of empathetic support. Communication between obstetrical caregivers and parents is difficult because of the crisis situation, where the parents’ ability to understand and retain information is reduced.18 Also, etiological knowledge regarding HDP is limited,6 so that a certain level of uncertainty cannot be avoided. However, the importance of dialogue creates new demands for the staff.

Psychological strain associated with caesarean section also shows similar results for the various types of HDP. The relatively little difference in psychosocial stress factors between the three different types of HDP show that psychological strain is determined more by a high-risk pregnancy, possibly resulting in premature birth and requiring hospitalization, than by specific features of HDP. The current results emphasize that the simple fact of being hospitalized has an important effect on maternal well-being.

As found in other studies,40 support provided by nurses was a main factor in reducing stress in the study we undertook. As expected, support provided by nurses and doctors was considered most important by women developing HELLP syndrome. Having a neonatal care unit nearby, the certainty that everyone is trying their best to improve the situation, and support provided by doctors ranked in place two to four of the list of stress-reducing factors to reduce stress associated with HDP. Interestingly, it seems to be even more important for women with gestational hypertension to be close to the neonatal unit than for women presenting either preeclampsia or HELLP syndrome. This difference might be due to the fact that these women often have more time to think about treatment of pregnancy complications because their situation does not worsen as quickly and as dramatically as in most of the cases of preeclampsia or HELLP syndrome.

In the free-text answers, the factor mentioned most often as reducing stress associated with HDP was support provided by the partner, family, and/or friends. However, results from Cignacco et al.11 show that the psychological strain in the actual situation is often underestimated by friends and family, which mostly results in trivialization of their experience. Therefore, parents cannot rely only on their private social circle, and psychosomatic support should be offered by professionals who are familiar with the specific problems in HDP.

There are limitations in the generalizability of the presented results: Because our analysis was performed retrospectively, which was the only way to obtain some of the data presented, we cannot exclude recall bias. Except for blood samples being taken, no differences in the estimation of psychological strain was found between those mothers having a healthy child after a pregnancy complicated by HDP and those mothers whose children suffer from long-term consequences of the HDP. Therefore, recall bias caused by the actual health status of the child seems not to influence these results. Since study participants were recruited in cooperation with the German Preeclampsia Self-Help Group, these respondents are not representative of all women developing HDP. As a result, women with HELLP syndrome are overrepresented. However, we think it is especially from these women that we can learn where and how current models for medical support should be improved. Because of the lack of validated questionnaires in this area, the authors had to use a self-developed questionnaire, and no data on reliability and validity are available. Still, it was the subjective estimation of the situation that was the focus of interest. Such subjective information has been proved as a helpful tool in the investigation of life-satisfaction.35

A strength of the study is the large group of women having experienced HDP; because there are no differences in sociodemographic characteristics between the three groups suffering from different types of HDP, these sociodemographic confounders were excluded. The authors are not aware of previous studies on the topic of psychosocial distress associated with HDP.

Future studies should include the psychological strain experienced during the postpartum period and during the often-prolonged time of convalescence.41 They should focus on individual risk factors for distress and investigate the efficacy of different counseling models for reducing stress. To improve well-being during treatment of HDP and reduce the risk of unfavorable long-term consequences for the mother and the child, psychosocial aspects should be integrated into current concepts for medical care in case of HDP.


  ACKNOWLEDGMENTS

 
The first and second author have contributed equally to the manuscript.

The authors thank Tracey Keenan for carefully revising the manuscript as a native speaker.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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