产后创伤后应激障碍影响因素的Meta分析

doi:10.12114/j.issn.1007-9572.2021.00.470

摘要/Abstract

摘要： 背景　产后创伤后应激障碍（PTSD）的影响因素复杂，对母婴健康构成严重威胁。因此，对产后PTSD的影响因素进行Meta分析至关重要。目的　通过Meta分析探讨产后PTSD的影响因素，为今后筛查和预防此类疾病的发生提供科学依据。方法　系统检索国外数据库（PubMed、EMBase、Cochrane Library、Web of Science、PsycINFO、Scopus）和中文数据库（中国知网、万方数据知识服务平台、维普网、中国生物医学文献数据库），筛选关于产后PTSD影响因素的横断面研究和队列研究，同时采取滚雪球的方式查阅所获文献的参考文献，检索时限为建库至2020年9月。使用美国卫生保健和研究机构（AHRQ）评价标准评价横断面研究质量，使用卡斯尔-渥太华量表（NOS）评价队列研究质量，由2名研究人员依据文献纳入和排除标准独立进行文献阅读和数据、资料提取。采用Stata 16.0和RevMan 5.3软件进行Meta分析。结果　共纳入12篇文献，其中6篇为横断面研究，6篇为队列研究；文献质量均为中高等。Meta分析结果显示，妊娠期不良心理（焦虑、抑郁）〔OR=10.73，95%CI（4.91，23.45）〕、妊娠期并发症〔OR=4.80，95%CI（1.91，12.03）〕、创伤性分娩体验〔OR=3.57，95%CI（2.20，5.80）〕、剖宫产〔OR=3.46，95%CI（2.82，4.24）〕、紧急剖宫产〔OR=3.05，95%CI（2.11，4.41）〕、器械分娩〔OR=2.47，95%CI（1.65，3.69）〕心理一致感水平低〔OR=2.27，95%CI（1.64，4.51）〕、硬膜外麻醉〔OR=1.55，95%CI（1.19，2.02）〕是产后PTSD的危险因素（P<0.05）；分娩满意度〔OR=0.30，95%CI（0.21，0.44）〕、早期母婴皮肤接触〔OR=0.20，95%CI（0.16，0.25）〕、社会支持〔OR=0.13，95%CI（0.03，0.48）〕是产后PTSD的保护因素（P<0.05）。敏感性分析结果显示，除紧急剖宫产外，其他因素均提示分析结果可靠，且无发表偏倚。结论　产后PTSD与多种影响因素有关，妊娠期不良心理（焦虑、抑郁）、妊娠期并发症、创伤性分娩体验、剖宫产、器械分娩、心理一致感水平低、硬膜外麻醉更易引发产后PTSD。

关键词: 应激障碍, 创伤后；产后期；影响因素分析；Meta分析

Abstract: Background　Postpartum post-traumatic stress disorder （PTSD） is a serious threat to maternal and child health due to its complex influencing factors.Therefore，it is essential to conduct a Meta-analysis of its influencing factors.Objective　We explored the influencing factors of postpartum PTSD through a Meta-analysis，to provide scientific evidence for screening and preventing such diseases in the future.Methods　Foreign databases （PubMed，EMBase，Cochrane Library，Web of Science，PsycINFO and Scopus） and domestic databases （CNKI，Wanfang Data，VIP，CBM） were searched systematically from inception to September 2020 for cross-sectional studies and cohort studies on the influencing factors of postpartum PTSD.Snowballing was used to search for the references of the included studies.Literature enrollment and data extraction were performed by two researchers separately according to the literature inclusion and exclusion criteria.AHRQ methodology checklist was used for assessing the quality of cross-sectional studies.The Newcastle-Ottawa Scale was used for assessing the quality of cohort studies.Meta-analysis was performed using Stata 16.0 and RevMan 5.3.Results　Finally，6 cross-sectional studies and 6 cohort studies were included，with moderate or high methodological quality.The Meta-analysis found that psychological problems during pregnancy （depression，anxiety）〔OR=10.73，95%CI （4.91，23.45）〕，pregnancy complications〔OR=4.80，95%CI（1.91，12.03）〕，traumatic delivery experience 〔OR=3.57，95%CI（2.20，5.80）〕，cesarean section 〔OR=3.46，95%CI（2.82，4.24）〕，emergency cesarean section 〔OR=3.05，95%CI （2.11，4.41）〕，instrumental delivery 〔OR=2.47，95%CI（1.65，3.69）〕，low level of psychological consistency 〔OR=2.27，95%CI （1.64，4.51）〕，and epidural anesthesia 〔OR=1.55，95%CI （1.19，2.02）〕 were associated with increased risk of postpartum PTSD （P<0.05）；satisfaction with childbirth services〔OR=0.30，95%CI （0.21，0.44）〕，early mother-infant skin-to-skin contact 〔OR=0.20，95%CI （0.16，0.25）〕，and social support 〔OR=0.13，95%CI （0.03，0.48）〕were associated with decreased risk of postpartum PTSD （P<0.05）.The combined results are relatively stable in the sensitivity analysis except for the emergency cesarean section and with no publication bias.Conclusion　Postpartum PTSD is associated with various factors，whose occurrence probability may increase with psychological distress during pregnancy （depression，anxiety），pregnancy complications，traumatic birth experience，cesarean section，instrumental delivery，low level of psychological consistency，and epidural anesthesia.

Key words: Stress disorders, post-traumatic；Postpartum period；Root cause analysis；Meta-analysis

陈颖,钱红艳,朱雨婷,等. 产后创伤后应激障碍影响因素的Meta分析[J]. 中国全科医学, 2021, 24(21): 2729-2733. DOI: 10.12114/j.issn.1007-9572.2021.00.470.
CHEN Ying,QIAN Hongyan,ZHU Yuting, et al. Influencing Factors of Postpartum Post-traumatic Stress Disorder：a Meta-analysis　[J]. Chinese General Practice, 2021, 24(21): 2729-2733. DOI: 10.12114/j.issn.1007-9572.2021.00.470.

参考文献

［1］ASADZADEH L，JAFARI E，KHARAGHANI R，et al．Effectiveness of midwife-led brief counseling intervention on post-traumatic stress disorder，depression，and anxiety symptoms of women experiencing a traumatic childbirth：a randomized controlled trial［J］．BMC Pregnancy Childbirth，2020，20（1）：142．DOI：10.1186/s12884-020-2826-1.
［2］ZAAT T R，VAN STEIJN M E，DE HAAN-JEBBINK J M，et al．Posttraumatic stress disorder related to postpartum haemorrhage：a systematic review［J］．Eur J Obstet Gynecol Reprod Biol，2018，225：214-220．DOI：10.1016/j.ejogrb.2018.04.012.
［3］ZHANG D，ZHANG J，GAN Q，et al．Validating the psychometric characteristics of the perinatal posttraumatic stress disorder questionnaire （PPQ） in a Chinese context ［J］．Archives of psychiatric nursing，2018，32（1）：57-61．DOI：10.1016/j.apnu.2017.09.016.
［4］ERICKSON N，JULIAN M，MUZIK M.Perinatal depression，PTSD，and trauma：impact on mother-infant attachment and interventions to mitigate the transmission of risk［J］．Int Rev Psychiatry，2019，31（3）：245-263．DOI：10.1080/09540261.2018.1563529.
［5］CHEN Y，YANG X，GUO C，et al．Prevalence of post-traumatic stress disorder following Caesarean section：a systematic review and meta-analysis［J］．J Womens Health：Larchmt，2020，29（2）：200-209．DOI：10.1089/jwh.2019.7750.
［6］COHEN M M，ANSARA D，SCHEI B，et al．Posttraumatic stress disorder after pregnancy，labor，and delivery ［J］．Journal of Women's Health （2002），2004，133（3）：315-24．DOI：10.1089/154099904323016473.
［7］ADEWUYA A O，OLOGUN Y A，IBIGBAMI O S.Post-traumatic stress disorder after childbirth in Nigerian women：prevalence and risk factors［J］．BJOG，2006，113（3）：284-288．DOI：10.1111/j.1471-0528.2006.00861.x.
［8］S?DERQUIST J，WIJMA B，WIJMA K.The longitudinal course of post-traumatic stress after childbirth［J］．J Psychosom Obstet Gynecol，2006，27（2）：113-119．DOI：10.1080/01674820600712172.
［9］THAM V，CHRISTENSSON K，RYDING E L.Sense of coherence and symptoms of post-traumatic stress after emergency caesarean section ［J］．Acta Obstet Gynecol Scand，2007，86（9）：1090-1096．DOI：10.1080/0001634070150769.
［10］夏宏伟.557名产妇产后42天应激障碍状况及影响因素分析［J］．中国健康心理学杂志，2012，20（5）：681-683.
XIA H W.Study on stress disorder status of 557 delivery women in 42 days after postpartum［J］．China J Heal Psychol，2012，20（5）：681-683.
［11］MODARRES M，AFRASIABI S，RAHNAMA P，et al．Prevalence and risk factors of childbirth-related post-traumatic stress symptoms［J］．BMC Pregnancy Childbirth，2012，12：88．DOI：10.1186/1471-2393-12-88.
［12］SRKALOVIC IM?IRAGIC A，BEGIC D，?IMICEVIC L，et al．Prediction of posttraumatic stress disorder symptomatology after childbirth-a croatian longitudinal study［J］．Women Birth，2017，30（1）：e17-23．DOI：10.1016/j.wombi.2016.06.007.
［13］LOPEZ U，MEYER M，LOURES V，et al．Post-traumatic stress disorder in parturients delivering by Caesarean section and the implication of anaesthesia：a prospective cohort study［J］．Health Qual Life Outcomes，2017，15（1）：118．DOI：10.1186/s12955-017-0692-y.
［14］HERNáNDEZ-MARTíNEZ A，RODRíGUEZ-ALMAGRO J，MOLINA-ALARCóN M，et al．Postpartum post-traumatic stress disorder：associated perinatal factors and quality of life［J］．J Affect Disord，2019，249：143-150．DOI：10.1016/j.jad.2019.01.042.
［15］HERNáNDEZ-MARTíNEZ A，RODRíGUEZ-ALMAGRO J，MOLINA-ALARCóN M，et al．Perinatal factors related to post-traumatic stress disorder symptoms 1-5 years following birth［J］．Women Birth，2020，33（2）：e129-135．DOI：10.1016/j.wombi.2019.03.008.
［16］OROVOU E，DAGLA M，IATRAKIS G，et al．Correlation between kind of cesarean section and posttraumatic stress disorder in Greek women ［J］．Int J Environ Res Public Health，2020，17（5）：1592．DOI：10.3390/ijerph17051592.
［17］刘婷婷，费英俊，李月.剖宫产后创伤后应激障碍调查及其影响因素分析［J］．中国医师杂志，2020，22（5）：714-717，722．DOI：10.3760/cma.j.cn431274-20190514-00572.
LIU T T，FEI Y J，LI Y.An investigation of postpartum post-traumatic stress disorder after cesarean delivery and its influencing factors［J］．J Chin Physician，2020，22（5）：714-717，722．DOI：10.3760/cma.j.cn431274-20190514-00572.
［18］DIKMEN-YILDIZ P，AYERS S，PHILLIPS L.Longitudinal trajectories of post-traumatic stress disorder （PTSD） after birth and associated risk factors［J］．J Affect Disord，2018，229：377-385．DOI：10.1016/j.jad.2017.12.074.
［19］DIKMEN-YILDIZ P，AYERS S，PHILLIPS L.Depression，anxiety，PTSD and comorbidity in perinatal women in Turkey：a longitudinal population-based study［J］．Midwifery，2017，55：29-37．DOI：10.1016/j.midw.2017.09.001.
［20］ROBERTS L，DAVIS G K，HOMER C S E.Depression，anxiety，and post-traumatic stress disorder following a hypertensive disorder of pregnancy：a narrative literature review［J］．Front Cardiovasc Med，2019，6：147．DOI：10.3389/fcvm.2019.00147.
［21］CIRINO N H，KNAPP J M.Perinatal posttraumatic stress disorder：a review of risk factors，diagnosis，and treatment［J］．Obstet Gynecol Surv，2019，74（6）：369-376．DOI：10.1097/OGX.0000000000000680.
［22］TüRKMEN H，YALNIZ DILCEN H，?Z?OBAN F A.Traumatic childbirth perception during pregnancy and the postpartum period and its postnatal mental health outcomes：a prospective longitudinal study［J］．J Reprod Infant Psychol，2020．DOI：10.1080/02646838.2020.1792429.
［23］ZHAO Y，GAO Y，SUN G，et al．The effect of initiating neuraxial analgesia service on the rate of cesarean delivery in Hubei，China：a 16-month retrospective study ［J］．BMC Pregnancy Childbirth，2020，20（1）：613．DOI：10.1186/s 1288 4-020-03294-z.
［24］EINAV M，MARGALIT M.Hope，loneliness and sense of coherence among bereaved parents［J］．Int J Environ Res Public Health，2020，17（8）：2797．DOI：10.3390/ijerph17082797.
［25］CROSSLAND N，KINGDON C，BALAAM M C，et al．Women's，partners' and healthcare providers' views and experiences of assisted vaginal birth：a systematic mixed methods review［J］．Reprod Health，2020，17（1）：83．DOI：10.1186/s12978-020-00915-w.
［26］GARCíA-MEJIDO J A，IDOIA-VALERO I，AGUILAR-GáLVEZ I M，et al．Association between sexual dysfunction and avulsion of the levator ani muscle after instrumental vaginal delivery［J］．Acta Obstet Gynecol Scand，2020，99（9）：1246-1252．DOI：10.1111/aogs.13852.
［27］MUNRO A，MACCORMICK H，SABHARWAL A，et al．Pharmacologic labour analgesia and its relationship to postpartum psychiatric disorders：a scoping review［J］．Can J Anaesth，2020，67（5）：588-604．DOI：10.1007/s12630-020-01587-7.
［28］AYERS S，BOND R，BERTULLIES S，et al．The aetiology of post-traumatic stress following childbirth：a meta-analysis and theoretical framework［J］．Psychol Med，2016，46（6）：1121-1134．DOI：10.1017/s0033291715002706.
［29］DILCEN H Y，ASLANTEKIN F，AKTAS N.The relationship of psychosocial well-being and social support with pregnant women's perceptions of traumatic childbirth ［J］．Scand J Caring Sci，2021，35（2）：650-658．DOI：10.1111/scs.12887.

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