Examining PTSD as a Complication of Infertility

, New York Hospital-Cornell Medical Center, New York City, , Manhattan Psychiatric Center, New York City, , New York Hospital-Cornell Medical Center, , Cornell University Medical College, , Advanced Fertility Services, New York City

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Case 2: NICU Flashbacks

After attempting for 2 years to become pregnant, a 39-year-old office manager with no previous psychiatric history saw a fertility expert and underwent treatment with pergonal. Within 4 months she was carrying triplets. Her obstetrician, a specialist in high-risk pregnancies, assiduously advised her of the health risks inherent in a triplet pregnancy. A devout Catholic, she wouldn't consider reduction to twins.

As part of a routine tour of the hospital for high-risk OB patients, she was shown the neonatal intensive care unit (NICU). The patient subsequently became traumatized for the duration of her pregnancy with the vision of small, premature infants attached to tubes and struggling for life; while expressing the fear that her babies would suffer a similar experience, she vowed to do all she could to prevent it.

The patient was placed on complete bed rest to prevent premature labor in her second trimester; during that time, she spent her days worrying about the pregnancy and experiencing flashbacks of the visit to the NICU, which triggered physiologic signs of anxiety. She began to experience the pregnancy as a prison sentence, or a process of slowly dying and having the life drained out of her. Giving birth to 3 healthy, full-term babies seemed, at first, like heaven to her, but this quickly gave way to feelings of severe emotional distress.

After several months, she finally sought psychiatric treatment at the urging of her obstetrician. At this time, she exhibited restricted affect, angry outbursts, flashbacks of the NICU and her confinement, exaggerated startle response, estrangement from her husband, and lack of sexual interest. She became tongue-tied when she attempted to express her feelings. Severely confused, she lost her way to appointments and showed up at the wrong times. She exhibited a stunned quality and said that she felt like an automaton. She expressed a sense of estrangement from family, friends, her husband, and even the infants.

Notably, her depression rating scales worsened at first with the initiation of pharmacotherapy. She improved after 2-and-a-half years of aggressive pharmacotherapy with various agents, including paroxetine, a selective serotonin reuptake inhibitor antidepressant; valproate, a mood stabilizer; buspirone, an anxiolytic; and lorazepam, a benzodiazepine anxiolytic, but still has not fully recovered.

Comment. Although the patient had no previous psychiatric history, her mother had died when she was 10 years old. The loss of a parent at an early age is a risk factor for development of postpartum depression.[7] That her depression rating scales worsened at first after the initiation of pharmacotherapy is typical in patients with emotional numbing characteristic of PTSD. This case also raises the issue as to whether the routine viewing of the NICU is advisable for certain high-risk OB patients.

Elderly primiparas are at increased risk for developing complications of pregnancy and delivery.[8] They are also generally better informed about the risks associated with single or multiple births. Perhaps increased awareness of actual risks leaves older new mothers with heightened fear and anxiety, which renders them more likely to perceive the pregnancy and birth as traumatic. Thus, these women may actually be more vulnerable to PTSD than those who are younger and less well informed.


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