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Cardiovascular disease (CVD) is the leading cause of death and disability for women in the United States, with CVD accounting for 1 of every 3 female deaths. Posttraumatic stress disorder (PTSD) significantly increases risk for CVD (Ebrahimi et al., 2021), and women are twice as likely as men to develop PTSD after trauma exposure (Kilpatrick et al., 2013). In the perinatal period, cardiovascular complications such as preeclampsia account for one third of maternal deaths, and emerging evidence indicates that PTSD increases risk for pregnancy-related CVD (Nash et al., 2019; Shaw et al., 2017). Outside of pregnancy, there is strong evidence that PTSD is associated with wear and tear on the stress response system (i.e., autonomic and hypothalamic-pituitary-adrenal axis) that may lead to cardiovascular disease over time. However, it is unclear how PTSD “gets under the skin” to influence cardiovascular risk over the brief gestational period. To address this gap, the aim of the current study was to evaluate the relationship between PTSD symptoms and autonomic and hypothalamic-pituitary-adrenal activity across pregnancy.

In this study, we investigated the associations among PTSD symptoms and two biological markers of the stress response system (i.e., cortisol and ambulatory blood pressure) in a sample of 254 pregnant people. PTSD symptoms were measured using a self-report measure for PTSD (i.e., PTSD Checklist for DSM-5). Salivary cortisol samples were collected at wake-up, 30 minutes after waking, and bedtime over one day at 12 and 32 gestational weeks. Blood pressure was measured for 24 hours at 12 and 32 gestational weeks. 

Results showed that pregnant people with higher PTSD symptoms displayed greater nighttime blood pressure and blood pressure variability in late pregnancy even after accounting for factors that are known to increase risk for adverse cardiovascular outcomes such as age, depressive symptoms, body mass index, smoking status, and past medical history of hypertension. Although elevated PTSD symptoms were associated with lower diurnal cortisol at awakening, this finding didn’t hold when controlling for depressive symptoms, suggesting that the association between PTSD and diurnal cortisol may be being driven by the negative mood symptoms of PTSD. 

The pattern of findings observed in this study indicate that PTSD is associated with circadian rhythm dysfunction of blood pressure. Studies are needed that investigate if evidence-based interventions treating PTSD, including those that target the brain-heart axis such as neuromodulation, results in regulation of circadian rhythms that decreases risk for adverse cardiovascular outcomes in pregnancy. Disruptions to blood pressure in late versus early pregnancy may also reflect pregnancy as a “cardiovascular stress test” in which vulnerability for cardiovascular dysregulation becomes more pronounced as pregnancy progresses (Valente et al., 2020).

Limitations of the study included the lack of verification of whether participants met DSM-5 Criterion A (i.e., exposure to qualifying traumatic event) and inability to confirm timing of salivary cortisol sampling times. Strengths include the repeated sampling of blood pressure and cortisol in early and late gestation as these systems are dynamic over pregnancy.

In light of these findings, mental health clinicians and obstetric providers may want to be alert to increased risk for cardiovascular complications of pregnancy among patients with PTSD. Collaborative care models, in which behavioral health interventions are embedded into obstetric care, are ideally poised to mitigate risk and promote wellness for pregnant patients with comorbid behavioral and obstetric conditions.

Target Article

Bublitz, M. H., Nillni, Y., Nugent, N. R., Sanapo, L., Habr, N., & Bourjeily, G. (2022). Posttraumatic stress disorder, diurnal cortisol, and ambulatory blood pressure in early and late pregnancy. Journal of Traumatic Stress.

Discussion Questions

  1. What new knowledge did you learn from this manuscript?
  2. What supports could be offered in prenatal care for people with elevated symptoms of PTSD?
  3. How can these results inform care delivered in the postpartum period?

About the Authors

Margaret H. Bublitz, PhD. Dr. Bublitz is Assistant Professor of Research at Brown Medical School and clinical psychologist at the Women’s Medicine Collaborative. She completed her PhD at the University of British Columbia and her residency and fellowship at the Brown Clinical Psychology Training Consortium. Her research investigates the mechanisms through which stress and trauma influence cardiovascular complications of pregnancy.

Yael Nillni, PhD. Dr. Nillni is an Assistant Professor in the Department of Psychiatry at Boston University School of Medicine and a Clinical Research Psychologist in the National Center for PTSD, Women’s Health Sciences Division at VA Boston Healthcare System. She completed her PhD at the University of Vermont, her residency at the University of Mississippi Medical Center/Veterans Affairs Medical Center Consortium, and her fellowship at the National Center for PTSD, Women's Health Sciences Division at VA Boston Healthcare System. Her research focuses on the intersection between trauma, posttraumatic stress disorder and comorbid mental health conditions, and women's reproductive health, particularly perinatal health.

References Cited

Ebrahimi, R., Lynch, K. E., Beckham, J. C., Dennis, P. A., Viernes, B., Tseng, C. H., Shroyer, A. L. W., & Sumner, J. A. (2021). Association of Posttraumatic Stress Disorder and Incident Ischemic Heart Disease in Women Veterans. JAMA Cardiology, 6(6), 642-651. https://doi.org/10.1001/jamacardio.2021.0227 
Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. Journal of Traumatic Stress, 26(5), 537-547. https://doi.org/10.1002/jts.21848 
Nash, M. C., Kip, K. E., Wang, W., Custer, M., & O'Rourke, K. (2019). Post-traumatic stress disorder and hypertensive disorders of pregnancy among military women. Paediatric and Perinatal Epidemiology, 33(3), 238-247. https://doi.org/10.1111/ppe.12546 
Shaw, J. G., Asch, S. M., Katon, J. G., Shaw, K. A., Kimerling, R., Frayne, S. M., & Phibbs, C. S. (2017). Post-traumatic Stress Disorder and Antepartum Complications: a Novel Risk Factor for Gestational Diabetes and Preeclampsia. Paediatric and Perinatal Epidemiology, 31(3), 185-194. https://doi.org/10.1111/ppe.12349 
Valente, A. M., Bhatt, D. L., & Lane-Cordova, A. (2020). Pregnancy as a Cardiac Stress Test: Time to Include Obstetric History in Cardiac Risk Assessment? Journal of the American College of Cardiology, 76(1), 68-71. https://doi.org/10.1016/j.jacc.2020.05.017