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Pregnancy and Severe Influenza Infection in the 2013-2014 Influenza Season

(45%) than were those with historical or no PTSD (32% and 28%, respectively). Military sexual trauma was reported by 57%, 46%, and 16% of those with active, historical, or no PTSD, respectively. Those with active and historical PTSD also had a significantly higher burden of active comorbid mental health, drug-related, and alcohol-related diagnoses (P<0.001 for all). The unadjusted proportion of spontaneous preterm birth was 9.2%, 8.0%, and 7.4% (P=0.02) in those with active, historical, or no PTSD, respectively. For the adjusted model, active PTSD remained associated with spontaneous preterm delivery [aOR 1.35; 95% confidence interval (CI), 1.14-1.61; P<0.001], but the association with historical PTSD was not significant (aOR 1.06; 95% CI, 0.841.61; P=0.6). Although military sexual trauma showed no association with spontaneous preterm birth (aOR 1.08; 95% CI, 0.94-2.34), when the interaction between military sexual trauma and PTSD was assessed, those with both active PTSD and military sexual trauma had the greatest and most significant risk (aOR 1.43; 95% CI, 1.15-1.77; P=0.001). When adjusting for covariates, the association between PTSD and preterm birth persisted only in those with active PTSD (aOR 1.35; 95% CI, 1.14-1.61; P<0.001). When adjusting for comorbid psychiatric disorders, the independent effect of PTSD remained similar and significant (aOR 1.30; 95% CI, 1.07-1.58; P<0.004). Clinicians must be aware of active PTSD as a risk factor in patients before conception and during pregnancy. These women must be referred to appropriate mental health care during the prenatal period for treatment to improve maternal and likely neonatal outcomes.