Alessandra AmbrosiniI; Erica Maria PaddeuII; Gianpaolo DonzelliII; Giovanni StanghelliniIII
IDipartimento di Scienze Psicologiche, Umanistiche e del Territorio, Università degli Studi G. d'Annunzio di Chieti, Chieti, Italy
IIDipartimento di Neuroscienze, Area del Farmaco e Salute del Bambino, Università degli Studi di Firenze, Florence, Italy
IIID. Portales University, Santiago, Chile
Background. In this brief note we present the preliminary findings of a study of 16 women who underwent liver transplants before becoming pregnant and giving birth. The aim of the study was to show the similarities and differences between ways women experience the transplanted organ (liver) and the fetus.
Methods. To explore bodily experiences, a semi-structured ad hoc interview was done on a sample of 16 transplanted women who had completed a pregnancy. The interview was designed to explore the possible similarities between their perception of the transplanted organ (liver) and of the fetus.
Results. The main findings that emerge from our study are the following: a) in the post-transplant, pre-pregnancy phase, these women develop a polarized attention on the transplanted organ; b) during pregnancy this attention shifts towards the fetus; c) after childbirth the hyper-attention on the transplanted organ disappears and the subject resumes a normal relationship with her body.
Conclusions. Therefore, pregnancy and childbirth are experiences that can normalize relations between a person who has undergone a transplant and their transplanted organ.
Key words: liver transplantation, pregnancy, childbirth, bodily experience
This article presents the preliminary findings of a study carried on 16 women who underwent liver transplants before becoming pregnant and giving birth. The aim of the study was to identify similarities and differences in the ways women experience the transplanted organ (liver) and the fetus. The ultimate objective of this research is the prevention and treatment of psychological and psychopathological problems related to pregnancy in female transplant recipients in the framework of a holistic approach, where the physician treats a person with liver disease, rather than just a transplanted liver . Holistic medicine is a kind of person-centered, rather than disease centered, approach whose aim is optimal health and wellness .
It was found that one experience was common to all the interviewed women: before pregnancy the transplanted organ was the focus of their attention, but as the fetus developed, the attention previously directed at the liver shifted towards the fetus. The principle findings that emerge from our study are the following: a) in the post-transplant, pre-pregnancy phase, these women develop a polarized attention on the transplanted organ; b) during pregnancy this attention shifts towards the fetus; c) after childbirth the hyper-attention on the transplanted organ disappears and the subject resumes a normal relationship with her body. Therefore, pregnancy and childbirth are experiences that can normalize relations between a person who has undergone a transplant and their transplanted organ.
MATERIAL AND METHODS
To explore bodily experiences, a semi-structured ad hoc interview was conducted on a sample of 16 transplanted woman who had completed a pregnancy. The interview was designed to explore the possible similarities between their perception of the transplanted organ (liver) and of the fetus.
To better compare and analyze the results we used two control samples: the first is made up of women who have undergone a liver transplant but have not had a pregnancy, the other women who have never undergone a transplant but have experienced the pregnancy (Table 1).
Table 2 reports the exact comments of the women interviewed. The comments regard our interviewees' perception of their liver and of their fetus. These comments highlight the differences between women who undergo transplant but do not undergo pregnancy, women who give birth after transplantation and women who experience pregnancy without having undergone a transplant.
Perception of the transplanted organ prior to pregnancy
The following comments made by women who had undergone liver transplantation are emblematic of what we have called polarized attention on the transplanted organ. They show a tension towards the organ that underlies all of the speakers positive and negative thoughts and feelings about it. The comments denote an unrestrained and explicit awareness of the presence of the transplanted organ.
Even now, after eight years, I stop to think and I feel that (the liver) is not really part of my body.
I do not know how to explain it, it's hard! But even when you feel better if you try not to think about it, all of a sudden you realize that it is a kind of obsession!.
I have been transplanted for 10 years now and the liver was always in my thoughts, I felt it, it bothered me, I felt like that was where I should not feel it.
I felt something like an inner flicker where there was just the liver even though I knew it was not possible that the liver itself could be the cause those feelings.
Perception of the fetus in women with liver transplantation
Women with liver transplantation have a more intense perception of the fetus. The following remarks of one of the women interviewed illustrates this point:
Do you ever happen to feel the fetus? Yes, I'm intensely aware of him, somehow I always felt it, right from the start.
When did you first feel him? My friends told me it was still too early but I already felt the presence of the fetus at the third month of pregnancy.
Do you feel the fetus in certain place in your body? Yes, sometimes I feel it is here (points to the right) because it feels harder and deformed, kicks, moves ....
Similarities between the perception of the liver and fetus
A series of questions were aimed at exploring possible similarities between the experience of the transplanted organ and the experience of the fetus. Both the transplanted organ and the fetus are in some ways, foreign bodies in relation to the schema and the usual bodily experience. A similarity can be seen between the proprioceptive sensitivity towards the transplanted organ and towards the fetus. As a rule, the organs of our body are not explicitly perceived, unless they are invested by some abnormal process that generates, for example, sensations of pain. In the case of organ transplants, an organ itself can be perceived as a body in the body. Not necessarily as a foreign body, but as an explicit presence of something that usually remains implicit and in the background. The transplanted women interviewed made the following comments about their perception of the liver.
Do you perceive the liver in any particular way? Yes, a little. I feel a sort of a pain, or discomfort, I don't know what to call it ... right here where the liver is even though the doctors told me that the liver does not hurt.
Do you feel that the fetus is in harmony with your body? At first I felt as if was pushing on my intestines I felt this after the transplantation too I had these problems. Now it's better ... however I don't feel that he has harmonized with my body.
None of the women, however, compared her experience of the transplanted organ with that of the fetus.
Slippage of the polarized attention from the liver to the fetus
As we have seen, in transplanted women, the liver's presence is perceived as explicit, as a body in the her own body. Following liver transplantation there is a polarization of attention on the new organ. The transplanted liver is no longer just implicitly present in the body, but appears, instead, in the foreground and is perceived as a separate part. Among our respondents, the transplanted liver is first imbued with this implicit presence transformed into explicit presence, then with pregnancy this feeling is imbued in fetus. The fetus almost completely removes the transplanted liver from the foreground of the respondents' perception. The following are typical answers:
When you think about your pregnancy what is the main emotion you associate with the presence of your transplanted liver? When I knew I was pregnant the excitement was great. You still think about the liver, but when you know it's alright, the priority becomes the child.
Did this happen more after the transplantation, during the pregnancy or is it happening more now? During pregnancy, no, I didn't think about liver problems, I did the test, I made sure that everything was fine and I thought of the child.
After the transplant did you think about the liver? Yes, always. But now I think more than anything else about my donor I'm no longer as worried as I was before about the liver itself.
Did you think about the liver during your pregnancy? No, not during pregnancy.
Have you ever felt a movement inside the liver? During pregnancy, no, but at first I felt something like a flicker, but during pregnancy, no.
Do you think about your liver? I just thought about the baby, and even now the important thing is that things are going well.
During pregnancy, did you happen to feel the liver? The liver was always in my thoughts, I felt it, and it bothered me, I felt like it wasn't were it was supposed to be, but during pregnancy I thought only of the child.
Thinking about your pregnancy what is the main emotion you associate with the presence of the liver? It never had any connection with pregnancy, I never associated ... it was as if the pregnancy had taken over my imagination.
During pregnancy did the liver feel like a foreign body? No, I say no because I thought more than anything else about the fetus, the liver was in my thoughts too, but not 100% as before.
During your pregnancy did you visualize your liver? No, as soon as I knew about my son, I put these things in the background, I no longer thought of the fact that I had a stranger's liver as I had done before, it was as if it were my own.
Would it be correct then to say that you didn't think about the liver? Yes, I didn't think about it as much, I didn't worry about hurting it, I didn't worry about doing something, making some movement that could compromise it. After I got pregnant these thoughts passed out of my mind, I just thought about the baby and tried to protect him.
When I found out I was pregnant the excitement was great and you think about the liver when you did the exams, but if you know it's alright, the priority becomes the child.
I thought about the liver very often, practically every day, but during pregnancy I was just hoping that everything was fine, that there were no complications.
After transplantation I thought a lot about the liver, but to tell the truth during pregnancy this didn't happen very often.
Now, after giving birth, every now and then, I still think of the liver, but much less than before. At first, I thought about it and always felt that it was not really part of my body.
Normalization of the polarized attention
The following statements suggest that after the birth of the child the polarized attention, rather than shifting back towards the liver, seems to normalize:
In the first period, at the beginning, I thought continually about the transplanted liver, I had almost a physical relationship with it, we talked ... Now, after pregnancy less, only sometimes.
I wanted this baby so much, during pregnancy I have been very concerned, the only thoughts were turned to the baby and I did not think much about the liver. Now I think about it every now and then but in a different way, I think my experience and luck that I had, first for the chance of the transplant and then for the possibility of having a baby.
Now, my attention, my thoughts have turned to my child, it is as if I didn't have the time or need to think about the fact that I have a liver transplanted.
In previous studies, we have tried to highlight the complexity of pregnancy and motherhood as a kind of existential situation that can deeply challenge the psychological equilibrium of a woman, her sense of self and identity, and contribute to determining the development of psychopathological decompositions in vulnerable subjects [3-6].
The majority of papers on the psychological conditions of transplanted people mainly provide information on the quality of life before and after transplantation [7-11] or about the presence of anxiety and depression [8, 9, 12, 13]. In one study that focus on the mental representation of new organ , the authors report that the lack or incomplete intrapsychic integration of the transplanted organ involves a difficult physical integration of the organ itself. In other words, people who complain of organic disorders related to the transplanted organ are those who show difficulties in mentally integrating the transplanted part.
In this study, we highlight the power of the experience of pregnancy and motherhood as the vehicle a more functional equilibrium. This is the case with women who have experienced motherhood after receiving a liver transplantation. Whereas before pregnancy the transplanted organ is the focus of abnormal and disturbing attention for female transplant recipients, during pregnancy the fetus received the majority of the mothers' attentions, fantasies and concerns related to their body, displacing the transplanted liver from its previous position of centrality. After giving birth, the liver does not come back to take the central role previously occupied. The experience of motherhood, therefore, may represent an opportunity to establish a new equilibrium with one's body that is more balanced when compared to the person's relationship with their body immediately after a liver transplant.
Conflict of interest statement
There are no potential conflicts of interest or any financial or personal relationships with other people or organizations that could inappropriately bias conduct and findings of this study.
1. Hoban S. The art of medicine: striving for a more holistic view of our patients. Lancet 2001;358:21.
2. Noble D. Why integration? Integ Med Res 2012;1:2-4.
3. Ambrosini A, Stanghellini G. The concepts of depressive pathogenic situation and melancholic type of personality as applied in the case of postpartum depression. In: Psychopathology: theory, perspectives and future approaches. NY: Nova Science Publishers; 2013. p. 23-50.
4. Stanghellini G, Ambrosini A, Donzelli G. I miti della maternità e la depressione postpartum. In: Rossi Monti M, Gosio N (Eds). La depressione: il paradigma errante. Milano: Franco Angeli Editore; 2013. p. 237-55.
5. Ambrosini A, Stanghellini G. Myths of motherhood. When culture develops into pathology. Ann Istit Super Sanità 2012;48(3):277-2.
6. Ambrosini A, Donzelli G, Stanghellini G. Motherhood seen as a crisis. Early perinatal diagnosis of mothers at risk of developing postpartum depression. A concise guide for obstetricians, midwives, neonatologists and paediatricians. J Matern Fetal Neonatal Med 2012;25(7):1096-101.
7. Sainz-Barriga M, Baccarani U, Scudeller L, Risaliti A, Toniutto PL, Costa MG, Ballestrieri M, Adani GL, Lorenzin D, Bresadola V, Ramacciatto G, Bresadola F. Quality-of-life assessment before and after liver transplantation. Transplant Proc 2005;7:2601-4.
8. Santos Junior R, Miyazaki MCOS, Domingos NAM, Valério NI, Silva RF, Silva RCMA. Patients undergoing liver transplantation: psychosocial characteristics, depressive symptoms, and quality of life. Transplant Proc 2008;40:802-4.
9. Santos GGd, Gonçalves LCS, Buzzo N, Mendes TAR, Dias TP, da Silva RCMA, da Silva RF, de Felicio HCC, Santos Júnior R, Miyazaki MCOS. Quality of life, depression, and psychosocial characteristics of patients awaiting liver transplants. Transplant Proc 2012;44:2413-5.
10. Martín-Rodríguez A, Fernández-Jiménez E, Pérez-San-Gregorio MA, Pérez-Bernal J, Gómez-Bravo MA. Longitudinal study of liver transplant recipients' of quality life as a function of their perception of general health: at waiting list and at 3, 6, and 12 months post-transplantation. Transplant Proc 2013;45:3653-5.
11. Tome S, Wells JT, Said A, Lucey MR. Quality of life after liver transplantation. A systematic review. J Hepat 2008;48:567-77.
12. Kam-Tao Li P, Kwok Hong Chu, Kai Ming Chow, Miu Fong Lau, Chi Bon Leung, Bonnie Ching Ha Kwan, Yuen Fan Tong, Cheuk Chun Szeto and Maggie Miu Man Ng. Cross sectional survey on the concerns and anxiety of patients waiting for organ transplants. Nephrology 2012;17:514-8.
13. Pascazio L, Nardone IB, Clarici A, Enzmann G, Grignetti M, Panzetta GO, Vecchiet C. Anxiety, depression and emotional profile in renal transplant recipients and healthy subjects: a comparative study. Transplant Proc 2010;42:3586-90.
14. Látos M, Barabás K, Lázár G, Szederkényi E, Szenohradszky P, Marofka F, Csabai M. Mental representations of the new organ and posttransplant patients' anxiety as related to kidney function. Transplant Proc 2012;44:2143-6.
Address for correspondence:
Dipartimento di Scienze Psicologiche, Umanistiche e del Territorio, Università degli Studi "G. d'Annunzio" di Chieti,
Via dei Vestini 31, 66100 Chieti, Italy.
Received on 9 September 2014.
Accepted on 2 March 2015.