PTSD Common After Early Pregnancy Loss

Nancy A. Melville

November 09, 2016

Early pregnancy loss, a potentially traumatic event that many women opt not to share with others, can result in posttraumatic stress disorder (PTSD), suggesting that screening for the disorder may be beneficial following miscarriage or ectopic pregnancy, new research suggests.

Results of a prospective study suggest that more than one third of women with early pregnancy loss meet diagnostic criteria for PTSD.

"The data presented are in the context of a pilot study; however, if our findings are supported by further large prospective studies, we believe that consideration should be given to screening all women who have suffered an early pregnancy loss for PTSD," the authors, with first author Dr Jessica Farren, of Tommy's National Center for Miscarriage Research, Queen Charlottes and Chelsea Hospital, Imperial College, London, United Kingdom, report.

The findings were published online November 2 in BMJ Open.

Swept Under the Carpet

The prospective study involved 186 women recruited from the Early Pregnancy Assessment Unit of a central London teaching hospital. The patients were surveyed at 1, 3, and 9 months following the diagnosis of an early pregnancy loss and at 1 month following the diagnosis of a viable ongoing pregnancy.

In the early pregnancy loss group, 69 of 114 women responded at 1 month, and 44 of 68 responded at 3 months. Of those who responded at 1 month, 28% met criteria for probable moderate or severe PSTD, assessed with the Post-Traumatic Diagnostic Scale; 32% met criteria for moderate to severe anxiety, assessed with the Hospital Anxiety and Depression Scale (HADS); and 16% had depression at 1 month, assessed with the HADS.

At 3 months, the corresponding rates were 38% for PTSD, 20% for anxiety, and 5% for depression.

Among the women in the control group, who had not experienced early pregnancy loss, none met the criteria for PTSD, and 10% met criteria for anxiety and depression.

Of the survey's questions, the statement that was the most commonly endorsed by women in the early pregnancy loss group at 1 month was "feeling emotionally upset when you were reminded of the loss of your pregnancy"; 58% of women described having such feelings at least two to four times per week.

The second most common report was "having upsetting thoughts or images about the loss of your pregnancy that came into your head when you did not want them"; 43% of women described the experience at least two to four times per week.

At 3 months, the most commonly endorsed symptom cluster was reexperiencing the pregnancy loss.

The findings offer an important glimpse into the psychological effects of early pregnancy loss, which can differ uniquely from other types of loss, the authors note.

"The psychological consequences associated with an early pregnancy loss cannot necessarily be extrapolated from our understanding of grief reactions in other contexts," they explain.

"They encompass both bereavement, and an often traumatic (and in some cases life-threatening) personal physical experience."

As opposed to pregnancy loss in later stages, early pregnancy loss can be a uniquely isolating experience, the authors note.

"We are particularly interested in early loss because it is incredibly common and yet hasn't been the focus of very much research in the past," Dr Farren told Medscape Medical News. It tends to be something that is "swept under the carpet, perhaps in part because people don't tend to share the news of a pregnancy before 12 weeks, and therefore often won't tell others about a loss at this stage.

"This deprives them of social support and time/room to grieve," she explained.

Furthermore, "the clinical management is often perfunctory," she said. "There is no routine follow-up in place to debrief or to check their emotional well-being, unlike after a later loss or a healthy pregnancy."

The findings on PTSD offer clues as to why counseling with a "broad-brush" approach that does not target PTSD following miscarriage is often unsuccessful, the authors note.

Dr Farren pointed out that most ob/gyn clinicians are not trained to assess or treat PTSD, and even if they were, the appropriate treatment for such cases is not established.

"While it is clear that there are some fundamental differences between the reaction to a pregnancy loss and that to any other bereavement, we are not currently in a position to recommend how treatment should be tailored to them," Dr Farren said.

Although the current pilot study was too small to identify specific risk factors associated with PTSD after early pregnancy loss, Dr Farren and her colleagues are evaluating the issues in a larger study of more than 800 women.

"I am personally interested to see whether multiple losses have a cumulative effect, and also whether it makes a difference if the loss follows a scan in which the fetus/heartbeat has been seen," she said.

Important Reminder

The study offers an important reminder of the vital need to consider patients' psychological needs after pregnancy loss ― an area that tends to receive less attention than medical problems, said Jeffrey M. Rothenberg, MD, president and executive director of medical education at St. Vincent College of Health Professionals, in Indianapolis, Indiana.

"I think it's a truism in medicine that we tend to do better as a profession with the science part and we're not as good with the psychosocial and humanistic aspects, but truly that is what makes us healers when we focus on that," he told Medscape Medical News.

"For instance, I would much rather have a trainee who has been mentored to put their hands on someone's shoulder and grieve with them when they've had a loss as opposed to someone who can tell you the five highest differential diagnoses that led to the loss.

"Focusing on the psychological aspects is so much more important at the end of the day," he added.

"Not that we want to ignore the science aspects, but it's something we need to focus on more in medicine."

Clinicians and staff should be particularly sensitive to the common tendency of women to blame themselves for the pregnancy loss and consider that, despite knowing that early pregnancy loss is very common, it nevertheless can be among the worst events in a woman's life.

A commonly overlooked consideration is the shared effect on the spouse or partner.

"Another group we often don't think about is the effect on the male. Pregnancy loss can be just as traumatic for the male, and I have seen some cases where in fact the male grieves more than the female, so it's important to understand there is a male out there who may be as deeply affected," said Dr Rothenberg.

"In general, the death of a child is one of the most traumatic things a person can go through, so I would think most ob/gyns would not be surprised by these findings," he added.

The authors and Dr Rothenberg have disclosed no relevant financial relationships.

BMJ Open. Published November 2, 2016. Full text

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