Pregnancy Loss Can Lead to Posttraumatic Stress

Ricki Lewis, PhD

January 21, 2020

Women experienced moderate to severe depression, moderate to severe anxiety, or posttraumatic stress a month following early pregnancy loss from miscarriage or ectopic pregnancy, and for some patients, these stress-related conditions persisted at 9 months, according to findings published online December 13, 2019, in the American Journal of Obstetrics and Gynecology.

Early pregnancy loss is known to lead to anxiety and depression in the short term, but a possible link to posttraumatic stress has not been investigated. Nor have studies distinguished miscarriage from ectopic pregnancy, which has more severe psychological sequelae. In addition, most studies had small samples and are more than a decade old.

Jessica Farren, PhD, of Imperial College, London, and colleagues investigated the psychological aftermath of miscarriage or ectopic pregnancy during early gestation. They used the term "posttraumatic stress," not "postraumatic stress disorder (PTSD)," because, per study protocol, they screened for probable PTSD.

The prospective cohort study consecutively enrolled women from early pregnancy and antenatal clinics at three hospitals. Participants completed emailed psychological assessment surveys — the Hospital Anxiety and Depression Scale and the Posttraumatic Stress Diagnostic Scale — at 1, 3, and 9 months following pregnancy loss.

Of 537 women who had miscarriages and 116 who had ectopic pregnancies, 492 completed the Hospital Anxiety and Depression Scale after 1 month, 426 did so after 3 months, and 338 did so after 9 months. Eighty-seven women with healthy pregnancies served as controls.

The researchers parsed the responses according to time elapsed and whether a woman had suffered a miscarriage or an ectopic pregnancy.

For the time analysis, 29% of the women with early pregnancy loss met criteria for posttraumatic stress after 1 month, and 18% did so after 9 months (adjusted odds ratio [aOR] per month, 0.80). Moderate to severe anxiety was reported by 24% of patients after 1 month and by 17% after 9 months (aOR per month, 0.69). Moderate to severe depression was reported by 11% of women after 1 month and by 6% after 9 months (aOR per month, 0.87).

Ectopic pregnancy appeared to be more distressing than miscarriage. After 9 months, for the women who experienced miscarriage, 17% reported posttraumatic stress, 17% had anxiety, and 5% had depression. The corresponding statistics for women who experienced ectopic pregnancy were 21%, 23%, and 11%.

Pregnancy was associated with anxiety and depression for women with healthy pregnancies, but not to the extent that it was for women who experienced pregnancy loss. Among the women with healthy pregnancies, 13% reported moderate to severe anxiety at 1 month (aOR, 2.14), and 2% reported moderate to severe depression (aOR, 3.88), compared with nonpregnant control participants.

The researchers conclude that the prevalence of posttraumatic stress among women who experience pregnancy loss is an important finding. "It is recognised that PTSD in other contexts can have a significant impact on work, social interaction, healthcare utilisation and risks in future pregnancies. Given annual incidences of miscarriage and ectopic (which may rise further if the trend towards later childbearing continues), this points to a significant public health issue," they write.

They suggest that clinical management become more attuned to the possible psychological effects of early pregnancy loss. "Women often suffer long waiting times for review or treatment, as well as insensitive communication or management. We should strive to provide access to specialist early pregnancy assessment care where expert advice is available, as well as an awareness of the potential psychological response and need for appropriate treatment," they write.

A limitation of the study was that online questionnaires might not have been as accurate in identifying anxiety, depression, or posttraumatic stress as assessment by a trained mental health professional.

The researchers have disclosed no relevant financial relationships.

Am J Obstet Gynecol. Published online December 13, 2019. Abstract

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