MERRY CHRISTMAS!

THE EFFECT OF MISCARRIAGE ON MENTAL HEALTH

A woman who has miscarried is at a higher risk of anxiety and depression than a woman who never miscarried¹. The response of a woman to a miscarriage is, however, dependent on the context within which the miscarriage happened. It is therefore important to recognise and treat each woman as an individual: expecting every woman who has a miscarriage to develop mental health issues is as remiss as assuming every woman who has a miscarriage gets over it easily and without help.

When assessing a woman after a pregnancy loss, it is important, as a health care professional, to be able to distinguish between a grief reaction (which is normal) and a depression reaction (which is pathological).

According to a study on grief and depression after a miscarriage, grief usually proceeds as shock à preoccupation with the deceased à resolution².

Central emotions in grief are sadness, loneliness and a sense of emptiness². Central emotions in depressions are dejection, guilt, discouragement, despair and the usual physical disturbances (i.e. sleep and appetite disturbances)².

Basically, if you talk to a woman who has just suffered a pregnancy loss and she reports feeling weepy all the time, thinking about the baby and wondering why it happened, with sadness increased any time she is faced with reminders of the pregnancy, she is going through a normal coping mechanism. She is obsessed with the baby she lost.

If, however, you talk to a woman after a pregnancy loss and she feels dejected, cannot cope with day-to-day tasks, feels irritable, restless and anxious, she may need professional help to deal with coping. She is obsessed with negative feelings.

This study also found that an ambivalent attitude towards the pregnancy usually resulted in a depression reaction to the loss of the pregnancy². This shows one cannot assume that just because the pregnancy was not planned or maybe not even wanted then the woman will be fine when it is over.

Multiple potential meanings can be attributed to a miscarriage¹. It is a part of our duty of care to ensure that the meanings attributed to the miscarriage by our patients do not result in an inability to cope with the loss. Health, after all, encompasses physical, mental and social wellbeing and we should strive for that.

REFERENCES.

1.       Swanson K M, “Research-based practice with women who have had miscarriages”, Journal of Nursing Scholarship, Vol 31(4), pp339-345, 1999.

2.      Beutel M, Deckardt R, von Rad M, Weiner H, “Grief and Depression after miscarriage: their separation, antecedents and course”, Psychosomatic Medicine, Vol 57(6), pp517-526, 1995.

COPING AFTER A MISCARRIAGE

A recent press release by researchers at the University of Michigan Health System confirmed an interesting fact: online forums can help women cope with pregnancy loss.

They surveyed over 1000 women on 18 different message boards and came to the conclusion that an important tool in dealing effectively with the loss is talking to someone who knows what you’re going through. A lot of family and friends are unwilling to talk about such matters: miscarriage, stillbirth and so on. It is an uncomfortable subject and many times, they do not understand the need to talk about it.

I personally know that the online forum specifically for women who had experienced a miscarriage on www.babycentre.co.uk was a lifeline for me. These women knew exactly how I felt and there was an abundance of cyber hugs and positive thoughts given and received freely between complete strangers united by loss.

In one of my posts, I shared Sarah’s story and she remembered that the first time she really felt like everything was going to be okay was when she was able to talk to a complete stranger that had also suffered a loss.

An interesting finding in this study was that the African-American population was significantly under-represented on these message boards even though they were statistically more likely to experience miscarriages and stillbirths than their Caucasian counterparts. I cannot assume to know why this is so but I am under the impression that in Africa, an online message board may also not work, even though there is internet access.

The key take home message for me is this: after a pregnancy loss, a woman will cope much better if she is able to talk to someone that understands what she is going through and is willing to talk about it with empathy and sensitivity.

SOURCE

Mary Elizabeth Dallas, “Online forums can help women cope with pregnancy loss”, November 4, 2011. Accessed from http://www.nlm.nih.gov/medlineplus/news/fullstory_118355.html  on November 22^nd 2011

SARAH’S STORY

Sarah* was basking in post-wedding euphoria. The excitement of finally marrying the man she loved had been heightened by her discovery that she was already pregnant with their first child. They were off to their honeymoon and life seemed perfect.

One morning, three days into the honeymoon, she woke up with a strange feeling. “I just felt kind of empty”, she later shared, “I wasn’t feeling pain, I wasn’t having any pain, I just felt alone”.

This feeling was really strange to her. It was as if the baby inside of her had left her. She was terrified and asked her husband to book an ultrasound scan appointment as soon as possible.

She was booked in for a 3-D ultrasound scan. She could see all the features of the baby on the scan but the doctor performing the scan simply informed her that no foetal heart rate could be detected. She was looking closely at the face on the screen as she tried to digest the news; the baby looked just like her husband. How could there be no heart beat? How could this pregnancy be over?

“I just started screaming when I found out”, said Sarah. “I couldn’t hold it in anymore. Two nurses had to come in to the room to talk to me; but I couldn’t comprehend anything they said because I was just too hurt”.

“It was horrible! I was utterly devastated”, Sarah shared, and “it was just awful. I wouldn’t wish it on my worst enemy. I told them to just put me to sleep and do the procedure; I didn’t want to know what was happening. So I just woke up and it was done”.

This was the beginning of a very difficult time for Sarah. She had expected a period of bliss as she adapted to married life and prepared for motherhood. Instead, she was struggling with devastating feelings of grief. Feelings that she wasn’t prepared for; feelings she could not handle.

“My family helped me to pull through because I was just shattered. It was really, really hard; really trying times”.

Sarah remembers the day that a tiny spark of hope was rekindled in her heart. Her husband had suggested that she indulge in some retail therapy and while they were out she met a lady in the changing room. This lady was heavily pregnant and she struck up a conversation with her.

It turns out that this lady had experienced a late miscarriage at twenty weeks. Talking to someone who had been through this experience did something to Sarah.

“I finally saw someone who had been through what I went through. Here she was, with child and positive about the future, telling me how things would be okay.”

For Sarah, it was like group therapy in the changing rooms. All the soothing, placatory words the nurses had said to her that fateful day, the words that did not make any sense to her at the time, finally made sense. Sarah finally realised that there was hope. By hearing the story of another woman, she no longer felt so alone in her experience. And that gave her the strength to carry on.

As of the time I spoke to Sarah, she has gone on to have two healthy children. However, “there is no day that goes by that I don’t pray for him or her and hope that one day we will meet again someday”.

*not her real name.

BED REST AND PREVENTION OF MISCARRIAGE

When I got pregnant again after my miscarriage, I suffered threatened miscarriage. The advice I received from my doctor in Nigeria was to go on bed rest till I was well into my second trimester. In fact I was on strict bed rest till I was at least 16weeks gestation.

A Cochrane review published in 2008 questions the effectiveness of bed rest, so widely prescribed as a preventive measure in cases of threatened miscarriage or past history of miscarriage. This is because bed rest suggests that hard work and exertion are causative factors in miscarriage. I personally know, from my research on the topic of miscarriage that this has not been objectively proven.

In arguing against bed rest, the reviewers state that it may do more harm than good, increasing the likelihood of thromboembolic events (pregnancy already predisposes to formation of blood clots and staying stationary may worsen matters). They also argue that enforcing bed rest might be very stressful for the woman and her family (if she has other children or responsibilities that require her to be active) and may result in self blame if the pregnancy does progress to a miscarriage as she may feel she did not comply properly with instructions and hence caused her loss; in fact, it may have been inevitable with or without bed rest.

Based on their inclusion and exclusion criteria, they had two studies to review. These two studies randomly allocated women to either bed rest at home versus bed rest in hospital +/- medication versus no bed rest. These women did not have a history of recurrent miscarriage (i.e. three or more consecutive miscarriages) and had experienced vaginal bleeding between 7 and 16 weeks gestation.

There was no significant difference in miscarriage outcomes in all the groups.

For a difference to be statistically significant the study should be able to prove that the observed differences between the two groups could not be due to chance alone but due to a specific benefit. This was not proven.

As discussed in previous posts, there is research already in progress to identify objective markers that can predict the outcome of a pregnancy with threatened miscarriage. If more research is conducted to build on this, medical practitioners will be better equipped to manage this condition in a manner that is unequivocally effective, based on specific information  on which to base prognosis. This would definitely make us more effective and make the woman and her family less stressed.

SOURCE

Aleman A, Althabe F, Belizan JM, Bergel E, Bed rest during pregnancy for preventing miscarriage, Cochrane database of systematic reviews 2005, Issue 2, Art.No.CD003576.

THERE IS A STRONG BOND, NO MATTER HOW EARLY

Studies have confirmed that even at a gestational age of eight weeks, a strong connection already exists between a woman and her unborn baby. This is why your sensitivity to her loss, no matter the stage of the pregnancy, is essential. Healthcare professionals need to appreciate that a miscarriage is a real loss and, in most cases, the woman already feels love for and a bond with the baby being lost.

To further buttress this point, I want to share excerpts of my dairy written in the early weeks of my first pregnancy before it ended in miscarriage during the 9^th week of gestation. These are my personal thoughts and feelings, written at the time as letters to my unborn child, shared for the very first time.

·        At 5⁺⁶ weeks: “I’m so excited...it’s been a roller coaster ride of symptoms all week, but to be honest, I’m loving it!

·        At 6⁺¹ weeks: “I’ll be happy when we can feel you; even happier when we can hold you in our arms”

·        At 6⁺³ weeks: “Tried...stuffing a sweater in my trousers to see what I’d look like with a bump. The sweater looked silly (lol)”

·        At 7⁺⁴ weeks: “I think about you so much...you’re all I ever think of nowadays...I love you babe”.

·        At 8⁺³ weeks: “How are you feeling in there?...I love you babe”.

·        At 9⁺¹ weeks: “I’ve booked an appointment for my first scan...Woohoo!!! What a great time to be alive, in love and expecting a baby...I’ll be seeing you in a week’s time. Stay healthy, perfect, beautiful”

·        At 9⁺⁴ weeks: “This is the day that the pregnancy ended...I feel robbed, cheated, completely devastated...I don’t know why I can’t have you...I grieve for you and for my dreams that died with you”.

PREDICTING THE OUTCOME OF THREATENED MISCARRIAGE (2)

THE STUDY

It was a prospective longitudinal study. Women were recruited at 6-10 weeks gestational age, presenting with vaginal bleeding in the presence of a sonographically viable intra-uterine pregnancy. They were seen weekly for five weeks. At each visit, they completed a Visual Analogue Scale of pain and bleeding intensity scores.

A visual analogue scale is a measurement instrument used to assess how a patient scores their medical symptom across a scale from mild to severe; it is used to assess their perception of the symptom. Being unique to each respondent, it cannot be used to compare between subjects but it can be used to compare the patient’s responses at different times.

At the end of the 5 weeks, an ultrasound scan was used to assess the outcomes of the pregnancies.

Primary outcome – identify biomarkers with significant relationships to pregnancy outcome.

Secondary outcome – derive a Pregnancy Viability Index (PVI) this would be a measure of the likelihood of the pregnancy succeeding. 

Tertiary outcome – assess the positive predictive value (PPV) and negative predictive value (NPV) of the derived PVI.

The predictive values of a test are determined by the sensitivity and specificity of the test and of the characteristics of the population being tested. So a test with very good sensitivity (able to detect those with the disease) and very good specificity (able to rule out those without disease) will have high positive and negative predictive values.

Of the 117 women recruited, 112 completed the study. Of these, 22 went on to pregnancy demise while 90 had their pregnancies continue. All miscarriages happened within 28days of presentation.

The following factors had significant Odds Ratios (i.e. the odds that these factors featured highly in those that miscarried versus those that did not miscarry were statistically significant): History of subfertility (difficulty conceiving), the baseline bleeding score (as rated by the patients on the scale), the baseline crown-rump length (on ultrasound scan), baseline Progesterone and baseline hCG levels. 

Factors that did not have significant Odds Ratio included previous pregnancy termination, Hb level and number of previous pregnancies.

Following further statistical analysis, the two factors that retained significance were the baseline bleeding score (BS) and the serum hCG.

They derived a PVI = hCG/BS × 1.87 ×10 and a high PVI meant a resulting miscarriage.

The PPV of the PVI was 94% and the NPV was 77%.

Of course, more research with a larger number of participants is needed to trial this score and even maybe practical testing in the clinics with resulting case reports may help to prove if this index is useful. But imagine how much easier life would be if we could tell on time which women with bleeding in the first trimester would simply need reassurance or would need early targeted counselling.

REFERENCE

Adam K, Developing a robust model for predicting the outcome of pregnancies complicated by threatened miscarriage in the first trimester of pregnancy. Session 34, ESHRE Stockholm,  July 2011.

PREDICTING THE OUTCOME OF THREATENED MISCARRIAGE (1)

 Threatened miscarriage is a common problem that presents in early pregnancy. This clinical presentation usually results in a lot of different advice, investigations and interventions. However, more often than not, the only thing we as healthcare professionals are able to do is “wait and see”.

The results of a study were recently presented at the 2011 European Society of Human Reproduction and Embryology at Stockholm. It had been conducted in St. Mary’s Hospital in Manchester, United Kingdom. Its findings are quite exciting and could make management of threatened miscarriage even easier.

Below is my summary of the presentation; it will be in two parts.

INTRODUCTION

There are two types of pregnancy loss and the prevalence of each is as follows:

·        Early pregnancy loss (loss before the woman even knew she was pregnant) – 11-27%

·         Clinical pregnancy loss (loss after pregnancy has been confirmed with an ultrasound scan) – 7.9-15%

It is very difficult to estimate the prevalence of threatened miscarriage as most are unreported. Observational studies have reported prevalence of 5.5-16.4% with institutional records reporting prevalence of as high as 20% of clinical pregnancies.

Off all pregnancies complicated by threatened miscarriage

3.4-20% result in pregnancy demise

while 71-95% of pregnancies continue

This shows that, more often than not, a pregnancy complicated by a threatened miscarriage will still continue to term.

Being able to predict which ones of the pregnancies complicated by threatened miscarriage will actually result in pregnancy demise will enable the following:

1.  Targeted counselling of women at risk of pregnancy demise with reassurance of those not at risk.
2. Reduction of unnecessary investigations into women who are already distressed by the symptoms.
3. Avoidance of harmful interventions (especially if one can predict that the pregnancy will continue in spite of the symptoms).
4.  Research into potential interventions to rescue at risk pregnancies.

Now that your appetite has been whetted, tune in for the details of the study and the results in the next blog post.

WHY SHOULD I BOTHER ABOUT THE EFFECTS OF MISCARRIAGE?

Miscarriage, the emotional response to it and the mental health risks following it are significant. But are they important?

One of the Millennium Development Goals (MDGs) is to improve maternal health. A lot of health ministers in the developing world seem to have interpreted this to be: to reduce maternal deaths. Of course, this is important but maternal health has to be more than surviving; the mother should be thriving. This focus of governments and NGOs on mortality ignores other health issues related to reproduction that cause significant distress in women’s lives¹.

First trimester miscarriage is classed under gynaecology. In general, there is a “culture of silence”¹ which prevents women from seeking healthcare for gynaecologic conditions.  Interestingly, there is no disease burden attached to miscarriage; it is not identifiable within the Global Burden of Disease. 
Women need the health services to respond to their perceived needs². After a miscarriage, they need their doctors and nurses to be a source of support to them. I confirmed this in the research I conducted among women in Lagos, Nigeria.

Fertility levels are very high in Nigeria, more than twice the accepted rate for population maintenance (accepted rate = 2, Nigeria = 5.2 according to UNICEF). If at least 15% of all recognised pregnancies result in miscarriage, then miscarriage is an even bigger problem in Nigeria than in the developed world.

Depression is chronically disabling³ and the WHO estimates that mental health disorders are the leading cause of poor health and disability globally⁴. Mental health, however, is another health issue with an “appalling lack of interest” from governments and NGOs⁴; this stigma makes it impossible to generate appropriate attention and support. All this is despite the fact that mental health disorders are very important to public health³.

Mental health affects progress towards achievement of the MDGs particularly the empowerment of women and improvement of maternal health³. The mental distress suffered as a result of a miscarriage needs to be widely appreciated in healthcare circles.

It is pertinent that the combined effects of stigmatised mental health and pregnancy loss do  not defeat the efforts of public health and maternal health advocates to arrest their effects on women’s lives. Dealing with mental health issues after a miscarriage and incorporating psychosocial support into antenatal care may seem like a waste of valuable resources (time, money and staff) but “there is no health without mental health”³.

REFERENCES

1.            Stones RW, Matthews Z, Gynaecological disease in developing countries: whose burden? Opportunity and Choices Working Paper, Reproductive Health Research, University of Southampton.
2.       Filipi Z, Ronsmanns C, Campbell OMR, Graham WJ, Mills A, Borghi J, Koblinsky M, Osrin D, Maternal Health in poor countries: the broader context and a call for action. The Lancet (published online) DOI:10.1016/S0140-6736(06)69384-7. September 28, 2006.
3.       Prine M, Patel V, Saxena S, Maj M, Maselko J, Phillips M, Rahman A, No health without mental health. The Lancet 370 (9590) pp859-877, 2007.
4.       Chambers A, Mental illness and the developing world, www.guardian.co.uk, Monday May 10, 2010. Accessed on September 17, 2011.

RECOVERY FROM MISCARRIAGE

Most women are stable enough to be discharged within a few hours of treatment for the miscarriage. The patient may bleed for up to two weeks and her menstrual period will return within four to six weeks.

Although a woman physically recovers from a miscarriage quickly, psychological recovery in general may take a long time. Miscarriage is a heart wrenching loss and emotions may range from anger to despair. How short a time the foetus lived in the womb may not matter for the feeling of loss. Reports include being overwhelmed with crushing, breath-taking grief and still others feel that they may be suffering punishment for something they did wrong or that they have failed as women. It has been determined that 7% of women four months after a miscarriage will have Post-Traumatic Stress Disorder and women who had a miscarriage were 2.5 times more likely than controls to develop a Major Depressive Disorder.

Apart from depression and anxiety, a study conducted in Norway compared the guilt felt by women who have an induced abortion with the guilt felt by women after a miscarriage. When confounding variables were taken into account there was no statistically significant difference between the two groups on the index of guilt/shame. This would give insight into the perception women have about themselves and their perceived roles where the termination of a pregnancy, whether planned or spontaneous, still results in feelings of guilt and shame.

Miscarriage therefore results in a myriad of emotions. However, frequently mismatches occur between how a miscarriage is experienced and how people think it ought to be experienced. Hence the actual emotional experience of the loss comes as a rude shock to the woman.

The biggest challenge facing women after a loss is the response or lack of response from others. Members of her healthcare team and of her social circle usually tend to avoid discussing the issue of the miscarriage. This may be because the subject is too painful or the people do not know what to say or are afraid of saying the wrong thing. However, the parents suffering this loss need to feel validated in their grief; they need to know that their babies, feelings and losses are real. For women, depression is one of the most common mental health problems they face when changes and losses become too difficult to bear. This makes a prompt and effective response by the healthcare provider essential as a preventive measure. The doctor should therefore consider a counselling session or at least an opportunity to discuss her feelings about the loss before discharge or at follow-up; this may facilitate healing.

SOURCES

1.       A. N. Broen, T. Moum, A. S. Bodtker and O. Ekeberg, “Psychological Impact of Miscarriage versus Induced Abortion: A 2-year Follow-up Study”, Journal of Psychosomatic Medicine 66:265-271, 2004.

2.       S. Dubovsky, “Predicting Severe Grief After Miscarriage”, Summary &Comment, Journal Watch Women’s Health, April 1^st 1997.

THE PERCEPTIVE PRACTITIONER

Clinical practice is constantly evolving and healthcare professionals are constantly finding themselves playing catch-up.

If you pride yourself on being the best you possibly can be, if you desire to deliver evidence-based and up-to-date clinical care, then you would have realised by now that there aren’t enough hours in the day to keep up with all you need to know and practice it as well.

Spontaneous miscarriage is the commonest medical complication of pregnancy and indeed the commonest medical complication in humans. Knowledge about all aspects of the management and healthcare of women after this event – physical, mental and social – is constantly evolving.

Empathy, by its very definition, requires the healthcare professional to be understanding and to be sensitive to the feelings and experiences of our patients, vicariously feeling what they feel without having actually felt it before. 

The questions that arise as a result include, "How do you empathise with a loss you have never felt before?" and "How do you provide holistic care when faced with a miscarriage?"

I hope, at least in this area of medicine, to be of great assistance to you. Evidence-based facts, news and advances in management, personal stories of miscarriage and pearls for practice will all be made available twice a month, every month.

I hope you will be able to find the time to read the posts. I hope you find this blog useful. I hope you tell others about it. I hope you will see the difference it will make to your practice.

Here’s to you: the perceptive practitioner.