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.