MUCH ADO ABOUT NOTHING?

As part of my online searches to discover new information about pregnancy loss research, coping strategies and management I stumbled upon an interesting thread of comments.

This comments thread was in response to a news article in The Guardian online. The article was about a lady who, after suffering multiple losses, decided to organise across the United Kingdom different commemorative services where people could come to say goodbye to their unborn babies. An opportunity, if you may, to have a “funeral” for the pregnancy loss and hopefully leave with some form of closure.

What sparked the debate was someone wondering if services like this would just make too much about an issue no one used to talk about in the past. Women would have a miscarriage, be it early or late or even have a stillbirth and the healthcare team would just pretty much clean her up and send her home. It seemed that this person was pining for such simpler times when people did not talk so much about their feelings and go on and on about the babies they lost.

The responses to this comment ranged from vehement disapproval: “you have obviously never lost a pregnancy!” (It turns out the person commenting never had, go figure!) to guarded support: “some women do take it too far”.

I do think times have changed. I think that the inevitable consequence of a society where women have a voice is that women will speak. At a time when, in the Western part of the world at least, women are educated, enlightened and empowered, people have to deal with the fact that these women will highlight issues that are important to them.

I have written already about the disenfranchised grief of pregnancy loss and so it should come as no surprise that I wholeheartedly support the idea of an avenue that permits women (and those close to them) to grieve.

I grant that there is a danger (in some circles) to talk this issue of pregnancy loss to death but from personal experience and from talking to others who have gone through it as well, there is a more present danger (especially where I come from) of not talking about it enough.

If, in Nigeria and other parts of developing society, we aspire to “promote gender equality and empower women” (MDG-3), then we need to find out and talk about the issues that are important to women – not just avoiding death but coping with life.

RESPECTFUL MATERNITY CARE

The Miscarriage Support and Information Centre is part of the White Ribbon Alliance and our June Action of the month is focused on respectful maternity care.

In their power point presentation designed for healthcare workers, they make a very valid point, a point that I am particularly passionate about.

“The concept of ‘safe motherhood’ is usually restricted to physical safety, but safe motherhood is more than just the prevention of death and disability. It is respect for women’s basic human rights, including respect for women’s autonomy, dignity, feelings, choices, and preferences”.

When having to manage complications of pregnancy such as early or late miscarriage, healthcare workers are often driven by a need to do what they feel is best to prevent death and disability. However, in caring for a woman during such a traumatic time, it is important to work with her and not just “for her own good”. It is important that she understands what is going on and why. It is important, for example, to respect her wish to not undergo a surgical evacuation even though you may feel it is the best option.

In the survey I conducted in Lagos, Nigeria of the 25 women who had experienced a miscarriage, 21 remember being treated with sympathy and understanding by the hospital staff. However, only 14 women felt that medical professionals were not to blame for the pregnancy loss. Why the disparity?

I strongly believe that these 11 who did not excuse the healthcare workers involved in their care are the women who did not understand what was going on, were not consulted, had nothing explained to them and had no choice in how the miscarriage was handled. Hence, they believe something was not done right.

When asked, in the same survey, about attributes in their healthcare professionals that were very important, “includes you in the choice of treatment” was not ranked very high by these women respondents. However, “tells you all that is going on and why” was ranked very important with “explains in words you understand” ranked highest of all.

As 2015 draws closer and closer, it is very important that healthcare workers and policy makers recognise that when we go beyond preventing maternal deaths and work towards maternal healthcare that is respectful of women’s feelings, choices and dignity we will not only “improve maternal health” but we will also “promote gender equality and empower women”.

UNBORN

I found this lovely video online. It is a choreographed expression of a woman’s feelings of grief and loss after a miscarriage.
Even if interpretative dance is not your cup of tea, the dance is beautifully performed and the video is short and skilfully directed.
Check it out.
http://vimeo.com/36184574 

ANITA’S STORY

Anita* was expecting her first child and was excitedly looking forward to buying baby clothes and preparing for her baby’s arrival. As she approached the completion of 7months of pregnancy, she couldn’t shake the niggling doubt that everything was not right.
“I started noticing that my tummy is going down as if someone is pressing my tummy”, she shared with me. She shared this fear with her husband but later dismissed it as she reassured herself that she had never missed an antenatal appointment or defaulted on any of her medications.
She however decided to arrange for an ultrasound scan. But the 5th of April, the day she chose to go for the scan, would prove to be a life altering day in Anita’s life.
According to Anita, the lady performing the scan suddenly burst into tears. One can only imagine the trepidation that went through Anita as she witnessed this. “I started asking the woman, ‘what is the problem? Tell me, what is the problem’ cos me I don’t understand why she is crying”, Anita recalled. Without being given any information, she was sent to a different place for a repeat scan.
With mounting anxiety, Anita watched as the man performed the scan again. He looked very sad and she could sense the pity in his demeanour as he looked at her. Once again, Anita demanded that she be told what was going on. All he did was ask her to go back to her clinic with the results of the scan.
That was when the bombshell hit. She was simply informed, “Ah. The baby is dead in your womb o”. Anita was in shock and in her own words, started to lose hope. She burst into tears and could not even compose herself to send for her husband; the staff at the clinic had to do that for her.
What followed was a traumatic two weeks and four days as she stayed in hospital undergoing all sorts of procedures and medication in order to push out her baby. When I asked her how she coped, she simply explained, “I have to have strong heart to save my own life...cos if I should lose hope, I could have been a dead somebody now” (sic). She admitted that the shock of the loss was still a very real and constant feeling but she felt that she needed to fight for her life; so this survival instinct took over and helped her through that physically and emotionally harrowing sixteen days.
As at the time when we spoke, Anita was still coming to terms with the loss. The main question that plagued her was what could have caused her baby to die. That was all she wanted to know. Was it something she did? Was it something the health workers missed? Time and again, she would find herself thinking about it and wondering what could have gone so horribly wrong. But, whenever she found herself deep in thought, her husband would get cross with her and tell her to stop thinking about it.
So now, all Anita can do is wait for her body to heal and hope that she will get pregnant again and that when she does, she will end up with a baby. As for her emotional scars; only time will tell.

* not her real name.

BREAKING BAD NEWS

As a House Officer, while on call we had a lady rushed into theatre for an emergency CS due to foetal bradycardia diagnosed on the CTG (i.e. the heart rate of the baby was reading about 80bts/min when a normal heart rate for a baby in the womb should be between 110 to 160bts/min). It turns out that the CTG (an out-of-date model compared to what is used in UK and the developed world) had been picking up the mother’s pulse and we delivered a macerated foetus (i.e. the baby had been dead for a while and was already decomposing – sorry for the graphic details).
It was left to the consultant paediatrician to leave the theatre and tell the father how a baby would not be coming out and why (the mother was under general anaesthesia and so was unaware of what had occurred).
Different guidelines on the management of pregnancy loss suggest that the most senior member of the team should break the news to the woman/couple wherever possible.
However, this raises a question for more junior doctors on the frontline of care. If, for example, you are the Medical Officer on NYSC (national service in Nigeria) posting and you are the first and only person most patients would see, how do you effectively deliver bad news? What qualifies you to deliver bad news? Can empathy only be gained with experience? Is that why the more senior health professionals should deliver bad news? If yes, does this mean that we will inevitably bungle up the delivery of bad news until we learn how to do it properly?
Personally, I was always uncomfortable with miscarriage and pregnancy loss. I am ashamed to admit that when I went in to see the mother the next day on my House Officer ward round, I could not look her in the eye, I did not offer my condolences for her loss; I just said, “good morning” and checked her vital signs. It wasn’t till I had experienced a loss myself and conducted the survey that I realised how lonely and scary such an experience could be. Empathy can really go a long way to make a difference in such instances.
While preparing for my PLAB exams (in order to be registered with the General Medical Council in the UK), breaking bad news was one of the skills I had to learn. It is also a module in BMJ Learning for continuing professional development. This is a topic that was never discussed while I was in medical school in Nigeria.
I don’t claim to know the answers to the who, how, when or why of the delivery of bad news. But I know that no matter what level you are at as a medical student, doctor, nurse or midwife, “I’m so sorry for your loss” is easy to say: there’s no law against that.

THE DISENFRANCHISED GRIEF OF PREGNANCY LOSS

Disenfranchised grief is defined as grief that is not socially supported, either because the relationship with the person lost is not recognised, the loss itself is not recognised or the griever is not recognised1. In the case of pregnancy loss, it is usually that the loss is not recognised making it difficult to grieve properly.
Across sub-Saharan Africa, death is traditionally perceived as the process by which a person becomes an ancestor2. With pregnancy loss, there was no opportunity for the foetus to become a person, not to talk of an ancestor; this makes it very difficult for a typical woman or couple to come to terms with what exactly has been lost and how to mourn that loss.
The mourning practices of Nigerians in particular stem from a religious perspective, due to Nigeria’s triple heritage of Christianity, Islam and Traditional religions1. There is, however, no mourning practice for a pregnancy loss. A change to this should be considered as it has been reported that unacknowledged loss and a lack of grief rituals for the loss can challenge healing after pregnancy loss3.
In Nigeria, obituaries and memorials are used to celebrate a person’s life achievements and position in society2; it is an opportunity to list out all the family members that will miss that person. After a miscarriage, there are people that are affected by the loss, people who already loved this tiny foetus and were dreaming of the day the child would be born and the changes he/she would bring to their lives. But the very nature of first trimester loss is that there is a sense that one has lost someone so loved but has nothing to show for it; there is no actual visible person to mourn.
There is a need for an accepted approach to the process of dealing with a pregnancy loss. Without this, there is the risk that the accompanying grief, which goes unacknowledged, may be too much for the woman to bear, especially if she does not have the essential social support or the empowerment that comes from education to deal with it in her own way.

REFERENCES
1. Eyetsemitan F, “Cultural interpretation of dying and death in a Non-Western society: the case of Nigeria”, Online Readings in Psychology and Culture, Unit 14, Chapter 1. ©International Association for Cross-Cultural Psychology, 2002.
2. “Death, Mourning and Ancestors”, accessed from http://www.novelguide.com/a/discover/aes_01/aes_01_00107.html on 29/04/11
3. Douglas K I, Fox J R, “Tears of blood: understating and creatively intervening in the grief of miscarriage”, Compelling Counselling Interventions: VISTAS 2009, pp89-100, ©American Counselling Association, 2009.

THE HEALTHCARE PROFESSIONAL’S ROLE (2)

Positive contacts with health care professionals have an impact on how well these women can cope after the loss (7). The woman’s ability to experience wellbeing after a miscarriage is enhanced by her receiving care from a provider that is well informed about the common human responses to miscarriage (6). Even though first trimester miscarriage is under-researched and imperfectly understood (5), there is a lot the healthcare professional can do to maximise the health of his/her patient after a loss. This may be by simply recognising the uniqueness of each loss (3), even though the medical process is the same and the occurrence of miscarriage is very common. 

In addition to this, the health care professional needs to recognise that, to his/her patient, that miscarriage is more than simply a medical event and deliberately avoid the tendency to “medicalise” (and by so doing trivialise) her loss (5). Where the health care professional does not trust in his/her ability to offer appropriate counselling, by being observant enough to identify those who may need a referral, he/she will be delivering quality healthcare.

It is a well known fact that early miscarriage is a distressing experience (2) (4), involving a major disturbance of self-identity (5). Psychological reactions to stressful events can result in physiologic effects (8); the actual miscarriage could be a straightforward process with no risk of complications that may pose a source of concern to the health care professional, but the way the woman perceives and responds to the miscarriage may be dangerous to her health. Therefore, the manner in which the health care is provided in the aftermath has the power to influence her response to the health care system (7).

Most women know little about miscarriage until they experience it and the occurrence of miscarriage is usually shrouded in secrecy (5). Those entrusted with their care should know enough to empower these women (and their partners) to successfully navigate the journey of healing in order to maximise their health. 

REFERENCES

1.      Ekwegh U. Women and miscarriage: knowledge, attitudes and needs. Printed by the Miscarriage Support and Information Centre. 2008.

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

3.       Douglas K I, Fox J R. Tears of blood: Understanding and creatively intervening in the grief of miscarriage. In Bleuer J C, Yep R K, Walz G R. (Eds) Compelling Counselling Interventions. Alexandria, VA, VISTAS: American Counselling Association, 2009.

4.       Swanson K M, Karmali Z A, Powell S, Pulvermakher F. Miscarriage effects on couples' interpersonal and sexual relationships during hte first year after loss: women's perceptions. Psychosomatic Medicine, Vol. 65, pp902-910, 2003.

5.       Frost J, Bradley H, Levitas R, Smith L, Garcia J. The loss of possibility: scientisation of death and the special case of early miscarriage. Sociology of Health and Illness, Vol. 297, pp 1003-1022, 2007.

6.       Swanson K. Effects of caring, measurement, and time on miscarriage impact and women's well-being . Nursing Research, Vol. 48 (6) pp288-298, 1999.

7.       Abboud L, Liamputtong P. When pregnancy fails: coping strategies, support networks and experiences with health care of ethnic women and their partners. Journal of Reproductive and Infant Psychology,  Vol. 23(1) pp. 3-18, 2005.

THE TRIPLE-R MODEL: ROLE (1)

It is obvious that I believe it is our role, as healthcare practitioners, to identify the risk and resilience factors in our patients that present with a miscarriage. However, our role as healthcare professionals is not simply to identify those at high or low risk of a significant negative response to the miscarriage. In my study of women in Nigeria who had experienced a miscarriage, the doctors and nurses were identified as their second most important source of support, second only to their spouses (1). 

In order to identify the type of support required the healthcare professional needs to be able to distinguish between a normal grief reaction and a pathological reaction to the miscarriage. This can only be achieved if the woman is allowed to talk about the loss and her feelings about it. Essentially, a grief reaction will manifest as a preoccupation with and longing for what was lost plus painful recollections and reminders in everyday life (2) (3). A depressive reaction will manifest as symptoms in the woman: irritability, restlessness, lack of concentration, sleep disturbances and so forth (2); in other words, a preoccupation with herself.

Women will, more often than not, welcome any opportunity to discuss their loss (4). However, there are some that may find it difficult to do so, due to feelings of guilt and shame (5). It is therefore very helpful if the health care professional creates an opportunity for the woman to discuss the miscarriage and what it meant to her. Following a miscarriage, women may have a strong desire for recognition and validation of the loss, particularly from their health care providers, who can help them to explore the meanings of the miscarriage (3). 

It has been confirmed by empirical research that women who receive counselling sessions, which were simply sessions where the women talked about the whole experience of the miscarriage, were more likely to show a decline in overall emotional disturbance (6).

...To be continued

THE TRIPLE-R MODEL: RESILIENCE

Just as there are red flags that suggest that a woman may find it difficult to cope after the experience of a pregnancy loss, there are encouraging aspects of her history that can foster healing, both physically and emotionally, after the loss.

·         Spousal/Social Support: it has been established that the support of the spouse, family and friends is a vital coping strategy. It is important to the woman to have her loss recognised and validated, to have a listening ear when she needs to talk and to have practical help (with chores for example) (1). When one considers that it is the cumulative impact of everyday hassles related to dealing with the loss that may have a detrimental effect on her health (2), it becomes apparent that at such a time, a woman who possesses a strong and supportive social network will fare much better than one who does not.

·         Hardiness: this is an attitude and an approach to life that can be protective in times of stress such as a miscarriage. A woman with hardiness would view the miscarriage as a challenge and an opportunity for personal growth with a strong belief in her ability to overcome this adversity and continue to enjoy a good life (2). She believes that everything happens for a reason and works out what it is. This may be due to the coping repertoire that she may have developed as a result of prior life experiences. Past life experiences can equip the woman with the emotional strength she needs to reach a state of resolution and healing after the miscarriage (3).

·         Spirituality: after a miscarriage, there is a struggle on the part of the woman to make sense of what often has been an inexplicable train of events (4). So she may seek spiritual guidance in order to make meaning of the miscarriage on a spiritual level so she can attach value to what happened (5). The complex narrative she develops in order to give religious meaning to her experience is an effort to draw positives out of a negative experience (4) and as she turns the loss over to God (5), there is a strength and peace that may follow, which overrides scientific explanation.

These factors protect against the impact of the stress of pregnancy loss and can be identified from a well-focused family and social history.

REFERENCES

1.       Abboud L, Liamputtong P. When pregnancy fails: coping strategies, support networks and experiences with health care of ethnic women and their partners. Journal of Reproductive and Infant Psychology,  Vol. 23(1) pp. 3-18, 2005.

2.       Gross R, Rolls G. Biological Psychology: Stress. In AQA (A) Psychology for AS. London, Hodder Education, Hachette UK, 2008.

3.       Swanson K M, Connor S, Jolley S N, Pettinato M, Wang T. Contexts and Evolution of Women's responses to miscarriage during the first year after loss. Research in Nursing and Health, Vol. 30. pp2-16, 2007.

4.       Frost J, Bradley H, Levitas R, Smith L, Garcia J. The loss of possibility: scientisation of death and the special case of early miscarriage. Sociology of Health and Illness, Vol. 297, pp 1003-1022, 2007.

5.       Douglas K I, Fox J R. Tears of blood: Understanding and creatively intervening in the grief of miscarriage. In Bleuer J C, Yep R K, Walz G R. (Eds) Compelling Counselling Interventions. Alexandria, VA, VISTAS: American Counselling Association, 2009.

THE TRIPLE –R MODEL: RISK

I had mentioned in an earlier post that I had developed a model based on existing evidence that may help to predict how well a woman will deal with the effects of a pregnancy loss. The following are risk factors that have been identified that may influence one’s ability to cope.

·         Nature of spousal support and/or social support: the receipt of poor social support is a very strong predictor for low emotional strength, intense emotional feelings and high risk of depression in the woman (1). A study also found that dissatisfaction with the spouse’s caring after a miscarriage was significantly raised in women who had a depression reaction to the miscarriage as opposed to those who simply had a grief reaction (2).

Simply put, the husband is vital to the woman’s healing  and grieving process.

·         Pre-existing vulnerability to anxiety/depression: The physical manifestation of a miscarriage usually causes anxiety during and after the event (3) and women who have miscarried have an increased risk of anxiety and depression that could last for years compared to women who never miscarried (4). A past history of depression could trigger a depressive reaction to the miscarriage (2). Some women may also possess a temperamental vulnerability to anxiety (5) and this may make her more prone to an anxiety response to the loss. The tendency to go beyond the normal grief response to a miscarriage and exhibit a pathological inability to cope and/or a state of despair is exacerbated by poor social support (2).

Simply put, if the woman is naturally anxious and easily worried or has suffered depression in the past, she is more likely to find it more difficult to cope after the pregnancy loss

·         Gestational age at the time of the loss: As early as 10weeks gestation, there is a real emotional connection to the pregnancy (2). When the gestational age is less than 20weeks, then the age of the foetus at the time of the loss does not make a difference in the strength or the duration of the grief, anxiety or depression (4). For pregnancies older than 20weeks, there is a longer grieving duration and a greater chance of depression, impacting negatively on close relationships (1) (4).

Simply put, a loss at 10weeks can be just as painful as a loss at 16weeks but a loss at 20+ weeks is potentially more devastating.

REFERENCES

1.       Swanson K M, Karmali Z A, Powell S, Pulvermakher F. Miscarriage effects on couples' interpersonal and sexual relationships during hte first year after loss: women's perceptions. Psychosomatic Medicine, Vol. 65, pp902-910, 2003.

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

3.       Swanson K M, Connor S, Jolley S N, Pettinato M, Wang T. Contexts and Evolution of Women's responses to miscarriage during the first year after loss. Research in Nursing and Health, Vol. 30. pp2-16, 2007.

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

5.       S, Rachman. Anxiety. UK : Psychology Press Ltd, 2004.

MY MISCARRIAGE EXPERIENCE

Even now, after I have had successful pregnancies and healthy children, I can still go back to that day in March 2007 (when I had the miscarriage).
I can still remember: 

• The fear, the heart-sinking, gut-wrenching fear I felt when I first saw the fresh blood stain. 
• The panic, the heart-breaking panic that came over me when, about 15 hours later, I could feel contractions as my body prepared to expel my baby. 
• The sense of despair that completely weakened me physically as I was examined in the hospital.
• The grief of losing someone that I loved so much but was never going to meet (that is a kind of grief that is very difficult to explain).

That was a dark time in my life and remembering it still has the power to bring tears to my eyes. The miscarriage changed me forever; I will never forget the events and the emotions of that experience. And I hope, the next time you see someone going through a pregnancy loss, you will remember my story and be a little more compassionate with her.

THE TRIPLE-R MODEL

This is a model I developed to explain the factors that influence the response of a woman to miscarriage.

A miscarriage could hardly be described as a life-threatening condition but its effects on the woman, both physically and emotionally, are significant (1). This significance of the miscarriage experience on her mental health and emotional wellbeing is unique to the woman: miscarriage, though very common is extremely personal. The women differ in needs and expectations as well as their actual experience of the miscarriage (2).

A woman’s appraisal of her miscarriage is typically in terms of what being pregnant meant to her and what was at stake for her in losing the pregnancy (3) (4). The attribution of meaning to the pregnancy may be responsible for observed clinically significant negative reactions to miscarriage. Reports exist of up to 51% of women developing clinical depression after a miscarriage with a minimum of 22% developing clinically significant levels of depression and/or anxiety (5). It is also understood whatever meaning is attributed to the miscarriage affects the woman’s view of medical care received (versus medical care desired) in the course of the miscarriage experience (3). 

There are strict, established and concise guidelines on the management of the medical features of a miscarriage but little guidance is offered as to how health care professionals are to manage the psychological or social aspects of this loss (6). Gynaecologists and midwives may not be familiar with the diagnosis or management of depression (5). It is therefore pertinent that comprehensible insight into the factors that surround clinically significant mental and emotional responses to a miscarriage is made available.

The Triple-R Model is simply an academic discourse of the evidence already in existence about the factors that influence the grief response to a miscarriage, either by attenuating it or by aggravating it. The three R’s stand for the factors that may pose a Risk, the factors that provide Resilience and the Role of the health care professional in caring for the woman/couple after a miscarriage.

In other words, Risk+ Resilience+ Role àResponse

By expanding on these factors, a clear picture of the role of the health care professional in the management of the woman’s response to the miscarriage will emerge.

REFERENCES

1. Abboud L, Liamputtong P. When pregnancy fails: coping strategies, support networks and experiences with health care of ethnic women and their partners. Journal of Reproductive and Infant Psychology,  Vol. 23(1) pp. 3-18, 2005.

2. Smith L, Frost J, Levitas R, Garcia J. Women's experiences of three early miscarriage options a qualitative study. British Journal of General Practice, Vol. 56(524) pp198-205, 2006.

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

4. Swanson K M, Karmali Z A, Powell S, Pulvermakher F. Miscarriage effects on couples' interpersonal and sexual relationships during hte first year after loss: women's perceptions. Psychosomatic Medicine, Vol. 65, pp902-910, 2003.

5. Lee D T S, Wong C K, Ungvari G S, Cheung L P, Haines C J, Chung T K H. Screening psychiatric morbidity after miscarriage: application of the 30-item General Health Questionnaire and the Edingburgh Postnatal Depression Scale. Psychosomatic Medicine, Vol. 59(2) pp207-210, 1997.

6. Frost J, Bradley H, Levitas R, Smith L, Garcia J. The loss of possibility: scientisation of death and the special case of early miscarriage. Sociology of Health and Illness, Vol. 297, pp 1003-1022, 2007.

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.