Miscarriage and ectopic pregnancy may trigger long-term post-traumatic stress

Summary: Ectopic pregnancy and early miscarriage can trigger lasting PTSD in one in six women. A month after pregnancy loss, 29% of women reported PTSD symptoms. 24% of women suffered moderate to severe anxiety, and 11% of women reported moderate to severe depression. Following up after nine months, 18% reported continuing PTSD symptoms, 17% reported severe anxiety, and 6% of women said they still experienced severe depression as a result of the loss of pregnancy.

Source: Imperial College London

One in six women experience long-term post-traumatic stress following miscarriage or ectopic pregnancy.

This is the finding of the largest ever study into the psychological impact of early-stage pregnancy loss, from scientists at Imperial College London and KU Leuven in Belgium.

The research, published in the journal American Journal of Obstetrics and Gynaecology, studied over 650 women who had experienced an early pregnancy loss, of whom the majority had suffered an early miscarriage (defined as pregnancy loss before 12 weeks), or an ectopic pregnancy (where an embryo starts to grow outside the womb and is not viable).

The study revealed that one month following pregnancy loss, nearly a third of women (29 percent) suffered post-traumatic stress while one in four (24 percent) experienced moderate to severe anxiety, and one in ten (11 percent) had moderate to severe depression.

Nine months later, 18 percent of women had post-traumatic stress, 17 percent moderate to severe anxiety, and 6 percent had moderate to severe depression.

The team behind the research, funded by the Imperial Health Charity and the Imperial NIHR Biomedical Research Centre, call for immediate improvements in the care women receive following an early-stage pregnancy loss.

Professor Tom Bourne, lead author of the research from Tommy’s National Centre for Miscarriage Research at Imperial College London said: “Pregnancy loss affects up to one in two women, and for many women it will be the most traumatic event in their life. This research suggests the loss of a longed-for child can leave a lasting legacy, and result in a woman still suffering post-traumatic stress nearly a year after her pregnancy loss.”

Professor Bourne, who is also a Consultant Gynaecologist, added: “The treatment women receive following early pregnancy loss must change to reflect its psychological impact, and recent efforts to encourage people to talk more openly about this very common issue are a step in the right direction. Whilst general support and counselling will help many women, those with significant post-traumatic stress symptoms require specific treatment if they are going to recover fully. This is not widely available, and we need to consider screening women following an early pregnancy loss so we can identify those who most need help.”

The research follows an earlier pilot study in 2016, which investigated the psychological impact of early-stage pregnancy loss in 128 women one and three months after miscarriage or ectopic pregnancy.

One in four pregnancies ends in miscarriage — most often before or around 12 weeks. Estimates suggest there are 250,000 miscarriages every year in the UK, and around 11,000 emergency admissions for ectopic pregnancies. The latter always result in pregnancy loss, as an embryo grows in an area outside of the womb and is unable to develop.

In the study 537 women had suffered a miscarriage before 12 weeks of pregnancy, while 116 had suffered an ectopic pregnancy.

The women in the study attended the Early Pregnancy Assessment Units at three London hospitals — Queen Charlottes and Chelsea, St Mary’s, and Chelsea and Westminster.

All were asked to complete questionnaires about their emotions and behaviour one month after pregnancy loss, then again three and nine months later.

Their responses were compared to 171 women who had healthy pregnancies. The results revealed the latter women’s levels of psychological symptoms were significantly lower than those found in women who had suffered early pregnancy loss.

The women in the study who met the criteria for post-traumatic stress reported regularly re-experiencing the feelings associated with the pregnancy loss, and suffering intrusive or unwanted thoughts about their miscarriage. Some women also reported having nightmares or flashbacks, while others avoided anything that might remind them of their loss.

The authors caution the study used a questionnaire for screening for post-traumatic stress, but formal diagnosis of post-traumatic stress disorder would require a clinical interview.

The team also explain that women who were already experiencing symptoms of post-traumatic stress and depression may have been more likely to respond to the questionnaire, which could mean the number of women suffering psychological symptoms may appear higher.

However, they add that the fact that such a large proportion were experiencing symptoms suggests many women could be suffering in silence. Dr Jessica Farren, first author of the research from Imperial College, and Obstetrician and Gynaecologist, said: “Post-traumatic stress can have a toxic effect on all elements of a person’s life — affecting work, home and relationships.”

“We have made significant progress in recent years in breaking the silence around mental health issues in pregnancy and postnatally, but early pregnancy losses are still shrouded in secrecy, with very little acknowledgement of how distressing and profound an event they are. Many women don’t tell colleagues, friends or family they are pregnant before the 12-week scan, leaving them feeling unable to discuss their emotions if they suffer a pregnancy loss. We also know partners can suffer psychological distress following miscarriage or ectopic pregnancy, and are investigating this in ongoing research.”

The team’s research will also now focus on identifying which women are at risk of developing psychological symptoms after pregnancy loss, the impact of early pregnancy loss on partners and also the best type of treatments and how to deliver these.

Ian Lush, Chief Executive of Imperial Health Charity, said: “As the dedicated charity for the Imperial College Healthcare NHS Trust hospitals, we are committed to supporting pioneering research that leads to real improvements in patient care through our annual research fellowships programme. “Dr Farren’s study clearly shows that a miscarriage or ectopic pregnancy can have profound and long-lasting impacts on women’s mental health and we look forward to seeing how this important research can be translated into better care for patients and their families in the future.”

Jane Brewin, Chief Executive of Tommy’s comments, said: “For too long women have not received the care they need following a miscarriage and this research shows the scale of the problem. Miscarriage services need to be changed to ensure they are available to everyone, and women are followed up to assess their mental wellbeing with support being offered to those who need it, and advice is routinely given to prepare for a subsequent pregnancy.”

This shows a woman sitting in the dark
Their responses were compared to 171 women who had healthy pregnancies. The results revealed the latter women’s levels of psychological symptoms were significantly lower than those found in women who had suffered early pregnancy loss. Image is credited to Imperial College London.

Kate Rawson, an actor and playwright, experienced two miscarriages in 2014 and 2015, one at 8 weeks and one at 11 weeks. She has written a radio play about recurrent miscarriage called Little Blue Lines. Here she discusses her experience:

“After my first miscarriage I was numb. I did not know how to react or who to approach. I did not know if it was grief that I was feeling, or if that was even a valid response to have about losing something so ‘small’. So I tried to believe reassuring words (‘it’s not your fault; you can try again; you’ve got time; it’s just one of those things.’)

The second time it happened I knew something was wrong immediately, just a faint pink patch in my pants, a slight cramping feeling. Then dread and anxiety at what was to come, and guilt at what I could have done to cause it; sadness for myself, but also my husband, my family, my friends who would have to do all those sad faces and texts and calls again. The physical miscarriage was a huge shock, one I was absolutely not prepared for and I will never forget it.

I tried to ‘move on’ as advised. ‘Trying again’ was full of anxiety that got worse when I fell pregnant for the third time. Happily that resulted in a healthy full term birth, but the first trimester was extremely stressful, for both myself and my husband. I struggled to keep perspective and flitted between wanting this baby more than anything else to wishing I would just bleed and get the awful thing over with and my life back.

It was only after my son was born I realized the enormity of what I had been through, and the need to process it — there are support groups at my hospital now but there was nothing available to me at the time — so I wrote about it.”

[divider]About this neuroscience research article[/divider]

Source:
Imperial College London
Media Contacts:
Kate Wighton – Imperial College London
Image Source:
The image is credited to Imperial College London.

Original Research: Open access
“Post-traumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multi-center, prospective, cohort study”. Jessica Farren, Maria Jalmbrant, Nora Falconieri, Nicola Mitchell-Jones, Shabnam Bobdiwala, Maya AL-Memar, Sophie Tapp, Ben Van Calster, Laure Wynants, Dirk Timmerman, Tom Bournel.
American Journal of Obstetrics and Gynecology doi:10.1016/j.ajog.2019.10.102.

Abstract

Post-traumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multi-center, prospective, cohort study

Background
Early pregnancy losses are common, but their psychologic sequelae are often overlooked. Previous studies have established links between miscarriage and early symptoms of anxiety and depression. However, the incidence of posttraumatic stress symptoms and the psychologic response specifically to ectopic pregnancies have not been investigated.

Objective
The purpose of this study was to investigate levels of posttraumatic stress, depression, and anxiety in women in the 9 months after early pregnancy loss, with a focus on miscarriage and ectopic pregnancy. Morbidity at 1 month was compared with a control group in healthy pregnancy.

Study Design
This was a prospective cohort study. Consecutive women were recruited from the early pregnancy and antenatal clinics at 3 London hospitals and received emailed surveys that contained standardized psychologic assessments that included the Hospital Anxiety and Depression Scale and Posttraumatic stress Diagnostic Scale, at 1, 3, and 9 months after loss. Control subjects were assessed after a dating scan. We assessed the proportion of participants who met the screening criteria for posttraumatic stress and moderate/severe anxiety or depression. We used logistic regression to calculate adjusted odds ratios.

Results
Seven hundred thirty-seven of 1098 women (67%) with early pregnancy loss (including 537 miscarriages and 116 ectopic pregnancies) and 171 of 187 control subjects (91%) agreed to participate. Four hundred ninety-two of the women with losses (67%) completed the Hospital Anxiety and Depression Scale after 1 month; 426 women (58%) completed it after 3 months, and 338 women (46%) completed it after 9 months. Eighty-seven control subjects (51%) participated. Criteria for posttraumatic stress were met in 29% of women with early pregnancy loss after 1 month and in 18% after 9 months (odds ratio per month, 0.80; 95% confidence interval, 0.72–0.89). Moderate/severe anxiety was reported in 24% after 1 month and in 17% after 9 months (odds ratio per month, 0.69; 95% confidence interval, 0.50–0.94). Moderate/severe depression was reported in 11% of the women after 1 month and 6% of the women after 9 months (odds ratio per month, 0.87; 95% confidence interval, 0.53–1.44). After miscarriage, proportions after 9 months were 16% for posttraumatic stress, 17% for anxiety, and 5% for depression. Corresponding figures after ectopic pregnancy were 21%, 23%, and 11%, respectively. In contrast, among control women with viable pregnancies, 13% reported moderate-to-severe anxiety (odds ratio loss at 1 month vs controls: 2.14; 95% confidence interval, 1.14–4.36), and 2% reported moderate-to-severe depression (odds ratio loss at 1 month vs control subjects: 3.88; 95% confidence interval, 1.27–19.2).

Conclusion
Women experience high levels of posttraumatic stress, anxiety, and depression after early pregnancy loss. Distress declines over time but remains at clinically important levels at 9 months.

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