Teni Davoudian, PhD, ABPPClinical Psychologist Assistant Professor in Psychiatry & Ob/ GynNovember 15, 2019

Psychological Aftermaths of Pregnancy Loss

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Grief

• Grief has physical, emotional, spiritual, and social components

• Non-linear process

o States rather than stages of grief

• Anger is component of grief OHSU

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Pregnancy Loss Grief

• Facilitates bond with deceased as a coping strategy

• “Prospective” grieving for the life and relationship projected into the future (versus retrospective grieving)

• Peaks at 6 months

• Women also grieving:

o Loss of confidence in one’s body

o Loss of confidence in medicine

o Loss of control

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Grief vs. Major Depression

Grief Major Depression

Course Decreases over time

Waves of grief (triggered by

thoughts/reminders of the deceased)

Persistent depressed mood

Emotional

Spectrum

Normal to experience positive emotions and

laughter while grieving

Fluctuating ability to feel pleasure

Pervasive unhappiness

Misery

Cognitive

Processes

Thoughts and memories of deceased Self-critical thoughts

Negative ruminations

Self-Esteem Mostly preserved through grief process

Some concerns about “failing” the deceased

Lowered self-esteem

Self-loathing

Worthlessness

Suicidal Ideation If SI occurs, it is in the context of reuniting

with the deceased

Focused on ending one’s life

due to feelings of

worthlessness and perceived

inability to cope with

depression

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Comorbid Psych Dx

• Major Depressive Disorder o RPL: 5x more likely to develop moderate/severe depression (Kolte,

2015)

• Generalized anxiety disordero RPL: Increased severity of generalized anxiety (Fertl et al, 2009)

• PTSD (Englehard, 2004)

• Guilt, self-blame, and isolation (Bardos et al., 2015)

• No validated psych screenings specific to pregnancy loss

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Public Perceptions of Miscarriage

• Majority believe that miscarriage occurs <5% of pregnancies (Bardos et al., 2015)

• Believed causes of miscarriage:o 95% genetic abnormalities o 76% stressful evento 64% lifting heavy objecto 31% past abortion o 28% previous use of IUDo 21% getting into an argument

• Possible psychological results of misconceptions:o Feelings of isolation and guilt among women who experience

miscarriage(s)

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Public Perceptions of Miscarriage

• Emotional reactions of women with history of miscarriage(s): (Bardos et al., 2015)

o 47% felt guilty

o 41% reported that they had done something wrong

o 41% felt alone

o 28% felt ashamed

o 19% blamed self even when cause of miscarriage found

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Pregnancy Loss & Relationships

• Gap in literature regarding experiences of same-sex couples, transgender individuals, single parents by choice

• Discordant/incongruent grief among men and women in heterosexual relationships (Serrano & Lima, 2006)

• Sexuality following pregnancy loss: (Zhang et al., 2016)

o Women: lowered libidoo Men: decreased sexual satisfaction, increased erectile

dysfunction

• Higher risk of relationship dissolution for up to 3 years after loss (Gold, Sen, & Hayward, 2010)

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Other Stakeholders• Surviving sibling(s) grieve: (Calister, 2006)

o Loss of their expected sibling o Loss of the parents as they knew them prior to the loss

• Supporting grieving children: o Recognize and acknowledge the child’s grief o Read children’s books about death (Erlandsson et al., 2010)

o Allow children to witness some of parent’s grief (Erlandsson et al., 2010) OHSU

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IUFD & Stillbirth• Elevated anxiety and depression for 2 years following IUFD (Cacciatore et al., 2008)

• Higher risk of relationship dissolution for up to 9-10 years after IUFD (Gold, Sen, & Hayward, 2010)

• IUFD has no major impact on women’s QoL or risk of experiencing depression 18 years after loss (Gravensteen et al., 2012)

• Interventions that may mitigate long-term psychopathology: (Gravensteen et al., 2012)

o Postpartum consultation with the obstetrician or midwife o Meeting with a psychologist/psychiatristo Follow-up from PCP o Consultation with a religious counsellor

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Supporting Patients

• Following a loss, patients desire: (Evans, 2012; Koert et al., 2018; Munsters et al., 2011)

o Inclusion of partner in consultations and treatments

o Reliable and accurate information about miscarriages

o Attention to both physical and psychological aspects of miscarriage

o Access to psychological treatment

o Practical advice about lifestyle and diet

o Written information

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Supporting Patients

• Mimic patient’s vocabulary regarding fetus

• Ask open ended questions

• Depending on gestational age, inquire about patient’s intent or interest in memorializing the fetus

• If appropriate, remind patient that she is not to be blamed

o Women who receive reassurance from their providers following a loss report less guilt and self-blame (Corbett-Owen &

Kruger, 2001)

• Avoid comments that may trivialize the patient’s loss

• Who are you trying to comfort? The patient(s) or yourself?

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Patient Care Factors to Consider • Setting (Covington, 2009)

o Privacy? Patient dressed?

• Perception of patient(s)o Assess her/his/their understanding of the loss

• Invite emotional reactionso “Would you like to talk about how you’re feeling right now?”

• Provide plan for next steps o What happens next? Which medical providers will be there?

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Resources Books: • Conquering Infertility: Dr. Alice Domar's Mind/Body Guide to Enhancing Fertility

and Coping with Infertility By Alice Domar, PhD

• Not Broken: An Approachable Guide to Miscarriage and Recurrent Pregnancy LossBy Lora Shahine

• Loved Baby: 31 Devotions Helping You Grieve and Cherish Your Child after Pregnancy Loss

By Sarah Philpott, PhD

Support Groups:• Resolve Support Group• Brief Encounters

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References • Abboud, L., & Liamputtong, P. (2005). When pregnancy fails: coping strategies, support networks and

experiences with health care of ethnic women and their partners. Journal of Reproductive and Infant Psychology, 23(1), 3-18.

• Armstrong, D. (2001). Exploring fathers’ experiences of pregnancy after a prior perinatal loss. MCN: The American Journal of Maternal/Child Nursing, 26(3), 147-153.

• Bardos, J., Hercz, D., Friedenthal, J., Missmer, S. A., & Williams, Z. (2015). A national survey on public perceptions of miscarriage. Obstetrics and gynecology, 125(6), 1313.

• Cacciatore, J., Rådestad, I., & Frederik Frøen, J. (2008). Effects of contact with stillborn babies on maternal anxiety and depression. Birth, 35(4), 313-320.

• Callister, L. C. (2006). Perinatal loss: A family perspective. Journal of Perinatal andNeonatal Nursing, 20(3), 227-234.

• Corbet-Owen, C., & Kruger, L. M. (2001). The health system and emotional care: Validating the many meanings of spontaneous pregnancy loss. Families, Systems, & Health, 19(4), 411.

• Covington, S. N. (2009). Pregnancy Loss: A Protocol to Help Patients COPE. Topics in Obstetrics & Gynecology, 29(9), 1-7.

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References • Due, C., Chiarolli, S., & Riggs, D. W. (2017). The impact of pregnancy loss on men’s health and wellbeing: a systematic

review. BMC Pregnancy and Childbirth, 17(1), 380.

• Engelhard, I. M. (2004). Miscarriage as a traumatic event. Clinical obstetrics and gynecology, 47(3), 547-551.

• Erlandsson, K., Avelin, P., Saflund, K., Wredling, R., & Radestad, I. (2010). Siblings’ farewell to a stillborn sister or brother and parents’ support to their older children: a questionnaire study from the parents’ perspective. Journal of Child Health Care, 14(2), 151-160.

• Fertl, K. I., Bergner, A., Beyer, R., Klapp, B. F., & Rauchfuss, M. (2009). Levels and effects of different forms of anxiety during pregnancy after a prior miscarriage. European Journal of Obstetrics & Gynecology and Reproductive Biology, 142(1), 23-29.

• Gameiro, S., van den Belt-Dusebout, A. W., Bleiker, E., Braat, D., van Leeuwen, F. E., & Verhaak, C. M. (2014). Do children make you happier? Sustained child-wish and mental health in women 11–17 years after fertility treatment. Human Reproduction, 29(10), 2238-2246.

• Gissler, M., Hemminki, E., & Lonnqvist, J. (1996). Suicides after pregnancy in Finland, 1987–94: register linkage study. Bmj, 313(7070), 1431-1434.

• Gravensteen, I. K., Helgadottir, L. B., Jacobsen, E. M., Sandset, P. M., & Ekeberg, Ø. (2012). Long-term impact of intrauterine fetal death on quality of life and depression: a case–control study. BMC pregnancy and childbirth, 12(1), 43.

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References • Gold, K. J., Sen, A., & Hayward, R. A. (2010). Marriage and cohabitation outcomes after pregnancy loss. Pediatrics,

125(5), e1202-e1207.

• He, L., Wang, T., Xu, H., Chen, C., Liu, Z., Kang, X., & Zhao, A. (2019). Prevalence of depression and anxiety in women with recurrent pregnancy loss and the associated risk factors. Archives of gynecology and obstetrics, 1-6.

• Kersting, A., Dölemeyer, R., Steinig, J., Walter, F., Kroker, K., Baust, K., & Wagner, B. (2013). Brief internet-based intervention reduces posttraumatic stress and prolonged grief in parents after the loss of a child during pregnancy: a randomized controlled trial. Psychotherapy and Psychosomatics, 82(6), 372-381.

• Kolte, A. M., Olsen, L. R., Mikkelsen, E. M., Christiansen, O. B., & Nielsen, H. S. (2015). Depression and emotional stress is highly prevalent among women with recurrent pregnancy loss. Human Reproduction, 30(4), 777-782.

• Koert, E., Malling, G. M. H., Sylvest, R., Krog, M. C., Kolte, A. M., Schmidt, L., & Nielsen, H. S. (2018). Recurrent pregnancy loss: couples’ perspectives on their need for treatment, support and follow up. Human Reproduction, 34(2), 291-296.

• Lok, I. H., & Neugebauer, R. (2007). Psychological morbidity following miscarriage. Best Practice & Research Clinical Obstetrics & Gynaecology, 21(2), 229-247.

• Lok, I. H., Yip, A. S. K., Lee, D. T. S., Sahota, D., & Chung, T. K. H. (2010). A 1-year longitudinal study of psychological morbidity after miscarriage. Fertility and sterility, 93(6), 1966-1975.

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References • Magee, P. L., MacLeod, A. K., Tata, P., & Regan, L. (2003). Psychological distress in recurrent miscarriage: the role of

prospective thinking and role and goal investment. Journal of Reproductive and Infant Psychology, 21(1), 35-47.

• Musters, A. M., Taminiau-Bloem, E. F., van den Boogaard, E., van der Veen, F., & Goddijn, M. (2011). Supportive care for women with unexplained recurrent miscarriage: patients’ perspectives. Human reproduction, 26(4), 873-877.

• O'Leary, J. M., & Gaziano, C. (2011). Sibling grief after perinatal loss. Journal of Prenatal & Perinatal Psychology & Health, 25(3), 173.

• Ockhuijsen, H. D., Boivin, J., van den Hoogen, A., & Macklon, N. S. (2013). Coping after recurrent miscarriage: uncertainty and bracing for the worst. J Fam Plann Reprod Health Care, 39(4), 250-256.

• Purandare, N., Ryan, G., Ciprike, V., Trevisan, J., Sheehan, J., & Geary, M. (2012). Grieving after early pregnancy loss--a common reality.) Irish Medical Journal, 105.

• Saraiya M, Green CA, Berg CJ, Hopkins FW, Koonin LM, Atrash HK (1999) Spontaneous abortion – related deaths among women in the United States – 1981–1991. Obstet Gynecol 94:172–176

• Serrano, F., & Lima, M. L. (2006). Recurrent miscarriage: psychological and relational consequences for couples. Psychology and Psychotherapy: Theory, Research and Practice, 79(4), 585-594

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References • Turton, P., Badenhorst, W., Hughes, P., Ward, J., Riches, S., & White, S. (2006). Psychological impact of stillbirth on

fathers in the subsequent pregnancy and puerperium. The British Journal of Psychiatry, 188(2), 165-172

• Wilson, R. E. (2001). Parents’ support of their other children after a miscarriage or perinatal death. Early Human Development, 61(1), 55-65.

• Zhang, Y. X., Zhang, X. Q., Wang, Q. R., Yuan, Y. Q., Yang, J. G., Zhang, X. W., & Li, Q. (2016). Psychological burden, sexual satisfaction and erectile function in men whose partners experience recurrent pregnancy loss in China: a cross-sectional study. Reproductive health, 13(1), 73.OHSU

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