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PTSD symptoms experienced by 1 in 6 women suffering miscarriage or ectopic pregnancy

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One in six women who experience an early miscarriage or ectopic pregnancy have symptoms of post-traumatic stress disorder nine months later, says a New Scientist report. As people can experience the symptoms of PTSD for months, it is important that women are able to access psychological support should they need it, say the researchers behind the work.

It is estimated that women have more miscarriages than live births over their lifetime. But the psychological effects are often “brushed under the carpet”, says Jessica Farren, an obstetrician and gynaecologist at St Marys Hospital in London. Women often don’t tell their friends, family and colleagues that they are pregnant until they have had their 12-week scan. If that scan reveals a miscarriage, they may feel unable to tell people, so miss out on support, says Farren.

She and her colleagues asked 737 women who experienced a miscarriage during the first 12 weeks of pregnancy or an ectopic pregnancy – in which the embryo attaches outside of the uterus, causing pregnancy loss – to fill out mental health questionnaires designed to diagnose anxiety, depression and post-traumatic stress disorder. The questionnaires were sent to the women one month after their pregnancy losses, and then again three and nine months after the losses.

Nine months after experiencing a pregnancy loss, 18% of women met the criteria for a PTSD diagnosis, 17% of women reported anxiety and 6% of women had symptoms of moderate to severe depression. The figures are “terrifyingly high”, says Farren. “We have a problem on our hands that we haven’t up until now properly acknowledged or looked to treat.”

That was the experience of Samantha* who had an early miscarriage last year. “Initially it was like a bereavement,” she says. “(My husband and I) both felt very connected to that baby and still do. I felt loss, emptiness, scared that I might not be able to have another child (but in some ways relieved that we’d been able to get pregnan). We both had and still have moments where it hurts.”

Samantha remembers hospital staff mentioning counselling, “but at the time, when I was in the middle of the physical miscarriage, it was too early for me to deal with or know whether that was what I wanted”, she says. She points out that her grieving husband “wasn’t offered anything, or even considered by the health professionals”. Given how busy her local medical practice is, Samantha didn’t consider trying to get an appointment with a doctor.

Ruth Bender Atik, national director of the UK charity Miscarriage Association, hears similar stories. “People get in touch with us all the time to tell us about the difficulties they are having after their pregnancy loss and the difficult emotions they go through,” she says. “Those who really need psychological services can find it extremely difficult to access.”

At the moment, the National Health Service in England doesn’t routinely offer psychological support and counselling to everyone who experiences pregnancy loss, says Farren. “It varies across NHS trusts,” says Bender Atik, or according to “how many staff they have on duty that day, and how alert they are to the needs of women [and their partners]”.

“In an ideal world, there would be some sort of screening [for mental health symptoms] after a miscarriage,” says Farren. There are ways that people who have experienced a pregnancy loss can find support, says Bender Atik. For general support, organisations like Miscarriage Association can help, she says. People who need psychological support should be able to access it through their GP.

Samantha, who experienced anxiety, insomnia and loss of confidence after her miscarriage, is now having counselling offered by a private practitioner. “Talking through things is helping,” she says.

Abstract
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.

Authors
Jessoca Farren, Maria Jalmbrant, Nora Falconier, Nicola Mitchell-Jones, Shabnam Bobdiwala, Maya Al-Memar, Sophie
Tap, Ben van Calster, Laure Wynants, Dirk Timmerman, Tom Bourne

New Scientist report

American Journal of Obstetrics and Gynaecology abstract

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