The emotional burden of miscarriage for women and their partners: trajectories of anxiety and depression over 13 months

Impact of miscarriage and termination of pregnancy on subsequent pregnancies: A longitudinal study of maternal and paternal depression, anxiety and eudaimonia

BACKGROUND

Although miscarriage and termination of pregnancy affect maternal mental illnesses on subsequent pregnancies, their effects on the positive mental health (e.g., eudaimonia) of both first-time and multi-time parents have received minimal attention, especially for fathers. This longitudinal study examines the effects of experiences of miscarriage and termination on parental well-being in subsequent pregnancies from prenatal to postpartum years, while simultaneously considering parity.

METHODS

Pregnant women and their partners were recruited during early prenatal visits in Taiwan from 2011 to 2022 and were followed up from mid-pregnancy to 1 year postpartum. Six waves of self-reported assessments were employed.

RESULTS

Of 1813 women, 11.3 % and 14.7 % had experiences of miscarriage and termination, respectively. Compared with the group without experiences of miscarriage or termination, experiences of miscarriage were associated with increased risks of paternal depression (adjusted odds ratio = 1.6, 95 % confidence interval [CI] = 1.13-2.27), higher levels of anxiety (adjusted β = 1.83, 95 % CI = 0.21-3.46), and lower eudaimonia scores (adjusted β = -1.09, 95 % CI = -1.99 to -0.19) from the prenatal to postpartum years, particularly among multiparous individuals. Additionally, experiences of termination were associated with increased risks of depression in their partner.

LIMITATIONS

The experiences of miscarriage and TOP were self-reported and limited in acquiring more detailed information through questioning.

CONCLUSIONS

These findings highlight the decreased well-being of men whose partners have undergone termination of pregnancy or experienced miscarriage, and stress the importance of interventions aimed at preventing adverse consequences among these individuals.

A Multidimensional and Longitudinal Exploratory Study of the Stability of Pregnancy Contexts in the United States

Objective

Evaluate the longitudinal stability of six pregnancy contexts, including intention, in a diverse cohort of individuals experiencing delivery, abortion, or miscarriage.

Methods

We enrolled individuals 16-44 years of age with pregnancies <24 weeks gestation in this longitudinal study between June 2014 and June 2015 in four US urban clinics. We assessed six pregnancy contexts (intention, wantedness, planning, timing, desirability, and happiness) at enrollment and 3-month follow-up. We constructed three-level categorical measures for each context defined as favorable, ambivalent, or unfavorable. We used Wilcoxon sign tests to evaluate changes in paired observations between pregnancy context measures over time and by pregnancy outcome.

Results

Among 121 participants at median gestational age of 7 weeks and 3 days, we found intention, wantedness, planning, timing, and happiness remained unchanged from enrollment in early pregnancy to 3-month follow-up. Individuals demonstrated changes in desirability; pregnancy assessments shifted toward less desirable from enrollment to follow-up (p = 0.01) (i.e., desired to ambivalent, or ambivalent to undesired). Among participants choosing delivery (57%), assessments shifted toward more favorable planning (i.e., unplanned to ambivalent, or ambivalent to planned) (p < 0.01), and less favorable desirability (i.e., desired to ambivalent or ambivalent to undesired) (p < 0.01) at follow-up. Among participants choosing abortion (28%), assessments shifted toward more unfavorable planning (i.e., planned to ambivalent, or ambivalent to unplanned) at follow-up (p < 0.01).

Conclusion

In multidimensional, longitudinal assessment, pregnant participants' perspectives on five of six pregnancy contexts remained unchanged between enrollment and 3-month follow-up; only desirability shifted. Pregnancy planning perspectives differed by pregnancy outcome.Human Research Subjects Protection Program: 1310012926.

Psychological impact over time of women with pregnancy loss due to gestational trophoblastic disease compared with miscarriage

OBJECTIVES

Pregnancy loss, occurring after miscarriage or after gestational trophoblastic disease, has a psychological impact. Besides pregnancy loss, women diagnosed with gestational trophoblastic disease have to deal with a prolonged period of follow-up and potential advice to postpone a future pregnancy. We studied the severity and course of the psychological impact after gestational trophoblastic disease and miscarriage, to identify whether women with gestational trophoblastic disease need different psychological care.

METHODS

A prospective multicenter study using online questionnaires was performed. Women diagnosed with gestational trophoblastic disease or miscarriage received the following questionnaires directly after diagnosis, and after 6, 6, and 12 months: a self-report questionnaire, the Hospital Anxiety and Depression Scale (HADS), the Impact of Event Scale, and the Reproductive Concerns Scale.

RESULTS

74 women with gestational trophoblastic disease and 76 women with miscarriage were included. At baseline, the proportion of women scoring above the cut-off level for the anxiety subscale of the HADS and for the Impact of Event Scale was significantly higher for women with gestational trophoblastic disease than for women after miscarriage (43.2% vs 28.9%, p=0.02 and 87.8% vs 78.9%, p=0.03, respectively). During follow-up, the differences between both groups vanished and only the Impact of Event Scale after 12 months remained significantly different between women with gestational trophoblastic disease and women after miscarriage (62.7% vs 37.3%, p=0.005). All outcomes, except the Reproductive Concerns Scale, showed a significant decline. However, in women who scored above the cut-off level on the HADS-total or Impact of Event Scale at baseline, and women with psychological or psychiatric history, significant higher scores persisted.

CONCLUSION

Although women with gestational trophoblastic disease at baseline had more anxiety and distress than women after miscarriage, no significant differences were seen using the HADS-total after 12 months. Using the HADS or Impact of Event Scale directly after pregnancy loss is helpful to identify women at risk of remaining psychological symptoms to provide them with extra psychological support.

Help-seeking behavior among miscarrying women with and without post-miscarriage health problems in Ghana

Understanding how frequently women seek assistance after experiencing a miscarriage could potentially help address unmet needs in managing post-miscarriage health problems (PMHP). However, most studies focus primarily on the causes and effects of PMHP and neglect the influence of help-seeking behavior on PMHP. This study examined help-seeking behavior among women who have experienced a miscarriage in Ghana, whether they sought help from healthcare professionals or not, and the impact it had on post-miscarriage health problems (PMHP). The study analyzed subsample data (N = 1,843) from the 2017 Ghana maternal health survey of miscarrying women aged 15-49 years who answered questions on help-seeking after a miscarriage from 900 clusters in ten administrative regions of Ghana, using a two-stage stratified cluster probability sampling design. The study used chi-square and modified Poisson with Generalized Estimating Equations (GEE) to examine help-seeking behavior among miscarrying women in Ghana and its impact on post-miscarriage health. The PMHP prevalence was 13.5% (95% CI: 12.0-15.1). Of the 1,843 women, 76.2% (95% CI: 74.3-78.2) sought help following a miscarriage, with 73.6% receiving help from healthcare professionals, 4.6% from non-healthcare professionals, and 21.8% receiving help from both groups. Help-seeking behavior was associated with factors such as education, place of residence, marital status, distance to a health facility, and money for treatment. Women who sought help had a 3.0% (Adjusted Prevalence Ratio, (aPR = 0.97, 95% Cl: 0.95-0.99) reduced prevalence of PMHP compared to those who did not seek help after controlling for other factors. Encouraging more women to seek help following a miscarriage could play a critical role in reducing PMHP, which can substantially improve their physical well-being. This finding highlights the need for more health education programs that address potential barriers in women at higher risk of miscarriage-related complications, including those aged ≥ 31 years, from seeking help after a miscarriage.

The effect of emotional freedom technique and music applied to pregnant women who experienced prenatal loss on psychological growth, well-being, and cortisol level: A randomized controlled trial

INTRODUCTION

Research has shown that application of emotional freedom technique and music ensures psychological growth, increases well-being, and decreases cortisol level.

PURPOSE

In the study, it was aimed to determine the effect of EFT and music applied to pregnant women who had experienced prenatal loss on their psychological growth, well-being, and cortisol level.

METHODS

The study was conducted as a randomized controlled trial in a city hospital in eastern Türkiye with 159 pregnant women, 53 of whom were in the EFT, 53 in the music group, and 53 in the control group. The study data were collected through Subjective Units of Disturbance Scale (SUDS), Subjective Units of Experience (SUE) Scale, Post Traumatic Growth Inventory (PTGI), and WHO-5 Well-Being Index, and saliva samples were taken for cortisol evaluation. EFT was applied to the women two times every other week; the women in the music group listened to music two times every other week. Throughout the week following the first intervention, the women continued the interventions at home.

RESULTS

It was determined that EFT and music significantly decreased the participants' subjective anxiety and salivary cortisol median scores, the lowest anxiety was in the EFT group, and PTGI and WHO-5 Well-Being Index mean scores increased (p < 0.005). Further analyses showed that EFT was more effective in terms of increasing well-being than music (p < 0.001; a > b > c). It was determined that the anxiety levels and salivary cortisol median values of the control group were statistically significantly higher compared to the EFT and music groups (p < 0.001).

CONCLUSION

It was found that EFT and music applied to the women who had experienced prenatal loss decreased anxiety, ensured psychological growth, improved well-being, and decreased salivary cortisol level.

The psychological impact of Early Pregnancy Loss in Portugal: incidence and the effect on psychological morbidity

Introduction

Worldwide, up to a quarter of all recognized pregnancies result in Early Pregnancy Loss (EPL), also known as miscarriage. For many women, this is a traumatic experience that leads to persistent negative mental health responses. The most common morbidity reported in studies from different countries is complicated grief, usually comorbid with depression, anxiety, and Post-Traumatic Stress Disorder (PTSD). To our best knowledge, no studies characterizing the psychological impact of EPL have been made in Portugal.

Methods

An online survey was conducted to evaluate clinical symptoms of perinatal grief, anxiety, depression, and PTSD in women who suffered a spontaneous loss within 20  weeks of gestation. Out of 1,015 women who answered this survey, 873 were considered eligible, and subsequently distributed in 7 groups according to the time passed between their loss and their participation in the study.

Results

The proportion of women showing symptoms of all comorbidities was greater in those whose loss had happened within a month, and there was a significant gradual decrease over time in scores and proportions of clinical perinatal grief and PTSD. In terms of depression symptoms, scores dropped significantly in the group whose loss occurred 13-24  months before their participation but proportions oscillated without great changes in the other groups. Regarding anxiety, there were small oscillations, but there was no significant decrease of symptoms over time.

Discussion

Overall, despite a general drop in scores for most morbidities over time, substantial proportions of women showed persistent symptoms of clinical morbidities 3  years or more after the loss. Therefore, it is essential to promote monitoring of possible complicated responses to the event, to provide appropriate and timely intervention to those women in need.

Pathways to adverse pregnancy outcomes: exploring the mediating role of intimate partner violence and depression: results from a South African rape cohort study

Adverse pregnancy outcomes (APOs) are common occurrences that contribute to negative maternal and child health outcomes. Our aim was to test the hypothesis that trauma exposure and depression are drivers of the better-recognised risk factors for miscarriage, abortion and stillbirths. Our comparative cohort study based in Durban, South Africa recruited women who reported a recent rape (n = 852) and those who had never experienced rape (n = 853), with follow-up for 36 months. We explored APOs (miscarriage, abortion or stillbirth) among those having a pregnancy during follow-up (n = 453). Potential mediators were baseline depression, post-traumatic stress symptoms, substance abuse, HbA1C, BMI, hypertension and smoking. A structural equation model (SEM) was used to determine direct and indirect paths to APO. Overall, 26.6% of the women had a pregnancy in the follow-up period and 29.4% ended in an APO, with miscarriage (19.9%) the most common outcome, followed by abortion (6.6%) and stillbirths (2.9%). The SEM showed two direct pathways from exposure to childhood trauma, rape and other trauma, to APO which were ultimately mediated by hypertension and/or BMI, but all paths to BMI were mediated by depression and IPV-mediated pathways from childhood and other trauma to hypertension. Food insecurity mediated a pathway from experiences of trauma in childhood to depression. Our study confirms the important role of trauma exposure, including rape, and depression on APOs, through their impact on hypertension and BMI. It is critical that violence against women and mental health are more systematically addressed in antenatal, pregnancy and postnatal care.

Memorable Messages Embedded in Men's Stories of Miscarriage: Extending Communicated Narrative Sense-Making and Memorable Message Theorizing

Miscarriage occurs in roughly one in five pregnancies in the United States. Although it is largely considered a "women's issue," non-miscarrying spouses also endure the mental and relational health effects of the loss. Drawing on communicated narrative sense-making (CNSM) theory, we interviewed heterosexual, cisgender, mostly white, married men (n = 45) to solicit their stories of their spouse's miscarriage. Six types of memorable messages (i.e., messages that affect the values, behaviors and/or beliefs of the receiver) from social network members emerged - have faith, brush it off, this (pain) is your fault, silence, I'm so sorry, and this happens a lot. These messages illuminate the importance of context in memorable message meaning-making; highlight the complexity of "message gaps" in narratively processing difficulty; and uncover ethical issues with attending to men's experiences with miscarriage. We explore how these findings inform memorable messages theorizing and research.

The association between history of prenatal loss and maternal psychological state in a subsequent pregnancy: an ecological momentary assessment (EMA) study

BACKGROUND

Prenatal loss which occurs in approximately 20% of pregnancies represents a well-established risk factor for anxiety and affective disorders. In the current study, we examined whether a history of prenatal loss is associated with a subsequent pregnancy with maternal psychological state using ecological momentary assessment (EMA)-based measures of pregnancy-specific distress and mood in everyday life.

METHOD

This study was conducted in a cohort of N = 155 healthy pregnant women, of which N = 40 had a history of prenatal loss. An EMA protocol was used in early and late pregnancy to collect repeated measures of maternal stress and mood, on average eight times per day over a consecutive 4-day period. The association between a history of prenatal loss and psychological state was estimated using linear mixed models.

RESULTS

Compared to women who had not experienced a prior prenatal loss, women with a history of prenatal loss reported higher levels of pregnancy-specific distress in early as well as late pregnancy and also were more nervous and tired. Furthermore, in the comparison group pregnancy-specific distress decreased and mood improved from early to late pregnancy, whereas these changes across pregnancy were not evident in women in the prenatal loss group.

CONCLUSION

Our findings suggest that prenatal loss in a prior pregnancy is associated with a subsequent pregnancy with significantly higher stress and impaired mood levels in everyday life across gestation. These findings have important implications for designing EMA-based ambulatory, personalized interventions to reduce stress during pregnancy in this high-risk group.

Prediction of risk factors for first trimester pregnancy loss in frozen-thawed good-quality embryo transfer cycles using machine learning algorithms

PURPOSE

Can the risk factors that cause first trimester pregnancy loss in good-quality frozen-thawed embryo transfer (FET) cycles be predicted using machine learning algorithms?

METHODS

This is a retrospective cohort study conducted at Sisli Memorial Hospital, ART and Reproductive Genetics Center, between January 2011 and May 2021. A total of 3805 good-quality FET cycles were included in the study. First trimester pregnancy loss rates were evaluated according to female age, paternal age, body mass index (BMI), diagnosis of infertility, endometrial preparation protocols (natural/artificial), embryo quality (top/good), presence of polycystic ovarian syndrome (PCOS), history of recurrent pregnancy loss (RPL), recurrent implantation failure (RIF), severe male infertility, adenomyosis and endometriosis.

RESULTS

The first trimester pregnancy loss rate was 18.2% (693/ 3805). The presence of RPL increased first trimester pregnancy loss (OR = 7.729, 95%CI = 5.908-10.142, P = 0.000). BMI, which is > 30, increased first trimester pregnancy loss compared to < 25 (OR = 1.418, 95%CI = 1.025-1.950, P = 0.033). Endometrial preparation with artificial cycle increased first trimester pregnancy loss compared to natural cycle (OR = 2.101, 95%CI = 1.630-2.723, P = 0.000). Female age, which is 35-37, increased first trimester pregnancy loss compared to < 30 (OR = 1.617, 95%CI = 1.120-2.316, P = 0.018), and female age, which is > 37, increased first trimester pregnancy loss compared to < 30 (OR = 2.286, 95%CI = 1.146-4,38, P = 0.016). The presence of PCOS increased first trimester pregnancy loss (OR = 1.693, 95%CI = 1.198-2.390, P = 0.002). The number of previous IVF cycles, which is > 3, increased first trimester pregnancy loss compared to < 3 (OR = 2.182, 95%CI = 1.708-2.790, P = 0.000).

CONCLUSIONS

History of RPL, RIF, advanced female age, presence of PCOS, and high BMI (> 30 kg/m2) were the factors that increased first trimester pregnancy loss.

The Posttraumatic Impact of Recurrent Pregnancy Loss in Both Women and Men

Introduction Recurrent pregnancy loss is usually associated with significant psychological distress for both partners of the couple. It may act as a traumatic experience resulting in a posttraumatic stress disorder. The object of this study is to examine the posttraumatic impact of recurrent pregnancy loss on men and women and their interdependencies. Methods Cross-sectional study. All couples referred to the special unit for recurrent pregnancy loss between March 2019 and October 2020 were asked to participate with a sample size of 105 couples and 17 women. They were invited to complete a questionnaire package estimating the prevalence of posttraumatic stress, with anxiety, depression, lack of social support and dysfunctional coping strategies as contributing risk factors. Couple data were analysed with the Actor Partner Interdependence Model, taking the couple as a dyad. Results The response rate was 82.3 percent, with posttraumatic stress being measured in 13.7% of the women versus 3.9% of the men (p = 0.017). For women, number of curettages, controlled for the number of losses, correlated with the severity of posttraumatic stress (p < 0.05). Higher levels of anxiety, depression and lack of social support in women correlated positively with posttraumatic stress in their partners. The men's coping strategy "trivialization and wishful thinking" as well as "avoidance" correlated with more severe posttraumatic stress in the female partners (both p < 0.05). Conclusion The posttraumatic risks within a couple with recurrent pregnancy loss are interdependent. Recurrent pregnancy loss clinics should assess posttraumatic risks of both partners in their routine diagnostic process.

Positive effects of fetal echocardiography on maternal anxiety: a prospective study in a tertiary center in Turkey

Aim: The aim of this study was to determine the anxiety levels of pregnant women who were referred to a tertiary center for fetal echocardiography (FE) and the effect of FE results on maternal anxiety.Methods: This prospective study was conducted between January 2020 and February 2021 and included 118 pregnant women. The anxiety levels of the participants were evaluated with the Spielberger State-Trait Anxiety Inventory, which evaluates state (STAI-I) and trait (STAI-II) anxiety. STAI-I and STAI-II were administered to participants at first admission using a standard interview technique prior to FE. After the FE was completed, a structured interview was performed and the state anxiety index (STAI-I-R) was re-administered to the participants.Results: Severe congenital heart disease (CHD) was detected in 63 (53.4%) fetuses. The participants' mean STAI-I scores were significantly higher than their mean STAI-II scores (44.19 ± 8.56 and 41.98 ± 5.98, respectively, t = 2.59 and p = 0.011). In pregnant women with fetuses with severe CHD, STAI-I-R scores were significantly lower compared to STAI-I scores (43.48 ± 7.97 and 46.28 ± 7.18, respectively, t = 2.13 and p = 0.037).Conclusion: Referral for FE is associated with increased maternal anxiety, and a structured interview may result in reduced anxiety levels even in those with abnormal FE.

Posttraumatic Stress Disorder Symptoms and Related Factors in Women with Early Pregnancy Loss

Aim: Women may experience emotions such as fear, anxiety, stress, anger or guilt after pregnancy loss, and it can lead to posttraumatic stress disorder if the women cannot cope with these emotions. This study aimed to identify posttraumatic stress disorder symptoms and related factors in women with early pregnancy loss. Material and Methods: The sample of this descriptive study consisted of 132 women hospitalised with early pregnancy loss in an Obstetrics and Gynecology service of a state hospital (

Incidence and risk factors for early pregnancy loss in women with first pregnancy undergoing in vitro fertilization-embryo transfer

Background

This study aimed to explore the incidence and influencing factors for early pregnancy loss (EPL) in infertility patients with first pregnancy undergoing in vitro fertilization (IVF) embryo transfer cycles in Jilin province, China.

Methods

A retrospective study of 2709 first pregnancy embryo transfer cycles collected from January 2016 to January 2021 was performed. The cycles were divided into the EPL group (n = 411) and the live birth group (n = 2298) according to the cycle outcomes.

Results

The EPL rate of the first-time pregnancies for infertility patients undergoing fresh/frozen-thaw embryo transfer cycle was 14.1%. Female patients aged 40 and older had increased odds of EPL compared to those under 35 (OR = 3.97, 95%CI: 2.80–7.55). Female patients with a body mass index (BMI) of 25 or greater were more likely to have EPLs than those in the normal BMI range (OR = 1.32, 95%CI: 1.03–1.70). The odds of EPL after frozen-thaw embryo transfer were higher than those after fresh embryo transfer (OR = 1.59, 95%CI: 1.11–2.27). A thin endometrium on the day of embryo transfer increased the odds of EPL (OR = 1.84, 95%CI: 1.01–3.33). Transferring more than two embryos had lower odds of EPL than single-embryo transfer (OR = 0.67, 95%CI: 0.50–0.90). Compared with other infertility diagnoses, tubal factor alone was associated with lower odds of EPL (OR = 0.72, 95%CI: 0.53–0.98).

Conclusions

The risk factors for EPL were age 40 and older, obesity, frozen-thaw cycle, thin endometrium, and non-isolated tubal factor.

Prognostic factors for post-traumatic stress, anxiety and depression in women after early pregnancy loss: a multi-centre prospective cohort study

OBJECTIVES

To investigate prognostic factors for anxiety, depression and post-traumatic stress (PTS) symptoms 1 month after early pregnancy loss (EPL).

DESIGN

A prospective cohort study. Consecutive women were recruited, and demographic and clinical data were collected. Surveys containing the Hospital Anxiety and Depression Scale (HADS) and Post-traumatic Stress Diagnostic Scale (PDS) were emailed 1 month after a loss. Univariable logistic regression was performed to link factors with caseness of anxiety, depression or PTS according to screening measures.

SETTING

Early pregnancy units of three central London hospitals.

PARTICIPANTS

737/1116 eligible women with an EPL were recruited. 492 responded to HADS and 487 to PDS.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome is the area under the curve (AUC) to predict any psychological morbidity (defined as moderate/severe anxiety or depression, or meeting screening criteria for PTS) for each variable. Further outcomes are explained variation (R²) and p value for any morbidity, and AUC, explained variation, and p value for each morbidity separately.

RESULTS

Women who had a past diagnosis of a psychiatric condition were more likely to meet criteria for anxiety, depression or PTS (75% for current diagnosis vs 55% for past vs 30% for no diagnosis; AUC 0.61; R² 8.4%; p<0.0001), as were those with previous pregnancy loss (48% vs 30%; AUC 0.59; R² 4.3%; p<0.0001). Most of the assessed factors did not demonstrate potential utility in predicting psychological distress, including gestational age, overnight admission, time taken for diagnosis, pre-existing children and the diagnosis itself (miscarriage vs ectopic vs other) (AUCs≤0.54; R²≤0.9%).

CONCLUSIONS

Women with a history of mental health problems, or those with previous losses, may be at higher risk of psychological illness 1 month after pregnancy loss. However, prognostic ability was poor overall. All women should be considered at risk.

Psychological impact of early miscarriage and client satisfaction with treatment: comparison between expectant management and misoprostol treatment in a randomized controlled trial

OBJECTIVES

To compare the short- and long-term emotional distress (grief, anxiety and depressive symptoms) after early miscarriage and satisfaction with treatment between women randomized to expectant management vs vaginal misoprostol treatment.

METHODS

This was a preplanned analysis of data collected during a randomized controlled trial comparing expectant management with misoprostol treatment in women with early anembryonic or embryonic miscarriage and vaginal bleeding. If the miscarriage was not complete on day 31 after inclusion, surgical evacuation was recommended. The main outcomes were levels of anxiety and grief, depressive symptoms and client satisfaction with the treatment, which were assessed using the following validated psychometric self-assessment instruments: Spielberger State-Trait Anxiety Inventory (STAI, Form Y), Perinatal Grief Scale (PGS), Montgomery-Åsberg Depression Rating Scale (MADRS-S; self-reported version) and Client Satisfaction Questionnaire (CSQ-8). All women were assessed at four timepoints: on the day of randomization, on the day when the miscarriage was judged to be complete, and at 3 months and 14 months after complete miscarriage. The psychometric and client satisfaction scores were compared between the misoprostol group and the expectant-management group at each assessment. Analysis was performed by the intention-to-treat principle.

RESULTS

Ninety women were randomized to expectant management and 94 to misoprostol treatment. The psychometric and client satisfaction scores were similar in the two treatment groups at all assessment timepoints. At inclusion, 41% (35/86) of the women managed expectantly and 37% (34/92) of those treated with misoprostol had a STAI-state score of > 46 ('high level of anxiety'), and 9% (8/86) and 10% (9/91), respectively, had symptoms of moderate or severe depression (MADRS-S score ≥ 20). In both treatment groups, symptom scores for anxiety and depression were significantly higher at inclusion than after treatment and remained low until 14 months after complete miscarriage. Grief reactions were mild in both groups, with a median PGS score of 40.0 at 3 months and 37.0 at 14 months after complete miscarriage in both treatment groups. Four women treated with misoprostol and two women managed expectantly had a PGS score of > 90 (indicating deep grief) 3 months after complete miscarriage, while one woman managed expectantly had a PGS score of > 90 14 months after complete miscarriage. Women in both treatment groups were satisfied with their management, as indicated by a median CSQ-8 score of > 25 at each assessment. More than 85% of participants in each of the two groups reported that they would recommend the treatment they received to a friend.

CONCLUSIONS

The psychological response to and recovery after early miscarriage did not differ between women treated with misoprostol and those managed expectantly. Satisfaction with treatment was high in both treatment groups. Our findings support patient involvement when deciding on the management of early miscarriage. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Evaluating Markers of Immune Tolerance and Angiogenesis in Maternal Blood for an Association with Risk of Pregnancy Loss

Pregnancy loss affects approximately 20% of couples. The lack of a clear cause complicates half of all miscarriages. Early evidence indicates the maternal immune system and angiogenesis regulation are both key players in implantation success or failure. Therefore, this prospective study recruited women in the first trimester with known viable intrauterine pregnancy and measured blood levels of immune tolerance proteins galectin-9 (Gal-9) and interleukin (IL)-4, and angiogenesis proteins (vascular endothelial growth factors (VEGF) A, C, and D) between 5 and 9 weeks gestation. Plasma concentrations were compared between groups defined based on (a) pregnancy outcome and (b) maternal history of miscarriage, respectively. In total, 56 women were recruited with 10 experiencing a miscarriage or pregnancy loss in the 2nd or 3rd trimester and 11 having a maternal history or miscarriage. VEGF-C was significantly lower among women with a miscarriage or pregnancy loss. Gal-9 and VEGF-A concentrations were decreased in women with a prior miscarriage. Identification of early changes in maternal immune and angiogenic factors during pregnancy may be a tool to improve patient counseling on pregnancy loss risk and future interventions to reduce miscarriage in a subset of women.

Karyotype of first clinical miscarriage and prognosis of subsequent pregnancy outcome

RESEARCH QUESTION

Is the karyotype of the first clinical miscarriage in an infertile patient predictive of the outcome of the subsequent pregnancy?

DESIGN

Retrospective cohort study of infertile patients undergoing manual vacuum aspiration with chromosome testing at the time of the first (index) clinical miscarriage with a genetic diagnosis and a subsequent pregnancy. Patients treated at two academic-affiliated fertility centres from 1999 to 2018 were included; those using preimplantation genetic testing for aneuploidy were excluded. Main outcome was live birth in the subsequent pregnancy.

RESULTS

One hundred patients with euploid clinical miscarriage and 151 patients with aneuploid clinical miscarriage in the index pregnancy were included. Patients with euploid clinical miscarriage in the index pregnancy had a live birth rate of 63% in the subsequent pregnancy compared with 68% among patients with aneuploid clinical miscarriage (adjusted odds ratio [aOR] 0.75, 95% CI 0.47-1.39, P = 0.45, logistic regression model adjusting for age, parity, body mass index and mode of conception). In a multinomial logistic regression model with three outcomes (live birth, clinical miscarriage or biochemical miscarriage), euploid clinical miscarriage for the index pregnancy was associated with similar odds of clinical miscarriage in the subsequent pregnancy compared with aneuploid clinical miscarriage for the index pregnancy (32% versus 24%, respectively, aOR 1.49, 95% CI 0.83-2.70, P = 0.19). Euploid clinical miscarriage for the index pregnancy was not associated with likelihood of biochemical miscarriage in the subsequent pregnancy compared with aneuploid clinical miscarriage (5% versus 8%, respectively, aOR 0.46, 95% CI 0.14-1.55, P = 0.21).

CONCLUSION

Prognosis after a first clinical miscarriage among infertile patients is equally favourable among patients with euploid and aneuploid karyotype, and independent of the karyotype of the pregnancy loss.

Perinatal Loss: The Impact on Maternal Mental Health

Importance

Psychological reactions to perinatal loss, although often self-limited, may lead to significant psychological morbidities. Obstetrician-gynecologists and other maternal health providers play a key role in recognizing the range of psychological responses to perinatal loss and providing education, support, and treatment options to their patients.

Objective

This review aims to define psychological reactions associated with perinatal loss, examine psychotherapy and psychopharmacologic treatments for psychiatric morbidities, discuss interpregnancy interval following perinatal loss, and highlight brief, psychological interventions that can be implemented by maternal health providers.

Evidence Acquisition

Search terms "perinatal loss psychology," "reproductive loss grief," "perinatal psychopharmacology," "psychopharmacology grief," and "interpregnancy interval" were utilized to search PubMed, Google Scholar, and PsycINFO.

Results

Grief is an expected, normal response to perinatal loss. Psychological morbidities, including major depressive disorder, generalized anxiety disorder, and posttraumatic stress disorder, are also associated with perinatal loss. Risk factors for these conditions include history of a psychiatric illness, childlessness, unknown cause of perinatal loss, limited social support, and marital/relationship discord. Careful interviewing and brief screening measures can help identify patients who may suffer from depressive or anxiety disorders following reproductive loss. Patients with perinatal loss can benefit from psychological and possibly pharmacologic treatments. Recommended interpregnancy interval after perinatal loss should be customized by gestational age and cause of loss.

Conclusions and Relevance

Patients with perinatal loss emotionally benefit from their reproductive health care providers acknowledging the psychological aspects of reproductive loss, inquiring about their emotional needs, and providing information regarding grief and mental health referrals.

Differences in post-traumatic stress, anxiety and depression following miscarriage or ectopic pregnancy between women and their partners: multicenter prospective cohort study

OBJECTIVES

To investigate and compare post-traumatic stress (PTS), depression and anxiety in women and their partners over a 9-month period following miscarriage or ectopic pregnancy.

METHODS

This was a prospective cohort study. Consecutive women and their partners were approached in the early pregnancy units of three hospitals in central London. At 1, 3 and 9 months after early pregnancy loss, recruits were e-mailed links to surveys containing the Hospital Anxiety and Depression Scale and the Post-traumatic Stress Diagnostic Scale. The proportion of participants meeting the screening criteria for moderate or severe anxiety or depression and PTS was assessed. Mixed-effects logistic regression was used to analyze differences between women and their partners and their evolution over time.

RESULTS

In total, 386 partners were approached after the woman in whom the early pregnancy loss had been diagnosed consented to participate, and 192 couples were recruited. All partners were male. Response rates were 60%, 48% and 39% for partners and 78%, 70% and 59% for women, at 1, 3 and 9 months, respectively. Of the partners, 7% met the criteria for PTS at 1 month, 8% at 3 months and 4% at 9 months, compared with 34%, 26% and 21% of women, respectively. Partners also experienced lower rates of moderate/severe anxiety (6% vs 30% at 1 month, 9% vs 25% at 3 months and 6% vs 22% at 9 months) and moderate/severe depression (2% vs 10% at 1 month, 5% vs 8% at 3 months and 1% vs 7% at 9 months). The odds ratios for psychological morbidity in partners vs women after 1 month were 0.02 (95% CI, 0.004-0.12) for PTS, 0.05 (95% CI, 0.01-0.19) for moderate/severe anxiety and 0.15 (95% CI, 0.02-0.96) for moderate/severe depression. Morbidity for each outcome decreased modestly over time, without strong evidence of a different evolution between women and their partners.

CONCLUSIONS

Some partners report clinically relevant levels of PTS, anxiety and depression after pregnancy loss, though to a far lesser extent than women physically experiencing the loss. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Risk Factors for Different Types of Pregnancy Losses: Analysis of 15,210 Pregnancies After Embryo Transfer

OBJECTIVE

To evaluate the risk factors for different types of pregnancy losses after embryo transfer (ET).

DESIGN

Retrospective cohort study.

SETTING

Reproductive medicine center.

PARTICIPANTS

A total of 15,210 pregnancies after fresh and frozen-thawed embryo transfer between January 2014 and June 2019.

MAIN OUTCOME MEASURES

The primary outcome was pregnancy loss (PL) throughout the entire pregnancy. Secondary outcomes were non-visualized PL, early miscarriage, late miscarriage, and stillbirth.

METHODS

The effect of patients' baseline characteristics and IVF/ICSI cycle-specific factors on the risk of PL after fresh and frozen-thawed ET was determined by multivariate logistic regression analysis.

RESULTS

Compared to women under 35 years old, those between 35 and 40 had an increased risk of early miscarriage [odds ratio (OR) 1.49, 95% confidence interval (CI) 1.22-1.83], while those after 40 appeared to have an increased risk of both early miscarriage (OR 3.82, 95% CI 2.65-5.51) and late miscarriage (OR 2.79, 95% CI 1.64-4.77). Overweight patients were observed to have a higher risk of late miscarriage (OR 1.38, 95% CI 1.16-1.65), while obese patients showed a higher risk of both early miscarriage (OR 1.47, 95% CI 1.14-1.91) and late miscarriage (OR 1.80, 95% CI 1.33-2.44). Polycystic ovary syndrome (PCOS) was an independent risk factor for late miscarriage (OR 1.58, 95% CI 1.28-1.96), and the detrimental effect of PCOS was independent of obesity status. Women with uterine factors had a higher risk of early miscarriage (OR 1.77 (95% CI 1.32-2.38) than women without uterine factors. A negative correlation was observed between the thickness of the endometrium and PL (OR 0.95 95% CI 0.92-0.97). There was an increased risk of PL after frozen-thawed ET versus fresh ET (OR 1.12, 95% CI 1.01-1.24). Women who transferred ≥2 embryos showed lower risk of overall PL than women who transferred a single embryo, with adjusted ORs ranged from 0.57~0.94. However, women who transferred three embryos demonstrated a higher risk of late miscarriage than women who transferred a single embryo (OR 2.23, 95% CI 1.36-3.66).

CONCLUSIONS

Patients with uterine factors demonstrated higher risk of early miscarriage and stillbirth. Being overweight, PCOS, and transferring three embryos was associated with late miscarriage. Being aged 40 and over, obese, and using frozen embryo transfer was associated with early and late miscarriage.

The genetic architecture of sporadic and multiple consecutive miscarriage

Miscarriage is a common, complex trait affecting ~15% of clinically confirmed pregnancies. Here we present the results of large-scale genetic association analyses with 69,054 cases from five different ancestries for sporadic miscarriage, 750 cases of European ancestry for multiple (≥3) consecutive miscarriage, and up to 359,469 female controls. We identify one genome-wide significant association (rs146350366, minor allele frequency (MAF) 1.2%, P = 3.2 × 10-8, odds ratio (OR) = 1.4) for sporadic miscarriage in our European ancestry meta-analysis and three genome-wide significant associations for multiple consecutive miscarriage (rs7859844, MAF = 6.4%, P = 1.3 × 10-8, OR = 1.7; rs143445068, MAF = 0.8%, P = 5.2 × 10-9, OR = 3.4; rs183453668, MAF = 0.5%, P = 2.8 × 10-8, OR = 3.8). We further investigate the genetic architecture of miscarriage with biobank-scale Mendelian randomization, heritability, and genetic correlation analyses. Our results show that miscarriage etiopathogenesis is partly driven by genetic variation potentially related to placental biology, and illustrate the utility of large-scale biobank data for understanding this pregnancy complication.

Effects of an Early Pregnancy Assessment Clinic (EPAC) on the Management of Spontaneous Abortions

OBJECTIVE

Patients who experience spontaneous abortion often present to the emergency department (ED), which may restrict the physician's recommendations for and the patient's choice of therapy. With support provided by an early pregnancy assessment clinic (EPAC), expectant and medical management may become more feasible options for spontaneous abortion. This study aimed to compare the therapeutic choices before and after the establishment of an EPAC and hypothesized that the proportion of miscarriages treated expectantly or medically would increase.

METHODS

We conducted a retrospective cohort study that compared patients presenting to the ED and the EPAC with spontaneous abortion. We excluded patients with hemodynamic instability, complete abortions, ectopic pregnancies, and molar pregnancies. The primary outcome was the initial chosen treatment. The retrospective chart review included demographics, type of spontaneous abortion and management, procedural dictations, ED notes, and EPAC clinic documentation. Secondary end points included wait times, repeat visits, and success rates for the initial treatment option.

RESULTS

We reviewed 103 ED and 92 EPAC patient records. Patients in the ED were 1.52 times more likely to choose surgery over expectant or medical management (P = 0.004). Patients in the ED were 1.41 times more likely to have surgery as their final treatment compared with patients in the EPAC (P = 0.006). There were no significant differences in length of stay, number of visits required, or adverse outcomes.

CONCLUSION

Our study demonstrates that an EPAC results in more patients choosing and successfully being treated by expectant or medical management for spontaneous abortion.

Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multicenter, 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.

Pregnancy after miscarriage in primiparae and multiparae: implications for women's psychological well-being

Introduction: Miscarriage is a stressful life event with negative consequences that can last into the subsequent gestation, increasing women's risk for psychological symptoms. Less clear in literature is whether having a living child may buffer the psychological impact of miscarriage on subsequent pregnancies.Objective: explore levels of depression, anxiety and fear of delivery in women with and without a previous miscarriage, taking into consideration the presence of a living child.Method: 208 women (M = 34.68) were recruited during the third trimester of gestation. The sample was composed of 159 women without a previous miscarriage (72.3% primiparae and 27.7% multiparae) and 49 women with a history of miscarriage (53.1% primiparae and 46.9% multiparae). Participants filled out a battery of questionnaires aimed at assessing anxiety, depression, and fear of delivery.Results: Primiparae reported higher levels of fear of childbirth than multiparae. Moreover, women without a history of previous perinatal loss showed lower levels of depression and fear of childbirth than women with a previous perinatal loss.Conclusions: Data highlight the importance of developing specific support groups, for primiparae, due to their great emotional vulnerability, and for women with past miscarriage, to help them cope in adaptive ways with a new pregnancy.

'There was just no-one there to acknowledge that it happened to me as well': A qualitative study of male partner's experience of miscarriage

Miscarriage occurs in up to one in four pregnancies and can be a devastating event affecting both men and women. Unfortunately, the male partner’s experience of miscarriage is seldom researched, particularly within Australia. This qualitative study involved semi-structured telephone interviews with 10 Australian men, whose partners miscarried between three months and ten years ago. Participants were recruited through professional networks and support organisations. Interviews explored men’s general miscarriage experience and the support received or lacking from both healthcare providers and social networks. Online health seeking behaviour and opinions on online support were also discussed. Data was transcribed verbatim and analysed thematically. Most men described feeling significant grief following miscarriage and felt that there was little acknowledgment of their loss, both from healthcare providers and within their social networks. Feelings of sadness, devastation, powerlessness, fear, shock and a loss of identity were common. All men felt their primary role at the time of miscarriage was to support their partner. Most men did not want to burden their partner with their emotions or grief, and struggled to find people within their social networks to talk to about their loss, leading to feelings of isolation. Overall participants felt there was inadequate support offered to men affected by miscarriage. Men wanted information, informed professionals to talk to and male-orientated support networks. A website was one mechanism suggested by men which could adequately contribute to information and support needs during this time. Men are often greatly affected by miscarriage and yet there is all too often little acknowledgement or support available to them at this time. Men affected by miscarriage want and need further support, including reputable, Australian based information and resources tailored their needs.

The psychological impact of early pregnancy loss

BACKGROUND

Early pregnancy loss (EPL) is a common event, with scope for long-term personal and societal impact. There are three decades worth of published evidence of profound psychological sequelae in a significant proportion of women. However, the wide variety of outcomes, screening instruments, assessment timings and geographical locations makes it challenging to form a coherent picture of the morbidity within the whole group and its subgroups.

OBJECTIVE AND RATIONALE

This review aims to investigate three questions. (1) What is the evidence for depression, anxiety and post-traumatic stress disorder (PTSD) following a miscarriage or an ectopic pregnancy in women and/or their partners? (2) What is the intensity and duration of these conditions, and how do they compare to those without losses? (3) Which patients have been found to be at highest risk of psychopathology? Answers to these questions are salient not only in day-to-day clinical interactions with those experiencing EPL, whose psychological needs may not be prioritized, but should also form the basis for tailoring healthcare policy in terms of screening for and treating the associated psychological morbidity.

SEARCH METHODS

The following databases were searched, from the start of each database up to July 2017: MEDLINE (Ovid interface, 1948 onwards), Embase classic + Embase (Ovid interface, 1947 onwards), and PsychINFO (Ovid interface, 1806 onwards). Search strategies were developed using medical subject headings (MeSH). The concepts of psychological morbidity (anxiety, depression or PTSD) and pregnancy loss (miscarriage or ectopic pregnancy) were first expanded with the Boolean operator 'or', then linked together using 'and'. Included studies were of prospective cohort design, including women or men following EPL (with the majority to have experienced losses before 24 weeks gestation), and reporting standardized psychometric measures for anxiety, depression and post-traumatic stress disorder. The timing of follow-up had to be specified and standardized across participants. Manuscript quality and risk of bias was assessed using the Newcastle-Ottawa Scale.

OUTCOMES

We found evidence of significant depression and anxiety in the first month following EPL in women. Partners were also shown to display depression and anxiety, albeit to a generally lower level. There is also evidence of post-traumatic stress symptoms relating to the EPL in three studies.

WIDER IMPLICATIONS

In view of their high frequency, EPLs can significantly contribute to the overall burden of psychopathology within a population. Recognition of this impact is important, so that severely affected individuals may be screened and treated appropriately. Further research to establish risk factors to promptly identify and treat these patients, and to optimize their management, is crucial.

Longitudinal study of emotional experiences, grief and depressive symptoms in women and men after miscarriage

OBJECTIVE

Although miscarriage is common and affects up to 20% of pregnant women, little is known about these couples' short term and long term experiences after miscarriage. The aim of the present study was to study emotional experience, grief and depressive symptoms in women and men, one week and four months after miscarriage.

RESEARCH DESIGN /SETTING

Women, (n = 103), and their male partner (n = 78), were recruited at the gynecological clinic after miscarriage. Control women were recruited from the general population. Three validated questionnaires concerning psychological wellbeing and mental health, RIMS, PGS and MADRS-S were answered by the participants one week and four months after the miscarriage.

FINDINGS

It was shown that for women, the emotional experiences of miscarriage, grief and depressive symptoms were more pronounced than for their male partners. Grief and depressive symptoms were reduced with time, which was not the case for the emotional experiences of miscarriage. Previous children was favorable for emotional experience while previous miscarriage or infertility treatment made the emotional experience worse.

CONCLUSION

Grief and depressive symptoms is reduced over time while emotional experiences such as isolation, loss of baby and a devastating event persist for longer time than four months. Lack of previous children, previous miscarriage and infertility diagnosis could increase negative emotional experiences after miscarriage, this was especially pronounced for grief reaction. The questionnaires could be used both clinically and in research to understand the emotional experiences after miscarriage.

Time-Varying Effects of Signs and Symptoms on Pregnancy Loss <20 Weeks: Findings from a Preconception Prospective Cohort Study

BACKGROUND

Although pregnancy loss affects one-third of pregnancies, the associated signs/symptoms have not been fully described. Given the dynamic nature of maternal physiologic adaptation to early pregnancy, we posited the relationships between signs/symptoms and subsequent loss would vary weekly.

METHODS

In a preconception cohort with daily follow-up, pregnancies were ascertained by self-administered sensitive home pregnancy tests on day of expected menses. We evaluated the effects of weekly time-varying signs/symptoms (including vaginal bleeding, lower abdominal cramping, and nausea and/or vomiting) on pregnancy loss <20 weeks in Cox proportional hazards models and calculated the week-specific probability of loss by the presence/absence of each sign/symptom.

RESULTS

Of 341 pregnancies ascertained by home pregnancy test, 95 (28%) ended in loss. Relationships between signs/symptoms and loss varied across time since first positive pregnancy test. In the first week following pregnancy confirmation, when many losses occurred, bleeding [hazard ratio (HR) 8.7, 95% confidence interval (CI) 4.7, 16.0] and cramping (HR 1.8, 95% CI 1.2, 2.7) were associated with loss even when accompanied by nausea and/or vomiting (HR 5.2, 95% CI 2.6, 10.5). After the second week, new relationships emerged with nausea and/or vomiting inversely associated (HR range 0.6-0.3, all 95% CI upper bounds <1.00) and bleeding no longer associated with loss. Probabilities of loss of ranged from 78% (95% CI 59%, 96%) with bleeding present in week 1 to 8% (95% CI 5%, 12%) with nausea/vomiting present in week 5.

CONCLUSIONS

Relationships between signs/symptoms and pregnancy loss vary in early pregnancy possibly reflecting maternal physiologic response.

Trends in Risk of Pregnancy Loss Among US Women, 1990-2011

BACKGROUND

Pregnancy loss can have physical and psychological consequences for women and their families. Though a previous study described an increase in the risk of self-reported pregnancy loss from 1970 to 2000, more recent examinations from population-based data of US women are lacking.

METHODS

We used data from the 1995, 2002, 2006-2010, 2011-2015 National Survey of Family Growth on self-reported pregnancy loss (miscarriage, stillbirth, ectopic pregnancy) among US women (15-44 years) who reported at least one pregnancy conceived during 1990-2011 that did not result in induced termination (n = 20 012 women; n = 42 526 pregnancies). Trends in the risk of self-reported pregnancy loss and early pregnancy loss (<12 weeks) were estimated, separately, by year of pregnancy conception (limited to 1990-2011 to ensure a sufficient sample of pregnancies for each year and maternal age group) using log-Binomial and Poisson models, adjusted for maternal- and pregnancy-related factors.

RESULTS

Among all self-reported pregnancies, excluding induced terminations, the risk of pregnancy loss was 19.7% and early pregnancy loss was 13.5% during 1990-2011. Risk of pregnancy loss increased by a relative 2% (rate ratio [RR] 1.02, 95% confidence interval [CI] 1.01, 1.02) per year in unadjusted models and 1% per year (RR 1.01, 95% CI 1.00, 1.02) during 1990-2011, after adjustment for maternal characteristics and pregnancy-related factors. In general, trends were similar for early pregnancy loss.

CONCLUSION

From 1990 to 2011, risk of self-reported pregnancy loss increased among US women. Further work is needed to better understand the drivers of this increase in reported pregnancy loss in the US.

Interpregnancy Interval After Pregnancy Loss and Risk of Repeat Miscarriage

OBJECTIVE

To assess whether interpregnancy interval length after a pregnancy loss is associated with risk of repeat miscarriage.

METHODS

This analysis includes pregnant women participating in the Right From the Start (2000-2012) community-based prospective cohort study whose most recent pregnancy before enrollment ended in miscarriage. Interpregnancy interval was defined as the time between a prior miscarriage and the last menstrual period of the study pregnancy. Miscarriage was defined as pregnancy loss before 20 weeks of gestation. Cox proportional hazard models were used to estimate crude and adjusted hazard ratios and 95% CIs for the association between different interpregnancy interval lengths and miscarriage in the study pregnancy. Adjusted models included maternal age, race, parity, body mass index, and education.

RESULTS

Among the 514 study participants who reported miscarriage as their most recent pregnancy outcome, 15.7% had a repeat miscarriage in the study pregnancy (n=81). Median maternal age was 30 years (interquartile range 27-34) and 55.6% of participants had at least one previous livebirth (n=286). When compared with women with interpregnancy intervals of 6-18 months (n=136), women with intervals of less than 3 months (n=124) had the lowest risk of repeat miscarriage (7.3% compared with 22.1%; adjusted hazard ratio 0.33, 95% CI 0.16-0.71). Neither maternal race nor parity modified the association. Attempting to conceive immediately was not associated with increased risk of miscarriage in the next pregnancy.

CONCLUSION

An interpregnancy interval after pregnancy loss of less than 3 months is associated with the lowest risk of subsequent miscarriage. This implies counseling women to delay conception to reduce risk of miscarriage may not be warranted.

The impact of pregnancy loss on men's health and wellbeing: a systematic review

Background

Research indicates that men’s psychological and physical health outcomes after pregnancy loss differ from those of women. Our goal was to identify all literature with a focus on men’s experiences of pregnancy loss in order to outline current evidence concerning men’s wellbeing.

Methods

A systematic review of literature on men and pregnancy loss was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Joanna Briggs Institute (JBI) and Social Care Institute for Excellence (SCIE) guidelines. Literature was sourced from PsycINFO, PubMed, Scopus, CINAHL, and Google Scholar. Inclusion criteria were 1) studies that focused on pregnancy loss (including miscarriage, stillbirth, and ectopic pregnancy, 2) that men’s voices were specifically represented, and 3) that studies were of primary data.

Results

A final sample of 29 articles was identified, of which 16 were quantitative, 10 qualitative, and 3 mixed methods. Quantitative and mixed methods studies indicated that while men tended to have less intense and less enduring levels of negative psychological outcomes than women, they are more likely to engage in compensatory behaviours, such as increased alcohol consumption. Qualitative studies indicated that men often feel that their role is primarily as a ‘supporter’ to their female partner, and that this precludes recognition of their own loss. These studies also reported that men may feel overlooked and marginalised in comparison to their female partners, whose pain is typically more visible.

Conclusions

Further research is needed on men’s experiences of pregnancy loss, focusing on cultural differences. The experience of gay and/or transgender men who face pregnancy loss is overlooked in the literature to date.

Psychological and support interventions to reduce levels of stress, anxiety or depression on women's subsequent pregnancy with a history of miscarriage: an empty systematic review

OBJECTIVE

The aim of this systematic review was to assess the effect of interventions to reduce stress in pregnant women with a history of miscarriage.

DESIGN

A systematic review of randomised controlled trials (RCTs).

DATA SOURCE

A total of 13 medical, psychological and social electronic databases were searched from January 1995 to April 2016 including PUBMED, CENTRAL, Web of Science and EMBASE.

ELIGIBILITY CRITERIA

This review focused on women in their subsequent pregnancy following miscarriage. All published RCTs which assessed the effect of non-medical interventions such as counselling or support interventions on psychological and mental health outcomes such as stress, anxiety or depression when compared with a control group were included. Stress, anxiety or depression had to be measured at least preintervention and postintervention.

RESULTS

This systematic review found no RCT which met our initial inclusion criteria. Of the 4140 titles screened, 17 RCTs were identified. All of them were excluded. One RCT, which implemented a caring-based intervention, included pregnant women in their subsequent pregnancy; however, miscarriage was analysed as a composite variable among other pregnancy losses such as stillbirth and neonatal death. Levels of perceived stress were measured by four RCTs. Different types of non-medical interventions, time of follow-up and small sample sizes were found.

CONCLUSION

Cohort studies and RCTs in non-pregnant women suggest that support and psychological interventions may improve pregnant women's psychological well-being after miscarriage. This improvement may reduce adverse pregnancy-related outcomes in subsequent pregnancies. However, this review found no RCTs which met our criteria. There is a need for targeted RCTs that can provide reliable and conclusive results to determine effective interventions for this vulnerable group.

Women's persistent depressive and perinatal grief symptoms following a miscarriage: the role of childlessness and satisfaction with healthcare services

The objectives of this cross-sectional study were to determine whether depressive and perinatal grief symptoms vary according to time since miscarriage and to test whether childlessness and satisfaction with healthcare services influence symptom duration. A total of 245 women who had experienced a miscarriage answered a self-report questionnaire, indicating the date of their miscarriage and assessing their present level of depressive and perinatal grief symptoms. They also provided sociodemographic characteristics and indicated their level of satisfaction with healthcare services. One-way analyses of variance indicated that women who had miscarried within the past 6 months reported higher scores for depressive symptoms than did women who had miscarried between 7 and 12 months ago and more than 2 years ago. However, when controlling for childlessness and satisfaction with healthcare services, those differences became respectively marginal and non-significant, indicating that depressive symptoms are similar across time for more than 2 years after the loss. Regarding perinatal grief, results revealed that symptoms significantly decreased across time only for women with children and women who were satisfied with healthcare services. For childless women and those dissatisfied with healthcare services, perinatal grief symptoms did not vary according to time since miscarriage. Results suggest that, particularly for women who are childless and/or dissatisfied with healthcare services, depressive and perinatal grief symptoms persist long after a miscarriage. These results highlight the importance of paying particular attention to more vulnerable women and of improving healthcare services post-miscarriage.

Cytogenetic analysis of the retained products of conception after missed abortion following blastocyst transfer: a retrospective, large-scale, single-centre study

Cytogenetic analysis of the retained products of conception (POC) is the most effective test for identifying miscarriage causes. However, there has been no large-scale study limited to blastocyst transfer. This study retrospectively reports the findings of 1030 cases in which POC analysis was performed after missed abortion following single blastocyst transfer performed at the Shinbashi Yume Clinic. We identified 19.4% as normal karyotypes and 80.6% as aneuploid. These cases broke down into: 62.3% trisomy; 7.8% double trisomy; 0.5% triple or quadruple trisomy; 1.3% monosomy 21; 3.2% monosomy X; 0.1% 47,XXY; 1.0% polyploidy; 1.0% mixed; 1.1% embryonic mosaicism; and 2.4% structural anomalies. In samples with normal karyotypes, 49.5% were female while 50.5% were male. The occurrence of trisomy and double trisomy were both significantly more frequent in the ≥38 years group than in the ≤37 years group (P < 0.01). Trisomy was significantly more frequently associated with fetal heartbeat (P < 0.01); double trisomy, polyploidy and normal karyotype were significantly more frequent with no fetal heartbeat (P < 0.01). There was no significant difference in the frequency of chromosomal abnormalities between the number of miscarriages or blastocyst quality. Thus, POC cytogenetic testing is highly valuable for ascertaining the cause of miscarriage.

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

OBJECTIVES

This is a pilot study to investigate the type and severity of emotional distress in women after early pregnancy loss (EPL), compared with a control group with ongoing pregnancies. The secondary aim was to assess whether miscarriage or ectopic pregnancy impacted differently on the type and severity of psychological morbidity.

DESIGN

This was a prospective survey study. Consecutive women were recruited between January 2012 and July 2013. We emailed women a link to a survey 1, 3 and 9 months after a diagnosis of EPL, and 1 month after the diagnosis of a viable ongoing pregnancy.

SETTING

The Early Pregnancy Assessment Unit (EPAU) of a central London teaching hospital.

PARTICIPANTS

We recruited 186 women. 128 had a diagnosis of EPL, and 58 of ongoing pregnancies. 11 withdrew consent, and 11 provided an illegible or invalid email address.

MAIN OUTCOME MEASURES

Post-traumatic stress disorder (PTSD) was measured using the Post-traumatic Diagnostic Scale (PDS), and anxiety and depression using the Hospital Anxiety and Depression Scale (HADS).

RESULTS

Response rates were 69/114 at 1 month and 44/68 at 3 months in the EPL group, and 20/50 in controls. Psychological morbidity was higher in the EPL group with 28% meeting the criteria for probable PTSD, 32% for anxiety and 16% for depression at 1 month and 38%, 20% and 5%, respectively, at 3 months. In the control group, no women met criteria for PTSD and 10% met criteria for anxiety and depression. There was little difference in type or severity of distress following ectopic pregnancy or miscarriage.

CONCLUSIONS

We have shown a large number of women having experienced a miscarriage or ectopic pregnancy fulfil the diagnostic criteria for probable PTSD. Many suffer from moderate-to-severe anxiety, and a lesser number depression. Psychological morbidity, and in particular PTSD symptoms, persists at least 3 months following pregnancy loss.

Signs and Symptoms of Early Pregnancy Loss

Approximately one-third of pregnancies end in loss; however, the natural history of early pregnancy loss, including signs and symptoms preceding loss, has yet to be fully described and its underlying mechanisms fully understood. We searched PubMed/MEDLINE and Embase to identify articles with prospective ascertainment of signs and symptoms, including vaginal bleeding, nausea, and vomiting, of pregnancy loss < 20 weeks gestation in spontaneous conceptions to ascertain existing literature on symptomatology of pregnancy loss. Two preconception and 16 pregnancy cohort studies that ascertained information on bleeding and/or nausea/vomiting prior to pregnancy loss ascertainment were included. Data from these studies indicated increased risk of loss with vaginal bleeding and decreased risk of loss with nausea/vomiting, though these studies were mostly comprised of pregnancies surviving into late first trimester. While such associations are biologically plausible, these study designs are subject to bias, given recruitment of women at later gestational ages and reliance on women presenting to care. Reporting symptoms to clinicians and over long periods may introduce reporting error. Data gaps remain regarding (1) relationships between signs and symptoms and losses occurring very early, prior to care entry; (2) empirical testing of whether relationships between signs and symptoms and loss differ across gestational age; (3) whether similar relationships between signs and symptoms and loss are observed in populations using assisted reproductive technologies; (4) the patterning of multiple signs and symptoms in relation to loss; and (5) how hormonal and physiologic adaptions to early pregnancy relate to symptomatology and pregnancy loss.

First trimester pregnancy loss after fresh and frozen in vitro fertilization cycles

OBJECTIVE

To characterize risks for early pregnancy loss after fresh and frozen IVF cycles and to investigate whether risk is modified by infertility diagnoses or transfer of embryos in fresh versus frozen cycles.

DESIGN

Retrospective cohort study using data from the National Assisted Reproductive Technology (ART) Surveillance System.

SETTING

Fertility centers.

PATIENT(S)

Clinical pregnancies achieved with fresh and frozen IVF cycles between 2007 and 2012 (N = 249,630).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

First trimester pregnancy loss.

RESULT(S)

A diagnosis of uterine factor was associated with an increased risk of loss in women aged 40 years and younger (<30 years: adjusted risk ratio (aRR) = 1.24, 95% confidence interval (CI) 1.04-1.48; 30-34 years: aRR = 1.27, 95% CI 1.17-1.38; 35-37 years: aRR = 1.12, 95% CI 1.03-1.21; 38-40 years: aRR = 1.08, 95% CI 1.01-1.17). There was an increased risk of loss in women with diminished ovarian reserve aged 30-34 years (aRR = 1.08, 95% CI 1.01-1.15) and in women with ovulatory dysfunction younger than 35 years (<30 years: aRR = 1.12, 95% CI 1.05-1.19; 30-34 years: aRR = 1.07, 95% CI 1.02-1.13). There was an increased risk of loss after frozen ETs versus fresh among women younger than 38 years, but this remained significant in the subanalysis of similar quality embryos only in women younger than 30 years (aRR = 1.16, 95% CI 1.04-1.32).

CONCLUSION(S)

Uterine factor had the largest increased risk of loss among infertility diagnoses, although the magnitudes of all risks were small. When transferring embryos of similar quality, the risks of loss were similar between fresh and frozen cycles.

A national survey on public perceptions of miscarriage

OBJECTIVE

To assess attitudes and perceptions of U.S. survey respondents regarding prevalence, causes, and emotional effects of miscarriage.

METHODS

We used a questionnaire consisting of 33 questions administered in January of 2013 to men and women aged 18-69 years across the United States.

RESULTS

Participants from 49 states completed the questionnaire: 45% male and 55% female (N=1,084). Fifteen percent reported they or their partner experienced at least one miscarriage. Fifty-five percent of respondents believed that miscarriage occurred in 5% or less of all pregnancies. Commonly believed causes of miscarriage included a stressful event (76%), lifting a heavy object (64%), previous use of an intrauterine device (28%), or oral contraceptives (22%). Of those who had a miscarriage, 37% felt they had lost a child, 47% felt guilty, 41% reported feeling that they had done something wrong, 41% felt alone, and 28% felt ashamed. Nineteen percent fewer people felt they had done something wrong when a cause for the miscarriage was found. Seventy-eight percent of all participants reported wanting to know the cause of their miscarriage, even if no intervention could have prevented it from occurring. Disclosures of miscarriages by public figures assuaged feelings of isolation for 28% of respondents. Level of education and gender had a significant effect on perceptions and understanding of miscarriage.

CONCLUSION

Respondents to our survey erroneously believed that miscarriage is a rare complication of pregnancy, with the majority believing that it occurred in 5% or less of all pregnancies. There were also widespread misconceptions about causes of miscarriage. Those who had experienced a miscarriage frequently felt guilty, isolated, and alone. Identifying a potential cause of the miscarriage may have an effect on patients' psychological and emotional responses.

LEVEL OF EVIDENCE

II.

Gender-specific mental health care needs of women veterans treated for psychiatric disorders in a Veterans Administration Women's Health Clinic

OBJECTIVE

This pilot study aims to ascertain the prevalence of self-reported premenstrual, perinatal, and perimenopausal influences on mental health, and of gynecologic conditions that could interact with psychiatric conditions, among women veterans receiving psychiatric care within a Veterans Administration (VA) Women's Health Clinic (WHC).

METHODS

Participants included all women veterans (N=68) who received psychiatric evaluations within a VA WHC over a 5-month period. This setting encompasses colocated and coordinated primary care, gynecologic and mental health services. Evaluations included a Women's Mental Health Questionnaire, a psychiatric interview, and medical record review. Deidentified data were extracted from a clinical data repository for this descriptive study.

RESULTS

High proportions of study participants reported that their emotional problems intensified premenstrually (42.6%), during pregnancy (33.3%), in the postpartum period (33.3%), or during perimenopause (18.2%). Unintended pregnancy (70.0% of pregnancies) and pregnancy loss (63.5% of women who had been pregnant) were prominent sex-linked stressors. Dyspareunia (22.1% of participants) and pelvic pain (17.6% of participants) were frequent comorbidities.

CONCLUSIONS

Among women veterans receiving psychiatric care within a VA WHC, there are high rates of self-reported premenstrual, perinatal, and perimenopausal influences on mental health. This population also has substantial comorbidity of psychiatric disorders with dyspareunia and pelvic pain. This underscores the importance of recognizing and addressing women veterans' sex-specific care needs, including interactions among reproductive cycle phases, gynecologic pain, and psychiatric symptoms. The findings support the need for greater awareness of the sex-specific mental health needs of women veterans, and for more definitive studies to further characterize these needs.