Between 12-15% of pregnancies end in a first trimester,
recognizable pregnancy loss. This may be a spontaneous
miscarriage or a "missed miscarriage" requiring
a D&C. Because this type of loss is so common,
it is often underestimated as a source of emotional
problems. It may or may not be surprising that rates
of depression are reported as high as 22-55% in the
year following a miscarriage. Grief, anger, anxiety
and panic are also reactions that may accompany pregnancy
loss.
There was a good summary review of this problem in
a recent article, Broquet K: Psychological reactions
to pregnancy loss. Prim Care Update Ob/Gyn 1999; 6:12-16.
It points out how a woman feels a sense of oneness
with the fetus in early pregnancy and it represents
her hopes and dreams. This tends to magnify the loss
and when very few support people are aware that a
miscarriage has taken place, the usual social customs
to recognize the loss are missing.
What are the circumstances that contribute to a strong
emotional reaction to an early pregnancy loss?
The greatest contributor to emotional reaction is
that a woman looks at the early pregnancy as part
of herself and when it is lost, there is an emptiness,
searching and incompleteness feeling because the fetus
is not viewed as a separate being. Also, the connection
to the fetus is much stronger for the woman than for
her partner and there is a great difference in the
intensity of the grieving process between the mother
and father. A woman becomes isolated because of this
and often has no emotional support for her feelings.
Even the usual social rituals of a death notice, a
funeral, and friends offering sympathy are absent
because very few people usually know of the event.
This prevents accepting the reality of the loss. If
there was any ambivalence about the pregnancy in the
first place guilt becomes a major component of the
grieving process.
What tasks are necessary to resolve the grief of
a pregnancy loss?
Workers is this field have identified four tasks to
be accomplished to work through the grieving process
in a psychologically constructive way. The general
time it takes is as much as 12-18 months after the
loss.
Accept the reality of the loss -- if the miscarriage
takes place before friends and family know of the
pregnancy, sharing the loss with others may help or
even some sort of commemorative steps either public
or private. If the pregnancy loss is further along,
a burial ceremony or even just holding the fetus can
help.
Allow experiencing the pain of grief -- if the grieving
process is suppressed, it is more likely to result
in psychological reactions. The woman needs to consciously
grieve for lost dreams. This process will wax and
wane but should not be suppressed by drugs, alcohol
or even the rapid attempt to become pregnant again
so as to relieve the pain more quickly.
Adjust to the new situation without the lost child
-- a woman must change her perception that part of
herself is lost. She needs to resume her role and
self-identity at least as it was prior to becoming
pregnant.
Reinvest emotional energy in new relationships --
a woman recovers and benefits from building new ties
and nourishing the relationships already present.
What are the psychiatric consequences of pregnancy
loss if the grief process does not progress to resolution?
The most common problems are depression and anxiety.
The general rate of depression in women is about 10-15%.
After miscarriage, this rate is reported to be 22-55%
and takes 12 months to return to the baseline rate
of depression in the general community. The highest
risk time for depression is the first 12 weeks after
a pregnancy loss. Risk factors for developing clinical
depression include previous depression, the further
along in pregnancy that the loss occurred, a history
of substance or alcohol abuse, a poor support system
and a history of poor coping skills.
Community rates of generalized anxiety or panic disorder
are about 3-5% in women. In the first 12 weeks after
a pregnancy loss, 22-41% of women demonstrate these
problems. As with depression these rates tend to return
to baseline community rates within 12 months. Compulsive
behaviors may increase during this time. Women who
have had previous pregnancy loss are at greater risk
of developing depression and anxiety in subsequent
pregnancies.
How do you know if the emotional reactions are just
normal grief or if they have gone into a full depression?
Sadness, mild depression, guilt, anger, fatigue and
somatic complaints are common to both grief and to
a clinical depression. Grief will result more in disbelief,
feelings of failure as a woman, and searching for
meaning or the loss, while major depression has strong
feelings of worthlessness, early morning awakening
and persistent suicidal thoughts. Specific symptoms
that require medical intervention include:
serious or persistent suicidal thoughts
significant feelings of worthlessness
terminal insomnia - falling asleep ok but awakening
predawn with increased anxiety or abnormal fear
significant physical listlessness or agitation
marked daily functioning difficulty - not eating,
not bathing, unable to work or care for children
prolonged symptoms (greater than one year)
drug or alcohol abuse or significant increase in use
Is the emotional reaction to an induced abortion
the same as it is to a miscarriage?
In general, the rate of emotional problems after elective
abortion are no greater than that of the general population
unless there has been a previous history of depression
or if the woman feels she was coerced into the abortion
or that it was morally wrong. In those cases, emotional
problems follow the same rate as an unexpected pregnancy
loss.
What can be done to help a woman who is having an
emotional reaction to a pregnancy loss?
Certain interventions have been shown to reduce the
rate of psychologic problems after a pregnancy loss.
The best preventative is a "crisis debriefing"
within the first 2-3 weeks after the miscarriage.
This would include giving a woman an opportunity to
discuss her feelings about what happened and making
sure she has the correct factual information such
as "it was not due to anything you did or did
not do". Also, resources for emotional support
should be identified at that time and if there are
not many within the existing family or social structure,
referring to support groups and recommending reading
materials on common reactions to miscarriage and grief.
There also should be some ongoing monitoring for depression
or anxiety reactions in the next year to make sure
the process is resolving.
Some additional interventions are:
Acknowledge the loss and educate the woman about
the natural grief response
Encourage use of family, friends and support groups
Provide reading materials
Encourage expression of feelings, including anger,
in a nondestructive manner
Address guilt with reassurance about reasons for loss
and future fertility
Ask directly about suicidal thoughts
Monitor for excessive anxiety, depression, substance
or alcohol use/abuse and refer if present
Monitor for marital discord which is common after
a pregnancy loss
Monitor for depression, anxiety, or grieving in subsequent
pregnancy
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