Early pregnancy loss is common, affecting up to 25% of pregnancies.  Studies looking at the emotional consequences of miscarriage have shown that most women do well; however, some women experience clinically significant symptoms of depression and anxiety. Other studies have demonstrated that many women also experience symptoms of post-traumatic stress disorder (PTSD).

Most of these studies have focused on psychological symptoms during the first few months after miscarriage; a recent study has followed women over a longer period of time, examining levels of posttraumatic stress, depression, and anxiety in women during the nine months after early pregnancy loss.

In this prospective cohort study, women were recruited from antenatal clinics at three London hospitals.  Participants received emailed surveys which included the Hospital Anxiety and Depression Scale and Posttraumatic stress Diagnostic Scale at 1, 3, and 9 months after the loss. 

Of the 737 women who experienced an early pregnancy loss, 493 women (67%) completed an assessment at 1 month, 426 women (58%) at 3 months, and 338 women (46%) at 9 months.  Criteria for posttraumatic stress were met in 29% of women with early pregnancy loss after 1 month and in 18% after 9 months.  Moderate to severe anxiety was reported in 24% of the women after 1 month and in 17% after 9 months. Moderate to severe depression was reported in 11% of the women after 1 month and 6% of the women after 9 months.

Compared to women with viable pregnancies, women who had an early pregnancy loss were about twice as likely to report moderate to severe anxiety (odds ratio 2.14) and nearly four times as likely to report moderate to severe depression (OR 3.88).

One of the strengths of this study is that it follows women for a longer period than previous studies; however, one of its limitations is that only about half of the women made it to the end of the study.  That said, its findings are consistent with previous studies, showing that about a third of the women experience high levels of anxiety and PTSD symptoms during the first three months after an early pregnancy loss.   

Over time, the number of affected women subsides; however, at nine months 18% of the women continue to report PTSD symptoms and 17% report moderate to severe anxiety.  

Typically women who have an early pregnancy loss do not receive any specific medical or psychological follow up.  Obviously the emotional symptoms a women may experience after a pregnancy loss can affect a woman’s quality of life and her ability to function, but we also need to be aware of the long-term effects of these experiences.  Some but not all studies suggest that stress and anxiety experienced by the mother may decrease her ability to conceive

If these symptoms do not resolve and carry into a subsequent pregnancy, there may be other risks.  Recent studies have demonstrated that women with PTSD symptoms during pregnancy have worse outcomes.  In one study, infants born to mothers with PTSD had lower mean birth weights than infants born to mothers without PTSD.  In addition, multiple studies have shown that women with PTSD are more likely to experience preterm birth.

It is, unfortunately, easy for these women to fall through the cracks.  We do not routinely screen for depression or anxiety after pregnancy loss, and after losing a pregnancy, women might not see their obstetric provider until they are pregnant again.  Thus, we must make an effort to educate women about the psychological symptoms they may experience after a pregnancy loss and we must help them to access mental health services, if needed.  

 

Ruta Nonacs, MD PhD

 

Farren J, Jalmbrant M, Falconieri N, Mitchell-Jones N, Bobdiwala S, Al-Memar M, Tapp S, Van Calster B, Wynants L, Timmerman D, Bourne T.  Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multicenter, prospective, cohort study.   Am J Obstet Gynecol. 2019 Dec 13.