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Psychological Aftermaths of Pregnancy Loss

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Psychological Aftermaths of Pregnancy Loss OHSUPsychological Aftermaths of Pregnancy Loss Teni Davoudian, PhD, ABPP Clinical Psychologist Assistant Professor in Psychiatry & Ob/Gyn November 15, 2019 Grief • Grief has physical, emotional, spiritual, and social components • Non-linear process o States rather than stages of grief • OHSUAnger is component of grief 2 Pregnancy Loss Grief • Facilitates bond with deceased as a coping strategy • “Prospective” grieving for the life and relationship projected into the future (versus retrospective grieving) • Peaks at 6 months • Women also grieving: OHSUo Loss of confidence in one’s body o Loss of confidence in medicine o Loss of control 3 Grief vs. Major Depression Grief Major Depression Course Decreases over time Persistent depressed mood Waves of grief (triggered by thoughts/reminders of the deceased) Emotional Normal to experience positive emotions and Pervasive unhappiness Spectrum laughter while grieving Misery Fluctuating ability to feel pleasure Cognitive Thoughts and memories of deceased Self-critical thoughts Processes Negative ruminations Self-Esteem Mostly preserved through grief process Lowered self-esteem OHSU Some concerns about “failing” the deceased Self-loathing Worthlessness Suicidal Ideation If SI occurs, it is in the context of reuniting Focused on ending one’s life with the deceased due to feelings of worthlessness and perceived inability to cope with depression 4 Comorbid Psych Dx • Major Depressive Disorder o RPL: 5x more likely to develop moderate/severe depression (Kolte, 2015) • Generalized anxiety disorder o RPL: Increased severity of generalized anxiety (Fertl et al, 2009) OHSU• PTSD (Englehard, 2004) • Guilt, self-blame, and isolation (Bardos et al., 2015) • No validated psych screenings specific to pregnancy loss 5 Public Perceptions of Miscarriage • Majority believe that miscarriage occurs <5% of pregnancies (Bardos et al., 2015) • Believed causes of miscarriage: o 95% genetic abnormalities o 76% stressful event o 64% lifting heavy object o 31% past abortion o 28% previous use of IUD OHSUo 21% getting into an argument • Possible psychological results of misconceptions: o Feelings of isolation and guilt among women who experience miscarriage(s) 6 Public Perceptions of Miscarriage • Emotional reactions of women with history of miscarriage(s): (Bardos et al., 2015) o 47% felt guilty o 41% reported that they had done something wrong o 41% felt alone o 28% felt ashamed o 19% blamed self even when cause of miscarriage OHSUfound 7 Pregnancy Loss & Relationships • Gap in literature regarding experiences of same-sex couples, transgender individuals, single parents by choice • Discordant/incongruent grief among men and women in heterosexual relationships (Serrano & Lima, 2006) • Sexuality following pregnancy loss: (Zhang et al., 2016) o Women: lowered libido OHSUo Men: decreased sexual satisfaction, increased erectile dysfunction • Higher risk of relationship dissolution for up to 3 years after loss (Gold, Sen, & Hayward, 2010) 8 Other Stakeholders • Surviving sibling(s) grieve: (Calister, 2006) o Loss of their expected sibling o Loss of the parents as they knew them prior to the loss • Supporting grieving children: o Recognize and acknowledge the child’s grief o Read children’s books about death (Erlandsson et al., 2010) OHSUo Allow children to witness some of parent’s grief (Erlandsson et al., 2010) 9 IUFD & Stillbirth • Elevated anxiety and depression for 2 years following IUFD (Cacciatore et al., 2008) • Higher risk of relationship dissolution for up to 9-10 years after IUFD (Gold, Sen, & Hayward, 2010) • IUFD has no major impact on women’s QoL or risk of experiencing depression 18 years after loss (Gravensteen et al., 2012) • Interventions that may mitigate long-term psychopathology: (Gravensteen et al., 2012) OHSUo Postpartum consultation with the obstetrician or midwife o Meeting with a psychologist/psychiatrist o Follow-up from PCP o Consultation with a religious counsellor 10 Supporting Patients • Following a loss, patients desire: (Evans, 2012; Koert et al., 2018; Munsters et al., 2011) o Inclusion of partner in consultations and treatments o Reliable and accurate information about miscarriages o Attention to both physical and psychological aspects of miscarriage OHSUo Access to psychological treatment o Practical advice about lifestyle and diet o Written information 11 Supporting Patients • Mimic patient’s vocabulary regarding fetus • Ask open ended questions • Depending on gestational age, inquire about patient’s intent or interest in memorializing the fetus • If appropriate, remind patient that she is not to be blamed o Women who receive reassurance from their providers following a loss report less guilt and self-blame (Corbett-Owen & OHSUKruger, 2001) • Avoid comments that may trivialize the patient’s loss • Who are you trying to comfort? The patient(s) or yourself? 12 Patient Care Factors to Consider • Setting (Covington, 2009) o Privacy? Patient dressed? • Perception of patient(s) o Assess her/his/their understanding of the loss • Invite emotional reactions OHSUo “Would you like to talk about how you’re feeling right now?” • Provide plan for next steps o What happens next? Which medical providers will be there? 13 Resources Books: • Conquering Infertility: Dr. Alice Domar's Mind/Body Guide to Enhancing Fertility and Coping with Infertility By Alice Domar, PhD • Not Broken: An Approachable Guide to Miscarriage and Recurrent Pregnancy Loss By Lora Shahine • Loved Baby: 31 Devotions Helping You Grieve and Cherish Your Child after Pregnancy Loss OHSUBy Sarah Philpott, PhD Support Groups: • Resolve Support Group • Brief Encounters 14 References • Abboud, L., & Liamputtong, P. (2005). When pregnancy fails: coping strategies, support networks and experiences with health care of ethnic women and their partners. Journal of Reproductive and Infant Psychology, 23(1), 3-18. • Armstrong, D. (2001). Exploring fathers’ experiences of pregnancy after a prior perinatal loss. MCN: The American Journal of Maternal/Child Nursing, 26(3), 147-153. • Bardos, J., Hercz, D., Friedenthal, J., Missmer, S. A., & Williams, Z. (2015). A national survey on public perceptions of miscarriage. Obstetrics and gynecology, 125(6), 1313. • Cacciatore, J., Rådestad, I., & Frederik Frøen, J. (2008). Effects of contact with stillborn babies on maternal anxiety and depression. Birth, 35(4), 313-320. OHSU• Callister, L. C. (2006). Perinatal loss: A family perspective. Journal of Perinatal and Neonatal Nursing, 20(3), 227-234. • Corbet-Owen, C., & Kruger, L. M. (2001). The health system and emotional care: Validating the many meanings of spontaneous pregnancy loss. Families, Systems, & Health, 19(4), 411. • Covington, S. N. (2009). Pregnancy Loss: A Protocol to Help Patients COPE. Topics in Obstetrics & Gynecology, 29(9), 1-7. 15 References • Due, C., Chiarolli, S., & Riggs, D. W. (2017). The impact of pregnancy loss on men’s health and wellbeing: a systematic review. BMC Pregnancy and Childbirth, 17(1), 380. • Engelhard, I. M. (2004). Miscarriage as a traumatic event. Clinical obstetrics and gynecology, 47(3), 547-551. • Erlandsson, K., Avelin, P., Saflund, K., Wredling, R., & Radestad, I. (2010). Siblings’ farewell to a stillborn sister or brother and parents’ support to their older children: a questionnaire study from the parents’ perspective. Journal of Child Health Care, 14(2), 151-160. • Fertl, K. I., Bergner, A., Beyer, R., Klapp, B. F., & Rauchfuss, M. (2009). Levels and effects of different forms of anxiety during pregnancy after a prior miscarriage. European Journal of Obstetrics & Gynecology and Reproductive Biology, 142(1), 23-29. • Gameiro, S., van den Belt-Dusebout, A. W., Bleiker, E., Braat, D., van Leeuwen, F. E., & Verhaak, C. M. (2014). Do children OHSUmake you happier? Sustained child-wish and mental health in women 11–17 years after fertility treatment. Human Reproduction, 29(10), 2238-2246. • Gissler, M., Hemminki, E., & Lonnqvist, J. (1996). Suicides after pregnancy in Finland, 1987–94: register linkage study. Bmj, 313(7070), 1431-1434. • Gravensteen, I. K., Helgadottir, L. B., Jacobsen, E. M., Sandset, P. M., & Ekeberg, Ø. (2012). Long-term impact of intrauterine fetal death on quality of life and depression: a case–control study. BMC pregnancy and childbirth, 12(1), 43. 16 References • Gold, K. J., Sen, A., & Hayward, R. A. (2010). Marriage and cohabitation outcomes after pregnancy loss. Pediatrics, 125(5), e1202-e1207. • He, L., Wang, T., Xu, H., Chen, C., Liu, Z., Kang, X., & Zhao, A. (2019). Prevalence of depression and anxiety in women with recurrent pregnancy loss and the associated risk factors. Archives of gynecology and obstetrics, 1-6. • Kersting, A., Dölemeyer, R., Steinig, J., Walter, F., Kroker, K., Baust, K., & Wagner, B. (2013). Brief internet-based intervention reduces posttraumatic stress and prolonged grief in parents after the loss of a child during pregnancy: a randomized controlled trial. Psychotherapy and Psychosomatics, 82(6), 372-381. • Kolte, A. M., Olsen, L. R., Mikkelsen, E. M., Christiansen, O. B., & Nielsen, H. S. (2015). Depression and emotional stress is highly prevalent among women with recurrent pregnancy loss. Human Reproduction, 30(4), 777-782. • Koert, E., Malling, G. M. H., Sylvest, R., Krog, M. C., Kolte, A. M., Schmidt, L., & Nielsen, H. S. (2018). Recurrent pregnancy loss: couples’ perspectives on their need for treatment, support and follow up. Human Reproduction, OHSU34(2), 291-296. • Lok, I. H., & Neugebauer, R. (2007). Psychological morbidity following
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