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 miscarriage. Best Practice & Research Clinical Obstetrics & Gynaecology, 21(2), 229-247.

• Lok, I. H., Yip, A. S. K., Lee, D. T. S., Sahota, D., & Chung, T. K. H. (2010). A 1-year longitudinal study of psychological morbidity after miscarriage. Fertility and sterility, 93(6), 1966-1975.

17 References

• Magee, P. L., MacLeod, A. K., Tata, P., & Regan, L. (2003). Psychological distress in recurrent miscarriage: the role of prospective thinking and role and goal investment. Journal of Reproductive and Infant Psychology, 21(1), 35-47.

• Musters, A. M., Taminiau-Bloem, E. F., van den Boogaard, E., van der Veen, F., & Goddijn, M. (2011). Supportive care for women with unexplained recurrent miscarriage: patients’ perspectives. Human reproduction, 26(4), 873-877.

• O'Leary, J. M., & Gaziano, C. (2011). Sibling grief after perinatal loss. Journal of Prenatal & Perinatal Psychology & Health, 25(3), 173.

• Ockhuijsen, H. D., Boivin, J., van den Hoogen, A., & Macklon, N. S. (2013). Coping after recurrent miscarriage: uncertainty and bracing for the worst. J Fam Plann Reprod Health Care, 39(4), 250-256.

• Purandare, N., Ryan, G., Ciprike, V., Trevisan, J., Sheehan, J., & Geary, M. (2012). Grieving after early pregnancy loss- -a common reality.) Irish Medical Journal, 105.

OHSU• Saraiya M, Green CA, Berg CJ, Hopkins FW, Koonin LM, Atrash HK (1999) Spontaneous abortion – related deaths among women in the United States – 1981–1991. Obstet Gynecol 94:172–176

• Serrano, F., & Lima, M. L. (2006). Recurrent miscarriage: psychological and relational consequences for couples. Psychology and Psychotherapy: Theory, Research and Practice, 79(4), 585-594

18 References

• Turton, P., Badenhorst, W., Hughes, P., Ward, J., Riches, S., & White, S. (2006). Psychological impact of stillbirth on fathers in the subsequent pregnancy and puerperium. The British Journal of Psychiatry, 188(2), 165-172

• Wilson, R. E. (2001). Parents’ support of their other children after a miscarriage or perinatal death. Early Human Development, 61(1), 55-65.

• Zhang, Y. X., Zhang, X. Q., Wang, Q. R., Yuan, Y. Q., Yang, J. G., Zhang, X. W., & Li, Q. (2016). Psychological burden, sexual satisfaction and erectile function in men whose partners experience recurrent pregnancy loss in China: a OHSUcross-sectional study. Reproductive health, 13(1), 73.

19 Questions? Contact me OHSU Physician Advice & Referral Service •503-494-4567 OHSU•800-245-6478 (toll-free)

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