The psychological impact of early pregnancy loss

Recurrent Miscarriage: Diagnostic and Therapeutic Procedures. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/050, May 2022)

Purpose The aim of this guideline is to standardize the diagnosis and therapy of recurrent miscarriage (RM) using evidence from the recent literature. This is done by using consistent definitions, objective evaluations and standardized treatment protocols.

Methods When this guideline was compiled, special consideration was given to previous recommendations in prior versions of this guideline and the recommendations of the European Society of Human Reproduction and Embryology, the Royal College of Obstetricians and Gynecologists, the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine, and a detailed individual search of the literature about the different topics was carried out.

Recommendations Recommendations about the diagnostic and therapeutic procedures offered to couples with RM were developed based on the international literature. Special attention was paid to known risk factors such as chromosomal, anatomical, endocrinological, physiological coagulation, psychological, infectious and immune disorders. Recommendations were also developed for those cases where investigations are unable to find any abnormality (idiopathic RM).

The association of smoking, use of snuff, and preconception alcohol consumption with spontaneous abortion: A population-based cohort study

INTRODUCTION

It is unclear whether tobacco in early pregnancy and alcohol use preceding pregnancy are associated with spontaneous abortion. The purpose was to investigate if use of tobacco and/or alcohol is associated with spontaneous abortion among women attending antenatal care, and if age and body mass index (BMI) attenuate the risk.

MATERIAL AND METHODS

A population-based cohort study based on data from the Swedish Pregnancy Register. All pregnant women having had the first antenatal visit from January 2014 to July 2018 were included (n = 525 604). The register had information about smoking and use of snuff before and in early pregnancy, as well as data on alcohol habits before pregnancy, measured by the Alcohol Use Disorders Identification Test (AUDIT), a validated questionnaire. Logistic regression analysis was used to estimate the association between lifestyle factors and spontaneous abortion, and multiple imputation was used to impute missing data.

RESULTS

In total, 34 867 (6.6%) pregnancies ended in a spontaneous abortion after the first visit to maternal health care. At the first maternal healthcare visit, daily smoking was reported by 24 214 (5.1%), and 6403 (1.2%) used snuff. For 19 837 (4.2%) women, a high alcohol score was reported for the year preceding pregnancy. After adjusting for potential confounders and multiple imputation, use of tobacco was associated with spontaneous abortion; smoking 1-9 cigarettes/day (adjusted odds ratio [aOR] 1.11, 95% confidence interval [CI] 1.04-1.18), smoking 10 or more cigarettes/day (aOR 1.12, 95% CI 1.-1.26), and use of snuff (aOR 1.20, 95% CI 1.06-1.37). Higher AUDIT scores were not significantly associated with spontaneous abortion (AUDIT 6-9: aOR 1.03, 95% CI 0.97-1.10 and AUDIT 10 or more: aOR 1.07, 95% CI 0.94-1.22). Increasing maternal age showed the highest risk of spontaneous abortion from the age of 35, and BMI of 30 kg/m² or more increased the risk. There were interactions between different lifestyle factors associated with spontaneous abortion that could either increase or decrease the risk of spontaneous abortion.

CONCLUSIONS

Smoking and use of snuff were associated with an increased risk of spontaneous abortion. The AUDIT scores preceding pregnancy were not associated with an increased risk of spontaneous abortion, which contradicts the results from previous studies.

Outdoor Air Pollution and Pregnancy Loss: a Review of Recent Literature

Purpose of Review

This review summarizes recent literature about the impacts of outdoor air pollution on pregnancy loss (spontaneous abortion/miscarriage and stillbirth), identifies challenges and opportunities, and provides recommendations for actions.

Recent Findings

Both short- and long-term exposures to ubiquitous air pollutants, including fine particulate matter < 2.5 and < 10 μm, may increase pregnancy loss risk. Windows of susceptibility include the entire gestational period, especially early pregnancy, and the week before event. Vulnerable subpopulations were not consistently explored, but some evidence suggests that pregnant parents from more disadvantaged populations may be more impacted even at the same exposure level.

Summary

Given environmental conditions conductive to high air pollution exposures become more prevalent as the climate shifts, air pollution’s impacts on pregnancy is expected to become a growing public health concern. While awaiting larger preconception studies to further understand causal impacts, multi-disciplinary efforts to minimize exposures among pregnant women are warranted.

Automated prediction of early spontaneous miscarriage based on the analyzing ultrasonographic gestational sac imaging by the convolutional neural network: a case-control and cohort study

Background

It is challenging to predict the outcome of the pregnancy when fetal heart activity is detected in early pregnancy. However, an accurate prediction is of importance for obstetricians as it helps to provide appropriate consultancy and determine the frequency of ultrasound examinations. The purpose of this study was to investigate the role of the convolutional neural network (CNN) in the prediction of spontaneous miscarriage risk through the analysis of early ultrasound gestational sac images.

Methods

A total of 2196 ultrasound images from 1098 women with early singleton pregnancies of gestational age between 6 and 8 weeks were used for training a CNN for the prediction of the miscarriage in the retrospective study. The patients who had positive fetal cardiac activity on their first ultrasound but then experienced a miscarriage were enrolled. The control group was randomly selected in the same database from the fetuses confirmed to be normal during follow-up. Diagnostic performance of the algorithm was validated and tested in two separate test sets of 136 patients with 272 images, respectively. Performance in prediction of the miscarriage was compared between the CNN and the manual measurement of ultrasound characteristics in the prospective study.

Results

The accuracy of the predictive model was 80.32% and 78.1% in the retrospective and prospective study, respectively. The area under the receiver operating characteristic curve (AUC) for classification was 0.857 (95% confidence interval [CI], 0.793–0.922) in the retrospective study and 0.885 (95%CI, 0.846–0.925) in the prospective study, respectively. Correspondingly, the predictive power of the CNN was higher compared with manual ultrasound characteristics, for which the AUCs of the crown-rump length combined with fetal heart rate was 0.687 (95%CI, 0.587–0.775).

Conclusions

The CNN model showed high accuracy for predicting miscarriage through the analysis of early pregnancy ultrasound images and achieved better performance than that of manual measurement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04936-0.

“A sorrow shared …”: a qualitative content analysis of what couples with recurrent miscarriages expect from one another and their families and friends

STUDY QUESTION

When couples have to face recurrent pregnancy loss (RPL), what are the partners’ wishes and needs and what is their perception of helpful and unhelpful factors with regard to their own, their partners’ and their families’ and friends’ ways of dealing with the problem?

SUMMARY ANSWER

Women and men with repeated miscarriages want open communication about their losses, but expect a sensitive and empathetic attitude from others, not pity or trivialization.

WHAT IS KNOWN ALREADY

RPL not only causes the women affected and their partners considerable emotional distress; it also has an impact on the couples’ relationships and the way they relate to their families and friends. Studies suggest that women have a greater need than their male partners to talk about their losses and that these differences may lead to dissatisfaction and cause relational tension. In addition, men often assume a ‘mainstay’ role, supporting their partners and displaying fortitude in the face of distress. As yet, however, little research has been conducted so far on the question of what the members of couples with RPL expect from one another and from their families and friends.

STUDY DESIGN, SIZE, DURATION

The study sample consisted of 147 couples and 17 women with at least 2 miscarriages attending the special unit for RPL at the University Women’s Hospital in Heidelberg (Germany) for the first time between September 2018 and October 2020 (response rate: 82.7%). The patients were asked to participate in this combined qualitative and questionnaire study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In order to explore the wishes and needs of those affected in more detail, the free text responses obtained were examined in this study by using qualitative content analysis. Categories and subcategories were created inductively to summarize and systematize content.

MAIN RESULTS AND THE ROLE OF CHANCE

Patients affected by RPL want their partners and their families and friends to deal with the topic openly and empathically. In the partnership itself, acceptance of individual grieving modes and sharing a common goal are important factors. Men, in particular, want their partners to be optimistic in facing up to the situation. Regarding communication with family and friends, it transpired that ‘good advice’, playing the matter down, inquiries about family planning, pity and special treatment are explicitly not appreciated.

LIMITATIONS, REASONS FOR CAUTION

The sample was a convenience sample, so self-selection effects cannot be excluded. In addition, the level of education in the sample was above average. Accordingly, the sample cannot be regarded as representative. The results of the content analysis are based on the respondents’ written answers to open-ended questions in the questionnaire. Unlike qualitative interview studies, further questioning was not possible in the case of ambiguities or to request more details.

WIDER IMPLICATIONS OF THE FINDINGS

Frank and sincere communication about miscarriages and about one’s own emotions and needs should be promoted both in the partnership and among family members and friends in order to strengthen the potential of social support as a resource. Open communication about the different needs of both partners is necessary to create mutual understanding. The results show the importance not only of empathy and consideration for the couples concerned but also their desire not to be pitied. Striking a fine balance between fellow-feeling and pity may also lead to tension, and this potential dilemma should be addressed in psychosocial counselling. Overall, the study contributes to a better understanding of what couples want from their families and friends when they are attempting to come to terms with RPL and highlights potential challenges in the interaction between affected couples and their families and friends.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was received for this study. None of the authors declared any conflicts of interest.

TRIAL REGISTRATION NUMBER

DRKS00014965.

Diagnosis and management of idiopathic recurrent pregnancy loss (RPL): Current immune testing and immunomodulatory treatment practice in the United Kingdom

Recurrent pregnancy loss (RPL) affects 1.9 % of couples. Despite the severe physical, psychological, and economic impact of RPL, miscarriage care provision remains highly heterogeneous. Due to the absence of strong scientific evidence, national and international guidelines on the diagnosis and treatment of this condition remain unclear and often contradictory. In the absence of identifiable RPL-associated risk factors, when the condition is termed "idiopathic", immunological tests and immunomodulatory treatments are sometimes suggested even though the contribution of aberrant immune activity to this condition remains undetermined. Through an online survey, distributed across the UK (37.7% response rate), a high variation in clinical practice was detected, with multiple RPL definitions utilized and different tests employed for potential risk factor identification. Immunological testing was found to be provided in 7.9 %(N = 3) of the included clinics. Moreover, multiple therapies, including immunomodulatory ones were utilized for the management of idiopathic RPL. These findings highlight a need for additional research on the implication of immune activity in this condition. The high variation between clinics regarding the tests employed for the diagnosis and management of idiopathic RPL also underlines the need for guidelines to direct clinical practice, taking into consideration both the patients' needs but also the strength of the available scientific evidence.

Preconception risk factors and health care needs of pregnancy-planning women and men with a lifetime history or current mental illness: A nationwide survey

Objectives

While depression and anxiety are common in women and men of reproductive age, preconception interventions to optimize the health of individuals with mental illness before pregnancy is limited and focuses primarily on psychotropic medication management. Comparing individuals with depression, anxiety, and comorbidity to those with neither condition, we identified areas of preconception care optimization related to psychosocial risk factors, general physical health, medication use, and uptake of high-risk health behaviours. We also investigated differences in preconception health care use, attitudes, and knowledge.

Method

We conducted a nationwide survey of 621 women (n = 529) and men (n = 92) across Canada who were planning a pregnancy within five years, including those with lifetime or current depression (n = 38), anxiety (n = 55), and comorbidity (n = 104) and those without mental illness (n = 413). Individuals with depression, anxiety, and comorbidity were compared to individuals without mental illness using logistic regression, adjusted for age, sex, and education level.

Results

Individuals with a lifetime or current mental illness were significantly more likely to have several risk factors for suboptimal reproductive and perinatal outcomes, including increased rates of obesity, stress, fatigue, loneliness, number of chronic health conditions, and medication use. Further, they were more likely to have high-risk health behaviours including increased substance use, internet addiction, poorer eating habits, and decreased physical activity. By assessing depression, anxiety, or both separately, we also determined there was variation in risk factors by mental illness type.

Conclusion

Our nationwide study is one of the first and largest to examine the preconception care needs of women and men with a lifetime or current mental illness who are pregnancy-planning. We found this population has many important reproductive and perinatal risk factors that are modifiable via preconception interventions which could have a significant positive impact on their health trajectories and those of their future children.

H1299R Variant in Factor V and Recurrent Pregnancy Loss: A Systematic Review and Meta-Analysis Protocol

Recurrent pregnancy loss (RPL) is defined as the loss of two or more pregnancies, affecting approximately 1 to 3% of women worldwide. Scientific data highlight a possible correlation between thrombophilic genetic variants and RPL. H1299R variant in the factor V gene would lead to an increased thrombotic risk associated with frequent miscarriages. However, the data are often conflicting, making this an interesting question for further investigations by evaluating genotype-phenotype correlations to improve the clinical management and genetic counseling of couples. A systematic review and meta-analysis will follow the preferred reporting elements for systematic review and meta-analysis protocols (PRISMA-P). The Pubmed (MEDLINE) and Embase (OVID) databases will be explored to identify suitable articles based on inclusion and exclusion criteria. Inclusion criteria are: (a) H1299R genotyping with clear data reported, referred to as Heterozygous (Het) and/or Homozygous (Hom); (b) articles written in English; (c) analyses of only RPL female patients having at least two or more previous pregnancy losses and compared with a control group. This analysis will present selected scientific evidence, addressing the questions concerning the association between the H1299R variant and RPL, hoping to clarify this still unresolved issue. PROSPERO registration number: CRD42022330077.

Can cell-free DNA (cfDNA) testing alleviate psychological distress in early miscarriage? A commentary

BACKGROUND

Psychological, emotional, and mental distress affects many patients who experience early pregnancy loss (EPL). A common concern is that the patient's actions or choices caused the loss. Understanding the cause of EPL may improve the distress of EPL patients and their partners. Chromosomal abnormalities leading to a significant portion of EPL. Cell-free DNA (cfDNA) testing, a non-invasive test providing high quality information about the chromosomal makeup of a fetus, may offer assurance that a fetal abnormality caused the loss, and provide more certainty or closure in processing EPL. CfDNA may be a useful adjunct to patient-centered care in the setting of EPL. This commentary explores the possibility of cfDNA testing in lessening the emotional distress that often accompanies EPL.

METHODS

The peer reviewed literature was explored for manuscripts addressing (1) the potential for cfDNA serum testing for patients experiencing EPL and screening products of conception to determine the cause of EPL; and/or (2) the impact that information might have on the psychological morbidity of EPL for patients and their partners. Themes generated from extracted data were used to generate key questions for future research.

RESULTS

Preliminary findings suggest fetal fraction values are instrumental in the success of cfDNA testing, and a successful cfDNA testing experience can have a positive impact on patients.

CONCLUSIONS

Ultimately, we conclude cfDNA testing could have a positive impact in patient care and improve the well-being of patients undergoing the emotional toll of EPL by reducing feelings of guilt and providing closure to those who learn the loss was associated with chromosomal abnormality. Further trials and studies that explore the intersection of mental health of EPL on patients should explore the efficacy of cfDNA testing as an adjunct to patient-centered care in these cases.

Ultrasound-guided Manual Vacuum Aspiration is an optimal method for obtaining products of conception from early pregnancy loss for cytogenetic testing

OBJECTIVE

The culture failure rate of conventional karyotyping in products of conception evacuated from early pregnancy loss by traditional electrical vacuum aspiration and/or dilation & curettage remains high. We aim to determine whether obtaining products of conception from early pregnancy loss via another evacuation approach, ultrasound-guided manual vacuum aspiration, could decrease the culture failure rate of karyotyping.

METHODS

For patients with early pregnancy loss, ultrasound-guided manual vacuum aspiration (Case group) and traditional electrical vacuum aspiration and/or dilation & curettage (Control group) were applied as surgical methods for pregnancy loss management respectively. The evacuated products of conception were subjected to cytogenetic karyotyping analysis. The primary outcome was the culture failure rate of karyotyping. Secondary outcomes included the chromosomal abnormality spectrum, maternal cell contamination, and complications from the manual vacuum aspiration procedure.

RESULTS

For the case group, 132 products of conception were genetically analyzed by conventional karyotyping. The culture failure rate was significantly lower than that of the control cohort (2.3% vs 7.4%, p = 0.027). 65.2% of cases were abnormal within the detection scope of karyotyping. The euploid female to male ratio was 0.82 (18:22), suggesting a lower likelihood of maternal cell contamination. The efficacy in achieving complete evacuation was 99.6%. There were no significant complications from the procedure.

CONCLUSION

Ultrasound-guided manual vacuum aspiration approach significantly decreased the culture failure rate of karyotyping and decreased maternal cell contamination tendency, enabling a high and accurate cytogenetic diagnosis. It is especially crucial when the cytogenetic analysis is required in the early pregnancy loss clinics.

Postnatal Depression and Post-Traumatic Stress Risk Following Miscarriage

The experience of miscarriage is an important population-level problem that affects approximately 10–25% of pregnancies. The physical consequences of miscarriage have been researched extensively, but psychological sequelae less so. First-person accounts show that women who have experienced miscarriage feel pressured to stay silent, to grieve, and to fight intense physical and psychological challenges alone. There is ample scientific evidence on the links between miscarriage and physical and mental health disorders, such as complicated grief, anxiety, depression, post-traumatic stress, suicidal risk, psychosomatic disorders, sexual health disorders, etc. However, there is a lack of deeper understanding of the specifics of psychological morbidity after miscarriage, as well as of the information on vulnerability and resilience factors. This study aims to assess the risk of postnatal depression and post-traumatic stress following miscarriage. A total of 839 Lithuanian women who had one or more miscarriages were asked to complete an online questionnaire, including the Edinburgh Postnatal Depression Scale (EPDS) and the Impact of Events Scale-Revised (IES-R). Of the women, 59.1% were found to be at increased risk of postnatal depression and 48.9% at high risk of postnatal depression; 44.7% of the women were considered to be at increased risk of post-traumatic stress. An impaired relationship with one’s body and childlessness has been the strongest predictors of psychological morbidity risk.

Abordagem psicossocial às perdas gestacionais na Atenção Primária à Saúde

Introdução: Perdas gestacionais são eventos comuns na vida reprodutiva. Tendo em vista a dificuldade individual e profissional de lidar com o sofrimento mental que ocasionam, indaga-se sobre a escolha da técnica, a periodicidade e o modo de execução das abordagens que melhor se adequariam ao enfrentamento dessa situação. Sendo assim, esta revisão clínica tem como objetivo avaliar a literatura recente acerca do tema e buscar as melhores evidências científicas em relação à abordagem psicossocial a essas perdas. Métodos: Foram utilizadas palavras-chave determinadas pelo Medical Subject Headings (MeSH) para selecionar títulos de estudos nas bases de dados: PubMed, ACCESSSS, British Medical Journal (BMJ), DYNAMED, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS). Os critérios de inclusão foram: ano de publicação entre 2010 e 2020; tipo de estudo (metanálise, revisão sistemática, ensaio clínico randomizado, ensaio clínico não randomizado, coorte ou caso controle); não abordar abortamento induzido; estar em inglês, português ou espanhol; ser passível de ser encontrado na íntegra. Resultados: Foram encontrados 28 artigos, que tiveram seus resumos avaliados; 14 foram excluídos e 14 lidos na íntegra. No fim, nove estudos foram incluídos nesta revisão. Foi possível observar que sintomas psicológicos são frequentemente apresentados após perdas gestacionais, que há diversas maneiras de acessar esses dados e que não há consenso sobre qual a melhor intervenção a ser feita. Além disso, em homens e casais homossexuais, há maior chance de invisibilidade do sofrimento e menor abordagem de luto por profissionais de saúde. Conclusão: Na falta de consenso sobre quais intervenções apresentam melhores resultados, recomenda-se o rastreamento de sofrimento mental e o compartilhamento da decisão com as partes envolvidas.

Chronic Inflammatory Placental Disorders Associated With Recurrent Adverse Pregnancy Outcome

Chronic inflammatory placental disorders are a group of rare but devastating gestational syndromes associated with adverse pregnancy outcome. This review focuses on three related conditions: villitis of unknown etiology (VUE), chronic histiocytic intervillositis (CHI) and massive perivillous fibrin deposition (MPFD). The hallmark of these disorders is infiltration of the placental architecture by maternal immune cells and disruption of the intervillous space, where gas exchange between the mother and fetus occurs. Currently, they can only be detected through histopathological examination of the placenta after a pregnancy has ended. All three are associated with a significant risk of recurrence in subsequent pregnancies. Villitis of unknown etiology is characterised by a destructive infiltrate of maternal CD8+ T lymphocytes invading into the chorionic villi, combined with activation of fetal villous macrophages. The diagnosis can only be made when an infectious aetiology has been excluded. VUE becomes more common as pregnancy progresses and is frequently seen with normal pregnancy outcome. However, severe early-onset villitis is usually associated with fetal growth restriction and recurrent pregnancy loss. Chronic histiocytic intervillositis is characterised by excessive accumulation of maternal CD68+ histiocytes in the intervillous space. It is associated with a wide spectrum of adverse pregnancy outcomes including high rates of first-trimester miscarriage, severe fetal growth restriction and late intrauterine fetal death. Intervillous histiocytes can also accumulate due to infection, including SARS-CoV-2, although this infection-induced intervillositis does not appear to recur. As with VUE, the diagnosis of CHI requires exclusion of an infectious cause. Women with recurrent CHI and their families are predisposed to autoimmune diseases, suggesting CHI may have an alloimmune pathology. This observation has driven attempts to prevent CHI with a wide range of maternal immunosuppression. Massive perivillous fibrin deposition is diagnosed when >25% of the intervillous space is occupied by fibrin, and is associated with fetal growth restriction and late intrauterine fetal death. Although not an inflammatory disorder per se, MPFD is frequently seen in association with both VUE and CHI. This review summarises current understanding of the prevalence, diagnostic features, clinical consequences, immune pathology and potential prophylaxis against recurrence in these three chronic inflammatory placental syndromes.

Factors affecting the emotional wellbeing of women and men who experience miscarriage in hospital settings: a scoping review

BACKGROUND

Miscarriage can be a devastating event for women and men that can lead to short- and long-term emotional distress. Studies have reported associations between miscarriage and depression, anxiety, and post-traumatic stress disorder in women. Men can also experience intense grief and sadness following their partner's miscarriage. While numerous studies have reported hospital-related factors impacting the emotional wellbeing of parents experiencing miscarriage, there is a lack of review evidence which synthesises the findings of current research.

AIMS

The aim of this review was to synthesise the findings of studies of emotional distress and wellbeing among women and men experiencing miscarriage in hospital settings.

METHODS

A systematic search of the literature was conducted in October 2020 across three different databases (CINAHL, MEDLINE and PsycInfo) and relevant charity organisation websites, Google, and OpenGrey. A Mixed Methods appraisal tool (MMAT) and AACODS checklist were used to assess the quality of primary studies.

RESULTS

Thirty studies were included in this review representing qualitative (N = 21), quantitative (N = 7), and mixed-methods (N = 2) research from eleven countries. Findings indicated that women and men's emotional wellbeing is influenced by interactions with health professionals, provision of information, and the hospital environment. Parents' experiences in hospitals were characterised by a perceived lack of understanding among healthcare professionals of the significance of their loss and emotional support required. Parents reported that their distress was exacerbated by a lack of information, support, and feelings of isolation in the aftermath of miscarriage. Further, concerns were expressed about the hospital environment, in particular the lack of privacy.

CONCLUSION

Women and men are dissatisfied with the emotional support received in hospital settings and describe a number of hospital-related factors as exacerbators of emotional distress.

IMPLICATIONS FOR PRACTICE

This review highlights the need for hospitals to take evidence-informed action to improve emotional support services for people experiencing miscarriage within their services.

Factors Associated with Ruptured Ectopic Pregnancy: A 10-Year Review at a District Hospital in Ghana

Background

Approximately 1–2% of all pregnancies are ectopic. Despite a decline in ectopic pregnancy-related mortality, there is still a paucity of information on the factors associated with clinical presentation and outcomes in Sub-Saharan Africa which is essential in determining the most appropriate treatment modalities.

Methods

We performed a ten-year retrospective chart review of cases of ectopic pregnancies managed at the Lekma hospital and assessed them for peculiar risk factors, clinical presentation, and outcomes. Associations between patients' sociodemographic characteristics, clinical presentation, and treatment outcome were evaluated using multiple logistic regression and reported as adjusted odds ratios (AOR). The confidence interval (CI) was set at 95%, and a p value <0.05 were considered significant.

Results

Over the ten-year period, there were 115 ectopic pregnancies and 14,450 deliveries (7.9/1,000). The mean age ± standard deviation of the 115 patients was 27.61 ± 5.56. More than half of the patients were single (59/115, 51.3%). The majority (71.3%) of the patients presented with a ruptured ectopic pregnancy. After adjusting for covariates, the odds of an ectopic pregnancy presenting as ruptured among single patients was 2.63 times higher than that of married patients (AOR = 3.63, 95% CI: 1.33–9.93, p=0.01). Ectopic pregnancies located in the isthmic region of the tube had a 77% lower odds of presenting as ruptured than those located in the ampullary region (AOR = 0.23, 95% CI: 0.07–0.74, p=0.01). The odds of rupturing were 1.69 times increased for every additional week after the missed period (AOR = 2.69, 95% CI: 1.56–4.64, p < 0.01). No mortalities were reported as a result of an ectopic pregnancy.

Conclusion

Most of the cases of ectopic pregnancy presented ruptured. Marital status and period of amenorrhoea were significantly associated with rupture.

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.

Health care support following miscarriage in Australia: a qualitative study. How can we do better?

Miscarriage occurs in one in four pregnancies in Australia and commonly results in adverse psychosocial sequelae, such as clinically significant levels of depression and anxiety. Women also commonly report a lack of support, understanding and acknowledgement of their loss. Research has shown that poor health care support experiences serve to exacerbate adverse psychosocial outcomes. This study explored the support experiences of women affected by miscarriage and their views on what support is needed, when it is needed and who should provide it, as well as their recommendations for improvement. Sixteen Australian women were purposively sampled to participate in qualitative semi-structured interviews. Interview data was analysed using content analysis. Approximately half the women reported positive experiences with healthcare providers, but, despite this, almost all pointed to areas where support was lacking. Insensitive comments and lack of emotional awareness were common. Participants suggested areas for increased clinician support, including mentioning the possibility of miscarriage earlier in routine pregnancies, offering more information before and at the time of miscarriage, providing emotionally sensitive care and offering follow up and psychological support. Women wanted healthcare providers to be proactive in offering support, information and emotionally sensitive care at the time of miscarriage, rather than having to seek it out themselves. Suggestions to improve support after miscarriage included mentioning the possibility of miscarriage earlier, offering more information about miscarriage and psychological support options.

The miscarriage circle of care: towards leveraging online spaces for social support

Background

Lack of social support during and after miscarriage can greatly affect mental wellbeing. With miscarriages being a common experience, there remains a discrepancy in the social support received after a pregnancy is lost.

Method

42 people who had experienced at least one miscarriage took part in an Asynchronous Remote Community (ARC) study. The study involved 16 activities (discussions, creative tasks, and surveys) in two closed, secret Facebook groups over eight weeks. Descriptive statistics were used to analyse quantitative data, and content analysis was used for qualitative data.

Results

There were two main miscarriage care networks, formal (health care providers) and informal (friends, family, work colleagues). The formal care network was the most trusted informational support source, while the informal care network was the main source of tangible support. However, often, participants’ care networks were unable to provide sufficient informational, emotional, esteem, and network support. Peers who also had experienced miscarriage played a crucial role in addressing these gaps in social support. Technology use varied greatly, with smartphone use as the only common denominator. While there was a range of online support sources, participants tended to focus on only a few, and there was no single common preferred source.

Discussion

We propose a Miscarriage Circle of Care Model (MCCM), with peer advisors playing a central role in improving communication channels and social support provision. We show how the MCCM can be used to identify gaps in service provision and opportunities where technology can be leveraged to fill those gaps.

The mental health impact of perinatal loss: A systematic review and meta-analysis

Perinatal loss can pose a significant risk to maternal mental health. There is limited data on the strength of association between perinatal loss and subsequent common mental health disorders (CMHD) such as anxiety, depression and post-traumatic symptoms (PTS). A systematic review and meta-analysis identified studies with control groups, published between January 1995 and March 2020 reporting validated mental health outcomes following perinatal loss. We identified 29 studies from 17 countries, representing a perinatal loss sample (n = 31,072) and a control group of women not experiencing loss (n = 1,261,517). We compared the likelihood of increased CMHD in both groups. Random-effects modelling on suggested that compared to controls, perinatal loss was associated with increased risk of depressive (RR = 2.14, 95% CI = 1.73-2.66, p < 0.001, k = 22) and anxiety disorders (RR = 1.75, 95% CI = 1.27-2.42, p < 0.001, k = 9). Compared to controls, Perinatal loss was also associated with increased depression (SMD = 0.34, 95% CI = 0.20-0.48, p < 0.001, k = 12) and anxiety scores (SMD = 0.35, 95% CI = 0.12-0.58, p < 0.003, k = 10). There were no significant effects for post-traumatic stress (PTS) outcomes (k = 3). Our findings confirm that anxiety and depression levels following perinatal loss are significantly elevated compared to "no loss" controls (live-births, non pregnant from community, or difficult live births). Elevated depression and anxiety rates were also reported for those who experienced loss during later stages of pregnancy. Assessing mental health following loss is a maternal health priority.

Grief in women with previous miscarriage or stillbirth: a systematic review of cross-sectional and longitudinal prospective studies

Background: Women who have had miscarriages or stillbirths are known to have a high risk for enduring grief. However, the course and frequency of enduring grief in this subgroup are not fully understood. Objective: Our aims were to assess the intensity of grief and its course in women with miscarriages or stillbirths and to estimate the frequency of severe grief reactions in this population. Additionally, we compared subgroups with miscarriages versus stillbirths and with single versus recurrent pregnancy loss. Method: A systematic literature search of the databases MEDLINE, psycINFO and PSYNDEX was conducted to consider all studies published between 2000 and 31 March 2022 in English or German on the prevalence and intensity of grief in women who had miscarriages or stillbirths. Studies that used validated assessment methods were included in this systematic review. The PRISMA guidelines were followed. Results: Study characteristics and grief data were extracted independently by two investigators from 13 cross-sectional and eight longitudinal studies from 11 countries (N = 2597). All studies used self-reporting instruments. According to 17 of 21 studies (81%), grief is markedly elevated in women after miscarriages or stillbirths. The studies are very heterogeneous regarding the samples, the length of pregnancies and the time of assessment regarding grief after miscarriages. Most studies document intense grief and frequent severe grief reactions - with a decrease over time - in women who have had miscarriages or stillbirths. Clear conclusions regarding corresponding differences between women with miscarriages and stillbirths or single and recurrent pregnancy losses cannot be drawn. Conclusions: Pronounced grief is frequent in women who had miscarriages or stillbirths. More longitudinal studies are needed to examine the course of grief in this group and to identify those women who develop prolonged grief disorder, depression or other mental-health problems.

Gradient boosted trees with individual explanations: An alternative to logistic regression for viability prediction in the first trimester of pregnancy

BACKGROUND

Clinical models to predict first trimester viability are traditionally based on multivariable logistic regression (LR) which is not directly interpretable for non-statistical experts like physicians. Furthermore, LR requires complete datasets and pre-established variables specifications. In this study, we leveraged the internal non-linearity, feature selection and missing values handling mechanisms of machine learning algorithms, along with a post-hoc interpretability strategy, as potential advantages over LR for clinical modeling.

METHODS

The dataset included 1154 patients with 2377 individual scans and was obtained from a prospective observational cohort study conducted at a hospital in London, UK, from March 2014 to May 2019. The data were split into a training (70%) and a test set (30%). Parsimonious and complete multivariable models were developed from two algorithms to predict first trimester viability at 11-14 weeks gestational age (GA): LR and light gradient boosted machine (LGBM). Missing values were handled by multiple imputation where appropriate. The SHapley Additive exPlanations (SHAP) framework was applied to derive individual explanations of the models.

RESULTS

The parsimonious LGBM model had similar discriminative and calibration performance as the parsimonious LR (AUC 0.885 vs 0.860; calibration slope: 1.19 vs 1.18). The complete models did not outperform the parsimonious models. LGBM was robust to the presence of missing values and did not require multiple imputation unlike LR. Decision path plots and feature importance analysis revealed different algorithm behaviors despite similar predictive performance. The main driving variable from the LR model was the pre-specified interaction between fetal heart presence and mean sac diameter. The crown-rump length variable and a proxy variable reflecting the difference in GA between expected and observed GA were the two most important variables of LGBM. Finally, while variable interactions must be specified upfront with LR, several interactions were ranked by the SHAP framework among the most important features learned automatically by the LGBM algorithm.

CONCLUSIONS

Gradient boosted algorithms performed similarly to carefully crafted LR models in terms of discrimination and calibration for first trimester viability prediction. By handling multi-collinearity, missing values, feature selection and variable interactions internally, the gradient boosted trees algorithm, combined with SHAP, offers a serious alternative to traditional LR models.

A Multidisciplinary, Family-Oriented Approach to Caring for Parents After Miscarriage: The Integrated Behavioral Health Model of Care

Miscarriage is increasingly gaining recognition, both in scientific literature and media outlets, as a loss that has significant and lasting effects on parents, though often disenfranchised and overlooked by both personal support networks and healthcare providers. For both men and women, miscarriage can usher in intense grief, despair, and difficulty coping, and for women in particular, there is evidence of increased prevalence of depression, anxiety, and post-traumatic stress. Additionally, miscarriage can contribute to decreased relationship satisfaction and increased risk of separation, all while stigma and disenfranchisement create a sense of isolation. Despite this increased need for support, research indicates that many parents experience their healthcare providers as dismissive of the significance of the loss and as primarily focusing only on the physical elements of care. Research exploring the barriers to providers engaging in more biopsychosocial-oriented care has identified time constraints, lack of resources, lack of training in addressing loss, and compassion fatigue as key areas for intervention. This paper will review the biopsychosocial elements of miscarriage and discuss a multidisciplinary, family-oriented approach that can be implemented in healthcare settings to ensure a high quality and holistic level of care for individuals, couples, and families experiencing pregnancy loss.

A Comparative, Randomized Control Trial in Patients of Per Vaginal Bleeding Comparing Efficacy of Oral Dydrogesterone Versus Vaginal Progesterone in Successful Pregnancy Outcome for Patients with Recurrent Pregnancy Loss

Background

Progesterone is essential for the maintenance of a healthy pregnancy. Any defect in the secretion of human chorionic gonadotropin or progesterone is associated with a significantly increased risk of first-trimester abortion. Progesterone is frequently prescribed to patients presenting with per vaginal (PV) bleeding in early pregnancy and a history of recurrent pregnancy loss.

Methods

Pregnant women up to 12 weeks of gestation with a history of more than two early pregnancy losses and presenting with vaginal bleeding were included in this study. All subjects were randomized to receive either vaginal progesterone 600 mg/day or oral dydrogesterone 30 mg/day. A detailed history-including menstrual history, previous pregnancies, previous miscarriages, and other risk factors-was obtained. The mean time required for the cessation of PV bleeding and continuation of pregnancy up to 24 weeks and till term was compared.

Results

A total of 200 patients were randomized to vaginal progesterone 600 mg/day (n = 100) or oral dydrogesterone 30 mg/day (n = 100). While 74 patients had two miscarriages in the progesterone group, 68 patients had two miscarriages in the dydrogesterone group. The time required for complete cessation of bleeding was significantly lesser among patients who received oral dydrogesterone compared to those who received intravaginal progesterone (53.90 ± 9.09 vs. 94.60 ± 7.29 h, p < 0.0001). Numerically higher number of patients receiving oral dydrogesterone had a successful continuation of pregnancy up to 24 weeks of gestation, as well as till full term compared to progesterone group (70 vs. 75).

Conclusion

Oral dydrogesterone is preferred over vaginal progesterone in patients presenting with vaginal bleeding during early pregnancy and a history of recurrent early pregnancy loss.

Ultrasound characteristics, serum biochemistry and outcome of ectopic pregnancies presenting during COVID-19 pandemic

OBJECTIVE

To describe and compare the characteristics of ectopic pregnancies (EPs) in the year prior to vs during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

This was a retrospective analysis of women diagnosed with an EP on transvaginal sonography conducted at a center in London, UK, providing early-pregnancy assessment, between 1 January 2019 and 31 December 2020. Women were identified via the Astraia ultrasound reporting system using coded and non-coded outcomes of EP or pregnancy outside the uterine cavity. Data related to predefined outcomes were collected using Astraia and Cerner electronic reporting systems. Main outcome measures included clinical, ultrasound and biochemical features of EP, in addition to reported complications and management.

RESULTS

There were 22 683 consultations over the 2-year period. Following consultation, a similar number and proportion of EPs were diagnosed in 2019 (141/12 657 (1%)) and 2020 (134/10 026 (1%)). Both cohorts were comparable in age, ethnicity, weight and method of conception. Gestational age at the first transvaginal sonography scan and at diagnosis were similar, and no difference in location, size or morphology of EP was found between the two cohorts. Serum human chorionic gonadotropin (hCG) levels at the time of EP diagnosis were higher in 2020 than in 2019 (1005 IU/L vs 665 IU/L; P = 0.03). The proportions of women according to type of final EP management were similar, but the rate of failed first-line management was higher during vs before the pandemic (16% vs 6%; P = 0.01). The rates of blood detected in the pelvis (hemoperitoneum) on ultrasound (23% vs 26%; P = 0.58) and of ruptured EP confirmed surgically (9% vs 3%; P = 0.07) were similar in 2019 vs 2020.

CONCLUSIONS

No difference was observed in the location, size, morphology or gestational age at the first ultrasound examination or at diagnosis of EP between women diagnosed before vs during the COVID-19 pandemic. Complication rates and final management strategy were also unchanged. However, hCG levels and the failure rate of first-line conservative management measures were higher during the pandemic. Our findings suggest that women continued to access appropriate care for EP during the COVID-19 pandemic, with no evidence of diagnostic delay or an increase in adverse outcome in our population. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

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.

Changes in the level of fetoplacental complex hormones in pregnant women with miscarriage

The purpose of the study was TO analyze the fetoplacental complex hormone levels and changes in their dynamics in pregnant women with miscarriage and the impact of these features on the subsequent course of pregnancy. Hormone levels were determined at different stages of gestation in 50 healthy women with a physiological course of pregnancy (control group) and 50 pregnant women with a history of miscarriage (main group). The women of the main group had a significantly slower rate of increase in hormones and a lag in quantitative indicators than the control group. The estradiol level indicators were 4.1 times (76.0%) and 2.89 times (65.5%) lower in women with miscarriage in the embryonic and late fetal period, respectively, compared to healthy women. Indicators of the level of placental lactogen and chorionic gonadotropin in the embryonic period in women with miscarriage were lower by 39.1% and 50.9%, respectively, compared to healthy women. In the late fetal period, the level of these hormones was lower by 72.9% and 35.4%, respectively. In the embryonic and late fetal periods, progesterone levels were lower by 67.4% and 68.4%, respectively, compared to the control group. The data obtained are evidence of a pronounced hormonal abnormality of the placenta, and hence a marker of fetoplacental dysfunction, which on the background of miscarriage develops at the early stages and continues to progress with the course of pregnancy.

Mindfulness-based intervention in Chinese pregnant women with recurrent miscarriage: A non-randomized controlled study

OBJECTIVE

Pregnant women with recurrent miscarriage have high rates of anxiety and depression. Mindfulness-based interventions have shown benefits in improving mental health in diverse populations; however, few studies have explored their efficacy in pregnant women with recurrent miscarriage, which was investigated in the present study.

DESIGN

A nonrandomized controlled study was carried out from August 2019 to November 2020.

SETTING

The study was conducted at a regional teaching hospital in Guangzhou, China that provides leading care for recurrent miscarriage.

PARTICIPANTS

A total of 158 pregnant women with recurrent miscarriage were recruited and allocated to the intervention group (n = 79) or the control group (n = 79); 131 women completed the study.

INTERVENTION

The mindfulness-based intervention consisted of a 1-h education session and daily mindfulness exercises guided by audio recordings during hospitalization.

MEASUREMENTS AND FINDINGS

Study outcomes included perceived stress measured with the Perceived Stress Scale; symptoms of anxiety and depression measured with the Self-rating Anxiety Scale and Edinburgh Postnatal Depression Scale, respectively; and positive and negative affect measured with the Positive Affect and Negative Affect Scale - Revised, respectively. Compared to the control group, participants in the intervention group showed significant decreases in perceived stress, depression symptoms, and negative affect and an increase in positive affect after the intervention. Anxiety increased significantly in the control group during the study but remained unchanged in the intervention group.

KEY CONCLUSIONS

A mindfulness-based intervention can reduce psychological symptoms and improve mental health in pregnant women with recurrent miscarriage.

IMPLICATIONS FOR PRACTICE

A mindfulness-based intervention should be incorporated into routine care to help improve the mental health of pregnant women with recurrent miscarriage.

Smoking, alcohol and coffee consumption and pregnancy loss: a Mendelian randomization investigation

OBJECTIVE

To determine the associations of smoking and alcohol and coffee consumption with pregnancy loss.

DESIGN

Mendelian randomization study.

SETTING

The UK Biobank study and FinnGen consortium.

PATIENTS

A total of 60,565 cases with pregnancy loss and 130,687 noncases from UK Biobank and 3,312 cases with pregnancy loss and 64,578 noncases from FinnGen.

INTERVENTION(S)

None.

MAINS OUTCOME MEASURE

Pregnancy loss.

RESULT(S)

Genetic predisposition to smoking initiation was associated with an increased risk of pregnancy loss in both UK Biobank and FinnGen. The combined odds ratio (OR) was 1.31 (95% confidence interval [CI], 1.25-1.37) for one standard deviation increase in the prevalence of smoking initiation. There were no significant associations of genetically predicted consumption of alcohol (OR, 1.09; 95% CI, 0.93-1.27) or coffee (OR, 0.96; 95% CI, 0.87-1.06) with pregnancy loss.

CONCLUSION(S)

This study on the basis of genetic data suggests the causal potential of the association of smoking but not moderate alcohol and coffee consumption with pregnancy loss.

Infertility and subsequent recurrent miscarriage: Current state of the literature and future considerations for practice and research

Background: Recurrent miscarriage (RM) and infertility are independently associated with adverse pregnancy outcomes, in addition to psychological sequelae. Experiencing pregnancy loss alongside infertility is particularly difficult. International guidance regarding RM is conflicting, and applicability to women with infertility is undetermined. The aim of this study was to: (i) establish if women/couples with a history of infertility are recognised in the literature on the investigation and management of RM, and (ii) determine if the specific needs of women/couples experiencing RM and infertility are ascertained and incorporated into clinical management strategies. Methods: We examined the wide-ranging literature to ascertain what gaps existed. Studies were retrieved through searches of PubMed and Google Scholar up to 21 January 2021 using appropriate controlled vocabulary and combinations of key words. No language or study design restrictions were applied. Results: While women/couples experiencing RM after infertility appear in studies evaluating investigations and proposed treatments, high-quality studies are lacking. Furthermore, they are largely excluded from international clinical guidance and qualitative research. Conclusions: The experiences of women/couples with RM and infertility and their specific care needs within maternity and fertility services are underexplored. It is unclear from current RM guidelines how best to manage and support this complex cohort. Women/couples with infertility and RM are underserved in the literature and in clinical guidance. Further robust studies are warranted to examine pregnancy outcomes, investigations and treatments currently used. Qualitative research is also required to identify their medical and psychological needs to better support this vulnerable group.

Risk of miscarriage in women with psychiatric disorders

BACKGROUND

Some psychiatric disorders have been associated with increased risk of miscarriage. However, there is a lack of studies considering a broader spectrum of psychiatric disorders to clarify the role of common as opposed to independent mechanisms.

AIMS

To examine the risk of miscarriage among women diagnosed with psychiatric conditions.

METHOD

We studied registered pregnancies in Norway between 2010 and 2016 (n = 593 009). The birth registry captures pregnancies ending in gestational week 12 or later, and the patient and general practitioner databases were used to identify miscarriages and induced abortions before 12 gestational weeks. Odds ratios of miscarriage according to 12 psychiatric diagnoses were calculated by logistic regression.

CONCLUSIONS

A wide range of psychiatric disorders were associated with increased risk of miscarriage. The heightened risk of miscarriage among women diagnosed with psychiatric disorders highlights the need for awareness and surveillance of this risk group in antenatal care.

Uncovering Prolonged Grief Reactions Subsequent to a Reproductive Loss: Implications for the Primary Care Provider

Introduction

There is a paucity of clinical guidelines for the routine assessment of maladaptive reproductive grief reactions in outpatient primary care and OB-GYN settings in the United States. Because of the disenfranchised nature of perinatal grief reactions, many clinicians may be apt to miss or dismiss a grief reaction that was not identified in the perinatal period. A significant number of those experiencing a reproductive loss exhibit signs of anxiety, depression, or post-traumatic stress disorder. Reproductive losses are typically screened for and recorded numerically as part of a woman’s well-visit intake, yet this process often fails to identify patients emotionally troubled by a prior pregnancy loss.

Materials and Methods

A summative content analysis of 164 recent website blogs from female participants who self-reported having experienced a miscarriage or abortion in their lifetime was conducted. The narratives were reviewed for details regarding the time span between the pregnancy loss and the composition of the blog post. The stories were analyzed for subsequent relationship problems and detrimental mental health conditions. Maladaptive reactions were contrasted for those that indicated a greater than 12 months’ time-lapse and those who had not.

Results

More than a third (39.6%) of the women reported in the narrative that at least one year or more had passed since experiencing the miscarriage or abortion. For those women, the median time span between the loss and composing the blog was 4 years with a range of 47 years. Mental health conditions attributed to the reproductive loss by those who reported longer bereavement times included subsequent relationship problems, substance misuse, depression, suicidal ideation, and PTSD. The percent of reported maladaptive issues was more than double (136.9% vs. 63.6%) for those who reported that a year or more had passed since the loss of the pregnancy.

Discussion

Grief reactions following the loss of a pregnancy may be prolonged or delayed for several months which can contribute to adverse biopsychosocial outcomes. Recognition and treatment of maladaptive grief reactions following a pregnancy loss are critical. Screening methods should be enhanced for clinicians in medical office settings to help identify and expedite the appropriate mental health assistance.

Maternal plasma genome-wide cell-free DNA can detect fetal aneuploidy in early and recurrent pregnancy loss and can be used to direct further workup

STUDY QUESTION

Can maternal plasma cell-free DNA (cfDNA) detect chromosomal anomalies in early pregnancy loss (EPL) and recurrent pregnancy loss (RPL)?

SUMMARY ANSWER

Genome-wide cfDNA testing can serve as an alternative to cytogenetic analysis in products of conception (POCs) in RPLs and can guide further management.

WHAT IS KNOWN ALREADY

Random chromosomal anomalies are the single most common cause for EPL and RPL. Cytogenetic analysis in POCs may be used to direct management in RPL because the detection of random chromosomal anomalies can eliminate further unwarranted testing.

STUDY DESIGN, SIZE, DURATION

This was a prospective diagnostic test study from March 2018 to January 2019 of 109 patients experiencing pregnancy loss before 14 weeks gestation at a tertiary-care academic medical center.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Blood samples were drawn for genome-wide cfDNA testing prior to chorionic villous sampling for cytogenetic analysis of POCs with both short-term cultures (STCs) and long-term cultures (LTCs). Final analysis included 86 patients with non-mosaic cytogenetic results in POCs and available cfDNA results. Aneuploidy detection rates by cfDNA testing and POC cytogenetic analysis were compared. The first 50 samples served as the Training Set to establish pregnancy loss-specific log-likelihood ratio (LLR) thresholds using receiver-operator characteristic (ROC)-like analyses. These were then used for the entire cohort.

MAIN RESULTS AND THE ROLE OF CHANCE

Seventy-eight samples (71.5%) had results available from both STC and LTC; 12 samples (11%) had a result from STC only, and 7 samples (6.4%) had a result from LTC only. A chromosomal anomaly was detected in 55/86 (64%). The rates of chromosomal anomalies were 61, 72, 73 and 44% in patients undergoing their first, second, third and ≥4th pregnancy losses, respectively. The median cfDNA fetal fraction was 5%. With standard LLR thresholds used for noninvasive prenatal screening, the sensitivity of cfDNA in detecting aneuploidy was 55% (30/55) and with a specificity of 100% (31/31). Using pregnancy loss-specific LLR thresholds, the sensitivity of cfDNA in detecting aneuploidy was 82% (45/55), with a specificity of 90% (28/31). The positive and negative likelihood ratios were 8.46 and 0.20, respectively. Fetal sex was correctly assigned in all cases.

LIMITATIONS, REASONS FOR CAUTION

Cases with a false-positive result by cfDNA analysis would not receive the indicated RPL workup. Specificity could be improved by using a fetal fraction (FF) cutoff of 4%, but this would result in exclusion of more than a quarter of cases.

WIDER IMPLICATIONS OF THE FINDINGS

cfDNA-based testing can serve as an alternative to POC cytogenetic analysis and can guide further RPL management: if cfDNA demonstrates aneuploidy, no further action is taken and if no abnormality is detected, the recommended RPL workup is performed.

STUDY FUNDING/COMPETING INTEREST(S)

Cell-free DNA testing was funded by Illumina, Inc., San Diego, CA. Y.Y. is a member of Illumina’s Clinical Expert Panel and has received travel grants. A.B. has received travel grants from Illumina. All authors have no competing interest to declare.

Experiences of women seeking post-abortion care services in a Regional Hospital in Ghana

Introduction

Abortions remain one of the highest contributors to maternal deaths in Ghana. In 2003, a policy on post-abortion care was introduced to help reduce abortion-related mortality and morbidity. However, depending on the method of pregnancy termination; women encounter varying experiences. This study examines the experiences of women seeking post-abortion care services in a Regional Hospital in Ghana.

Materials and methods

In-depth interview technique was used to collect data from 20 purposively selected post-abortion care clients at the Volta Regional Hospital. Data were analysed manually using a qualitative content analysis technique.

Results

The study found that medical abortion was the main method of pregnancy termination used by women who participated in the study to induce abortion. Spontaneous abortion, however, was attributed mainly to engaging in activities that required the use of excessive energy and travelling on bad roads by pregnant women. The study also revealed that, women do not seek early post-abortion care services due to stigma and poverty.

Conclusions

We found that severity of pain from complications, stigma and financial constraints were factors that influenced women’s decision to seek post-abortion care services. Our findings also suggest that women who experienced spontaneous abortion mainly received financial and emotional support from partners and other family members. To encourage women to seek early post-abortion care services, the Ministry of Health and the Ghana Health Service should take pragmatic steps to educate women on the dangers associated with delay in seeking post-abortion care services and the factors that expose women to spontaneous abortions.

Racial Disparities in Mental Health Outcomes Among Women With Early Pregnancy Loss

The risk for major depression is common 30 days after treatment for early pregnancy loss, especially among Black women.

OBJECTIVE:

To explore the relationship between race and depression symptoms among participants in an early pregnancy loss clinical trial.

METHODS:

We performed a planned secondary analysis of a randomized trial by comparing treatments for medical management of early pregnancy loss. We hypothesized that Black participants would have higher odds of risk for major depression (measured with the CES-D [Center for Epidemiological Studies-Depression] scale) 30 days after early pregnancy loss treatment when compared with non-Black participants. We analyzed the data as a cohort, with the primary exposure being race and secondary exposure being high adverse childhood experience scores (measured with the Adverse Childhood Experience scale). Our primary outcome was risk for major depression (score of 21 or higher on the CES-D scale) 30 days after early pregnancy loss treatment.

RESULTS:

Three hundred participants diagnosed with a nonviable intrauterine pregnancy from 5 to 12 weeks of gestation were randomized as part of the original trial from May 2014 to April 2017. Of 275 respondents included in this analysis, 120 [44%] self-identified as Black and 155 [56%] self-identified as non-Black. After early pregnancy loss treatment, 65 [24%] participants were at risk for major depression. Black participants had an increased risk for major depression (57%) after early pregnancy loss treatment compared with non-Black participants (43%; odds ratio [OR] 2.02; 95% CI 1.15–3.55). After adjustment for risk for baseline depression, adverse childhood experience score, and parity, the odds of risk for major depression 30 days after pregnancy loss treatment remained higher for Black participants when compared with non-Black participants (OR 2.02; 95% CI 1.15–3.55; adjusted OR 2.48; 95% CI 1.28–4.81).

CONCLUSION:

Overall, approximately one quarter of women who experience an early pregnancy loss are at an increased risk for major depression 30 days after treatment. This risk is about twice as high for Black women compared with non-Black women. There is a need for appropriate mental health resources for women undergoing early pregnancy loss care.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, NCT02012491.

Using a logic model to develop an intervention for improving miscarriage care in the emergency department

Miscarriage is the most common pregnancy-related complication and is frequently treated at the emergency department (ED). Parents have expressed dissatisfaction with the care they received at the ED and few interventions have been developed for improving miscarriage care. When planning an intervention, it is crucial to develop a program theory specifying what must be done for an intervention to achieve its objectives. The purpose of this paper is to describe the logic model process for developing an intervention intended to improve parents' miscarriage experience at the ED. The six steps of W. K. Kellogg Foundation (2004) theory logic model were used to 1) describe the problem; 2) conduct a needs assessment; and to identify 3) expected results, 4) influential factors, 5) intervention strategies, and 6) assumptions related to change strategies. A community-based participatory approach was used. It included two planning groups: parents who had visited the ED for a miscarriage (N = 9) and health professionals (N = 8). The theory logic model provided a rigorous framework for intervention development based on theories, scientific evidence, and the experiences of parents and health professionals. Detailed description of the intervention should facilitate its implementation, evaluation, and replication for other health problems.

The Needs of Dutch Women During Decision-Making About Treatment for Miscarriage

OBJECTIVE

To explore the needs of women during decision-making about treatment for miscarriage.

DESIGN

Descriptive qualitative design.

SETTINGS

University and teaching hospitals in the Netherlands.

PARTICIPANTS

We selected a purposive sample of 16 women who needed treatment for miscarriage from an electronic patient file system. We ensured maximum variation by sampling in different hospitals and selecting women with different ages, numbers of children, miscarriage histories, treatment types, and educational levels.

METHODS

We conducted face-to-face individual, semistructured interviews and used thematic analysis to identify, analyze, and describe themes.

RESULTS

We identified one overarching theme, Decision Based on Reason and Emotion, and three related subthemes: Certainty, Information, and SupportFrom Environment.

CONCLUSION

Health care professionals should be aware of how women's decision-making is structured in the context of treatment choices for miscarriage, and discussion regarding treatment should address reason and emotion.

Complementary and Alternative Medicine for Threatened Miscarriage: Advantages and Risks

Threatened miscarriage is one of the most common complications causing pregnancy loss, and it affects approximately 20% of confirmed pregnancies. More and more women are seeking treatment with complementary and alternative medicine (CAM) for this common complication, and it has been reported that women have had successful pregnancies after threatened miscarriage when being treated with CAM, which mainly includes Chinese herbal medicines, acupuncture, and nutritional supplements as well as psychological interventions and other approaches. However, many experts are concerned about the safety and adverse events of certain CAM approaches in women with threatened miscarriage. Therefore, this review focuses on the status of CAM for threatened miscarriage and presents the potential therapeutic efficacy and safety of CAM based on some clinical and experimental studies. We thus hope to provide some instructive suggestions for the application of CAM for treating threatened miscarriage in the future.

Pre-implantation genetic testing for aneuploidy: motivations, concerns, and perceptions in a UK population

Purpose

Pre-implantation genetic testing for aneuploidies (PGT-A) is a technique used as part of in vitro fertilisation to improve outcomes. Despite the upward trend in women utilising PGT-A, data on women’s motivations and concerns toward using the technology, and perceptions having undergone the process, remain scarce.

Methods

This cross-sectional survey, based at a fertility clinic in the UK, utilised an electronic questionnaire to assess the motivations of women who undergo PGT-A and their perceptions and attitudes toward PGT-A after using it.

Results

One hundred sixty-one women responded. The most significant motivating factors to undergo PGT-A were to improve the probability of having a baby per cycle (9.0 ± 2.1) and enhance the chance of implantation (8.8 ± 2.5). The least important motivations were reducing the number of embryos transferred per cycle (2.7 ± 3.3) and saving money by reducing the number of procedures required (4.6 ± 3.4). The most significant concerning factors identified included not having embryos to transfer (5.7 ± 3.4) and the potential for embryo damage (5.2 ± 3.3). The least concerning factors included religious (0.6 ± 1.7) or moral (1 ± 2.2) concerns. The majority of women were satisfied/very satisfied following treatment (n = 109; 68%). The proportion of those who were satisfied/very satisfied increased to 94.2% (n = 81) following a successful outcome, and reduced to 43.5% (n = 27) in those who had an unsuccessful outcome or had not undergone embryo transfer (p < 0.001).

Conclusion

This study highlights that perceptions amongst women who use PGT-A are mostly positive. We also demonstrate a significant association between satisfaction and reproductive outcomes, with those who achieve a live birth reporting more positive perceptions toward PGT-A.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10815-021-02130-3.

Effects of Pregnancy Loss on Subsequent Postpartum Mental Health: A Prospective Longitudinal Cohort Study

Pregnancy loss, natural or induced, is linked to higher rates of mental health problems, but little is known about its effects during the postpartum period. This study identifies the percentages of women receiving at least one postpartum psychiatric treatment (PPT), defined as any psychiatric treatment (ICD-9 290-316) within six months of their first live birth, relative to their history of pregnancy loss, history of prior mental health treatments, age, and race. The population consists of young women eligible for Medicaid in states that covered all reproductive services between 1999-2012. Of 1,939,078 Medicaid beneficiaries with a first live birth, 207,654 (10.7%) experienced at least one PPT, and 216,828 (11.2%) had at least one prior pregnancy loss. A history of prior mental health treatments (MHTs) was the strongest predictor of PPT, but a history of pregnancy loss is also another important risk factor. Overall, women with a prior pregnancy loss were 35% more likely to require a PPT. When the interactions of prior mental health and prior pregnancy loss are examined in greater detail, important effects of these combinations were revealed. About 58% of those whose first MHT was after a pregnancy loss required PPT. In addition, over 99% of women with a history of MHT one year prior to their first pregnancy loss required PPT after their first live births. These findings reveal that pregnancy loss (natural or induced) is a risk factor for PPT, and that the timing of events and the time span for considering prior mental health in research on pregnancy loss can significantly change observed effects. Clinicians should screen for a convergence of a history of MHT and prior pregnancy loss when evaluating pregnant women, in order to make appropriate referrals for counseling.

Long-Term High Risk of Postpartum Post-Traumatic Stress Disorder (PTSD) and Associated Factors

Postpartum post-traumatic stress disorder (PTSD) is not a specific process but can last for months and may manifest itself during any subsequent pregnancies or even become chronic. This study aimed to determine the factors associated with long-term PTSD symptoms one year after delivery. A cross-sectional study was conducted on 1301 Spanish puerperal women. Data were collected on sociodemographic, obstetric, and neonatal variables. The Perinatal Post-Traumatic Stress Disorder Questionnaire (PPQ) was administered online through midwives' associations across Spain. Crude odds ratio (OR) and adjusted odds ratio (aOR) and their 95% confidence intervals were calculated. A PPQ score ≥ 19 (high-risk) was recorded for 13.1% (171) of the participants. Identified risk factors were not respecting a birth plan (aOR = 1.89 (95% CI 1.21-2.94)), formula-feeding of the baby at discharge (aOR = 2.50 (95% CI 1.20-5.17)), postpartum surgical intervention (aOR = 2.23 (95% CI 1.02-4.85)), hospital readmission (aOR = 3.45 (95% CI 1.21-9.84)), as well as verbal obstetric violence (aOR = 3.73 (95% CI 2.52-5.53)) and psycho-affective obstetric violence (aOR = 3.98 (95% CI 2.48-6.39)). During childbirth, some clinical practices, such as formula-feeding of the newborn at discharge or types of obstetric violence towards the mother, were associated with a higher risk of PTSD symptoms one year after delivery.

A New Stepwise Molecular Work-Up After Chorionic Villi Sampling in Women With an Early Pregnancy Loss

Objective: To explore the use of a new molecular work-up based on the stepwise use of Quantitative Fluorescence PCR (QF-PCR) extended to eight chromosomes and single nucleotide polymorphism array (SNP-array) in chorionic villi obtained by chorionic villi sampling (CVS) offered to women experiencing an early pregnancy loss.

Methods: During a 3-year period (January 2016–December 2018), CVS was offered to women experiencing an early pregnancy loss before the evacuation of the products of conception (POC) to retrieve chorionic villi, irrespective of the number of previous losses. A new molecular work-up was prospectively assayed encompassing a first QF-PCR round (with the 21, 18, 13, 7, X, and Y chromosomes), a second QF-PCR round (with the 15, 16, and 22 chromosomes), and a high resolution SNP-array in those cases with normal QF-PCR results. A control group in which POC were collected after surgical uterine evacuation was used to be compared with the intervention group.

Results: Around 459 women were enrolled in the intervention group (CVS) and 185 in the control group (POC after uterine evacuation). The QF-PCR testing success rates were significantly higher in the intervention group (98.5%: 452/459) as compared to the control group (74%: 109/147; p < 0.001), while the chromosomal anomaly rate at the two QF-PCR rounds was similar between the two groups: 52% (234/452) in the intervention and 42% (46/109) in the control group (p = 0.073). The SNP-array was performed in 202 QF-PCR normal samples of the intervention group and revealed 67 (33%) atypical chromosomal anomalies (>10 Mb), 5 (2.5%) submicroscopic pathogenic copy number variants, and 2 (1%) variant of uncertain significance (VOUS).

Conclusion: Eighty-two percent of women experiencing an early pregnancy loss opted for a CVS. The testing success rates were higher in the intervention group (CVS; 98%) as compared to the control group (POC; 74%). The overall yields were 52% by QF-PCR (including three complete hydatiform moles), and 16% by SNP-array, including 15% atypical chromosomal anomalies and 1.1% submicroscopic pathogenic copy number variants.

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.

Week-by-week alcohol consumption in early pregnancy and spontaneous abortion risk: a prospective cohort study

BACKGROUND

Half of women use alcohol in the first weeks of gestation, but most stop once pregnancy is detected. The relationship between timing of alcohol use cessation in early pregnancy and spontaneous abortion risk has not been determined.

OBJECTIVE

This study aimed to evaluate the association between week-by-week alcohol consumption in early pregnancy and spontaneous abortion.

STUDY DESIGN

Participants in Right from the Start, a community-based prospective pregnancy cohort, were recruited from 8 metropolitan areas in the United States (2000-2012). In the first trimester, participants provided information about alcohol consumed in the prior 4 months, including whether they altered alcohol use; date of change in use; and frequency, amount, and type of alcohol consumed before and after change. We assessed the association between spontaneous abortion and week of alcohol use, cumulative weeks exposed, number of drinks per week, beverage type, and binge drinking.

RESULTS

Among 5353 participants, 49.7% reported using alcohol during early pregnancy and 12.0% miscarried. Median gestational age at change in alcohol use was 29 days (interquartile range, 15-35 days). Alcohol use during weeks 5 through 10 from last menstrual period was associated with increased spontaneous abortion risk, with risk peaking for use in week 9. Each successive week of alcohol use was associated with an 8% increase in spontaneous abortion relative to those who did not drink (adjusted hazard ratio, 1.08; 95% confidence interval, 1.04-1.12). This risk is cumulative. In addition, risk was not related to number of drinks per week, beverage type, or binge drinking.

CONCLUSION

Each additional week of alcohol exposure during the first trimester increases risk of spontaneous abortion, even at low levels of consumption and when excluding binge drinking.

Effect of supportive care on the psychosocial health status of women who had a miscarriage

PURPOSE

This study aims to determine the effect of individualized care provided based on Swanson's Caring Theory on the grief, depression, anxiety, and stress levels of women who had a miscarriage.

DESIGN AND METHODS

A total of 104 women who experienced a miscarriage were randomized as study (n = 52) and control (n = 52) groups.

FINDINGS

The women's physical, emotional, behavioral, and cognitive grief symptoms decreased after receiving Swanson's care (P < .001). Negative feelings about the future, level of depression, and anxiety levels diminished after receiving Swanson's Care (P < .001).

PRACTICE IMPLICATIONS

Supportive care and counseling provided after miscarriage were found to contribute to women's psychosocial well-being and to improve their ability to cope with psychological symptoms.

Heart Rate Variability Indices as Possible Biomarkers for the Severity of Post-traumatic Stress Disorder Following Pregnancy Loss

Background: Psychological distress, such as posttraumatic stress disorder (PTSD), is commonly evaluated using subjective questionnaires, a method prone to self-report bias. The study's working hypothesis was that levels of autonomic dysfunction determined by heart rate variability (HRV) measures are associated with the severity of PTSD in women following pregnancy loss. Methods: This was an observational prospective cohort study with 53 patients enrolled. The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) PTSD scale (PCL-5) was used to assess the severity of PTSD in women after pregnancy loss. The cardiac autonomic function was assessed using HRV measurements during a deep breathing test using an HRV scanner system with wireless ECG enabling real-time data analysis and visualization. HRV measures were: standard deviation (SD) of normal R-R wave intervals [SDNN, ms], square root of the mean of the sum of the squares of differences between adjacent normal R wave intervals [RMSSD, ms], and the number of all R-R intervals in which the change in consecutive normal sinus intervals exceeds 50 milliseconds divided by the total number of R-R intervals measured [pNN50 = (NN50/n-1)^*100%] [pNN50%]. Results: The PCL-5 scores had a statistically significant association with HRV indices (SDNN; RMSSD, and pNN50%). Patients with PTSD had similar mean heart rate values as compared to patients without PTSD (PCL-5), but significantly higher SDNN [median[IQR, interquartile range]: 90.1 (69.1-112.1) vs. 52.5 (36.8-65.6)], RMSSD [59.4 (37.5-74.9) vs. 31.9 (19.3 - 44.0)], and PNN50% values [25.7 (16.4-37.7) vs. 10.6 (1.5-21.9)]. The SDNN of the deep breathing test HRV was effective at distinguishing between patients with PTSD and those without, with an AUC = 0.83 +/- 0.06 (95 % CI 0.94, p = 0.0001) of the ROC model. Conclusions: In this study, HRV indices as biomarkers of cardiac dysautonomia were found to be significantly related to the severity of PTSD symptoms in women after pregnancy loss.

Psychological aspects and fertility issues of GTD

Gestational trophoblastic disease (GTD) represents a spectrum of rare pregnancy-related disorders, including both premalignant and malignant entities. Although GTD's medical outcomes have been widely explored, limited data are available regarding the related psychological, sexual, and fertility issues. The present chapter aims to enhance comprehension of the psychosocial impact of GTD by discussing the main quantitative and qualitative evidence available in this field. Although patients globally report a good quality of life, clinically significant levels of anxiety and depression have been consistently found across studies. Similarly, despite the quality of couple relationships being generally satisfactory, they often complain of a lack of sexual desire. Moreover, pregnancy loss may raise significant and long-term fertility-related concerns. Specific socio-demographic and clinical factors have been identified as predictors of psychosocial outcomes. At the clinical level, research suggests that there is a need to provide multidisciplinary care to patients.