Pregnancy following miscarriage: course of grief and some determining factors

Women pregnant after previous perinatal loss: relationships between adult attachment, shame, and prenatal psychological outcomes

BACKGROUND

Insecure adult attachment, shame, self-blame, and isolation following perinatal loss place bereaved women at risk of adverse psychological outcomes, which can impact child and family outcomes. To date, no research has considered how these variables continue to influence women's psychological health in pregnancy subsequent to loss.

OBJECTIVE

This study explored associations between prenatal psychological adjustment (less grief and distress) and adult attachment, shame, and social connectedness, in women pregnant after loss.

METHOD

Twenty-nine pregnant Australian women accessing a Pregnancy After Loss Clinic (PALC) completed measures of attachment styles, shame, self-blame, social connectedness, perinatal grief, and psychological distress.

RESULTS

Four 2-step hierarchical multiple regression analyses revealed adult attachment (secure/avoidant/anxious; Step 1), shame, self-blame, and social connectedness (Step 2) explained 74% difficulty coping, 74% total grief, 65% despair, and 57% active grief. Avoidant attachment predicted more difficulty coping and higher levels of despair. Self-blame predicted more active grief, difficulty coping, and despair. Social connectedness predicted lower active grief, and significantly mediated relationships between perinatal grief and all three attachment patterns (secure/avoidant/anxious).

CONCLUSIONS

Although avoidant attachment and self-blame can heighten grief in pregnancy after loss, focusing on social connectedness may be a helpful way for prenatal clinicians to support pregnant women during their subsequent pregnancy - and in grief.

Patterns and predictors of depressive and anxiety symptoms in mothers affected by previous prenatal loss in the ALSPAC birth cohort

BACKGROUND

Studies investigating the patterns or predictors of psychological distress in expecting and postpartum mothers affected by previous prenatal loss, are limited. The study objectives were to explore longitudinal trajectory patterns of depressive and anxiety symptoms in mothers affected by previous prenatal loss from early in a subsequent pregnancy up to pre-adolescence, and to identify early factors predictive of elevated symptom trajectory patterns.

METHODS

A total of 2854 mothers from the Avon Longitudinal Study of Parents and Children self-identified as having experienced a previous prenatal loss. A latent class analysis identified trajectory patterns of symptoms across 10 timepoints from 18-weeks' gestation up to 134-months postpartum, multivariate regression analysis identified predictors of elevated symptom trajectories, and hierarchical regression analysis determined predictive accuracy between predictors and elevated trajectory patterns.

RESULTS

Three distinct longitudinal trajectory patterns of depressive and anxiety symptoms reflected low (54%), sub-clinical (34%), and clinical symptoms (12%). Key factors that predicted elevated symptom trajectory patterns better than increased symptom scores early in subsequent pregnancy include history of severe depression or other psychiatric problem, experiencing three or more stressful events from mid-pregnancy, inadequate social support, history of induced abortion, and history of abuse. Predictive accuracy of elevated trajectories was 0.542 (depression) and 0.432 (anxiety).

LIMITATIONS

Generalizability may be compromised by attrition, under-reporting, and recall bias.

CONCLUSION

Including factors predictive of long-term sub-clinical or clinical depressive and anxiety symptoms in early assessments will improve clinician's ability to identify mothers who may benefit from immediate and/or ongoing monitoring, and psychotherapeutic intervention after prenatal loss.

Being PAL: Uncertainty and Coping in r/PregnancyAfterLoss

Women who become pregnant again following miscarriage or stillbirth are in a particularly vulnerable position as they grapple with uncertainty about the current pregnancy's viability and outcomes. In this study, we examine the types of uncertainty that emerge in pregnancy after loss (PAL) and how women manage that uncertainty. Framed by the theory of communication and uncertainty management, we thematically analyzed threads (N = 636) from the online discussion board Reddit, focusing on the specific subreddit community r/PregnancyAfterLoss. Themes of physiological, emotional, and social uncertainty dominated the PAL experiences of these online community members. Uncertainty management and coping strategies included direct information seeking, bracing, mantras, and accepting uncertainty as part of the PAL experience. Theoretical contributions of this study include an initial conceptualization of emotional uncertainty in health communication. In addition, we draw parallels between uncertainty in PAL and in illness and highlight the unique features of PAL that expand our understanding of uncertainty in health. Practical implications are drawn from members' expressed needs and uncertainty management practices, and provide direction for supporting women through the PAL experience.

A systematic review of instruments measuring grief after perinatal loss and factors associated with grief reactions

OBJECTIVE

Expectant parents who live through perinatal loss experience intense grief, which is not always acknowledged or accepted. A screening tool to detect bereaved parents' grief reactions can guide professionals, including perinatal palliative care teams, to provide follow-up for those in need. This review's goal is to identify and synthesize the international published literature on existent instruments specifically measuring the grieving process after any perinatal loss and to identify factors that could moderate grief reactions.

METHOD

Systematic review (PROSPERO # CRD42018092555) with critical synthesis. PUBMED, Cochrane, and PsycINFO databases were searched in English language articles using the keywords "perinatal" AND ("grief" OR "bereavement" OR mourning) AND ("scale" OR "questionnaire" OR "measure" OR "assessment") up to May 2018. Eligibility criteria included every study using a measure to assess perinatal grief after all kinds of perinatal losses, including validations and translations to other languages and interventions designed to alleviate grief symptoms.

RESULTS

A total of 67 papers met inclusion criteria. Seven instruments measuring perinatal grief published between 1984 and 2002 are described. The Perinatal Grief Scale (PGS) was used in 53 of the selected studies. Of those, 39 analyzed factors associated with grief reactions. Six articles used PGS scores to evaluate pre- and post-bereavement interventions. Studies in English language only might have limited the number of articles.

SIGNIFICANCE OF RESULTS

The PGS is the most used standardized measures to assess grief after perinatal loss. All parents living through any kind of perinatal loss should be screened.

The effects of a postmiscarriage menstrual period prior to reconceiving

BACKGROUND

The optimal interpregnancy interval after a single pregnancy loss is controversial. It is common obstetrical practice to recommend that women who have had a miscarriage in the first trimester of pregnancy should wait for 1 or more menstrual cycles before attempting to conceive again.

OBJECTIVE

This study aimed to assess whether conception before the first menstrual period after a spontaneous pregnancy loss is associated with a risk of repeat miscarriage or adverse perinatal outcomes.

STUDY DESIGN

This retrospective cohort study included 107 women who had a spontaneous miscarriage in the first trimester of pregnancy followed by a subsequent pregnancy with an interpregnancy interval of <12 weeks. All miscarriages had ended in either spontaneous expulsion of the products of conception or medical or surgical evacuation of the uterus. The perinatal outcome measures of 57 women who conceived after the first menstrual period following a spontaneous miscarriage were compared with perinatal outcome measures of 50 women who conceived before the first menstrual period following a spontaneous miscarriage. The primary outcome was rate of pregnancy loss, and the secondary outcomes were gestational age at delivery and birthweight.

RESULTS

The rate of recurrent miscarriage was 10.4% for women who conceived before the first menstrual period following a spontaneous miscarriage and 15.8% for those who conceived after (P=.604). There were no differences in the gestational age at delivery (38.9 vs 38.7 weeks; P=.66) or the birthweight (3347±173 vs 3412±156 g; P=.5) between the 2 groups. Other outcomes, such as mode of delivery and 5-minute Apgar score, were also similar for both groups. A multiple logistic regression analysis confirmed that conception before the first menstrual period following a spontaneous miscarriage was not associated with a higher incidence of subsequent miscarriage (odds ratio, 1.74; P=.46) or any other untoward outcome.

CONCLUSION

Conception shortly after a spontaneous miscarriage without waiting for at least the first postmiscarriage menstrual period is not associated with adverse maternal or neonatal outcomes compared with those of women with similar interpregnancy intervals who conceived after their next menstrual period.

Pregnancy after miscarriage in primiparae and multiparae: implications for women's psychological well-being

Introduction: Miscarriage is a stressful life event with negative consequences that can last into the subsequent gestation, increasing women's risk for psychological symptoms. Less clear in literature is whether having a living child may buffer the psychological impact of miscarriage on subsequent pregnancies.Objective: explore levels of depression, anxiety and fear of delivery in women with and without a previous miscarriage, taking into consideration the presence of a living child.Method: 208 women (M = 34.68) were recruited during the third trimester of gestation. The sample was composed of 159 women without a previous miscarriage (72.3% primiparae and 27.7% multiparae) and 49 women with a history of miscarriage (53.1% primiparae and 46.9% multiparae). Participants filled out a battery of questionnaires aimed at assessing anxiety, depression, and fear of delivery.Results: Primiparae reported higher levels of fear of childbirth than multiparae. Moreover, women without a history of previous perinatal loss showed lower levels of depression and fear of childbirth than women with a previous perinatal loss.Conclusions: Data highlight the importance of developing specific support groups, for primiparae, due to their great emotional vulnerability, and for women with past miscarriage, to help them cope in adaptive ways with a new pregnancy.

Pregnancy decisions after fetal or perinatal death: systematic review of qualitative research

OBJECTIVES

To synthesise the findings of qualitative research exploring parents' experiences, views and decisions about becoming pregnant following a perinatal death or fetal loss.

DESIGN

Systematic review and meta-synthesis of qualitative research.

DATA SOURCES

Medline, Web of Science, CINAHL, PsycINFO, ASSIA, Embase, PUBMED, Scopus and Google Scholar.

ELIGIBILITY CRITERIA

Nine electronic databases were searched using predefined search terms. Articles published in English, in peer-reviewed journals, using qualitative methods to explore the experiences and attitudes of bereaved parents following perinatal or fetal loss, were included.

DATA EXTRACTION AND SYNTHESIS

Qualitative data relating to first-order and second-order constructs were extracted and synthesised across studies using a thematic analysis.

RESULTS

15 studies were included. Four descriptive themes and 10 subthemes were identified. The descriptive themes were: deciding about subsequent pregnancy, diversity of reactions to the event, social network influences, and planning or timing of subsequent pregnancy. The decision to become pregnant after death is complex and varies between individuals and sometimes within couples. Decisions are often made quickly, in the immediate aftermath of a pregnancy loss, but may evolve over time. Bereaved parents may feel isolated from social networks.

CONCLUSIONS

There is an opportunity to support parents to prepare for a pregnancy after a fetal or perinatal loss, and conversations may be welcomed at an early stage. Health professionals may play an important role providing support lacking from usual social networks.

PROSPERO REGISTRATION NUMBER

CRD42018112839.

Parenting while grieving: the impact of baby loss

Purpose

The purpose of this paper is to explore the impact of pregnancy or baby loss on families, and their ability to access suitable support. Miscarriage and stillbirth are not rare events and losing a baby can have an overwhelming and long-term impact on parents and on existing and subsequent children.

Design/methodology/approach

This paper provides an overview of current relevant research, policy and practice.

Findings

Much research and service provision focuses on pregnancy or baby loss for parents without living children. This is predicated on the widely held assumption that existing children provide a protective factor mitigating the loss and going on to have another child is the best antidote to grief. Research does not substantiate this but highlights the difficulties parents experience when coping with pregnancy or baby loss alongside the needs of looking after existing children.

Originality/value

The identification of a “hidden” group of parents and children whose mental health and wellbeing is at risk without the provision of services. A tailored approach to the needs of the family is called for, including greater collaboration between statutory and third sector organisations.

The Impact of Computing Interpregnancy Intervals Without Accounting for Intervening Pregnancy Events

BACKGROUND

Short interpregnancy intervals (IPI) are associated with poor birth outcomes. Often, only livebirths are considered to estimate IPI. The objective of our work is to explore whether the associations between demographic, behavioural, and pregnancy variables and IPI change when events other than livebirth are included.

METHODS

We used data from the 2006-10 and 2011-13 period of the National Survey of Family Growth (NSFG). We defined IPI using the conception date of the index pregnancy and the event date of the previous one ending in (i) livebirth; (ii) stillbirth; (iii) miscarriage; (iv) abortion; or (v) any of these events. Risk ratios (RR) were estimated for short IPI (<18 months), and demographic, pregnancy, and behavioural variables using log-linear models.

RESULTS

When intervening events are included, the association between short IPI and its predictors vary by definition, especially for unintended versus intended pregnancies (only livebirth risk ratio [RR] 1.34, 95% confidence interval [CI] 1.2, 1.5) versus livebirth and miscarriage RR 1.14, 95% CI 1.0, 1.3) and women older than 30 vs. younger than 20 at resolution of the previous pregnancy (only livebirth RR 1.22, 95% CI 1.0, 1.5 versus livebirth and miscarriage RR 1.36, 95% CI 1.2, 1.6).

CONCLUSIONS

Including miscarriage as an intervening event in the calculation of IPI changes the association between several risk factors and short IPI. However, the association between short IPI and preterm birth does not vary when different IPI calculations are used.

Parent Distress and the Decision to Have Another Child After an Infant's Death in the NICU

OBJECTIVE

To examine associations among parent perceptions of infant symptoms/suffering, parent distress, and decision making about having additional children after an infant's death in the NICU.

DESIGN

Mixed-methods pilot study incorporating mailed surveys and qualitative interviews.

SETTING

Midwestern Level IV regional referral NICU.

PARTICIPANTS

Participants were 42 mothers and 27 fathers whose infants died in the NICU.

METHODS

Parents reported on infant symptoms/suffering at end of life and their own grief and posttraumatic stress symptoms. Qualitative interviews explored decision making about having additional children.

RESULTS

Approximately two thirds of bereaved parents had another child after their infant's death (62% of mothers, 67% of fathers). Mothers who had another child reported fewer infant symptoms at end of life compared with mothers who did not (p = .002, d = 1.28). Although few mothers exceeded clinical levels of prolonged grief (3%) and posttraumatic stress symptoms (18%), mothers who had another child endorsed fewer symptoms of prolonged grief (p = .001, d = 1.63) and posttraumatic stress (p = .009, d = 1.16). Differences between fathers mirrored these effects but were not significant. Parent interviews generated themes related to decision making about having additional children, including Impact of Infant Death, Facilitators and Barriers, Timing and Trajectories of Decisions, and Not Wanting to Replace the Deceased Child.

CONCLUSION

Having another child after infant loss may promote resilience or serve as an indicator of positive adjustment among parents bereaved by infant death in the NICU. Prospective research is necessary to distinguish directional associations and guide evidence-based care.

"Not just a normal mum": a qualitative investigation of a support service for women who are pregnant subsequent to perinatal loss

BACKGROUND

Following previous perinatal loss, women in a subsequent pregnancy may experience heightened emotions, such as anxiety and fear, with a range of longer-term implications. To support these women, the Mater Mothers' Bereavement Support Service in Brisbane, Australia, developed a Pregnancy After Loss Clinic (PALC) as a specialised hospital-based service. The present study investigated the experiences of mothers with previous perinatal loss in relation to: (a) their subsequent pregnancy-to-birth journey, and (b) the PALC service. Such research seeks to inform the ongoing development of effective perinatal services.

METHOD

A qualitative interview-based research design was employed with a purposive sample of 10 mothers who had previously experienced perinatal loss and who attended the Mater Mothers' PALC during their subsequent pregnancy in 2015. All mothers had subsequently delivered a live baby and were in a relationship with the father of the new baby. Women were aged between 22 and 39 years, primiparous or multiparous, and from a range of cultural backgrounds. Semi-structured interviews, conducted either at the hospital or by telephone by an experienced, independent researcher, lasted between 20 min and one hour. All interviews were audio-recorded and transcribed verbatim, with participant names changed. Interviews were analysed using content analysis by two researchers who were not involved in the service delivery or data gathering process.

RESULTS

Seven themes were identified from the interview material: The overall experience, The unique experience of first pregnancy after loss, Support from PALC, Experiences of other services, Recommendations for PALC services, Need for alternative services, and Advice: Mother to mother.

CONCLUSIONS

Participants spoke positively of the PALC services for themselves and their families. Anxieties over their subsequent pregnancy, and the desire for other health professionals to be more understanding were frequently raised. Recommendations were made to extend the PALC service and to develop similar services to support access for other families experiencing perinatal loss.

Women's persistent depressive and perinatal grief symptoms following a miscarriage: the role of childlessness and satisfaction with healthcare services

The objectives of this cross-sectional study were to determine whether depressive and perinatal grief symptoms vary according to time since miscarriage and to test whether childlessness and satisfaction with healthcare services influence symptom duration. A total of 245 women who had experienced a miscarriage answered a self-report questionnaire, indicating the date of their miscarriage and assessing their present level of depressive and perinatal grief symptoms. They also provided sociodemographic characteristics and indicated their level of satisfaction with healthcare services. One-way analyses of variance indicated that women who had miscarried within the past 6 months reported higher scores for depressive symptoms than did women who had miscarried between 7 and 12 months ago and more than 2 years ago. However, when controlling for childlessness and satisfaction with healthcare services, those differences became respectively marginal and non-significant, indicating that depressive symptoms are similar across time for more than 2 years after the loss. Regarding perinatal grief, results revealed that symptoms significantly decreased across time only for women with children and women who were satisfied with healthcare services. For childless women and those dissatisfied with healthcare services, perinatal grief symptoms did not vary according to time since miscarriage. Results suggest that, particularly for women who are childless and/or dissatisfied with healthcare services, depressive and perinatal grief symptoms persist long after a miscarriage. These results highlight the importance of paying particular attention to more vulnerable women and of improving healthcare services post-miscarriage.

Trying to Conceive After an Early Pregnancy Loss: An Assessment on How Long Couples Should Wait

OBJECTIVE

To compare time to pregnancy and live birth among couples with varying intervals of pregnancy loss date to subsequent trying to conceive date.

METHODS

In this secondary analysis of the Effects of Aspirin in Gestation and Reproduction trial, 1,083 women aged 18-40 years with one to two prior early losses and whose last pregnancy outcome was a nonectopic or nonmolar loss were included. Participants were actively followed for up to six menstrual cycles and, for women achieving pregnancy, until pregnancy outcome. We calculated intervals as start of trying to conceive date minus pregnancy loss date. Time to pregnancy was defined as start of trying to conceive until subsequent conception. Discrete Cox models, accounting for left truncation and right censoring, estimated fecundability odds ratios (ORs) adjusting for age, race, body mass index, education, and subfertility. Although intervals were assessed prior to randomization and thus reasoned to have no relation with treatment assignment, additional adjustment for treatment was evaluated given that low-dose aspirin was previously shown to be predictive of time to pregnancy.

RESULTS

Couples with a 0-3-month interval (n=765 [76.7%]) compared with a greater than 3-month (n=233 [23.4%]) interval were more likely to achieve live birth (53.2% compared with 36.1%) with a significantly shorter time to pregnancy leading to live birth (median [interquartile range] five cycles [three, eight], adjusted fecundability OR 1.71 [95% confidence interval 1.30-2.25]). Additionally adjusting for low-dose aspirin treatment did not appreciably alter estimates.

CONCLUSION

Our study supports the hypothesis that there is no physiologic evidence for delaying pregnancy attempt after an early loss.

Psychiatric symptoms and pregnancy distress in subsequent pregnancy after spontaneous abortion history

Objectives:

Spontaneous abortion is one of the most important complications of pregnancy with short and long adverse psychological effects on women. This study assesses the implications of a spontaneous abortion history has on women’s psychiatric symptoms and pregnancy distress in subsequent pregnancy less than one years after spontaneous abortion.

Methods:

A case-control study was conducted on pregnant women of Babol city from September 2014 to May 2015. In this study, 100 pregnant women with spontaneous abortion history during a year ago and 100 pregnant women without spontaneous abortion history were enrolled. All the participants in two groups completed the Symptom Checklist-90-Revised (SCL-90-R), and pregnancy Distress Questionnaire (PDQ).

Results:

Women with spontaneous abortion history had significantly higher mean of many subscales of SCL-90 (depression, anxiety, somatization, obsessive-compulsiveness, interpersonal sensitivity, psychoticism, hostility, paranoid, and Global Severity Index) more than women without spontaneous abortion history. Also, women with spontaneous abortion history had significantly higher mean of two subscales of PDQ concerns about birth and the baby, concerns about emotions and relationships) and total PDQ more than women without spontaneous abortion history.

Conclusion:

Pregnant women with less than a year after spontaneous abortion history are at risk of psychiatric symptoms and pregnancy distress more than controls. This study supports those implications for planning the post spontaneous abortion psychological care for women, especially women who wanted to be pregnant during 12 month after spontaneous abortion.

Effect of previous miscarriage on depressive symptoms during subsequent pregnancy and postpartum in the first baby study

Our objective was to test the hypothesis that nulliparous women with a history of miscarriage have an increased risk of depression during late pregnancy, and at 1, 6, and 12 months postpartum compared to women without a history of miscarriage. We conducted secondary analysis of a longitudinal cohort study, the First Baby Study, and compared 448 pregnant women with a history of miscarriage to 2,343 pregnant women without a history of miscarriage on risk of probable depression (score >12 on the Edinburgh Postnatal Depression Scale). Logistic regression models were used to estimate odds ratios at each time point and generalized estimating equations were used to obtain estimates in longitudinal analysis. Women with a history of miscarriage were not more likely than woman without a history of miscarriage to score in the probable depression range during the third trimester or at 6 or 12 months postpartum but were more likely at 1 month postpartum, after adjustment for sociodemographic factors (OR 1.66, 95% CI 1.03-2.69). Women with a history of miscarriage may be more vulnerable to depression during the first month postpartum than women without prior miscarriage, but this effect does not appear to persist beyond this time period. We support the promotion of awareness surrounding this issue and recommend that research is planned to identify risk factors that may position a woman with a history of miscarriage to be at higher risk for depression.

The effect of a very short interpregnancy interval and pregnancy outcomes following a previous pregnancy loss

OBJECTIVE

We sought to assess the relationship between a short interpregnancy interval (IPI) following a pregnancy loss and subsequent live birth and pregnancy outcomes.

STUDY DESIGN

A secondary analysis of women enrolled in the Effects of Aspirin in Gestation and Reproduction trial with a human chorionic gonadotropin-positive pregnancy test and whose last reproductive outcome was a loss were included in this analysis (n = 677). IPI was defined as the time between last pregnancy loss and last menstrual period of the current pregnancy and categorized by 3-month intervals. Pregnancy outcomes include live birth, pregnancy loss, and any pregnancy complications. These were compared between IPI groups using multivariate relative risk estimation by Poisson regression.

RESULTS

Demographic characteristics were similar between IPI groups. The mean gestational age of prior pregnancy loss was 8.6 ± 2.8 weeks. The overall live birth rate was 76.5%, with similar live birth rates between those with IPI ≤3 months as compared to IPI >3 months (adjusted relative risk [aRR], 1.07; 95% confidence interval [CI], 0.98-1.16). Rates were also similar for periimplantation loss (aRR, 0.95; 95% CI, 0.51-1.80), clinically confirmed loss (aRR, 0.75; 95% CI, 0.51-1.10), and any pregnancy complication (aRR, 0.88; 95% CI, 0.71-1.09) for those with IPI ≤3 months as compared to IPI >3 months.

CONCLUSION

Live birth rates and adverse pregnancy outcomes, including pregnancy loss, were not associated with a very short IPI after a prior pregnancy loss. The traditional recommendation to wait at least 3 months after a pregnancy loss before attempting a new pregnancy may not be warranted.

Effect of miscarriage history on maternal-infant bonding during the first year postpartum in the first baby study: a longitudinal cohort study

Background

Miscarriage, the unexpected loss of pregnancy before 20 weeks gestation, may have a negative effect on a mother’s perception of herself as a capable woman and on her emotional health when she is pregnant again subsequent to the miscarriage. As such, a mother with a history of miscarriage may be at greater risk for difficulties navigating the process of becoming a mother and achieving positive maternal-infant bonding with an infant born subsequent to the loss. The aim of this study was to examine the effect of miscarriage history on maternal-infant bonding after the birth of a healthy infant to test the hypothesis that women with a history of miscarriage have decreased maternal-infant bonding compared to women without a history of miscarriage.

Methods

We completed secondary analysis of the First Baby Study, a longitudinal cohort study, to examine the effect of a history of miscarriage on maternal-infant bonding at 1 month, 6 months, and 12 months after women experienced the birth of their first live-born baby. In a sample of 2798 women living in Pennsylvania, USA, we tested our hypothesis using linear regression analysis of Shortened Postpartum Bonding Questionnaire (S-PBQ) scores, followed by longitudinal analysis using a generalized estimating equations model with repeated measures.

Results

We found that women with a history of miscarriage had similar S-PBQ scores as women without a history of miscarriage at each of the three postpartum time points. Likewise, longitudinal analysis revealed no difference in the pattern of maternal-infant bonding scores between women with and without a history of miscarriage.

Conclusions

Women in the First Baby Study with a history of miscarriage did not differ from women without a history of miscarriage in their reported level of bonding with their subsequently born infants. It is important for clinicians to recognize that even though some women may experience impaired bonding related to a history of miscarriage, the majority of women form a healthy bond with their infant despite this history.

Effect of previous miscarriage on the maternal birth experience in the First Baby Study

OBJECTIVE

To determine whether a history of miscarriage is related to birth experience and/or maternal fear of an adverse birth outcome for self or infant during a subsequent delivery.

DESIGN

Secondary analysis of a prospective cohort study, the First Baby Study.

SAMPLE

Women age 18 to 35 who were expecting to deliver their first live-born infants in Pennsylvania between January 2009 and April 2011.

PARTICIPANTS

Four hundred fifty-three pregnant women who reported perinatal loss prior to 20 weeks gestation (miscarriage) in a previous pregnancy and 2401 pregnant women without a history of miscarriage were interviewed during pregnancy and again one month after their first live birth.

METHODS

Maternal birth experience and fear of an adverse birth outcome measured via telephone interview were compared across groups.

RESULTS

Maternal birth experience scores did not significantly differ between women with and without previous miscarriage. Women with a history of miscarriage reported that they feared an adverse birth outcome for themselves or their infants more frequently than women without a history of miscarriage (52.1% vs. 46.6%; p = .033), however, this relationship was not significant after adjustment for confounders.

CONCLUSION

Our findings indicate that there is no association between miscarriage history and birth experience. Additional research on this topic would be beneficial including an in-depth examination of fear of adverse outcome during birth. However, nurses and midwives may consider using therapeutic communication techniques to ensure that women with a history of miscarriage receive strong emotional support and reassurance during birth.

Complicated grief after perinatal loss

The loss of an infant through stillbirth, miscarriage, or neonatal death is recognized as a traumatic life event. Predictors of development of complicated grief after prenatal loss include lack of social support, pre-existing relationship difficulties, or absence of surviving children, as well as ambivalent attitudes or heightened perception of the reality of the pregnancy. Risk of complicated grief was found to be especially high after termination of a pregnancy due to fetal abnormality. Studies have revealed that men and women show different patterns of grief, potentially exacerbating decline in a relationship. Although it is clear that prenatal loss has a large psychological impact, it is concluded that there is a substantial lack of randomized controlled studies in this field of research,

Healthcare utilization in the pregnancy following a perinatal loss

PURPOSE

To evaluate the influence of previous perinatal loss, anxiety, depressive symptoms, impact of the previous loss, and maternal investment in the baby on mothers' healthcare utilization (HCU) during the subsequent pregnancy and postpartum periods.

STUDY DESIGN AND METHODS

A longitudinal, cohort study design gathered telephone interview data from 36 mothers with a history of prior perinatal loss, 32 mothers with no loss history, and 38 first-time mothers. These data were collected during the third trimester of pregnancy until 8 months postpartum.

MEASURES

Centers for Epidemiologic Studies-Depression Scale, Spielberger State-Trait Anxiety Scale, Pregnancy Outcome Questionnaire, Impact of Events Scale, Maternal Attitude Questionnaire, and a questionnaire regarding HCU.

RESULTS

Mothers with a history of prior perinatal loss utilized more healthcare resources in the subsequent pregnancy when compared with non-loss controls. Increased HCU during pregnancy was associated with increased maternal anxiety and depressive symptoms after birth.

CLINICAL IMPLICATIONS

Mothers with a history of prior perinatal loss may attempt to cope with their anxiety in pregnancy and depression in early postpartum with requests for additional healthcare resources. Nurses need to listen with compassion, providing appropriate education and information, and make referrals to mental healthcare providers and support groups as indicated. These nursing interventions during the subsequent pregnancy may be a better use of healthcare resources than providing extra, but medically unnecessary, laboratory and ultrasound testing for the sole purpose of fleeting reassurance.

Interconception care for couples after perinatal loss: a comprehensive review of the literature

Perinatal loss can be emotionally devastating for couples who experience miscarriage, fetal or neonatal death. Nurses in a variety of settings can assist couples through their grief by providing emotional support, giving information about the grief process, and in planning for a future pregnancy or deciding to forego future childbearing. This article explicates the relationship between grief and perinatal loss and its effects on couples, specifically in the interconception period, when the initial grief and distress have begun to subside. Interconception care focuses on bridging the couple from the end of the postpartum period to the subsequent pregnancy or decision not to conceive again. Nurses assist couples in distinguishing between uncomplicated grief, complicated grief, and depression, and make appropriate referrals. Openness to expressions of grief, helping couples mobilize support, considering readiness for another pregnancy, and directing couples to useful Internet sites are essential nursing interventions.

[Pregnancy after perinatal death: concerning the relationship of mother with the survivor baby]

The objective of this study was to investigate the maternal mood after pregnancy and premature childbirth after perinatal loss which is defined as the fetal death occurred in the last weeks of gestation or the newborn in the first few weeks after delivery. The study is part of the work executed during a phD course in Woman's Health (Fundação Oswaldo Cruz-Instituto Fernandes Figueira) using the qualitative method of research in health for the construction of life histories by means of techniques of opened, non-directive interviews, and participant comment. The field work consisted in accompanying of the double mother-baby during hospitalization and six months after discharge. The sample of the selected subjects was chosen from the relative criterion to the accompaniment by 24 hours of internments with equal or superior duration of 30 days. This article if relates one of four histories of constructed lives. The result was the production of knowledge on the state of maternal mood in mothers of premature babies after hospital discharge through the identification of emotional reactions characteristics of a work of mourning linked to specific perinatal loss in its relationship with the syndromes of the "baby of substitution" and "vulnerable child".

Effect of interpregnancy interval on outcomes of pregnancy after miscarriage: retrospective analysis of hospital episode statistics in Scotland

OBJECTIVE

To determine the optimum interpregnancy interval after miscarriage in a first recorded pregnancy.

DESIGN

Population based retrospective cohort study.

SETTING

Scottish hospitals between 1981 and 2000.

PARTICIPANTS

30,937 women who had a miscarriage in their first recorded pregnancy and subsequently became pregnant.

MAIN OUTCOME MEASURES

The primary end point was miscarriage, live birth, termination, stillbirth, or ectopic pregnancy in the second pregnancy. Secondary outcomes were rates of caesarean section and preterm delivery, low birthweight infants, pre-eclampsia, placenta praevia, placental abruption, and induced labour in the second pregnancy.

RESULTS

Compared with women with an interpregnancy interval of 6-12 months, those who conceived again within six months were less likely to have another miscarriage (adjusted odds ratio 0.66, 95% confidence interval 0.57 to 0.77), termination (0.43, 0.33 to 0.57), or ectopic pregnancy (0.48, 0.34 to 0.69). Women with an interpregnancy interval of more than 24 months were more likely to have an ectopic second pregnancy (1.97, 1.42 to 2.72) or termination (2.40, 1.91 to 3.01). Compared with women with an interpregnancy interval of 6-12 months, women who conceived again within six months and went on to have a live birth in the second pregnancy were less likely to have a caesarean section (0.90, 0.83 to 0.98), preterm delivery (0.89, 0.81 to 0.98), or infant of low birth weight (0.84, 0.71 to 0.89) but were more likely to have an induced labour (1.08, 1.02 to 1.23).

CONCLUSIONS

Women who conceive within six months of an initial miscarriage have the best reproductive outcomes and lowest complication rates in a subsequent pregnancy.

The impact of miscarriage and parity on patterns of maternal distress in pregnancy

The purpose of the current study was to examine patterns of state anxiety and pregnancy-specific distress across pregnancy in a diverse sample of women with (n = 113) and without (n = 250) prior miscarriage. For both groups, state anxiety and pregnancy-specific distress were highest in the first trimester and decreased significantly over the course of pregnancy. Compared to women without prior miscarriage, women with prior miscarriage experienced greater state anxiety in the second and third trimesters. Having a living child did not buffer state anxiety in women with a prior miscarriage. Attention to patterns of distress can contribute to delivery of appropriate support resources to women experiencing pregnancy after miscarriage and may help reduce risk for stress-related outcomes.

The parental experience of pregnancy after perinatal loss

OBJECTIVE

To review the research literature on the parental experience of pregnancy, primarily maternal, subsequent to perinatal loss.

DATA SOURCES

Computerized searches on CINAHL and PubMed databases.

STUDY SELECTION

Articles from indexed journals relevant to the objective were reviewed from January 1997 to December 2007. Only research-based studies in English were included.

DATA EXTRACTION

The review was performed using the methodology of Whittemore and Knafl (2005). Data were extracted and organized under headings: author/year/setting; purpose; sample; design/instruments; results; and nursing implications for parents during a pregnancy following a perinatal loss.

DATA SYNTHESIS

Depression and anxiety are frequently seen in pregnant women subsequent to a perinatal loss. The parental experience is filled with intense and conflicting emotions as parents balance being hopeful while worrying about another potential loss.

CONCLUSIONS

It is important for health care providers to evaluate the woman's obstetric history, acknowledge and validate previous perinatal loss, and discuss with her what would be helpful during the prenatal period with respect to the previous perinatal loss.

Stepping back to gain perspective: pregnancy loss history, depression, and parenting capacity in the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B)

Previous empirical studies of pregnancy loss have predominantly focused on complex grief response and emergent problems associated with future parenting in self-selected samples of bereaved women. This article presents findings from a retrospective secondary data analysis conducted with a racially and ethnically diverse sample of currently parenting women in the United States (N = 10,688) that examined the relationships among pregnancy loss history, current maternal depressive symptoms, and mother-infant interaction with the enrolled child. Study findings underscore a racial-ethnic disparity in pregnancy loss history for African American women, whereas current maternal depressive symptoms remain fairly constant across racial-ethnic groups. Multiple loss history is associated with a slight elevation in overall symptoms of depression, but there is no relationship between pregnancy loss history and current mother-infant interaction in the study sample. An important limitation in this study is that the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B) data does not allow for inferences specific to the type of loss, gestational age of fetus, time since loss, or whether the loss was spontaneous or induced. However, study findings highlight areas of incongruity between clinical and population-based research that deserve further investigation. Ultimately, the findings from this population-based research contribute to a wider perspective regarding maternal response to reproductive loss that can inform future research and targeted bereavement support.

The emotional burden of miscarriage for women and their partners: trajectories of anxiety and depression over 13 months

OBJECTIVE

To identify the trajectories of anxiety and depression in women and in their partners over 13 months after miscarriage.

DESIGN

A prospective study with follow up at 6 and 13 months after miscarriage.

SETTING

Three Scottish Early Pregnancy Assessment Units.

SAMPLE

Of the 1443 eligible individuals approached, 686 (48.3%) consented to participate (432 women; 254 men). Complete data were obtained from 273 women and 133 men at baseline, 6, and 13 months.

METHODS

On completion of the management of the index miscarriage, eligible and consenting women and men underwent an initial assessment comprising a semi-structured interview and a standardised self-report questionnaire. The latter was readministered at the follow-up assessments.

MAIN OUTCOME MEASURES

The hospital anxiety and depression scale (HADS), a reliable and valid measure of general psychopathology for use in nonpsychiatric samples.

RESULTS

Compared with depression, anxiety was overall the greater clinical burden. Over the 13-month period, women reported higher levels of anxiety and depression than men. Over time, a significantly greater level of adjustment was reported by women particularly with regards to the resolution of anxiety symptoms. The effect of time on HADS scores in either gender was similar between subgroups of socio-demographic and clinical factors.

CONCLUSIONS

These findings verify that early pregnancy loss represents a significant emotional burden for women, and to some extent for men, especially with regards to anxiety. For many, the detrimental effects of miscarriage are enduring and display a complex course of resolution. These findings are discussed in terms of their clinical implications for early identification and management.

Thrombophilia and pregnancy outcomes

Pregnancy complications are still a challenge for physicians, because knowledge of pathomechanisms and prophylactic measures is still limited. In recent years thrombophilia as a risk factor for pregnancy complications has gained much attention in the scientific community. However, data on this topic in the literature are conflicting. Besides an established association between antiphospholipid antibodies and pregnancy loss, available data suggest additional associations for antithrombin deficiency, hyperhomocysteinemia and also for factor (F)V Leiden, prothrombin G20210A variation, and protein S-deficiency. The contribution of thrombophilia to the risk of pre-eclampsia is less well established and recent studies did not confirm earlier data suggesting an association between thrombophilia and pre-eclampsia. A limited number of prospective studies have failed to reveal an increased risk of pregnancy complications in unselected women with thrombosis risk factors. Low-molecular weight heparin (LMWH) seems to have a positive effect on pregnancy outcome after single or recurrent abortions, however, data from only one controlled trial are available. Experience in the prevention of pre-eclampsia by prophylactic heparin is very limited, and in addition, data on pregnancy complications in women with known heritable thrombophilia or a history of thrombosis are inconsistent. These women will usually have a favorable pregnancy outcome referring to the European Prospective Cohort on Thrombophilia Study. In conclusion, thrombophilia screening might be justified in women with pregnancy loss and treatment with LMWH might be considered in those with pregnancy loss and thrombophilia. Further prospective studies and controlled interventional trials are urgently needed.

Pregnancy as a stressful life event

Pregnancy and childbirth typically are associated with positive emotions and with motherhood, but the reality is that this is not the case for all women or for all pregnancies. This review addresses a different aspect of these reproductive events, focusing on stressful circumstances surrounding pregnancy, as well as times when the pregnancy itself becomes a stressful life event. Pregnancy-related topics that tend to receive less attention will be emphasized. These include issues related to infertility; unplanned pregnancy; stress associated with testing and diagnosis of common medical complications; peripartum cardiomyopathy; fear of childbirth; and pregnancy loss as a risk factor for psychopathology. Epidemiologic information will be presented, as will relevant psychosocial factors related to each phenomenon. Healthcare providers should be sensitive to the distress and anxiety experienced by many women and their families as a consequence of these adverse events and the stressful challenge of any consequential decision-making, as well as stressors in their broader life context that can further exacerbate their distress, and make mental health referrals as appropriate.

Affective state of women following a prenatal diagnosis: predictors of a negative psychological outcome

OBJECTIVE

The benefits of prenatal diagnostic procedures are well documented. However, the investigation of psychological consequences related to these procedures has remained a surprisingly neglected area of research. The main aim of the present study was to investigate the potential relationship between psychological outcome and associated (socio-demographic, psychological and obstetric) variables in women attending a tertiary referral center for prenatal diagnosis and therapy for ultrasound scanning (due to the suspicion of a fetal malformation raised by the gynecologist in private practice), amniocentesis or chorionic villus sampling.

METHODS

Affective state was assessed by means of standardized measures of anxiety and depression (State-Trait Anxiety Inventory; Mood Scale) in 77 consecutive, unselected women. A follow-up investigation, including an additional assessment of coping mechanisms, took place 6 months after the first contact. Given the considerable number of intervening and correlating factors, a path analysis was undertaken.

RESULTS

We found that all women in our sample experienced acute distress, not only those with proven fetal malformations, genetic disorders or intrauterine fetal death, but also those with the diagnosis of a sonographic sign. At baseline (i.e. immediately after the diagnostic procedure), mood and anxiety scores in our sample were found to be comparable to those of patients with a major depressive episode. A high trait anxiety level, implementation of negative coping strategies and loss of the child during pregnancy were found to be predictive of a negative psychological outcome at follow-up. Socio-demographic variables did not have a significant predictive function for the psychological outcome.

CONCLUSIONS

We assume that a considerable number of women undergoing prenatal diagnostic procedures experience psychological distress, which may be underestimated by workers in prenatal care. Establishment of interdisciplinary treatment settings, in which access to psychological support is facilitated, may be extremely beneficial for women following a prenatal diagnosis.

Anxiety following miscarriage and the subsequent pregnancy: a review of the literature and future directions

OBJECTIVE

This is the first comprehensive review to summarize the research literature regarding anxiety symptomatology and disorders following miscarriage.

METHODS

Both "controlled" and "uncontrolled" designs are considered, with the inferential limitations of studies lacking comparison groups highlighted.

RESULTS

The limited research available suggests that miscarrying women are at increased risk for anxiety symptoms immediately following miscarriage and continuing until approximately 4 months post-loss. Beyond 4 months, reports are inconsistent. There is evidence to suggest increased risk for some anxiety disorders in the 6 months following loss; however, studies using larger sample sizes and comparison groups are needed.

CONCLUSIONS

This is the first review to consider the incidence of anxiety disorders following miscarriage, as well as the psychological impact of loss on the pregnancy subsequent to miscarriage, and the impact on partners of miscarrying women. Areas warranting further study are noted and are intended to guide future investigation.

The lived experience of miscarriage after infertility

PURPOSE

To describe women's experiences of miscarriage after infertility treatments. Published studies in which fertile women were interviewed after miscarriage have found that the women universally look to another pregnancy as the solution to their grief. However, for women undergoing infertility treatments, the possibility of another pregnancy is not a certainty. Despite this, little is known about the unique experience of this group of women. Appropriate interventions based on evidence require research to discover these women's needs.

DESIGN

Phenomenology.

METHOD

Eight women who had experienced miscarriage after infertility were interviewed. Interviews were audiotaped and transcribed verbatim. Data saturation guided the sample size. Colaizzi's methods for phenomenologic analysis were used. Analyzed data were brought back to the women for fact checking and to ensure trustworthiness and reliability of the data.

RESULTS

Themes included : going back to "square one," an inner struggle between hope and hopelessness for future fertility, running out of time, anger/frustration, lack of understanding by others, guilty feelings, feeling alone/numb with their grief, and gaining strength from adversity.

CLINICAL IMPLICATIONS

This study provides a first glimpse of women who miscarry after infertility treatments, and demonstrates that they feel profoundly alone, and grieve intensely. They worry that they caused the miscarriage, and find it difficult to hope that they will ever become pregnant again. Several women described being hospitalized for their miscarriage on postpartum units. This was unbearable for them, and should remind all of us in healthcare that this type of unthinking treatment of women who miscarry after infertility is not acceptable.

Coping with grief after involuntary pregnancy loss: perspectives of African American women

OBJECTIVE

To present the coping strategies used by African American women following their miscarriages, ectopic pregnancies, fetal deaths, and still-births, which the authors have termed involuntary pregnancy losses or IPLs.

DESIGN

Semistructured audiotaped interviews; grounded theory methods used to collect and analyze the data.

SETTING

Urban community-based sites in the Western United States.

PARTICIPANTS

20 African American adult women who reported a history of involuntary pregnancy loss within 3 years of interview.

RESULTS

In this study, the women's responses to their IPL were grouped into four areas. They coped with personal reactions, reactions of others, memories of the baby, and subsequent pregnancies.

CONCLUSION

The women in this study used inner resources to develop self-help strategies to cope with reactions following IPL. Nurses are challenged to harness the influence of family, friends, religion, and cultural traditions to assist women in processing the cognitive, emotional, and social traumas associated with IPL. Educating women to recognize grief responses after IPL and to manage these responses effectively may prevent adverse outcomes to their physical and mental health. A culturally sensitive framework of clinical assessment and intervention for African American women experiencing IPL has been developed.

Experiences with a psychological help service for women following a prenatal diagnosis: results of a follow-up study

The aim of this study is to provide a description of a psychological help service for women following a prenatal diagnosis at the Division of Prenatal Diagnosis and Therapy at Vienna University Hospital. The investigation group consisted of 77 psychologically treated women. The follow-up took place six months after the first contact. For baseline evaluation the State-Trait Anxiety Inventory, a mood scale and a documentation instrument were used. In the follow-up patients were again investigated by the test inventory and the Freiburger Coping Behavior Scale and a special follow-up instrument. The women showed extreme high scores of general mood scale and state anxiety compared with a normal population. After six months the scores had decreased significantly. Approximately 56% of the patients showed former prenatal incidents in their case histories. A significant correlation was found between the use of negative coping strategies and the development of somatic problems and changes in the private life in the follow-up period. In total 97% of the women quoted the psychological treatment as very important for coping with the prenatal incident and 100% of the women stressed the implementation of a permanent psychological help service. In conclusion, psychological treatment should be available in the event of a prenatal diagnosis, if necessary with the partner. Special attention should be given to women traumatized by a former prenatal incident.

Neonatal outcomes in immediate versus delayed conceptions after spontaneous abortion: a retrospective case series

OBJECTIVE

This study was undertaken to determine differences in neonatal outcomes between successful pregnancies conceived immediately after a spontaneous abortion (SAB) and successful pregnancies conceived after two menstrual cycles or at least 100 days from the spontaneous abortion.

STUDY DESIGN

This study was a retrospective case series. Deliveries were identified from the University of California-San Francisco Perinatal Database among patients with a history of one SAB. Medical records of 268 patients were reviewed. Sixty-four patients fulfilled study criteria, with 19 in the immediate conception group and 45 in the delayed conception group. Categorical variables were analyzed using chi(2) tests and Fisher exact tests for variables with expected values of <5, whereas continuous variables were analyzed using Student t tests.

RESULTS

Neonatal outcomes for the 2 groups were similar, although neonates in the delayed conception group were more likely to have at least one of the following: low birth weight, an Apgar score <7 at 5 minutes, or admission to the neonatal intensive care unit.

CONCLUSION

In this small retrospective case series, there was no evidence of adverse neonatal outcomes associated with conception immediately after a SAB.

International comparison of studies using the perinatal grief scale: a decade of research on pregnancy loss

The Perinatal Grief Scale (PGS) has been used in many studies of loss in pregnancy, including miscarriage, stillbirth, induced abortion, neonatal death, and relinquishment for adoption. This article describes 22 studies from 4 countries that used the PGS with a total of 2485 participants. Studies that report Cronbach's alpha for their own samples give evidence of very high internal consistency reliability. Evidence for the validity of the PGS is also reviewed, such as convergent validity seen in its association with measures of mental health, social support, and marital satisfaction. The standard errors of the means for the total scale and for the subscales reveal fairly consistent scores, in spite of very different samples and types of loss; computation of means and standard deviations for the studies as a whole permits us to establish normal score ranges. Significantly higher scores were found in studies that recruited participants from support groups and self-selected populations rather than from medical sources, and from U.S. studies compared with those in Europe.

One foot in-one foot out: weathering the storm of pregnancy after perinatal loss

Pregnancies after perinatal loss are oftentimes anxiety-laden and lacking in joy. This may lead to potential negative obstetrical and parenting outcomes. The purpose of this qualitative inquiry was to gain insights into women's pregnancy after perinatal loss experiences, including major features and helpful provider responses. Thirteen women, at varying points surrounding pregnancy after perinatal loss, participated in either a focus group or interview. An overall metaphor of "One Foot In-One Foot Out" and seven themes within four contexts emerged from the data. Women found themselves living within the contexts of (a) reliving the past, (b) trying to find a balance in the present, (c) recognizing their changed reality, and (d) living with wavering expectations. Seven themes characterized their navigation of the pregnancy: (1) setting the stage, (2) weathering the storm, (3) gauging where I am, (4) honoring each baby, (5) expecting the worst, (6) supporting me where I am, and (7) realizing how I've changed. Trying to stay balanced is the major challenge in pregnancy after perinatal loss.

Predicting Outcomes after Pregnancy Loss: Results from Studies Using the Perinatal Grief Scale

There are widely diverse findings in the literature on the types of variables that best predict grief following a pregnancy loss. This article compares the results from twenty-two studies, carried out in four countries, which all used the Perinatal Grief Scale as their outcome measure. Results of the comparison support the value of the measure for such investigations and indicate strong commonalities among the findings. Specifically, lower grief scores are consistently related to male gender, older age, shorter pregnancy, passage of more time since the loss, mental health, good marital relationship and social support, and a subsequent pregnancy. Conclusions suggest the need for studies that include more diverse populations and evaluate the impact of attributions, coping, and interventions following a loss.

The Impact of Postpregnancy Loss Services on Grief Outcome: Integrating Research and Practice in the Design of Perinatal Bereavement Programs

A national sample of 249 bereaved mothers and 114 of their male partners was investigated retrospectively, using a mailed questionnaire and the Perinatal Grief Scale, to determine the impact of postpregnancy loss services on grief outcome. Participants ranged in age from eighteen to forty-seven and experienced from one to twelve pregnancy losses with gestational age of two to forty-two weeks. A three-stage multiple regression analysis determined that predictors differed by gender and that services contributed to the prediction of grief outcome above and beyond demographic variables. Significant predictors for mothers were months since loss, attending counseling, and attending support group; significant predictors for fathers were length of pregnancy, talking with friends, and timing of talking with family. A large-scale longitudinal study that controls for service variables could inform the development of future perinatal bereavement programming in addressing the unique needs of bereaved mothers and fathers.