A Swedish study of midwives' and nurses' experiences when women are diagnosed with a missed miscarriage during a routine ultrasound scan.

OBJECTIVES: The aim was to describe midwives' and nurses' experiences when women are diagnosed with a missed miscarriage during a routine ultrasound scan in pregnancy weeks 18-20. STUDY DESIGNS: A qualitative content analysis with an inductive approach and 13 semi-structured interviews were used for data collection from these three domains: midwives at an ultrasound department, midwives at a maternity clinic and nurses at a gynecological ward. Content analysis resulted in six codes, four categories and one primary theme. MAIN OUTCOME MEASURES: The four categories identified were: the interviewees' experiences of women's reactions, support from the midwife and nurse, the interviewees' experiences of men's reactions and communication between care providers and women. The main theme focused on the interviewees' noting that women had a premonition that something was wrong with their pregnancy. This could for example have been in the form of minor bleeding or the fact that pregnancy symptoms had receded and there were no movements by the fetus. The midwives carried out a follow-up with assessment. CONCLUSIONS: Women need confirmation of their premonitions of a missed miscarriage so that a diagnosis can be made as early as possible in their pregnancy. Women and their partners who have suffered a missed miscarriage need extended support on an individual basis in addition to follow-up assistance as assessed by the midwives.

The influence of medical and psychological interventions on women's distress after miscarriage.

OBJECTIVE: The aim of this study was to examine the impact of medical and psychological interventions on women's distress after early miscarriage. METHODS: This was a prospective study of women attending for a routine scan at 10-14 weeks of gestation and found to have a missed miscarriage. An intervention group of 66 women had medical investigations to ascertain the cause of miscarriage, and at 5 weeks after the scan, they all had a medical consultation to discuss the results of the investigations. These 66 women were randomly allocated into a group which received further psychological counselling (MPC, n=33), and a group which received no psychological counselling (MC, n=33). They were compared to a control group of 61 women who received no specific postmiscarriage counselling. All participants completed preintervention and postintervention measures and 4-month follow-up questionnaires. RESULTS: The scores on the outcome variables decreased significantly with time for all three groups. In group MPC, compared to controls, there was a significantly greater decrease over time in the levels of grief, self-blame, and worry and, compared to MC group, a significantly greater decrease in grief and worry. In group MC, compared to controls, there was a significantly greater decrease in self-blame. In the MC and MPC groups, those with an identified cause of the miscarriage had significantly lower levels of anxiety and self-blame over time than those with a nonidentified cause. CONCLUSIONS: Psychological counselling, in addition to medical investigations and consultation, is beneficial in reducing women's distress after miscarriage. However, absence of an identifiable cause of miscarriage led to the maintenance of the initial anxiety levels, which should have otherwise decreased with time.

The evolutionary biology of cryptic pregnancy: A re-appraisal of the "denied pregnancy" phenomenon.

Previous research on 'denied pregnancy', i.e. lack of subjective awareness of pregnancy until the end of gestation in pregnant women, is reviewed and reinterpreted in an evolutionary biological framework. Recent epidemiological studies show that this condition has a much higher incidence than previously thought (about 1:475). Very often, bodily symptoms of pregnancy (nausea, amenorrhea and abdomen swelling) are absent or greatly reduced, and neonates tend to be underweight; in many cases, pregnancy goes undetected also by relatives and physicians. Current explanations in the clinical literature are based on psychodynamic hypotheses about pregnancy-related unconscious conflicts; the lack of symptoms is accounted for by 'somatic denial'. I argue that such psychodynamic accounts are misguided for two reasons: (1) they rest on a failure to recognize the active biological role of the fetus in determining the course of pregnancy, and (2) they ignore the many levels of mother-fetus conflict over resource allocation described by biological theories of parent-offspring conflict. Here I propose to redefine this condition as 'cryptic pregnancy', and begin to explore its possible physiological correlates and evolutionary significance. In the light of parent-offspring conflict theory, cryptic pregnancy appears to reduce the costs of pregnancy, both energetic and ecological (mobility, dependence on kin/mate, etc.), thus favoring the mother at the expense of the fetus. Reduced hCG production and/or effectiveness is likely to be involved in the process. I propose and discuss three nonexclusive evolutionary hypotheses to account for this phenomenon: (1) cryptic pregnancy could be a nonadaptive outcome of conflict resolution processes over resource allocation in pregnancy, possibly related to minor disruptions of genomic imprinting mechanisms. (2) Cryptic pregnancy could result from missed spontaneous abortions of low-quality fetuses. (3) Finally, cryptic pregnancy could be an adaptive pattern of 'forced cooperation' between mother and fetus in stressful or threatening ecological circumstances, as suggested by the reported association with elevated psychosocial stress. In case of reduced survival probability, both mother and fetus would benefit if the mother reduced investment in pregnancy in order to maximize her chances of surviving and reaching delivery.

Personal coping resources, responsibility, anxiety and depression after early pregnancy loss.

This cross-sectional study aimed at assessing the relationship of feeling of personal responsibility for miscarriage and personal coping resources (self-esteem and self-efficacy), with symptoms of anxiety and depression in 138 women at 19 to 400 days following the diagnosis of a missed abortion. Multiple regression analyses controlling for demographic and obstetric variables demonstrated that higher feelings of personal responsibility, and lower personal resources were significantly associated with anxiety and depression. Self-esteem had the most salient effect on women's level of affective psychopathology; higher levels of self-esteem were associated with lower anxiety and depression. Women with high levels of self-esteem also reported significantly lower feelings of personal responsibility for miscarriage than those with low levels of self-esteem. Interventions aimed at enhancing feelings of self-worth, and at altering exaggerated feelings of personal responsibility for miscarriage, could lessen the potential negative emotional impact of pregnancy loss on women.

Psychological outcomes following missed abortions and provision of follow-up care.

This cross-sectional study of 204 women who had experienced a missed abortion, diagnosed at 10-14 weeks of pregnancy, examined the availability and desirability of routine follow-up care, and whether such care is associated with reduced psychological morbidity in the aftermath of miscarriage. Clinically elevated anxiety and depression were observed in 45% and 15% of women, respectively, and the mean score of grief was 2.52 which is similar to that observed in people who suffer death of a close relative. A follow-up appointment after the miscarriage was thought to have been desirable by 92% of women but was offered to only 30%. No significant association between such care and reduced psychological morbidity was identified. However, there were significantly more women with clinically elevated levels of anxiety among those who felt that they were not provided with an opportunity to discuss their feelings during the follow-up, suggesting that such a follow-up either had a deleterious effect on women's psychological state or the distress itself led to such a perception of care. One-third of women in our sample would have liked psychological counselling to help them deal with the emotional aspects of their loss.

PIP: The 10-14 week ultrasound scan has been introduced to routine prenatal care for early diagnosis of major defects and screening for chromosomal abnormalities. In about 3% of such scans, the diagnosis of missed abortion is made. Despite evidence of substantial emotional stress associated with early pregnancy loss, follow-up care is not routinely provided. The present study investigated the availability and effectiveness of such follow-up care in 204 women (median age, 36 years) from London, England, who received a diagnosis of missed abortion or anembryonic pregnancy at 10-14 weeks of gestation in 1995-96. At the time of the survey, 19-400 days after the ultrasound, clinically elevated anxiety and depression were observed in 45% and 15% of women, respectively. The mean grief score was 2.52, which exceeded that reported in another study of persons who suffered the death of a close relative (2.23). 187 women (92%) expressed the belief a follow-up appointment after diagnosis would have been desirable; 73 (36%) thought they would have benefited from emotional counseling. However, a follow-up appointment was offered to only 61 women (30%). Even among women offered a follow-up visit, 22 (42%) indicated they were not provided an opportunity to discuss their feelings about the miscarriage. Women who attended the follow-up but felt they were not given an opportunity to express feelings had significantly higher mean anxiety and depression scores than women who did not have follow-up care or those who attended the follow-up and discussed their feelings. Overall, these findings indicate that miscarriage and the evacuation of retained products of conception are traumatic experiences that are too often dismissed as routine by medical staff.

Psychiatric outcome of termination of pregnancy for foetal abnormality.

Termination of pregnancy for foetal abnormality has become frequent with the increasing sophistication of techniques of antenatal diagnosis. The aim of this study was to obtain quantitative and qualitative information about psychiatric morbidity in women after termination of pregnancy for foetal abnormality. Two samples of women were compared. The first consisted of 71 women who had had a termination of pregnancy for foetal abnormality (FA group). The second consisted of 26 women who had experienced so-called missed abortion (MA group). Both groups had lost a pregnancy in the mid-trimester of pregnancy, but the MA group had no element of choice. Standardized psychiatric and social measures were used to assess both groups on three occasions after the termination. In both groups, 4 weeks after the termination psychiatric morbidity was high (four to five times higher than in the general population of women), and social adjustment was impaired. Six months and 12 months after the abortion, levels of psychiatric morbidity were near normal. Semi-structured interviewing was used to obtain information about the experience of grief after mid-trimester termination. For many women, symptoms of grief persisted throughout the year. These symptoms included typical features of grief as well as grief symptoms specific to pregnancy loss. The findings have implications for the counselling of women after termination for foetal abnormality or after missed abortion.