Evidence
Alert

Pregnancy loss leads to post-traumatic stress in one in three women

Almost one in three women develop post-traumatic stress disorder (PTSD) after early pregnancy loss, a new study shows. For some, signs of PTSD, anxiety and depression are still evident nine months later.

Early pregnancy losses are common, but the consequences and psychological impact are often overlooked. Current care varies, but most women receive no formal psychological support. They often rely on patient support groups for information and guidance.

This study aimed to investigate levels of PTSD, depression, and anxiety in the nine months after early pregnancy loss. Researchers hope the findings will help shape future response and support for women.

What’s the issue?

In the UK, there are an estimated 250,000 miscarriages and 10,000 ectopic pregnancies (in which an embryo starts to grow outside the uterus) every year. This makes it one of the most common reasons young women visit their family doctor or attend hospital.

Early pregnancy loss includes miscarriage (loss before 24 weeks) and ectopic pregnancy. Both can involve serious pain or bleeding and require emergency procedures in hospital.

There is evidence that early pregnancy loss has a psychologic impact. This may be anxiety, depression, or even PTSD. To date, this aspect of pregnancy loss has not been a major focus for research or treatment.

What’s new?

This is the first report from the larger Psychological Impact of Early Pregnancy Events study.  It included 492 women seen at three central London hospitals. They completed a survey one month after early pregnancy loss. Another 87 women with healthy pregnancies acted as a comparison group.

Researchers used recognised assessment scales for moderate/severe anxiety and depression, and PTSD, to assess the impact of early pregnancy loss.

At one month, among women with early pregnancy loss:

  • nearly one in three (29%) had PTSD, compared to none with healthy pregancies
  • one in four (24%) had anxiety, compared to one in eight (13%) women with healthy pregnancies
  • one in 10 (11%) had depression, compared to one in 50 (2%) women with healthy pregnancies.

At nine months, none of the women with healthy pregnancies had PTSD, anxiety or depression. But among women with early pregnancy loss:

  • almost one in five (18%) had PTSD
  • one in six (17%) had anxiety
  • one in 20 (6%) had depression.

These results show that PTSD, anxiety, and depression decline over time, but they remain common at nine months.

The researchers believe this study, from Tommy's National Centre for Miscarriage Research, is the largest to assess PTSD, anxiety, and depression following pregnancy loss.

Why is this important?

For many women, miscarriage or ectopic pregnancy is traumatic and has a lasting impact. Given the numbers of miscarriage and ectopic pregnancies, the researchers are concerned that this is a hidden public health issue.

They hope their research will highlight the associated psychological distress. It could prompt those closest to the women - friends, colleagues, employers and family members - to better support them and their partners following a pregnancy loss.

These findings could encourage women with PTSD to seek help. The researchers call for clinical management to be more sensitive to the psychologic implications of early pregnancy loss; delays in access to treatment to be reduced; and for women to be able to access specialist care for early pregnancy loss.

What’s next?

Some women recovered from PTSD without intervention in the first three months after a pregnancy loss. But the number of women with PTSD changed little between three and nine months. The researchers therefore suggest that women should be screened for significant psychological effects three months after a pregnancy loss.

Those reaching the criteria for significant anxiety and depression, and in particular PTSD, should then be offered an assessment by a psychologist possibly leading to cognitive behavioural therapy (CBT), which is a first line therapy for PTSD in NICE guidance.

Researchers are planning randomised trials to determine the impact of the use of visuospatial cognitive tasks and trauma focussed CBT for the treatment for PTSD associated with pregnancy loss. They will compare it with the standard support that is given to for women following an early pregnancy loss.

In the meantime, guidelines have not yet changed. But the researchers hope people will be made more aware of the psychological impact of pregnancy loss and that professionals will look for it in clinical practice.

You may be interested to read

The full paper: Farren J, and others. Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multicenter, prospective, cohort study. Am J Obstet Gynecol. 2020;222:367.e1-22

An initial study by the same researchers to investigate the type and severity of emotional distress in women after early pregnancy loss. Farren J, and others. Post-traumatic stress, anxiety and depression following miscarriage or ectopic pregnancy: a prospective cohort study. BMJ Open. 2016;6:e011864

A review of existing studies by the same researchers: Farren, J, and others. The psychological impact of early pregnancy loss. Human Reproduction Update. 2018;24:731–749

Websites for patients: The Miscarriage Association, Tommy’s Charity, and The Ectopic Pregnancy Trust

 

Funding: This study was funded by the Imperial Health Charity, NIHR Biomedical Research Centre and FWO (Research Foundation-Flanders).

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study author

Society has allowed early pregnancy loss to be shrouded in secrecy, and not really acknowledged or thought about in terms of a ‘traumatic event’. Very few studies have examined post-traumatic stress in relation to miscarriage and none on ectopic pregnancy. We started this study to investigate the issue, and because we had noticed the level of psychological distress among our patients in clinical practice. We wanted to have evidence to quantify this.

We hope people will take away the fact that early pregnancy loss is associated with high levels of psychological distress, and in particular post-traumatic stress. Having a greater appreciation of this hopefully will enable friends, colleagues, employers and family members to better support women and their partners going through a pregnancy loss. They may also spot some of the symptoms associated with post-traumatic stress and encourage women to seek help.

Tom Bourne, Professor of Gynaecology, Imperial College, London

Miscarriage Association

This is an important and high quality piece of research. While the researchers are clear about possible weaknesses, it is perhaps the most useful picture we have to date of the incidence of mental health problems following miscarriage and ectopic pregnancy.

Its findings were reflected in the results of the Miscarriage Association’s own small-scale research in 2018 which formed the basis of our resources on pregnancy loss and mental health. We quoted it further in the collaborative report, Out of Sight, Out of Mind, which was discussed in Parliament in October 2019. We expected from that debate that the new Maternity Outreach Clinic working group looking at mental health care for parents would be extended to include those with pregnancy or baby loss. We do not, however, know of any progress in this regard.

The findings should alert policymakers, commissioners and clinicians to the need for better communication with, assessment of, and provision of targeted psychological services for early pregnancy loss patients at risk of anxiety, depression and PTSD. It should be included in updates to NICE guidance NG126.

Increased public awareness of the issue may highlight the impact of even the earliest pregnancy losses on some women and partners. But without routine and robust systems of assessment and without adequate availability of NHS psychological services for those needing them, it is not enough. Both are sorely needed.

Ruth Bender Atik, National Director, The Miscarriage Association