Miscarriage and ectopic pregnancy may trigger post-traumatic stress disorder

Women may be at risk of post-traumatic stress disorder following a miscarriage or ectopic pregnancy, suggests a new study.

The team behind the research, from Imperial College London, say the findings suggest women should be routinely screened for the condition, and receive specific psychological support following pregnancy loss.

In the study, published in the journal BMJ Open, the team surveyed 113 women who had recently experienced a miscarriage or ectopic pregnancy.

The majority of the women in the study had suffered a miscarriage in the first three months of pregnancy, while around 20 per cent had suffered an ectopic pregnancy, where the baby starts to grow outside of the womb.

The results revealed four in ten women reported symptoms of post-traumatic stress disorder (PTSD) three months after the pregnancy loss.

Miscarriage affects one in four pregnancies in the UK, and is defined as the loss of a baby before 24 weeks - although most miscarriages occur before 12 weeks.

Ectopic pregnancies are much rarer, affecting around one in 90 pregnancies. The fertilised egg usually implants in the fallopian tubes connected to the womb, where it cannot grow, and so the pregnancy either miscarries or must be ended surgically or with medicine.

In the new study, funded by the Imperial College Healthcare Charity, the scientists sent the women questionnaires asking them about their thoughts and feelings after their pregnancy loss.

All of the women had attended the Early Pregnancy Assessment Unit at Queen Charlotte's and Chelsea hospital, West London.

The results revealed that three months after the pregnancy loss, nearly four in ten women (38 per cent) met criteria for probable PTSD.

Among the women who suffered a miscarriage, 45 per cent reported PTSD symptoms at this time, compared to 18 per cent of the women who suffered an ectopic pregnancy.

PTSD explained

Post-traumatic stress disorder is caused by stressful, frightening or distressing events, and causes people to relive the event though nightmares, flashbacks, or intrusive thoughts or images that appear at unwanted moments.

The symptoms can start weeks, months or even years after a traumatic event and can cause sleeping problems, anger, and depression.

The women in the study who met the criteria for PTSD reported regularly re-experiencing the feelings associated with the pregnancy loss, and suffering intrusive or unwanted thoughts about their miscarriage.

Some women also reported having nightmares or flashbacks, while others avoided anything that may remind them of their loss, or friends and family who are pregnant.

Furthermore, nearly a third said their symptoms had impacted on their work life, and around 40 per cent reported their relationships with friends and family had been affected.

Dr Jessica Farren, lead author of the research from the Department of Surgery and Cancer at Imperial, said this research suggests women should have an opportunity to discuss their emotions with a medical professional.

"We were surprised at the high number of women who experienced symptoms of PTSD after early pregnancy loss. At the moment there is no routine follow-up appointment for women who have suffered a miscarriage or ectopic pregnancy. We have checks in place for postnatal depression, but we don't have anything in place for the trauma and depression following pregnancy loss.

"Yet the symptoms that may be triggered can have a profound effect on all aspects of a woman's everyday life, from her work to her relationships with friends and family."

Brushed under the carpet

Dr Farren, who is based at Tommy's National Centre for Miscarriage Research at Imperial, explained that previous research has suggested women who experience a stillbirth may develop post-traumatic stress disorder. However this is the first research to only focus on early pregnancy loss.

"There is an assumption in our society that you don't tell anyone you are pregnant until after 12 weeks. But this also means that if couples experience a miscarriage in this time, they don't tell people. This may result in the profound psychological effects of early pregnancy loss being brushed under the carpet, and not openly discussed," she said.

The team, who conducted their research in collaboration with the University of Leuven in Belgium, also questioned a control group of 50 women with ongoing pregnancies.

The study results also revealed around one in five women had symptoms of moderate anxiety at three months after their pregnancy loss. In the control group, one in ten reported symptoms of anxiety.

Furthermore, one in 20 women reported symptoms of depression three months after their loss.

Professor Tom Bourne, senior author of the study, said the team are now planning larger follow-up studies, to confirm the findings and help identify at-risk women.

"Not all women who suffer a miscarriage or an ectopic pregnancy will go on to develop PTSD or anxiety and depression. Therefore we are now investigating why some women may be more at risk than others, to help medical professionals identify who may need extra support."

Jane Brewin, chief executive of the charity Tommy's, who part-funded the research, said: "This study gives a voice to many women who have suffered miscarriage in silence and the often significant consequences that follow. The message is clear: in a civilised society it is not acceptable for women to suffer in this way. 

"Following this study there must now be added impetus to change miscarriage treatment and care; many women need more support following a miscarriage and the NHS needs to rethink how women are treated throughout the experience so they do not suffer from PTSD and other psychological impacts.

"Tommy's Centre for Early Miscarriage Research was opened this year with the support of many families who want to bring about change and we'd encourage all families to join with us to find answers to miscarriage and help improve care for everyone."

Professor Bourne added that in addition to improving diagnosis of psychological disorders following miscarriage, researchers need to assess what treatments may help.

"We know that talking therapies, such as cognitive behavioural therapy, have been successful at treating PTSD. However we need to investigate how this treatment should be tailored to women who have suffered an early pregnancy loss."

Ian Lush, chief executive of Imperial College Healthcare Charity, who funded the study, added: "Clearly, losing a baby at any stage is devastating for parents. We recognised early on the potential this piece of research had, and equally, how important the findings would be to patients and clinical staff right across the NHS.

"The outcomes that are being shared will hopefully mean the effects of early pregnancy loss deservedly get the spotlight shone on them, and women and their partners, thanks to better understanding of those effects, get the extra support they need." 

" I was crippled with anxiety": Nicole Martin

Nicole Martin, 42, suffered three miscarriages between 2013 and 2014. Although she didn't take part in the trial, she understands the enormous emotional toll of early pregnancy loss.

The PR associate director from London recalled: "We started trying for our second child after my daughter turned one. We became pregnant with twins, but the first baby died five weeks into the pregnancy, and the second at around 10 weeks.

Nicole Martin says her miscarriages "robbed me of my personality"

We immediately started trying again and I fell pregnant a month or two later. I was crippled with anxiety and took pregnancy tests every day. However, we miscarried again at seven weeks.

I became consumed with what happened to us. I returned to work but was a shadow of my former self, and wracked with guilt that I was unable to give my daughter a sibling. I withdrew from social situations, and felt unable to laugh or smile.

I also found it very hard to be around or even see people who had more than one child.

We were pregnant again within a couple of months, but were thrown into despair and disbelief when we miscarried a third time.

Two month later, a few weeks after my 40th birthday, we became pregnant again and our beautiful son Joseph was born in March last year.

Although we are now extremely happy, I often say the miscarriages robbed me of my personality. I stopped engaging with life; even with my daughter; and was consumed by my almost compulsive desire to have another baby.

I couldn't find joy in anything; and hated the jealousy I felt towards other pregnant women.

My relationship with my husband was put under strain but somehow we got through it and, in many ways, it brought us closer together, and I will forever be grateful for the unfailing support he - and many others - gave me during that time."

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The research was funded by the Imperial College Healthcare Charity, Tommy's, and the National Institute of Health Research Imperial Biomedical Research Centre

"Post-traumatic stress, anxiety and depression following miscarriage or ectopic pregnancy: a prospective cohort study" by J. Farren at al is pubished in BMJ Open