The Emotional Effects of Miscarriage

Frederick R. Jelovsek MD

Between 12-15% of pregnancies end in a first trimester, recognizable pregnancy loss. This may be a spontaneous miscarriage or a "missed miscarriage" requiring a D&C. Because this type of loss is so common, it is often underestimated as a source of emotional problems. It may or may not be surprising that rates of depression are reported as high as 22-55% in the year following a miscarriage. Grief, anger, anxiety and panic are also reactions that may accompany pregnancy loss.

There was a good summary review of this problem in a recent article, Broquet K: Psychological reactions to pregnancy loss. Prim Care Update Ob/Gyn 1999; 6:12-16. It points out how a woman feels a sense of oneness with the fetus in early pregnancy and it represents her hopes and dreams. This tends to magnify the loss and when very few support people are aware that a miscarriage has taken place, the usual social customs to recognize the loss are missing.

Strong Emotions

What are the circumstances that contribute to a strong emotional reaction to an early pregnancy loss?

The greatest contributor to emotional reaction is that a woman looks at the early pregnancy as part of herself and when it is lost, there is an emptiness, searching and incompleteness feeling because the fetus is not viewed as a separate being. Also, the connection to the fetus is much stronger for the woman than for her partner and there is a great difference in the intensity of the grieving process between the mother and father. A woman becomes isolated because of this and often has no emotional support for her feelings. Even the usual social rituals of a death notice, a funeral, and friends offering sympathy are absent because very few people usually know of the event. This prevents accepting the reality of the loss. If there was any ambivalence about the pregnancy in the first place guilt becomes a major component of the grieving process.

Resolve Grief

What tasks are necessary to resolve the grief of a pregnancy loss?

Workers is this field have identified four tasks to be accomplished to work through the grieving process in a psychologically constructive way. The general time it takes is as much as 12-18 months after the loss.

1. Accept the reality of the loss -- if the miscarriage takes place before friends and family know of the pregnancy, sharing the loss with others may help or even some sort of commemorative steps either public or private. If the pregnancy loss is further along, a burial ceremony or even just holding the fetus can help.
2. Allow experiencing the pain of grief -- if the grieving process is suppressed, it is more likely to result in psychological reactions. The woman needs to consciously grieve for lost dreams. This process will wax and wane but should not be suppressed by drugs, alcohol or even the rapid attempt to become pregnant again so as to relieve the pain more quickly.
3. Adjust to the new situation without the lost child -- a woman must change her perception that part of herself is lost. She needs to resume her role and self-identity at least as it was prior to becoming pregnant.
4. Reinvest emotional energy in new relationships -- a woman recovers and benefits from building new ties and nourishing the relationships already present.

What are the psychiatric consequences of pregnancy loss if the grief process does not progress to resolution?

The most common problems are depression and anxiety. The general rate of depression in women is about 10-15%. After miscarriage, this rate is reported to be 22-55% and takes 12 months to return to the baseline rate of depression in the general community. The highest risk time for depression is the first 12 weeks after a pregnancy loss. Risk factors for developing clinical depression include previous depression, the further along in pregnancy that the loss occurred, a history of substance or alcohol abuse, a poor support system and a history of poor coping skills.

Community rates of generalized anxiety or panic disorder are about 3-5% in women. In the first 12 weeks after a pregnancy loss, 22-41% of women demonstrate these problems. As with depression these rates tend to return to baseline community rates within 12 months. Compulsive behaviors may increase during this time. Women who have had previous pregnancy loss are at greater risk of developing depression and anxiety in subsequent pregnancies.

Full Depression

How do you know if the emotional reactions are just normal grief or if they have gone into a full depression?

Sadness, mild depression, guilt, anger, fatigue and somatic complaints are common to both grief and to a clinical depression. Grief will result more in disbelief, feelings of failure as a woman, and searching for meaning or the loss, while major depression has strong feelings of worthlessness, early morning awakening and persistent suicidal thoughts. Specific symptoms that require medical intervention include:

• serious or persistent suicidal thoughts
• significant feelings of worthlessness
• terminal insomnia - falling asleep ok but awakening predawn with increased anxiety or abnormal fear
• significant physical listlessness or agitation
• marked daily functioning difficulty - not eating, not bathing, unable to work or care for children
• prolonged symptoms (greater than one year)
• drug or alcohol abuse or significant increase in use

Abortion Emotions

Is the emotional reaction to an induced abortion the same as it is to a miscarriage?

In general, the rate of emotional problems after elective abortion are no greater than that of the general population unless there has been a previous history of depression or if the woman feels she was coerced into the abortion or that it was morally wrong. In those cases, emotional problems follow the same rate as an unexpected pregnancy loss.

How To Help

What can be done to help a woman who is having an emotional reaction to a pregnancy loss?

Certain interventions have been shown to reduce the rate of psychologic problems after a pregnancy loss. The best preventative is a "crisis debriefing" within the first 2-3 weeks after the miscarriage. This would include giving a woman an opportunity to discuss her feelings about what happened and making sure she has the correct factual information such as "it was not due to anything you did or did not do". Also, resources for emotional support should be identified at that time and if there are not many within the existing family or social structure, referring to support groups and recommending reading materials on common reactions to miscarriage and grief. There also should be some ongoing monitoring for depression or anxiety reactions in the next year to make sure the process is resolving.

Some additional interventions are:

• Acknowledge the loss and educate the woman about the natural grief response
• Encourage use of family, friends and support groups
• Provide reading materials
• Encourage expression of feelings, including anger, in a nondestructive manner
• Address guilt with reassurance about reasons for loss and future fertility
• Ask directly about suicidal thoughts
• Monitor for excessive anxiety, depression, substance or alcohol use/abuse and refer if present
• Monitor for marital discord which is common after a pregnancy loss
• Monitor for depression, anxiety, or grieving in subsequent pregnancy

Major Support Group
SHARE (Source of Help in Airing and Resolving Experiences)
Support group for parents grieving the loss of a baby through miscarriage, ectopic pregnancy, stillbirth or early neonatal death.

National SHARE Office
St. Joseph Health Center
300 1st Capitol Drive
St. Charles, MO 63301-2893
1-800-821-6819

Internet Source - SHARE ATLANTA

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