Miscarriage and ectopic pregnancy may trigger long-term post-traumatic stress

One in six women experience long-term post-traumatic stress following miscarriage or ectopic pregnancy.

This is the finding of the largest ever study into the psychological impact of early-stage pregnancy loss, from scientists at Imperial College London and KU Leuven in Belgium.

Pregnancy loss affects up to one in two women, and for many women it will be the most traumatic event in their life. Professor Tom Bourne Study author

The research, published in the journal American Journal of Obstetrics and Gynaecology, studied over 650 women who had experienced an early pregnancy loss, of whom the majority had suffered an early miscarriage (defined as pregnancy loss before 12 weeks),  or an ectopic pregnancy (where an embryo starts to grow outside the womb and is not viable).

The study revealed that one month following pregnancy loss, nearly a third of women (29 per cent) suffered post-traumatic stress while one in four (24 per cent) experienced moderate to severe anxiety, and one in ten (11 per cent) had moderate to severe depression.

Nine months later, 18 per cent of women had post-traumatic stress, 17 per cent moderate to severe anxiety, and 6 per cent had moderate to severe depression. 

Access to treatment

The team behind the research, funded by the Imperial Health Charity and the Imperial National Institute of Health Research Biomedical Research Centre, call for immediate improvements in the care women receive following an early-stage pregnancy loss.  

Professor Tom Bourne, lead author of the research from Tommy’s National Centre for Miscarriage Research at Imperial College London said: “Pregnancy loss affects up to one in two women, and for many women it will be the most traumatic event in their life. This research suggests the loss of a longed-for child can leave a lasting legacy, and result in a woman still suffering post-traumatic stress nearly a year after her pregnancy loss.”

Professor Bourne, who is also a Consultant Gynaecologist, added: “The treatment women receive following early pregnancy loss must change to reflect its psychological impact, and recent efforts to encourage people to talk more openly about this very common issue are a step in the right direction.  Whilst general support and counselling will help many women, those with significant post-traumatic stress symptoms require specific treatment if they are going to recover fully. This is not widely available, and we need to consider screening women following an early pregnancy loss so we can identify those who most need help.”

The research follows an earlier pilot study in 2016, which investigated the psychological impact of early-stage pregnancy loss in 128 women one and three months after miscarriage or ectopic pregnancy.

The toll of early pregnancy loss

One in four pregnancies ends in miscarriage – most often before or around 12 weeks. Estimates suggest there are 250,000 miscarriages every year in the UK, and around 11,000 emergency admissions for ectopic pregnancies. The latter always result in pregnancy loss, as an embryo grows in an area outside of the womb and is unable to develop.

In the study 537 women had suffered a miscarriage before 12 weeks of pregnancy, while 116 had suffered an ectopic pregnancy.

The women in the study attended the Early Pregnancy Assessment Units at three London hospitals - Queen Charlottes and Chelsea, St Mary’s, and Chelsea and Westminster. 

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All were asked to complete questionnaires about their emotions and behaviour one month after pregnancy loss, then again three and nine months later.

Their responses were compared to 171 women who had healthy pregnancies. The results revealed the latter women’s levels of psychological symptoms were significantly lower than those found in women who had suffered early pregnancy loss.

Nightmares and flashbacks

The women in the study who met the criteria for post-traumatic stress 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 might remind them of their loss.

The authors caution the study used a questionnaire for screening for post-traumatic stress, but formal diagnosis of post-traumatic stress disorder would require a clinical interview.

Post-traumatic stress can have a toxic effect on all elements of a person’s life – affecting work, home and relationships Dr Jessica Farren Study author

The team also explain that women who were already experiencing symptoms of post-traumatic stress and depression may have been more likely to respond to the questionnaire, which could mean the number of women suffering psychological symptoms may appear higher.

However, they add that the fact that such a large proportion were experiencing symptoms suggests many women could be suffering in silence. Dr Jessica Farren, first author of the research from Imperial, and Obstetrician and Gynaecologist, said: “Post-traumatic stress can have a toxic effect on all elements of a person’s life – affecting work, home and relationships.”

“We have made significant progress in recent years in breaking the silence around mental health issues in pregnancy and postnatally, but early pregnancy losses are still shrouded in secrecy, with very little acknowledgement of how distressing and profound an event they are. Many women don’t tell colleagues, friends or family they are pregnant before the 12-week scan, leaving them feeling unable to discuss their emotions if they suffer a pregnancy loss. We also know partners can suffer psychological distress following miscarriage or ectopic pregnancy, and are investigating this in ongoing research.”

Miscarriage services need to change

The team’s research will also now focus on identifying which women are at risk of developing psychological symptoms after pregnancy loss, the impact of early pregnancy loss on partners and also the best type of treatments and how to deliver these.

Ian Lush, Chief Executive of Imperial Health Charity, said: “As the dedicated charity for the Imperial College Healthcare NHS Trust hospitals, we are committed to supporting pioneering research that leads to real improvements in patient care through our annual research fellowships programme. Dr Farren’s study clearly shows that a miscarriage or ectopic pregnancy can have profound and long-lasting impacts on women’s mental health and we look forward to seeing how this important research can be translated into better care for patients and their families in the future.”

Jane Brewin, Chief Executive of Tommy’s comments, said: “For too long women have not received the care they need following a miscarriage and this research shows the scale of the problem. Miscarriage services need to be changed to ensure they are available to everyone, and women are followed up to assess their mental wellbeing with support being offered to those who need it, and advice is routinely given to prepare for a subsequent pregnancy.”

"I did not know how to react or who to approach"

Kate Rawson, an actor and playwright, experienced two miscarriages in 2014 and 2015, one at 8 weeks and one at 11 weeks. She has written a radio play about recurrent miscarriage called Little Blue Lines. Here she discusses her experience:

“After my first miscarriage I was numb. I did not know how to react or who to approach. I did not know if it was grief that I was feeling, or if that was even a valid response to have about  losing something so ‘small’. So I tried to believe reassuring words  (‘it’s not your fault; you can try again; you’ve got time; it’s just one of those things.’)

The second time it happened I knew something was wrong immediately, just a faint pink patch in my pants, a slight cramping feeling. Then dread and anxiety at what was to come, and guilt at what I could have done to cause it; sadness for myself, but also my husband, my family, my friends who would have to do all those sad faces and texts and calls again. The physical miscarriage was a huge shock, one I was absolutely not prepared for and I will never forget it.

I tried to ‘move on’ as advised.  ‘Trying again’ was full of anxiety that got worse when I fell pregnant for the third time. Happily that resulted in a healthy full term birth, but the first trimester was extremely stressful, for both myself and my husband. I struggled to keep perspective and flitted between wanting this baby more than anything else to wishing I would just bleed and get the awful thing over with and my life back.

It was only after my son was born I realized the enormity of what I had been through, and the need to process it – there are support groups at my hospital now but there was nothing available to me at the time – so I wrote about it.”

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'Post-traumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multi-center, prospective, cohort study' by J. Farren et al is published in the American Journal of Obstetrics and Gynecology. DOI: https://doi.org/10.1016/j.ajog.2019.10.102

See the press release of this article