THE TRAGEDY OF ANOTHER LOSS:HELPING PATIENTS WITH RECURRENT MISCARRIAGE

Ruth Lathi, MD

Director of Recurrent Pregnancy loss Stanford University

Disclosures• No financial disclosures• I am not a psychologist or licensed therapist

Learning objectives• Review emotional aspects of pregnancy loss• Define normal grief response• Identify patients who are at risk for major depression• Discuss how and when to refer patients

Miscarriage• Most women with miscarriage or RM have never

experienced limitations in their health before• General knowledge about miscarriage is limited• My personal experience is that emotional reactions to

miscarriage affect patient care in a variety of ways• Distrust• Inability to concentrate/remember• Lack of engagement in treatment• Giving up• Poor self care• Loss of social support – social withdrawl

5 stages of Grief• Denial• Anger• Bargaining• Depression• Acceptance• Overly simplistic and not linear – variable

• Experiencing pain, accepting loss, adjusting to new world

Kubler-Ross 1969

TearfulnessInsomniaLoss of AppetiteLoss of concentrationDecreased libidoSomatic s symptomsGuilt

Preservation ofSelf Esteem

Ability to Imaginea Future

HopelessnessDecreased Self Esteem

and Feelings ofWorthlessness

Suicidal IdeationAnhedonia

Anergy

Major DepressionUncomplicated Grief

Major Depression and Miscarriage

• Controlled studies report that miscarriage is associated with an increased risk for, or recurrence of major depression • Women with a previous history of major depression are

an especially high risk group for recurrence of MDD• Increased risk for depression lasts up to one year after

miscarriage• Poor social support, low self esteem, prior losses

increase risk of depression

(Neugebauer et. al. JAMA, 277(5): 383-8,1997; Klier et al, J Affect Disord 59: 15-21, 2000)

Prevalence of Major Depression in Women with Recurrent Miscarriage

Klock SC et al. Psychosomatics 1997; 38: 503-507.

40-70% of women with RPL had some symptoms of Depression without meeting clinical criteria for MDD

DSM V Criteria Major Depression

Five or more of the following symptoms have been present during the same 2 week period and represent a change from previous functioning and at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure:

1) depressed mood most of the day2) markedly diminished interest or pleasure in activities3) significant weight changes4) insomnia or hypersomnia5) psychomotor agitation or retardation6) fatigue or loss of energy7) feelings of worthlessness or inappropriate guilt8) diminished ability to think or concentrate, indecisiveness9) recurrent thoughts of death

• Psychological reactions and adaptation

after miscarriage

Common Themes

• Profound Grief • Anniversary reactions• Need to make sense of the experience• Sense of responsibility

• Harris and Daniluk, Human Reproduction, 2010

Miscarriage: Gender Specific Issues

• Sexual Issues

Both Men and Women: • Body image distortions + Lowered self esteem=decreased

libido and sexual dysfunction

• Grief Symptoms Women: Longer duration of grief; more intrusion

Men: More avoidance

• Communication IssuesWomen: Intensity of grief directly related to perceived sense of

communication quality

Men: Sexual satisfaction directly related to perceived communication

Breutel et al, 1996; Conway & Russel, 2000

Gender Differences inMajor Depressive Disorder (MDD)

• Major depression is approximately twice as common in women as in men

• Onset of gender difference is in early adolescence• 1 month point prevalence:

• Women 5%-9%• Men: 2%-3%

• Lifetime risk• Women: 10%-25%• Men: 5%-12%

• Kessler et al. J Affect. Disord 1993

Psychological Reactions in Women with History of Recurrent Miscarriage and Infertility

• Psychological disengagement from future pregnancies/fertility treatments*

• Intense feeling of lack of control*• Shared sense of loss with partner*• Strong sense of injustice/unfairness*• Extreme sense of social awkwardness*

Harris and Daniluk, Human Reproduction, 2010

Gender Differences inClinical Features of Major Depression

• Women are more likely to present with atypical depression (increased appetite and weight gain, hypersomnia, rejection sensitivity)

• Women are more likely to have a seasonal pattern with onset of depression during fall/winter

• Women are more likely to have associated somatic/pain symptoms

Gender Differences inMDD Co-Morbidities

• Women with MDD have higher rates of co-morbid anxiety and eating disorders compared to men

• Men with MDD have higher rates of co-morbid substance abuseMarcus, SM. J Affect Disord 2005; 87: 141-50.

Psychopharmacological Treatment for Major Depression

• Antidepressants• Buproprion• Serotonin Reuptake Inhibitors (SSRIs)• Serotonin Norepinephrine Reuptake Inhibitors

(SNRIs)

Psychological Treatments for Major Depression in Women

• Cognitive Behavioral Therapy• Interpersonal Psychotherapy

• Grief• Interpersonal Role Transitions• Interpersonal Role Disputes• Interpersonal Deficits

• Psychodynamic Psychotherapy

Risk Factors for Major Depression

• Female Sex• Age • Family History• Early parental loss/separation• Negative Life Events• Previous history of depression

When to Refer• impairment of normal activities, work, fun, sleep etc..• suicidality (of course)• persistent tearfulness• Persistent guilt/ perseveration/delusion• grief symptoms lasting more than 1 month?• patient request• concern of partner• H/O depression or anxiety

Summary

Miscarriage is a vulnerable time for most women.

Helpful to know how to differentiate normal grief from symptoms concerning for MDD

Low threshold for referral –or screen everyone

CBT can help

Not everyone needs medication

Tender loving care is proven to help –

That’s where we come in!

Moving forward - TLC• Patients should be reassured that they did NOTHING

wrong• RPL patients have a high chance of live birth with

persistence• We don’t need an answer to give patients realistic

prognosis (“counsel with confidence”)

Keep the door open• Most women have a live birth• Give hope whenever possible• Tragic when patients give up without knowing all facts

Thank you• Questions?