A Study of Miscarriage: Development and Validation of the Perinatal Grief Intensity Scale

Objective: This article outlines the development of the Perinatal Grief Intensity Scale (PGIS). It is based on a theoretical model developed to predict intensity of grief response to early pregnancy loss.
Design: Participants completed the PGIS by mail and made an overall assessment of their grief intensity by completing a single Likert-type item.
Participants: A convenience sample of 186 women who had experienced a miscarriage before 16 weeks gestation in the previous 12–18 months.
Results: Fourteen items were retained after factor analyses, loading at .4 or greater. The 14 items loaded on a three-factor solution as predicted and accounted for 65% of the variance. Three factors were found to influence intensify of grieving: Reality of the pregnancy and baby within (Reality), congruence between the actual miscarriage experience and the woman's standard of the desirable (Congruence), and the ability of parents to make decisions or act in ways to increase this congruence (Confront Others). Chronbach's alpha for the entire instrument was .82, with subscale reliability scores of .89 (Reality), .84 (Confront Others), and .71 (Congruence).
Conclusion: The PGIS demonstrates acceptable beginning reliability and validity in predicting grief intensity. Further testing of the instrument is needed with all types of pregnancy losses. The level of score needed to predict intense responses also needs to be determined.     

Pregnancy after perinatal loss: association of grief,anxiety and attachment

Objectives: The aim of this study was to explore the psychological experience of pregnancy after a previous perinatal loss and to bring to light the risk factors of psychological distress and disorders in instituting antenatal attachment with the subsequent child. Methods: 96 pregnant women, having experienced a previous perinatal loss answered several questionnaires which measured the feelings of perinatal grief (PGS), anxio‐depressive symptomatology (HADS), acceptance of pregnancy, identification with the maternal role (PSEQ) and perinatal attachment (MAAS). The control group included 74 women with no experience of perinatal loss. Results: Women having suffered from perinatal loss reported significantly higher scores of grief and anxio‐depressive symptoms compared to the control group. These variables were significant predictors of prenatal attachment. Conclusion: Findings reveal the intense psychological distress during pregnancy following a perinatal loss and underscore the need for psychosocial and clinical care when there is a perinatal loss, care that should be extended up to the birth of the subsequent child.     

Grief and Perinatal Loss

Hospital health-care professionals sometimes fail to recognize the depth to which parents grieve over a stillbirth and to acknowledge the validity of the parents' grief. By interacting with SHARE (Support and Help in Airing and Resolving Experiences), a parent support group for those who have experienced a perinatal loss, a hospital team was able to develop a written protocol with support measures to use when stillbirth occurs. This protocol has been in effect for three years and the staff has seen dual benefits. Staff members find constructive ways of offering support, and parents derive a sense of comfort and direction from the approach.     

Early pregnancy loss in Belagavi,Karnataka, India 2014–2017: a prospective population-based observational study in a low-resource setting

Background

The prevalence of early pregnancy loss through miscarriage and medically terminated pregnancy (MTP) is largely unknown due to lack of early registration of pregnancies in most regions, and especially in low- and middle-income countries. Understanding the rates of early pregnancy loss as well as the characteristics of pregnant women who experience miscarriage or MTP can assist in better planning of reproductive health needs of women.

Methods

A prospective, population-based study was conducted in Belagavi District, south India. Using an active surveillance system of women of childbearing age, all women were enrolled as soon as possible during pregnancy. We evaluated rates and risk factors of miscarriage and MTP between 6 and 20 weeks gestation as well as rates of stillbirth and neonatal death. A hypothetical cohort of 1000 women pregnant at 6 weeks was created to demonstrate the impact of miscarriage and MTP on pregnancy outcome.

Results

A total of 30,166 women enrolled from 2014 to 2017 were included in this analysis. The rate of miscarriage per 1000 ongoing pregnancies between 6 and 8 weeks was 115.3, between 8 and 12 weeks the miscarriage rate was 101.9 per 1000 ongoing pregnancies and between 12 and 20 weeks the miscarriage rate was 60.3 per 1000 ongoing pregnancies. For those periods, the MTP rate was 40.2, 45.4, and 48.3 per 1000 ongoing pregnancies respectively. The stillbirth rate was 26/1000 and the neonatal mortality rate was 24/1000. The majority of miscarriages (96.6%) were unattended and occurred at home. The majority of MTPs occurred in a hospital and with a physician in attendance (69.6%), while 20.7% of MTPs occurred outside a health facility. Women who experienced a miscarriage were older and had a higher level of education but were less likely to be anemic than those with an ongoing pregnancy at 20 weeks. Women with MTP were older, had a higher level of education, higher parity, and higher BMI, compared to those with an ongoing pregnancy, but these results were not consistent across gestational age periods.

Conclusions

Of women with an ongoing pregnancy at 6 weeks, about 60% will have a living infant at 28 days of age. Two thirds of the losses will be spontaneous miscarriages and one third will be secondary to a MTP. High maternal age and education were the risk factors associated with miscarriage and MTP.

Trial registration

The trial is registered at clinicaltrials.gov. ClinicalTrial.gov Trial Registration: NCT01073475.

     

The psychological implications of a subsequent pregnancy outcome in couples with a history of miscarriage

ABSTRACT

Objectives

The present study expands upon reproductive research by examining perinatal grief in couples following a miscarriage and throughout a subsequent pregnancy. The aim of the study was to address the question of whether the outcome of a successful live birth mitigates the negative impact of a previous miscarriage.     

Younger maternal age (at initiation of childbearing) and recurrent perinatal mortality

Objective

To assess whether young maternal age at initiation of childbearing is associated with recurrence of perinatal mortality (PM), as well as its components: stillbirth and neonatal death.

Study design

We conducted a population-based, retrospective cohort study on the Missouri maternally linked longitudinal data files comprising adolescent (10-19 years; n = 73,533) or mature (20-24 years; n = 78,618) mothers in their first pregnancy with follow-up in their second pregnancy to document the occurrence of PM or its components. The study covered the period 1989-2005. We used unconditional logistic regression modeling to generate odds ratios and to control for confounding.

Results

A history of perinatal mortality, stillbirth, or neonatal mortality increased the risk of a recurrence by 4-5 times. Among women with a history of PM or stillbirth in the first pregnancy, maternal age at initiation of pregnancy was not a risk factor for subsequent PM or its components. However, adolescent mothers with a history of neonatal mortality in the first pregnancy were about 5 times as likely to experience stillbirth in the second pregnancy, as compared to their mature counterparts.

Conclusions

Young maternal age at the initiation of childbearing is not associated with an overall increased risk of recurrent perinatal loss. However, prior history of neonatal mortality among teen mothers is strongly predictive of subsequent stillbirth.     

Perinatal outcome in pregnancy with polyhydramnios in comparison with normal pregnancy in department of obstetrics at Shiraz University of Medical Sciences

Objective: Polyhydramnios can lead to maternal and fetal complication during pregnancy, so diagnosis and management can decrease some perinatal complications.

Study design: One hundred and fourteen singleton pregnancies were diagnosed with idiopathic polyhydramnios in the department of obstetrics at Shiraz University of Medical Sciences between January 2000 and January 2011 and were compared with 114 normal pregnancies for their perinatal outcome. Variables include birth weight, admission to neonatal intensive care unit (NICU), meconium staining, respiratory distress, fetal death, neonatal death, low 1-min and 5-min APGAR score, primary cesarean section (C/S), preterm delivery (<37?weeks), postpartum bleeding, and placental abruption.

Results: Low birth weight (<2500?g), macrosoma (>4000?g), NICU admission, fetal distress, fetal death, lower 1-min and 5-min APGAR score, preterm delivery, and neonatal death were higher in the case group. However, meconium staining and malpresentation were equal between the two groups. Except for prematurity and 1-min and 5-min APGAR scores, there were no significant differences in other maternal or fetal outcomes considering the severity of polyhydramnios.

Conclusion: Idiopathic polyhydramnios should be considered as a high-risk pregnancy that warrants close surveillance. More studies should be done to detect the best time and interval of fetal surveillance in these patients. Chromosomal and torch studies can determine the definite cause of polyhydramnios.     

Psychologic and obstetric predictors of couples' grief during pregnancy after miscarriage or perinatal death

OBJECTIVE: To determine if the psychologic constructs of self-criticism and marital adjustment, considered jointly with obstetric and demographic factors, are significant predictors of grief during a pregnancy after a miscarriage or perinatal death. METHODS: Participants included 60 pregnant women with previous miscarriages or perinatal deaths, and 50 of their partners. Participants completed a package of psychometric instruments between the tenth and 19th week of gestation. Predictors of grief (active grief, difficulty coping, despair) included (1) psychologic factors: marital adjustment and self-criticism; (2) demographic factors: age and number of living children; and (3) obstetric factors: gestational age at time of loss, number of losses, and time between loss and subsequent conception. RESULTS: Stepwise regression analyses were conducted for each grief component for women and men. For women, active grief was significantly associated with high self-criticism and later losses (R(2) = 0.31). Later losses and longer time between loss and conception were significantly associated with difficulty coping (R(2) = 0.55) and despair (R(2) = 0.44). In men, active grief was associated with high self-criticism and later losses (R(2) = 0.28), difficulty coping (R(2) = 0.18), and despair (R(2) = 0.25) with high self-criticism. A trend was found for poor marital adjustment to be associated with higher levels of difficulty coping and despair in men. CONCLUSION: High levels of self-criticism and later gestational age at time of loss are predictors of increased grief during a pregnancy after a miscarriage or perinatal death. Increased time between loss and subsequent conception is also predictive of increased grief for women. For men, low levels of marital adjustment are predictive of increased grief. These results may be helpful in counselling couples considering pregnancy after a loss.     

Perinatal trauma with and without loss experiences

Objective: The present study explored differences in mental health between women who experienced a trauma which involved a loss of fetal or infant life compared to women whose trauma did not involve a loss (difficult childbirth). Method: The sample consisted of 144 women (mean age = 31.13) from the UK, USA/Canada, Europe, Australia/New Zealand, who had experienced either stillbirth, neonatal loss, ectopic pregnancy, or traumatic birth with a living infant in the last 4 years. Results: The trauma without loss group reported significantly higher mental health problems than the trauma with loss group (F (1,117) = 4.807, p = .03). This difference was observed in the subtypes of OCD, panic, PTSD and GAD but not for major depression, agoraphobia and social phobia. However, once previous mental health diagnoses were taken into account, differences between trauma groups in terms of mental health scores disappeared, with the exception of PTSD symptoms. Trauma groups also differed in terms of perceived emotional support from significant others. Conclusion: The findings illustrate the need for a change in the focus of support for women’s birth experiences and highlighted previous mental health problems as a risk factor for mental health problems during the perinatal period.     

Perinatal outcomes of women with a prior history of unexplained recurrent miscarriage

Objective: We sought to determine subsequent pregnancy outcomes in a cohort of women with a history of unexplained recurrent miscarriage (RM) who were not receiving medical treatment.

Study design: This was a prospective cohort study, of women with a history of three unexplained consecutive first trimester losses, who were recruited and followed in their subsequent pregnancy. Control patients were healthy pregnant patients with no previous adverse perinatal outcome.

Results: A total of 42 patients with a history of unexplained RM were recruited to the study. About nine (21.4%) experienced a further first trimester miscarriage, one case of ectopic and one case of partial molar pregnancy. About 74% (23/31) of the RM cohort had a vaginal delivery. There was one case of severe pre-eclampsia. The RM group delivered at a mean gestational age of 38?+?2 weeks and with a mean birthweight of 3.23?kg. None of the neonates were under the 10th centile for gestational age. Overall, there was no significant difference in pregnancy outcomes between the two cohorts.

Conclusion: Our study confirms the reassuring prognosis for achieving a live birth in the unexplained RM population with a very low incidence of adverse events with the majority delivering appropriately grown fetuses at term.     

Subsequent Pregnancy Following the Birth of an Extremely Low Birth-weight Infan

Of 103 mothers who delivered an extremely low birth-weight (ELBW, less than 1,000g) infant, 29% were primiparous; 51% of those who were multiparous had at least one previous miscarriage or perinatal death. The 41 (40%) mothers who decided against subsequent pregnancy were significantly older than the remaining mothers. Mothers were also significantly more likely to decide against subsequent pregnancy if their ELBW infant had survived. The outcome of subsequent pregnancies within 3 years of the ELBW birth was ascertained; 28% ended in miscarriage, 3% in stillbirth, 1% in neonatal death, 21% in a surviving preterm infant and 51% in a survivor born at term. Mothers diagnosed to have cervical incompetence had a significantly higher risk of a subsequent preterm birth. During the study period, 87% of mothers who became pregnant subsequent to their ELBW infant gave birth to at least one surviving child. Of the subsequent livebirths, 36% were less than 2,500g, 11% were less than 1,500g and 5% were less than 1,000g. Significantly more mothers whose ELBW infant had died conceived again within 1 year compared to those whose ELBW infant had survived. The necessary time for recovery from bereavement may be cut short by the subsequent pregnancy. The psychological problems as a result of unresolved mourning which mothers experience and their effects on subsequent children need to be further studied.     

Factors That Affect Perinatal Outcomes of the Second Pregnancy of Adolescents

Study ObjectiveWe assessed factors that might affect perinatal outcomes in second pregnancies in adolescents.Design, Setting, Participants, Interventions, Main Outcome MeasuresThis longitudinal retrospective study was carried out on 66 adolescents who experienced 2 deliveries during their adolescence. Data were collected for the first and second pregnancies. Odds ratios (ORs) and 95% confidence intervals (CIs) for adverse perinatal outcomes in the second pregnancy were calculated using a logistic regression model and SPSS software (version 17.0 for Windows; SPSS Inc, Chicago, IL). A P value < .05 was considered to indicate statistical significance.ResultsBody mass index, number of antenatal care visits, weight gain during pregnancy, incidence of anemia, smoking status, gestational week at delivery, cesarean section rate, and birth weight were similar between the first and second pregnancies of these adolescents. Neonatal intensive care unit admission rate, preeclampsia rate, low neonatal birth weight rate, and 5-minute Apgar scores <7 were significantly higher in the first than in the second pregnancy (P < .001). Age of 16 years or younger at the time of first pregnancy (OR = 1.5; 95% CI, 0.9-2.1; P < .01), less than an 18-month interval between births (OR = 1.4; 95% CI, 0.2-1.7; P < .04), presence of gestational complications in the first pregnancy (OR = 1.9; 95% CI, 1.0-3.4; P < .01), and the presence of perinatal complications in the first pregnancy (OR = 1.3; 95% CI, 1.0-1.9; P < .01) were found to be significant indicators for adverse neonatal outcomes in second pregnancies of adolescents.ConclusionWe found that the second pregnancies of adolescents were associated with fewer adverse perinatal outcomes than were their first pregnancies. However, some factors regarding the presence of perinatal complications in the first pregnancy, such as maternal age of 16 years or younger at the time of the first pregnancy and interval between first and second pregnancy of less than 18 months, were found to increase the risk of adverse perinatal outcomes for the second births.     

Translation and validation of the Perinatal Grief Scale in a sample of Greek women with perinatal loss during the 1st and 2nd trimester of pregnancy

Objective: To translate and validate the Perinatal Grief Scale (PGS) (short version) in a sample of Greek women with perinatal loss during the first and second trimester of pregnancy.

Methods: One hundred seventy-six women were approached a few hours after the loss. Along with the PGS, three more questionnaires were completed: the Edinburgh Postnatal Depression Scale (EPDS), the Hospital Anxiety and Depression Scale (HADS) and the State-Trait Anxiety Inventory (STAI), in order to assess the convergent validity of the PGS.

Results: Total sample mean age was 34.1 years (SD?=?5.2). Mean values and Cronbach’s alpha coefficients for PGS subscales exceeded the minimum reliability standard of 0.70. Mean score for “Active grief” was 31.47 (SD?=?9.31), for “Difficulty Coping” was 23.13 (SD?=?7.54) and for “Despair” was 21.07 (SD?=?7.07). By applying Pearson’s correlation coefficients, PGS subscales positively correlated with scores on EPDS, STAI and HADS.

Conclusions: The PGS Greek version is a reliable instrument in terms of internal consistency and the Cronbach’s alpha coefficients are high. The Greek version of PGS can be a useful instrument for the detection of the psychological impact after a perinatal loss and it has implications for both scientific research and clinical routine.     

Macroscopic and microscopic morphology of first trimester miscarriage and subsequent pregnancy outcome - An exploratory study

IntroductionReduced chorionic villous vascularization is associated with first trimester miscarriage and second trimester fetal loss. Differences in villous vascularization have been observed in combination with complications in the third trimester of pregnancy. The aim of this study was to investigate whether abnormal morphology and reduced chorionic villous vascularization in first trimester miscarriages are associated with an increased risk on adverse outcome and/or pregnancy complications in subsequent pregnancy. Secondly, to assess the influence of these parameters on the length of the interpregnancy interval and infertility.MethodsIn a retrospective cohort study 134 consecutive women who underwent dilatation and curettage for a miscarriage were included. The degree of chorionic villous vascularization in miscarriage tissue was determined by a pathologist. Ultrasound details of these miscarriages and clinical data on the subsequent pregnancy of these women were obtained.ResultsNeither reduced vascularization nor early embryonic arrest in first trimester miscarriages are associated with an increased risk of a subsequent miscarriage or adverse obstetric and perinatal outcome of subsequent pregnancy. Abnormal morphology of the first trimester miscarriage did not influence the time to subsequent pregnancy. A shorter mean interpregnancy interval between miscarriages was observed after miscarriages with reduced chorionic villous vascularization (5.5 vs. 10.7 months; p = 0.051), showing a trend towards an association.DiscussionChorionic villous vascularization and morphology have no influence on subsequent pregnancy outcome. Therefore it remains unknown what aspects of miscarriage are causing the increased risk on subsequent miscarriage and complications in the third trimester of the subsequent pregnancy.     

Maternal and Perinatal Outcomes of Extreme Obesity in Pregnancy

ObjectiveTo evaluate the effects of extreme obesity (pre-pregnancy BMI ≥ 50.0 kg/m²) in pregnancy on maternal and perinatal outcomes.MethodsWe conducted a population-based cohort study using the Newfoundland and Labrador Perinatal Database to compare obstetric outcomes in women with extreme obesity and those with a normal BMI (pre-pregnancy BMI 18.50 to 24.99 kg/m²). We included women with singleton gestations who gave birth between January 1, 2002, and December 31, 2011. Maternal outcomes of interest included gestational hypertension, gestational diabetes, Caesarean section, shoulder dystocia, length of hospital stay, maternal ICU admission, postpartum hemorrhage, and death. Perinatal outcomes included birth weight, preterm birth, Apgar score, neonatal metabolic abnormality, NICU admission, stillbirth, and neonatal death. A composite morbidity outcome was developed including at least one of Caesarean section, gestational hypertension, birth weight ≥ 4000 g, birth weight < 2500 g, or NICU admission. Univariate analyses and multivariate logistic regression analyses (controlling for maternal age, parity, smoking, partner status, and gestational age) were performed, and adjusted odds ratios (aORs) and 95% confidence intervals were calculated.ResultsA total of 5788 women were included in the study: 71 with extreme obesity and 5717 with a normal BMI. Extremely obese women were more likely to have gestational hypertension (19.7% vs.4.8%) (aOR 1.56; 95% CI 1.33 to 1.82), gestational diabetes (21.1% vs.1.5%) (aOR 2.04; 95% CI 1.74 to 2.38), shoulder dystocia (7.1% vs.1.4%) (aOR 1.51; 95% CI 1.05 to 2.19), Caesarean section (60.6% vs.25.0%) (aOR 1.46; 95% CI 1.29 to 1.65), length of hospital stay more than five days (excluding Caesarean section) (14.3% vs.4.7%) (aOR 1.42; 95% CI 1.07 to 1.89), birth weight ≥ 4000 g (38.0% vs. 11.9%) (aOR 1.58; 95% CI 1.38 to 1.80), birth weight ≥ 4500 g (16.9% vs.2.1%) (aOR 1.87; 95% CI 1.57 to 2.23), neonatal metabolic abnormality (8.5% vs.2.0%) (aOR 1.50; 95% CI 1.20 to 1.86), NICU admission (16.9% vs.7.8%) (aOR 1.28; 95% CI 1.07 to 1.52), stillbirth (1.4% vs.0.2%) (aOR 1.68; 95% CI 1.00 to 2.82) and composite adverse outcome (81.7% vs.41.5%) (aOR 1.57; 95% CI 1.35 to 1.83).ConclusionWomen with extreme obesity have increased risks of a variety of adverse maternal and perinatal outcomes. As approximately 6 per 1000 women giving birth in our population have extreme obesity, it is important to address these risks pre-conceptually and encourage a healthier BMI before pregnancy.     

When the bough breaks: Charles street parent and baby day unit

Abstract

Charles Street Parent and Baby Day Unit (PBDU), is a specialized, multi-disciplinary, psychiatric day hospital in Stoke-on-Trent, Staffordshire, that provides a comprehensive service of high intensity, customized treatment to parents with psychological disorders associated with pregnancy, childbirth, stillbirth, miscarriage and termination (Cox et al., 1993). The unit is the major component in the perinatal psychiatry service, which also involves a liaison psychiatry service to the North Staffordshire Maternity Hospital and an in-patient facility in an acute admission ward. These concentrated efforts led to national recognition in 1992 when the unit was awarded the Hospital Doctor Team of the Year Award. This report briefly outlines the service and the clinical and socio-demographic characteristics of clients referred to the PBDU over a 1-year period.     

The risk of perinatal mortality with each week of expectant management in obese pregnancies

Introduction: The risk of stillbirth associated with maternal obesity increases with gestational age; however, it is unclear if earlier delivery reduces the overall perinatal mortality rate. Our objective was to compare the risk of perinatal mortality associated with each additional week of expectant management to that of immediate delivery.

Methods: This was a retrospective cohort study of singleton non-anomalous births in Texas between 2006 and 2011. Analyses were stratified based on maternal pre-pregnancy BMI class. For each BMI class, we calculated the rate of neonatal death and stillbirth at each week of gestation from 34 to 41 weeks. A composite risk of perinatal mortality associated with 1 week of expectant management was estimated combining the stillbirth rate of the current week and the neonatal death rate of the following week. This was compared with the rate of neonatal death of the current week.

Results: After all exclusions, 2,149,771 births remained for analysis. In the normal weight group, stillbirth risk increased from 0.8 per 10,000 births at 34 weeks to 5.7 per 10,000 births at 42 weeks, whereas the neonatal death risk decreased from 76.5 per 10,000 births at 34 weeks to 30.4 per 10,000 births at 42 weeks, there were no differences between expectant management and delivery for any gestational week. In the obese group, stillbirth risk increased from 1.8 per 10,000 births at 34 weeks to 10.5 per 10,000 births at 42 weeks, whereas the neonatal death risk decreased from 67.7 per 10,000 births at 34 weeks to 26.2 per 10,000 births at 42 weeks, the perinatal mortality risk favored delivery at 39 weeks (RR: 1.17; 99% CI: 1.01–1.36) and not thereafter. In contrast, in the morbidly obese group, stillbirth risk increased from 8.8 per 10,000 births at 34 weeks to 83.7 per 10,000 births at 42 weeks, whereas the neonatal death risk decreased from 63.6 per 10,000 births at 34 weeks to 15.5 per 10,000 births at 42 weeks, the perinatal mortality risk favored delivery from 38 weeks (RR: 1.53; 99% CI: 1.16–2.02) through 41 weeks (RR: 5.39; 99% CI: 1.83–15.88).

Conclusion: The findings reported here suggest that delivery by 38 weeks in gestation minimizes perinatal mortality in pregnancies complicated by maternal morbid obesity.