Practice recommendations
- Provide counsel and support to women after a spontaneous abortion. Research indicates that many women will talk with their physician about their emotional distress and that physicians provide good information after the spontaneous abortion (B).1,2
- Evaluate women for acute stress disorder (ASD) after a spontaneous abortion. Research found that women reporting physical, emotional, or sexual abuse are more likely to experience ASD (B).3,4
- Patients should be assessed for posttraumatic stress disorder in follow-up visits 1 month after the initial visit (C).5,6 Research has found that up to 25% of women meet criteria for PTSD 1 month post the spontaneous abortion and 7% met criteria at 4 months. Physicians should refer women who are experiencing traumatic stress to a behavioral health professional (C).7
Would you know the key symptoms or historical factors to look for in determining whether a patient will develop acute stress disorder (ASD)5 or posttraumatic stress disorder (PTSD)?9 Most women discharged from the hospital after spontaneous abortion consult their primary care doctor for emotional distress related to the lost pregnancy.1 (See TABLE 1 for diagnostic criteria.)
Some authors have projected that 10% of women who experience a spontaneous abortion meet criteria for acute stress disorder and 1% for posttraumatic stress disorder.7 Subsequent research has indicated even higher levels of acute stress disorder and posttraumatic stress disorder.5,6 Approximately 15% met criteria for acute stress disorder at 3 weeks,5 25% met criteria for posttraumatic stress disorder at 1 month, and 7% met criteria for posttraumatic stress disorder at 4 months.6
Our pilot study sought to validate research that found high rates of acute stress disorder and posttraumatic stress disorder in this population,5,6 examine potential risk-factors for acute stress disorder, examine women’s perception of support after their spontaneous abortion, and determine whether acute stress disorder is predictive of posttraumatic stress disorder.
We begin by sharing the take-home points of our study, and follow with the details of methods used and study results.
TABLE 1
Symptom criteria for acute and postraumatic stress disorder17
| Exposure to a traumatic event Response involves intense fear, helplessness, or horror |
| Repeatedly reexperience trauma (eg, dreams, flashbacks, thoughts) |
| Avoidance of trauma-related stimuli |
| Increased arousal (eg, hypervigilence, exaggerated startle response, irritability) |
| Significant impairment in important areas of functioning |
| Three or more dissociative symptoms (eg, derealization, depersonalization, numbing) (for ASD only) |
| Duration: 2 days–4 weeks (for ASD), >1 month (for PTSD) |
Lessons from our study
Acute and posttraumatic stress disorders are common
Twenty-eight percent of women met criteria for acute stress disorder soon after spontaneous abortion, and 39% met criteria for posttraumatic stress disorder at 1 month. These findings were consistent with other research.5,6 Moreover, women who developed acute stress disorder were significantly more likely to exhibit subsequent posttraumatic stress disorder.
Women whose acute stress disorder symptoms remain untreated following a miscarriage may maintain their symptom level or experience further exacerbation of acute stress disorder symptoms.
Predictors of acute stress disorder
In the event of a miscarriage, several characteristics may be related to later acute stress disorder (TABLE 2).
Half of women reporting a self-perceived medical problem (eg, collapsed gestational sac, ulcer) during pregnancy met criteria for acute stress disorder.
Echoing previous research,2,4,8 women reporting an abuse history were more likely to experience acute stress disorder. Thus, physicians should assess for past traumatic experiences that could influence the patient’s emotional response to the spontaneous abortion.
Several psychological beliefs and perceptions also were related to acute stress disorder. Women were significantly more likely to develop acute stress disorder if they felt personally responsible for the miscarriage, lacked a sense of control in their lives, or reported feeling bonded to the unborn child. However, no group differences were found for variables thought to be associated with level of bonding (eg, viewing an ultrasound of the unborn child).9,10
TABLE 2
Relationship of acute stress disorder and miscarriage-related variables
| VARIABLE | N | χ2 | U | P | COHEN’S D |
|---|---|---|---|---|---|
| Mother’s condition/self-perception | |||||
| Medical problem | 24 | 3.60* | .03 | ||
| Feeling personally responsible | 23 | 2.61* | .05 | ||
| Control over life | 25 | 23.00* | .005 | 1.13 | |
| Mother and unborn infant | |||||
| Bonded to unborn infant | 24 | 39.50† | .08 | 0.71 | |
| Image of unborn infant | 25 | 1.19 | .014 | ||
| Viewed infant after miscarriage | 25 | 0.20 | .33 | ||
| Selected name for unborn infant | 25 | 1.47 | .11 | ||
| Mother’s abuse history | |||||
| Childhood physical abuse | 23 | 4.09* | .02 | ||
| Childhood emotional abuse | 23 | 4.09* | .02 | ||
| Childhood sexual abuse | 23 | 1.79† | .09 | ||
| PTSD Time 2 | 18 | 8.08* | .002 | ||
| *P<.05. | |||||
| † P<.10. | |||||
Ask your patients about support
An individual’s support system may help mitigate the potentially traumatic effects of a spontaneous abortion. Most women said their spouse was the most supportive individual.
While the role of spousal support in buffering the effects of a spontaneous abortion requires further investigation, women lacking spousal support may need increased support from you and others on their health care team (TABLE 3).5,7 Previous research indicated that patients who miscarried perceived 79% of nurses as supportive and 70% of the doctors as providing good information immediately following discharge from the hospital. At a 3-week follow-up, patients rated nurses at 59% and doctors at 61% in these respective areas.2 This study found more than half the women identified physicians as supportive; therefore, medical professionals can play an important role in the patient’s support system.