Martyna Maciejewska1, Inga Janik-Fuks1, Patrycja Zielińska1, Agata Mularczyk1, Olimpia Sipak2
2DEPARTMENT OF OBSTETRICS AND PREGNANCY PATHOLOGY, POMERANIAN MEDICAL UNIVERSITY IN SZCZECIN, SZCZECIN, POLAND
The purpose of our case study was to identify psychological and medical dependencies affecting subsequent pregnancies of women after early pregnancy loss. The patient miscarried three times, gave birth to two children. The case study describes her state of health, emotional reactions and social support in these situations. Based on medical information, psychological interview and questionnaires (STAI, CISS, BHI-R, ISEL) are described factors influencing the patient’s coping with such a difficult situation as the loss of pregnancy.
KEY WORDS: psychological aspects, coping, repeated miscarriages, case study
Wiad Lek 2019, 72, 10, 2046-2049
In the moment a woman realizes she is pregnant, changes in the biological, psychological and social sphere begin. This situation aims to protect the developing fetus and change the current lifestyle, preparing for new requirements posed by the body.
Although pregnancy is a woman’s area of health, not illness, it is such a specific and important state – physically, mentally and emotionally – that it is currently subject to special control and care. Pregnancy can often cause negative reactions: sleep disorders, problems with concentration, as well as negative emotions, anxiety or even depression – especially when problems arise during pregnancy [1, 2]. A miscarriage is the loss of pregnancy before 22nd week . The specificity of regret after a miscarriage is focused on the imaginations of the expected future and the lost role in opposition to the recollection of past events .
The process of coping after experiencing such a loss is described in terms of subsequent stages of mourning . A miscarriage is a traumatic experience, so it is extremely important to provide adequate support to a person who has lost a child [7, 8].
The purpose of our case study was to identify psychological and medical dependencies affecting subsequent pregnancies of women after early pregnancy loss.
In 2018, a 39-year-old multipara reported to the Clinic of Pregnancy Pathology SPSK2 of the Pomeranian Medical University (PUM) in Szczecin in the 5th week of the fifth pregnancy for a check-up visit. Due to the eventful obstetric history (two early miscarriages and antiphospholipid syndrome), Clexane 1x 0.4 g / 0.4 ml was implemented.
During subsequent visits during the ultrasound examination, fetal heartbeat was not observed, during the 8th week of pregnancy a stillbirth was found. The patient was hospitalized to terminate this pregnancy. From the interview: the first pregnancy ended in the 9th week due to a stillbirth. The second pregnancy also ended around 9 weeks of pregnancy, due to bleeding from the genital tract, where spontaneous abortion took place. Both pregnancies ended with curettage of the uterine cavity. Two years before the first pregnancy, the patient was diagnosed with hyperthyroidism, Graves’ disease, and a partial thyroidectomy was performed due to nodules. She took Euthyrox after the treatment due to the hypothyroidism difficult to compensate. After the second miscarriage, the patient was referred to the Clinic of Pregnancy Pathology SPSK1 PUM in Szczecin, where a whole series of diagnostic tests, both hormonal and immunological, were made, searching for the causes of miscarriages. Decompensated thyroid gland and increased values of cardiolipid IgM antibodies and beta2 glycoprotein 1 were found. In the patient’s and her partner’s karyotype no abnormalities were observed. The patient was referred to the Rheumatology Outpatient Clinic, where Acard 75 mg was prescribed, which was poorly tolerated in the form of headaches, and which was discontinued after 3 months.
After about a year, the patient became pregnant with her third pregnancy, during which she was under the care of the Clinic of Pregnancy Pathology SPSK1 PUM in Szczecin. From the 5th week of pregnancy, Clexane was implemented at a prophylactic dose of 0.4g/0.4ml, which was discontinued at 36th week of pregnancy. In additional tests at the beginning of pregnancy, diet-dependent gestational diabetes G1 was diagnosed, for which reason she was under the care of a diabetologist.
She received Euthyrox at a dose of 75 ug throughout her pregnancy. In the 35th week of pregnancy edema and hypertension appeared, so she was hospitalized several times. The ultrasound examination revealed suppression of intrauterine fetal growth (IUGR). Dopegyt was implemented at a dose of 3x500mg. At the 37th week of pregnancy, the patient reported severe headaches accompanied by hypertension up to 180/104. It was decided to terminate the pregnancy by means of Caesarean section, she gave birth to a live daughter, in good condition, with a birthweight of 2300g. In the first day of puerperium sub-facial hematoma was found, due to which the laparotomy was decided. Next days of puerperium pursued its normal course. On 7th puerperium day, discharged home in good condition.
After about 1.5 years she became pregnant for the 4th time, from the 5th week of pregnancy she received Clexane 0.4g / 0.4ml and was under the control of Clinic of Pregnancy Pathology SPSK1 PUM in Szczecin. In the first and second trimesters of pregnancy, she was hospitalized because of initially threatened miscarriage, and then threatened premature labor. In the 39th week of gestation she gave birth by C–section to a full-term live son, weight of 4000g in good condition. The course of the puerperium without complications.
Information about mental functioning on the basis of the interview
The patient got married in the age of 27, she and her husband wanted to have children. The first miscarriage aroused strong negative emotions in both of them.
The patient underwent a curettage of the uterine cavity in another city, away from her husband. After the surgery, her parents and sister were visiting her. From that time,
she remembers her sister’s attitude, describing it: “she was very unhappy when she came to the hospital, as if she had a grudge against me, that I had miscarried in purpose.” She judged her husband’s attitude as supportive. They had time for themselves, for mourning, the husband would hug her, they were talking about their experiences of miscarriage. During the interview, the patient said: “At the beginning it was very difficult to talk about it. Only with time it came to normal. The worst was perspective that maybe we would not be able to have children at all. That thought was the worst. Helplessness, because one does not know why. Also such anger that often women who do not want to have children, have them, and you cannot and want to. Such a sense of injustice.” The second pregnancy was miscarried, the 3rd one she managed to carry to term and delivered a daughter. The childbirth was by caesarean section, which was a difficult experience for the patient – she dreamed about childbirth with the forces of nature. After the birth the patient probably experienced baby blues – frustration during the care and breastfeeding of her daughter, great tiredness, social closeness, weepiness. The patient was not diagnosed for emotional problems by the hospital staff and did not receive psychological support. She describes the first weeks of care for a newborn daughter as very difficult and demanding. As the time passed by, the situation has changed for good with the support of her husband. From the interview with the patient, having children is a great value for her, that is why together with her husband made another attempt to enlarge the family.
he fourth pregnancy was also carried to term. A son was born by another caesarean section. This time the patient was happy with this mode of delivery because it turned out that the childbirth would be difficult. Emotions that appeared with 4th pregnancy were ambivalent: “this time when I was doing a pregnancy test, my hands were shaking, on the one hand positive emotions, on the other – stress, I had such mixed feelings. I was afraid it will end like the two previous pregnancies. There was fear and fright.” The patient actively draws here attention to the fact that the pregnancy proceeded emotionally, despite the complications, quite differently than the first one. She emphasizes that it was important that they were already raising an older child – they wanted another child, but there was no despair in this situations. The patient said: “The beginning was also stressful, but later I did not even have time to think about the danger or listen to myself. I just did not have time for this because my daughter was 1.5 years old, I left it itself and I did not think about it. When you already have a child, you take it differently.” In 2017, the patient became pregnant for the 5th time. In the 6th week, the ultrasound showed that the fetus had died.
She described emotions from that moment: “It was some resentment, I was sad, my husband too, but it did not last very long. Two weeks after the surgery I returned to work. It is different if you already have children. It is worse if you do not have them at all and you are waiting, then it is harder.” Mourning after the last pregnancy lasted much shorter and was less intense than the previous ones. Speaking of miscarriages, the respondent emphasized that support from the husband, parents and mother-in-law was helpful – conversations, sharing and understanding emotions, but also concrete economic support and help in caring for children. In the patient’s judgement, the medical staff was positive. However, she mentioned a doctor from another city, whose behavior aroused negative emotions in her. In the situation of miscarriage he suggested that she was not pregnant at all, he referred her to the main doctor: “It was a very unpleasant situation, I was scheduled for an ultrasound in Szczecin, but I did not manage to be there. The doctor said something strange, asked me if I am pregnant at all, because this uterus was so small, and added that if I am treated in Szczecin, I should go there.” In addition to this situation, it was emotionally difficult for the patient after finished pregnancy to be in one room with a woman expecting a baby. The patient herself stressed that this was not due to bad will of the staff but to the lack of places in the ward.
Information on the style of coping with stress, level of hope, anxiety level as trait and state and evaluation of social support
The patient is characterized by a avoidance coping with stress (CISS results: task-oriented style – sten 5, emotion-oriented style – sten 6, avoidance oriented – sten 7, involvement in substitute activities – sten 7, search for social contacts – sten 5). This means that in difficult situations causing a strong emotional tension, she looks for various substitute activities (for example watching television, shopping, sleeping) so as not to confront the experienced situation. She may also avoid thinking about the problem and seeking its solution. The patient may not allow emotions lived in a given situation.
She is characterized by a high level of hope (results of BHI-R – 60 points). The higher level of hope, the easier it is for people to come to terms with difficult events, and the world and people are perceived as more friendly. A strong belief in favor and meaningfulness makes it easier to reconcile with new difficult situations that appear in life. This belief allows the subject to adapt to new events with more readiness and confidence. Also more adaptive behaviors in difficult situations are conditioned by a high level of hope. The patient is characterized by an average level of anxiety as a state and high level as a trait (STAI results: x1 – sten 6, x2 sten 8). This means that she may show a greater tendency to perceive objectively non-threatening stimuli as threatening. She can also experience higher anxiety in situations that are extremely threatening. The patient obtained high scores in the assessment of social support. According to her, she experiences instrumental, emotional, financial and self-esteem support (ISEL general score – 40, tangible subscale – 10, belonging subscale – 10, self-esteem subscale – 10, appraisal subscale – 10). The social support factor is a very important element affecting the ability to cope better in various difficult situations, such as miscarriage.
The frequency of spontaneous abortions in the first trimester of pregnancy is estimated at 10-24%.  In recent years, the most frequently mentioned psychiatric consequences of early pregnancy loss due to a miscarriage are: depression, anxiety and panic attacks, compulsive disorders, PTSD. [9−11] A woman after a miscarriage experiences, in addition to physical pain, also a number of negative emotions – regret, anger, as well as lower self-esteem or even depressive reactions, mental disorders, and suicidal thoughts. A breakdown of faith in sense of life, a violation of sense of safety and self-control appear. Our case study fits into the above-mentioned symptoms.
During the first miscarriage, the subject experienced sense of meaninglessness of life, a lack of justice, a significant reduction in mood; passed the subsequent stages of mourning. However, the support of the nearest people allowed her to cope with this situation. Also, medical staff plays an important role in the mental support of a woman and her family after a child loss. Professionalism, experience, knowledge and the ability to communicate are necessary in pursuit to achieve goals such as: helping in reconciling with loss, allowing to experience suffering and regret, help in accepting reality and life without a child.  The respondent positively assessed the behavior and support of the medical staff she experienced during hospitalization.
Bowles et al.  draws attention to the special need for psychological care within a month after miscarriage. The study conducted by Murlikiewicz and Sieroszewski [9, 14] showed that the emotion-focused style of coping with stress, highly anxious personality, as well as previous experience of miscarriage, had an impact on the increase in the results of three variables examined (level of depression, anxiety and post-traumatic stress) and may be treated as risk factors for depression and PTSD. The subject is characterized by avoidance style of coping with stress, an average level of anxiety as a state and high level as a trait; with a high level of hope and high scores in the assessment of social support. The description obtained on the basis of the results of the questionnaires shows an incoherent picture – on the one hand her style of coping with stress proved to be favorable, she did not delve into the negative experiences.
She managed better in this difficult situation thanks to the high sense of hope and the support she received from the family and the medical staff. The high level of anxiety as a trait was unfavorable – it is an aspect that could have a negative effect on her emotional functioning after miscarriages. However, the possessed resources allowed for the passage through mourning and reconciliation with the situation, as well as for subsequent attempts to get pregnant. Andersson et al.  conducted a similar study – qualitative, individual interviews with pregnant women who had previously experienced a miscarriage. Their conclusion coincides with ours – women in such a situation need a broad support: from a family, friends, medical and psychological staff. However, most often, similarly to our subject, they manage themselves. In the absence of formal support – from doctors and psychologists, they are able to rely only on help of their relatives. Most women waiting for the birth of their children hope that they will be born healthy and on estimated due date. Reproductive failures are perceived as failure to fulfill a parental role. The situation of a pregnancy at risk and change of delivery date is a surprise for a mother and her family, an unpredictable event that one cannot be prepared .
The interviewee underlined the difference in the course of mourning and coping after a miscarriage – not being a mother, and having children. The first two miscarriages and the first full term pregnancy were extremely difficult for her, while the second pregnancy at risk and the last miscarriage were not so negatively burdened emotionally. The subject pointed out that the main difference was that she was already a mother. In this situation, despite the constant difficulties in maintaining pregnancy, the fact of playing the social role so important for her, was extremely helpful. Perhaps it even allowed the positive end of the fourth pregnancy.
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Martyna Maciejewska – 0000-0002-2017-5196
Inga Janik-Fuks – 0000-0002-4238-0465
Patrycja Zielińska – 0000-0001-7390-8296
Agata Mularczyk – 0000-0002-8273-6737
Olimpia Sipak – 0000-0002-3410-1809
Conflict of interest:
Authors declare no conflict of interest.
Department of Obstetrics and Pregnancy Pathology,
Pomeranian Medical University in Szczecin,
71-210 Szczecin, 48 Żołnierska St.
tel.: +48 91 48 00 983,