Psychological impact over time of women with pregnancy loss due to gestational trophoblastic disease compared with miscarriage.

OBJECTIVES: Pregnancy loss, occurring after miscarriage or after gestational trophoblastic disease, has a psychological impact. Besides pregnancy loss, women diagnosed with gestational trophoblastic disease have to deal with a prolonged period of follow-up and potential advice to postpone a future pregnancy. We studied the severity and course of the psychological impact after gestational trophoblastic disease and miscarriage, to identify whether women with gestational trophoblastic disease need different psychological care. METHODS: A prospective multicenter study using online questionnaires was performed. Women diagnosed with gestational trophoblastic disease or miscarriage received the following questionnaires directly after diagnosis, and after 6, 6, and 12 months: a self-report questionnaire, the Hospital Anxiety and Depression Scale (HADS), the Impact of Event Scale, and the Reproductive Concerns Scale. RESULTS: 74 women with gestational trophoblastic disease and 76 women with miscarriage were included. At baseline, the proportion of women scoring above the cut-off level for the anxiety subscale of the HADS and for the Impact of Event Scale was significantly higher for women with gestational trophoblastic disease than for women after miscarriage (43.2% vs 28.9%, p=0.02 and 87.8% vs 78.9%, p=0.03, respectively). During follow-up, the differences between both groups vanished and only the Impact of Event Scale after 12 months remained significantly different between women with gestational trophoblastic disease and women after miscarriage (62.7% vs 37.3%, p=0.005). All outcomes, except the Reproductive Concerns Scale, showed a significant decline. However, in women who scored above the cut-off level on the HADS-total or Impact of Event Scale at baseline, and women with psychological or psychiatric history, significant higher scores persisted. CONCLUSION: Although women with gestational trophoblastic disease at baseline had more anxiety and distress than women after miscarriage, no significant differences were seen using the HADS-total after 12 months. Using the HADS or Impact of Event Scale directly after pregnancy loss is helpful to identify women at risk of remaining psychological symptoms to provide them with extra psychological support.

Symptoms of anxiety and depression in women with gestational trophoblastic disease compared to women who had a miscarriage: a cross-sectional study.

This study was conducted between March 2020 and February 2021 to analyze anxiety and depression symptoms in 64 women with gestational trophoblastic disease (GTD) and 99 women who had miscarried. The Hospital Anxiety and Depression Scale (HADS) was applied by telephone three months after pregnancy loss. Multivariate analysis was performed using hierarchical logistic regression to evaluate associations between variables. Probable anxiety (HADS-A ≥ 8) and depression (HADS-D ≥ 8) were found in 53.1% and 43.8% of the GTD group and 49.5% and 39.4% of the miscarriage group, with no difference between the groups. Severe symptoms of anxiety (HADS-A 15-21) and depression (HADS-D 15-21) were found, respectively, in 12.5% and 4.7% of the GTD group and in 9.1% and 4.0% of the miscarriage group, also with no difference between the groups. Lack of partner support proved a risk factor for anxiety and depression, while poor education increased the risk of depression symptoms 3.43-fold following pregnancy loss. In conclusion, three months after pregnancy loss the frequency of anxiety and depression symptoms was similarly high in both groups, with poor education and lack of partner support being significant risk factors for the subsequent development of psychiatric morbidity.

Efectos emocionales que causa el aborto espontáneo / Emotional effects caused by spontaneous abortion

Introducción: en el contexto mexicano la maternidad suele ser una de las prioridades de la mujer, por lo cual, cuando se interrumpe el proceso se desencadena un conjunto de emociones que le afectan de manera negativa, pudiendo limitar su actuar cotidiano. Objetivo: identificar las emociones que surgen a causa del aborto espontáneo en mujeres jóvenes. Metodología: estudio descriptivo y cualitativo. Se aplicó una escala de actitudes hacia el aborto y una entrevista semiestructurada validada por juicio de expertos. Resultados: los hallazgos evidencian tristeza, enojo y rabia, que mantienen a las participantes en estado de confusión, decepción, retraimiento, inseguridad y vacío existencial. Conclusiones: el aborto espontáneo trae como consecuencia la ruptura del ideal de la mujer, ya que esta se representa como procreadora, lo cual coincide con el perfil mexicano de la maternidad; por ende, ante un aborto ya no se cumple con la supuesta función principal de la mujer.

Introduction: In the Mexican context, motherhood is the reason for being of a woman, therefore, when the process is interrupted, a set of emotions are triggered that affect negatively, and can even limit her daily actions. Objective: To identify the emotions that arise due to spontaneous abortion in young women. Methodology: Descriptive and qualitative study. A semi-structured interview validated by expert judgment was applied. Results: The findings show sadness, anger and rage that keep the informants in a state of confusion, disappointment, withdrawal, insecurity and existential emptiness. Conclusions: Spontaneous abortion results in the rupture of the ideal of women, since this is represented as procreating, which coincides with the Mexican profile of motherhood; therefore, in the face of an abortion, the main function of the woman is no longer fulfilled.

Construction of meaning in pregnancy loss: qualitative study with brazilian couples / Construção de significados na perda gestacional: estudo qualitativo com casais brasileiros / Construcción de significados en la pérdida gestacional: estudio cualitativo con parejas brasileñas

We investigated the process of meaning construction in pregnancy loss in 11 Brazilian couples. The reports were submitted to inductive and deductive thematic analysis using the categorization system from the integrative model of meaning construction in grief. Regarding the original dimensions of the model (Sense-making of death, benefit from the experience of loss, and identity change), there was a lack of meaning for death, perception of strengthened bonds within the couple as a benefit, and parenting as an identity project. We propose an additional dimension (Meaning-making process) that includes gender differences, lack of social recognition, and emotional intensity of the experience. As for coping strategies, spirituality and the search for peers were identified, especially in social media. After a pregnancy loss, the process of meaning construction proved similar to that of other types of loss, validating this experience. We discuss the implications of the category system used in this study. (AU)

Investigou-se o processo de construção de significados na perda gestacional em 11 casais brasileiros. Os relatos foram submetidos à análise temática indutiva e dedutiva, utilizando o sistema de categorização do modelo integrativo de construção de significado no luto. Em relação às dimensões originais do modelo (Sentido para a morte, benefício na experiência de perda e modificação da identidade), constatou-se falta de sentido para a morte, fortalecimento de vínculo do casal como benefício e parentalidade enquanto projeto identitário. Foi proposta uma dimensão adicional (Processo de construir significado) que incluiu diferenças de gênero, falta de reconhecimento social e intensidade emocional da experiência. Enquanto estratégias de enfrentamento, identificou-se espiritualidade e busca por iguais, especialmente nas mídias sociais. O processo de construir significados na perda gestacional mostrou-se semelhante ao de outros tipos de perdas, validando esta experiência. Foram discutidas as implicações do sistema de categorias utilizado. (AU)

Se investigó el proceso de construcción de significados en la pérdida gestacional en 11 parejas brasileñas. Los informes fueron sometidos a un análisis temático inductivo y deductivo, usando el sistema de categorización del modelo integrador de construcción de significado en el duelo. En cuanto a las dimensiones originales del modelo (Significado para la muerte, beneficio en la experiencia de pérdida, cambio de identidad), se encontró falta de significado para la muerte, fortificación de lazos de la pareja como un beneficio y la parentalidad como un proyecto de identidad. Se ha propuesto una dimensión adicional (Proceso de construcción de significado) que incluye diferencias de género, falta de reconocimiento social e intensidad emocional de la experiencia. Como estrategias de afrontamiento, se identificó la espiritualidad y la búsqueda de los iguales, especialmente en las redes sociales. El proceso de construir significado en la pérdida gestacional demostró ser similar al de los otros tipos de pérdida, validando esta experiencia. Son discutidas las implicaciones del sistema de categorías utilizado. (AU)

Effect of a family planning program on documented emotional support and reproductive goals counseling after previable pregnancy loss.

OBJECTIVES: To evaluate the effect of the Ryan Program for family planning training on patient counseling surrounding previable pregnancy loss. METHODS: We conducted a retrospective cohort study of patients with first- and second-trimester miscarriages, therapeutic abortions, ectopic and molar pregnancies, from years before and after establishing a Ryan Program. We compared documentation of coping and future reproductive goals by patient factors, using chi square testing and logistic regression. RESULTS: We included 285 pregnancies: 138 pre-Ryan, 147 post-Ryan. Documentation of coping and future goals was greater post-Ryan than pre-Ryan (57.8% vs. 26.8% for coping, 72.8% vs. 50.7% for goals; both p < 0.001). Coping was less likely to be documented for adolescents (aOR 0.02), patients of Asian race (aOR 0.08), those diagnosed in the emergency department (aOR 0.22), and those with ectopic or molar pregnancy (aOR 0.14) (all p < 0.005). Coping documentation increased with second-trimester loss (aOR 6.19) and outpatient follow-up (aOR 3.41) (all p < 0.005). CONCLUSIONS: Establishment of a Ryan Program was associated with greater attention to patient coping and goals after previable pregnancy loss. Patients experiencing medically-dangerous pregnancy losses receive less attention to their coping. PRACTICE IMPLICATIONS: Comprehensive family planning training and outpatient access may improve patient-centeredness of care for previable pregnancy loss.

Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss.

Miscarriage is generally defined as the loss of a pregnancy before viability. An estimated 23 million miscarriages occur every year worldwide, translating to 44 pregnancy losses each minute. The pooled risk of miscarriage is 15·3% (95% CI 12·5-18·7%) of all recognised pregnancies. The population prevalence of women who have had one miscarriage is 10·8% (10·3-11·4%), two miscarriages is 1·9% (1·8-2·1%), and three or more miscarriages is 0·7% (0·5-0·8%). Risk factors for miscarriage include very young or older female age (younger than 20 years and older than 35 years), older male age (older than 40 years), very low or very high body-mass index, Black ethnicity, previous miscarriages, smoking, alcohol, stress, working night shifts, air pollution, and exposure to pesticides. The consequences of miscarriage are both physical, such as bleeding or infection, and psychological. Psychological consequences include increases in the risk of anxiety, depression, post-traumatic stress disorder, and suicide. Miscarriage, and especially recurrent miscarriage, is also a sentinel risk marker for obstetric complications, including preterm birth, fetal growth restriction, placental abruption, and stillbirth in future pregnancies, and a predictor of longer-term health problems, such as cardiovascular disease and venous thromboembolism. The costs of miscarriage affect individuals, health-care systems, and society. The short-term national economic cost of miscarriage is estimated to be £471 million per year in the UK. As recurrent miscarriage is a sentinel marker for various obstetric risks in future pregnancies, women should receive care in preconception and obstetric clinics specialising in patients at high risk. As psychological morbidity is common after pregnancy loss, effective screening instruments and treatment options for mental health consequences of miscarriage need to be available. We recommend that miscarriage data are gathered and reported to facilitate comparison of rates among countries, to accelerate research, and to improve patient care and policy development.

Experiências de mulheres com doença falciforme que vivenciaram perdas gestacionais / Experiencias de mujeres con anemia falciforme que pasaron por pérdidas gestacionales / Experiences of women with sickle cell disease who experienced pregnancy losses

Resumo Objetivo Compreender as experiências das mulheres com doença falciforme diante de perdas gestacionais provocadas por aborto espontâneo e natimorto. Métodos Trata-se de estudo descritivo, exploratório, com abordagem qualitativa, desenvolvido com 20 mulheres diagnosticadas com doença falciforme e atendidas em um ambulatório de referência do município de Salvador-BA. A coleta dos dados foi realizada no período de julho a setembro de 2017, através de entrevista semiestruturada e a análise foi realizada utilizando-se o Discurso do Sujeito Coletivo. Resultados Os resultados indicam 4 eixos centrais: o estado emocional das mulheres é alterado no processo do abortamento espontâneo; Após tudo preparado para o nascimento, veio a perda com o feto natimorto; O apoio do companheiro e da família, gera forças para suportar o processo de perda; A ausência de equipe qualificada e o racismo institucional intensificam os sentimentos no processo de perda. Conclusão Conclui-se que a dor vivida na experiência e a crise imediatamente instalada na vida dessas mulheres são pouco acolhidas pelo sistema de saúde e sentidas como não vistas pela sociedade. Elas sentem a necessidade de que exista mais alguém que compreenda sua dor e não apenas as que tenham passado por uma experiência igual.

Resumen Objetivo Comprender las experiencias de las mujeres con anemia falciforme ante pérdidas gestacionales provocadas por aborto espontáneo y mortinato. Métodos Se trata de un estudio descriptivo, exploratorio, con enfoque cualitativo, llevado a cabo con 20 mujeres diagnosticadas con anemia falciforme y atendidas en consultorios externos de referencia del municipio de Salvador, estado de Bahia. La recopilación de datos se realizó en el período de julio a septiembre de 2017 mediante entrevista semiestructurada, y el análisis se realizó utilizando el Discurso del Sujeto Colectivo. Resultados Los resultados indican cuatro ejes centrales: El estado emocional de las mujeres se ve alterado en el proceso del aborto espontáneo; Después de tener todo preparado para el nacimiento, ocurrió la pérdida con el feto mortinato; El apoyo del compañero y de la familia genera fuerzas para sobrellevar el proceso de la pérdida; La ausencia de un equipo calificado y el racismo institucional intensifican los sentimientos en el proceso de pérdida. Conclusión Se concluye que el dolor vivido durante la experiencia y la crisis inmediatamente instalada en la vida de estas mujeres tienen poca contención por parte del sistema de salud y parece que no son vistos por la sociedad. Ellas sienten la necesidad de que exista alguien más que comprenda su dolor, no solo las personas que pasaron por la misma experiencia.

Abstract Objective To understand the experiences of women with sickle cell disease in the face of pregnancy losses caused by spontaneous and stillborn abortion. Methods This is a descriptive, exploratory study with a qualitative approach, developed with 20 women diagnosed with sickle cell disease and treated at a reference clinic in the city of Salvador-BA. Data collection was carried out from July to September 2017, through semi-structured interviews and analysis was performed using the Discourse of the Collective Subject. Results The results indicate 4 central axes: Women's emotional status is altered in the process of spontaneous abortion; After everything was prepared for birth, loss came with a stillborn fetus; Partner and family support generates strength to support the loss process; The absence of a qualified team and institutional racism intensify feelings in the loss process. Conclusion It is concluded that the pain experienced in the experience and the crisis immediately installed in the lives of these women are little welcomed by the health system and felt as not seen by society. They feel the need for someone else who understands their pain and not just those who have had an equal experience.

Parentalidade na perda gestacional: o tempo de luto para o retorno às atividades profissionais - aspectos emocionais e legais / Parenting in pregnancy loss: the time of mourning for the return to professional activities - emotional and legal aspects

O repouso remunerado de mulheres, pautado pela lei brasileira, após perda gestacional menor que 22 semanas é de apenas duas semanas. Com relação ao pai, inexiste licença trabalhista nesta situação, acentuando uma desigualdade de gênero. Através de entrevistas semiestruturadas propõe-se verificar as condições emocionais das mães e suas vivências, para retorno as atividades profissionais pós-perda gestacional espontânea. As condições emocionais dos pais para manter a rotina de trabalho, sob a ótica de suas companheiras, foi também objeto de investigação, além de conhecer a dor paterna pelos relatos de alguns pais presentes nas entrevistas. Utilizou-se perguntas norteadoras para verificar percepções do momento que estavam vivendo, sobre adaptação à rotina de vida e sobre o luto e qualidade do exercício profissional. Originou-se oito categorizações, a partir dos núcleos de sentido das entrevistas: sintomas do luto; tempo de retorno ao trabalho e rotina; não reconhecimento do luto pela sociedade; luto e espiritualidade; relação cuidador (hospital)/paciente; dor paterna; querer alguém consigo; quem é este bebê. O retorno das mães enlutadas ao trabalho e o amparo na religião foram estratégias de elaboração do luto (terapia laboral) e de enfrentamento. Nas entrevistas, foram evidenciados os sentimentos: sensação de perda de controle da própria vida, quebra de sonhos, sentimento de incompletude, culpa e derrota pessoal. Sentimentos de menos valia como mulher em relação a visão do feminino pela sociedade. Evidenciouse uma vulnerabilidade trabalhista, com necessidade de assistir o pai, na perda gestacional, dor não reconhecida e não amparada legalmente. Para as mulheres a perda não foi só do bebê, evidenciou-se perdas subjetivas, perda de identidade, ideal, erotismo e do papel da mulher. A relação da mulher com ela mesma, com outra mulher, a maternidade, com o ideal, dentre outras, são temas significativos levando a abrir espaço para mais investigação na abordagem do luto gestacional.

The paid rest for women, according to Brazilian law, related to cases of gestational loss with less than 22 weeks, is it equivalent to two weeks. Regarding the father, we have no labor license in this situation, which accentuates gender inequality. With the use of semi-structured interviews, this work addresses the emotional conditions of mothers and their experiences, evaluating if they can return to professional activities after spontaneous pregnancy loss. The father's emotional conditions to maintain their usual work routine, seen from the eyes of their partners was also an object of investigation. Some fathers also gave testimonies expressing their grief during the process. Guiding questions were used to verify their perception on the moment they went through. These questions were related to their adaptation of routine, their mourning, and the quality of their own professional practice. After analysing the testimonies and their respective meanings, eight categorizations emerged: symptoms of grief; time to return to work and routine; non-recognition of mourning by society; grief and spirituality; caregiver (hospital) / patient relationship; paternal pain; the need of wanting someone with you; Who is this baby. Some of the strategies bereaved mothers used in order to cope, were seeking support in religion and in work. During the interviews, some feelings were highlighted: loss of control over one's life; shattered dreams; feeling of incompleteness; guilt and personal defeat; and feelings of being considered "less of a Woman" by society's eyes. A labor vulnerability was shed to light, with regard of assisting the fathers in their grief during the gestational loss, a pain that is neither recognized nor legally supported. For women, the loss was not only of their babies, there was also subjective loss, loss of identity, loss of ideal, eroticism and their role as women. The women's resolution towards themselves, to other women, motherhood, the ideal of a woman, among others, are significant themes, that lead the opening for a space of further investigation in how to approach and deal with gestational mourning.

Choosing Words Wisely: Residents' Use of Rhetorical Appeals in Conversations About Unnecessary Tests.

PURPOSE: To characterize how residents employ rhetorical appeals (i.e., the strategic use of communication to achieve specifiable goals) when discussing unnecessary diagnostic tests with patients. METHOD: In 2015, senior hematology residents from 10 Canadian universities participating in a national formative objective structured clinical examination (OSCE) completed a resource stewardship communication station. In this communication scenario, a standardized patient (SP) portrayed a patient requesting unnecessary thrombophilia testing following early pregnancy loss. The authors performed a thematic analysis of audio transcripts using a qualitative description approach to identify residents' rhetorical appeals to logic (rational appeals), credibility, and emotion. RESULTS: For persuasive communication, residents (n = 27) relied primarily on rational appeals that fit into 3 categories (with themes) focused on medical evidence (poor utility, professional guidelines and recommendations), avoidance of harm (insurance implications, unnecessary or potentially harmful interventions, patient anxiety), and reassurance to patient (normalizing, clinical pretest probability, criteria for reconsidering testing). Appeals to credibility and emotion were rarely used. CONCLUSIONS: In an OSCE setting, residents relied predominantly on rational appeals when engaging SPs in conversations about unnecessary tests. These observations yield insights into how recent emphasis within residency education on appropriate test utilization may manifest when residents put recommendations into practice in conversations with patients. This study's framework of rational appeals may be helpful in designing communication curricula about unnecessary testing. Future studies should explore rhetoric about unnecessary testing in the clinical environment, strategies to teach and coach residents leading these conversations, and patients' preferences and responses to different appeals.

PHENOTYPIC CHARACTERISTICS OF TROPHOBLASTIC HYPERPLASIA AND MICROENVIRONMENT ALTERATIONS IN CHORIONIC VILLI IN SPONTANEOUS ABORTIONS.

Hydatidiform mole represents the major cause of the molar pregnancy, which is a special cause of spontaneous abortions. We analysed phenotypic characteristics of epithelial hyperplasia and tumor microenvironment alterations in different types of hydatidiform moles. Standard immunohistochemistry was used for the detection of Ki67, Cyclin D1, p53, BCL2, E-cadherin, p63, Vimentin, CD34, CD3, CD4, CD8 and CD68. In addition, epithelial hyperplasia has been assessed in standard diagnostic haematoxylin and eosin stained tissue specimens. The results of our study indicated that both cytotrophoblast and sincitiptrophoblast layers are characterised with marked epithelial hyperplasia and high proliferation index in partial and complete moles, whilst apoptotic index is minimal. Early complete mole resembles the partial mole, rather than complete mole. Lymphocyte infiltration, marked by CD3, CD4 and CD8 is also higher in complete and partial moles, whilst macrophage infiltration is relatively lower. Macrophage infiltration marked by CD68 correlates with microvessel density marked by CD34. The evaluation of proliferation and apoptotic markers, as well as microenvironment, might serve as additional diagnostic markers in patients with hydatidiform moles and hydropic abortions.

Lessons from the Field Beyond the Numbers: Narratives of Professionals on Women who Experienced Severe Maternal Morbidity.

OBJECTIVE: Several factors might affect the health and the quality of life of women who had a severe maternal morbidity (SMM) or a maternal near-miss (MNM) episode. The objective of the present study was to explore the perspectives of the professionals on the repercussions of SMM or of MNM after interviewing women who survived such episodes. METHOD: Selected cases that captured the attention of professionals were reported. The professionals built individually 10 narratives, which were analyzed with the technique of content analysis. RESULTS: According to the perspectives of the professionals, women surviving a severe maternal condition and their families experienced clinical and psychosocial consequences. Some cases portrayed the intense psychological distress in mourning for the loss of the fetus or of their reproductive capacity and changes in family dynamics generating emotional overload, depression, and gender violence. CONCLUSION: The analysis of narratives may offer an idea on the complexity of the perception of care by professionals and on the need for an interdisciplinary follow-up of women surviving an SMM or an MNM episode.

OBJETIVO: Diversos fatores podem afetar a saúde e a qualidade de vida das mulheres que tiveram um episódio de morbidade materna grave (MMG) ou near-miss materno (NMM). O objetivo do presente estudo foi explorar as perspectivas dos profissionais sobre as repercussões da MMG ou do NMM após terem entrevistados mulheres que sobreviveram a um desses episódios. MéTODOS: Casos selecionados que chamaram a atenção dos profissionais foram relatados. Estes profissionais construíram individualmente 10 narrativas, que foram analisadas com a técnica de análise de conteúdo. RESULTADOS: Segundo as perspectivas dos profissionais, as mulheres que sobreviveram a uma condição materna grave e suas famílias vivenciaram consequências clínicas e psicológicas. Alguns casos relataram um intenso estresse psicológico no luto pela perda do feto ou de sua capacidade reprodutiva e de mudanças da dinâmica familiar, gerando sobrecarga emocional, depressão e violência de gênero. CONCLUSãO: A análise das narrativas pode oferecer uma ideia sobre a complexidade da percepção do cuidado de profissionais e sobre a necessidade de um seguimento interdisciplinar das mulheres sobreviventes de um episódio de MMG ou de NMM.

Lessons from the field beyond the numbers: narratives of professionals on women who wxperienced severe maternal morbidity / Lições do campo para além dos números: narrativas de profissionais sobre mulheres que tiveram morbidade materna grave

Abstract Objective Several factors might affect the health and the quality of life of women who had a severe maternal morbidity (SMM) or a maternal near-miss (MNM) episode. The objective of the present study was to explore the perspectives of the professionals on the repercussions of SMM or of MNM after interviewing women who survived such episodes. Method Selected cases that captured the attention of professionals were reported. The professionals built individually 10 narratives, which were analyzed with the technique of content analysis. Results According to the perspectives of the professionals, women surviving a severe maternal condition and their families experienced clinical and psychosocial consequences. Some cases portrayed the intense psychological distress in mourning for the loss of the fetus or of their reproductive capacity and changes in family dynamics generating emotional overload, depression, and gender violence. Conclusion The analysis of narratives may offer an idea on the complexity of the perception of care by professionals and on the need for an interdisciplinary follow-up of women surviving an SMM or an MNM episode.

Resumo Objetivo Diversos fatores podem afetar a saúde e a qualidade de vida das mulheres que tiveram um episódio de morbidade materna grave (MMG) ou near-miss materno (NMM). O objetivo do presente estudo foi explorar as perspectivas dos profissionais sobre as repercussões da MMG ou do NMM após terem entrevistados mulheres que sobreviveram a um desses episódios. Métodos Casos selecionados que chamaram a atenção dos profissionais foram relatados. Estes profissionais construíram individualmente 10 narrativas, que foram analisadas com a técnica de análise de conteúdo. Resultados Segundo as perspectivas dos profissionais, asmulheres que sobreviveram a uma condição materna grave e suas famílias vivenciaram consequências clínicas e psicológicas. Alguns casos relataram um intenso estresse psicológico no luto pela perda do feto ou de sua capacidade reprodutiva e de mudanças da dinâmica familiar, gerando sobrecarga emocional, depressão e violência de gênero. Conclusão A análise das narrativas pode oferecer uma ideia sobre a complexidade da percepção do cuidado de profissionais e sobre a necessidade de um seguimento interdisciplinar das mulheres sobreviventes de um episódio de MMG ou de NMM.

Factors associated with a positive depression screen after a miscarriage.

INTRODUCTION: Miscarriages are a common pregnancy complication and positive depression screen after a miscarriage has been shown to be high in our population. Various factors are associated with an increased risk of developing depression after a miscarriage. However, these factors vary across populations studied with no studies existing in our region. We set out to determine the factors associated with a positive depression screen among post-miscarriage women at the Aga Khan University hospital, Nairobi. METHODS: Patients were recruited at the 2 weeks clinic review after a miscarriage in the gynaecological clinics. They were screened using the Edinburgh postnatal depression scale for depression after a miscarriage. Analysis was done using Univariate and multivariate analysis to compare clinical variables between the screen - positive and screen - negative women in order to delineate the potential pattern of association between the two among the study subjects. RESULTS: Positive depression screen was detected in 34.1% of the patients recruited. Univariate analysis revealed that education level (p = 0.039) and mode of conception (p = 0.005) impacted on the outcome of the depression screen. In multivariate analysis, multiple factors impacted on the depression screen and these included: age (p = 0.009), education level (p = 0.001), gestation at miscarriage (p = 0.04), marital status (p = 0.043), prior miscarriage (p = 0.011) and mode of conception (p = 0.03). CONCLUSION: Factors that seem to impact on the positive depression screen include a younger age, low education level, an older gestational age at miscarriage, being single, an assisted mode of conception and prior miscarriage. These factors may be used to triage women after a miscarriage in order to pick up those who may screen positive for depression after a miscarriage.

Perinatal bereavement and palliative care offered throughout the healthcare system.

The aims of this article are twofold: (I) provide a general overview of perinatal bereavement services throughout the healthcare system and (II) identify future opportunities to improve bereavement services, including providing resources for the creation of standardized care guidelines, policies and educational opportunities across the healthcare system. Commentary is provided related to maternal child services, the neonatal intensive care unit (NICU), prenatal clinics, operating room (OR) and perioperative services, emergency department (ED), ethics, chaplaincy and palliative care services. An integrated system of care increases quality and safety and contributes to patient satisfaction. Physicians, nurses and administrators must encourage pregnancy loss support so that regardless of where in the facility the contact is made, when in the pregnancy the loss occurs, or whatever the conditions contributing to the pregnancy ending, trained caregivers are there to provide bereavement support for the family and palliative symptom management to the fetus born with a life limiting condition. The goal for respectful caregiving throughout an entire hospital system is achievable and critically important.

University students' awareness of causes and risk factors of miscarriage: a cross-sectional study.

BACKGROUND: Spontaneous miscarriage is the most common complication of pregnancy, occurring in up to 20% of pregnancies. Despite the prevalence of miscarriage, little is known regarding peoples' awareness and understanding of causes of pregnancy loss. The aim of this study was to explore university students' understanding of rates, causes and risk factors of miscarriage. METHODS: A cross-sectional study including university students. An online questionnaire was circulated to all students at the University College Cork using their university email accounts in April and May 2016. Main outcomes included identification of prevalence, weeks of gestation at which miscarriage occurs and causative risk factors for miscarriage. RESULTS: A sample of 746 students were included in the analysis. Only 20% (n = 149) of students correctly identified the prevalence of miscarriage, and almost 30% (n = 207) incorrectly believed that miscarriage occurs in less than 10% of pregnancies. Female were more likely to correctly identify the rate of miscarriage than men (21.8% versus 14.5%). However, men tended to underestimate the rate and females overestimate it. Students who did not know someone who had a miscarriage underestimated the rate of miscarriage, and those who were aware of some celebrities who had a miscarriage overestimated the rate. Almost 43% (n = 316) of students correctly identified fetal chromosomal abnormalities as the main cause of miscarriage. Females, older students, those from Medical and Health disciplines and those who were aware of a celebrity who had a miscarriage were more likely to identify chromosomal abnormalities as a main cause. However, more than 90% of the students believed that having a fall, consuming drugs or the medical condition of the mother was a causative risk factor for miscarriage. Finally, stress was identified as a risk factor more frequently than advanced maternal age or smoking. CONCLUSION: Although almost half of the participants identified chromosomal abnormalities as the main cause of miscarriage, there is still a lack of understanding about the prevalence and most important risk factors among university students. University represents an ideal opportunity for health promotion strategies to increase awareness of potential adverse outcomes in pregnancy.

Fertility management experiences of women with polycystic ovary syndrome in Australia.

BACKGROUND: Women with polycystic ovary syndrome (PCOS) are usually told that the condition is associated with fertility difficulties. However, little is known about their fertility management including contraceptive use, childbearing desires, and pregnancy outcomes. AIM: To compare the fertility management experiences and outcomes of Australian women with and without PCOS. METHOD: The 2013 Australian electoral roll was used to identify a random sample of 18- to 50-year-old women who were sent the Understanding Fertility Management in Australia survey to be completed anonymously. Factors associated with fertility management and outcomes were identified in multivariable analyses. RESULTS: Among the 1543 women who completed and returned the survey, 113 (7.3%) reported having PCOS. Women with PCOS reported a similar rate of current contraceptive use as women without PCOS (50.4% vs. 52.6%, p = .66). However, they were significantly younger at first pregnancy (24.9 vs. 26.8 years, p = .015), more likely to have consulted a health professional about fertility management (OR: 3.86, 95% CI: 2.50-5.96, p < .001), and perceive that it would be difficult to conceive (OR: 2.31, 95% CI: 1.41-3.79, p = .001) than women without PCOS. There were no significant differences in the number of desired children, unintended pregnancies, live births, abortions or miscarriages between women with and without PCOS. CONCLUSION: These findings indicate that women with PCOS need more nuanced information about their fertility potential. While they may experience fertility difficulties because of their condition, they should also be informed that they can conceive spontaneously and need reliable contraception to avoid pregnancy when it is not wanted.

Prevalence of positive depression screen among post miscarriage women- A cross sectional study.

BACKGROUND: Miscarriages are a common pregnancy complication affecting about 10-15% of pregnancies. Miscarriages may be associated with a myriad of psychiatric morbidity at various timelines after the event. Depression has been shown to affect about 10-20% of all women following a miscarriage. However, no data exists in the local setting informing on the prevalence of post-miscarriage depression. We set out to determine the prevalence of positive depression screen among women who have experienced a miscarriage at the Aga Khan University hospital, Nairobi. METHODS: The study was cross-sectional in design. Patients who had a miscarriage were recruited at the post-miscarriage clinic review at the gynecology clinics at Aga Khan University Hospital, Nairobi. The Edinburgh postpartum depression scale was used to screen for depression in the patients. Prevalence was calculated from the percentage of patients achieving the cut -off score of 13 over the total number of patients. RESULTS: A total of 182 patients were recruited for the study. The prevalence of positive depression screen was 34.1% since 62 of the 182 patients had a positive depression screen. Moreover, of the patients who had a positive depression screen, 21(33.1%) had thoughts of self-harm. CONCLUSION: A positive depression screen is present in 34.1% of women in our population two weeks after a miscarriage. Thoughts of self-harm are present in about a third of these women (33.1%) hence pointing out the importance of screening these women using the EPDS after a miscarriage.

Treatment Decisions at the Time of Miscarriage Diagnosis.

OBJECTIVE: To describe the factors patients and physicians prioritize during first-trimester miscarriage management and assess what drives satisfaction with care. METHODS: We conducted a mixed-methods study of clinically stable women seeking surgical, medical, or expectant miscarriage treatment. Women with first-trimester fetal demise or anembryonic gestation (N=55) completed demographic and psychosocial surveys. Using purposive sampling, 45 (82%) completed in-depth interviews. Fifteen obstetricians were interviewed. Participants described factors that informed their counseling (physicians) or decision-making (patients). Content analysis used an integrated approach with inductively and deductively derived codes. Patient-derived themes were stratified by treatment choice. Associations between variables and treatment choices were analyzed. RESULTS: Thirty-four women (62%) received surgical management, 19 (35%) received medical, and two (4%) received expectant. Physicians expected that women with prior pregnancies have strong management preferences, and indeed, multigravid patients were less likely to change their initial treatment choice after counseling than primigravid patients (12% compared with 42%, odds ratio [OR] 0.18, 95% confidence interval [CI] 0.04-0.81, P=.03). Physicians favored patient-centered decisions and patients chose the treatment that they thought would least affect other responsibilities. Those ultimately receiving surgical management had a higher monthly income (adjusted OR 1.30, 95% CI 1.04-1.63, P=.023) and more social support (adjusted OR 2.45, 95% CI 1.07-5.61, P=.035) than the medical group. The surgical group cited loss acceptance, a favorable perception of surgery, and a desire to expedite the miscarriage as decisive factors. The medical group endorsed control over, and timed completion of, the miscarriage in a more intimate setting, an aversion to surgery or anesthesia, and a perception of improved fertility preservation as decisive factors. Regardless of treatment choice, satisfaction with treatment was linked to a supportive clinical team and expeditious resolution. CONCLUSION: Prior pregnancy experiences, obligations, and sociodemographic factors influence miscarriage management decision-making. Structured counseling, especially for primigravid patients, could improve both the physician and the patient experience with miscarriage care.