Understanding Miscarriages: Causes and Risks

Background:

The term miscarriage describes the clinical condition about the death of the embryo foetus before reaching the 20th week of pregnancy. The condition usually occurs in the early stage of pregnancy and it is evident from the statistical data that about 8 out of 10 miscarriages happen during the first 3 months of pregnancy. Most of the women experience the trauma of miscarriages and it is estimated that about 10 – 20 percent of pregnancies ends in miscarriages. The signs and symptoms associated with miscarriages are spotting, vaginal bleeding which starts light but gradually turns up to heavy bleeding, associated cramps, pain in the back region or in the abdomen, occurrence of fever, weakening condition of the body and frequent vomiting. There are several clinical conditions that results in miscarriages such as infection of the womb, hormonal problems in mother which includes thyroid, diabetes, structural abnormalities in the mother such as the uterine abnormalities and due to the responses generated from the immune system. Certain other factors that increases the risk of miscarriage, such as if the women had a past medical record of miscarriages and if the age of the women is above 35 years. Another important reason of miscarriage is the presence of condition cervical insufficiency where due to the weakness of the cervix, it cannot hold the pregnancy (Garrido-Gimenez, et al, 2015; Regan, et al; 2000). Miscarriage is a traumatic event for women and their families. Therefore the condition induces an intense emotional stress. Though the condition of the emotional stress improves within a several months but certain psychological problems persists. Depression and anxiety is the two most psychological issues that have to be dealt with care after miscarriage. Though these women can again become pregnant but the psychological issues still exist in that condition. More than 20 percent of the women who experience miscarriage are symptomatic for depression and anxiety and the symptoms may persists for about 1-3 years having a poor impact on the quality of life and subsequent chances of pregnancies. The women who faces these kinds of problems are usually younger in age, may have undergone a planned pregnancy with a medical history of infertility or miscarriages, poor support from the family and have little coping strategies. Immediately after the miscarriage the women remains in the state of intense emotional distress and it becomes very difficult for the professionals to differentiate the stage of grief from depression as few women suffers from the signs of depression for several months after miscarriage (Brier, et al, 1999).

Psychodynamic Theory

Therefore clinicians should evaluate the patients for the symptoms of depression at the early phase of 6 weeks with the use of Patient Health Questionnaire and should propose for the mental health treatment and evaluation. It is also evident from several studies that although 90% of the women who suffers miscarriages demands specific follow up care from their physicians but only 30% of them receives such care. The society fails to understand the loss of the parents who have undergone miscarriage which contributes more to the distress. The primary care providers are the family physicians, obstetricians and the other health care professionals. Most of the women who experience early loss of pregnancy are not screened for the mental health symptoms and therefore left untreated with an increased rate of mental health problems. Study reported that 68% of the women who experienced miscarriage remains upset for the next 2 years and 64% reported that it affected the decision of subsequent pregnancy. This increases the complication rate in the first trimester of the next pregnancy such as vaginal bleeding, fatigue, hospitalization, and low APGAR (Appearance, Pulse, Grimace, Activity, and Respiration) scores in the neonate. There are several factors that increase the chances of the mental health problems after pregnancy: loss of planned pregnancy, having medical records of infertility, no warning signs of the miscarriage, prior repeated incidents of miscarriages, social isolation, absence of previous children, relationship problems between the partners and with the family, poor coping skills and history of still birth. When the subjects were interviewed after 6-8 weeks of miscarriages revealed more symptomatic features of depression in comparison to the matched cohort of non pregnant women. Similarly 11% and 1.4% of Chinese women suffers from depression and anxiety disorders after 6 weeks of miscarriages though the incidence of depression is lower among the women of Western countries (Neugebauer, 2003; Beutel, et al, 1995; Gong, et al, 2013). There are lot of discrepancies about the care demands of the patients. About 74% of the heath care providers feel that routine psychological support will be beneficial but only 11 % feels that the level of care provided was adequate. The Hospital Anxiety And Depression Scale (HADS) had been used to measure the level of anxiety and depression among women. Several women want to know the reason behind their miscarriages, about the chances of subsequent pregnancies. Patient satisfaction score demands improvement in the follow up. The dissatisfaction of the patient highlights the psychological issues and though most of the women were followed up after the miscarriage but the level of psychological dissatisfaction is found to be same among them and the women who did not attend the follow up. As it is a very crucial issue, so, extensive research on this topic can guide the doctors and the health care providers regarding the management of the patient (Lok, et al, 2004; Neugebauer, 2003; Beutel, et al, 1995; Gong, et al, 2013; Tavoli, et al, 2018; Nynas, et al, 2015).

Methodologies Adopted:

Several high impact peer-reviewed journals have been studied via comprehensive search method and the approach for the evaluation of the literature review has been implemented. The Critical Appraisal Skills Programme (CASP) methodology framework developed in Oxford in 1993 by Dr. Amanda Burls (Singh, 2013), has been applied for the critical appraisal of the literature search evidences.

Framing the Research Questions:

The study was conducted with a broad definition for the study population, results, interventions so that a detailed coverage can be obtained in the search strategy with the clearly defined concept was maintained which could be continuously refined based on the number of references and scope, parameters are set. The assigned research questions were framed using the PICO process or framework which is generally used in the evidence based practice to design a clinical health related question. It is used to develop the literature search strategies to conduct a systemic review (Schardt, et al, 2007). Following are the assigned research questions:

1) What is the prevalence of women experiencing psychological problems in the society?

2) What are the factors that contribute to the development of psychological problems among women?

3) What are the varied psychological problems that women suffer after miscarriage?

4) What are the different management interventions that can be applied to deal with these patients?

Study Selection:

The inclusion and exclusion criteria are developed once the research idea becomes familiar with the literature search. To define the inclusion criteria the title of the article and abstract should contain the keywords or the definite search item. Relevant search should be done to match the requisite of research question though it may not contain the keywords or the search items within the title or abstract of the articles. To define the exclusion criteria, any studies that are falling “out of scope” for the review and not matching with the set research questions will not be considered. Any literature not written in the English language will not be considered for the review purpose. Therefore all the pieces of literature based on the defined inclusion and exclusion criteria are considered for the literature review.

The table on the inclusion and exclusion criteria for the present study:

Systemic review approach has been referred as the process for the purpose of literature review. It is done by applying systematic method process such as critical appraisal research studies (CASP), analysis of the secondary data, and the data that had been produced quantitatively and qualitatively (Saunders, et al. 2018; Bettany-Saltikov and McSherry, 2016). This particular approach has been used to obtain a detailed and exhaustive analysis of all the available literatures on the electronic databases based on the inclusion criteria. The website of the programme is (www.casp-uk.net) and it is a virtual platform. The benefits associated with this method of review is that it uses scientific methods for identifying and selecting the research which in turn reduces any form of bias in the study along with the productions of accurate and reliable results and conclusions in relation to the research hypothesis of the study. The researchers can study a wide number of literatures which helps them to evaluate the fact properly and present them in an accurate manner. The researcher has to be very attentive while compiling the results from a wide range of studies to ensure the accurate validity of the results. The title of the research articles should match with the research questions and to ensure the accuracy the abstract has to be studied. All the evidence will be included in the CASP flowchart in terms of retrieved, included and excluded studies (Lewis, et al, 2019).

Database search:

Primary studies (including both published data and unpublished studies are included) and reviews are selected based on the best understanding of the central research question. Therefore, a strategy was adopted where research evidence was searched from different sources. Suitable sources were identified after reviewing multiple electronic databases which comprises a huge number of high impact peer review contents such as Cumulative Index to Nursing and Allied Health Literature, PsycINFO, PubMed, Google Scholar, Medline, Taylor, Karger, Plos-One and Francis Online. Grey literature databases, utilised by the researcher for searching scientific contents are GreyNet International, Open Grey and Med Nar. The search was done with restriction to the most updated contents up to the year 2019 so that relevant and latest content can be available for the literature review purpose. One particular limitation was faced by the researcher was the non-availability of the full-length document apart from the abstract due to the registration service particulars of the University. All the in-text references of the resulted papers were also reviewed to analyse and evaluate the content of the relevant databases.

Conclusion:

At last it can be concluded that it depends upon the researcher to decide the reliability of the results presented in a paper and whether that data could be used to provide better care service to the patients. There are no single critical appraisal tools that can be applied in all types of the study but there are several checklists available online that can guide the researcher to understand that whether the paper had followed the specific criteria that has to be employed in an epidemiological study.

References:

Garrido-Gimenez, C. and Alijotas-Reig, J., 2015. Recurrent miscarriage: causes, evaluation and management. Postgraduate medical journal, 91(1073), pp.151-162.

Regan, L. and Rai, R., 2000. Epidemiology and the medical causes of miscarriage. Best practice & research Clinical obstetrics & gynaecology, 14(5), pp.839-854.

Brier, N., 1999. Understanding and managing the emotional reactions to a miscarriage. Obstetrics & gynecology, 93(1), pp.151-155.

Lok, I.H., Lee, D.T., Yip, S.K., Shek, D., Tam, W.H. and Chung, T.K., 2004. Screening for post-miscarriage psychiatric morbidity. American journal of obstetrics and gynecology, 191(2), pp.546-550.

Neugebauer, R., 2003. Depressive symptoms at two months after miscarriage: interpreting study findings from an epidemiological versus clinical perspective. Depression and anxiety, 17(3), pp.152-161.

Gong, X., Hao, J., Tao, F., Zhang, J., Wang, H. and Xu, R., 2013. Pregnancy loss and anxiety and depression during subsequent pregnancies: data from the C-ABC study. European Journal of Obstetrics & Gynecology and Reproductive Biology, 166(1), pp.30-36.

Tavoli, Z., Mohammadi, M., Tavoli, A., Moini, A., Effatpanah, M., Khedmat, L. and Montazeri, A., 2018. Quality of life and psychological distress in women with recurrent miscarriage: a comparative study. Health and quality of life outcomes, 16(1), p.150.

Nynas, J., Narang, P., Kolikonda, M.K. and Lippmann, S., 2015. Depression and anxiety following early pregnancy loss: recommendations for primary care providers. The primary care companion for CNS disorders, 17(1).

Schardt, C., Adams, M.B., Owens, T., Keitz, S. and Fontelo, P., 2007. Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC medical informatics and decision making, 7(1), p.16.

Saunders, B., Sim, J., Kingstone, T., Baker, S., Waterfield, J., Bartlam, B., Burroughs, H. and Jinks, C., 2018. Saturation in qualitative research: exploring its conceptualization and operationalization. Quality & quantity, 52(4), pp.1893-1907.

Bettany-Saltikov, J., Kandasamy, G., Van Schaik, P., McSherry, R., Hogg, J., Whittaker, V., Arnell, T. and Racero, G.A., 2019. School‐based education programmes for improving knowledge of back health, ergonomics and postural behaviour of school children aged 4–18: A systematic review. Campbell Systematic Reviews, 15(1-2), pp.1-11.

Lewis, J.M., Feasey, N.A. and Rylance, J., 2019. Aetiology and outcomes of sepsis in adults in sub-Saharan Africa: a systematic review and meta-analysis. Critical Care, 23(1), p.212.