Navigating Perinatal Loss

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Case Study 

“Ms Anderson” is a 36-year-old G6P2 with past medical and psychiatric history significant for major depressive disorder (MDD) in full remission, 3 prior first-trimester perinatal losses, and gestational hypertension, who was admitted to the obstetrical hospital at 34 weeks with concern for decreased fetal movement. You see her for psychiatric consultation after stillborn delivery with no postpartum complication of hypertension. The obstetrics team was concerned as Ms Anderson appeared very tearful and was expressing increased anxiety and sadness following her delivery.

On interview with the psychiatry team, Ms Anderson reports experiencing sadness related to the death of her baby. She reports that the stillbirth was a shock because the pregnancy was uncomplicated. Given her history of recurrent losses, she was monitored very closely by her obstetrician and felt reassured as the pregnancy was progressing without major concerns. Following the delivery, she reports that hearing beeps from medical equipment and alarms from intravenous pumps in the hospital has been triggering to her as it reminds her of the delivery. She also reports that the delivery reminded her of her prior losses. Because of this, she is feeling anxious and unable to calm herself. She finds the hospital a difficult place to be, but has been told she needs to remain there for 1 or 2 additional days.

As Ms Anderson speaks to you, she is holding her newborn throughout the interview. She is cooperative with the interview and is tearful throughout. Her mood is sad and her affect is mood-congruent and with restricted range. Her examination is otherwise unremarkable.

Epidemiology of Perinatal Loss

Perinatal loss is common, with approximately 15% of recognized pregnancies ending in miscarriage.¹ Recurrent pregnancy loss, generally defined as 2 or more losses at before 20 weeks gestation, affects about 2.5% of women.² Stillbirth, defined by the Centers for Disease Control and Prevention (CDC) as a loss after 20 weeks gestation, is less common than miscarriage but nonetheless affects a substantial number of families. Per the CDC, stillbirths comprise about 1 in 175 births, resulting in more than 20,000 stillbirths annually in the United States.³ In 2021, the fetal mortality rate for pregnancies at a gestation of 20 weeks or greater was 5.73 fetal deaths per 1000 live births and fetal deaths.⁴ The fetal mortality rate during the third trimester (28 weeks gestation or greater) was 2.80 per 1000 live births and fetal deaths in 2021.

The cause of perinatal loss is often unknown. Various risk factors, including tobacco use, multifetal gestation, fetal congenital anomalies, maternal age, and maternal diabetes or hypertension, are associated with an elevated risk of stillbirth.^4,5

There are also substantial disparities in rates of perinatal loss, with certain racial and ethnic minority groups disproportionately affected. In 2021, the stillbirth rate was 7.48 per 1000 for American Indian or Alaska Native women and 9.89 for Black women, compared with 4.85 for White non-Hispanic women.⁴ This disparity likely stems in part from structural factors, including systemic racism experienced by BIPOC populations (Black, indigenous, and people of color).⁶ Structural barriers can result in decreased screening for perinatal mental health disorders and decreased access to care among marginalized groups.

Psychiatric Sequelae

Psychiatrists may encounter patients who have experienced pregnancy loss in many different settings and must be prepared to screen for and treat common psychiatric concerns in this population. In addition, they should be aware of certain groups that are at higher risk of developing mental health conditions or experiencing an exacerbation of a preexisting mental health condition, including MDD and anxiety disorders, in the wake of a loss. These groups include individuals with a history of infertility or recurrent loss, LGBTQ+ populations, and BIPOC populations.⁷

Perinatal loss is a traumatic event, and some individuals who experience loss also have a history of birth trauma. Common responses to loss and trauma include psychological distress, grief, postpartum blues, and posttraumatic symptoms, including detachment and numbness.⁷ Some patients go on to develop other conditions, including postpartum depression, postpartum anxiety disorders, acute stress disorder or posttraumatic stress disorder (PTSD), and adjustment disorder. Reactions to a loss can be complex, and psychiatrists may experience challenges in distinguishing among normal grief, pathological grief, MDD, and other common postpartum conditions.

Symptoms of grief and bereavement, including sadness, frequent thoughts related to the loss, and yearning for the deceased, are common and should not be treated as pathological. In some circumstances, however, patients may develop more complicated or pathologic grief requiring intervention. These patients may experience symptoms of grief that are prolonged, disruptive, and interfere more substantially with functioning.⁸ In distinguishing grief from MDD, psychiatrists should consider the time course of symptoms as well as the presence of depressive symptoms, including feelings of guilt and self-blame, hopelessness, worthlessness, and suicidal ideation.

Treatment Strategies

Accurate diagnosis is key in allowing psychiatrists to identify appropriate treatments for individuals who have experienced perinatal loss. Conducting a thorough risk assessment identifies individuals who may require a greater level of support or higher level of psychiatric care.

Nonpharmacologic strategies will often be first-line treatment in the immediate care of patients experiencing perinatal loss. This approach includes connecting the individual with additional support through local bereavement doulas, support groups, and loss support organizations. In hospital-based settings, allowing the bereaved to spend time with the deceased and produce mementos such as handprints and photos can ease the grieving process. Deferring to patients for preference for language around the loss is imperative. For example, patients may prefer to avoid terms such as miscarriage, stillbirth, and fetus, and using nonpreferred terms can harm the therapeutic alliance. Hospital-based social work teams may lead this process, and psychiatry teams should coordinate with them. Referral to psychotherapy may be offered to allow for ongoing processing of the loss.

Pharmacologic management can be helpful for individuals experiencing symptoms consistent with MDD, a postpartum anxiety disorder, or PTSD, though it is rarely indicated in the immediate aftermath of perinatal loss. In instances where a medication is indicated, limited data guide the selection of pharmacologic therapy for patients who have experienced a loss, though selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are commonly used and are first-line pharmacologic treatment for postpartum depression, anxiety, and PTSD. Psychiatrists may additionally consider newer agents such as brexanolone or zuranolone in the setting of moderate to severe depression. However, some patients may find the inpatient administration of brexanolone to be a barrier given negative associations with the hospital environment following a traumatic birth or loss.⁷ More treatment strategies for common post-loss symptoms and conditions can be found in the Table.

Table. Treatment Strategies for Common Post-Loss Symptoms and Conditions

In the case of Ms Anderson, you learn that she has a history of depression (low mood, poor sleep, low appetite, anhedonia, guilty thoughts, passive death wish) lasting 2 to 3 months at a time following the birth of her first child, as well as following her prior losses. However, she denies any history of suicidal ideation and homicidal ideation, and she denies a history of suicide attempts. Based on the interview, her symptoms were thought to be consistent with normal bereavement with some posttraumatic symptoms related to the birth. She was connected with grief resources, including a local support group. She was referred to an outpatient therapist and psychiatrist given her history of depressive episodes so that her symptoms would be closely monitored following discharge.

Concluding Thoughts

Perinatal loss is common, and those who have experienced loss may experience a range of reactions, including both normal and complicated grief as well as depressive, anxiety-spectrum, and trauma- related disorders. Psychiatrists should be mindful of the vast disparities in rates of perinatal loss as well as psychiatric complications stemming from loss, and should take care to screen for these conditions. Treatment will vary based on presentation, but often includes nonpharmacologic strategies including referral to psychotherapy, connection to local support groups and loss support organizations, and allowing the bereaved to produce mementos and spend time with the deceased.

Dr Lavingia is a PGY-4 psychiatry resident at the University of Pittsburgh. Her clinical and research interests include women’s mental health and consultation-liaison psychiatry. Dr Spada is an assistant professor of psychiatry at the University of Pittsburgh. She is an associate program director for the psychiatry residency program at UPMC. She is also codirector of the residency program’s Academic Administrator, Clinician Educator Track and codirector of the Women’s Mental Health and Reproductive Psychiatry Area of Concentration. Dr Gopalan is an associate professor of psychiatry and obstetrics, gynecology and reproductive sciences in the Department of Psychiatry at the University of Pittsburgh. She is also medical director of the Psychiatry Consultation-Liaison Service, chief of psychiatry at Magee Women’s Hospital, and codirector of the Academic Administrator/Clinician Educator Track, Office of Residency Training.

References

References

1. Quenby S, Gallos ID, Dhillon-Smith RK, et al. Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. Lancet. 2021;397(10285):1658-1667.

2. Dimitriadis E, Menkhorst E, Saito S, et al. Recurrent pregnancy loss. Nat Rev Dis Primers. 2020;6(1):98.

3. Data and statistics on stillbirth. Centers for Disease Control and Prevention. May 15, 2024. Accessed July 24, 2024. https://www.cdc.gov/stillbirth/data-research/index.html#:~:text=Stillbirth%20affects%20about%201%20in,the%20first%20year%20of%20life

4. Gregory ECW, Valenzuela CP, Hoyert DL. Fetal mortality: United States, 2021. Natl Vital Stat Rep. 2023;72(8):1-21.

5. Flenady V, Koopmans L, Middleton P, et al. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. Lancet. 2011;377(9774):1331-1340.

6. Stillbirth Working Group of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Council. Working to address the tragedy of stillbirth. March 15, 2023. Accessed July 24, 2024. https://www.nichd.nih.gov/sites/default/files/inline-files/STILLBIRTH_WG_REPORT_03152023.pdf

7. Gopalan P, Spada ML, Shenai N, et al. An overview for the general psychiatrist evaluating patients with obstetric and neonatal complications and perinatal loss. Focus (Am Psychiatr Publ). 2024;22(1):35-43.

8. Kersting A, Wagner B. Complicated grief after perinatal loss. Dialogues Clin Neurosci. 2012;14(2):187-194.