PTSD After Pregnancy Loss

I have taken the bones (and admittedly, most of the meat) from the post, PTSD after childbirth, to construct this post. I know personally and from talking to others that women can experience Post-traumatic Stress Disorder (PTSD) and Post-partum Depression (PPD) following birth losses. We enter our pregnancies with the fear of loss in the background – some worry more than others – but ultimately expect to be holding our beautiful babies in a mere 8 months after getting that BFP (big “fat” positive) on the home pregnancy test. I myself have been pregnant 4 times and have one living child. I have a lot to be thankful for. But 3 consecutive losses were almost too much for me.http://www.flickr.com/photos/parapet/

Yes, women can and do experience PTSD and PPD after miscarriage, pre-term birth loss, and still birth. The Florida Psychotherapy blog applies the DSM-IV-TR to childbirth related trauma. Let me apply the criteria outlined in that post to PTSD after loss(es).

According to the DSM-IV-TR, the following criteria must be met to be diagnosed with Post Traumatic Stress Disorder (PTSD):

A. The person has experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others AND the person’s response involved fear, helplessness or horror.

How a prospective mother views early pregnancy can contribute to PTSD. One of my sister-in-laws had an early loss but wasn’t terribly affected by it. I was shattered after my first loss. How did the prospective mother react to her loss? Did she panic? Did she cry a lot? Does she remember the entire experience? Has she withdrawn from her life? These and other reactions can be stress responses to her loss.

B. The traumatic event is persistently re-experienced in at least one of the following ways:

  • Recurrent and intrusive distressing recollections of the event.
  • Recurrent distressing dreams of the event.
  • Acting or feeling as though the event were recurring (including flashbacks when waking or intoxicated).
  • Intense psychological stress at exposure to events that symbolize or resemble an aspect of the event.

Women who have experienced pregnancy losses can have nightmares about her losses. Strong images and flashbacks may occur at random moments, or she may have trouble NOT thinking about her experiences with pregnancy loss. Women who do participate in support groups and especially on-line forums need to be careful here. By continuing to relive and replay the experience, you may slow down your recovery.

C. Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before the event) as indicated by at least three of the following:

  • Effort to avoid thoughts or feelings associated with the event.
  • Efforts to avoid activities or situations which arouse recollections of the event.
  • Inability to recall an important aspect of the event (psychogenic amnesia.)
  • Markedly diminished interest in significant activities, such as hobby or leisure time activity.
  • Feeling of detachment or estrangement from others.
  • Restricted range of affect; eg, inability to experience emotions such as feelings of love.
  • Sense of a foreshortened future such as not expecting to have a career, more children or a long life.

Here are some examples of how this many manifest. She may avoid places where she is most likely to encounter other pregnant women – play groups, gynecologist, church, heck . . . even the grocery store. She may have trouble relating to other friends with children and friends who are currently pregnant. She may be unable to watch shows that feature pregnancy and birth, look at milk cartons, hear about abused or murdered children, etc. She may no longer find pleasure in activities she once enjoyed. She may avoid sex and/or intimacy with her partner. She may not remember that she was bleeding all over the bathroom and that her young daughter saw the blood . . .

D. Persistent symptoms of increased arousal (not present before the event) as indicated by at least two of the following:

  • Difficulty in falling or staying asleep.
  • Irritability or outbursts of anger.
  • Difficulty concentrating.
  • Hyper-vigilance.
  • Exaggerated startle response.
  • Physiological reactivity on exposure to events that resemble an aspect of the event, eg breaking into a sweat or palpitations.

Moms may have an anxiety reaction when driving past their birth centers or hospitals. They may get anxious when discussing the birth or when birth stories come up in conversation. They may also feel detached from their baby, partner, family, or friends.

E. B, C, and D must be present for at least one month after the traumatic event.

I certainly experienced many of the above symptoms. I had an outright panic attack shortly after my first loss. After my second and third losses I was taking medicine to keep that from happening. I’ve had an incredibly difficult time concentrating since my losses began. I’m doing better now, but last Spring was agonizing.

F. The traumatic event caused clinically significant distress or dysfunction in the individual’s social, occupational, and family functioning or in other important areas of functioning.

Like postpartum depression, PTSD is highly treatable, meaning the woman can get better, sometimes very quickly. Treatment options include

  • talk therapies such as cognitive-behavioral therapy
  • medications and herbs
  • acupuncture
  • body therapies such as Eye Movement Desensitization and Reprocessing (EMDR), biofeedback, and hypnosis

I wasn’t able to recover quickly or easily and was prone to relapses. My last relapse was in August 2008. I went to a therapist and got tired of being told that “this is normal.” There is nothing normal about considering suicide. That is NOT an acceptable response, in my opinion, to any situation – merely “stressful” or absolutely traumatic. There is nothing normal about excessive drinking. There is nothing normal about not wanting to be around your partner or child (children). There is nothing normal about being nearly incapacitated for months and months. There is nothing normal about going out drinking and accidentally getting so drunk that you throw up in public, have to be driven home, black out, and want to kill yourself all over again. Of course, this last paragraph is MY situation, and I’m sure it may seem a normal response to recurrent pregnancy loss, but that doesn’t make it ok. I share these deep dark secrets with you so that you know if you experience these same or similar things, that you’re not alone. It may be normal, but it’s not ok. Please get help!

Additional resources:

And PCOS too

Well . . .my uterus looks just fine.  Looks like I’m healed up from the surgery – the “stripe” looked just lovely.  I still have a posterior fibroid, but I don’t think that was the one the RE messed with this summer since the adenomyoma was just above the cesarean scar.

I have Polycystic Ovarian Sydrome (PCOS).  My OB just discovered it today via ultrasound – the “string of pearls” were clear as day.  I don’t know how much of an affect that has on RPL.  GETTING pregnant hasn’t been my issue, and it seems to me that most women who have PCOS and suffer from infertility are having trouble conceiving.  Maybe that’s inaccurate.

My appointment was very interesting.  My OB doesn’t believe in the luteal phase defect.  That’s not to say that he’s antagonistic – he’s more than willing to treat with HCG and progesterone injections.  What I learned today is that some reproductive endocrinologists don’t believe that the luteal phase has anything to do with conception issues.  It’s the 1st half of the cycle that governs cycle length.  Evidently, if you ovulate then you will have a sufficient luteal phase.  REs that ascribe to this philosophy are more likely to treat with ovulation triggers like clomid, especially with PCOS.

That’s about all I have to say right now.  Just wanted to give the faithful an update and those of you who struggle with faith a bit of information, hope, and comfort.  YOU ARE NOT ALONE!

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Think of Me: Post-Op Ultrasound

I’m a bit of a wreck today.  I seem to get pretty antsy and stressed out before OB visits anymore.  Hmm, wonder why.  Anyway, I have an ultrasound scheduled tomorrow to check on my healing from the hysteroscopic myomectomy that was performed in August.  The myomectomy was supposed to remove a fibroid from the uterus and uterine muscle.  However, the surgeon found NOT a fibroid but an adenomyoma, endometrium growing in the muscle layer.  He’s not sure how much he was able to remove.

I must admit that I’m not feeling terribly confident.  I think I’m feeling less discomfort during ovulation from before, but that’s the only noticeable positive change.  I had one ok period followed by a horrific one in September where I was bleeding and clotting so heavily, and of course, I was busy at a conference at that time.  This last cycle only lasted 22-24 days.  I started spotting on the 22nd day and started heavy flow on the 24th day.  Bummer.  My progesterone must really suck.

I suppose the two possible outcomes for tomorrow are: (1) things look healed, so go for it, or (2) things don’t look so great.  I wonder how distorted my uterus still is?  I wonder if the myoma really had anything to do with my losses?  If things don’t look great, will that mean another surgery?  Or will it just mean more agonizing waiting?

And then what?  I can’t hardly remember any more.  I think I’m supposed to start on antibiotics and low-dose aspirin the cycle before conception.  Then I’ll have HCG shots during my luteal phase and progesterone shots once I get a ++.  My husband and I are both itching for another baby.  It’s crazy, really.  However, we don’t feel like our family is “done.”

What would I do if I lost another baby . . . God forbid.

Please keep me in your thoughts over the next 24 hours.  Thank you!

A Hole in My Venus

I’ve been looking through stock and Creative Commons Licensed photos tonight that deal with pregnancy.  I figured that while I’m in the mood I’d look for some photos that we could possibly use for the upcoming ICAN Conference in April in Atlanta.

I find this a particularly interesting portrayal of Venus, the goddess of fertility among others.  Notice that in this piece of artwork, she is missing her lower abdomen.  There is a hole there.  This is how I feel – like a goddess (albeit worldly, a woman who is quite fertile) whose corrupted uterus has been excised from her body.  It is so hard not to point at the cesarean as the root of my current woes.

I am so sorry that so many of you know how I feel.  No one deserves it.

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Loss Never Ending

I can’t hardly breathe tonight.

My phone rang today.  Our good friends are in need.  She’s about to have their third baby, and since baby Y-H is about a week early, my friends parents haven’t arrived yet.  Other good friends are out of town, and I feel honored that they turn to us for support during this most important time.

But now as I clean up around the house . . . and am faced with new baby coupons and childbirth books and gmail friends’ status messages updating us on pregnancies and new babies . . . I am overwhelmed by my losses.

June 4 was a lifetime ago.  Geez, no, early April, my first loss due date was a lifetime ago.  That’s right, my June baby was my “perfect timing baby.”  And the unimagineable still happened.  I lost another baby.  My baby was due around September 15.  I (should) have a 4-week-old baby, and my best friend is about to have her baby.  She found out about her baby a few days before I lost mine.  No wonder she was such a wreck when she first saw me after my loss.  She was pregnant and pukey and in agony since her dream was coming true and my dream was dashed yet again.

She’s about to have her baby.  Her third baby.  I have coupons.

RPL Update Number I Lose Count

I started writing up a big post about the more recent developments in my journey through recurrent pregnancy loss.  I still need to finish it up, but in the meantime, he’s a quick update:

  1. In August I had a hysteroscopic myomectomy done in Denver.  The idea was to hopefully remove a fibroid that was bulging into my uterus.  Instead of a fibroid, the surgeon found an adenomyoma located directly above my cesarean scar.  I have to review my records from my 1 successful pregnancy to determine whether or not the fibroid that was present during that pregnancy changed into this adenomyoma.  Otherwise, it is likely a lovely by-product of the 2004 cesarean section that was performed on me and my daughter.
  2. I have a substantial progesterone deficiency.  Progesterone levels should not drop below 8-10 in 2nd luteal phase draw, and mine dropped to 3.  I will have to have HCG shots during the luteal phase and progesterone shots during the first trimester to support the corpus luteum and developing baby.  It makes me INSANE that the last OB I asked to test my progesterone outright refused.  I lost that baby, obviously.
  3. I have to wait until November to have an ultrasound performed to let me know if my uterus and endometrium have repaired from the surgery.  Then we can talk about ttc.

That’s my nutshell.

Recurrent Pregnancy Loss Update

It’s hard to believe that it’s nearly a year since my first loss and only 4-1/2 months since my last loss.  But I am starting to put the pieces together.  Here’s the list of causes my Reproductive Endocrinologist outlined for me at my early June visit as well as my status in each of these areas.  I hope this may help others who have experienced multiple losses advocate for the help they need.

INFECTION
Yeah, it really stinks to think that I could have lost babies due to low-grade infection, but it is possible.  The RE recommends that I do a round of antibiotics during early pregnancy.

IMMUNOLOGICAL PROBLEMS
This category refers to things like clotting disorders, immuno-deficiency illnesses, and the like that can and do contribute to primary and secondary infertility.  When clear immunological problems are not identified through extensive blood testing, doctors seem to recommend taking a baby aspirin (81 mg) a day as a possible protective measure.  My bloodwork came back just fine and dandy!

STRUCTURAL PROBLEMS
Structural problems can be congenital or acquired.  An example of a congenital structural problem is a bicornuate uterus.  Some women with this uterine shape have difficulty maintaining pregnancy to term and their babies may not descend optimally (vertex, anterior-ish) into the birth canal.  I had a HSG done in late April, and my OB believed that I had a congenital uterine defect.  However, my follow-up (and second opinion) with the RE has not confirmed this to be the case.  Rather, it appears that a relatively small (1-1/2 inch or so in diameter) fibroid is distorting the left side of my uterus.  Even though it is intramural (in the muscle, not in the uterine cavity), the RE thinks it is enough of a problem to justify a laparoscopic myomectomyI am not convinced and will hold off on this invasive procedure until all other avenues have been exhausted.

HORMONES
This is where we enter a major realm of disagreement in the medical world.  Some doctors believe in progesterone deficiency and luteal phase defect; others don’t.  Some of the doctors who don’t will still agree to supplement since conventional wisdom suggests that supplementing progesterone production isn’t dangerous.  As luck would have it and non-traditional practitioners have told me time and time again, I have a progesterone deficiency.  A fairly marked deficiency, actually.  I had my progesterone levels checked twice during my last cycle – the first level was 20 (good); the second level taken only 48 hours later was 3 (NOT good).

LUCK OF THE DRAW
The fact remains that not all pregnancies are viable.  All children are a blessing, but not all babies – in utero – are meant for this world.  I do take some comfort in knowing that if any of these babies were just not going to be healthy, that they were not put on this earth.  I’ve had friends and family members choose to terminate pregnancies in the 2nd trimester, and I am thankful that I have never been given that choice.  On the other hand, knowing that my body is not producing enough progesterone to sustain pregnancy makes me sad and incredibly angry.

I am sure that the sadness is quite apparent if you’ve read anything on my blog this past year.  The sadness and loss has been overwhelming at times.  I am quite certain that my baby boy has been trying so hard this past year to come home to me, so it’s been particularly trying and emotional.

Why am I angry?  First, it is extremely frustrating to have seen three practitioners who have disparate diagnoses and protocols for dealing with repeat pregnancy loss.  Secondly, being refused services is infuriating.  Thirdly, doctors who contradict themselves and/or make stuff up make me insane.

OB 1 doesn’t (WON’T) test hormone levels during early pregnancy.  I am angry because she refused to order a simple progesterone test, and now that I know I have trouble maintaining adequate progesterone levels during the luteal phase, I resent her even more than I did before.  She has contradicted herself; she has refused services; she told me I would have to schedule a repeat cesarean for future births moments after waking up from sedation following an unwanted (but needed) D&C; she didn’t ever give good justifications for her protocols; she wanted to put me on Clomid; etc.  Mostly I am angry with HER.

OB 2 doesn’t believe in luteal phase defect but is willing to treat with progesterone supplementation.  My beef with this doctor is that he made up a term on my HSG report – partially-didelphic uterus.  It doesn’t exist.  OB 2 is great in that he’s willing to collaborate with specialists and takes the time to explain the evidence underlying various protocols.  I also appreciate that he is cautious when it comes to reproductive surgery.  He told me that I shouldn’t consider a myomectomy at this time – isn’t one uterine scar enough?

RE 1 I appreciate because he has been very thorough.  Perhaps there has been some overkill, but at this point, more information is good.  I am glad that we can (for the most part) rule out acquired or inherited thrombophilia, for instance.  I wish he hadn’t been so quick to suggest surgery for my fibroid.  I wish he hadn’t invalidated my concern for what this myomectomy would mean for my reproductive future.  Sure it may improve my fertility (possibly), but it would certainly necessitate cesarean deliveries from here on out.  I got the feeling that since my uterus is already scarred, that he assumed additional scars were negligible concerns.  He wasn’t listening.  Additionally, my last conversation with the RE’s nurse was confusing – I almost wonder if he has me confused with another patient?  Or perhaps he consulted with other doctors in his group regarding my file and has revised his protocol.  It would be nice to know for certain.

I will likely seek another opinion from a RE since I am in a big city this summer.  Recommendations for surgery really need to be followed up on with additional unrelated practitioners.  You’d get a second opinion if a doctor recommended back surgery, right?

Next up – a sonohysterogram in about a week.

RESOURCES

http://www.rialab.com/miscarriages_prevented.php

http://repro-med.net/info/cat.php

http://www.instituteofalternativemedicine.com/bioidhormone.htm

http://www.ivf.com/recurrent.html

http://www.cushings-help.com/infertility.htm [luteal phase defect section]

http://infertilityblog.blogspot.com/2007/01/so-your-uterus-is-bicornuate-check.html

http://stirrup-queens.blogspot.com/2008/01/two-part-sonohystogram.html

http://www.coe.ucsf.edu/fibroids/bg_diagnosis.html