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 Has she withdrawn from her life?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:

Aimless

I hardly know what to do with myself.  My normal internet activities have been disrupted by my miscarriage, and I find myself wondering what I’m supposed to be doing when I get onto the internet.

I can’t visit my “December Darlings” because they have what I don’t – growing families.  That may seem strange and selfish, but I just can’t deal with seeing the absolutely adorable pictures of my friends’ children.

I can’t even visit the main ICAN list . . . too many pregnant women there.  Too many women worried about their upcoming birth experiences, something I certainly can’t relate too right now.  Plus there’s the issue of having been told that my effing scar is too thin to attempt a VBAC.  (I haven’t had my follow-up with the OB yet to find out how she decided my fate for me.)  How am I supposed to encourage women to VBAC when I’ve now been given this news?  If my scar (which from the outside looks like nothing) can’t be trusted then how can I tell other women to trust their scars?  I feel like a hack.

I can’t visit Mothering’s forums, MDC.  I did today, but it’s been two weeks since I’ve been over there.  And today seeing the signatures of women whose pregnancies weren’t as far along as mine when I lost my baby . . . aaaa, it really stings.

I’m not in a good place right now.  Not at all.  I don’t feel “healed” in any way.  I’m just more drunk than I was 2 weeks ago.  Wow, that’s something to be proud of . . .

Every Day Is Different

Every day people ask me how I’m doing.  When I can tell that they really mean to ask “how are you doing?” I tell them:  “Each day is different.”  Actually, each moment is different.  I can be going about my daily routine and completely get caught off guard.

Today my only child wanted “up” for “snuggles.”  “I can’t pick you up right now, baby,” I explained.  “How come???”  And I told her that when the baby went to see God that it hurt my belly.  Then, feeling her soft baby(ish) skin against me I was overcome with sadness.  “Mommy, are you crying?  Do you miss the baby?  Mommy, you miss the baby just like I miss the baby.”  I picked up my 40-pound toddler even though I’m not supposed to do so, and she dried my tears with her shirt.  Ugh, when a 3-year-old is consoling a 35-year-old . . . pretty sad.

Monday was my first day back at work.  I had seen a psychologist the Wednesday before.  He thought it was incredibly poor form for the OB to have suggested that I would go back to work 2 days after a curretage procedure for a third-time miscarriage.  Indeed, I felt incredibly guilty but relieved not to be at work the rest of last week.  I went to a student recital on Tuesday night, and I could hardly take the sadness, concern, and sympathy in my students’ and colleagues’ eyes.

This past Monday I was more or less ready to be back at work.  Tuesday I was already feeling tired and overwhelmed.  Today was awful.  I taught 6 voice lessons and a theory class and didn’t have time during my lunch break for lunch.  I got home and my husband had to leave, so I was left to figure out dinner and put our daughter to bed.

I am not winning any mother of the year awards.  I found a pizza in the freezer.  My daughter is watching Noggin’ while I type.  My husband should be done with his stuff in 5 minutes, but I need to put her to bed before he gets home.  I dread night time still.  Night time means sleep which means that the next day sneaks up on me.  It’s been 2 weeks since I first became aware of problems with my pregnancy.  How can that be?  How has nearly 2 weeks passed since the ultrasound that revealed my dead baby???

I’ve slept some since then.  I’ve drunk some since then.  I’ve taken zanax since then.

Every day is different.  Perhaps that is what gives me the strength to keep waking up “tomorrow.”  No, that’s not it – it’s knowing that my little family depends on me.  Right now there’s not much more that gets me to “tomorrow,” but maybe that’s ok. 

Caring for Women Who Suffer Birth Loss

I posted the information below elsewhere on the internet in response to a request for advice regarding care protocol for women who experience miscarriage or stillbirth.  I am amazed at how upset I got just writing these seven points.  Women who miscarry or otherwise lose their babies are treated so strangely.  I’ve been reading a terrific book called Motherhood Lost which looks at birth loss from a feminist perspective.  It really speaks to me, so click on the link and check it out.

For what it’s worth, here was my personal advice regarding birth loss “care” – something we don’t always experience when we’re being “treated”:

1. Take women having active bleeding IMMEDIATELY to a room. Don’t make them sit bawling their eyes out around other pregnant women or in a horrible ER waiting room.2. Don’t subject them to unnecessary protocols when they make a request – I was “forced” to accept a heplock, and not only was it completely unnecessary, but the nurse sucked at getting it into place.

3. Don’t tell a woman (especially when you’re not her provider) that she put the pregnancies too close together and that she pushes herself too much. We already blame ourselves enough.

4. Don’t misread ultrasounds. Misread ultrasound leads to misdiagnosis which further complicates care and treatment. Because of this misdiagnosis, I was treated like a woman who wasn’t miscarrying “correctly” instead of a woman experiencing “threatened miscarriage” due to a subchorionic hematoma.  5w4d may be too early to see a fetal pole, and the presence of a yolk sac implies the existence of a fetal pole.  I did NOT have a blighted ovum.

5. If your patient miscarries over the weekend . . . follow-up with her. It’s the least you could do.6. Make the billing process more clear and more simple to digest. I don’t know where all of my bills come from and why I continue to have to pay so much out of pocket. I thought I had insurance???

7. Make sure you have RESOURCES to share with your patients/clients in the form of personal support, support groups/networks, reading materials, etc.

Yeah . . . all of this (and more, I’m sure) I experienced with my 10/07 miscarriage. That was my one and only experience with our local hospital. I won’t be going back there unless I’m seriously dying.

BFP Sturm und Drang

BFP = Big Fat (or your favorite “f” word) Positive; used on TTC (trying to conceive) and birth loss boards on the internet.  Women who use this terminology tend to record BBTs (basal body temps) and other fertility signs.

Sturm und Drang = German for “storm and longing” or “storm and stress”

From Wikipedia:

” . . . the name of a movement in German literature and music taking place from the late 1760s through the early 1780s in which individual subjectivity and, in particular, extremes of emotion were given free expression in response to the confines of rationalism imposed by the Enlightenment and associated aesthetic movements. The philosopher Johann Georg Hamannis considered to be the ideologue of Sturm und Drang, and Johann Wolfgang von Goethe was a notable proponent of the movement . . .”

And since Goethe was one of those poets who was set by “everyone and their dawg” in the Classical musical period, I’ve come across the theme quite a bit.

What does Sturm und Drang have to do with BFP?  Here I type, “barely” pregnant, bearer of the positive pee stick (home pregnancy test), being pulled by my rational mind and wild emotion.  I have been pregnant 3 times in the past 5 months.  My June cycle led to pregnancy and a 5 week miscarriage in early August.  We waited a full cycle and conceived again, but I miscarried between 5 and 7 weeks in early October.  We waited 8 weeks for my menses to return, and in the third cycle following the miscarriage I “accidentally” got pregnant again. 

The rational mind says: (1) miscarriage is a possibility, and a higher possibility now that I’ve had 2 back-to-back miscarriages; (2) although miscarriage is a possibility, I am statistically MORE likely to carry the pregnancy successfully to term; (3) there’s nothing I can do to cause a miscarriage; (4) there is nothing I can do to necessarily prevent or treat a miscarriage; (5) that I’ll survive another miscarriage should that be the journey.

The emotional heart says: (1) Trust God; (2) God won’t necessarily spare me from another miscarriage; (3) I can’t bear another miscarriage; (4) I’ll survive a miscarriage if I have to . . . my family needs me; (5) Bond with this pregnancy; (6) Stay emotionally detached from the pregnancy . . .

Another aspect of Sturm und Drang as it applies to BFPdom is guilt.  I have guilt on two levels.  First, I didn’t intend to become pregnant this cycle, so I am a bit embarrassed about being pregnant so soon and feeling foolish for having “accidentally” gotten pregnant in the first place.  My herbalist wanted me to be on a particular herbal regiment for about 3-6 months before TTC.  Second, I participate on a birth loss forum.  Some of the women in my group have been trying for months if not years to become pregnant.  Some have been trying for months if not years to become pregnant and see a pregnancy through to term.  Some have suffered multiple losses.   So I sometimes feel guilty and petty because I do have one beautiful daughter and have at least experienced pregnancy now 4 times.

As happy as I am for me, I grieve for these kind women on my board.  It’s hard to see one of them go on to a pregnancy board and continue with their pregnancy and birth.  It’s hard to see them return after a pregnancy was lost.  It’s hard for all of us to be excited about possibly being pregnant and scared that the inevitable (menses, miscarriage, stillbirth, etc.) will fall upon us.  It’s rough waiting for the next hcg or progesterone test or ultrasound that assures us that the pregnancies are moving forward. 

I love these women dearly.  I wish the circumstances that brought us together were different, but I learn something new every day.  Someone posts something heart-felt every day that touches me.  These hopeful grieving women have marked me and I them.