LISBON – Depression and emotional stress did not lead to poorer pregnancy outcomes 1 year after referral for recurrent pregnancy loss in a prospective, longitudinal study.
Among 287 women with recurrent pregnancy loss (RPL), 132 had a live birth or an ongoing pregnancy after 12 weeks gestation 1 year after referral to a tertiary RPL unit.
High scores on the PSS (Cohen Perceived Stress Scale) at referral were not associated with the chance of a subsequent live birth or ongoing pregnancy in unadjusted analysis (odds ratio, 1.012 ; 95% confidence interval 0.98-1.045) or after adjustment for maternal age and number of pregnancy losses prior to referral (OR, 1.015; CI 0.98-1.050).
Moderate to severe depression on the Major Depression Inventory (MDI) also was not associated with the chance of either outcome in unadjusted (OR, 2.12; CI 0.91-4.93) or adjusted (OR, 1.86; CI 0.78-4.42) analyses.
“We did not find an association between emotional distress at referral and the chance for a positive pregnancy outcome,” study author Dr. Astrid Marie Kolte said at the annual meeting of the European Society of Human Reproduction and Embryology.
It is well-known that pregnancy loss is a significant major life event that can invoke grief similar to that after a neonatal death. Studies have also shown that depression and stress are highly prominent among women with RPL.
In a recent study by Dr. Kolte and her associates, moderate to severe depression was identified in 8.6% and high stress levels in 41.2% of 301 women with three or more pregnancy losses before 12 weeks gestation, compared with rates of 2.2% and 23.2%, respectively, among 1,813 women without RPL (Hum. Reprod. 2015;30:777-782).Other groups have found significantly higher prevalence rates of moderate to severe depression in RPL patients, in the range of 15% to 33%, Dr. Kolte of the RPL Unit, Copenhagen University Hospital Rigshospitalet, said.
Data are scarce and results mixed, however, on the impact of depression and stress on subsequent live birth rates, prompting the investigators to examine pregnancy outcomes among the 301 previously studied women.
A total of 185 participants completed a follow-up questionnaire at 1 year containing the same PSS and MDI filled out a referral, along with questions about their pregnancy. Reliable data was available for 102 pregnancies among the 116 nonrespondents, resulting in 287 patients in the current analysis.
Among these women, 82 had given birth to a live child within the first year after referral, 50 had an ongoing pregnancy after 12 weeks’ gestation, and 11 were pregnant at less than 12 weeks’ gestation.
Interestingly, women with a live birth or ongoing pregnancy after 12 weeks’ gestation had significantly lower MDI (13.59 vs. 10.12) and PSS (16.94 vs. 12.47) scores on follow-up. This was not the case for patients without a positive pregnancy outcome for either the MDI (12.65 vs. 12.92) or PSS (16.86 vs. 15.49), Dr. Kolte said.
She noted that the study may have been insufficiently powered because of the low prevalence (8.6%) of major depression at referral and remarkably similar perceived stress among patients with and without live births. However, the study used validated psychometric scales, had good obstetrical follow-up, and is by far the largest study of emotional stress and live birth/ongoing pregnancy to date, she said.
Dr. Kolte expressed frustration at providing the best care for these patients, observing that there is a severe lack of understanding of the pathophysiology of recurrent pregnancy loss and no evidence-based treatment for the majority of RPL patients.
“You can indeed discuss whether a cumulative live birth rate of 70% on average is a good prognosis, but this is still a distressing event for these patients and their partners,” she said.
All newly referred patients and their partners are now being screened for major depression and perceived stress in the Danish RPL Unit, but providers do not have the means to treat those patients with psychological morbidities and must refer them back to their general physician.
“In my opinion, this is an understudied and underprioritized area in early pregnancy management, at least in Denmark,” Dr. Kolte said.
Several attendees echoed this frustration and asked Dr. Kolte for advice. While not all women will need psychological medication, having a psychologist associated with a RPL program is essential, as is a good working relationship with a psychiatrist, she replied.
University Hospital Copenhagen Rigshospitalet funded the study. Dr. Kolte reported having no financial disclosures.