Original Research Obstetrics| Volume 222, ISSUE 4, P367.e1-367.e22, April 2020

Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multicenter, prospective, cohort study

Published:December 13, 2019DOI:


      Early pregnancy losses are common, but their psychologic sequelae are often overlooked. Previous studies have established links between miscarriage and early symptoms of anxiety and depression. However, the incidence of posttraumatic stress symptoms and the psychologic response specifically to ectopic pregnancies have not been investigated.


      The purpose of this study was to investigate levels of posttraumatic stress, depression, and anxiety in women in the 9 months after early pregnancy loss, with a focus on miscarriage and ectopic pregnancy. Morbidity at 1 month was compared with a control group in healthy pregnancy.

      Study Design

      This was a prospective cohort study. Consecutive women were recruited from the early pregnancy and antenatal clinics at 3 London hospitals and received emailed surveys that contained standardized psychologic assessments that included the Hospital Anxiety and Depression Scale and Posttraumatic stress Diagnostic Scale, at 1, 3, and 9 months after loss. Control subjects were assessed after a dating scan. We assessed the proportion of participants who met the screening criteria for posttraumatic stress and moderate/severe anxiety or depression. We used logistic regression to calculate adjusted odds ratios.


      Seven hundred thirty-seven of 1098 women (67%) with early pregnancy loss (including 537 miscarriages and 116 ectopic pregnancies) and 171 of 187 control subjects (91%) agreed to participate. Four hundred ninety-two of the women with losses (67%) completed the Hospital Anxiety and Depression Scale after 1 month; 426 women (58%) completed it after 3 months, and 338 women (46%) completed it after 9 months. Eighty-seven control subjects (51%) participated. Criteria for posttraumatic stress were met in 29% of women with early pregnancy loss after 1 month and in 18% after 9 months (odds ratio per month, 0.80; 95% confidence interval, 0.72–0.89). Moderate/severe anxiety was reported in 24% after 1 month and in 17% after 9 months (odds ratio per month, 0.69; 95% confidence interval, 0.50–0.94). Moderate/severe depression was reported in 11% of the women after 1 month and 6% of the women after 9 months (odds ratio per month, 0.87; 95% confidence interval, 0.53–1.44). After miscarriage, proportions after 9 months were 16% for posttraumatic stress, 17% for anxiety, and 5% for depression. Corresponding figures after ectopic pregnancy were 21%, 23%, and 11%, respectively. In contrast, among control women with viable pregnancies, 13% reported moderate-to-severe anxiety (odds ratio loss at 1 month vs controls: 2.14; 95% confidence interval, 1.14–4.36), and 2% reported moderate-to-severe depression (odds ratio loss at 1 month vs control subjects: 3.88; 95% confidence interval, 1.27–19.2).


      Women experience high levels of posttraumatic stress, anxiety, and depression after early pregnancy loss. Distress declines over time but remains at clinically important levels at 9 months.

      Key words

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        • National Institute for Health and Care Excellence
        Ectopic pregnancy and miscarriage: diagnosis and initial management Clinical guideline cg154.
        (Available at:)
        • Office for National Statistics
        Dataset: Vital statistics in the UK: births, deaths and marriages - 2018 update.
        (Available at:)
        • Cumming G.P.
        • Klein S.
        • Bolsover D.
        • et al.
        The emotional burden of miscarriage for women and their partners: trajectories of anxiety and depression over 13 months.
        BJOG. 2007; 114: 1138-1145
        • Engelhard I.M.
        • van den Hout M.A.
        • Arntz A.
        Posttraumatic stress disorder after pregnancy loss.
        General Hospital Psychiatry. 2001; 23: 62-66
        • Hunter A.
        • Tussis L.
        • MacBeth A.
        The presence of anxiety, depression and stress in women and their partners during pregnancies following perinatal loss: a meta-analysis.
        J Affect Disord. 2017; 223: 153-164
        • Chojenta C.
        • Harris S.
        • Reilly N.
        • Forder P.
        • Austin M.P.
        • Loxton D.
        History of pregnancy loss increases the risk of mental health problems in subsequent pregnancies but not in the postpartum.
        PloS One. 2014; 9e95038
        • Janssen H.J.
        • Cuisinier M.C.
        • Hoogduin K.A.
        • de Graauw K.P.
        Controlled prospective study on the mental health of women following pregnancy loss.
        Am J Psychiatry. 1996; 153: 226-230
        • Cheung C.S.
        • Chan C.H.
        • Ng E.H.
        Stress and anxiety-depression levels following first-trimester miscarriage: a comparison between women who conceived naturally and women who conceived with assisted reproduction.
        BJOG. 2013; 120: 1090-1097
        • Daly S.F.
        • Harte L.
        • O’Beirne E.
        • McGee H.
        • Turner M.J.
        Does miscarriage affect the father?.
        J Obstet Gynaecol. 1996; 16: 260-261
        • Kulathilaka S.
        • Hanwella R.
        • de Silva V.A.
        Depressive disorder and grief following spontaneous abortion.
        BMC Psychiatry. 2016; 16: 100
        • Neugebauer R.
        • Kline J.
        • O’Connor P.
        • et al.
        Depressive symptoms in women in the six months after miscarriage.
        Am J Obstet Gynecol. 1992; 166: 104-109
        • Farren J.
        • Mitchell-Jones N.
        • Verbakel J.Y.
        • Timmerman D.
        • Jalmbrant M.
        • Bourne T.
        The psychological impact of early pregnancy loss.
        Hum Reprod Update. 2018; 24: 731-749
        • Zigmond A.S.
        • Snaith R.P.
        The hospital anxiety and depression scale.
        Acta Psychiatr Scand. 1983; 67: 361-370
        • Bjelland I.
        • Dahl A.A.
        • Haug T.T.
        • Neckelmann D.
        The validity of the Hospital Anxiety and Depression Scale: an updated literature review.
        J Psychosom Res. 2002; 52: 69-77
        • Foa E.
        • Cashman L.
        • Jaycox L.
        • Perry K.
        The validation of a self-report measure of posttraumatic stress disorder: the Posttraumatic Diagnostic Scale.
        Psychol Assess. 1997; 9: 445-451
        • Ehring T.
        • Kleim B.
        • Clark D.M.
        • Foa E.B.
        • Ehlers A.
        Screening for posttraumatic stress disorder: what combination of symptoms predicts best?.
        J Nerv Ment Dis. 2007; 195: 1004-1012
        • Neuhaus J.M.
        • Kalbfleisch J.D.
        Between- and within-cluster covariate effects in the analysis of clustered data.
        Biometrics. 1998; 54: 638-645
        • van Buuren S.
        • Groothuis-Oudshoorn K.
        Mice: multivariate imputation by chained equations in R.
        J Stat Softw. 2011; 45: 1-67
        • Rosellini A.J.
        • Stein M.B.
        • Colpe L.J.
        • et al.
        Approximating a DSM-5 diagnosis of PTSD using DSM-IV criteria.
        Depress Anxiety. 2015; 32: 493-501
        • O’Donnell M.L.
        • Alkemade N.
        • Nickerson A.
        • et al.
        Impact of the diagnostic changes to post-traumatic stress disorder for DSM-5 and the proposed changes to ICD-11.
        Br J Psychiatry. 2014; 205: 230-235
        • Murphy F.A.
        • Lipp A.
        • Powles D.L.
        Follow-up for improving psychological well being for women after a miscarriage.
        Cochrane Database Syst Rev. 2012; 3: CD008679