INTRODUCTION AND AIM OF THE STUDY Bleeding per vagina complicates approximately 20% Of all pregnancies in the first trimester the prevalence reducing exponentially as pregnancy advances and about 50-60% of all bleeding from the uterus in the first trimester will end in miscarriage

INTRODUCTION AND AIM OF THE STUDY

Bleeding per vagina complicates approximately 20% Of all pregnancies in the first trimester the prevalence reducing exponentially as pregnancy advances and about 50-60% of all bleeding from the uterus in the first trimester will end in miscarriage (Ugwumadu and manyonda , 1998) .

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A Woman who has had a bad even pregnancy loss may experience high levels of anxiety and a tendency to depression which may spoil her next pregnancy or even all her life. if they experience a loss the initiates a natural feeling of grief they may convince themselves that they are “Breaking down ” and this may indeed increase the risk that they will (Black, 1998)

According to text revision of DSM-IV-TR, symptoms must appear within three months of a stressor’s beginning .The nature and severity of stressors is not specified. However, the stressor is more often every day events that are ubiquitous rather than rare, catastrophic events (Sadock and Sadock, 2004).

Coping to face a spontaneous pregnancy loss (SPL) may take one or more of several patterns, styles or strategies. For example, denial often constitutes the primary stage of grieving experienced by pregnant mothers being told they are having SPL. When a mother discovers that she become pregnant ,cradling a newborn in her arms becomes all she thinks thought about .To imagine that joy being suddenly taken away from her is difficult to bear ,Blaming self is another normal occurrence when a pregnancy terminates itself .It is perfectly normal to guilt herself that if something has been done ,or avoided ,she would have had her pregnancy saved ,However ,in most cases it is nothing she did or missed to do to cause the loss (Van,2001).

The healthcare provider (e.g., psychiatric obstetrician maternity nurses and psychiatry nurses) should emphasize to the mother that least one out of four pregnancies end in miscarriage .she is not alone and not to blame .Life often is not fair and this is one of those terrible times when an unfair deal is dealing with .Healthcare providers should realize that facing these fears is unimaginable and the mother does not have to accept it right away .Denial is perfectly all right and going with those feelings initially will assist her in the healing and coping process (Bakermans-Brandenburg etal.,1999).

Potter and Perry (2001) emphasized that every person experiences stress from time to time ,and normally a person is able to adapt or cope with stress until passes .Stress ( e.g., pregnancy loss ) can place heavy demands on the mother ,and if she is unable to adapt ,illness can result.

Coping occurs a cognitive mediating process when stress is appraised .this cognitive appraisal determines how an individual views, reacts to and handles a situation. In other words , the way a person interprets a situation helps determine the emotional reaction .These appraisals and emotions in turn influence the choice of coping strategies .thus , a per –

a total of 23 sub-items ,7 for withdrawal .3 for projection,3 for nervous reactions .4 for daydreams and fantasies and 6 for resigning the self to the fate.

– Problem-oriented coping strategies: it comprises a total of 14 sub- items, reflecting actions of the patient to deal with the stressful situation itself and solving the problem, (10 sub-items describe active coping strategies and 4 describe passive coping strategies).

RESULTS

Table (1) shows that participants from Sohag and Mansoura were matched as regards age (33.6 ± 11.9 years and 34.8±12.7 years ,respectively) , parity (14% and 18% , respectively were nulliparous ),educational status (36% and 20% , respectively were illiterate) and their timing of pregnancy loss (42% and 28% , respectively during the first trimester and 24% , respectively during the second trimester and 22% , and 30%,respectively during the third trimester).

Table (2) shows that after spontaneous pregnancy loss ,incidence rates of psychiatric disorders among participants from Sohag and Monsoura were almost equal ( 58% and 62% ,respectively .the main psy-
The typical response of friends and relatives are those of trying to get pregnant again right away. This thought may initially offer some comfort to the grieving mother that there is hope but it does not eradicate her pain from the baby she did lose. No matter how much she may want another baby , no child can be re-placed by a sibling (Hsu et al., 2002)

Adjustment complaints are short term maladaptive reactions to what a layperson would call a personal calamity, but in psychiatric expressions would be referred to as a psychosocial stressor. An adjustment disorder is expected to concern soon after the stressor terminates, or if it continues, a new level of adaptation is attained. Symptoms of the complaint usually resolve within six months , although they may last longer if created by one with long-lasting magnitudes (Bonelli et al.,2000)
son who notices a stressful episode will apply coping process .Some coping strategies may increase the risk of pain, illness ,or maladaptation, while others decline it (McCaffery and Pasero ,1999).

The study aims to explore different psychiatric sequels and coping strategies adopted by mothers who sustained recent SPL

METHODOLOGY

Setting
This study was implemented at the Obstetrics and gynecology wards of a university hospital in upper Egypt (Sohag University Hospital) and another in the delta (Mansoura University Hospital).

Study Design
This study utilized a cross sectional study design to investigate the stressors attributed to recent pregnancy loss and the coping strategies adopted by women with that pregnancy loss.

Sampling
This study comprised a convince sample containing of 100 mothers who sustained recent (within one week) spontaneous (not included) pregnancy loss (abortion or stillbirth) at Sohag University Hospital (n=50) and Mansoura University Hospital (n=50).Inclusion criteria comprised no past history of psychiatric disorders.

Study tools
1-Interview data sheet, including personal data (e.g.; age, residence, parity, education, etc.).

2- Psychiatric interview history and mental examination sheet of Manley (Sadock and Sadock, 2000).

3- Modified Jalowiec Coping Scale (JCS ): This scale was adapted from Jalowiec Coping Scale (Jalowiec and powers ,1981).it comprised 37 items that are rated on a Lickert scale reflecting the extent of followed coping strategy ,with 1 indicating “Never “;2 indicating “Occasionally “; 3 indicating ” about half the time ” 4 indicating “often “;and 5 indicating “always ” responses regarding coping strategies were classified into :

Affective –oriented coping strategies : it comprises

Chiatric disorder after the spontaneous pregnancy loss was the major depressive episode (40%), panic disorder (12%) and brief psychotic disorder and manic episode (4% for both).There were no significant differences in incidence rates for these psychiatric disorders among participants from Sohag and Monsoura..

Table (3) shows that affective-oriented coping strategies were adopted by more than two – thirds of participants from Sohag while about one –third adopted problem-oriented coping strategies .On the other hand ,almost half of participants from Mansoura followed affective –oriented coping strategies and the rest followed problem-oriented coping strategies.

Table (4) shows that participants who did not have psychiatric disorders were significantly more inclined to follow problem-oriented coping strategies ,while those who had psychiatric disorder were more inclined to follow affective –oriented coping strategies (
p; 0.001). Participants who developed major depressive episode, brief psychotic disorder, and manic episode tended to adopt affective oriented coping strategies, while those who had panic disorder tended to follow problem – oriented coping strategies.

DISCUSSION
Parks (1998) stated that people with losses are of particular importance to members of the healthcare professions because their physical and mental health may be at risk. In fact, physicians, and nurses may be the only people who are in a position to help.

Receiving the news that a mother has lost her baby is difficult and painful to describe. The heartache felt by the mother is an extreme stress that is hard to put into words and the loss can be devastating .itis a tragedy that is very difficult to cope with (Van and Meleis ,2003)

The present studies revealed that the incidence rate of psychiatric disorders was high after spontaneous pregnancy loss among participants from Sohag and Mansoura (58%and 62%, respectively).
Itself in a number of psychiatric sequelae such as depression , anniversary reactions ,posttraumatic stress disorders ,suicidal tendencies (65%had suicidal thoughts )and dysfunctional interpersonal and family relationships

Vought (1991) stated that as many as 90% of the women recognized guilt and shame feelings related to their abortion, while 74% of the women with spontaneous pregnancy loss admitted feeling of isolation ,76% had suffered from depression ,25% suffered from insomnia ,57% identified a feeling of despair and hopelessness in their lives ,some feel out of control (71%), overemotional (68%,confused (63% ) ,or unable to express emotions at all (56%).He added that 41% reported suicidal thoughts and 10% had attempted suicide . Gissler et al, (1996) concluded that the suicide rate after abortion is three times the common suicide rate and six times that related with birth.

A high incidence rate for psychiatric disorders was reported by Reardon (1997), who stated that 94% of participants showed negative psychological effects attributable to abortion .Rue (1998) reported that blame, criticalness, depression, perfectionistic personalities, controlling, even suicidal ideation and /or gestures may all be secondary to unacknowledged or unresolved anger following an abortion.

Ney (1994) explained that pregnancy loss creates more psychological turmoil and the loss is much more difficult to mourn because (1) it creates more complicated conflicts ;(2) of the ambivalent regard (love and hate )for the bereaved object ;(3) the fetus is never held ,named ,buried or mourned ;(4) there is no one they can talk to easily ; (5) it is an event that is not supposed to have happened .Moreover ,Rue (1998)added that pregnancy loss may be interpreted by the woman as a personal failure confirmatory of low self-esteem for either actions taken or actions she should have done but did not .

In the present study, differences in psychiatric disorders between participants according to study location were not manifest .However, the presents study showed that affective – oriented coping strategies were more adopted by Egyptian women than problem-oriented coping strategies, especially in Sohag.

Understanding adjustment disorders is s is an understanding of 3 factors: the nature of the stressor, the conscious and unconscious meaning of the sensor, and the patient’s pre-existing vulnerability. Several psychoanalytic researchers have pointed out that the same stress can produce a range of responses in various normal human beings.

The difference in strategies of coping between par-ticipants from Mansour and those from Sohag has been explained by Bonelli and Bugram (2000) , who stated that psychoanalytic research has emphasized the role of rearing environment in a person ‘s later capacity to respond to stress . Sadock and Sadock (2000) noted that defense mechanisms most commonly used by a person to deal with unpleasant situations or distressing internal affective states constitute a significant component of that person ‘s character . Sadock and Sadock (2004) added that throughout early development, each child develops a unique set of defense mechanisms to deal with stressful events. Because of more amounts of trauma or greater constitutional susceptibility, some children have less mature defense constellations than other children. This disadvantage may cause them as adults to react with substantially diminished functioning when they are faced with stressful events. Those who develop mature defense mechanisms are less vulnerable and bounce back quickly from the stressor.

The cultural and social differences between women in Mansoura and those in Sohag may explain the differences in observed patterns of adopted coping strategies .compared with participants from Mansoura, those from Sohag perhaps enjoy relatively better social support from others but are less educated and have less freedom to move .
CONCLUSIONS:
This study concluded that spontaneous pregnancy loss induces psychiatric disorders and stimulates coping among women. Both effective and problem oriented Coping strategies are usually followed. However, the affective oriented coping strategies are more used by mothers who experience spontaneous pregnancy loss. Cultural and social factors may influence the patterns of coping strategies of women with recent spontaneous pregnancy loss.

These findings are in agreement with those reported by several authors. Turell et al. (1990) described that women experience emotional distress after abortion .they noted the existence of a post abortion syndrome, (a sense of loss, emptiness and grief) similar to that reported by trauma survivors’ .CUtE-Aresnault and Mahlangu (1999) stated that both depression and anxiety were greater in women who had experienced stillbirth. However, they are variable patterns and incidence rates for psychiatric disorders among women who realize that they have lost their current pregnancy.

Speckhard (1987) reported that after spontaneous pregnancy loss, 69% of participants experienced self –hatred /self–degradation, 73% had the feeling of bitterness, and 92% had the feeling of depression .She added that unresolved grief may persist and manifest.
The finding is consistent with the reported by Kanona (2002), in Menoufiya .Egypt, who concluded that Egyptians patients used affective –oriented coping methods more than problem –oriented coping methods. She explained that, by nature, Egyptian females tend to use affective –oriented coping more than males.

According to Mahat (1997), who emphasized the relationship between perceived stressors and the methods of coping, the reasons why affective oriented coping was more followed by our patients could be the result of several factors .First ,all patients are females .Second ,low educational levels ,as low educated people may not consider their problems ,or try to solve their problems and educated people are usually knowledgeable about their health and manage their health problem-focused coping strategies to be more effective.

The present study also showed that the incidence of psychiatric disorders among participants who had spontaneous pregnancy loss was significantly lower among those who adopted problem –oriented coping than those who adopted affective –oriented coping.

Turell et al. (1990) emphasized that it is important to identify the demographic, geographic, social, and psychological factors that place them at risk of such are action. Of the significant social variables lack of support from significant others has been linked in some studies to emotional distress after abortion.

Sadock and Sadock (2000) noted that defense mechanisms may be adaptive and healthy, as well as pathological .In normal functioning ,they are critical to the preservation of the psychological welfare .the level of self-protective functioning results in optimal adaptation in the control of stressors .These defenses usually maximize gratifications and allow the conscious awareness of feelings ,ideas ,and their consequences .They also promote an optimal balance among conflicting motives .Commonly ,the more the healthy coping is adopted by a stressed person, the less psychiatric disorders may develop .
Sadock and Sadock (2004) noted that pivotal to

RECOMMENDATIONS
Proper management of pregnancy loss, psychiatrist and nursing staff should offer the necessary support by providing counseling. Support, information, critical analysis, and alternative problem- solving strategies to further improve their coping mechanisms. Medical treatment for pregnancy loss should cover any observed psychiatric disorders. Further in- depth study of social and cultural factors that influence the patterns of psychiatric sequelae and coping strategies of women with recent spontaneous pregnancy loss is recommended.

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