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The Problem of Spontaneous Abortion
THE PROBLEM OF SPONTANEOUS ABORTION III. Psychosomatic and Interpersonal Aspects of Habitual Abortion* R. J.
WEIL,
M.D.,
AND LuciLLE
C.
STEWART, M.Sc., HALIFAX, NovA ScoTIA
(From the Department of Obstetrics and ·Gynecology, Dalhousie University)
i I':t~!~ t~:Pi~p:~t:::r:~t~d:~:;_~:~:b~~~:!l:~~~~~~r~:~~i~~~;;::; ~~:~~~:;:~ 8
tion to the understanding of a pathological process; the possibility of a relationship between emotional and hormonal changes; and the value of psychotherapy in the treatment of habitual abortion. In pathological pregnancies, deviations from the normal homeostatic pattern in the maternal organism have been demonstrated. Browne, 5 Hain, 8 Jones and Delfs, 11 and others have reported low levels of estrogen, pregnanediol, and chorionic gonadotrophin in the urine of women who threaten to abort, or who have poor obstetrical histories. Abortion may also occur in the presence of apparently normal hormone levels. It has been suggested that pre-existing emotional conflicts, or emotional disturbances occurring during the period of pregnancy may be contributing factors to spontaneous abortion. 4 • 7 • 14• 15 • 17 Psychotherapy has been known to be successful in interrupting a series of spontaneous abortions. Emotional support appears to be one factor contributing to the successful treatment of habitual abortion, as mentioned by Berle and Javert, 2 Javert, 10 and Bevis. 3 The work of these authors seems to indicate that emotional factors may play an important role in spontaneous premature interruption of pregnancy. Since no correlative studies between hormone levels and psychological changes during pregnancy are available in the literature, this aspect became a focus of interest in our long-term observations of our patients. The psychiatrist sees these patients in weekly interviews of one hour. The patient collects urine for 48 hours prior to the interview. This collection is analyzed for chorionic gonadotrophin, 9 • 12 pregnanediol/ 6 estrogen/· 18 17-ketosteroids,S and creatinine. A number of patients have been studied in this manner; the following seemed most interesting of these cases. Case History First Admission.-L. B. was first admitted Sept. 2, 1953, in the sixth week of pregnancy. No difficulty had been experienced during the present pregnancy; the patient came for investigation because previous pregnancies had ended in abortion. Between 1949 and 1953 this patient had had seven consecutive abortions before the third month of pregnancy, and therefore seemingly had a very small chance of carrying the present pregnancy to term.1a Throughout all her previous pregnancies this patient was under competent observation and care. *This report is part of the work of a multidisciplinary study, "Abortion Research Project" supported by a Federal Health Grant, under the directorship of Dr. W. R. c. Tupper.
322
Volume 73 Number 2
PROBLEM OF SPONTANEOUS ABOR'riON. TIL
323
After reviewing the history of her past pregnancies and on the basis of present find· ings tho obstetrician stated that there were no gynecological or obstetrical reasons why these miscarriages should have occurred. The physical examination was negative. The biochemical findings were as follows: cholesterol, 178 mg. per cent; vitamin E, 1.\H mg. per cent; vitamin C, 1.1 mg. per cent; all of which are within the normal limits. The hormone levels were founll to be: estrogens, 0.11 mg. per 24 hours; pregna.nediol, 2.5 mg. per 24 hours; chorionic gonadotrophins, greater than 163,000 M.U. per 24 hours; 17· ketosteroids, 5.0 mg. per 24 hours. '!'he pregnanediol and estrogen values were low and the others normal for her period of pregnancy, as judged by our own data and the normal ]pvels reported in the literature.* 'L'he vaginal smear showed predominantly cornified cells with ragged edges, inter· preted by the obstetrician as indicating a lowered estrogen level. '!'he psychiatric history condensed from a lengthy history follows. This was a 31· year·old, attractive, Protestant, married woman of average height and build. She was uorn in a small town where she lived until she went to college. She said that she had a happy childhood. She had no neurotic traits other than fingernail biting. She went to a large city where she continued her college education. She joined the Civil Service and remained in it until a year after her marriage at the age of 25 to a meteorologist. Since her marriage she has traveled about considerably due to frequent transfers of her husband. Her father is a professional man of 58. He is described by the patient as a quiet, unolemonstrative, ann kind man, who wanted to see his children become independent as soon as possible. Here I quote from one of the interviews, "Even to catch a cold was a disgrace because it meant that we were not careful enough. This fight for independenct• made a woman of me." Her father always had a fear of tuberculosis and had several bouts of colitis. Her mother was described as a home-loving, quiet person, who was very interested in her family. There was no marital friction between the parents, but the patient's mother maintained the peace by catering to her husband's hypochondriacal tendencies. The patient had two sisters, aged 29 and 26. Both were married. The oldest did not become pregnant until the sixth year of marriage. During her only pregnancy, she had no difficulties, and gave birth to a normal child in uncomplieated labor. The second sister only recently married and has never been pregnant. The patient was never seriously ill but she suffered from mild dysmenorrhea. especially during her college years when she also had occasional bouts of diarrhea and her stomach woulol "go into knots." She had her menarche at age 12, having been adequately prepared by her mother. She reported no sexual difficulties in her marriage. The husband was the same age as the patient. He was kind, thoughtful, well liked, and made friends easily. She knew him at least a year before marriage. During the pe· rioll of study he was serving abroad. She said about herself, "I have a temper and would like to fight at times but my husband doesn't. I was quite good at my job but I would rather keep house than work. [ have a small circle of friends and I like parties and people around me.'' On the basis of these investigations the patient appeared to be a physically and emo· tionally healthy woman. On first contact with the psychiatrist, the patient was pleasant, cooperative, and showed a good understanding of the nature of the project. Alithough pessimistic about the outcome of her pregnancy, she was eager to participate in the study and willing to see the psychiatrist weekly and to colleet the urine specimens. The psychological tests suggested that she was a woman to whom appearances were very important. She tried to present a picture of herself as a normal, calm person living in a happy home. However, under the pressure of the teBts this picture dissolved to show • All biochemical and hormonal determinations are done in the Division of Biochemistry, Department of Public Health.
324
\VEIL AND STEWART
,\m.
J. Obst.
& Gyne<. February, Jq:-;
a tense, depressed woman living in a rather disturbed home and aware of her own precarious hold on security. Anxiety was aroused by many things in a world that she found rather unpleasant. However, she judged that her general social adjustment was satisfactory, that she had good friends, and was able to handle people well. In spite of the patient's need to present a pleasant picture to "outsiders" she herself admitted that she was a person with inadequate emotional control, and one who was characteristically sensitive and tense. It can be said, therefore, that although this patient tried to impress others, she was reasonably honest in her dealings with herself.* Arrangements for continued contact with the patient were discussed by the team, and approved by the patient, but before they could be acted upon, the patient had to be admitted to the hospital with signs and symptoms of threatening abortion.
Second Admission.-The patient was admitted to the hospital during the tenth week of pregnancy on Sept. 17, 1953, with pain and vaginal bleeding. Gynecological and physical examination showed no cause for the present signs and symptoms of abortion. The hormone data were as follows: pregnanediol, 3.5 mg. per 24 hours; estrogen, 0.09 mg. per 24 hours; chorionic gonadotrophin, 48,COO M.U. per 24 hours; 17-ketosteroids, 8.0 mg. per 24 hours. Again the pregnanediol and estrogen values were below the normal range, the 17-ketosteroii!s were normal, and the chorionic gonadotrophins had fallen belo~.r the normal limit. This had occurred at the en
•Thanks are due Mrs. Joan Morris for administering and interpreting the psychological
Volume 73 ~umber
2
PROBLEM OF SPONTANEOUS ABORTION. III.
325
By the eighteenth week the excretion of pregnanediol had increased to the normal minimum. The chorionic gonadotrophins were still falling. Nov. 21, 1953 (nineteenth week of pregnancy): The interview of the nineteenth week revealed the consequences of communication difficulties between patient and psychiatrist. These difficulties gave rise to feelings of insecurity in the patient. Nov. 28, 1953 (twentieth week of pregnancy): Upon realizing these communication difiiculties the psychiatrist discussed them with the patient. Both the patient and the psychiat.rist felt that this hour clarified the nature of their interpersonal relationship. By this date the chorionic gonadotrophins had fallen to the lowest value since the beginning of this study-20,000 M.U. per 24 hours, at the very lower limit of normalcy. Dec. 3, 195$ (twenty-first week of pregnancy): At this time the patient revealed that she had a diary covering a long period, and the next few interviews were spent in discussing the events and experiences surrounding the previous abortions. Dec. 10, 1953 (tu·enty-second week of pregnancy): A certain repetitive pattern in bnhavior during the abortion period could be detected from her own descriptions in the diaries. On each occasion when the patient found herself pregnant, she feared that she might inconvenience her husband. Her need to remain independent was enhanced by pregnancy. ·when the process of abortion commenced, the patient denied it by trying to ignore it. Even when the symptoms were severe, she rejected help. The patient became restless, reaching a maximum of activity immediately after the completion of the abortion. During the period in which this material was discussed, she was depressed and overactive, mirroring her behavior and attitude at the time of her previous abortions. Following the interview of the twenty-sixth week, the psychiatrist finally realized the significance of this change in the patient's behavior. Therefore, between the interviews of the twenty-sixth and twenty-seventh weeks, the psychiatrist discussed this behavior pattern with her. From an enilocrinological point of view, this period from the twenty-second to the twenty-sixth week was characterized by a continuous, rapirl fall in the chorionic gonadotrophins from 1G3,000 M.U. to 8,000 M.U., just below the normal limit, but probably not significantly so. The fall from the previous level was, however, dramatic. Following the interview of December 10, the patient became more relaxed, until the Christmas holiday, during and following which she again became restless and upset. 'l'bis was a~crihed to mild external stresses. Jan. 28, 1954 (twenty-ninth week of pregnancy): her inner restlessness with the patient.
'fhc psychiatrist again discussed
Feb. 2, 1954 (thirtieth week of pregnancy): The following week the psychiatrist was absent and the patient was without support during another stressful period. The chorionic gonadotrophins fell to 2,000 M.U., the lmwst value noted throughout the entire study, and definitely below normal. 1/'eb. 11, 1954 (thirty· fir/it week of pregnlt/ricy); The patient \Vas seven months pregnant and felt well. She was not as anxious and restless as during the two preceding interviews. She took her time and organized her affairs more efficiently. The chorionic gonadotrophins had risen to 40,000 M.U., a normal level.
Feb. 19 to Mar. 5, 1954: At this stage of pregnancy she was sufficiently reassured by her well-being so that she was able to make realistic arrangements for the arrival of the baby. This positive attitude to her pregnancy, and to the psychiatrist, prevailed until the patient gave birth to a normal full-term baby in natural childbirth and without complication. Psychiatl'i
326
WElL AND STEW ART
Am.]. Obst. & Gyne ... February, 19 ~ 7
which seemed to have disappeared since her marriage. She was sensitive to failure and to the reaction of others to her, and was loath to inconvenience others. Pregnancy seemed to represent a stress to her, to which she responded by becoming more independent, thus counteracting her biological and emotional needs. Relevant to this psychia:tric summary is the result of the :foliowing final psychological testing done just prior to the confinement: "The picture was somewhat changed from that presented at the first testing. The patient was less tense and less productive on the Rorschach tests. Although she was not doing as much as she was capable of, what she did was more org,anized and logical. There was less variance of mood and less anxiety around her emotional responsiveness. The feeling of unpleasantness and tension formerly attached to her need for affection from others had lessened. She was now better able to accept this need. Although she was able to express her emotions more freely, there was still the necessity for gaining prestige and presenting a good front. "Her relationship with her husband, judging from the psychological test material, seemed to have undergone some changes. Her feeling of responsibility toward him had increased, and there were more common interests, although it was still the husband who gave in to the wife when there was variance. She was able to admit that unpleasantness existed and she could verbalize a resentment toward her husband, and toward her mother. She saw children as a bother and inconvenience." It appears that psychotherapy permitted the continuance of the pregnancy, possibly because it produced positive persouality changes. It will be noted that by the eighteenth week (November 12) with no treatment other than psychotherapy, the level of excretion of pregnanediol and the estrogens had climbed to normal values. In charting the results of the hormone assays, we were impressed by the fluctuations encountered from week to week in the level of the chorionic gonadotrophins, which are gre!liter than would be expected on the basis of control assays, and the rises and falls do not coincide with those of a "normal" pregnancy. It will be noted that at the ninth (September 17), twentieth (November 28), twentysixth (January 5), and thirtieth (February 2) weeks, the chorionic gonadotrophins reached low levels, falling markedly from the preceding levels. At these times the patient seemed to be under stress, some of which m'ay havo been induced by the tensions within the interpersonal relationship of the psychiatrist and the patient. The pregnanediol excretion levels showed similar but not as marked fluctuations. The estrogens showed a steady slow increment, but remained at or slightly below the normal minimum throughout pregnancy. Since the study of this patient several others have been followed in equal detail, and confirm some of the observations in this case.
Comment Although we are well aware that any general conclusions drawn from the study of only one patient may be misleading or even invalid, we feel that the presented case is of sufficient interest to warrant a report. The patient discussed in detail serves as an internal control, since her history of seven consecutive abortions indicates that unassisted she seemed to have a very small chance of carrying a pregnancy to a successful conclusion. Therefore it seems reasonable to assume that psychotherapeutic contact may have contributed to the successful conclusion of her pregnancy. Any treatment, if it is a prolonged one, is of necessity associated with attention and support from the physician which may gratify a specific need of the patient. This is a factor common to many of the courses of therapy prescribed in threatened abortion, and may well be a factor in the measure of success which they achieve. The specific therapy offered the patient discussed
\\~lume
73
PROBLEM OF SPONTANEOUS ABORTION. lii.
l\'umher 2
in this paper may be analogous to the more general aid offered by the physician in connection with other treatment. We have the impression from the larger group studied that the attention the women receive while undergoing study is of benefit to them. The majority of these women seem to be of an immature, dependent type, either receiving inadequate support from their husbands and social group, or unable to utilize the available support even though needing it. This study also seems to indicate the importance and potency of interpersonal contacts between investigator and subject, in research studies as well as during treatment of all kinds. The investigator may find it difficult, if not impossible, to avoid interpersonal involvement, thus altering the processes under investigation and consequently the results obtained. In our own study, we see indications that stresses of all kinds but especially of communication (Lifficulties between patient and psychiatrist coincided with an alteration nf the level of the chorionic gonadotrophins. Summary 1. A long-term study of a successful pregnancy in a patient with a history of seven consecutive abortions and no living children is discussed. Obstetrical, biochemical, hormonal, psychiatric, and psychological data are given, and a possible correlation between psychological and hormonal findings pointed out. 2. The role of psychotherapy in the treatment of spontaneous abortion is emphasized. :3. The research implications of the interpersonal relationship between investigator and patient are considered. For tho steroids used in setting up tho analytical methods we are indebt en to tho following: Dr . .E. Lozinski and Dr. A. D. Odell of Charles E. Frosst an
References 1. Bates, R. W., and Cohen, H.:
2. 3. 4. 5.
Federation Proc. 6: 236, 1947. Berle, B. B., and Javert, C. T.: Obst. & Gynec. 3: 298, 1954.. Bevis, C. A.: Lancet 2: 207, 1951. Budinsky, J., and Kouba, K.: Ceskoslov. gynaek. 18: 55, 1953. Browne, J. S. L., Henry, J. S., and Venning, E. H.: AM. J.
0BST.
&
GYNEC.
38: 927,
193lJ.
6. Callow, N. H., Callow, R. K., and Emmens, C. vV.: Biochem. J. 32: 1312, 1938. 7. Deutsch, H.: An Introduction to the Discussion of the Psychological Problems of Pregnancy, in Problems of Early Infancy, New York, 1948, Josiah Macy, Jr., Foundation. 8. Rain, A. M.: J·. Endocrinol. 3: 10, 1942. 9. Heller, C. G., and Heller, E. J.: Endocrinology 24: 319, 1939. 10. Javert, C. T.: Obst. & Gynec. 3: 420, 1954. 11. Jones, G. E. S., and Delfs, E.: J. A.M. A. 146: 1212, 1951. 12. Levin, L., and Tyndale, H. H.: Endocrinology 21: 619, 1937. 13. Mlalpas, P.: J. Obst. & Gynaec. Brit. Emp. 45: 932, 1938. 14. Mandy, T. E., Scher, E., Farkas, R., and Mandy, A. J.: South. M. J. 44: 1054, 1951. 15. Sala,' S. L., and Salerno, E.: Bol. Soc. obst. y ginec. de Buenos Aires, 24: 243, 1945. 16. Sommerville, I. F., Gough, N., and Marrian, G. F.: .J. Endocrinol. 5: 247, 194k. 17. Squier, R., and Dunbar, F.: Psychosom. Med. 8: 161, 1946. 18. Venning, E. H., Evelyn, K. A., Harkness, E. Y., and Browne, .T. S. L.: .T. Biol. Chem. 120: 225, 1937.
WEIL,
M.D.,
AND LuciLLE
C.
STEWART, M.Sc., HALIFAX, NovA ScoTIA
(From the Department of Obstetrics and ·Gynecology, Dalhousie University)
i I':t~!~ t~:Pi~p:~t:::r:~t~d:~:;_~:~:b~~~:!l:~~~~~~r~:~~i~~~;;::; ~~:~~~:;:~ 8
tion to the understanding of a pathological process; the possibility of a relationship between emotional and hormonal changes; and the value of psychotherapy in the treatment of habitual abortion. In pathological pregnancies, deviations from the normal homeostatic pattern in the maternal organism have been demonstrated. Browne, 5 Hain, 8 Jones and Delfs, 11 and others have reported low levels of estrogen, pregnanediol, and chorionic gonadotrophin in the urine of women who threaten to abort, or who have poor obstetrical histories. Abortion may also occur in the presence of apparently normal hormone levels. It has been suggested that pre-existing emotional conflicts, or emotional disturbances occurring during the period of pregnancy may be contributing factors to spontaneous abortion. 4 • 7 • 14• 15 • 17 Psychotherapy has been known to be successful in interrupting a series of spontaneous abortions. Emotional support appears to be one factor contributing to the successful treatment of habitual abortion, as mentioned by Berle and Javert, 2 Javert, 10 and Bevis. 3 The work of these authors seems to indicate that emotional factors may play an important role in spontaneous premature interruption of pregnancy. Since no correlative studies between hormone levels and psychological changes during pregnancy are available in the literature, this aspect became a focus of interest in our long-term observations of our patients. The psychiatrist sees these patients in weekly interviews of one hour. The patient collects urine for 48 hours prior to the interview. This collection is analyzed for chorionic gonadotrophin, 9 • 12 pregnanediol/ 6 estrogen/· 18 17-ketosteroids,S and creatinine. A number of patients have been studied in this manner; the following seemed most interesting of these cases. Case History First Admission.-L. B. was first admitted Sept. 2, 1953, in the sixth week of pregnancy. No difficulty had been experienced during the present pregnancy; the patient came for investigation because previous pregnancies had ended in abortion. Between 1949 and 1953 this patient had had seven consecutive abortions before the third month of pregnancy, and therefore seemingly had a very small chance of carrying the present pregnancy to term.1a Throughout all her previous pregnancies this patient was under competent observation and care. *This report is part of the work of a multidisciplinary study, "Abortion Research Project" supported by a Federal Health Grant, under the directorship of Dr. W. R. c. Tupper.
322
Volume 73 Number 2
PROBLEM OF SPONTANEOUS ABOR'riON. TIL
323
After reviewing the history of her past pregnancies and on the basis of present find· ings tho obstetrician stated that there were no gynecological or obstetrical reasons why these miscarriages should have occurred. The physical examination was negative. The biochemical findings were as follows: cholesterol, 178 mg. per cent; vitamin E, 1.\H mg. per cent; vitamin C, 1.1 mg. per cent; all of which are within the normal limits. The hormone levels were founll to be: estrogens, 0.11 mg. per 24 hours; pregna.nediol, 2.5 mg. per 24 hours; chorionic gonadotrophins, greater than 163,000 M.U. per 24 hours; 17· ketosteroids, 5.0 mg. per 24 hours. '!'he pregnanediol and estrogen values were low and the others normal for her period of pregnancy, as judged by our own data and the normal ]pvels reported in the literature.* 'L'he vaginal smear showed predominantly cornified cells with ragged edges, inter· preted by the obstetrician as indicating a lowered estrogen level. '!'he psychiatric history condensed from a lengthy history follows. This was a 31· year·old, attractive, Protestant, married woman of average height and build. She was uorn in a small town where she lived until she went to college. She said that she had a happy childhood. She had no neurotic traits other than fingernail biting. She went to a large city where she continued her college education. She joined the Civil Service and remained in it until a year after her marriage at the age of 25 to a meteorologist. Since her marriage she has traveled about considerably due to frequent transfers of her husband. Her father is a professional man of 58. He is described by the patient as a quiet, unolemonstrative, ann kind man, who wanted to see his children become independent as soon as possible. Here I quote from one of the interviews, "Even to catch a cold was a disgrace because it meant that we were not careful enough. This fight for independenct• made a woman of me." Her father always had a fear of tuberculosis and had several bouts of colitis. Her mother was described as a home-loving, quiet person, who was very interested in her family. There was no marital friction between the parents, but the patient's mother maintained the peace by catering to her husband's hypochondriacal tendencies. The patient had two sisters, aged 29 and 26. Both were married. The oldest did not become pregnant until the sixth year of marriage. During her only pregnancy, she had no difficulties, and gave birth to a normal child in uncomplieated labor. The second sister only recently married and has never been pregnant. The patient was never seriously ill but she suffered from mild dysmenorrhea. especially during her college years when she also had occasional bouts of diarrhea and her stomach woulol "go into knots." She had her menarche at age 12, having been adequately prepared by her mother. She reported no sexual difficulties in her marriage. The husband was the same age as the patient. He was kind, thoughtful, well liked, and made friends easily. She knew him at least a year before marriage. During the pe· rioll of study he was serving abroad. She said about herself, "I have a temper and would like to fight at times but my husband doesn't. I was quite good at my job but I would rather keep house than work. [ have a small circle of friends and I like parties and people around me.'' On the basis of these investigations the patient appeared to be a physically and emo· tionally healthy woman. On first contact with the psychiatrist, the patient was pleasant, cooperative, and showed a good understanding of the nature of the project. Alithough pessimistic about the outcome of her pregnancy, she was eager to participate in the study and willing to see the psychiatrist weekly and to colleet the urine specimens. The psychological tests suggested that she was a woman to whom appearances were very important. She tried to present a picture of herself as a normal, calm person living in a happy home. However, under the pressure of the teBts this picture dissolved to show • All biochemical and hormonal determinations are done in the Division of Biochemistry, Department of Public Health.
324
\VEIL AND STEWART
,\m.
J. Obst.
& Gyne<. February, Jq:-;
a tense, depressed woman living in a rather disturbed home and aware of her own precarious hold on security. Anxiety was aroused by many things in a world that she found rather unpleasant. However, she judged that her general social adjustment was satisfactory, that she had good friends, and was able to handle people well. In spite of the patient's need to present a pleasant picture to "outsiders" she herself admitted that she was a person with inadequate emotional control, and one who was characteristically sensitive and tense. It can be said, therefore, that although this patient tried to impress others, she was reasonably honest in her dealings with herself.* Arrangements for continued contact with the patient were discussed by the team, and approved by the patient, but before they could be acted upon, the patient had to be admitted to the hospital with signs and symptoms of threatening abortion.
Second Admission.-The patient was admitted to the hospital during the tenth week of pregnancy on Sept. 17, 1953, with pain and vaginal bleeding. Gynecological and physical examination showed no cause for the present signs and symptoms of abortion. The hormone data were as follows: pregnanediol, 3.5 mg. per 24 hours; estrogen, 0.09 mg. per 24 hours; chorionic gonadotrophin, 48,COO M.U. per 24 hours; 17-ketosteroids, 8.0 mg. per 24 hours. Again the pregnanediol and estrogen values were below the normal range, the 17-ketosteroii!s were normal, and the chorionic gonadotrophins had fallen belo~.r the normal limit. This had occurred at the en
•Thanks are due Mrs. Joan Morris for administering and interpreting the psychological
Volume 73 ~umber
2
PROBLEM OF SPONTANEOUS ABORTION. III.
325
By the eighteenth week the excretion of pregnanediol had increased to the normal minimum. The chorionic gonadotrophins were still falling. Nov. 21, 1953 (nineteenth week of pregnancy): The interview of the nineteenth week revealed the consequences of communication difficulties between patient and psychiatrist. These difficulties gave rise to feelings of insecurity in the patient. Nov. 28, 1953 (twentieth week of pregnancy): Upon realizing these communication difiiculties the psychiatrist discussed them with the patient. Both the patient and the psychiat.rist felt that this hour clarified the nature of their interpersonal relationship. By this date the chorionic gonadotrophins had fallen to the lowest value since the beginning of this study-20,000 M.U. per 24 hours, at the very lower limit of normalcy. Dec. 3, 195$ (twenty-first week of pregnancy): At this time the patient revealed that she had a diary covering a long period, and the next few interviews were spent in discussing the events and experiences surrounding the previous abortions. Dec. 10, 1953 (tu·enty-second week of pregnancy): A certain repetitive pattern in bnhavior during the abortion period could be detected from her own descriptions in the diaries. On each occasion when the patient found herself pregnant, she feared that she might inconvenience her husband. Her need to remain independent was enhanced by pregnancy. ·when the process of abortion commenced, the patient denied it by trying to ignore it. Even when the symptoms were severe, she rejected help. The patient became restless, reaching a maximum of activity immediately after the completion of the abortion. During the period in which this material was discussed, she was depressed and overactive, mirroring her behavior and attitude at the time of her previous abortions. Following the interview of the twenty-sixth week, the psychiatrist finally realized the significance of this change in the patient's behavior. Therefore, between the interviews of the twenty-sixth and twenty-seventh weeks, the psychiatrist discussed this behavior pattern with her. From an enilocrinological point of view, this period from the twenty-second to the twenty-sixth week was characterized by a continuous, rapirl fall in the chorionic gonadotrophins from 1G3,000 M.U. to 8,000 M.U., just below the normal limit, but probably not significantly so. The fall from the previous level was, however, dramatic. Following the interview of December 10, the patient became more relaxed, until the Christmas holiday, during and following which she again became restless and upset. 'l'bis was a~crihed to mild external stresses. Jan. 28, 1954 (twenty-ninth week of pregnancy): her inner restlessness with the patient.
'fhc psychiatrist again discussed
Feb. 2, 1954 (thirtieth week of pregnancy): The following week the psychiatrist was absent and the patient was without support during another stressful period. The chorionic gonadotrophins fell to 2,000 M.U., the lmwst value noted throughout the entire study, and definitely below normal. 1/'eb. 11, 1954 (thirty· fir/it week of pregnlt/ricy); The patient \Vas seven months pregnant and felt well. She was not as anxious and restless as during the two preceding interviews. She took her time and organized her affairs more efficiently. The chorionic gonadotrophins had risen to 40,000 M.U., a normal level.
Feb. 19 to Mar. 5, 1954: At this stage of pregnancy she was sufficiently reassured by her well-being so that she was able to make realistic arrangements for the arrival of the baby. This positive attitude to her pregnancy, and to the psychiatrist, prevailed until the patient gave birth to a normal full-term baby in natural childbirth and without complication. Psychiatl'i
326
WElL AND STEW ART
Am.]. Obst. & Gyne ... February, 19 ~ 7
which seemed to have disappeared since her marriage. She was sensitive to failure and to the reaction of others to her, and was loath to inconvenience others. Pregnancy seemed to represent a stress to her, to which she responded by becoming more independent, thus counteracting her biological and emotional needs. Relevant to this psychia:tric summary is the result of the :foliowing final psychological testing done just prior to the confinement: "The picture was somewhat changed from that presented at the first testing. The patient was less tense and less productive on the Rorschach tests. Although she was not doing as much as she was capable of, what she did was more org,anized and logical. There was less variance of mood and less anxiety around her emotional responsiveness. The feeling of unpleasantness and tension formerly attached to her need for affection from others had lessened. She was now better able to accept this need. Although she was able to express her emotions more freely, there was still the necessity for gaining prestige and presenting a good front. "Her relationship with her husband, judging from the psychological test material, seemed to have undergone some changes. Her feeling of responsibility toward him had increased, and there were more common interests, although it was still the husband who gave in to the wife when there was variance. She was able to admit that unpleasantness existed and she could verbalize a resentment toward her husband, and toward her mother. She saw children as a bother and inconvenience." It appears that psychotherapy permitted the continuance of the pregnancy, possibly because it produced positive persouality changes. It will be noted that by the eighteenth week (November 12) with no treatment other than psychotherapy, the level of excretion of pregnanediol and the estrogens had climbed to normal values. In charting the results of the hormone assays, we were impressed by the fluctuations encountered from week to week in the level of the chorionic gonadotrophins, which are gre!liter than would be expected on the basis of control assays, and the rises and falls do not coincide with those of a "normal" pregnancy. It will be noted that at the ninth (September 17), twentieth (November 28), twentysixth (January 5), and thirtieth (February 2) weeks, the chorionic gonadotrophins reached low levels, falling markedly from the preceding levels. At these times the patient seemed to be under stress, some of which m'ay havo been induced by the tensions within the interpersonal relationship of the psychiatrist and the patient. The pregnanediol excretion levels showed similar but not as marked fluctuations. The estrogens showed a steady slow increment, but remained at or slightly below the normal minimum throughout pregnancy. Since the study of this patient several others have been followed in equal detail, and confirm some of the observations in this case.
Comment Although we are well aware that any general conclusions drawn from the study of only one patient may be misleading or even invalid, we feel that the presented case is of sufficient interest to warrant a report. The patient discussed in detail serves as an internal control, since her history of seven consecutive abortions indicates that unassisted she seemed to have a very small chance of carrying a pregnancy to a successful conclusion. Therefore it seems reasonable to assume that psychotherapeutic contact may have contributed to the successful conclusion of her pregnancy. Any treatment, if it is a prolonged one, is of necessity associated with attention and support from the physician which may gratify a specific need of the patient. This is a factor common to many of the courses of therapy prescribed in threatened abortion, and may well be a factor in the measure of success which they achieve. The specific therapy offered the patient discussed
\\~lume
73
PROBLEM OF SPONTANEOUS ABORTION. lii.
l\'umher 2
in this paper may be analogous to the more general aid offered by the physician in connection with other treatment. We have the impression from the larger group studied that the attention the women receive while undergoing study is of benefit to them. The majority of these women seem to be of an immature, dependent type, either receiving inadequate support from their husbands and social group, or unable to utilize the available support even though needing it. This study also seems to indicate the importance and potency of interpersonal contacts between investigator and subject, in research studies as well as during treatment of all kinds. The investigator may find it difficult, if not impossible, to avoid interpersonal involvement, thus altering the processes under investigation and consequently the results obtained. In our own study, we see indications that stresses of all kinds but especially of communication (Lifficulties between patient and psychiatrist coincided with an alteration nf the level of the chorionic gonadotrophins. Summary 1. A long-term study of a successful pregnancy in a patient with a history of seven consecutive abortions and no living children is discussed. Obstetrical, biochemical, hormonal, psychiatric, and psychological data are given, and a possible correlation between psychological and hormonal findings pointed out. 2. The role of psychotherapy in the treatment of spontaneous abortion is emphasized. :3. The research implications of the interpersonal relationship between investigator and patient are considered. For tho steroids used in setting up tho analytical methods we are indebt en to tho following: Dr . .E. Lozinski and Dr. A. D. Odell of Charles E. Frosst an
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