Pregnancy after loss — structured SAQ (15 marks)

(a) Pregnancy after loss as a distinct entity (3 marks)

One mark for the obstetric risks; one for the psychological risks; one for the framing stance. ^[1][3]

• Obstetric risks: miscarriage — especially recurrent miscarriage — is a sentinel marker for later obstetric risk including preterm birth, fetal growth restriction, abruption and stillbirth. This is therefore a higher-risk pregnancy, not a routine one.^[1]
• Psychological risks: pregnancy-specific anxiety, anniversary reactions at the gestation of the previous loss, emotional cushioning (withholding attachment as self-protection), and a measurable rate of PTSD that does not resolve just because she is pregnant again.^[3]
• The framing stance: this is a distinct clinical entity needing continuity of carer, additional surveillance, mental health screening, and a plan for the anniversary gestation — not a routine pregnancy with a footnote in the history.^[1][3]

(b) Operational components of pregnancy-after-loss care (5 marks)

One mark per correctly specified component. ^[1][3]

• Continuity of carer — a named clinician and a named midwife from booking to postnatal.
• An early reassurance scan at the first contact, then additional scans at agreed milestones — including the gestation of the previous losses.
• A mental health screen at every contact using a validated tool, with a clear pathway to perinatal mental health for those who screen positive.
• Fetal movement advice individualised to the woman, with an explicit plan for what to do if she is worried.
• A documented plan for the anniversary gestation — what she will be offered, when, and by whom — and a planned, structured discharge at the end rather than a drift out of care.^[1][3]

(c) Mental health screening (3 marks)

One mark for naming both tools; one for the comparative performance; one for what to do with the result. ^[3][4]

• I would screen with the Edinburgh Postnatal Depression Scale (EPDS) for depression and the Perinatal Anxiety Screening Scale (PASS) for anxiety, at booking and at every contact through the pregnancy.
• The rationale for using both: at its optimal cut-off the PASS identified 68% of women with a diagnosed anxiety disorder, compared with 36% detected by the EPDS anxiety subscale (Somerville 2014). Using the EPDS alone misses anxiety.^[4]
• I would also screen explicitly for post-traumatic stress symptoms tied to the previous loss, and ask directly about self-harm and suicidal ideation at every contact, documenting the answer and acting the same day where indicated.^[3]

(d) Interpregnancy interval (2 marks)

One mark for the position; one for the numbers. ^[5]

• There is no evidence-based reason to make her wait six months before conceiving after a miscarriage. The older advice is obsolete.
• The Kangatharan meta-analysis of over one million women found that conceiving within six months of a miscarriage was not associated with adverse outcomes, and was associated with lower risks of further miscarriage (RR 0.82, 95% CI 0.78 to 0.86) and preterm delivery (RR 0.79, 95% CI 0.75 to 0.83).^[5]

(e) Progesterone evidence (2 marks)

One mark for the trial result; one for the honest framing. ^[6]

• PROMISE (836 women with unexplained recurrent miscarriage, NEJM 2015) found no significant difference in live birth between progesterone (65.8%) and placebo (63.3%) — relative rate 1.04 (95% CI 0.94 to 1.15).
• I would frame progesterone honestly: it did not significantly increase live birth in unexplained recurrent miscarriage, and I would not offer it as a certainty. If she still wishes to take it, I would discuss the evidence and document the shared decision.^[6]