*2.1.5 Shock*

 Shock could be hypovolemic or cardiogenic from massive hemorrhage or even septic from Gram negative sepsis with its very high mortality rate.

### *2.1.6 Organ injury*

Though more common with induced abortion, uterine perforation can also occur following curettage or manual vacuum aspiration in the management of incomplete miscarriage. In acute state this can cause acute abdomen and may require hospitalization and even laparotomy. This affects maternal health in the short run and even in the long run depending on the nature and severity of the injury.

Bladder and injury to the intestinal injuries have also been reported. A couple times in the Accident and Emergency department of the University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria, patients have presented with large intestine protruding from the introitus through the uterus following manual vacuum aspiration for incomplete miscarriage done by unskilled health care provider.

More often, these will require laparotomy, repair of uterine perforation, bowel resection and anastomosis.

Bladder injury may even be more devastating when genito-urinary fistula manifest with continuous leakage of urine, with its accompanying morbidities- vulva excoriations/ itching, disgusting and nauseating offensive ammoniacal smell, social stigma, subfertility and sometimes marital disharmony and divorce. The emotional and psychological trauma is unparalleled.

## **2.2 Late morbidities**

Some morbidities may not manifest immediately or early but become apparent months or even years following miscarriage or treatment of miscarriage.

### *2.2.1 PID/frozen pelvis*

 Pelvic inflammatory disease may complicate poorly treated incomplete miscarriage. This may subsequently lead to chronic PID especially in resource poor settings where people resort to self-management of the condition using sometimes unorthodox methods. They may present with chronic pelvic pain, dysmenorrhea or even amenorrhea depending on the severity, dyspareunia, chronic vaginal discharge and or low back pain. In some instances they may develop tubo-ovarian mass or abscess resulting in frozen pelvis. All these no doubt will negatively impact maternal health.

### *2.2.2 Asherman's syndrome/infertility*

Oligomenorrhea, amenorrhea and subfertility constitute Asherman's syndrome. This results from scarring occasioned by healing from endometritis or healing from overzealous curettage in management of incomplete miscarriage.

### **2.3 Psychological/emotional morbidities**

Prior miscarriage or even just perception of miscarriage can have profound and tremendous psychologic and emotional effects on mothers before or during subsequent gestations.

 Studies have shown that compared to women without prior miscarriage, women with previous history of miscarriage had greater state anxiety in the second and third trimesters. Having a living child did not buffer state anxiety in women with a prior miscarriage. Attention to patterns of distress can contribute to delivery of appropriate support resources to women experiencing pregnancy after miscarriage and may help reduce risk for stress-related outcomes.

 Just like other stressful experiences, the effects of miscarriage vary considerably across individuals [1], but for many women, miscarriage can be a tragic, and life-altering experience [2] and results in significant suffering [3, 4]. In the last 20 years, research on the emotional and psychological impact of miscarriage has grown, including studies of women who have experienced miscarriage exclusively and mixed-sample studies of various types of perinatal loss including miscarriage, stillbirth, and neonatal death, establishing an empirical foundation for understanding the livid experiences of miscarriage. Women who experience miscarriage worry about future pregnancies [4] and may perceive a subsequent pregnancy as especially precious and very desirable [5]. Pregnancy after miscarriage can be experienced as emotionally and psychologically distressing [4, 6]. According to descriptive studies of pregnancy following miscarriage, for some women the subsequent pregnancy is perceived as threatening [7] and involves tremendous vulnerability and anxiety related to uncertainty about its outcome [8].

 Researchers who included comparison groups of mothers without a prior history of miscarriage have found that women with a history of miscarriage, experience significantly higher state anxiety, pregnancy-specific anxiety, worry, depression, and less attachment to the subsequent pregnancy than women without prior miscarriage [9, 10].

 The most prevalent finding is that pregnancy-specific anxiety is higher in those with prior loss [10, 11], but more generalized distress does not differ significantly between the groups [10, 12] of perinatal loss. It has been demonstrated that pregnancy anxiety decreased significantly over the course of pregnancy [7]. focus group discussion with parturients attending antenatal care in Port Harcourt, Nigeria, revealed similar findings. The psychosomatic stress experienced by women who have had a prior miscarriage is better imagined then experienced. The feeling of being responsible for the loss coupled with the premium placed on childbirth leads to profound anxiety, sadness and depression. Understanding and empathy from healthcare providers and family members aided the recovery process.

### **3. Conclusion**

Miscarriage or even just perception of miscarriage can have profound and tremendous psychologic and emotional effects on mothers before or during subsequent gestations. The associated early and long term complications are devastating for women. Every effort must be made to show understanding and empathy.

*Miscarriage and Maternal Health DOI: http://dx.doi.org/10.5772/intechopen.82117* 
