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Perinatal loss is common and can be devastating. Although the impact of perinatal loss is beginning to be recognised, many individuals still feel the subject to be taboo. The first paper presents a review of the literature focusing on the impact of miscarriage and stillbirth in the subsequent pregnancy, and on attachment in the subsequent pregnancy. There is some evidence to suggest that psychological distress following perinatal loss extends into, and can be reactivated in subsequent pregnancy. Research which has focused upon attachment in subsequent pregnancy following perinatal loss has not been conclusive. The second paper explores eleven women's thoughts and feelings about subsequent pregnancy, six to ten months following stillbirth. Modified grounded theory was used to guide the research methodology and analyse the data. A model was developed to illustrate participant's experiences of decision making in relation to subsequent pregnancy, and of subsequent pregnancy itself. The process of healing underpinned the model. Women in these circumstances may find it beneficial to discuss their beliefs about healing, and how these contribute to their thoughts and feelings about subsequent pregnancy, as well as their experiences of subsequent pregnancy.

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Recurrent miscarriage, is defined as three or more consecutive pregnancy losses before 20 weeks of gestation. It affects 0.5-2% of pregnant women. A great variety of aetiologic factors has been identified, but a specific cause is still unknown in 50% of cases. It has been suggested that immune causes, including abnormalities in either cytokine production or immune cell populations may be the reason for some of these cases. It is also known that some women with recurrent miscarriage have an endometrial defect, which may lead to abnormal development of the feto-placental unit and subsequent miscarriage. Cytokines are known to be important in the control of embryo implantation and therefore it is possible that abnormalities in endometrial cytokine expression could provide an explanation for unexplained recurrent miscarriages. This study has therefore focused on the possible role of some pro-inflammatory cytokines and leptin in recurrent miscarriage. In the first part of the study, polymerase chain reaction (PCR) was used to establish the frequency of alleles of IL1RN, IL1beta and leptin receptor genes in the DNA extracted from peripheral blood from women who suffer recurrent miscarriage and compared to that seen in controls. The results for both IL1RN tandem repeat polymorphism and IL1beta-511 polymorphism showed that there was no significant difference between the genotype distribution or allele frequency in recurrent miscarriage women and the control population. For IL1beta-511 this was true whether the analysis was carried out on data obtained from the recurrent miscarriage group as a whole or when the women were divided according to the cause of the miscarriage. In the case of IL1RN polymorphism, an increased frequency of 2,2 genotype was seen in recurrent miscarriage women with PCOS, but the numbers in this group were very small. The GLN223ARG leptin receptor polymorphism investigated in this study results in the substitution of amino acids glutamine to arginine in the transmembrane section of the receptor. The results showed no significant difference between the distribution of GLN223ARG leptin receptor genotypes in the recurrent miscarriage women as a whole group compared to the control group.when divided according to the cause of recurrent miscarriage there was a significant increase in the AA genotype in women with secondary recurrent miscarriage and those whose aetiology is unknown. In the second part of the study, expression of IL-11 and IL-11Ralpha in endometrium of recurrent miscarriage and control women were compared using RT-PCR and immunocytochemistry. The results showed that IL-11 and IL-11 Ralpha mRNA and protein were expressed in the endometrium throughout the menstrual cycle by both stromal and epithelial cells. IL-11 and IL-11 Ralpha protein expression was greater in epithelial cells than stromal cells. IL-11 and IL-11Ralpha mRNA and protein were significantly higher in the late secretory phase compared to the proliferative phase of the menstrual cycle. The high levels of IL-11 and IL-11Ralpha mRNA and protein in the late secretory phase suggest that IL-11 may play a role in the functional differentiation that occurs during decidualization of human endometrial stromal cells. IL-11 and IL-11Ralpha were also expressed in the endometrium of women with recurrent miscarriage. There was no significant difference in amounts of IL-11 Ralpha mRNA and protein in the endometrium obtained from normal fertile women or recurrent miscarriage women during the peri-implantation period. However, IL-11 protein expression was decreased in endometrial epithelial cells in the recurrent miscarriage women compared to that seen in normal fertile women. Taken together these results, show decrease endometrial IL-11 production by women with recurrent miscarriage. They also suggest that leptin may be important in preventing miscarriage in some groups of recurrent miscarriage. However, further studies on large groups of recurrent miscarriage women need to be carried out in order to define the importance of this polymorphism. Although, the IL-1RN tandem repeat and IL-1beta-511 polymorphisms appear not to be associated with recurrent miscarriage, this does not mean that the IL-1 system is not involved in causing recurrent miscarriage, as plasma levels of IL-1 did not appear to be different in women with different genotypes.

La recherche explore les traces et remaniements du deuil prénatal au cours d'une grossesse suivant une Interruption Médicale de Grossesse (IMG) pour raison fœtale. Le statut du fœtus/bébé y est triplement complexe: entre humain et non humain sur le plan légal ; objet perceptible mais non directement visible dans la réalité matérielle ; à la fois prolongement narcissique et objet interne - partiel et potentiellement total dans la réalité psychique. Cet extrême paradoxe constitue un défi majeur du travail psychique du deuil prénatal. Selon le contexte culturel et les choix singuliers, maternels et paternels, face à ces possibles, les pratiques autours de sa mort seront différentes et aboutiront à des processus de deuil contrastés. Dans le cas particulier d'une IMG, l'expérience clinique nous invite à envisager deux aspects fondamentaux. D'un côté, la décision prise par la mère avec le choix qui s'impose à elle d'interrompre ou non la grossesse - et par là la vie du fœtus/bébé - interroge d'emblée ses éventuelles traces actualisées de culpabilité. De l'autre, être enceinte d'un fœtus porteur d'une pathologie grave représente pour la femme une blessure narcissique renvoyant au concept de honte. Dans leur articulation avec les processus narcissiques et objectaux, la honte et la culpabilité sont des prismes pertinents pour étudier les spécificités d'une grossesse suivant une IMG au cours de laquelle les liens entre objets internes, objets externes, sujet et groupe sont mis en exergue. Dans ce contexte, trois questions constituent la problématique de cette étude: le mode d'investissement du fœtus/bébé décédé est-il réactualisé par l'investissement du fœtus/bébé de la grossesse actuelle ? La grossesse active-t-elle de manière particulières des traces de honte et de culpabilité que nous nommons pour les singulariser vivances ? De quelle façon ces vivances s'articulent-elles avec les mouvements psychiques de la femme dans les processus de deuil ? Méthodologie: Cette recherche qualitative se réfère à une méthodologie hypothético-déductive et s'inscrit dans un référentiel psychanalytique. La population est constituée de 11 femmes (primipares et multipares) enceintes après avoir vécu une IMG pour raison fœtale après 15 Semaines d'Aménorrhée (SA). Des entretiens semi-structurés ont été menés auprès de ces femmes aux trois trimestres de la grossesse. Elles ont également rempli des auto-questionnaires à chaque temps de la recherche (PAI, PGS, EPDS, STAI, DAS, PCLS). L'analyse des entretiens, audio-enregistrés, croise une observation approfondie de chaque cas avec une analyse de contenu thématique, prenant en compte le vécu subjectif de chaque femme, afin de répondre aux hypothèses de recherche. Résultats : Les résultats mettent en avant une réactualisation du processus de deuil au cours de la grossesse suivante. Ils vont dans le sens de la confirmation de la portée heuristique et clinique de l'étude de la honte et de la culpabilité lors d'une grossesse suivant une IMG. La honte se manifeste chez ces femmes par des vécus de dévoilement et d'exclusion, un sentiment de perte de contrôle, voire d'emprise, et un vécu d'échec et d'indignité. L'élaboration des vivances de honte est un bon marqueur de la possible résolution des dimensions narcissiques et développementales du processus de deuil. La culpabilité est très présente, en lien avec la pathologie fœtale, la décision d'interrompre la grossesse et vis-à-vis du bébé de la grossesse actuelle. Dans ce contexte, la honte et la culpabilité sont à comprendre comme les deux pôles d'un gradient continu. Sur le terrain périnatal, l'articulation sémiologique et psychopathologique de la dialectisation entre honte et culpabilité lors d'une grossesse suivant une IMG, permet de donner des repères cliniquement organisateurs dans le cadre d'une prévention transdisciplinaire médico-psycho-sociale des troubles de la parentalité et des dysharmonies relationnelles précoces. / The aim of this research is to explore the traces and updates of prenatal grief during a pregnancy subsequent to a Medical Termination of Pregnancy (MTP). The status of the fetus is triply complex: between human and non-human on a legal dimension ; perceptible object but that cannot directly be seen in the plan of material reality; both narcissistic extension and internal object - partial and potentially total - in psychic reality. This extreme paradox is the major challenge of the psychic work during prenatal bereavement. Depending on the cultural background and singular maternal and paternal choices among those possibilities, the practices surrounding the death of the baby will be different and lead to contrasting grieving processes. In the particular case of MTP, the clinical experience leads us to consider two fundamental aspects. On one hand, the decision taken by the mother with the choice that she has to make to interrupt the pregnancy or not - and thereby the fetus/baby's life - questions on possibles feelings of guilt. From the other hand, being pregnant with a fetus with a severe pathology represents a narcissistic injury referring to the concept of shame. Shame and guilt, because of their relationship with narcissistic and object-relation processes seem to be quite relevant to study the specificities of a pregnancy following a MTP. In this context, three main questions constitutes the problematic of this study : Is the investment of the dead fetus/baby updated by the investment of the current fetus/baby ? Is the pregnancy activating in a particular way feelings of shame and guilt ? What is the articulation of these feelings with the grieving process ? Methodology: This qualitative research refers to a hypothetical-deductive method and lays on a psychoanalytic background. Our population is composed with 11 women (primiparous and multiparous) pregnant after a MTP for fetal reasons occurred after 15 weeks of amenorrhea (WA). Semi-structured interviews were conducted on the three trimestre of the pregnancy. They also each time completed self-questionnaires (PAI, PGS, EPDS, STAI, DAS, PCLS). The analysis of the interviews, that were recorded, crosses a thorough observation of each case with a thematic content analysis, taking into account the subjective experience of each woman, in order to answer the research hypotheses. Results: The results highlight an updating of the grieving process during the following pregnancy. They are in line with the confirmation of the heuristic and clinical significance of the study of shame and guilt in a pregnancy following a MTP. For these women, shame is manifested by a feeling of unveiling and exclusion, loss of control, and an experience of failure and unworthiness. The elaboration of shame is a good marker for possible resolution of narcissistic and developmental dimensions of the grieving process. Guilt is very present, connected with fetal pathology, the decision to terminate the pregnancy and towards the baby of the current pregnancy. Shame and guilt can be understood as the two poles of a continuous gradient. Their study in the context of a pregnancy following a medically terminated one makes possible to offer pertinent semiological and psychopathological markers in the framework of primary and secondary prevention of troubles in parentality and in early relational dysharmonies.

Grâce à des entretiens non directifs réalisés auprès de 16 sages-femmes et 16 obstétricien(ne)s, cette recherche tente de cerner l’impact que la mort périnatale a sur eux et sur leur travail, au-delà de celui qu’elle a sur les parents avec le deuil périnatal. Face à des progrès médicaux sans précédent, la société, les parents et les soignants eux-mêmes s’attendent peu à la survenue de la mort dans la naissance. Interruption médicale de grossesse ou mort périnatale inattendue confrontent cependant ces soignants à des épreuves au travail susceptibles d’avoir sur eux des répercussions majeures selon le contexte et l’âge de la grossesse. Elles donnent lieu à des déficits de la reconnaissance, qu’elle soit sociale, professionnelle ou personnelle. Leur restauration nécessite le recours actif à l’intersubjectivité engagée auprès des pairs comme auprès des parents afin que les soignants puissent continuer leur travail et y rester. / Through 32 open-ended interviews with midwives and obstetricians, this work attempts to identify, beyond parental mourning, the impact of perinatal death on childbirth professionals and their work. Unprecedented medical advances result in a relative absence of expectation of death in birth for the society, medical professionals and for the parents. Medically motivated induced termination or unexpected perinatal death, however, confronts caregivers at work with an ordeal which can have major repercussions depending on the context and the term of the pregnancy involved. These events cause deficits in social, professional and personal recognition in these caregivers. To be restored, symbolic processing is necessary for all concerned through the implication of subjectivity at work with peers and parents in order for these caregivers to be able to continue to work.