Ž .International Journal of Gynecology & Obstetrics 65 1999 39]45

Article

Timing of suicide attempts by self-poisoning duringpregnancy and pregnancy outcomes

U ´A.E. Czeizel , L. Tımar, E. Susanszky´ ´ ´Department of Human Genetics and Teratology, National Institute of Public Health } WHO Collaborating Centre for the

Community Control of Hereditary Diseases, Budapest, Hungary

Received 3 August 1998; received in revised form 20 November 1998; accepted 1 December 1998

Abstract

Objecti e: The purpose of this study was to examine the timing and consequences of suicide attempts byself-poisoning during pregnancy. Methods: A population-based prospective study was organised in the toxicologicalin-patient hospital in Budapest which is responsible for health services for adult inhabitants poisoned by ingestingchemicals in Budapest and the surrounding area involving 3 million people between 1985 and 1993. All women aged

Ž .between 16 and 50 years 22 969 who were admitted to the study hospital due to suicide attempts by drug ingestionwere examined by a sensitive serum pregnancy test. Results: Of 559 self-poisoned pregnant women, two died. Thepeak period of suicide attempts was found to be in the first postconceptual month and its majority resulted in a veryearly fetal loss. The second highest figure was recorded in the second postconceptual month. Thus, 61% of suicideattempts occurred before the third postconceptual month. Later pregnancies had a significantly lower proportion ofattempting suicide parallel with advanced fetal development. Conclusions: Most suicide attempts by self-poisoningoccurred after the early recognition of unwanted pregnancies and most resulted in a very early fetal loss. Pregnancieswith advanced gestation months had a significantly lower proportion of attempting suicide. Q 1999 InternationalFederation of Gynecology and Obstetrics.

Keywords: Suicide; Self-poisoning; Pregnancy; Very early fetal loss

U Corresponding author. TelrFax: q36 1 3944712; e-mail: czeizel@oki.jakobi.hu

0020-7292r99r$20.00 Q 1999 International Federation of Gynecology and Obstetrics.Ž .PII: S 0 0 2 0 - 7 2 9 2 9 9 0 0 0 0 7 - 7

( )A.E. Czeizel et al. r International Journal of Gynecology & Obstetrics 65 1999 39]4540

1. Introduction

Hungary was first in the world statistics ofsuicide mortality for a long period in the 1970sand 1980s with a maximum of 4.59r10 000 people

w xin 1983 and 1984 1 . The rate of suicide attemptswas not known exactly, but self-poisonings ex-ceeded 90% of suicide attempts in the last decades

Ž .and the proportion of survivors )95% in-creased considerably due to the more effective

w xmedical treatments 2 . Those attempting suicideby self-poisoning are predominantly young and

Ž .female 65% , thus suicide by drug ingestion isnot exceptionally rare during childbearing yearsw x3]5 .

In previous studies the peak period of suicidew x w xattempts 6 and suicide deaths 7,8 during preg-

nancies was found to be in the third month whilethere was a significant decrease in suicide at-

w xtempts as the pregnancy progresses 8,9 . The aimof this study was to revisit these observationsafter the introduction of sensitive early pregnancytests in a population-based prospective study ofsuicide during pregnancy in Hungary.

2. Subjects and methods

The In-patient Clinic of Toxicological InternalMedicine, Sandor and Frigyes Koranyi Hospital is´ ´solely responsible for providing health services tothe adult inhabitants poisoned by ingestingchemicals in Budapest and the surrounding area,comprising 3 million people. Blood samples werecollected from all women admitted to this hospi-tal to determine the types of drugs used forself-poisoning. A pregnancy test based on the

Žbeta-hCG SIGMA C 7659, Sigma Immuno. w xChemical, St. Louis, USA 10 was also per-

formed on the blood sample of each woman aged16]50 years during the study period between the1 January 1985 and the 31 December 1993. Preg-nancy was diagnosed if the concentration of beta-hCG exceeded 100 mIUrml. Pregnancy was sus-pected in women with beta-hCG concentrationover 50 mIUrml and the pregnancy test wasrepeated 2 or more days later. In pregnant womenpersonal and clinical data were extracted from

medical files. Before the discharge of pregnantwomen, they were asked to give written informedconsent concerning their participation in thestudy; in addition information regarding the caseand obstetrical history, menstrual cycle detailsincluding the last menstrual period, the timing ofwomen’s own recognition of the pregnancy stud-ied in relation to the timing of their suicideattempt, reasons for self-poisoning, sexual activityand lifestyle was obtained. Finally participants ofthe study were asked to inform us about theirpregnancy outcomes. If women did not want tocontinue their pregnancies, pregnancy termina-tion was arranged on the basis of medical need.The postconceptual fetal development was calcu-lated from the first day of the third week of thelast menstrual period, i.e., from the assumed dayof conception. Thus, we did not use the traditio-nal obstetric method based on the first day of lastmenstrual period because we wanted to omit thefirst 2 weeks of gestation when women are notpregnant yet. If participants did not inform usabout their pregnancy outcome after 1 month ofexpected date of delivery, they were visited athome by a staff member since informed consentauthorized us to visit them at home if informationabout pregnancy outcome was not received ontime.

Case women were matched for age and gesta-tional week on a one-to-one basis with controlsubjects selected prospectively from the partici-

w xpants of the Hungarian periconceptional care 10within 1]2 months from the admission of thestudy women. The same pregnancy test was usedand pregnancy outcomes were also ascertained bya similar method.

Among fetal deaths, very early fetal loss, ec-Žtopic pregnancy, miscarriage including missed

.abortion or blighted ovum and stillbirth weredifferentiated. Pregnancy outcomes, except veryearly fetal loss, were medically documented. Thedefinition of very early fetal loss was a positivepregnancy test without any other later symptomsof pregnancy, but this diagnosis was accepted only

Ž .in those women who 1 had a ‘delay’ in men-Ž .strual bleeding, or missed menstrual period; 2

Žhad a good chance for pregnancy sexual life

( )A.E. Czeizel et al. r International Journal of Gynecology & Obstetrics 65 1999 39]45 41

without contraception or with misused contracep-. Ž .tion ; and 3 had no induced abortion, miscar-

riage or delivery in the previous week.The Chi-square test was used for statistical

analysis of pregnancy outcomes and adjusted oddsŽ . Ž .ratios OR with 95% confidence interval CI

were calculated for potential confounders usingthe conditional logistic regression model.

3. Results

Of 22 969 women admitted to the study hospitaldue to chemical poisoning between 1985 and 1993,645 had positive pregnancy tests. After the evalu-ation of available information, 52 women wereexcluded from the study because they had acci-

Ždental poisonings poisonous mushroom, carbon-. w xmonoxide, etc 11 . In addition, 17 and 12 women

had induced abortions or miscarriages, respec-tively, and two women delivered their newborninfants in the previous week. These 31 womenwere also excluded because their pregnancy out-comes in the week preceding the self-poisoningcould have resulted in a possible false positivity ofpregnancy test. Thus, current pregnancy was eval-uated in 559 women who had 562 self-poisonings,because three women attempted suicide twiceduring the pregnancy study. Of 559 women, twoŽ .0.36% died due to self-poisoning.

The mean age of the 559 women in the casestudy and their matched control subjects was 26.0"8.0 and 25.9"5.7, respectively, while the num-ber of births before the study pregnancy was1.84 " 1.13 and 1.15 " 0.57, respectively. Themean number who had completed school was9.0"2.3 in the case study and 13.3"2.4 in thecontrol group. The percentage distribution of their

Žemployment percentages of control subjects. Ž .shown in brackets was: professionals 5% 40% ,

Ž . Ž .managers 6% 22% , skilled workers 27% 24% ,Ž .semi- and unskilled workers 35% 5% , home-

Ž . Ž .makers 14% 5% , students 6% 3% and unem-Ž .ployed 7% -1% which also reflected the lower

socio-economic status of cases. Of the 559 women,Ž .274 49% were single, divorced or widowed, whileŽ . Ž .251 45% had husbands, the rest 34 6% had a

partner in life. Control subjects were made up of6% being single, divorced or widowed and, 89%

being married females, while 5% had a lifepart-ner. Half of the 557 surviving case study womenwere smokers while this figure was 9% in control

w xsubjects 12 . Of the 557 surviving women, 50Ž .9.0% were heavy drinkers and of the 557matched control subjects, there was only oneŽ .0.2% heavy drinker. Of the 557 women in the

Ž .case study, only 277 49.7% used contraceptionand most pregnancies were unplanned, however,accurate figures cannot be determined retrospec-tively.

Familial, mainly sexual partner’s troubles;abortion induction; economic problems and un-wanted pregnancies were mentioned as the rea-

Ž . Ž .son for self-poisoning by 339 60.9% , 43 7.7% ,Ž . Ž .40 7.2% , and 12 2.1% surviving case women,

Ž .respectively, while 123 22.1% had no explana-tion. Thus, the main reason for suicide attemptswas a response to unwanted pregnancies and re-lated tension or crisis. Of the 557 surviving case

Žstudy women, 359 recognized due to previous.pregnancy tests or medical examinations and a

Žfurther 102 supposed due to the missing men-.strual period their pregnancies. Of 98 case study

women who didn’t realise they were pregnant, 88had self-poisoning in the first postconceptualmonth and 10 had self-poisoning in the secondpostconceptual month.

The time of self-poisonings during pregnancyŽ .Table 1 shows an obvious inverse correlationwith the postconceptual months of fetal develop-

Ž .ment: the maximum 37.9% occurred in the firstŽ .postconceptual month, the minimum 0.4% in

Žthe tenth month however, if we reduce continu-ously the number of women with early pregnancyoutcomes from the denominator, percentage fig-

.ures are higher . Of 213 self-poisonings in thefirst postconceptual month, 101 occurred in thethird and 102 in the fourth postconceptual week.There was a higher proportion of abortion induc-tion in this subgroup. The timing of 10 self-poi-sonings occurred in the second postconceptualweek, however, repeated pregnancy tests con-firmed these pregnancies.

Of 559 case study women with self-poisoning,pregnancy outcomes were not known in two lethalcases and in a further 44 cases, 26 were not

Žwilling to collaborate they did not give an in-

( )A.E. Czeizel et al. r International Journal of Gynecology & Obstetrics 65 1999 39]4542

Table 1The timing of self-poisoning in the function of fetal development and pregnancy outcomes

Postconceptual Self-poisoning Pregnancy outcomesŽ .months weeks of No. % Very early Induced Miscarriage Livebirth Unknown

fetal development fetal loss abortion

No. % No. % No. % No. % No. %

bŽ .I. 1]4 213 37.9 111 97.4 73 36.0 3 16.7 12 6.7 14 30.4bŽ .II. 5]8 128 22.8 3 2.6 94 46.3 6 33.3 15 8.4 10 21.7

Ž .III. 9]12 71 12.6 0 0.0 30 14.8 5 27.8 28 15.7 8 17.4Ž .IV. 13]15 40 7.1 0 0.0 5 2.5 4 22.2 26 14.6 5 10.9Ž .V. 17]20 30 5.3 0 0.0 1 0.5 0 0.0 27 15.2 2 4.4Ž .VI. 21]24 28 5.0 0 0.0 0 0.0 0 0.0 25 14.1 3 6.5

a aŽ .VII. 25]28 23 4.1 0 0.0 0 0.0 0 0.0 21 11.8 1 2.2a aŽ .VIII. 29]32 22 3.9 0 0.0 0 0.0 0 0.0 18 10.1 3 6.5a aŽ .IX. 33]36 5 0.9 0 0.0 0 0.0 0 0.0 4 2.2 0 0.0

Ž .X. 37] 2 0.4 0 0.0 0 0.0 0 0.0 2 1.1 0 0.0

Total 562 100.0 114 100.0 203 100.0 18 100.0 178 100.0 46 100.0

a One case repeated self-poisoning in the given month, thus these are not included into the evaluation of pregnancy outcomes.bOne woman died due to self-poisoning.

.formed consent and we were not able to visitanother 18 women due to their submission offalse addresses. The pregnancy outcomes of 513case women and their matched control subjectsare shown in Table 2. A significantly higher rateof induced abortion was found in the case study

Ž .group: 203 39.6% pregnancies were terminatedbecause they were neither planned nor wanted, inadditon the possible teratogenic risk of drugsused for self-poisoning supported this decision ofsome women. However, the major reason of theirpregnancy termination was the social-familial

factor. The Hungarian ratio of the mean num-ber of livebirths and induced abortions was124 838]85 560 during the study period and this

Ž .high proportion of induced abortion 40.6% wasŽ .lower than the similar rate 53.3% in the case

study group. Among induced abortions there wasno selective abortion due to severe fetal abnor-malities in the case group. All control subjectsplanned and wanted their pregnancies, one selec-tive abortion was due to a chromosomal aberra-

Ž .tion of the fetus. More than one-fifth 22% ofcase study women had very early fetal loss, while

Table 2Pregnancy outcomes of the case and control groups

Ž .Pregnancy outcomes Case group Control group OR 95% CI

No. % No. %

a Ž .Induced abortion 203 39.6 1 0.2 333.28 66.86, 1681.30Fetal death

Ž .Very early fetal loss 114 22.2 23 4.5 6.09 3.82, 9.71Ectopic pregnancy 0 0.0 0 0.0 ] ]

Ž .Miscarriage 18 3.5 42 8.2 0.41 0.23, 0.72Stillbirth 0 0.0 0 0.0 ] ]

Ž .Livebirth 178 34.7 447 87.1 0.08 0.06, 0.11

Total 513 100.0 513 100.0 1.00 ]

a Selective abortion due to chromosomal aberration.

( )A.E. Czeizel et al. r International Journal of Gynecology & Obstetrics 65 1999 39]45 43

this proportion was 4.5% in the control group.This figure is not recorded in the national statis-tics. In addition, of 199 women in the case studygroup with known pregnancy outcomes after self-poisoning in the first postconceptual month, 111Ž .55.8% had very early fetal loss. A further threevery early fetal losses occurred among 118 casewomen with known pregnancy outcomes who hadself-poisoning in the second postconceptualmonth. The timing of very early fetal loss wasbefore the usual timing of induced abortions andthese pregnancies were not really realised in themajor part of women. It is strange that the pro-portion of miscarriages based on all pregnancyoutcomes was higher in the control group than inthe case group. The Hungarian rate of recordedmiscarriages was approximately 12% in all preg-nancies without induced abortions during thestudy period while the similar rate was 9.2% inthe case and 8.6% in the control group. TheHungarian rate of ectopic pregnancies and still-births was 0.7% and 0.8%, respectively, duringthe study period, but these pregnancy outcomeswere not recorded in the study.

The number of males and females was 84 and94 in 178 infants born from self-poisoning moth-ers, while this ratio was 228:219 in the controlgroup. Multiple births did not occur in the casegroup, while eight twin livebirths were recordedin the control group, i.e. of 513 control pregnantwomen, four had liveborn twin pairs.

4. Discussion

The strengths of our study are that it waspopulation-based with prospective approach,pregnancies were confirmed by a sensitive serumtest and pregnancy outcomes except very earlyfetal losses were medically documented. However,this study also had some disadvantages:

1. The major goal was the teratogenic evalua-tion of large doses of chemicals, mainly drugsw x4 thus the psychosocial aspect and possible

Ž .medical reasons e.g. depression of suicide,in addition the previous suicide attempts werenot scrutinized.

2. This material represents only suicide with

self-poisoning, other kinds of suicides as gas,stabbing, hanging, drowning, leaping, etc.could not be studied, however, the proportionof other suicides is low in pregnant women.

3. Only women admitted to the study hospitalwere evaluated, thus the proportion of self-poisonings without hospitalisation is not

Žknown however, it may be a very low per-.centage according to Hungarian experts .

4. Pregnant women with undetectable levels ofbeta-hCG, i.e. before the 12]16 postconcep-tual days could not be ascertained.

5. We do not have data concerning the possibledisturbing effect of self-poisoning on the

w xserum pregnancy test 13 . The validity of thispregnancy test was good in the periconceptio-

w xnal care 10 .6. The assumed day of conception was not ad-

justed by the length of menstrual cycle be-cause these data were unreliable, thus thereis a bias at the calculation of postconceptualweeks.

The educational and socioeconomic status ofcase women is lower than those of their matchedcontrol subjects and it may explain their highermean birth order. The proportion of unmarried,smokers and heavy drinkers was also significantlyhigher in the case group.

Of 590 case women with self-poisoning, 31 hadpregnancies which ended in the week precedingthe self-poisoning. This 5.3% proportion may in-dicate a higher rate of suicide attempts after twodeliveries, 17 induced abortions and 12 miscar-riages. Short term postnatal blues occur in

w x45]70% of women 14 while a non-psychoticw xdepression takes place in 10% of women 15]17

in weeks immediately postpartum. In addition, anincreased risk for puerperal psychosis has been

w xreported 18 . A grief period caused by miscar-riage may also cause transient sadness or anxietyw x19 . Recently the harmful effects of inducedabortions on mental health have been also shownw x20 , though the termination of unwanted preg-nancies results in a psychological relief in mostwomen. Past psychiatric history of our patientswas not followed.

The results of this population-based prospec-

( )A.E. Czeizel et al. r International Journal of Gynecology & Obstetrics 65 1999 39]4544

tive study partly confirmed previous findingsconcerning the timing of suicide attempts duringpregnancy, that the peak of suicide was found atthe earliest phase when pregnancy was diagnosedandror recognized and pregnancies with ad-vanced gestation months had an obvious decrease

w xin the rate of attempting suicide 6]9 . However,the peak period of suicide attempts or deaths wasfound in the third month of pregnancy in previousstudies because pregnancy was first diagnosedafter the second missed menstrual bleeding in thepast. This study indicates that 60.7% of suicideattempts occurred before the third postconcep-tual month, and 37.9% in the first postconceptualmonth mainly in the third and fourth postconcep-tual weeks, i.e. immediately after the first missedmenstrual period. These very early suicide at-tempts during pregnancy could not be ascertainedin previous studies. The point is that most suicideattempts occur in the earliest phase of pregnancyduring the changing andror vulnerable psycho-logical condition of women when conflicts withtheir partners are culminating after the recogni-tion of unplanned and in general unwanted preg-

Ž .nancies or rarely approx. 8% they attempt touse high doses of drugs as aborticides. The lowrate of suicide deaths is another characteristicfeature in pregnant women. This rate was approx-

w ximately 4% in nonpregnant 2 and 0.4% in preg-nant women after self-poisoning during the studyperiod and the comparison of doses for suicideattempts between pregnant and nonpregnantwomen seems to confirm their less aggressiveself-poisoning attitude. The low rate of suicideattempts in subsequent months of gestation is inagreement with other reports on suicidal behavior

w xin pregnant women 8,9 .Another new finding of the study is the ex-

tremely high proportion of ¨ery early fetal lossafter self-poisoning in the first postconceptualmonth. The intensive prenatal selection in thevery early phase of fetal development after self-poisoning is supported by a majority of girlsŽ .52.8% among liveborn infants, because, in gen-

Žeral newborn infants are predominantly male e.g.proportion of girls was 48.4% in Hungary during

.the study period and 49.0% in the control group .On the other hand, no twin was found among 178

liveborn infants of self-poisoned women whileŽ .eight twins 1.8% were recorded in 451 liveborn

infants of 447 control women. Thus, the earliestphase of fetal development seems to be verysusceptible to the exposures of drugs and other

Ž .factors antidotes, hospitalization of suicide at-tempts. This finding is consistent with high earlyfetal loss after in vitro fertilisation and the results

w xof other studies. Wilcox et al. 21 identified 198pregnancies by an increase in the hCG level nearthe expected time of implantation and 22% endedbefore pregnancy was detected clinically. Miller

w xet al. 22 detected 152 conceptions and in 50Ž .32.9% the sole evidence of pregnancy was anincreased concentration of urinary hCG.

In conclusion, there is a maternal risk for sui-cide attempts after the early recognition of un-wanted pregnancies, which associates with a highbut not too serious risk for fetus due to thelimited clinical importance of very early fetal loss.

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