A miscarriage is the loss of a pregnancy that occurs during the first 23 weeks. Around three quarters of miscarriages happen during the first 12 weeks of pregnancy (the first trimester).

While a miscarriage does not usually seriously affect a woman’s physical health, it can have a significant emotional impact. Many couples experience feelings of loss and grief.

For most women, a miscarriage is a one-off event and they go on to have a successful pregnancy in the future.

It is thought that two thirds of early miscarriages are due to abnormal chromosomes in the baby.

Losing three or more pregnancies in a row (recurrent miscarriages) is uncommon and affects around 1 in 100 women. Even in cases of recurrent miscarriages, an estimated three quarters of women go on to have a successful pregnancy in the future.

SYMPTOMS

The most common symptom is vaginal bleeding. The bleeding may come and go over several days and can vary from light spotting or brownish discharge, to heavy bleeding and bright red blood.

Light vaginal bleeding is common during the first 12 weeks of pregnancy, and therefore does not necessarily indicate a miscarriage. However, anyone with bleeding in the first 12 weeks of pregnancy should contact their local maternity services.

Other symptoms include:

• lower abdominal cramping and pain

• vaginal discharge

•noticing the absence of normal pregnancy symptoms e.g. breast tenderness or sickness

Emergency services should be contacted if a woman experiences:

•heavy vaginal bleeding (soaking more than one sanitary pad every hour)

•persistent and severe abdominal pain

•pain in the shoulder tip

•feeling very faint and light-headed, and possibly fainting

The above could be symptoms of an ectopic pregnancy which usually occurs between weeks 5-14 of the pregnancy. An ectopic pregnancy is a medical emergency.

CAUSES

If a miscarriage happens during the first trimester of pregnancy (the first 12 weeks), it is usually due to problems with the unborn baby.

If a miscarriage happens during the second trimester of pregnancy (between weeks 14 and 26), it is usually the result of an underlying health condition in the mother.

First trimester miscarriages

Chromosome problems

Chromosomes are blocks of DNA. They contain a detailed set of instructions that control a wide range of factors.

Sometimes, something can go wrong at conception and the foetus receives too many or not enough chromosomes. The reasons for this are often unclear, but it means that the baby will not develop normally, resulting in a miscarriage.

Up to two thirds of early miscarriages are associated with chromosome abnormalities. 

Placental problems

The placenta links the mother’s blood supply to the baby. If there is a problem with the development of the placenta it can also lead to a miscarriage.

Risk factors

Age

The age of the mother is one of the most important risk factors:

•Women under 30: 1 in 10 pregnancies will end in miscarriage.

•Women 35-39: up to 2 in 10 pregnancies will end in miscarriage.

•Women over 45: more than half of all pregnancies will end in miscarriage.

Other risks factors

•obesity 

•smoking during pregnancy

•drug misuse during pregnancy (particularly cocaine)

•drinking more than 200mg of caffeine a day: one mug of tea contains around 75mg of caffeine, and one mug of instant coffee contains around 100mg of caffeine

•drinking more than two units of alcohol a week: one unit is half a pint of bitter or ordinary strength lager, a small glass of wine or a 25ml measure of spirits

Second trimester miscarriages

There are several long-term health conditions that can increase the risk of having a miscarriage:

• poorly controlled diabetes

•severe high blood pressure

•lupus (where the immune system attacks healthy tissue)

•kidney disease 

•an overactive thyroid gland

•an underactive thyroid

•coeliac disease

Infections

Some infections may increase the risk of having a miscarriage:

•rubella (German measles)

•cytomegalovirus

•toxoplasmosis

•a bacterial infection of the vagina - bacterial vaginosis

•HIV

• chlamydia, gonorrhoea and syphilis 

•malaria

Medicines

•misoprostol  

•retinoids (used for eczema and acne)

•methotrexate

•non-steroidal anti-inflammatory drugs

To be sure that a medicine is safe in pregnancy, always check with your doctor, midwife or pharmacist before taking it.

Antibodies

Antibodies are proteins that are produced by the immune system to fight infection.

Some women who have had three or more miscarriages in a row (recurrent miscarriages) have a higher than usual level of an antibody called antiphospholipid (aPL) in their blood. The aPL antibodies are known to cause blood clots. These blood clots can block the supply of blood to the foetus, which can cause a miscarriage. Having a high number of aPL antibodies in your blood is known as Hughes syndrome.

Womb structure

Abnormalities with the womb can also lead to second trimester miscarriages. Possible problems include:

•non-cancerous fibroid growths in the womb

•scarring on the surface of the womb

Weakened cervix

In some cases, the muscles of the neck of the womb are weaker than usual. This is known as cervical incompetence. This may be due to a previous injury to this area, or may be something the woman is born with.

The muscle weakness causes the cervix to open during pregnancy, leading to a miscarriage.

Hyperprolactinaemia

Prolactin is a hormone produced during pregnancy. Prolactin helps to prepare the breasts for breastfeeding. High levels of prolactin in the body may be linked to an increased risk of miscarriage.

Polycystic ovary syndrome

 PCOS can lead to hormonal imbalances and is a leading cause of infertility. There is some evidence to suggest that it may also be linked to an increased risk of miscarriage in women who are still fertile. The exact role that PCOS plays in miscarriages is unclear.

MYTHS

An increased risk of miscarriage is NOT linked to:

•a mother experiencing stress or having depression

•having a shock or fright during pregnancy

•exercise during pregnancy (but discuss what type of exercise is suitable for you during pregnancy with your GP or midwife)

•lifting or straining during pregnancy

•working during pregnancy

•having sex during pregnancy

DIAGNOSIS

•blood tests to measure hormones associated with pregnancy, such as beta-human chorionic gonadotropin (hCG) and progesterone

•a transvaginal ultrasound scan: a small probe is inserted into the vagina to take a close-up image of the womb

•a pelvic examination

The test are done in order to determine if the pregnancy has ended in miscarriage. The tests will also tell if:

•There is still some foetal tissue left in your womb (an incomplete miscarriage).

•All the foetal tissue has been passed out of your womb (a complete miscarriage). 

Sometimes a miscarriage is diagnosed during a routine scan. The scan may reveal that the baby has no heartbeat, or that the baby is too small for the date of the pregnancy. This is called a missed or delayed miscarriage

TREATMENT

Treatment depends on whether the miscarriage has been complete or incomplete.

Complete miscarriage

When there is no foetal tissue left in the womb no further medical treatment is required. Miscarriage can have a significant emotional effect counselling or support may be offered.

Incomplete miscarriage

When there is tissue left in the womb this needs to be removed as there is a risk that it could become infected. This can be done by:

•using minor surgery to remove the tissue

•using medication to remove the tissue

•waiting for the tissue to pass naturally out of your womb (expectant management)

The doctor in charge of your care should discuss the benefits and risks of each option that should be considered when making the decision.

Surgery

There are circumstances where immediate surgery is advised, including:

• continuous heavy bleeding

•infection of the remaining foetal tissue

•if medication or waiting for the tissue to pass out naturally have been unsuccessful

Surgery is usually performed under general anaesthetic and the tissue will be removed using a suction device. This type of surgery is known as evacuation of retained products of conception (ERPC).

Medication

This involves taking tablets that cause the cervix to open, allowing the tissue to pass out. There are two types of tablets:

•tablets that are swallowed

•tablets called pessaries that are inserted directly into the vagina, where they dissolve

The effects of the tablets usually begin within a few hours. Medication is successful in removing foetal tissue in around 9 out of 10 cases. However, if the medication is unsuccessful surgery will be required. The woman will experience symptoms like a heavy period - cramping and vaginal bleeding.

Waiting method

It can take time for the natural passage of the womb contents and bleeding can last up to 3 weeks.

For more than half of miscarriages, this method is unsuccessful in removing foetal tissue. In these cases medication or surgery will be required.

In some cases, if a cause of the miscarriage has been identified, it may be possible to have treatment to prevent this causing any more miscarriages. 

Hughes syndrome

Hughes syndrome, an autoimmune condition that causes blood clots. Research has shown that a combination of aspirin and heparin can improve pregnancy outcomes in women with Hughes syndrome.

Weakened cervix

A weakened cervix, also known as cervical incompetence, can be treated with an operation to put a small stitch of strong thread around the cervix to keep it closed. This is usually carried out after the first 12 weeks of pregnancy, and is removed around week 37.

COMPLICATIONS

A miscarriage can have a profound emotional impact, not only on the woman herself but also on her partner, friends and family.

Emotional impact

Sometimes this is felt immediately whereas in other cases it can take several weeks.

The most common emotions that are felt are grief and bereavement.

Physical symptoms:

•fatigue

•loss of appetite

•poor concentration

•sleep problems

Emotional symptoms:

•guilt

•shock and numbness

•anger

•an overwhelming sense of sadness

Different people grieve in different ways. Some people find it comforting to talk about their feelings while others find the subject too painful to discuss.

Miscarriage can also cause feelings of anxiety or depression, and can lead to relationship problems.

Some women their partners may need further treatment and counselling. There are support groups that can provide or arrange counselling for people who have been affected by miscarriage.

The following organisations can also help:

•The Miscarriage Association is a charity that offers support to people who have lost a baby. They have a helpline 01924 200 799 (Monday to Friday, 9am to 4pm) and an email address info@miscarriageassociation.org.uk and can put you in touch with a support volunteer.

•Cruse Bereavement Care helps people understand their grief and cope with their loss. They have a helpline 0844 477 9400 (Monday to Friday, 9am to 5pm) and a network of local branches where you can find support. 

PREVENTION

One can't often prevent a miscarriage. However, there are ways to lower the risk:

•Do not smoke during pregnancy

•Do not drink alcohol during pregnancy.

•Do not use illegal drugs during pregnancy.

•Drink at least 1.2 litres (six to eight glasses) of fluids, such as water and fruit juice, every day.

•Eat a healthy, balanced diet with at least five portions of fruit and vegetables a day.

Debbie's story-
 

Debbie suffered 5 Miscarriages and an Ectopic pregnancy over a period of 7 years. She also found out that she has Endometriosis. During these years Debbie was put on medication to help her fertility, had blood tests and tried IVF. She found out that Dr Siobhan Quenby (who has been funded by Wellbeing of Women in a number of studies) was researching recurrent miscarriage. After being part of this new research and treatment she then went on to have her son Samuel.

 
“We began trying for a baby when I was 33 years old in May 1999.”

If you would like to tell us your story so we can help and inform other women; there is more information available HERE

Expert interview with Professor Siobhan Quenby

This interview was recorded in November 2009.
 

    Recurrent Miscarriage: Text Version    

Hello we are joined today by Dr Siobhan Quenby to discuss recurrent miscarriage. Thank you Siobhan for joining us today. Can I start by asking you, what exactly is a recurrent miscarriage?

So a recurrent miscarriage means that you have had several miscarriages in a row. As a doctor we have a strict definition of what a miscarriage is, and that is in fact three miscarriages in a row. However if you’ve only had two miscarriage it’s still perfectly reasonable to see a doctor and discuss this, although the doctor may not do as many tests on you as if you had had three in a row.

Could you explain some of the reasons for recurrent miscarriage?

So there are some known reasons for a miscarriage, one of these is sticky blood in the context of recurrent miscarriage, is antiphospholipid syndrome. This is something that can be easily tested for by the doctor and has an effective treatment.
There are some other things which are thought to be associated with recurrent miscarriage and these involve problems with your thyroid gland, having diabetes or having a condition called polycystic ovary disease, it can also be genetic conditions or conditions in your uterus that maybe causing your miscarriages and I will go on to explain these in more detail later.

Is it more common in older mothers?

Yes the older you are the more likely you are to miscarry. There is a very simple reason for this; all the eggs you will ever have are born with you, so as you are getting older the eggs are getting older and there is an increased incidence of a genetic abnormality in the eggs. This particularly becomes important after the age of 35 and even more so after the age of 40 so if you do conceive after the age of 40 you are much more likely to miscarry than a younger woman. However even at this age you have plenty of healthy eggs and there is plenty of possibility you will have a completely normal pregnancy.

Do the genetics of the parents play a role?

Yes some people have what is called a translocation, which is a genetic abnormality which is easily detected by a blood test, it means that although the parents are normal themselves they will pass on a genetic abnormality to their offspring. This genetic abnormality is so serious that it usually results in miscarriage, however it is a rare cause of recurrent miscarriage only occurring in 2-4% of people suffering with the condition. Even if you do have this abnormality there is a chance you will still have a normal pregnancy, as there is every possibility that the baby will inherit your healthy genes and then you end up with a healthy baby.

What kinds of tests can be done to investigate the cause of recurrent miscarriage?

Most people who have recurrent miscarriage are referred to a hospital doctor, there they will do a series of blood tests such as the test of sticky blood, and in most hospitals they do more tests for sticky blood, this is called a thrombophilla screen. They test you thyroid and your diabetic level, they also do an ultra sound scan to check for PCOS, quite often they will also look at your uterus with the ultra sound scan or sometimes look into your uterus with a hysteroscopy. They will also take the blood from both the mother and father to see if there are any genetic conditions.

What about a disease such as Asherman’s Syndrome?

Ashermans Syndrome is a rare cause of recurrent miscarriage. It seems to occur after you have had an operation in your womb. What it means is the two sides of the womb stick together, so you have adhesions or little filmy pieces of tissue in your uterus this can cause infertility and problems with miscarriage. However it is easily treated by gynaecologists and can be detected by a hysteroscopy.

What research is being done to investigate the causes?

One of the problems with recurrent miscarriage is that it is very difficult to find the cause. So despite all these blood tests and scans and looking in your uterus, there is no obvious cause for recurrent miscarriage. So Wellbeing of Women is funding research to look into the new reasons behind recurrent miscarriage. One of the areas that I am particularly looking in is looking at the lining of the blood, rather than the blood in people with recurrent miscarriage, and I found some people with recurrent miscarriage have more of the NK cells in the lining of the womb, and this research is funded by Wellbeing of Women and I am using the research to develop a new treatment, however that is still in the testing stage. Wellbeing of Women is also funding research into the link between PCOS and recurrent miscarriage and it is funding a tissue bank that will give us new causes and answers in the future.

Can you tell us a bit more about your research?

So basically I have been working very hard to try and understand what is wrong in the lining of the womb for people who suffer with recurrent miscarriage compared with those who don’t. I found that these women have more of what we call NK (natural killer) cells in the lining of their wombs. However the problem with finding that was we didn’t know why that caused the recurrent miscarriage. With funding from Wellbeing of Women we were able to do further research to discover that this causes more blood vessels in the womb and these abnormalities in blood vessels seem to be the cause of recurrent miscarriage.

Is there anything that can be done to prevent a women suffering further with recurrent miscarriage?

Initially you need to have all the blood tests. Some of the conditions we have talked about are treatable; so for example if you have sticky blood we know from research done in London, that if you have aspirin and heparin it prevents miscarriage. If you have a problem in your uterus such as Ashermans Syndrome it may also be treatable. Other things we still need to do further research. We need to do further research to understand what to do with people suffering from PCOS and recurrent miscarriage and people who have these high NK cells and recurrent miscarriage. But the exciting thing is that there is lots being done in these subjects and probably the best thing you can do at the moment is become part of the research surrounding these projects.

There are a number of myths surrounding recurrent miscarriage, one of which is many women believe it is their fault that she suffered.

This is a very common feeling as women always blame themselves but it really isn’t their fault. The most common reason for a miscarriage is that the baby is abnormal and it is nature’s way of preventing an abnormal baby getting to term. Some people think it is because they smoked cigarette or had a glass of wine, but these things definitely don’t cause a miscarriage. Another common thought is that because you had a previous termination of pregnancy it causes a miscarriage, but this isn’t true at all either.

Another misconception is that you can stop a miscarriage by lying down?

This is absolutely not true at all, lying down will make no difference at all. And in fact lying down for a very long period of time when you are pregnant can actually be harmful as it increases your risk of getting blood clots.

Many people believe that if you have had one miscarriage you will be certain to have another is this true?

No. 15% of pregnancies result in miscarriage so having one miscarriage out of three births is deemed normal. Although having three or more in a row may increase the risk a bit and these people should be seen by doctors who will help them more intensively through their pregnancy.

There are a number of things people believe cause a miscarriage such as sex, lifting small children, drinking or smoking, or excessive exercise?

None of these things have definitely been linked to miscarriage, whether the pregnancy continues or not is down to a complicated interaction between the mother’s and baby’s cell in the uterus. However if you have had one miscarriage, your anxiety levels will be considerably raised and therefore I would advise that you book in at your doctors for an ultrasound early in your pregnancy to reduce your anxiety.

I would like to thank Siobhan for joining us today.

It’s been a pleasure.

There are a number of myths surrounding recurrent miscarriage and it can be an emotional time for a woman who often feels responsible for her pregnancy ending. Here Dr Quenby gets to the bottom of some of the most common myths in circulation.

It is a woman's own fault if she has a miscarriage

This is a very common feeling as women always blame themselves but it really isn’t their fault. The most common reason for a miscarriage is that the baby is abnormal and it is nature’s way of preventing an abnormal baby getting to term. Some people think it is because they smoked cigarette or had a glass of wine, but these things definitely don’t cause a miscarriage. Another common thought is that because you had a previous termination of pregnancy it causes a miscarriage, but this isn’t true at all either.

You can stop a miscarriage by lying down

This is absolutely not true at all, lying down will make no difference at all. And in fact lying down for a very long period of time when you are pregnant can actually be harmful as it increases your risk of getting blood clots.

If you have had one miscarriage you will be certain to have another

No. 15 percent of pregnancies result in miscarriage so having one miscarriage out of three births is deemed normal. Although having three or more in a row may increase the risk a bit and these people should be seen by doctors who will help them more intensively through their pregnancy.

The following activities can cause a miscarriage: sex, lifting small children, drinking or smoking, or excessive exercise

None of these things have definitely been linked to miscarriage, whether the pregnancy continues or not is down to a complicated interaction between the mother’s and baby’s cell in the uterus. However if you have had one miscarriage, your anxiety levels will be considerably raised and therefore I would advise that you book in at your doctors for an ultrasound early in your pregnancy to reduce your anxiety.

To find out about our research follow these links:
 

• Role of immune proteins in early miscarriage

For more studies see recurrent miscarriage section.

• The Royal College of Obstetricians and Gynaecologists website has a wide range of information and guidelines on many women’s health topics. This can be found at: http://www.rcog.org.uk/womens-health/patient-information 

• NHS Choices website also has a range of health information. This can be found at: http://www.nhs.uk/Pages/HomePage.aspx