Miscarriage is more common than many people think. Unfortunately as many as 1 in 5 pregnancies end in miscarriage. Estimates vary as many miscarriages are unreported; for women who have a confirmed pregnancy statistics vary from 1 in 5 to 1 in 10 pregnancies.
Miscarriage can affect women in different ways, it can be deeply distressing and there is no single ‘best way’ to cope with it. It is important that women and their families receive support and get appropriate and sensitive care.
Miscarriage means the loss of a pregnancy before 23 completed weeks. The most usual time for this to happen is during the first 12 weeks of pregnancy. After having a single miscarriage there is an 80 percent chance of the next pregnancy being successful. Recurrent miscarriage is less common but still affects around 1 in 100 women.
When a baby develops, it grows inside a sac of fluid in the womb. Miscarriage occurs when this sac separates from the womb lining. The womb then contracts and the pregnancy is usually expelled from the body.
There are different medical terms to describe the type and stage of a miscarriage.
Threatened - there may be some light bleeding in early pregnancy and when investigated the neck of the womb (or cervix) is closed. Most of the time the bleeding will settle and women go on to have a normal pregnancy. However, sometimes these symptoms may progress and a miscarriage then happens.
Incomplete - bleeding is present and some of the pregnancy sac has come out of the womb but some remains inside.
Complete - all of the pregnancy sac has come out and the cervix closes again, the bleeding and cramps should then subside.
Silent or missed - the baby has stopped developing but the pregnancy sac is still present. There may be no symptoms and this is usually found at a scan appointment.
Recurrent Miscarriage - is the loss of three consecutive pregnancies, before 23 weeks gestation. Women experiencing this should be referred to a gynaecologist (specialist) for further investigation.
Causes & Risk Factors
Genetic: Most early miscarriages are caused because there has been an unavoidable genetic problem when the embryo (developing baby) is forming.
In some cases there are more complicated medical issues that may cause miscarriage, these are detailed in the recurrent miscarriage section.
There are also several risk factors that can increase the chance of a miscarriage:
Age: Women who are older have an increased chance of miscarriage as the genetic information in their eggs deteriorate with time. There is therefore a higher chance of a genetic problem when the pregnancy is forming.
Other: Other known risk factors include; smoking, infections and medications taken for other conditions.
Symptoms
Many women have miscarriages at home and do not require any further medical treatment. In these cases women experience bleeding like a heavy period, clots passed and some abdominal cramps. Symptoms can include:
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Vaginal bleeding- maybe light red, brown or can be heavy with clots
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Abdominal pain - cramping pain in the lower abdomen
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Normal pregnancy symptoms may stop
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Some women have no symptoms of a miscarriage and it may only be found at a routine scan.
Bleeding in early pregnancy does not always mean a miscarriage is happening, but advice should still be sought.
Please note if the bleeding is heavy, or you have persistent pain or you feel faint or generally unwell you should immediately seek advice from a doctor. This can be through your General Practioner (GP), the local hospital early pregnancy unit, or A + E if out of hours. These symptoms may be a sign of miscarriage or could also be a sign of ectopic pregnancy.
Diagnosis
A GP or Early Pregnancy Unit may carry out certain tests depending on each individual situation.
Scan
A scan is most useful after 6 weeks from the last period. After 6 weeks it can assess the size of the baby and if there is a heartbeat present. A scan before 6 weeks may be unclear and not helpful as it can be too early to see the heart beat and another scan maybe needed at a later date.
Blood tests
There may also be a need for blood tests to assess hormone levels.
Treatment
Treatment In some cases medical treatment may not be needed. Often miscarriages will happen and complete with no medical treatment.
If a miscarriage is Silent, Incomplete or if any further problems occur there are three options:
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Conservative management: if there are no medical concerns after being assessed there may be the option to go home to allow the miscarriage to happen without intervention.
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Medical Management: tablets can be given at certain intervals to make the womb contract and the pregnancy deliver.
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Surgical management: this is called an “evacuation of retained products of conception” (ERPC) also known as a D&C. This is a procedure given under general anaesthetic to remove remaining pregnancy products from the womb. It may be advised if there is worrying bleeding or signs of infection.
The doctor will discuss the advantages and disadvantages of all procedures and give advice appropriate for situation and symptoms.
After being diagnosed or treated for a miscarriage you should seek help from the maternity services if you experience any of the following symptoms:
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Fever or flu like symptoms
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Severe pain
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Heavy bleeding (more than a period)
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Feeling faint
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Pain in your shoulders
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Vaginal discharge which smells
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.”
Debbie and her family then went through 7 years of emotional and physical turmoil until January 2004.
“I had read an article in a national newspaper about a lady who had suffered a lot of miscarriages and was tested for NK cells in the lining of her womb as they thought they could be attacking the foetus.In January 2005 I had an appointment at Liverpool Women’s Hospital and met Dr Siobhan Quenby. I then found out that the NK cells in my womb were at 19% and the normal range is between 4-5% so therefore I was a candidate for her research trial and I could try taking a course of steroid treatment.To my amazement in June 2005 I found out I was pregnant, I was extremely nervous, it was my sixth pregnancy and I had some bleeding. I then went into labour at 39 weeks and our beautiful baby boy was born on February 21st 2006 weighing 6 lb 8oz and he was just perfect. We named him Samuel as this meant “answers to prayers for a child” and he was truly our little miracle from heaven! I feel so lucky as for some women this treatment was not successful. However, I truly believe the steroid treatment that Dr Quenby put me on was the reason this pregnancy survived, so I would like to thank her for all her hard work in researching miscarriages.”
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.
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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.
