Recurrent miscarriage is defined as the loss of 2 or more clinical pregnancies in a row and affects 1 in 100 (1%) of women trying to have a baby. A clinical pregnancy is when it is documented by an ultrasound, which is different from sporadic losses that are before 10 weeks.
A miscarriage is the loss of a baby before 24 weeks. There are numerous causes of miscarriage, but they are usually split into two groups, early and late. Early miscarriages occur in the first 12 weeks of pregnancy. Late miscarriages occur between 12 and 24 weeks. In most cases, there is no clear reason why it occurs; however, recurrent early miscarriages are most commonly due to structural problems of the uterus or chromosomal or genetic problems of the embryo, with 50-80% of sudden losses having abnormal chromosomal numbers. Recurrent late miscarriage can be the result of abnormalities of the uterus, autoimmune problems, premature labour or an incompetent cervix.
Unfortunately, early miscarriages are common, with 10 – 20% pregnancies ending this way. Late miscarriages are less common with 1 – 2% pregnancies ending in a late miscarriage. Recurrent miscarriage is uncommon. If you have experienced 1 miscarriage, the likelihood is that it will not happen again; however, the risks get higher the older you are, so it is more common in older women.
On rare occasions, miscarriages occur because the pregnancy develops outside of the womb. This is known as an ectopic pregnancy. Ectopic pregnancies are potentially serious as there is a risk you could experience internal bleeding.
Symptoms of Recurrent Miscarriage
If you experience 2 or more miscarriages, you have recurrent pregnancy loss. Each miscarriage you have may be different; one could result in pain and bleeding, while another could show no symptoms.
The main sign of a miscarriage is vaginal bleeding followed by abdominal cramping and pain in your lower abdomen. However, be aware that light vaginal bleeding is relatively common during the first 3 months of pregnancy and does not necessarily indicate a miscarriage. Other symptoms may include:
- Weight loss
- White-pink vaginal mucus discharge
- Painful contractions occurring every 5 – 20 minutes
- An abrupt drop in pregnancy symptoms such as nausea and breast tenderness
- Tissue discharge, like a clot, from your vagina
If you do notice that you are bleeding, try to keep track of the amount of bleeding that occurs. Also, if you notice any tissue has passed, try to save it. Many doctors will want it for laboratory examination to help determine the cause of the miscarriage.
Causes of Recurrent Miscarriage
There are many reasons why a miscarriage occurs. Sometimes there is a reason found for recurrent miscarriage, in other cases, no underlying problem can be identified. Doctors believe that most miscarriages are caused when the chromosomes controlling the development of the baby are incorrect. An embryo with too many or not enough chromosomes will not develop correctly and this can lead to miscarriage. This type of genetic problem occurs by chance; there is no medical cause, although it can become more common in women of increased reproductive age.
If a miscarriage occurs during the first 3 months (trimester) of pregnancy, it is normally a result of a problem with the unborn baby (foetus). Around 3 out of 4 miscarriages occur during this period. If a miscarriage occurs following the first trimester of pregnancy, it may be a result of an underlying health condition in the mother.
Various factors can play a part in causing recurrent miscarriage, these include:
Age
The older the mother and the father are, the greater the risk of a miscarriage occurring. If the woman is over the age of 40, around 1 in 2 pregnancies end in a miscarriage. At the age of 35, you have approximately 20% risk, at the age of 40, the risk is around 40%.
Antiphospholipid Syndrome (APS)
APS is an autoimmune disorder that makes your blood more likely to clot. The disorder is uncommon but can result in recurrent miscarriage and late miscarriage, along with other symptoms and side effects.
Thrombophilia
Thrombophilia is an inherited condition that means your blood may be more likely to clot, which may result in recurrent miscarriage.
Genetic Factors
2 – 5% of couples with recurrent miscarriage may find that one partner will have an irregularity on one of their chromosomes. Although this may not affect the parent, in some cases it can result in a miscarriage.
Weak Cervix
Weakness of the cervix is a condition known to cause miscarriage from 14 – 23 weeks of pregnancy. This condition can be hard to diagnose when you are not pregnant. It may be suspected if your waters broke early in a previous pregnancy, or if the neck of the womb opened without any pain.
Previous Miscarriage
Women who have experienced 2 or more consecutive miscarriages are at a higher risk of further miscarriage.
Chronic Conditions
Women who have diabetes or thyroid disorders can be at a higher risk of miscarriage. The disorders do not result in recurrent miscarriage, as long as they are managed and kept under control.
Smoking, Drugs and Alcohol
Women who smoke, use illicit drugs or drink alcohol during pregnancy are at a higher risk of having a miscarriage.
Weight
Being underweight or overweight has been linked with an increased risk of miscarriage.
Diagnosis of Recurrent Miscarriage
If you have experienced 3 miscarriages, your doctor will probably want to carry out some tests. They will ask you about your medical history, details about any past pregnancies and carry out a physical, pelvic exam. Your doctor may order blood tests and imaging tests to look at your uterus. They may also order special testing to look for genetic reasons that you are experiencing miscarriages.
One or more of the tests listed below may be necessary in diagnosing possible causes of your recurring miscarriages:
Karyotype
A picture mapping of your chromosomes can be used to diagnose genetic defects.
Hysterosalpingogram
HSG is a radiology X-ray procedure that is used to examine the inside of the uterus and check that the fallopian tubes are open.
Saline Sonohysterogram (SIS or SHG)
This is a procedure to evaluate the uterus and shape of the uterine cavity. Sterile water is placed into the cavity of the uterus whilst carrying out a transvaginal ultrasound. This procedure is useful to look for any abnormalities that may increase the risk of miscarriage.
Hysteroscopy
A hysteroscopy is a procedure that involves a doctor looking inside your uterus using a narrow telescope with a camera. This enables your surgeon to investigate concerns, diagnose conditions and potentially treat you at the same time.
Vaginal Ultrasound
A scan that uses high frequency sound waves to identify abnormalities in and around the uterus, ovaries, and fallopian tubes.
Blood Tests
Blood tests can reveal the levels of certain hormones in your blood, such as prolactin, thyroid stimulating hormone, and progesterone.
Endometrial Biopsy
An endometrial biopsy is a procedure in which a sample of the endometrial tissue is examined under a microscope to determine if there is an infection, preventing the pregnancy from progressing.
Glucose Screening
Glucose screening is a blood test used to diagnose diabetes. If diabetes is left uncontrolled, it increases the likelihood of miscarriage.
Antiphospholipid Antibody Testing
Blood tests used to detect an immune system abnormality.
Ovarian Reserve Testing
This technique of testing checks egg quantity and quality and may help determine if pregnancy loss is age related.
Sperm DNA Fragmentation Testing
This is a test to determine if sperm quality and DNA fragmentation may be contributing to the loss of pregnancy.
Treatment of Recurrent Miscarriage
Your doctor will talk to you about your particular situation and your likelihood of having a further miscarriage. If a specific cause of your repeated miscarriages can be identified during the diagnosis tests, your doctor may suggest a treatment method that addresses the cause and improves your chance of a successful pregnancy.
Both parents will usually be advised to think about any lifestyle factors that may be having an impact. It is unclear how important smoking, weight and alcohol are in contributing to recurrent miscarriage; however, whatever is healthy for you improves the chance of a healthy pregnancy. Limiting alcohol and caffeine intake may help along with stopping smoking and taking illicit drugs. Being overweight has been linked to a higher risk of miscarriage, so healthy weight loss may help lower the risk of miscarriage. There is no proven link with stress, anxiety or mild depression and recurrent miscarriage.
If you have been diagnosed with APS or certain other blood clotting complications, then you may be advised to take blood-thinning medication during any future pregnancies such as aspirin and heparin to lower the risk of miscarriage. Make sure you discuss this with your doctor before using these medicines as they increase the chances of bleeding problems, such as stomach ulcers.
If a treatable irregularity of the uterus has been discovered, an operation to correct it may reduce the risk of further miscarriage. For women who have a weak neck of the cervix, a stitch can be inserted during early pregnancy to keep it closed. Correcting the shape of the inside of the uterus is usually a one-day procedure and can often lower your chances of miscarriage.
Psychological support, such as counselling, can be helpful as recurrent miscarriages are very upsetting and distressing and are bound to affect you and your partner. It may also be useful to look at the resources of a support organisation.
Recurrent miscarriage may be related to certain medical problems. These include irregular blood sugar levels, an over or underactive thyroid gland, or high levels of the hormone prolactin. Treating medical conditions such as diabetes, thyroid dysfunction, or high prolactin levels may improve the chances of having a healthy, full-term pregnancy.
In many cases, no cause is discovered and no treatment has been found to be effective. Therefore, no treatment may be appropriate in many cases. It still can be good news when no cause is found, however, as this makes it more probable that future pregnancies will be successful.
In about 5% of couples who experience recurrent miscarriage, one of the parents has an irregularity of their chromosomes. If one parent has an abnormality of their chromosomes, this can cause foetuses with chromosome imbalances to miscarry. If a chromosomal problem is found, your doctor may suggest genetic counselling. If you are still unable to conceive a healthy pregnancy naturally, your doctor may suggest fertility treatments such as in vitro fertilization (IVF). The IVF procedure involves mixing the eggs and sperm outside of the body in a laboratory. Following IVF, prior to the embryos being returned to the uterus, they can be tested. This allows the embryos without abnormalities to be chosen to increase the chance of a healthy, full term pregnancy.
Complications of Recurrent Miscarriage
If you have experienced a miscarriage, you are probably aware of the unique physical and emotional challenges that come with it. In some cases, women also experience complications following a miscarriage. These complications include:
- Uterine infection, also known as a septic miscarriage. Signs that you have an infection may include a fever, chills, bleeding and cramping for longer than 2 weeks, or foul-smelling vaginal discharge.
- Excessive bleeding. Some bleeding is normal; too much bleeding however, can be dangerous for you.
- Lower abdominal tenderness.
- Depression and anxiety disorders. Signs that you may be experiencing depression include difficulty sleeping or sleeping too much, weight fluctuation, lack of interest in activities and hobbies, low or suicidal thoughts or trouble concentrating and making decisions.
- An incomplete miscarriage. Relatively common, an incomplete miscarriage means that you still have some tissue retained in your uterus from the pregnancy. The most common sign of an incomplete miscarriage is bleeding or cramping longer than would be expected after a complete miscarriage.
Often, there is nothing you can do to prevent a miscarriage. It is important to focus on taking care of yourself and wellbeing for you and your baby. Endeavour to seek regular prenatal care, avoid known miscarriage risk factors such as smoking, alcohol and drugs, taking a daily multivitamin and limit your caffeine intake. If you suffer from an existing chronic condition, work with your doctor and health care team to manage it and keep it under control.
Outlook
The outlook depends on the results from test carried out. If no cause has been found, 3 out of 4 women will go on to have a healthy pregnancy and baby. However, if you are over the age of 40 and have experienced more than 2 miscarriages, the success rate is not as promising. Following tests, your doctor will be able to give you a better idea about the chances of a successful pregnancy.
Going through a miscarriage does not mean you necessarily have a fertility problem with around 1% of women experiencing repeated miscarriages (3 or more). Remember that generally a miscarriage cannot be prevented and often occurs because the pregnancy is abnormal. If you have had 3 or more miscarriages in a row, you should put off trying to conceive, use birth control and ask your doctor about diagnostic testing to determine the cause of the miscarriages.
Need Help?
Our Consultant Gynaecologists are highly experienced in supporting women who are currently experiencing recurrent miscarriages, with our medical team and nursing staff offering support in a sensitive and caring manner at all times.
To make an appointment to see a Consultant Gynaecologist consultant, please contact the reservations team on 01233 364 036 or email ashford.info@onehealthcare.co.uk
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