It’s devastating experiencing one miscarriage, but even more so if it happens multiple times. This is known as recurrent miscarriage. However, it should be comforting to know that individuals and couples who experience recurrent miscarriage can definitely go on to have a healthy pregnancy.
This guide will explain the following:
What is recurrent miscarriage?
What causes recurrent miscarriage?
Which specialist should you see if you experience recurrent miscarriage?
What assessment can an obstetrician provide for recurrent miscarriage?
What happens if a pathological cause for recurrent miscarriage is found?
How can subsequent pregnancies be managed?
What is recurrent miscarriage?
Miscarriage can be a devastating outcome, yet it’s a relatively common occurrence with approximately 1 in 5 pregnancies resulting in miscarriage. For most people, the next pregnancy will bring a happier outcome, however in a small proportion of cases, the subsequent pregnancy will not have the desired result. Specifically, approximately 2% of people experience two consecutive miscarriages and less than 1% suffer three consecutive miscarriages.
How is recurrent miscarriage defined?
The definition of recurrent miscarriage varies - traditionally it has referred to three or more consecutive failed pregnancies. However, many guidelines now define it as two or more consecutive failed clinical pregnancies (this means the pregnancy was initially confirmed via ultrasound, not just on a home pregnancy test).
What causes recurrent miscarriage?
I often see couples despairing after a second consecutive pregnancy loss, with some even blaming themselves for their miscarriages.
I commonly get asked: “Was it something I ate?” or “Was it because I pushed myself too far at the gym?” or “Did this happen because we had sex after finding out we were pregnant?”
Well I can reassure these people with absolute confidence that this outcome has not been self-inflicted. Somewhat frustratingly for those going through recurrent miscarriage, in 50% of cases no cause will be found - the good news is that the majority in this group will still achieve a healthy pregnancy with no additional interventions.
Which specialist should you see if you experience recurrent miscarriage?
In order to determine whether or not an underlying abnormality exists, those who experience recurrent miscarriage should see an obstetrician who can perform relevant investigations and manage subsequent pregnancies. This should ideally be an obstetrician with a particular interest in the area of recurrent miscarriage and pregnancy loss.
What assessment can an obstetrician provide for recurrent miscarriage?
A thorough medical history will be taken, along with a history of each pregnancy including your miscarriages. From this, your obstetrician may also arrange for a number of relevant medical investigations to be performed. These may include:
Specialist pelvic ultrasound to assess for abnormalities of the uterus
Bloods tests, including tests for thyroid disease and antiphospholipid syndrome
Genetic testing of the parents where indicated
What happens if a pathological cause for recurrent miscarriage is found?
Whilst 50% of cases of recurrent miscarriage are unexplained, the other 50% of cases are due to underlying pathology.
Possible recognised pathologies include:
Genetic problems in one or both parents
Abnormalities in the shape of the uterus, due to either congenital factors (including uterine septum or bicornuate / ‘heart-shaped’ uterus) or acquired factors, such as fibroids
Hormonal issues such as poorly controlled thyroid disease or diabetes
Autoimmune disorders such as antiphospholipid syndrome
Where identified, any underlying condition should be treated - the exact treatment will depend on what the cause is, and what approaches the patient is comfortable exploring. Some examples include:
For couples where a genetic issue is identified, genetic counselling should be arranged. IVF with preimplantation genetic diagnosis (PGD) may be used to avoid implantation of an affected embryo thereby improving pregnancy outcome
Uterine abnormalities may require surgery
Thyroid disease and antiphospholipid syndrome require medications prior to and/or after conception to reduce the risk of a subsequent miscarriage - these will often be prescribed in consultation with another specialist, such as an endocrinologist or haematologist respectively
How can subsequent pregnancies be managed?
Any future pregnancies should be managed by a specialist obstetrician, ideally one who specialises in high risk pregnancies. If you do not yet have an obstetrician, please speak to your GP for a referral to an appropriate specialist.
Along with the correct medical support, it is essential to have adequate psychological support as well. Those with a history of recurrent miscarriage often experience significant anxiety in each subsequent pregnancy, and frequent appointments with an obstetrician to ensure the well-being of the pregnancy can be incredibly reassuring. For my patients, appointments are made weekly between 6 and 13 weeks gestation. At each appointment, a blood test and ultrasound will be performed. Your obstetrician may also refer you also to a psychologist or other mental health professional for support during this time.
Key points:
Recurrent miscarriage is two or more failed consecutive clinical pregnancies.
50% of the time, the cause of recurrent miscarriage is unknown; 50% of the time there is an underlying medical pathology.
Those who experience recurrent miscarriage should be under the care of a specialist obstetrician to reduce their risk of future miscarriages.
There are a number of possible medical interventions that can be applied to optimise the chance of future successful pregnancies (dependent on individual cases).
Those who experience recurrent miscarriage are at a high risk of anxiety, and psychological support is important during the preconception, antenatal and postnatal periods.