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Skip Navigation LinksRecurrent Miscarriage Overview
Page modified at: 28/08/2011

Click here for prices and booking informationRecurrent Miscarriage

 

 DiceAbout 1 in 6 of all pregnancies (15%) end in miscarriage, affecting around a quarter of a million women in the UK each year.

Recurrent miscarriage, the loss of three or more consecutive pregnancies, affects about 1 in 100 women (1%) when the calculated risk should be about 1: 300 women (0.3%).

This means that about 2/3 of women with recurrent miscarriage must have some underlying reason for it though we may not always be able to find out what it is or treat it.


Maternal age and previous number of miscarriages are two independent risk factors for a further miscarriage. Fortunately there is only a fraction of a percent increase in the risk of miscarriage in a subsequent pregnancy following one or even two previous miscarriages. Advanced maternal age adversely affects ovarian function, giving rise to a decline in the number of good quality eggs which often don’t develop properly and hence the risk of miscarriage.

 Maternal age and previous number of miscarriages are two independent risk factors for a further miscarriage. Fortunately there is only a fraction of a percent increase in the risk of miscarriage in a subsequent pregnancy following one or even two previous miscarriages. Advanced maternal age adversely affects ovarian function, giving rise to a decline in the number of good quality eggs which often don’t develop properly and hence the risk of miscarriage.

 

If all investigations are negative the likely successful pregnancy rate for a woman with a history of recurrent miscarriage would fall by about 5-15% to about 70-80%. (Over the age of 35 years the miscarriage rate for both chromosomally normal and abnormal pregnancies increases to about 20% at 35-39 years (80% successful) and to 40% (60% succesful) over the age of 42).

There are a lot of theories and treatments for recurrent miscarriage but few have been shown to be scientifically sound. The development of specific Miscarriage Clinics with appropriate expertise have been suggested in the British Journal of Obstetricians and Gynaecologists in February 1996 (pages 106-110) though this service has been available at the Spire Hospital in Cardiff for some time.

 

We offer a Pre-Pregnancy Counselling Service where you (and your partner) will be offered a sympathetic consultation with an experienced Consultant with expertise in the investigation and treatment of women with recurrent miscarriage. The relevant investigations and treatment will be discussed and a management plan formulated for your subsequent pregnancy wherever you choose to deliver.

Further Information on Recurrent Miscarriage is available from the Royal College of Obstetricians and Gynaecologists (RCOG) and the Miscarriage Association.

Risk Factors

Endocrine or Hormonal causes


Although low levels of hormones such as progesterone have been observed in early pregnancy in women with recurrent miscarriage there is no evidence of any beneficial effect of giving progesterone or hCG injections.
Although traditionally blamed in the past, well controlled diabetes and thyroid disease do not appear to be a cause.
Elevated luteinising hormone (LH) found in Polycystic Ovarian Syndrome may however play a part and this can be treated if the diagnosis is confirmed on a pelvic ultrasound scan.
 
 
 
 
 

Genetic or chromosomal causes
DNA
Abnormal chromosomes in either the woman or her partner may be responsible for about 3-5% of cases and this can be excluded by both having a simple blood test. If either test is abnormal then referral to a Clinical Geneticist will be arranged for counselling.

 
 


Immune system and Clotting


APA-Inappropriate production of antibodies by the woman known as the antiphospholipid antibody (APA) syndrome can cause recurrent miscarriage, clots (eg in the leg known as a DVT) or a low platelet count (a deficiency of small cells in the blood responsible for clotting and hence a tendency to bruising).

Blood SpeedThe commonest antibodies are the lupus anticoagulant (LA) and the anticardiolipin antibodies (ACA) which can be detected by a blood test. Up to 15% of women with recurrent miscarriage have APA syndrome though it is found in about 2% of normal women. APA in women with a normal past obstetric history causes a pregnancy loss rate of 50-75%. If they have had recurrent miscarriages and are not treated the loss rate rises to 90%. The exact mechanism is not understood but APA seems to affect the placenta (afterbirth) and its supply of blood and nutrients to the baby.

Various treatments are available including low dose aspirin (75mg daily), heparin (Clexane) injections and steroids (Prednisone) with successful pregnancies in up to 80% of treated cases. Clexane is given as a self administered subcutaneous injection (20mg daily) and unlike older heparin preparations does not cause significant osteoporosis (loss of calcium from the bone). It can, however, reduce the platelet count (small blood cells responsible for clotting) and this will be checked after 7-10 days of treatment.

Tissue Type - Close matching of the woman's partner's tissue type prevents the normal recognition of the pregnancy as foreign to her body, which is essential for the normal formation of the placenta (afterbirth). Despite no proof for this as a cause of recurrent miscarriage some people have been treating such women with transfusions of white blood cells from donors or their partner to try and sensitise them to a subsequent pregnancy. There is no scientific evidence to support this and there are risks from the transfusion to the woman. Furthermore, the main test used to identify women suitable for this treatment is flawed.

 

Natural Killer Cells (NK Cells)

Natural Killer Cell (NK Cell) attacks an embryo

Recently there has been new research to suggest that some miscarriages may be due to immune factors in the lining of the womb (endometrium) called NK or Natural Killer Cells and if found in high numbers these can be suppressed by treatment with steroids prior to conception.

These NK cells bind to the developing embryo and release toxic granules which destroy it.

 

 

Infection
Blood
Severe persistent infection usually making the woman unwell and often associated with a fever and rash is a recognised cause in some women. The organisms involved include Rubella (German Measles), Toxoplasmosis and Listeria. Bacterial Vaginosis, an upset in the normal vaginal organisms found in all women can cause mid pregnancy losses and premature labour but not early miscarriage. A vaginal swab and blood test are required to exclude infection.


 
Abnormalities of the uterus
(womb) or cervix (neck of the womb)

Uterus - The role of uterine abnormalities is disputed and surgery is not thought to be beneficial in most cases even when abnormalities are found. A hysterosalpingogram (dye injection and X-ray), hysteroscopy (telescope examination through the cervix) or transvaginal scan may be required.

 
 
Cervical Incompetence - Mid pregnancy miscarriage may be due to an inadequate cervix either following damage from surgery (such as a D&C or termination) or it may be present from birth. It usually presents as a painless rupture of the membranes in mid pregnancy followed by delivery. Tests include an internal examination to look at the cervix by a gynaecologist, hysterocervicogram (dye injection and X-ray), or repeat ultrasound scans in early pregnancy. If the diagnosis is made, a stitch is usually put in at around 14 weeks pregnant or, in extreme cases, before the pregnancy.
 
 

Unknown
Women who have been properly investigated for recurrent miscarriages in a specialised centre and who have been found to have no underlying risk factors for their miscarriages can be reassured that they have an 80% chance of a livebirth in a subsequent pregnancy.
 

They can be offered psychological support and regular ultrasound scans for reassurance during the early weeks of any subsequent pregnancy.

 

Anyone who has lost a baby through late miscarriage or stillbirth can get support from the charity SANDS who offer advice, support and information to women, men, family and friends of anyone affected.

 

 

 


General Advice
* There is some evidence that women who smoke are at increased risk of miscarriage and that this risk is related to the number of cigarettes smoked.
* Similarly, women with an excessive alcohol intake are thought to be more prone to have a higher rate of miscarriage.
* Recent research shows that there is no association between the use of video display units (VDUs) and miscarriage.

Reference
R Rai, K Clifford, L Regan. The modern preventative treatment of recurrent miscarriage. British Journal of Obstetrics and Gynaecology. 1996; 103:106-110
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