Pregnancy After Miscarriage

Pregnancy can be a time of excitement and eager anticipation as you look forward to your new arrival. However, for some women, particularly those who have previously experienced a miscarriage, the excitement is tempered by feelings of worry, stress and anxiety. This heightened anxiety is exacerbated further in women who have experienced multiple miscarriages.

The inefficiency of reproduction

A miscarriage is defined as the spontaneous loss of a pregnancy before 20 weeks gestation. Fertilisation occurs when a sperm from the male fertilizes a female’s egg. The process of human reproduction is so inefficient that only about one third of successful fertilisations will result in a live birth. Many potential pregnancies fail prior to implantation and before the female even realises that she is pregnant. Approximately 15% of clinical pregnancies (meaning an ultrasound has been used to confirm successful implantation of the fertilised egg into the wall of the uterus) end in miscarriage, usually as a result of embryo chromosomal abnormalities.

It is significantly less common for a miscarriage to occur between weeks 12 and 20, so much so that many women are confident to share their news after their 12 week scan. Losses after week 12 are termed late miscarriages and occur in approximately 4% of cases.

If I have had one miscarriage, how likely am I to have another?

Having one miscarriage does not usually place a woman at increased risk of having another miscarriage. However, having two or more consecutive miscarriages does increase her risk.

The European Society of Human Reproduction and Embryology (ESHRE) defines recurrent miscarriage (RM) as three or more consecutive losses occurring before 20 weeks gestation. Women who experience RM have a 43% chance of experiencing further miscarriages. Approximately 1% of couples who are attempting to conceive experience RM and there is no doubt that repeated miscarriages will cause extensive emotional turmoil.

What causes recurrent miscarriage?

Various factors have been associated with RM including parental chromosome abnormalities (10 times more prevalent in couples who have experienced RM, than in the general population), immune dysfunction, endocrine disorders (thyroid conditions and PCOS), damage to the DNA in the male’s sperm and uterine structural abnormalities (endometrisis). However, in approximately 50% of cases of RM, the exact cause is unknown.

How long should I wait after a miscarriage before attempting to conceive again?

In the last set of guidelines published by the World Health Organisation in 2005, it was recommended that couples wait 6 months after miscarriage before attempting to conceive again. However, more recent work has disputed this and even found that couples who fell pregnant within three months of miscarrying got pregnant faster, had a higher live birth rate and were no more likely to experience complications, when compared to those who waited for longer than 3 months to start trying to conceive.

What is absolutely essential to consider before trying to conceive after a miscarriage is whether you are ready emotionally. Whilst your body may be physically fit, it is important to remember that you have experienced a loss and, as such, may still be grieving. Giving yourself time to heal mentally is just as important as allowing your body to recover.

If you have experienced RM, your doctor will likely have screened both you and your partner for chromosomal abnormalities. If any of these screens came back positive, it is important to consider what the implications are for future pregnancies, prior to attempting to conceive again. The type of abnormality will determine whether you are capable of carrying a pregnancy to term and how likely it is that children you give birth to will have genetic disorders. Your doctor will be able to counsel and advise you accordingly.

Pregnancy after miscarriage

In the majority of cases it is difficult to advise on how to have a successful pregnancy after miscarriage. The reasons for miscarriage are varied and, in many cases, poorly understood. Doctors do agree, however, that it is worth adopting a healthy lifestyle; increasing your folic acid intake, eating healthily, stopping smoking and reducing your alcohol intake. In combination these factors maximise your chances of both conceiving and experiencing a problem-free pregnancy.

Pregnancy after miscarriage can be a scary thing. Women who have previously miscarried are often hesitant to get excited about their next pregnancy, fearing the same outcome. The main thing is to take it a day at a time, focusing on getting to each recognised milestone; for example, the 12 week scan, the 20 week scan, the age at which the foetus becomes viable if born (approximately 23 weeks). Hopefully as you draw closer to your delivery date you will be able to start relaxing and making plans for your new arrival.

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Sources:

• Branch, D. Ware, et al. “Recurrent Miscarriage.” New England Journal of Medicine, vol. 363, no. 18, 28 Oct. 2010, pp. 1740–1747., doi:10.1056/nejmcp1005330.
• Jauniaux, E, et al. “Evidence-Based Guidelines for the Investigation and Medical Treatment of Recurrent Miscarriage.” Human Reproduction, vol. 21, no. 9, Sept. 2006, pp. 2216–2222., doi:10.1093/humrep/del150.
• Larsen, E C, et al. “New Insights into Mechanisms behind Miscarriage.” BMC Medicine, vol. 11, no. 154, 26 June 2013, doi:10.1186/1741-7015-11-154.
• Moreuil, Claire, et al. “Hydroxychloroquine May Be Beneficial in Preeclampsia and Recurrent Miscarriage.” British Journal of Clinical Pharmacology, vol. 86, no. 1, 21 Oct. 2019, pp. 39–49., doi:10.1111/bcp.14131.
• “Pregnancy after Miscarriage: What You Need to Know.” Mayo Clinic, 12 Mar. 2019, www.mayoclinic.org/healthy-lifestyle/getting-pregnant/in-depth/pregnancy-after-miscarriage/art-20044134.
• Schliep, K C, et al. “Trying to Conceive After an Early Pregnancy Loss: An Assessment on How Long Couples Should Wait.” Obstetrics and Gynecology, vol. 127, no. 2, Feb. 2016, pp. 204–212., doi:10.1097/AOG.0000000000001159.
• World Health Organization Report of a WHO technical consultation on birth spacing, Geneva Switzerland 13-15 June 2005. Available at: http://www.who.int/maternal_child_adolescent/documents/birth_spacing.pdf. Accessed 06/05/2019.