After the miscarriage: next time

Unfortunately, miscarriage affects as many as 1-in-5 clinically recognised pregnancies - and even more than that with sensitive pregnancy testing. Up to one-in-two pregnancies are unsuccessful due to a random mismatch in the sharing genetic material when the egg and sperm meet. Miscarriages in this situation are nature's way of ensuring a baby is healthy throughout pregnancy and its ongoing life into adulthood.

Bicornuate uterus

It can be highly distressing to lose a second pregnancy to miscarriage, even though you may know that 1-in-25 women will experience just that due to the reasons above. Most women who experience two miscarriages go on to have a successful pregnancy, and even after three miscarriages, pregnancy success is still more likely than not.

Investigations and treatment for recurrent pregnancy loss can provide reassurance and, in some situations, improve the chances of success next time.

Investigations that have been found helpful include testing for:

• Antiphospholipid syndrome - an immune condition in which miscarriage might be the only symptom

• Thyroid issues

• Ultrasound to check for normal pelvic organs

• Screening for polycystic ovary syndrome

• Parental genetic testing

• A hereditary tendency for developing blood clots (thrombophilia) - this is sometimes done, but there is clear evidence now that there is no link with first-trimester recurrent miscarriage and treatments like blood thinners don’t prevent miscarriage, even if you have a genetic thrombophilia. It is recommended for second-trimester pregnancy loss.

Preconception counselling should include advice about normalising body weight, addressing smoking, alcohol and other harmful drug exposure, and beneficial nutrients such as folate and vitamin D. Optimising other health conditions will make pregnancy success more likely.

Many treatments have been tried, and several are beneficial in specific situations. These include:

Progesterone pessaries

• Treatment of actual and perhaps subclinical underactive thyroid conditions.

• Progesterone treatment may improve the live birth rate after three miscarriages (8% increase).

• Aspirin and heparin therapy can improve outcomes in women affected by the antiphospholipid syndrome. There is no evidence it helps in other thrombophilias or women affected by unexplained pregnancy loss.

• Metformin may help in polycystic ovary syndrome, but more research is needed.

• If there is bleeding in a pregnancy after miscarriage, progesterone can be helpful and is established as the standard of care in other countries.

• There is benefit in reassurance visits and scans with a trusted care provider in the first trimester.

Micronutrients, immunotherapy and hCG don't improve outcomes.

Recurrent miscarriage is a devastating experience for most couples, and advice from a specialist can help guide the right investigations and treatment that could help in your specific situation.

After any pregnancy loss, a post-miscarriage pregnancy plan can give you reassurance, clarity and control over your fertility.

Make an appointment to discuss optimising your chance of a successful pregnancy outcome.