9828 MA Preg Loss 24/04/2013 11:43 Page 17

33456_WhyMe_3425_DM:9828 MA preg loss 24/04/2013 11:43 Page 17

Why me? 33456_WhyMe_3425_DM:9828 MA preg loss 24/04/2013 11:43 Page 2

Miscarriages happen for lots of different reasons. Sometimes the cause is known but often it isn’t. Some women benefit from treatment but others don’t need it. This leaflet looks at the possible causes of miscarriage and the tests and treatment that might help you.

What is a miscarriage? What happens now? Miscarriage is when you lose your If this is your first or second baby any time up to 24 weeks of miscarriage, you probably won’t be pregnancy. After 24 weeks losing a offered tests or treatment. That’s baby during pregnancy or labour is because most women go on to have a called a stillbirth. successful pregnancy next time.

Miscarriage is very common. No one But if you think there is a good reason knows exactly how many miscarriages for having tests now, perhaps because happen, but experts think that more of your age or the time it took you to than one pregnancy in every five ends conceive, you might want to talk to in miscarriage. your GP about an earlier referral.

There is still a lot that we don’t know If you’ve had three miscarriages or about miscarriage, and you may never more in a row, you should be offered find out why it happened to you. That tests. That’s because a cause is more can be hard to cope with. likely to be found at this stage. But even then, there may not be a What we can say is that miscarriage is treatment that can help. hardly ever caused by something you did – or didn’t do. And the chances are That doesn’t mean your next that your next pregnancy will result in pregnancy won’t be successful. Even if a healthy baby. there is no treatment, you should still

get extra support from doctors and

midwives next time. And research Miscarriages are so shows that this alone can improve common, but you “ your chances of having a healthy “don’t really think pregnancy. 1,2 about it until it happens to you.

2 33456_WhyMe_3425_DM:9828 MA preg loss 24/04/2013 11:43 Page 3

Different types of I was told yesterday

miscarriage that my baby “stopped growing at

Doctors use various different terms to six weeks but I describe miscarriage. Here we explain should be 12 “ weeks what they mean. now and I had no idea anything was Threatened miscarriage wrong. This term is often used when you have some bleeding – or ‘spotting’ – from your vagina. Sometimes a scan shows that the baby Many women still go on to have a has died or not developed even healthy pregnancy, even if the bleeding though you haven’t had a miscarriage. is heavy. But sometimes the baby has There are different ways of describing already died. And sometimes a scan this: shows a healthy heartbeat but the Missed miscarriage baby dies later. (also called ‘delayed’ or ‘silent’ miscarriage) It can be very stressful if the first scan isn’t clear and you have to go back for This means the baby has died but is another one a week or two later. still in your uterus. This is sometimes discovered during a routine scan; and It is important to know that scans and you may have had no sign that internal (vaginal) examinations do not anything was wrong. cause miscarriages. It can come as a shock because you Complete miscarriage may still feel pregnant and have a positive pregnancy test. This means that the baby has died or has not developed and your uterus (womb) has emptied naturally. This sometimes happens over several days.

You may need a scan to confirm that the miscarriage is complete.

3 33456_WhyMe_3425_DM:9828 MA preg loss 24/04/2013 11:43 Page 4

Blighted ovum I was told I had a This term is sometimes used when a missed miscarriage “and was then sent scan shows a pregnancy sac with nothing inside it. The early cells of the home to think baby and/or the beginning embryo about the various have failed to grow; but the sac where options. I decided

the baby should develop continues to to wait for things

grow. As with a missed miscarriage, to happen naturally you may still feel pregnant and have a as I wanted to keep positive pregnancy test. control of what“ was happening to Some doctors call this ‘anembryonic me – as much as pregnancy’, which means a pregnancy you can. without an embryo. Other doctors call it ‘early embryo loss’.

Incomplete miscarriage Late miscarriage This means that the pregnancy is over This is a miscarriage that happens after but the uterus has not emptied 14 weeks of pregnancy. It may start completely. You will probably still have with bleeding, cramps or your waters pain and heavy bleeding. breaking. But sometimes there are no signs and a routine scan shows that In all these situations where you the baby has died. haven’t yet miscarried, it will happen in time; but you may be offered one of If a late miscarriage is not complete, these choices: you will probably need to be admitted to hospital. You will probably have your • Go home and wait for the labour induced rather than an miscarriage to start or finish operation and this can be a very naturally; distressing time. • Have a minor operation to remove You may be admitted to the any pregnancy tissue left in your gynaecology ward or the labour ward. uterus. This is called Surgical Wherever you are treated, everything Management of Miscarriage (SMM) should be fully explained to you. or ERPC and can be done under general or local anaesthetic; For more detail see our leaflet Late • Take tablets to start or complete miscarriage. the miscarriage.

You may need time to think about what you want to do.

Our leaflet Management of miscarriage may be helpful.

4 33456_WhyMe_3425_DM:9828 MA preg loss 24/04/2013 11:43 Page 5

Recurrent miscarriage The tests may be carried out at your This is the medical term for three or local hospital or at a specialist centre. more miscarriages in a row. They may Having tests doesn’t necessarily mean have different causes or the same you will have an answer as to why you underlying cause. Sometimes there is miscarried. And even if a cause is more than one problem that might found, it may not be something that cause your miscarriages. can be treated. But you might still feel Doctors usually offer to do tests for better if you know what might have possible causes only after three caused your miscarriages. miscarriages. But sometimes they will Half of the people who have tests refer you for tests after two, e.g.: after recurrent miscarriage don’t have • If you had a late miscarriage, where a specific problem found. That can be the baby died after 14 weeks of difficult to accept, but it is actually pregnancy good news. It means there is a very good chance that you will have a • If you have fertility problems, such healthy pregnancy without any as taking a long time to conceive particular treatment.

There is more detailed information in our leaflet Recurrent miscarriage.

Being told all my tests were ‘normal’ was initially

“ heartbreaking. I remember

feeling angry with the consultant for not finding something and I couldn’t “ help but feel this was the worst news possible. I wanted a reason and a cure.

5 33456_WhyMe_3425_DM:9828 MA preg loss 24/04/2013 11:43 Page 6

Other types of Molar pregnancy pregnancy loss (hydatidiform mole) There are two other ways that This is when an abnormal fertilised egg pregnancy loss can happen: starts to grow in the uterus. The cells that should become the placenta grow Ectopic pregnancy too quickly and leave no room for a baby to develop. This is a pregnancy that is growing in the wrong place – usually in one of Because pregnancy hormones are the fallopian tubes leading to the made by the placenta, you will have a uterus. In this case, it is sometimes positive pregnancy test and may feel called a tubal pregnancy. extremely tired and sick.

A tubal ectopic pregnancy can’t Sometimes a molar pregnancy can be develop because there isn’t enough seen on a scan. But it is more likely to room for the embryo to grow beyond be discovered after a miscarriage about eight weeks. There is also a risk through routine tests. that the tube could burst, which can be life-threatening. If you have had a molar pregnancy you will be referred to a specialist centre Ectopic pregnancy may be diagnosed for follow-up; and this can be a very before you even know you are worrying time. pregnant. Often the first sign is bad pain, usually on one side of your There is more information in our abdomen. leaflet Molar pregnancy.

Some women with ectopic pregnancies can be treated with The blood tests

medication called methotrexate; but showed that my others need an emergency operation “hormone levels

to remove the pregnancy and were far beyond sometimes the tube too. It can be a anything normal.“ very frightening time. That explained why There is more information in our I had been feeling leaflet Ectopic pregnancy. so unwell.

6 33456_WhyMe_3425_DM:9828 MA preg loss 24/04/2013 11:43 Page 7

Causes, tests and Hormonal causes treatment Women with high levels of a chemical This section looks at the known called ‘luteinising hormone’ (LH) in causes of miscarriage and tests and their blood may find it harder to treatments that may help. conceive; and when they do conceive, they are more likely to miscarry. Around half of miscarriages are due to the first cause, genetic abnormalities. In many cases scans show a problem The other causes listed are much less called ‘polycystic ovaries’. This is when common, or even very rare. the ovaries, which make the eggs, contain small cysts that shouldn’t be Genetic causes there. About half of all early miscarriages are Some women are found to have caused by one-off genetic faults in the ‘polycystic ovary syndrome’ (PCOS), egg or the sperm, or in how the which is a more serious hormone fertilised egg develops. We don’t know disorder. what causes these faults, though they are more common with older Despite a lot of research into these mothers. hormonal problems, there is still no tried and tested treatment. However, If your miscarriage was caused by this you may be offered treatment as part type of random genetic fault, there is a of a research trial. good chance that your next pregnancy will be healthy.

In a very few cases miscarriage is caused by a genetic fault in the mother or father. This would be picked up in routine testing after recurrent miscarriage. If you or your partner are found to have such a problem you will be offered genetic counselling. This can

help you understand the chances of it

affecting future pregnancies and help you think about trying again. When I miscarried I cou“ ldn't understand how everything could go so horribly wrong when I “already had a perfect daughter, and not one single health problem.

7 33456_WhyMe_3425_DM:9828 MA preg loss 24/04/2013 11:43 Page 8

I’ve found lots of Antiphospholipid antibody

information on the syndrome (also called APS, “internet, but Hughes syndrome or sticky different sites say “ blood syndrome different things. It’s This is when antibodies called ‘lupus really hard to know anti-coagulant’ or ‘anti-cardiolipin’ in what to believe. the mother’s blood cause problems in the placenta. Blood clots may form in the placenta and it may not develop Progesterone and hCG normally. (human chorionic High levels of these antibodies are gonadotrophin) found in up to 15 per cent of women The hormone progesterone is needed who have recurrent miscarriages. to establish a pregnancy and keeping it going. HCG keeps progesterone levels Blood tests can show whether high and helps the placenta to develop. antibody levels are high. But you can be sure you have APS only after two Some women are found to have low positive tests at least six weeks apart. levels of one of these hormones during their pregnancy or after Treatment for APS is aimed at miscarriage. But it is difficult to know preventing blood clots. Most women whether this caused the miscarriage are treated with low doses of aspirin, or is just a sign of things going wrong. starting early in pregnancy or even before conception. Doctors Some doctors prescribe progesterone sometimes also recommend injections or hCG in the hope of preventing with another blood-thinning drug miscarriage. There is no proof that it called ‘heparin’. This is normally given works but it is unlikely to do any once you are pregnant and the baby’s harm. heartbeat has been seen on a scan.

More research is under way to test Your should not start taking aspirin unless the value of hormone treatment. it has been prescribed by your doctor.

Research is still being done to work out how these antibodies are linked to miscarriage and what treatment works best.

For more information, see ourleaflet Antiphospholipid syndrome and pregnancy loss.

8 33456_WhyMe_3425_DM:9828 MA preg loss 24/04/2013 11:43 Page 9

Infection and Chlamydia miscarriage This infection is usually sexually Mild infections like coughs and colds transmitted; but a rare form called are not harmful in pregnancy, but very Chlamydia psittaci , can be caught high fevers and some illnesses can from touching infected cattle or sheep, increase the risk of miscarriage. If an particularly during lambing or calving. infection causes miscarriage, it tends Chlamydia can lead to miscarriage, to happen only once because your ectopic pregnancy or premature body will become immune to the labour; it can also harm your fertility. infection. Toxoplasmosis Infections of the vagina or This is a parasitic infection sometimes uterus carried by cats. It can be caught These can be a cause of late through contact with soiled cat litter, miscarriages (after 14 weeks). The with contaminated soil or through infection may cause the baby to die in eating poorly cooked contaminated the uterus; or it may make your meat. waters break prematurely. Parvovirus Doctors can test for this kind of This is a viral infection, which is infection and treat it if necessary. sometimes called ‘slap-cheek’. Although Sometimes your partner also needs it can cause miscarriage, most women treatment to avoid re-infecting you. who are infected have a normal pregnancy. Listeria This is caused by eating unpasteurised Other infections cheese and other dairy products. It Some other infections are especially isn’t usually harmful to women but it harmful in pregnancy although they can be a cause of late miscarriage. don’t usually cause miscarriage. These include cytomegalovirus (CMV), rubella (German measles), genital herpes and HIV.

9 33456_WhyMe_3425_DM:9828 MA preg loss 24/04/2013 11:43 Page 10

Anatomical problems Fibroids Miscarriage is sometimes caused by These are harmless growths that can problems with your uterus or cervix develop inside the uterus; more rarely (neck of the womb. Your doctor may they develop outside the uterus. Small refer you to a specialist for further fibroids are fairly common and don’t assessment and possibly treatment. usually cause problems in pregnancy; but large ones can be a cause of Weak cervix (also called miscarriage. ‘incompetent cervix’) If you have a very large fibroid that has Your cervix is a kind of ‘gateway’ changed the shape of your uterus, between your uterus and vagina. your doctor may suggest removing it During a normal birth the cervix under anaesthetic before you get dilates (widens) to allow the baby to pregnant again. be born.

Some women – probably less than one Irregular-shaped uterus in a hundred – have a weakness in the Your uterus is formed from two cervix. This means it may dilate too separate tubes that fused together early, leading to premature labour or before you were born. Sometimes, late miscarriage. though, this goes wrong and the uterus develops an irregular shape. Sometimes the weakness has been There may not be enough room for there since birth; but the cervix can the baby to grow and this can lead to become weak as a result of previous miscarriage, usually after 14 weeks. surgery or injury. If you have this problem and your A weak cervix can be difficult to doctor thinks it may have caused your diagnose. If your doctor suspects it, miscarriage, he or she might suggest perhaps because of your pregnancy or an operation to correct or reduce it. medical history, he or she may suggest You should be given clear information putting in a ‘cervical stitch’. to help you decide: this will include the possible risks of surgery and how This involves stitching a tape around likely it is to improve your chance of the cervix to support it and to try to having a healthy pregnancy next time. stop the baby being born too early.

For more information, see our leaflet About the cervical stitch.

10 33456_WhyMe_3425_DM:9828 MA preg loss 24/04/2013 11:43 Page 11

Other causes of Rhesus negativity miscarriage If your blood group is Rhesus negative and you miscarry or bleed in Abnormal development of pregnancy, you may need a special the baby injection known as ‘anti-D’. This is to Some miscarriages are caused by prevent you developing antibodies that problems in the baby. These include could cause problems in the next spina bifida and heart defects. pregnancy. It is important to know that having a Illness in the mother Rhesus negative blood group will not Some chronic illnesses like diabetes actually cause a miscarriage. and kidney disease are linked with miscarriage. If you have such an illness For more information see our fact and are taking long term medication, sheet on anti-D.

you should probably talk to your GP

or a specialist before getting pregnant again. In this day and age it’s unusual to have something “ happen to you and for you to never to know why. “ Something so important and life-changing. Years later, I still have moments where I wonder ‘why?’.

11 33456_WhyMe_3425_DM:9828 MA preg loss 24/04/2013 11:43 Page 12

Personal factors Weight This section looks at things about you Women who are very underweight or and your lifestyle that could affect very overweight are more likely to your risk of miscarriage. miscarry

Age Diet Your risk of miscarriage increases as Your risk of miscarriage may be higher you get older. One reason is that older if you: eggs are more likely to be abnormal. • Eat unpasteurised dairy products, But even if you are in your early 40s, such as blue cheese, which can with up to three miscarriages, the cause listeria; odds are still in your favour; you are • Eat raw or undercooked meats, more likely to have a successful which can cause toxoplasmosis. This pregnancy than another miscarriage 3. is especially harmful before conception or in the first three It’s not just your age that counts. months of pregnancy; Research shows that babies of older fathers are also more likely to miscarry, • Eat raw or partly cooked eggs, as in even when the mother is young 4. home-made mayonnaise or mousse; this can cause salmonella infection; Pregnancy and fertility • Take in large amounts of caffeine, problems especially in coffee, tea, cola and Your risk of miscarriage is higher if: energy drinks. Drinking more than • You have miscarried before, two or three cups of coffee a day is especially after three miscarriages thought to increase your risk of miscarriage • You have taken a long time to conceive: women who take more • Drink regularly, heavily or in than a year to conceive are twice ‘binges’. The highest risk is if you as likely to miscarry as those who drink alcohol every day and/or conceive within three months drink more than 14 units in a week. • You are pregnant with twins, If you eat a well-balanced diet, with triplets or more; this applies plenty of fruit and vegetables, you may

whether they were conceived have a lower risk of miscarriage. 4

naturally or with help from fertility treatment. I did everything I should have – healthy diet, no “ alcohol or smoking, taking folic acid etc. I know “there’s no order of how things happen in life, but after doing everything right, it just feels so unfair.

12 33456_WhyMe_3425_DM:9828 MA preg loss 24/04/2013 11:43 Page 13

Smoking, drugs and Things you don’t need medicines to worry about Your risk of miscarriage may be higher These are things that don’t seem to if you: increase the risk of miscarriage even • Smoke regularly in pregnancy. though people often worry about If your partner smokes, his sperm them in pregnancy: can be affected and this may also • Exercise increase the risk of miscarriage; • Working full time • Take drugs like cocaine, crack and heroin; • Work that involves sitting or standing for long periods • Use some over-the-counter medicines, such as ibuprofen; • Heavy lifting • Take particular prescribed • Sex medicines, including some • Travel by air antidepressants. You may need to ask your doctor which medicines • Eating spicy food are safe in pregnancy. • Being pregnant for the first time

Stress and work • Getting pregnant soon after a previous birth or miscarriage Women under stress are more likely to miscarry; and the more stressful • Living near electric pylons or events they go through, the higher the mobile telephone masts risk. • Not wanting to be pregnant or But we can’t be sure that stress on its thinking about termination. own actually causes miscarriage.

Work that is demanding and very

stressful may increase the risk of I am having a

miscarriage, especially if the stress second miscarriage goes on for a long time. “and worry i“ f this is Your risk of miscarriage may be higher because I fell so if you are exposed to such workplace quickly after the hazards as toxic chemicals, solvents, first. lead or radiation.

13 33456_WhyMe_3425_DM:9828 MA preg loss 24/04/2013 11:43 Page 14

Why me: a summary There is still a lot we don’t understand about the causes of miscarriage.

It can be difficult to know how much to believe what you hear from friends, family or the media.

And it can be very hard to tell the difference between proper research evidence and unproved theories.

You may never know exactly why you miscarried; and that uncertainty can be very hard to live with.

But the good news is that most women who miscarry – even several times – go on to have a healthy pregnancy in the end. And that often happens without any treatment at all.

Recovering from two “ miscarriages is a work in progress – it never really leaves you. But I am proud and comforted to know that I did my best,

that it wasn’t my fault.

When life throws you the ball, sometimes you are“ n’t going to catch it, but next time you might.

14 33456_WhyMe_3425_DM:9828 MA preg loss 24/04/2013 11:43 Page 15

Useful reading References Leaflets from the Miscarriage 1 Stray-Pederson & Stray-Pederson Etiologic factors and subsequent reproductive performance in Association: 195 couples with a prior history of habitual Antiphospholipid syndrome and pregnancy abortion . American Journal of Obstetrics & Gynaecology. 1984; 148: 2 : 140-146 loss 2 Liddell, Pattinson & Zanderigo Recurrent Ectopic pregnancy miscarriage – outcome after supportive care in early pregnancy . Australian & New Zealand Hydatidiform mole Journal of Obstetrics & Gynaecology. 1991; 31: 4: 320-322 Management of miscarriage 3 Brigham, Conlon & Farquharson A longitudinal Recurrent miscarriage study of pregnancy outcome following idiopathic recurrent miscarriage. Human Reproduction. Late miscarriage 1999; 14: 11 : 2868-2871 4 N Maconochie, P Doyle, S Prior, R Simmons. Patient information from the Royal Risk factors for first trimester miscarriage: results College of Obstetricians & from a UK-population-based case-control study . BJOG, 2007; 114(2): 170-186 Gynaecologists: Early miscarriage Recurrent and late miscarriage Ectopic pregnancy

All available on www.rcog.org.uk/womens- health/patient-information

Need to talk to someone who understands? Call our support line on 01924 200799. Monday to Friday, 9am-4pm Or email [email protected]

15 33456_WhyMe_3425_DM:9828 MA preg loss 24/04/2013 11:43 Page 16

The Miscarriage Association 17 Wentworth Terrace Wakefield WF1 3QW Telephone: 01924 200799 e-mail: [email protected] www.miscarriageassociation.org.uk

Why/04/13