The widespread annual incidence of miscarriage is estimated to impact one in 10 women in their lifetime, but experts say it needs better diagnosis, investigation and management according to a substantial three-part report published in medical journal The Lancet in April.
Dr Dean Conrad, obstetrician, gynaecologist and specialist with City Fertility said he usually only sees patients after they have had two or three miscarriages and are often very anxious by this stage.
“There is a pervasive view in women’s health that ‘common’ is the same as ‘normal’”, Dr Conrad said.
“Although miscarriages are common, dismissing them as ‘normal’ ignores the devastating impact many women experience. As a consequence, it is often only at the second or third miscarriage that women are provided with the appropriate care they need.”
The substantial three-part report by international leaders in the medicine of early pregnancy states that while estimates suggest an annual miscarriage incidence rate of 15%, recurrent miscarriages are 2% and three or more is less than 1%. But these figures may be well underestimated ‘as many miscarriages are managed at home and go unreported or unrecognised.
The report recommends that after the first miscarriage, patients should be provided with information about miscarriage and guidance to support future pregnancy in the form of patient groups, online self-help, or lifestyle services. Following two miscarriages it recommends an appointment with a miscarriage clinic (or gynaecologist) for full blood count and thyroid function tests and discussion of risk factors. After three miscarriages, additional tests and treatments are advised under the care of a medical consultant: ‘Genetic testing of pregnancy tissues should be offered’ as well as pelvic ultrasound and, if necessary, parental genetic testing’.
Dr Conrad said most health organisations in Australia recommend seeking specialist advice after three miscarriages.
“After the first miscarriage I agree with the report’s recommendations that patients should be provided with guidance and information about miscarriage, and not just told to ‘just try again’ and be sent away.”
“But waiting until three miscarriages for specialist advice represents a missed opportunity to have early investigations to exclude preventable causes and avoid the devastating consequences of a miscarriage.”
Dr Conrad said at City Fertility, the recommended tests include investigation of parental chromosomes (to rule out structural rearrangement) as well as lupus, diabetes, thyroid, antiphospholipid syndrome and a detailed pelvic ultrasound. It is also important to identify male factors by undertaking sperm studies.
“Additionally, for couples experiencing recurrent miscarriages or failed IVF attempts, pre-implantation genetic testing (PGT) may increase IVF conception rates by helping to identify the normal embryos. This method prioritises the embryos for transfer most likely to produce an ongoing pregnancy.
Facts about miscarriages:
- They are estimated to affect up to one in ten women or about 1 in 4 pregnancies .
- They mostly occur in the first 12 weeks but can occur up to 24 weeks.
- The risk of miscarriage reduces significantly with advancing gestation. Recent research reported once a pregnancy reaches six weeks’ gestation there is only a 9.4 per cent chance of miscarriage and this reduces to a 0.7 per cent chance by 10 weeks.
- After three or more miscarriages (known as recurrent miscarriages), tests are commonly done to look for the cause.
- Many risk factors have been implicated in miscarriage but uterine malformations and parental balanced chromosomal rearrangements are the most commonly recognised ones.
- Other risk factors include: advancing age; lifestyle (particularly smoking, caffeine, alcohol, drugs and weight); medical conditions (such as uncontrolled diabetes, fibroids and thyroid problems); diagnostic procedures (amniocentesis); and cervical abnormalities.
- Research suggests about 9 out of 10 miscarriages 5 happen because chromosomes in the embryo are abnormal and the pregnancy does not develop properly from the start.
- Investigating the cause of miscarriage can include: looking at lifestyle factors; checking parental chromosomes; carrying out blood tests to check for diabetes, thyroid and other issues; a hysteroscopy and ultrasound to investigate uterine and cervical problems; and semen tests to check sperm quality.
 Miscarriage: ‘The era of telling women to “just try again” is over’ ESHRE Focus on Reproduction, 5 May 2021 https://www.focusonreproduction.eu/article/News-in-Reproduction-Miscarriage-report
 Quenby S, Gallos ID, Dhillon-Smith RK, et al. Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. Lancet 2021; https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00682-6/fulltext
 Coomarasamy A, Dhillon-Smith RK, Al-Memar M, et al. Sporadic miscarriage: evidence to provide effective care. Lancet 2021; https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00683-8/fulltext
 3. Coomarasamy A, Dhillon-Smith RK, Papadopoulou A, et al. Recurrent miscarriage: evidence to accelerate action. Lancet 2021. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00681-4/fulltext
 Royal Australia and New Zealand College of Obstetricians and Gynaecologists, Pregnancy Loss, 2019 https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Patient%20information/Pregnancy-Loss_2.pdf?ext=.pdf