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Causes and risk factors of miscarriage

There is still a lot we don’t understand about the causes of miscarriage. 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 people who miscarry – even several times – go on to have a healthy pregnancy. And that often happens without any treatment at all.

Things you don’t need to worry about

These are things that don’t seem to increase the risk of miscarriage even though people often worry about them in pregnancy:

  • Anxiety
  • Exercise
  • Working full time
  • Work that involves sitting or standing for long periods
  • Heavy lifting
  • Sex
  • Flying
  • Eating spicy food
  • Being pregnant for the first time
  • Getting pregnant soon after a previous birth or miscarriage
  • Living near electric pylons or telephone masts
  • Not wanting to be pregnant or thinking about termination.

“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.”

Risk factors

Even if one or more of these apply to you, it may be something else entirely that caused your loss. You can’t change your age, your pregnancy or fertility history or your ethnicity. All you can do is to be aware of them and how they might affect your future fertility.

Miscarriage risk increases with age. It is highest if you are over 40 and miscarriages may also be more common if the biological father is over 40.

Women are born with all the egg cells they will ever have. The older you are, the older your egg cells and the more likely they are to carry a genetic error. There seem to be age-related issues with male sperm too. But even in your early 40s with up to three miscarriages, you are still more likely to have a healthy pregnancy than another miscarriage.

Risk increases with the number of miscarriages you have had in the past. But even after three miscarriages, most people will have a healthy pregnancy next time. 

The risk of miscarriage increases if:

  • you have miscarried before, especially after three miscarriages
  • it has taken more than a year to conceive
  • you are pregnant with twins or more.

Black and Black mixed heritage women have a 43% higher risk of miscarriage compared to white women. They also have an increased risk of stillbirth and are more likely to suffer poor maternal outcomes. Researchers are working to find out why this is and whether there are any actions that could reduce the risk.

If you already are what’s considered a healthy weight (BMI between 19 and 25), there’s no need to change.  If not, your GP or practice nurse may be able to advise and support you.  If you smoke, they will be able to support you in stopping. Experts agree that it is best to limit the amount of caffeine you drink (tea, coffee or caffeinated soft drinks) to two cups or glasses a day.  They also advise either not to drink alcohol at all or to avoid drinking regularly or to excess.

Some medicines like Ibuprofen may increase miscarriage risk.  If you take regular prescribed medicine, including some anti-depressants, it’s best to ask your doctor which are safe in pregnancy and not just stop them yourself.

Overall, research suggests that there is a link between stress and miscarriage –miscarriage or being pregnant after loss can cause stress.  But there is no clear evidence that stress causes miscarriage.  Your risk of miscarriage may be higher if you are exposed to workplace hazards such as toxic chemicals, solvents, lead or radiation. Research also suggests that working nights, shifts and/or long hours are linked to increased miscarriage risk, but again, don’t necessarily cause it.

Mild infections like coughs and colds are not harmful in pregnancy, but very high fevers and some serious infections can cause or increase the risk of miscarriage. If an infection causes miscarriage, it tends to happen only once because your body will then become immune to the infection.

Sometimes an infection of the vagina or uterus can cause late miscarriage (from 14 weeks). The infection may cause the baby to die in the uterus; or it may make your waters break prematurely. Doctors can test for this kind of infection and treat it if necessary.  Depending on the infection, your partner may need treatment to avoid re-infecting you.

This is caused by eating unpasteurised cheese and other dairy products, pâté or uncooked smoked fish. It isn’t usually harmful to non-pregnant women but it can be a cause of late miscarriage.

This infection is usually sexually transmitted; but a rare form called Chlamydia psittaci, can be caught from touching infected sheep or cattle, particularly during lambing or calving. Chlamydia can lead to miscarriage, ectopic pregnancy or premature labour; it can also harm your fertility if left untreated.

This is a parasitic infection sometimes carried by cats. It can be caught through contact with used cat litter, with contaminated soil, or through eating poorly cooked contaminated meat.

This is a viral infection, which is sometimes called ‘slap-cheek’. Although it can cause miscarriage, most women who are infected have a normal pregnancy.

Some other infections are especially harmful in pregnancy although they don’t usually cause miscarriage. These include cytomegalovirus (CMV), rubella (German measles), genital herpes and HIV.

Causes of miscarriage

Chromosome problems

The chromosomes in every cell of your body carry information in the form of genes. A baby inherits half its chromosomes from each parent. About half of all miscarriages are caused by random (one-off) genetic faults in the egg or the sperm, or in how the fertilised egg develops.

We don’t know what causes these faults, although they are more common in women in their late 30s and older. If your miscarriage was caused by a random genetic fault, there is a 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. 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.

Antiphospholipid syndrome (APS)

This is a blood clotting disorder, sometimes called ‘sticky blood syndrome’. It happens when your immune system makes abnormal antibodies that can cause blood clots in the placenta or stop the embryo from implanting properly, causing an early miscarriage.

APS can also cause problems in later pregnancy, including the baby not growing enough, pre-eclampsia or stillbirth. It also increases your risk of developing blood clots.

If you are found to have APS, you will be treated with low dose aspirin tablets and heparin injections.  Together, these make your blood less likely to clot and can increase your chance of having a live baby.

You should not start taking aspirin unless it has been prescribed by your doctor.

You will have blood tests to check for antiphospholipid antibodies (aPL). They will test the blood for three types of antibodies. The reason for the three tests is that they measure aPL in different ways which means that one test alone could miss the diagnosis:

  • lupus anticoagulant (LA)
  • anticardiolipin antibody (aCL)
  • anti beta-2 glycoptein I antibodies

Don’t be confused by the first of these, “lupus anticoagulant”, which is a rather misleading term. It doesn’t mean you are being tested for lupus. And it doesn’t mean you have an anticoagulant (blood thinner) in your blood.

If any of the tests are positive, they should be repeated. This is because aPL can occur just for a short time due to infection or some medicines. Another reason for repeating the test is that antibody levels vary over time.

Laboratories differ in the way they measure their tests, so it is not possible to provide a single guideline indicating the positive and negative ranges. However, your results should show whether you are negative or positive, according to your laboratory’s specific classification.

You will be diagnosed with APS if you have:

  • two positive tests for aPL, taken at least 12 weeks apart and one or more of the following:
  • a history of three or more first trimester miscarriages, with no other cause being found.
  • previous pre-eclampsia and intrauterine growth restriction, resulting in a baby being born before 34 weeks.
  • a second or third trimester pregnancy loss or stillbirth.
  • a previous thrombosis (blood clot).

Antiphospholipid antibodies (aPL) can cause different problems at different stages of pregnancy in different women. In some women with aPL, in the first 13 weeks, the antibodies can prevent the pregnancy from embedding properly in the womb, increasing the chances of a first trimester miscarriage. In the second and third trimesters of pregnancy (from 14 weeks gestation until birth), aPL in some women can cause blood clots in the placenta, This can lead to poor blood and oxygen supplies to the baby, causing poor growth, pre-eclampsia or even stillbirth. Some women with aPL will have no problems in pregnancy at all. Researchers are still trying to find out more about the link between APS and pregnancy loss.

If you are diagnosed with APS, you may well have no other symptoms or conditions. Some people with APS, however, have one or more of the following:

  • Approximately one fifth of people with APS have a blotchy, mottled appearance to their skin.
  • A tendency to bruise easily. This is unusual. Occasionally women with APS have a low platelet count (platelets are cells in the blood that help the blood to clot).
  • Blood clots in the vein. The most common blood clot in the vein is a deep vein thrombosis (DVT) of the leg.
  • There may be a history of joint pain or swelling in the joints (arthritis).
  • Neurological problems – some people with APS have migraine-like symptoms or brief loss of vision or balance, or even stroke.
  • Abdominal or heart disease – rarely, APS can cause liver, heart or kidney problems, due to blood clots. If you are diagnosed with APS, you may be referred for tests such as an echocardiogram of your heart, to check that it is healthy.

Unfortunately, there is no cure for APS, but treatment can improve your chances of having a healthy future pregnancy. Once you have an APS diagnosis, you will likely be given daily doses of aspirin or daily injections of a drug called heparin – sometimes you might be prescribed both. These aim to prevent blood clots and are safe to take during pregnancy. Sometimes, where a person has APS and has experienced a blood clot (thrombosis) already, the blood thinner Warfarin is prescribed. However, it is not recommended during pregnancy as it carries a small risk of causing birth defects. If you have been taking Warfarin and become pregnant, don’t simply stop taking it – speak to your GP or specialist so they can change the medication, usually to heparin. You will continue to take medication throughout a future pregnancy and for several weeks after birth to help prevent blood clots. Never stop taking your medication unless your health professional tells you to.

Other blood clotting problems

Some inherited blood clotting disorders can cause recurrent miscarriage. Some of these, such as Factor V Leiden and Protein S deficiency are linked to a slightly higher risk of miscarriage.  If you have one of these problems, you might be offered heparin injections in your next pregnancy, depending on your individual circumstances.

Cervical weakness (also sometimes called ‘incompetent cervix’)

Your cervix is a kind of ‘gateway’ between your uterus and vagina, and it normally dilates (widens) during labour to allow the baby to be born.  If the cervix is weakened or damaged, it might dilate too early in pregnancy. This is a known cause of some second trimester (late) miscarriages.

A weak cervix can be difficult to diagnose.  If your doctor suspects it, perhaps because of your pregnancy or medical history, they may offer you regular scans of the length of your cervix in your next pregnancy.  They might suggest putting in a ‘cervical stitch’ in your next pregnancy – an operation that may reduce the risk of the cervix opening too early. The Royal College of Obstetricians and Gynaecologists have more information on this procedure here: https://www. rcog.org.uk/for-the-public/browse-ourpatient-information/cervical-stitch/

Abnormally shaped uterus or other uterine problems

A small number of women (5-6 in 100) are born with an unusually shaped uterus. This is somewhat more common (13 in 100) in women with recurrent miscarriage, so it is considered a possible cause of miscarriage.

Your uterus is formed from two separate tubes that fused together before you were born. Sometimes, though, the uterus develops an irregular shape, for example, a septate or bicornuate uterus.

There may not be enough room for the baby to grow inside the uterus and this can lead to miscarriage, usually after 14 weeks. If you have this problem and your doctor thinks it may have caused your miscarriage, they might suggest an operation to correct or reduce it. You should be given clear information to help you decide whether or not to have surgery. This will include the possible risks of the operation and how likely it is to improve your chance of having a healthy pregnancy next time.

Fibroids or scar tissue

Fibroids are harmless growths that can develop inside the uterus or, more rarely, outside the uterus. Small fibroids are fairly common and don’t usually cause problems in pregnancy, but large ones can be a cause of miscarriage. If you have a very large fibroid that has changed the shape of your uterus, your doctor may suggest removing it under anaesthetic before you get pregnant again. Scar tissue in your uterus, caused by previous surgery or infection, may also affect your risk of miscarriage, but this depends on its extent and position.

Hormonal problems

There are several hormonal conditions that are sometimes linked to miscarriage. Polyendocrine metabolic ovarian syndrome (PMOS), previously know as Polycystic ovarian syndrome (PMOS) is associated with an increased risk of miscarriage and it can also mean that it takes longer to conceive.

This may be due to increased levels of insulin and the hormone testosterone that many women with this condition have, but the relationship is not clear.  Despite research, there is no recommended treatment for PMOS but there are some treatments which may help and your doctor will be able to advise you.

Thyroid disease or high levels of thyroid stimulating hormone (TSH) or thyroid antibodies may increase miscarriage risk. If you are found to have either diabetes or thyroid disease, you will be supported to control this as well as possible before your next pregnancy.

Abnormal levels of the hormone prolactin may increase the risk of miscarriage.  There is no recommended treatment if you have a prolactin imbalance, but you might be offered treatment as part of a clinical trial.

Many people ask about treatment with progesterone supplements as a way to prevent miscarriage. Research has shown that for women with bleeding in early pregnancy and a history of recurrent (multiple) miscarriages, progesterone treatment slightly reduced their chances of miscarrying. This treatment is now recommended and early pregnancy units will discuss with women when they might be offered it.

Signs and symptoms

If you think you’re having a miscarriage, find out the common signs and symptoms.

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