Arri Coomarasamy, Professor of Gynaecology, University of Birmingham, and Director of the Tommy’s National Centre for Miscarriage Research, writes...
In my first month as a senior house officer in obstetrics and gynaecology, I observed a stark contrast. I was diligently shadowing an experienced registrar as part of my induction. There was a woman who’d had a stillbirth, and the registrar’s job was to seek permission for a post-mortem of the baby. The registrar was solemn, deeply thoughtful and caring, took the time to listen, and I recall her sitting down and holding the woman’s hand, as she spoke. I thought this registrar was not just offering medical assistance, but also there to heal and empathise.
A little while later, we were called to see a woman who’d had a miscarriage, and now the registrar’s job was to offer the options of either ‘medical management’ with tablets, or surgery. She was visibly irritated as to why this job had landed on her, and could not have been done by the GP-trainee on duty. She walked briskly into the room where the couple were, explained the options, and when the couple chose surgery, asked me to sort out the paperwork, and left. It took a maximum of 3 minutes. I didn’t think my registrar had noticed that the couple were crying. The couple told me that they thought it was a girl, and they were calling her Sarah; I realised that it was Sarah that I had referred to as ‘products of conception’ a little while earlier when I obtained consent for the surgery.
Miscarriage is often minimised by healthcare providers and endured in silence by women. Why is that? Is it because it is so common? But something being common is not an explanation or consolation to the couple who have experienced a miscarriage. Is it because people think it wasn’t ‘really a baby’, because there weren’t any outward signs of pregnancy? A woman doesn’t need to have a swollen belly to bond with a new life. Is it because miscarriage can be seen to be an isolated physical event? Yet miscarriage is a major life event for many couples and can have profound mental health effects for years to come. Is it because we feel hopeless that nothing can be done to stop a miscarriage? Well, this misconception needs to be dispelled. We know, for example, progesterone hormone treatment can reduce the risk of miscarriage in women with a history of miscarriage and current pregnancy bleeding. There are steps that can be taken to improve the outcomes.
Our new Lancet Series of 3 articles aims to put the record straight. It is calling for an overhaul in our thinking about miscarriage and how we approach the care we provide to women at risk of or suffering from a miscarriage.
Our first paper documents the toll miscarriage takes (1) – an estimated £471 million per year in the UK, as a short-term economic impact, on top of the human cost of this issue. An estimated 23 million miscarriages occur every year worldwide, translating to 44 pregnancy losses each minute. The miscarriage risk is 15% of all recognised pregnancies. The population prevalence of women who have had one miscarriage is 11%, two miscarriages is 2%, and three or more miscarriages is 0.7%. Risk factors for miscarriage include very young or older female age (younger than 20 years and older than 35 years), older male age (older than 40 years), very low or very high body-mass index, Black ethnicity, previous miscarriages, smoking, alcohol, stress, working night shifts, air pollution, and exposure to pesticides. The consequences of miscarriage are both physical, such as bleeding or infection, and psychological: increases in the risk of anxiety, depression, post-traumatic stress and suicide. Miscarriage - and especially recurrent miscarriage - is linked to complications in future pregnancies, including fetal growth restriction, placental abruption, and premature birth or even stillbirth. It’s also a predictor of longer-term health problems, such as cardiovascular disease and venous thromboembolism.
Our second paper in the Lancet Series addresses sporadic miscarriage (2). It emphasises the importance of early pregnancy services providing an effective ultrasound service (which is central to the diagnosis of miscarriage) and being able to provide expectant management of miscarriage, medical management with mifepristone and misoprostol, and surgical management with manual vacuum aspiration. Women with the dual risk factors of early pregnancy bleeding and a history of previous miscarriage can be recommended vaginal micronised progesterone to improve the prospects of livebirth (3). Healthcare funders and providers are urged to invest in early pregnancy care, with specific focus on training for clinical nurse specialists and doctors to provide comprehensive miscarriage care within the setting of dedicated early pregnancy units.
Our third paper in the Lancet Series addresses recurrent miscarriage (4). The paper urges caregivers to individualise care according to the clinical needs and preferences of women and their partners. The recommended essential investigations include measurements of lupus anticoagulant, anticardiolipin antibodies, thyroid function, and a transvaginal pelvic ultrasound scan. The key treatments to consider are first trimester progesterone administration, levothyroxine in women with subclinical hypothyroidism, and the combination of aspirin and heparin in women with antiphospholipid antibodies. Appropriate screening and care for mental health issues and future obstetric risks - particularly preterm birth, fetal growth restriction and stillbirth - will need to be incorporated into the care pathway for couples with a history of recurrent miscarriage. The paper concludes with a recommendation for the healthcare services to structure care using a graded model in which women are offered online healthcare advice and support, care in a nurse or midwifery-led clinic, and care in a medical consultant-led clinic, according to clinical needs.
Families should not suffer the heartache of miscarriage in silence. Healthcare providers should not minimise miscarriage. We hope the clarion call of the Lancet Series represents a turning point in miscarriage care. I have lost touch with my registrar, but I hope the Lancet articles find her.
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- Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. Lancet. Quenby S et al. DOI:https://doi.org/10.1016/S0140-6736(21)00682-6
- Sporadic miscarriage: evidence to provide effective care. Lancet. Coomarasamy A et al. DOI:https://doi.org/10.1016/S0140-6736(21)00683-8
- Progestogens for preventing miscarriage: a network meta-analysis. Devall AJ, Papadopoulou A, Podesek M, Haas DM, Price MJ, Coomarasamy A, Gallos ID. Cochrane Database Syst Rev. 2021 Apr 19;4:CD013792. DOI:https://doi.org/10.1002/14651858.CD013792.pub2
- Progestogens for preventing miscarriage: a network meta-analysis. Lancet. Coomarasamy A et al. DOI:https://doi.org/10.1016/S0140-6736(21)00681-4