EDITORIAL

Effect of miscarriage on
future pregnancies
“...loss of a pregnancy causes great distress to couples and undermines their
confidence in achieving future reproductive success.”

Miscarriages occur in 12–15% of all clinically are comparable with women with a previous
recognised pregnancies [1] . However, early loss miscarriage. Women with a previous termina-
of a pregnancy causes great distress to couples tion of pregnancy at a similar gestational age
and undermines their confidence in achieving may provide a suitable comparison group, but
future reproductive success. To date, clinical data on abortion are difficult to obtain, and Sohinee
attention has mainly centered around the many databases do not distinguish between Bhattacharya†
m anagement of recurrent pregnancy loss, spontaneous and induced abortions.
which is known to have an adverse effect on Recurrent miscarriages occur in 1% of
subsequent pregnancies. By contrast, a single women. Despite their rarity, the effects of
miscarriage has not traditionally been perceived recurrent miscarriages on subsequent repro-
as a major clinical problem. It is rarely life ductive outcomes have dominated the litera-
threatening, its diagnosis and management ture. Relatively little is known about the con-
is usually s traightforward, and any prejudi- sequences of a single miscarriage on future Siladitya
cial effect on future reproductive potential reproductive health. Reproductive outcomes Bhattacharya
remains unproven. following miscarriage can include no further
pregnancies, miscarriage or ectopic preg-
“Despite their rarity, the effects nancy, termination of pregnancy, or ongoing
of recurrent miscarriages on pregnancy beyond 24 weeks resulting in either
subsequent reproductive outcomes live birth or stillbirth. In the section below we
have dominated the literature. consider each of these situations.
†
Author for correspondence
Relatively little is known about the Effect of miscarriage on future fertility Division of Applied Medicine,
consequences of a single miscarriage Following the loss of a wanted pregnancy, most School of Medicine, University of
on future reproductive health.” women are likely to keep trying until a live Aberdeen, Aberdeen Maternity
Hospital, Foresterhill, Aberdeen,
birth is achieved. Thus, the chances of concep- AB25 2ZD, Scotland
Research into the reproductive conse- tion following a miscarriage should be higher Tel.: +44 122 455 4672
quences of miscarriage presents a number of than those following a live birth. In a cohort Fax: +44 122 455 3708
c hallenges. The fi rst involves criteria for the of 261 women followed up for 6 years after a sohinee.bhattacharya@
diagnosis of the clinical entity itself. The cur- miscarriage, natural conception occurred in abdn.ac.uk
rent defi nition of miscarriage as spontaneous 97.7% of those without known fertility prob-
loss of pregnancy before 24 weeks of gestation lems [3] . Another study reported that the preg-
(fetal weight <500 g) has been strongly influ- nancy rate at 12 months was 76.2% in women
enced by advances in neonatal intensive care discontinuing contraception [4] . The slightly
and notions of perceived viability. Problems reduced pregnancy rates in the second study
with ascertainment and recall bias present may be explained by the shorter duration of
a second challenge. Most data on miscar- follow-up and nonexclusion of women prone
riage are derived from hospital episodes and to subfecundity owing to advanced age, obe-
therefore exclude cases occurring at home. sity or other lifestyle factors. A study involving
Self-reported cases of miscarriage in popula- Saudi Arabian women found a conception rate
tion-based surveys are susceptible to report- of 81.3% at 4 years, with 75.2% pregnancies
ing bias [2] . Third, epidemiological studies of occurring within the fi rst year [5] . Maternal
outcomes following miscarriage are limited by age had a strong influence on pregnancy rates,
the absence of an ideal comparison group. In which were 90% in women under the age of part of
terms of future obstetric events, neither parous 20 years, as opposed to 63.5% in women aged
women nor women in their fi rst pregnancies over 35 years.

10.2217/17455057.5.1.5 © 2009 Future Medicine Ltd Women's Health (2009) 5(1), 5–8 ISSN 1745-5057 5
EDITORIAL – Bhattacharya & Bhattacharya

Effect of miscarriage on subsequent the effects of a single miscarriage on a subse-

pregnancy loss quent continuing pregnancy [13] . We found that
A previous miscarriage is known to increase the women with a previous miscarriage were prone
likelihood of a subsequent pregnancy loss. In to adverse perinatal outcomes in the next preg-
1938, mathematical modeling by Malpas esti- nancy in comparison with; a) women who had
mated the risk of recurrence to be 73% [6] . While a successful first pregnancy; and b) women with
the risks for recurrence reported by subsequent no previous pregnancies. Women with a previ-
researchers have been lower, they remain mark- ous miscarriage were at higher risk of threatened
edly higher than that in control women. Stirrat miscarriage and preterm delivery. They were
coined the phrase ‘recurrent miscarriage’ to more likely to have interventions during labor
describe three or more consecutive miscarriages and delivery and their babies tended to be small
occurring in the same woman [7] . Although for their gestational age. However, despite evi-
initially an epidemiological concept based on a dence of statistical significance in terms of rela-
review of existing literature, the term ‘recurrent tive risks, the absolute risks of adverse perinatal
miscarriage’ has since dominated the clinical outcomes were low.
literature. As a clinical entity it enjoys a promi-
nence in terms of the need for formal investi- Effect of recurrent miscarriage
gations and management denied to the more There are a number of publications regarding
common ‘sporadic’ or isolated miscarriage. the risks of pregnancy complications following
There are few data on the risks of ectopic recurrent miscarriage, often reporting conflict-
pregnancy or induced abortion after miscar- ing results. Reginald et al. found increased rates
riage. Hassan and Killick reported higher odds of preterm delivery, small for gestational age
of ectopic pregnancy following miscarriage [4] . babies and perinatal deaths in pregnancies fol-
In addition, a previous live birth prior to the mis- lowing recurrent miscarriage [14] . Hughes et al.
carriage enhances the likelihood of an induced found these rates to be no higher than that in
termination. Despite reports of increased rates of the control population [15] . More recent stud-
termination for congenital anomalies, induced ies have reported higher risks of preterm deliv-
abortion following miscarriage is less common ery, growth retardation and perinatal mortality
than after either a previous live birth or an [16,17] . The risk of preterm delivery appears to
induced termination of pregnancy. be a consistent finding in pregnancies following
miscarriage and tends to show a dose-dependent
Effect on a subsequent rise in incidence [18] .
ongoing pregnancy
Over 70% of women who miscarry in their Effect of maternal age on
first pregnancy are destined to carry a subse- pregnancy outcomes
quent pregnancy beyond 24 weeks. However, Advanced maternal age has been consistently
as yet relatively little is known about the poten- shown to affect pregnancy outcomes [19] . Age
tial complications in this second pregnancy. has a profound effect not only on future preg-
An extensive search of the literature identified nancy outcome, but also on fertility itself [4,5] .
four publications. Of these, two focused exclu- On the other hand, increasing the interpreg-
sively on the effects of second trimester miscar- nancy interval following a miscarriage appears
riage [8,9] , while one was unable to distinguish to improve perinatal outcomes in the next preg-
between spontaneous and induced abortion [10] . nancy. A report of a WHO technical consul-
Nevertheless, all produced remarkably consis- tation on birth spacing recommends delaying
tent fi ndings. The risks of preterm birth and the next pregnancy for a minimum of 6 months
perinatal death were increased in women with a following a miscarriage or abortion in order to
previous miscarriage and were markedly higher optimize outcomes. This recommendation was
in cases of late miscarriage. Other complications based on the findings from a single large Latin
that were inconsistently shown to be more com- American study, which found that abortion–
mon in these women include pre-eclampsia [11] pregnancy intervals of less than 6 months were
and bleeding in early pregnancy [12] . These data associated with increased risk of preterm birth
need to be interpreted with caution since sam- and growth restriction [20] . By contrast, a retro-
ple sizes for most of these studies, (especially spective case series based in California found no
those limited to second trimester miscarriage) evidence of adverse neonatal outcomes associ-
are small, resulting in wide confidence inter- ated with conceptions immediately following a
vals. In a recently published study we examined miscarriage [21] . Ultimately, the adverse effects of

6 Women's Health (2009) 5(1) future science group

 Effect of miscarriage on future pregnancies – EDITORIAL

advancing age should be balanced against delay- • Early fetal losses. Occurs between 8–12 weeks
ing subsequent pregnancies and advice should be of gestation. These are often associated with
tailored to the needs of individual women. antiphospholipid syndrome or thrombophilia
and appropriate investigations are recommended
Investigating women after miscarriage: to confirm the diagnosis;
clinical options
• Late fetal loss or spontaneous second trimester
At present, existing guidelines in the UK make a
losses. These should be investigated for the pres-
clear distinction between the management of spo-
ence of anatomical abnormalities of the uterus
radic and recurrent miscarriages. While no inves-
and cervix. Investigations to rule out bacterial
tigations are currently recommended after one or
vaginosis should be carried out in women with
two miscarriages [101] , three miscarriages appears
a history of preterm rupture of membranes.
to be the threshold for initiating investigations to
determine the cause of miscarriage [102] . Such a In this way, it is possible to develop an
policy does not take into account maternal age, algorithm of investigations specific to the timing
previous infertility or chromosomal make-up of and perhaps the cause of miscarriage.
the conceptus (where available).
The reason for such an approach is unclear, Conclusion
but is likely to be informed by economic con- Experience of one or more previous miscarriages
siderations. In a National Health Service set- can increase the risks in a subsequent pregnancy.
ting, the cost implications of investigating all Fortunately for most women, absolute risk of
women after a single miscarriage are likely to future complications remains low. However,
be prohibitive. There are two possible alterna- this does suggest the need for greater vigilance
tive strategies. The first, although not specified in the next pregnancy and obstetric surveillance
in the guidelines, is often practiced in many of women should not be restricted to those with
early pregnancy units. Investigations for recur- recurrent miscarriage.
rent miscarriage are considered following two
consecutive miscarriages if the female partner is Financial & competing interests disclosure
above the age of 35 years. The second option is The authors have no relevant affi liations or financial
based on a classification of recurrent miscarriage involvement with any organization or entity with a finan-
suggested by Dawood et al. [22] . Extending their cial interest in or financial conflict with the subject matter
classification to include sporadic miscarriages, or materials discussed in the manuscript. This includes
miscarriages are classified as: employment, consultancies, honoraria, stock ownership or
• Pre-embryonic or embryonic. These occur options, expert testimony, grants or patents received or
before 8 weeks of gestation and are often due pending, or royalties.
to karyotypic or immunological abnormalities. No writing assistance was utilized in the production of
Investigations should include karyotyping; this manuscript.

6. Malpas P: A study of abortion sequences. 11. Eras JL, Saftlas AF, Triche E, Hsu CD,
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8 Women's Health (2009) 5(1) future science group