Miscarriage is when a baby (or foetus or embryo) dies in the uterus during pregnancy. This applies to pregnancies up to 23 weeks and 6 days.

Any loss from 24 weeks is called a stillbirth. If the baby is born alive, even before 24 weeks, and lives even for a matter of minutes, that is considered a live birth and a neonatal death

We at Chana are here to support anyone who has experienced a loss of any time length. Contact information for anyone in this situation can be found under the baby loss tab at the top of the page.

An ectopic pregnancy is when a fertilised egg implants itself outside of the womb, usually in one of the fallopian tubes.

The fallopian tubes are the tubes connecting the ovaries to the womb. If an egg gets stuck in them, it won't develop into a baby and your health may be at risk if the pregnancy continues.

Unfortunately, it's not possible to save the pregnancy. It usually must be removed using medicine or an operation.

Most ectopic pregnancies develop in the fallopian tubes (tubal pregnancy) but, rarely they can occur in other places.

What is pregnancy of unknown location (PUL)?

A pregnancy of unknown location (PUL) means that you have a positive pregnancy test but there is no identified pregnancy on an ultrasound scan.

This may be due to three possible reasons:

• you may have a very early pregnancy within the uterus that is too small to be seen on a scan

• you may have miscarried; your pregnancy test can remain positive for up to 2–3 weeks following a miscarriage

• you may have an ectopic pregnancy.

Uncertainty about your pregnancy can be very stressful for you and your family. While it may take time, it is important to reach the correct diagnosis before your doctor discusses your treatment options with you. With a PUL you will be advised to have regular blood tests to measure your pregnancy hormone levels and your treatment plan will be based on the results of these blood tests, ultrasound scan reports and clinical features.

What are the symptoms of an ectopic pregnancy?

Each woman is affected differently by an ectopic pregnancy. Some women have no symptoms, some have a few symptoms, while others have many symptoms. Most women get physical symptoms in the 6th week of pregnancy (about 2 weeks after a missed period). You may or may not be aware that you are pregnant if your periods are irregular, or if the contraception you are using has failed.

Because symptoms vary so much, it is not always straightforward to reach a diagnosis of an ectopic pregnancy.

The symptoms of an ectopic pregnancy may include:

Pain in your lower abdomen: This may develop suddenly for no apparent reason or may come on gradually over several days. It may be on one side only.

Vaginal bleeding: You may have some spotting or bleeding that is different from your normal period. The bleeding may be lighter or heavier or darker than normal.

Pain in the tip of your shoulder: This pain is caused by blood leaking into the abdomen and is a sign that the condition is getting worse. This pain is there all the time and may be worse when you are lying down. It is not helped by movement and may not be relieved by painkillers. You should seek urgent medical advice if you experience this.

Upset tummy: You may have diarrhoea or feel pain on opening your bowels.

Severe abdominal pain/collapse: If the fallopian tube bursts (ruptures) and causes internal bleeding, you may develop intense abdominal pain or you may collapse. In rare instances, collapse may be the very first sign of an ectopic pregnancy. This is an emergency, and you should seek urgent medical attention.

Should I seek medical advice immediately?

Yes. An ectopic pregnancy can pose a serious risk to your health. If you have had sexual intercourse within the last 3 or 4 months (even if you have used contraception) and are experiencing these symptoms, you should get medical help immediately. Seek advice even if you do not think you could be pregnant.

You can get medical advice from:

Your GP or midwife

The A&E department at your local hospital

An Early Pregnancy Assessment Unit (EPAU); details of the unit nearest to you can be found at: www.aepu.org.uk/find-a-unit

NHS 111 (England and Wales) and NHS 24 (Scotland) on 111; support is available 24 hours a day, 365 days a year, by dialling 111; calls are free from landlines and mobile phones.

Am I at increased risk of an ectopic pregnancy?

Any woman of childbearing age could have an ectopic pregnancy. You have an increased risk of an ectopic pregnancy if:

• You have had a previous ectopic pregnancy

• You have a damaged fallopian tube. The main causes of damage are:

• Previous surgery to your fallopian tubes, including sterilisation

• Previous infection in your fallopian tubes

• You become pregnant when you have an intrauterine device (IUD/coil) or if you are on the progesterone-only contraceptive pill (mini pill)

• Your pregnancy is a result of assisted conception, i.e. in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI)

• You smoke

How is it diagnosed?

Most ectopic pregnancies are suspected between 6 and 10 weeks of pregnancy. Sometimes the diagnosis is made quickly. However, if you are in the early stages of pregnancy, it can take longer (a week or more) to make a diagnosis of an ectopic pregnancy.

Your diagnosis will be made based on the following:

Consultation and examination

Your doctor will ask about your medical history and symptoms and will examine your abdomen. With your consent, your doctor may also do a vaginal (internal) examination. You should be offered a female chaperone (someone to accompany you) for this. You may also wish to bring someone to support you during your examination.

Urine pregnancy test

If you have not already had a positive pregnancy test, you will be asked for a urine sample so that this can be tested for pregnancy. If the pregnancy test is negative, it is very unlikely that your symptoms are due to an ectopic pregnancy.

Ultrasound scan

A transvaginal scan (where a probe is gently inserted in your vagina) is known to be more accurate in diagnosing an ectopic pregnancy than a scan through the tummy (transabdominal scan). Therefore, you will be offered a transvaginal scan to help identify the exact location of your pregnancy. However, if you are in the early stages of pregnancy, it may be difficult to locate the pregnancy on scanning and you may be offered another scan after a few days.

Blood tests

A test for the level of the pregnancy hormone βhCG (beta human chorionic gonadotrophin) or a test every few days to look for changes in the level of this hormone may help to give a diagnosis. This is usually checked every 48 hours because, with a pregnancy in the uterus, the hormone level rises by 63% every 48 hours (known as the ‘doubling time’) whereas, with ectopic pregnancies, the levels are usually lower and rise more slowly or stay the same.

Laparoscopy

If the diagnosis is still unclear, an operation under a general anaesthetic called a laparoscopy may be necessary. The doctor uses a small telescope to look at your pelvis by making a tiny cut, usually into the umbilicus (tummy button). This is also called keyhole surgery. If an ectopic pregnancy is confirmed, treatment may be undertaken as part of the same operation. This would be discussed with you before surgery, unless surgery is necessary due to an acute emergency.

What happens when an ectopic pregnancy is suspected or confirmed?

When an ectopic pregnancy is suspected or confirmed, your doctor will discuss your treatment options with you. The options usually depend on where the ectopic pregnancy is suspected or located.

Make sure that you:

• Fully understand all your options

• Ask for more information if there is something you do not understand

• Raise your concerns, if any

• Understand what each option means for your fertility

• Have enough time to make your decision.

What are the options for treatment of tubal ectopic pregnancy?

Because an ectopic pregnancy cannot lead to the birth of a baby, all options will end the pregnancy to reduce the risks to your own health.

Your options depend upon:

• how many weeks pregnant you are

• your symptoms and clinical condition

• the level of βhCG

• your scan result

• your fertility status

• your general health

• your personal views and preferences – this should involve a discussion about your future pregnancy plans

• the options available at your local hospital.

The treatment options for tubal ectopic pregnancy are listed below. Not all may be suitable for you, so your healthcare professional should guide you in making an informed decision.

• Expectant management (wait and see)

Ectopic pregnancies sometimes end on their own – similar to a miscarriage. Depending on your situation, it may be possible to monitor the βhCG levels with blood tests every few days until these are back to normal. Although you do not have to stay in hospital, you should go back to hospital if you have any further symptoms. You should be given a direct contact number for the emergency ward or gynaecology ward at your hospital.

Expectant management is not an option for all women. It is usually only possible when the pregnancy is still in the early stages and when you have only a few or no symptoms. Success rates with expectant management are highly variable and range from 30% to 100%. This mainly depends on your pregnancy hormone levels, with higher serum βhCG levels associated with a lower chance of success.

• Medical treatment

In certain circumstances, an ectopic pregnancy may be treated by medication (drugs). The fallopian tube is not removed. A drug (methotrexate) is given as an injection – this prevents the ectopic pregnancy from growing and the ectopic pregnancy gradually disappears.

Most women only need one injection of methotrexate for treatment. However, 15 in 100 women (15%) need to have a second injection of methotrexate. If your pregnancy is beyond the very early stages or the βhCG level is high, methotrexate is less likely to succeed. Seven in 100 women (7%) will need surgery even after medical treatment.

Many women experience some pain in the first few days after taking the methotrexate, but this usually settles with paracetamol or similar pain relief. Although it is known that long-term treatment with methotrexate for other illnesses can cause significant side effects, this is rarely the case with one or two injections as used to treat ectopic pregnancy. Treatment of ectopic pregnancy with methotrexate is not known to affect the capacity of your ovaries to produce eggs.

You may need to stay in hospital overnight and then return to the clinic or ward a few days later. You will be asked to return sooner if you have any symptoms. It is very important that you attend your follow-up appointments until your pregnancy hormone levels are back to normal. You are also advised to wait for 3 months after the injection before you try for another pregnancy.

• Surgical treatment

An operation to remove the ectopic pregnancy will involve a general anaesthetic.

The surgery will either be:

Laparoscopy (Keyhole surgery).

Your stay in hospital is shorter (24–36 hours) and physical recovery is quicker than after open surgery. Laparoscopy might not be an option for some women and your doctor will discuss this with you.

Open surgery (Laparotomy).

This is done through a larger cut in your abdomen and may be needed if severe internal bleeding is suspected. You will need to stay in hospital for 2–4 days. It usually takes about 4–6 weeks to recover.

The aim of surgery is to remove the ectopic pregnancy. The type of operation you have will depend on your wishes or plans for a future pregnancy and what your surgeon finds during the operation (laparoscopy).

To have the best chance of a future pregnancy inside your uterus, and to reduce the risk of having another ectopic pregnancy, you will usually be advised to have your affected fallopian tube removed (this is known as a salpingectomy).

If you already have only one fallopian tube or your other tube does not look healthy, your chances of getting pregnant are already affected. In this circumstance, you may be advised to have a salpingotomy that aims to remove the pregnancy without removing the tube. It carries a higher risk of a future ectopic pregnancy but means that you are still able to have a pregnancy in the uterus in the future. You will be advised to have blood tests for checking your pregnancy hormone levels after salpingotomy as part of follow-up. Some women may need further medical treatment or another operation to remove the tube later if the pregnancy has not been completely removed during salpingotomy. The decision to perform salpingectomy or salpingotomy may sometimes only be made during laparoscopy under anaesthetic. There are risks associated with any operation: from the surgery itself and from the use of an anaesthetic. Your surgeon and anaesthetist will discuss these risks with you.

What are the options for treatment of non-tubal ectopic pregnancy?

The treatment of a non-tubal ectopic pregnancy depends on where the pregnancy is growing (refer to the various sites of non-tubal ectopic pregnancy in the leaflet). Your doctor will discuss the available treatment options with you based on a number of factors, including the location of the ectopic pregnancy, the levels of the pregnancy hormone βhCG in your blood and the ultrasound scan report.

Treatment options may include expectant management, medical treatment with methotrexate or surgical operation.

In an emergency situation

If the tubal or non-tubal pregnancy has burst, emergency surgery is needed to stop the bleeding. This operation is often life-saving. It is done by removing the ruptured fallopian tube and pregnancy. Your doctors will need to act quickly and this may mean that they have to make a decision on your behalf to operate. In this situation you may need a blood transfusion.

What happens to your pregnancy remains?

To confirm that you have had an ectopic pregnancy, tissue removed at the time of surgery is sent for testing in the laboratory. The healthcare team will discuss with you (and your partner) the options around what happens to your pregnancy remains afterwards.

What happens next?

It is important that you attend your follow-up appointments. The check-ups and tests that you need will depend on the treatment that you had. If you had treatment with methotrexate, you should avoid getting pregnant for at least 3 months after the injection.

How will I feel afterwards?

The impact of an ectopic pregnancy can be very significant. It might mean coming to terms with the loss of your baby, with the potential impact on future fertility, or with the realisation that you could have lost your life.

Each woman copes in her own way. An ectopic pregnancy is a very personal experience. This experience may affect your partner and others in your family, as well as close friends. If you feel you are not coping or not getting back to normal, you should talk to your GP and/ or Chana for support.

It is important to remember that the pregnancy could not have continued without causing a serious risk to your health.

Before trying for another baby, it is important to wait until you feel ready emotionally and physically. However traumatic your experience of an ectopic pregnancy has been, it may help to know that the likelihood of a normal pregnancy next time is much greater than that of having another ectopic pregnancy.

What about future pregnancies?

The chances of having a successful pregnancy in the future are good. Even if you have only one fallopian tube, your chances of conceiving are only slightly reduced.

For most women an ectopic pregnancy is a ‘one-off’ event.

You should seek early advice from a healthcare professional when you know you are pregnant. You may be offered an ultrasound scan at between 6 and 8 weeks to confirm that the pregnancy is developing in the uterus.

If you do not want to become pregnant, seek further advice from your doctor or family planning clinic, as some forms of contraception may be more suitable after an ectopic pregnancy.

References- https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/ectopic-pregnancy-patient-information-leaflet/

https://www.nhs.uk/conditions/ectopic-pregnancy/

A miscarriage is the loss of a pregnancy during the first 23 weeks. If this happens in the first 3 months of pregnancy, it is known as a first trimester or early miscarriage.

Symptoms

The main sign of a miscarriage is vaginal bleeding, which may be followed by cramping and pain in your lower abdomen. If you have vaginal bleeding, contact a GP or your midwife. Most GPs can refer you to an early pregnancy unit at your local hospital straight away if necessary. You may be referred to a maternity ward if your pregnancy is at a later stage.

But bear in mind that light vaginal bleeding is relatively common during the first trimester (first 3 months) of pregnancy and does not necessarily mean you're having a miscarriage.

Causes of a miscarriage

There are potentially many reasons why a miscarriage may happen, although the cause is not usually identified.

It's very unlikely that a miscarriage is caused by anything that you did or didn't do.

• Genetic factors

The most common cause of one miscarriage, or of recurrent miscarriage, is that the pregnancy has developed with abnormal chromosomes. 1 in 2 (50%) miscarriages happen because of this, and it gets more common as parents get older. In most cases, this happens even though the parents themselves have normal chromosomes. However, in 6 in 100 (6%) couples who have experienced three miscarriages, one parent may have their own chromosomes in an abnormal arrangement. Although this does not affect the parent, if it is passed on to the embryo it can cause a miscarriage.

• Age

The older you are, the more likely you are to have a single miscarriage, or to have recurrent miscarriage. This is because as you get older the quality of your eggs declines.

Miscarriages may also be more common if the father is more than 40 years old.

• Ethnicity

If you are of Black African or Black Caribbean background, you are more likely to have an early miscarriage. We do not fully understand at present why this is.

• Lifestyle factors

Being overweight (body mass index (BMI) more than 25) or underweight (BMI less than 19) increases your chance of having one or more miscarriages. Cigarette smoking and drinking more than the recommended amount of alcohol or caffeine may also increase your chance of miscarriage.

• Blood clotting factors

Antiphospholipid syndrome (APS): this is a condition that can cause you to have recurrent miscarriage or later pregnancy complications. It also puts you at risk of developing blood clots. Inherited blood clotting problems (thrombophilia): there are several different types of inherited blood clotting problems. Testing for them is not recommended, as there is no clear evidence that these can cause you to have recurrent miscarriage. See https://www.chana.org.uk/medical-conditions for more information.

• Abnormalities in the shape of your uterus (womb)

Five to six in 100 women are born with a uterus that is an unusual shape, known as a ‘congenital uterine anomaly’. In women with recurrent miscarriage, it is more common to have a uterus that is an unusual shape (around 13 in 100 women). Certain uterine shapes may increase your chance of miscarriage, such as a septate uterus and a bicornuate uterus. A septate uterus is when there is a thin wall of tissue in the middle of the uterus. A bicornuate uterus is where there is a deep indentation of the muscle at the top of the uterus, dividing it into two halves.

Some women develop fibroids (knots of muscle in the wall of the uterus), or scar tissue within their uterus, over their lifetime. How they affect you, and whether they affect your chance of miscarriage, may depend on their size and position. You may wish to discuss this further with your healthcare professional. We do not yet fully understand when treatment might improve your chances of a healthy pregnancy.

• Hormonal problems

There are several different hormonal conditions that may be related to miscarriage:

Diabetes- Well-controlled diabetes does not increase your risk of miscarriage. However, if you have poorly controlled diabetes you may have a higher chance of miscarriage.

Thyroid problems – Well-controlled thyroid disease does not cause miscarriage. However, high levels of the ‘thyroid stimulating hormone’ (TSH) or the presence of thyroid antibodies, may put you at higher risk of miscarriage.

Polycystic ovarian syndrome (PCOS) - Women with PCOS are at increased risk of miscarriage. It is not clear why this is, but it could be due to the raised insulin and testosterone hormones that are sometimes seen in this condition.

Prolactin imbalances - If you have abnormal prolactin hormone levels you may be at increased risk of miscarriage.

• Immune factors

It has been suggested that some women miscarry because their immune system does not respond normally to pregnancy. There is no clear evidence to support this theory at present and further research is needed.

• Sperm factors

If your partner has abnormal DNA in their sperm, there may be a higher possibility of recurrent miscarriage. We do not currently have any good evidence that we can change sperm health to reduce the risk of miscarriage, and therefore testing of sperm is not usually offered.

In most cases, a miscarriage is a one-off event and most people go on to have a successful pregnancy in the future.

Preventing a miscarriage

The majority of miscarriages cannot be prevented. But there are some things you can do to reduce the risk of a miscarriage.

• Avoid smoking, drinking alcohol and using drugs while pregnant

• Being a healthy weight before getting pregnant, eating a healthy diet and reducing your risk of infection can also help

What happens if you think you're having a miscarriage

If you have the symptoms of a miscarriage, you'll usually be referred to a hospital for tests. In most cases, an ultrasound scan can determine if you're having a miscarriage.

When a miscarriage is confirmed, you'll need to talk to your doctor or midwife about the options for the management of the end of the pregnancy.

Often the pregnancy tissue will pass out naturally in 1 or 2 weeks. Sometimes medicine to assist the passage of the tissue may be recommended, or you can choose to have minor surgery to remove it if you do not want to wait.

After a miscarriage

A miscarriage can be an emotionally and physically draining experience. You may have feelings of guilt, shock and anger. Chana are here for anyone that needs advice and support after a miscarriage.

You can try for another baby as soon as your symptoms have settled and you're emotionally and physically ready. It's important to remember that most miscarriages are a one-off and are followed by a healthy pregnancy.

How common are miscarriages?

Miscarriages are much more common than most people realise. Among people who know they're pregnant, it's estimated about 1 in 4 pregnancies will end in miscarriage. Many more miscarriages happen before a person is even aware they're pregnant.

Losing 3 or more pregnancies (not necessarily consecutively) is called recurrent miscarriages but is not as common and only affects around 1 in 100 women.

Reference- https://www.nhs.uk/conditions/miscarriage/

What is a miscarriage?

If you lose a baby before 24 weeks of pregnancy, it is called a miscarriage. If this happens in the first 3 months of pregnancy, it is known as an early miscarriage. Unfortunately, early miscarriages are common, with 10–20% of pregnancies ending this way.

Late miscarriages, after 3 months of pregnancy but before 24 weeks, are less common with 1–2% pregnancies ending in a late miscarriage.

What is recurrent miscarriage?

When a miscarriage happens three or more times it is called recurrent miscarriage. Recurrent miscarriage affects 1 in 100 (1%) couples trying to have a baby.

Why do recurrent miscarriages and late miscarriages happen?

Sometimes there are reasons found for recurrent and late miscarriage. In other cases, no underlying problem can be found. Most couples are likely to have a successful pregnancy in the future, particularly if test results are normal.

There are a number of factors that may play a part in causing recurrent and late miscarriage:

Age: The older you are, the greater your risk of having a miscarriage. If the woman is aged over 40, more than 1 in 2 pregnancies end in a miscarriage. Miscarriages may also be more common if the male partner is older.

Antiphospholipid syndrome (APS): A syndrome that makes your blood more likely to clot is uncommon but is a cause of recurrent miscarriage and late miscarriage.

Thrombophilia: Thrombophilia (an inherited condition that means that your blood may be more likely to clot) may cause recurrent miscarriage and in particular late miscarriages.

Genetic factors: In about 2–5 in 100 couples (2–5%) with recurrent miscarriage, one partner will have an abnormality on one of their chromosomes (the genetic structures within our cells that contain our DNA and the features we inherit from our parents). Although this may not affect the parent, it can sometimes cause a miscarriage.

Weak cervix: Weakness of the cervix is known to be a cause of miscarriage from 14 to 23 weeks of pregnancy. This can be difficult to diagnose when you are not pregnant. It may be suspected if in a previous pregnancy your waters broke early, or if the neck of the womb opened without any pain.

Developmental problems of the baby: Some abnormalities of the baby may lead to a miscarriage but are unlikely to be the cause of recurrent miscarriage.

Infection: Any infection that makes you very unwell can cause a miscarriage. Milder infections that affect the baby can also cause a miscarriage. The role of infections in recurrent miscarriage is unclear.

Shape of the uterus: It is not clear how much an abnormally shaped uterus contributes to recurrent miscarriage or late miscarriages. However, minor variations do not appear to cause miscarriage.

Diabetes and thyroid problems: Diabetes or thyroid disorders can be factors in miscarriages. They do not cause recurrent miscarriage, as long as they are treated and kept under control.

Immune factors: It has been suggested that some women miscarry because their immune system does not respond to the baby in the usual way. This is known as an alloimmune reaction. There is no clear evidence to support this theory at present. Further research is needed.

Are there any other risk factors?

Being very overweight or very underweight increases miscarriage risk. Smoking and too much caffeine as well as excessive alcohol is known to be harmful to a developing baby and drinking five or more units a week may increase the risk of miscarriage.

The chance of a further miscarriage increases slightly with each miscarriage. Women with three miscarriages have a 4 in 10 chance of having another one. This means that 6 out of 10 women (60%) in this situation will go on to have a baby next time.

Why are investigations helpful?

Finding out whether or not there is a reason or treatable cause for your recurrent miscarriages is important so that you can be offered the support and treatment that is best for you. You should see your healthcare professional for referral for further investigations, which may be arranged in a clinic dedicated to recurrent miscarriage. If possible, you and your partner should be seen together.

Sometimes it can take time to arrange, or time to get the results from, these investigations. It is up to you whether you continue to try for a pregnancy while you wait for the results of these investigations, and you may wish to discuss this with your healthcare professional.

Blood tests

APS test: To confirm if you have APS you need: to have positive results on two blood tests at least 12 weeks apart, and at least 6 weeks after a miscarriage.

Thyroid tests: including thyroid antibody tests.

Diabetes tests: if your medical history suggests this could be a factor.

If your healthcare professional suspects that you may have other hormonal problems, such as PCOS or prolactin imbalance, you will be offered blood tests to check for these.

Genetic tests

At the time of your third or further miscarriage, your healthcare professional should offer to test whether there were any inherited chromosomal problems causing this miscarriage.

Both you and your partner may be offered genetic testing if:

It has not been possible to test the pregnancy, or

The testing of the pregnancy suggests the problem could have been inherited.

A scan of your uterus

You should be offered a pelvic ultrasound scan to look at the shape of your uterus. If your healthcare professional suspects that your uterus is an unusual shape, you may be offered further investigations to look at this in more detail.

What are my treatment options?

Lifestyle modifications- Your healthcare professional will discuss with you how to maintain a healthy weight. They can support you in stopping smoking. You should limit the amount of caffeine you drink to less than 200 mg/day (around two cups of tea or instant coffee), and should avoid drinking alcohol regularly or to excess.

Treatment for Antiphospholipid syndrome (APS)- If you have APS and have had recurrent miscarriages, treatment with low-dose aspirin tablets and blood thinning injections (heparin) in pregnancy can increase your chance of having a successful pregnancy. Aspirin and heparin make your blood less likely to clot. Having APS means you are at increased risk of complications throughout your pregnancy so you will be closely monitored by your healthcare team.

Treatment for inherited thrombophilia - Routine treatment for inherited thrombophilia has not been found to improve your chance of a healthy pregnancy. If you have been found to have an inherited blood clotting condition, you may be offered heparin. If you are known to have an inherited blood clotting condition, you may be offered treatment by your healthcare professional. This will depend on your individual circumstances and your additional risks of developing blood clots during pregnancy.

Referral for genetic counselling - If either you or your partner is found to have a genetic abnormality, you should be offered the chance to see a genetics counsellor. They will discuss your chances of future miscarriage and will explain what your options are depending on your individual circumstances.

Surgery to your uterus- If you have a uterine septum you may be offered an operation to correct this. It is unclear whether surgery for fibroids or other conditions affecting the internal shape of your womb reduces your risk of miscarriage. The potential benefits and risks of having surgery on your uterus should be discussed with you by your healthcare professional, depending on your individual circumstances (for example, the size and position of a fibroid).

Hormone treatment - If you have diabetes or thyroid disease, you will be supported to control this as well as possible before your next pregnancy.

There is no evidence that progesterone treatment prevents recurrent miscarriage unless you experience bleeding in early pregnancy. If you have had a previous miscarriage and are bleeding in pregnancy, you should be offered progesterone to try to prevent miscarriage.

What if no cause is found?

It is very common that recurrent miscarriage is unexplained. In this situation, there is currently no evidence that any form of medical treatment will reduce your chance of a further miscarriage. Your chance of a successful pregnancy next time will depend on your individual circumstances but is likely to be good, even without changing anything.

It may be important in your future pregnancies to have supportive care from healthcare professionals who are experienced in caring for women with recurrent miscarriage. This may include having ultrasound scans for reassurance.

What does this mean for future pregnancies?

You and your partner should be seen together by a specialist health professional. This may be within a clinic dedicated to recurrent and late miscarriage. Your GP will refer you to the clinic.

Your doctor will talk to you both about your particular situation and your likelihood of having a further miscarriage and a successful pregnancy. If a cause has been found, possible treatment options will be offered to you to improve your chance of a successful pregnancy.

Women who have supportive care from an early pregnancy assessment unit from the beginning of a pregnancy have a better chance of a successful birth. For couples where no cause for recurrent miscarriage has been found, 75 in 100 (75%) will have a successful pregnancy with this care.

Mental health after recurrent miscarriage

Having recurrent miscarriage can be a difficult experience which may affect you physically and emotionally. You and your partner should be offered information and support by your healthcare professionals and support groups are available. Some people experience significant symptoms of anxiety, depression and/or post-traumatic stress after pregnancy loss. You may wish to discuss your mental health with your healthcare professional, as you can be offered referral for further support and treatment.

Miscarriage association- https://www.miscarriageassociation.org.uk/

Reference- https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/recurrent-and-late-miscarriage-patient-information-leaflet/

Molar pregnancy (also called hydatidiform mole) occurs when a pregnancy does not develop properly. In healthy pregnancies, an embryo (baby) develops when a sperm fertilises an egg and the genetic material (chromosomes) from each combines to produce a baby which has half of its genes from each parent. A molar pregnancy is abnormal from the very moment of conception because of an imbalance in the number of chromosomes supplied from the mother and the father.

There are two types of molar pregnancy - complete mole and partial mole.

A complete molar pregnancy – this is where abnormal cells grow in the womb after conception and there's no sign of a baby

A partial molar pregnancy – this is where there may be early signs of a baby, but it cannot fully develop or survive

Molar pregnancies are rare, happening with roughly 1 case for every 600 pregnancies in the UK.

If you have or had a molar pregnancy, Chana is here to support you.

Finding out you have a molar pregnancy

You may find out during your 1st pregnancy ultrasound scan at around 8 to 14 weeks.

Some people find out after their pregnancy ends with a miscarriage.

See a GP urgently if:

• you have any bleeding or a dark discharge from your vagina

• you're feeling or being sick often (severe morning sickness)

• you think your bump looks bigger than it should for your stage of pregnancy

• you have any other symptoms you're worried about

What happens next

If a midwife or doctor thinks you have a molar pregnancy they will need to do

- blood tests to check your level of the pregnancy hormone hCG, which is usually higher than normal in a molar pregnancy

- an ultrasound scan

- an appointment with a specialist (gynaecologist) or at an early pregnancy assessment unit

Treatment for a molar pregnancy

A molar pregnancy will not be able to survive. It may end on its own, with a miscarriage. If this does not happen, it's usually treated with a procedure to remove the pregnancy. You'll usually be given a general anaesthetic before the procedure, so you'll be asleep.

Sometimes you might be able to take medicine to end a molar pregnancy.

Follow-up care

After treatment for a molar pregnancy you'll have regular blood and urine tests to check your hCG hormone level is returning to normal. If your hormone level does not return to normal you will need further treatment.

Intercourse, contraception, and trying for a baby after a molar pregnancy

You can have intercourse as soon as you feel ready, but it's important to use contraception while you're getting follow-up care. Talk to a GP about what type of contraception is right for you.

Having a molar pregnancy does not affect your chances of getting pregnant again. But it's important to wait until your doctor tells you it's safe before you start trying for a baby.

Causes of a molar pregnancy

A molar pregnancy happens by chance. It's not caused by either partner doing something wrong.

You may be more likely to have a molar pregnancy if:

you're a young teenager or older than 45 when you get pregnant

you've had a molar pregnancy before

Where to get support

It can take time to recover after a molar pregnancy, both physically and emotionally.

The specialists looking after you can give you advice if you need support as well as the team at Chana.

The Miscarriage Association runs an online support group for people diagnosed with a molar pregnancy but not needing treatment.- https://www.miscarriageassociation.org.uk/information/molar-pregnancy/

Reference- https://www.nhs.uk/conditions/molar-pregnancy/

Antiphospholipid syndrome (APS)- Hughes syndrome, is a disorder of the immune system that causes an increased risk of blood clots. The immune system produces abnormal antibodies that make the blood "stickier" than normal. This means people with APS are at greater risk of developing conditions such as:

• DVT (deep vein thrombosis, a blood clot that usually develops in the leg

• Arterial thrombosis (a clot in an artery), which can cause a stroke or heart attack

• Blood clots in the brain, leading to problems with balance, mobility, vision, speech and memory

Pregnant women with APS also have an increased risk of having a miscarriage, although the exact reasons for this are uncertain.

What causes antiphospholipid syndrome?

APS is an autoimmune condition. This means the immune system, which usually protects the body from infection and illness, attacks healthy tissue by mistake. In APS, the immune system produces abnormal antibodies called antiphospholipid antibodies. These target proteins attached to fat molecules (phospholipids), which makes the blood more likely to clot. It's not known what causes the immune system to produce abnormal antibodies. As with other autoimmune conditions, genetic, hormonal and environmental factors are thought to play a part.

Who's affected?

APS can affect people of all ages, including children and babies, but most people are diagnosed with APS between 20 and 50 years of age. It affects 3 to 5 times as many women as men.

Diagnosing APS

An accurate diagnosis of antiphospholipid syndrome (APS) is important because blood clots can have serious consequences. Diagnosis of APS is based on the results of specific blood tests and a medical assessment. If APS is suspected, you'll usually be referred to hospital to see a specialist doctor such as:

a haematologist (a specialist in conditions affecting the blood)

or

a rheumatologist (a specialist in conditions affecting the immune system)

Specific blood tests - To diagnose APS, the blood needs to be tested for the abnormal antiphospholipid antibodies that increase the risk of blood clots. This requires a blood test specifically designed to look for these antibodies. A diagnosis of APS can only be made after 2 abnormal blood test results, with at least a 12-week gap between them. This is because harmless antiphospholipid antibodies can sometimes develop in the body for short periods of time. Usually, this is the result of an infection or a side effect of medication, such as antibiotics.

If antiphospholipid antibodies are identified during the first blood test, another test will be needed later to confirm whether the abnormal antibodies are still present.

Medical assessment - If blood tests confirm you have APS, your medical history will be carefully assessed to check whether you have experienced any previous symptoms that may be caused by APS. A diagnosis of APS can usually be confirmed if you have had 1 or more confirmed blood clots and, if applicable:

- 1 or more unexplained late miscarriage at or after week 10 of your pregnancy

- 1 or more premature birth at or before week 34 of your pregnancy

- 3 or more unexplained early miscarriages before week 10 of your pregnancy

Causes, Symptoms and treatment

Most people respond well to treatment and can lead normal, healthy lives. But a small number of people with APS continue to experience blood clots despite extensive treatment. This means people with APS are more likely to develop blood clots in their veins and arteries, which can cause serious or life-threatening health problems.

These include:

-High blood pressure

-DVT (deep vein thrombosis)

-A stroke or a transient ischaemic attack (TIA) ("mini-stroke")

-Heart attacks

-Pulmonary embolism (a blockage in one of the blood vessels in the lungs)

People with APS may also experience any of the following symptoms:

-Balance and mobility problems

-Vision problems, such as double vision

-Speech and memory problems

-A tingling sensation or pins and needles in your arms or legs

-Fatigue (extreme tiredness)

-Repeated headaches or migraines

-Pregnancy problems

- Recurrent (3 or more) early miscarriages, usually during the first 10 weeks of pregnancy

- 1 or more later miscarriages, usually after week 10 of pregnancy

- Premature birth, usually at or before week 34 of pregnancy, which may be caused by pre-eclampsia (where a woman develops high blood pressure during pregnancy)

It's not clear why these abnormal antibodies are produced, or why many people have antiphospholipid antibodies but don't develop blood clots. A combination of genetic and environmental factors is thought to be responsible.

About Antiphospholipid antibodies

Antibodies are proteins produced by the immune system to help fight off infection and illness. In APS, the immune system produces abnormal antibodies that rather than attacking bacteria and viruses, mistakenly attack proteins found on the outside of cells in the blood and blood vessels. It's not known how this causes the blood to clot more easily, but most experts believe that keeping your blood at the correct consistency (not too runny and not too sticky) is a delicate balancing act that relies on different types of proteins and fats working together. This balance may be disrupted by abnormal antibodies in people with APS.

Genetic factors

Research into the genetics around APS is still at an early stage, but it seems the genes you inherit from your parents may play a role in the development of abnormal antiphospholipid antibodies. APS isn't passed down directly from parents to children in the same way as other conditions, such as haemophilia and sickle cell anaemia, but having a family member with antiphospholipid antibodies increases the chance of your immune system also producing them. Studies have shown that some people with APS have a faulty gene that plays a role in other autoimmune conditions, such as Lupus.

This may explain why some people develop APS alongside another immune system condition.

Environmental factors

It's thought that one or more environmental triggers may be needed to start APS in some people. These include:

-Viral infections, such as the cytomegalovirus (CMV) or slapped cheek syndrome (parvovirus B19)

-Bacterial infections, such as E. coli (a bacteria often associated with food poisoning) or leptospirosis (an infection usually spread by certain animals)

-Certain medications, such as anti-epileptic medicine or the oral contraceptive pill

Another theory is that many people with abnormal antiphospholipid antibodies only go on to develop APS if they have a higher risk of developing blood clots. For example, if they: eat an unhealthy diet, leading to high cholesterol levels in the blood, don't do enough exercise, take the contraceptive pill or hormone replacement therapy (HRT), smoke or are obese.

However, this doesn't explain why some children and adults who don't have any of these risk factors still develop APS.

How antiphospholipid syndrome is treated

As part of your treatment, you'll be prescribed anticoagulant medicine such as warfarin, or an antiplatelet medication such as low-dose aspirin. These work by interrupting the process of blood clot formation. This means blood clots are less likely to form when they're not needed. If blood tests show you have abnormal antiphospholipid antibodies, but you don't have a history of blood clots, low-dose aspirin tablets are usually recommended.

If you can't take aspirin, you may be prescribed an alternative antiplatelet tablet called clopidogrel.

Warfarin tablets are usually recommended if you have APS and a history of blood clots, such as previously having DVT (deep vein thrombosis) or a stroke. But this needs to be changed if you become pregnant or are planning a pregnancy. Tell your doctor if this is the case.

If you develop a blood clot or your symptoms suddenly become severe, injections of an anticoagulant called heparin may be needed. These injections may be given in hospital, or you may be trained to give them yourself.

Side effects

Side effects of these medications are uncommon and generally mild, such as indigestion or feeling sick (nausea). But there's a risk that the disruption to the blood's ability to clot can cause excessive bleeding (a haemorrhage). Symptoms of excessive bleeding can include: blood in your urine or stool, black stool, severe bruising, prolonged nosebleeds (lasting longer than 10 minutes), blood in your vomit , coughing up blood

Contact your GP immediately if you have any of these symptoms while taking an anticoagulant. If this isn't possible, call your local out-of-hours service or NHS 111.

Treatment during pregnancy

Women diagnosed with APS are strongly advised to plan for any future pregnancy. This is because treatment to improve the outcome of a pregnancy is most effective when it begins as soon as possible after an attempt to conceive. Some medications used to treat APS can also harm an unborn baby.

If you don't plan your pregnancy, it may be several weeks before you realise you're pregnant. This may increase the risk of treatment to safeguard the pregnancy being unsuccessful. Treatment during pregnancy involves taking daily doses of aspirin or heparin, or a combination of both. This depends on whether you have a history of blood clots and previous complications during pregnancy. Warfarin isn't recommended during pregnancy because it carries a small risk of causing birth defects.

Treatment with aspirin or heparin, or both, is usually started at the beginning of the pregnancy and may continue for 1 to 6 weeks after you have given birth. If you do want to have a baby, you should talk to the doctor in charge of your treatment for APS.

Lifestyle changes

If you're diagnosed with APS, it's important to take all possible steps to reduce your risk of developing blood clots.

Effective ways of achieving this include:

Quit smoking

Eating a healthy, balanced diet – low in fat and sugar and containing plenty of fruit and vegetables

Taking regular exercise

Maintaining a healthy weight and losing weight if you're obese (have a body mass index of 30 or more)

It is recommended that you wear a medical alert bracelet or similar. This is because it is important for medical staff to know you have a blood clotting disorder in case of an accident.

Reference- https://www.nhs.uk/conditions/antiphospholipid-syndrome/

Lupus is a long-term condition that causes joint pain, skin rashes and tiredness. It is an autoimmune disease. This means the body's natural defence system (immune system) attacks healthy parts of your body. It is not contagious. There is no cure, but symptoms can improve if treatment starts early. Lupus, also called systemic lupus erythematosus, is not always easy to diagnose because it can be similar to other conditions.

Symptoms include inflammation of different parts of the body including the lungs, heart, liver, joints and kidneys. The GP will usually do some blood tests. High levels of a type of antibody, combined with typical symptoms, means lupus is likely. You might be referred for X-rays and scans of your heart, kidney and other organs if the doctor thinks they might be affected.

Once lupus is diagnosed, you'll be advised to have regular checks and tests, such as regular blood tests to check for anaemia and urine tests to check for kidney problems.

Symptoms of Lupus can flare up (relapse) and become worse for a few weeks, sometimes longer, and can then settle down again (remission). The reason why is not known. Some people do not notice any difference and their symptoms are constant.

Lupus is generally treated using:

• Anti-inflammatory medicines like ibuprofen

• Hydroxychloroquine for fatigue and skin and joint problems

• Steroid tablets, injections and creams for kidney inflammation and rashes

• Rituximab and Belimumab, are sometimes used to treat severe lupus. These work on the immune system to reduce the number of antibodies in the blood.

The causes of lupus are not fully understood. Possible causes include:

Viral infection

Certain medicines

Sunlight

Puberty

Childbirth

Menopause

Pregnancy and lupus

Lupus can cause complications in pregnancy.

Most women with lupus should be able to have a baby if they wish to, but it's best to discuss your plans with your doctor before trying to get pregnant so that your treatments can be altered if need be. Try to plan your pregnancy when your lupus is inactive and you're taking as little medication as possible.

A small number of women with very severe lupus may be advised against having a baby as pregnancy can put a great strain on the heart, lungs and kidneys. There's an increased risk of pregnancy complications in women whose lupus affects several different organs and who find it difficult to control their symptoms without certain medications.

If you're thinking of having a baby, always discuss your plans with your doctor or specialist nurse before you start trying. You may need to see an obstetrician with a special interest in lupus for further advice. Doctors are naturally cautious about which drugs are used during pregnancy. Steroids are usually well tolerated and many people have used Prednisolone, hydroxychloroquine and Azathioprine throughout pregnancy without ill effects.

If you have high levels of antiphospholipid antibodies, there's an increased risk of miscarriage. However, treatment with aspirin and/or heparin reduces this risk, and there are now many more successful pregnancies in women who have these antibodies.

There's conflicting evidence about whether pregnancy is likely to cause a flare-up of Lupus. If your condition is well controlled at the time the baby is conceived, and you don't have kidney disease, then you're unlikely to have any problems. If you do have kidney disease, then you may well have increased protein in your urine during the later stages of pregnancy. It is important, but sometimes difficult, to distinguish between proteins in the urine due to kidney disease which is associated with Lupus, or to a more common complication of pregnancy, known as pre-eclampsia. The doctors looking after your pregnancy will check for this and consult your rheumatologist if they need to.

In pregnant women who have anti-Ro antibodies there's a small risk (about 1 in 50) that their babies will have Neonatal (newborn) Lupus Syndrome. This means the baby may have a rash and/or a slow heartbeat. There's a slightly greater risk in further pregnancies, so make sure you discuss this in detail with your rheumatology and obstetric team before considering another pregnancy. Most babies born to mothers with anti-Ro antibodies will be fine, but it's important to have regular scans of the baby's heart during the pregnancy.

Lupus does not reduce a woman’s chances of getting pregnant. Less than 50% of pregnancies in women with lupus have complications, but all lupus pregnancies are considered high-risk. Lupus can complicate pregnancy with an increased risk of miscarriage, premature delivery, and preeclampsia, as well as heart problems in the baby. If you have lupus and are considering having a baby, consider these tips to ensure a safe pregnancy and healthy baby.

Before you get pregnant:

Assemble your lupus health care team. Prior to getting pregnant, women with lupus should meet with a rheumatologist, a doctor who specializes in diseases like lupus, a perinatologist or high-risk obstetrician, and a pediatric cardiologist. Some pregnancies will require treatments early on. These treatments counteract risks of complications and should begin within the first few weeks of pregnancy for best results. The risk of complications is greater if you are having a lupus flare, so it’s important to work with your doctor.

Determine your personal risk for pregnancy complications. Every lupus case is different. Lupus doesn’t seem to increase the risk of first-trimester miscarriages, but women with lupus do have an increased risk of miscarriage later in pregnancy or even stillbirth because of anti-phospholipid and anti-cardiolipin antibodies. About 33% of women with lupus have these antibodies, which increase the risk of developing blood clots. Your doctor can recommend specific blood tests to check for the presence of the antibodies.

Placental blood clots can endanger your baby’s food and oxygen supply and slow the baby’s growth. If you do have an increased risk of blood clots, your doctor might prescribe a blood thinner such low-dose aspirin, or heparin. You might also be screened for anti-Ro/SSA and anti-La/SSB antibodies. These antibodies pose an increased risk of the baby having a congenital heart block.

Kidney or liver damage caused by lupus increases the chance of complications during pregnancy. Pregnancy tends to increase stress on the damaged organs.

Alter your lupus medicines to protect your pregnancy. Your doctor can help you decide on a lupus treatment plan that’s safe for your baby. Hydroxychloroquine (Plaquenil) and prednisone are considered safe during pregnancy. Methotrexate and cyclophosphamide (Cytoxan) should not be used in pregnancy and should be discontinued for at least a month prior to getting pregnant. Ask your doctor to help you weigh the benefits and risks all your medications.

Plan your pregnancy

It isn’t always easy to plan a pregnancy. But you should only consider getting pregnant after a thorough health care evaluation. You should also plan to get pregnant during a period of remission or reduced disease activity. You’ll have far fewer complications if your disease isn’t active.

Pregnancy is no longer considered an impossibility if you have lupus. Advancing technology and better understanding of the disease and its effects on the body have improved pregnancy outcomes over the last 40 years. Your chances for a successful pregnancy are excellent if you plan properly—when lupus symptoms are in remission—and your rheumatologist and specialists in maternal-fetal medicine monitor you closely.

Once you become pregnant:

See your doctor often. Frequent doctor visits can help identify abnormalities, monitor the baby’s growth, and offer you reassurance. About 25% of lupus pregnancies may result in premature birth of the infant, and between 20% and 30% of women with lupus will experience preeclampsia. This is a sudden increase in blood pressure and protein in the urine, which leads to swelling in body tissue. Preeclampsia often requires urgent treatment and can only be cured by delivery of the baby; therefore seeing your doctor often is of the utmost importance. Your doctor can also monitor your baby’s growth through sonograms or ultrasounds, which are harmless for you and your baby

Watch for signs of lupus flares. Recent studies show that lupus flares are rare during pregnancy. In fact, many women experience improvement in their lupus symptoms during pregnancy. If you get pregnant after six months of remission, you’ll be less likely to experience a lupus flare than you would if your lupus were active. Symptoms of a lupus flare can mirror symptoms of pregnancy, so it is important to determine with your doctor whether you are experiencing a lupus flare or just the normal signs of pregnancy. Both can be marked by joint swelling and fluid accumulation, facial rashes, and hair changes.

Take it easy to avoid lupus fatigue. Pregnancy can be hard on a woman’s body, and lupus can add challenges to a pregnancy. Getting enough rest is extremely important. Women with lupus should not gain excess unnecessary weight during pregnancy and should follow a well-balanced and healthy diet. Be prepared to modify your activities and routine if you feel tired or are in pain.

Prepare for the possibility of premature delivery. About 50% of pregnancies in women with lupus deliver prematurely because of complications related to lupus. Choose a hospital that specializes in infant care and offers a neonatal intensive care unit should your baby arrive early or have any health issues. Though prematurity does present risks to the baby, most issues can be properly treated in a hospital that specializes in infant care.

Risk factors 

Certain factors can make you at higher risk for lupus flares and poor fetal outcome during your pregnancy:

• Pre-existing or present hypertension

• History or presence of kidney disease

• History of previous preeclampsia

• History of low platelets

• History of blood clots

• History or presence of antiphospholipid antibodies 

Your pregnancy should be managed by a perinatologist or maternal-fetal specialist (an obstetrician experienced in high-risk pregnancies) and your regular rheumatologist, or a rheumatologist who specializes in pregnancy and autoimmune conditions.  These are the necessary laboratory tests your doctor will request once you are pregnant:

Urinalysis – to check for protein in the urine

Complete blood count

Blood chemistry tests – to look at kidney and liver function

Antiphospholipid antibodies – to check for risk of miscarriage

Anti-SSA/Ro and Anti-SSB/La antibodies – to see if the fetus has a risk of heart block (neonatal lupus), in which case the doctor will request a fetal echocardiogram starting at 18 weeks

Anti-DNA antibodies

Complement levels

You will need to do your part as well:

See your rheumatologist at least once every trimester—more often if you have a lupus flare. If you have a flare, you may need to be treated with prednisone, which does not cross the placenta except at high doses.

See your perinatologist and obstetrician regularly and frequently, and follow their instructions about rest, exercise, diet, and medications.

Pay very close attention to what your body is telling you and tell your doctors about anything that doesn’t seem right.

Make the right lifestyle choices: Don’t smoke, drink alcohol, or take recreational drugs, and limit caffeine.

References-

https://www.nhs.uk/conditions/lupus/

https://www.webmd.com/lupus/features/lupus-pregnancy-pregnant#1