Miscarriage Care

How companies can support families who experience miscarriage.

Paolo Nicolello via Unsplash

Trigger warning — this article discusses the causes and consequences of pregnancy loss which might be upsetting.

Inspiration for this post came in part from the excellent book Not Broken by Lora Shahine, MD, FACOG. Buy it here.

Definitions:

Miscarriage — loss of a pregnancy during the first 23 weeks (UK definition) or less than 20 weeks (US definition).

Recurrent pregnancy loss — is defined in the UK and Europe by the Royal College of Obstetricians and Gynaecologists (RCOG) and European Society of Human Reproduction and Embryology (ESHRE) as three or more consecutive pregnancy losses. In the US, the American Society for Reproductive Medicine (ASRM) define it as two or more consecutive clinical pregnancy losses.

Clinical pregnancy — is defined as a pregnancy documented by ultrasonography or histopathological examination.

Chemical pregnancy — also called a biochemical pregnancy, is a miscarriage that happens after a positive pregnancy test but before pregnancy can be seen on ultrasound. Chemical pregnancies are not usually included in counting pregnancy losses towards a recurrent pregnancy loss diagnosis and providers are conflicted in terms of the evaluation and treatment.

How common is miscarriage?

Miscarriage affects many however it is still shrouded in secrecy. Most choose not to share news of their pregnancy until 12 weeks or beyond in case they have to tell friends and family about a lost pregnancy. This is an incredibly personal choice but it means those that do miscarry often do so without the support of their loved ones.

The American Society for Reproductive Medicine (ASRM) estimates that 15–25% of clinical pregnancies end in miscarriage. If chemical pregnancies are included the percentage is higher (1).

“Miscarriage is the secret club that has so many members but no one wants to join.” (Unknown)

This equates to every year there being around 23m miscarriages (2) globally which is probably the better part of 45m potential parents (noting of course many choose to have a child as a single parent and some people will experience multiple miscarriages). If things remain constant that means in the next 10 years there will be 230m miscarriages globally, affecting nearly half a billion people.

In the UK it is estimated there are 250,000 pregnancy losses per year.

Recurrent pregnancy loss

Sadly around 5% of people will have two or more miscarriages and 1% will have 3 or more. In 2013 the ASRM changed the definition of recurrent pregnancy loss to 2 or more clinical miscarriages, down from 3.

The ASRM’s new definition means that providers will test women earlier. This is important because some data suggests the chance of loss after a second is the same as after three and suggest if a cause for the first 2 miscarriages can be found the 3rd might be avoided.

However the ASRM’s definition does not include miscarriages that occur before they can be defined as clinical pregnancies. This is important as some evidence supports that biochemical miscarriages are prognostically important for recurrent pregnancy loss (3).

Evaluation of recurrent pregnancy loss

The evaluation of a couple having recurrent miscarriages focuses on determining whether there is an underlying cause. However often these tests come back as normal which can be incredibly frustrating.

Potential causes include: unexplained; chromosomal abnormality — including balanced translocation; endocrine and chronic disease — such as uncontrolled diabetes, thyroid issues or debatably polycystic ovary syndrome; antiphospholipid syndrome/clotting disorders; uterine issues — such as uterine septum, fibroids, polyps, adhesions or scarring; cervical weakness — particularly in those experiencing late miscarriage (4).

Where can companies have a positive impact?

Despite an (albeit back of napkin) estimate that miscarriage will affect nearly half a billion people over the next 10 years, there is a dearth of startups focusing on miscarriage care. There is the opportunity for companies to provide thoughtful and considered support to families, make a real impact on their recovery and potentially even develop preventative solutions in future. Some ways companies could help:

• Mental and emotional support

Although fertility clinics offer counselling (it is requirement by the HFEA), most women that experience miscarriage won’t be under clinical care. Even women miscarrying after IVF sometimes have to wait weeks (some up to 8!) before they can access support.

More prompt emotional and psychological support could help prevent the associated incidence of post-traumatic stress, depression, anxiety, and sleeping disorders as well as addressing feelings of guilt that can arise following the loss of a baby. Support should also be available long-term given studies have shown the intensity of grief reactions may take a year before subsiding (5).

• Relationship & psychosexual counselling

The impact of a miscarriage on couples is huge. The data suggests that couple that experience miscarriage are significantly more likely to have a breakdown of their marriage or relationship (6). The impact on children a family already has can also be significant. Offering family support and/or psychosexual counselling for couples could be one potential solution.

• Lifestyle interventions & aftercare

There is some data to suggest lifestyle interventions and optimising preconception health can reduce the risk of miscarriage or recurrent pregnancy loss. Smoking, obesity and other lifestyle habits such as drug use and excessive alcohol consumption have all been associated (4). Helping women and people recover from the physical impact of having a miscarriage is also important.

• Earlier investigation

While the current UK guidelines require 3 consecutive miscarriages for investigation for recurrent pregnancy loss many may opt for investigation after 2 (in line with the American guidelines) if given the choice. Although the chances of finding a treatable cause may be low, the individual may want to weigh this against the high emotional and physical consequences of a further miscarriage.

• Men and semen

Research into the role of male’s contribution to miscarriage is still lacking. However genetic and epigenetic modification of sperm is an exciting area of research. Companies such as Inherent Bio are looking into the space. Lifestyle programmes for men focusing on preconception health is also an area of interest. Companies such as Exseed are developing these.

• Prevention

The PRISM trial, published in 2019, showed that in women with early pregnancy bleeding and a history of recurrent miscarriage, progesterone treatment reduced the risk of miscarriage (7). It is hard to know how widely this practice is being implemented currently in primary care.

• Future developments inc. biomarkers

A range of potential biomarkers for recurrent pregnancy loss have been previously investigated and could represent areas of future development. For instance, Stortoni et al (8) reported changes in the expression levels of thrombomodulin in patients with recurrent pregnancy loss compared to the control group. Bao et al (9) determined that serum Dickkopf -1 (Dkk 1) levels were increased in patients with recurrent pregnancy loss compared with a control group. Similarly in threatened miscarriage plasma kisspeptin (10) and ca-125 (11) have also been investigated. However the clinical significance for these is yet to be determined.

If you’ve been affected by miscarriage

Firstly, I am so sorry for your loss. There are a number of great charities that provide support and resources that you might want to check out:

• The Miscarriage Association — has information, support groups and a helpline
• Child Bereavement — offers support and guidance, resources for professionals and training
• Tommy’s — provides support and information for people that have been affected by miscarriage, including dad’s and partners

Anyone that would like to support these charities can also make a donation. I have made a personal donation to The Miscarriage Association.

After writing this article I found two companies doing work in the space — Seek who are providing an integrative medicine approach to pregnancy loss and Box for Loss who curate miscarriage support boxes with holistic products.

If you’ve been affected by baby loss and you’d like to have a chat, or if you are an entrepreneur who is looking at the space, you can connect with me here.

References

1. Practice committee of american sociey of reproductive medicine. Definitions of infertility and recurrent pregnancy loss: a committee opinion. Fertil Steril 2013. Link
2. Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. Lancet 2021. Link
3. Non-visualised pregnancy losses are prognostically important for unexplained recurrent miscarriage. Hum Reprod 2014. Link
4. Evaluation and treatment of recurrent pregnancy loss: a committee opinion. ASRM 2012. Link
5. Psychological outcomes following missed abortions and provision of follow-up care. Ultrasound Obstet Gynecol 1998. Link
6. Marriage and Cohabitation Outcomes After Pregnancy Loss. Pediatrics 2010. Link
7. The Miscarriage Association. Website. Link
8. Placental thrombomodulin expression in recurrent miscarriage. Reprod Biol Endocrinol 2010. Link
9. Increased Dickkopf-1 expression in patients with unexplained recurrent spontaneous miscarriage. Clin Exp Immunol 2013. Link
10. Kisspeptin, a promising biomarker for miscarriage in early pregnancy. Fertil Steril 2021. Link
11. Role of serum biomarkers in the prediction of outcome in women with threatened miscarriage: a systematic review and diagnostic accuracy meta-analysis. Human Reproduction Update 2015. Link