Facts About Miscarriage

Catrina Skepper: For pregnant women, there is nothing more devastating than a miscarriage. Professor Lesley Regan, an Obstetrician and Gynecologist from Imperial College at St. Mary's Hospital in London, is here to answer questions on miscarriage. Why they happen and whether anything could be done to prevent them? Welcome Lesley. This is such a big topic, but it's also perhaps one of the most talked about and yet misunderstood topics about pregnancy because people fear it. What exactly is a miscarriage? Lesley Regan: Well, a miscarriage is any pregnancy that ends spontaneously before the baby has got to a viable state. Catrina Skepper: And a viable state -- Lesley Regan: -- which is all heard of posh words for saying it anything between the time of the positive pregnancy test and 24 weeks into the pregnancy. Catrina Skepper: So assuming that you know you're pregnant, you would obviously know that you've miscarried. Lesley Regan: Well, most women do. Most women have symptoms of bleeding, pain. Of course, there are some women there in which the pregnancy will die and they don't find out and this is happened until they go along for a hospital appointment and have a scan. And for those women, I think it could be particularly devastating not a loss of the baby, but there is also a feeling, oh, my god and I didn't even recognize that the baby had died. And that I think often makes many of them feel very, very inadequate as well as distressed by the news. Catrina Skepper: Yes, because the distress is compounded by the fact that immediately you must think I have done something wrong. It could have been averted. I'm assuming the most commonly asked question is, why? Lesley Regan: What could I have done to stop it? What did I do to make it happen? I think most of the time, I can reassure people or I can try to reassure them that nothing they could have done about it, would have changed it. And that having sex, riding a horse, swimming, going to the yoga club, none of this would have actually affected it. But of course, because miscarriage is so common and because women in the first three months of pregnancy are usually feeling relatively well and are active. They are embarking on doing things and I have very common question is, oh, I miscarry and I keep miscarrying after I've been in airplane. I must not fly again. Of course, it's nothing to do with being on the airplane. It's to do with the fact that you're more likely to be traveling somewhere at six weeks or eights weeks into the pregnancy rather than the 36 weeks. And those things occur then. Catrina Skepper: Did you say by what we know what we know medically and scientifically the reasons for miscarriages are still pretty complex, but on the other hand, we know and feel a lot more than we did. Women now ask the questions, after the miscarriage obviously. Lesley Regan: Yes. Catrina Skepper: What has changed so much? What is it that you now can do to help women without fear before they have miscarried, to prevent the miscarriage from occurring if there is the slightest chance? Lesley Regan: Well, I think here we have to talk about women who have had their several miscarriages because these are the women that who are wanting to have answers and questions, answers to their questions. In fact, now expect to be investigated in quite a sophisticated way. I think it's fair to say that in the last 20 years, things have really changed. When I was a Junior Registrar and first in this field, I was completely and utterly perplexed by the lack of information in text books and I would be faced by couples in the middle of the night and saying well, why did it happen, and all I had in my repertoire was, well it's bad luck and it's nature where certain things happen. It became very obvious to me that this really wasn't acceptable to most couples and I tried to put myself in this women's position and now I wouldn't want them to tell me that either. Catrina Skepper: Of course you did, because the amount of research you've done is led to obviously some really answers that you're now able to give. Lesley Regan: Well that's kind. A lot of other people who have been very involved in this field too and they said it's all teamwork. But we have actually changed things I think in terms of the fact, that now if you go to the miscarriage, because you've had several loses, the doctor there will have been trained to work through a checklist of investigations and categories. What I think is particularly important, is that those headlines or categories or areas of investigation are changing, have changed and will be change in the future. So in the past, perhaps 20 years ago, all we knew was that most miscarriages caused were caused by a chromosome or genetic abnormality in the baby which was out of the blue, bad luck, couldn't help it, nature's way. Also sometimes for some women who didn't have the right sort of hormonal environment in which the tiny embryo would implant successfully. Now women go throughout the checklist we've got genetics, we've got infection, we've got hormones, we've got all sorts of other things and particularly, we've developed this whole understanding of prothrombotic or thrombophilic disorders, these strange things in which during pregnancy the women's blood system or clotting system changes. We believe now that there are many cases of recurrent pregnancy loss are due to an exaggerated response to this normal reaction in pregnancy. Catrina Skepper: The next question is there something that you can do about that to prevent that from and can you detect a women's potential to that? Lesley Regan: Well, in this particular field, this is where I think things have changed quite a bit, the whole concept of prothromobotic tendencies and pregnant women being susceptible to them, if we can identify before they get pregnant, then we can start treating them the moment they get pregnant with drugs that have been enormously successful and in improving the life. And that's of course is what is all about. Catrina Skepper: Right. An idea is well would women actually go and have their blood tested before they even thought of getting pregnant? Is that what you would think? Lesley Regan: No, I think it's important to recognize that we couldn't do that because we would be absolutely inundated and we just could fund it but also because if we go through a routine normal antenatal clinic, we will find some women with these abnormalities in their blood, who are fine. But there are sub-group who do have problems and I think what's important for us all to understand that is when they've declared themselves as being an at risk group, that we're pulling that group and then investigate them comprehensively. There are lots of other areas that have changed, not just this one. Catrina Skepper: Am I right in thinking that the treatment, because you're the one who do the research into the Aspirin benefits, is that right? Lesley Regan: That's right. We are particularly interested in phospholipids syndrome, all these special antibodies that are simply speaking, probably cause the blood to be more sticky. It's a bit more sophisticated than that because in fact what we realize now is that way before you've got blood supply going around this little baby, you have got these antibodies, actually attacking the placenta or the tiny -- Catrina Skepper: The environment. Lesley Regan: The environment in which she is implanting. But these phospholipid antibodies are very good example of what I was saying early about how things have changed. They started off being recognized as an autoimmune disorder in the mother and then we realized that they were clotting or prothombototic problem. And now, it's got even more complicated because we recognized that this is one form of clotting disorder and acquired clotting disorder and there are other types. And we now recognize, that in addition to being a clotting problem that as I've just said these antibodies probably affect the placenta and also the womb lining and how receptive it is to this invading embryo. So things are moving on and my hope is that, if we were to have this conversation in another five years that we'll be talking about additional categories in that checklist. And that we will continue to explore more. And so hopefully, the unexplained or can't explain what had happened group will becomes smaller and smaller. Catrina Skepper: Is it though still perhaps true, as we like to comfort our friends and say won't you know that just way it was probably never meant to be -- there might be something wrong with the baby. Those are the things we say to comfort each other. But in reality, is it usually not the problem of the fetus but the problems of the host environment like you have been saying. Lesley Regan: We'll, I think that's really important thing to remember about the fetus. Although we are all chasing these tiny little, we are chasing the minority of cases which are caused by specific abnormality like these prothombotic disorders. Well, we have to remember still the vast majority of pregnancies will be because the babies got the wrong chromosomes in the wrong cells and it's all out of the blue bad luck. That's one of the difficult things I think for women who have come to a specialist clinic to understand. Let's say, that you give them the diagnosis, you've got this. And fortunately, we've got this wonderful treatment and it produces fantastic results. We come back to the early pregnancy clinic full of hope and then bang, they miscarry again. Of course what they find extraordinarily difficulty to understand is that because they've got a syndrome X and treatment Y that they're not immune from having a miscarriage from the commonest cause of miscarriage world wide. And that's very difficulty pill to swallow I think. Catrina Skepper: Also, because I think for women who does miscarry between very often having had healthy babies that I'm right in thinking that miscarriage-- Lesley Regan: Why did some go right and why did some go wrong yet? Catrina Skepper: Some people even think that there is something to do, the sex determination. I know my sister had four girls and she is always sure that the miscarriages she had in between her pregnancies, were as a result of carrying boys. Is that actually a myth? Lesley Regan: Well, it's a lovely story. Isn't it? Catrina Skepper: I can't carry boys or I can't carry. Lesley Regan: No, there is really a clinic that goes important when someone doesn't come out with a question. Is it because I can't carry girls, but then equal in number of questions, as because I can't carry boys? And if we look at the dynamics of the birth rate in terms of the sex ratio, this can't be an issue because it doesn't change dramatically. Catrina Skepper: How then do you treat women? Presumably, you can come, if you can come to a clinic about miscarriage or you called your doctor. What do you do if you miscarry and you're still in very early stages of pregnancy? Do you try and get treatment? Do you wait till the next pregnancy? Because I heard that you also have to wait for perhaps three miscarriages before you can actually get specialist treatment. Is that correct? Lesley Regan: Well, I know it sounds very callus, but the problem here is that one percent of couples in the UK this year will have three miscarriages. And if we say, that the definition of recurrent miscarriage and the definition of the number of experiences you have to suffer before you get to the third is two. Then we go from one percent to five percent of couples and looked at the way round. That means providing investigations in possible treatment for one in a hundred couples and then increasing it to one in twenty couples who are trying to have a child. The healthcare resources you need for that are enormous and it's an enormous chunk. So yes, it sounds incredibly callus, but I think now we're getting a little bit more refined and we're saying that yes, we want to recognize women who have had three or more early loses. And that prior to that time is not going to be possible to investigate them in the NHS. But we're also saying that if you've had a late loss, so if you've had a pregnancy that's being lost after 12 weeks which is much, much rarer. And if we can document that on scan to show it was actually 12 or 14 or 18 week size baby. Then that woman needs to be sent to a specialist clinic straight away. We're also -- brought it further to recognize that some late pregnancy complications like pre-eclampsia and preterm labor and very, very severe growth restriction in babies, when it occurs, when the onset is very early that those women have probably got reproductive problems, akin to miscarriage. But at another end of that spectrum, they really warrant sophisticated investigation at an earlier stage. Catrina Skepper: Now the thing that I think has happened in our society generally is that women are having children much later. You cannot help it one day if age is a real factor when you get told, when you're pregnant, the first question you are asked is your age and the test and your ratios go up and it's actually becoming common for women to have children in their early 40s. Is it a factor in miscarriage? Lesley Regan: It's a major factor. It's an irrefutable factor. And that after the age of 35, the increasing chromosome abnormalities in the fetus due to the age of the mother's eggs, increases exponentially. Having said all that, not all pregnancies are going to miscarry, but if the pregnancies that miscarry, the vast majority. Over 80% of them are chromosomally abnormal. So chromosome abnormalities in older women very much high but I think it's important that we're not too negative about it because as you say, there are lot of older women who are being successful. Although, I think it will be irresponsible of me as an obstetrician gynecologist to encourage women to delay their reproductive -- or their pregnancies. It is important to remember that not every pregnancy after that age is going to be unsuccessful and let's face it because I look after women with problems. My antenatal clinic is jam packed with older women because you can't change your age and the clock ticks on. Catrina Skepper: The only thing that one would obviously say, for older women tickle is if you have one miscarriage, are you then going to have a higher risk of carrying of having another miscarriage? Lesley Regan: Well, I did somewhat long time ago, which suggested that the yes, in fact one most important predictive factors for a miscarriage is your past reproductive history. That if you've had live children in the past and you're much more likely to go on be successful. And then after you've one or two miscarriages, there is an increased risk of miscarry again, but that's not exclusive. It doesn't mean that you're not going to be able to achieve a successful outcome. Catrina Skepper: It's also I think the guilt factor comes in with miscarriage a great deal? And of course, a woman who perhaps at a younger age had an abortion or termination, obviously, it might feel that is a cause. Is that something that you know? Lesley Regan: I'm really glad you've mentioned that point because I think it's a source of enormous distress to many of the couples that I see. Some of whom have gone through anguish, deciding amongst themselves whether they're even going to confess to each other because it would be probably a new relationship with somebody else many years ago. Catrina Skepper: That's the important thing you know. Lesley Regan: Exactly. So I'm very glad you brought it up because I feel quite confident in saying that, if you've had an uncomplicated early termination of pregnancy, but this does not change your outcome in terms of miscarriage in a future. Catrina Skepper: Lesley what advice, lifestyle advice, would you give to somebody who's had a miscarriage and is hoping obviously to get pregnant as soon as possible? Lesley Regan: Well, I think diet is very important. To have a sensible diet as possible. Make sure you're talking a folic acid because it's a department of health recommendation and you should do. Stop smoking and make it today not next week, today. Try and limit your alcohol intake and I think a sensible exercise program. And I think also and trying to get just yourself feel as confident as possible. I think the only way you can do that is to have as much information at your fingertips as possible. Catrina Skepper: Fantastic. Lesley, thank you so much for your invaluable advice. Thank you. Lesley Regan: Thank you for inviting me here.