Women who have multiple miscarriages to get support earlier says new guidance

‘I had a miscarriage at five weeks after my first IVF cycle in 2016,’ infertility blogger Vanessa Haye tells Metro.co.uk.

Vanessa has been through numerous heartbreaking experiences with pregnancy loss and fertility issues, and she believes she wasn’t given the support she needed.

‘Then, in 2019, after a spontaneous natural pregnancy, I informed my GP, and also shared my concerns with pain I was having at five weeks.

‘I was shocked to not have been offered an early pregnancy scan given my medical history.

‘That pregnancy ended in a near fatal ectopic pregnancy at nine weeks.’

Vanessa believes that if she had been offered help after her first pregnancy loss, and had her specific risk factors taken into consideration, the outcome may have been different.

‘In hindsight, had I have received earlier care and intervention, it may have lowered the severity and outcome of my case,’ she says, ‘even if the end result couldn’t have been prevented.’

However new guidance published for consultation by the Royal College of Obstetricians and Gynaecologists is hoping to change this.

The guide suggests that women should be offered support for future pregnancies after experiencing just one miscarriage.

Currently in the UK, women can only access specific support and additional investigations after they have experienced three miscarriages in a row.

But experts are calling for women to be offered information and guidance after one miscarriage, an appointment at a miscarriage clinic for initial investigations after two miscarriages, and a full series of evidence-based investigations and care after three. 

The term ‘recurrent miscarriage’ is also being redefined in this guideline to include non-consecutive miscarriages, meaning more women will be able to have investigations at an earlier stage.

‘What happened to me shows that earlier access and support is needed to inform women about their reproductive health issues and subsequent help seeking behaviours,’ Vanessa adds.

The new Recurrent Miscarriage guideline – last published in 2011 – supports a move towards a graded model of care, as proposed by experts in The Lancet in April, where women are provided with individualised care earlier.  

The guideline also highlights the health disparities facing women from Black, Asian or minority ethnic backgrounds who are at a higher risk of having a miscarriage and calls for more research to be done to understand why this is the case. 

‘The research indicates that sporadic miscarriage is higher in this group – Black, Asian and minority ethnic mothers – and there are known risk factors such as PCOS, fibroids etc. which can contribute to the causes of miscarriage,’ adds Vanessa.

She says that while the new guideline is a ‘step forward’, she still has her doubts about the practicality and effectiveness.

‘It still comes across as a prescriptive “one size fits all” model, implying that the help may still not reach most who are affected across the UK after every miscarriage,’ she says.

‘My concerns in particular are for disproportionately affected groups such as Black women – who have a 43% higher chance of experiencing a miscarriage.

‘However, the new guidance only mentions that Black ethnicity is a risk factor and is yet to identify the root causes of this issue. This makes me think that the revised guidance in place doesn’t offer any solution or individualised care for this group despite the high cases of miscarriage, and the proposed urgency to lower the cases.’

What are the changes to miscarriage treatment?

The Royal College of Obstetricians and Gynaecologists (RCOG) wants the NHS to overhaul its rules so that any woman who suffers one miscarriage receives information and guidance to help them cope with their loss and plan future pregnancies.

Anyone who has two miscarriages should automatically be offered an appointment for an initial investigation at a specialist miscarriage clinic.

After three pregnancy losses, a mother should receive a more in-depth exploration of their health.

The term ‘recurrent miscarriage’ is also being redefined in this guideline to include non-consecutive miscarriages, meaning more women will be able to have investigations at an earlier stage.

The guideline also calls for more research to be done to understand the health disparities that mean Black, Asian and ethnic minority women are disproportionately affected by pregnancy loss.

Lead guideline developer, Professor Dame Lesley Regan, says: ‘A significant proportion of cases of recurrent miscarriage remain unexplained, despite detailed investigation. These women and their partners can be reassured that the prognosis for a successful future pregnancy with supportive care alone is in the region of 75%.

‘Miscarriage can be a devastating loss for women, their partners and families. We, therefore, hope this guideline will provide women and the clinicians caring for them with a consistent and evidence based approach to diagnostic tests, treatment options and supportive care to increase their chances of a successful birth in future.’

For this first time, the guideline highlights that increasing paternal age is a risk factor for recurrent miscarriage, although not as markedly as with maternal age.

Other risk factors include having previous miscarriages, being underweight or overweight, smoking and excess caffeine intake – although the authors note that a significant proportion of women with unexplained recurrent miscarriage are healthy women with repeated sporadic miscarriages and no known cause.

The guideline also incorporates the results from a major clinical trial published in 2019 – PRISM – which found that giving women with early pregnancy bleeding and a history of miscarriage self-administered twice daily progesterone pessaries can prevent some miscarriages.

Crucially, the guideline also highlights where the evidence is lacking for interventions to prevent miscarriage – such as preimplantation genetic screening. Researchers say couples should be informed of the risk and significant cost of undergoing such treatment, as well as the lack of evidence regarding any improvement in reproductive outcomes.

‘The right care can reduce the risk of miscarriage, and the right support can help parents if they experience loss – but that help isn’t reaching everyone across the UK after every miscarriage; this can and must change,’ says Jane Brewin, chief executive at baby charity Tommy’s.

‘It’s great to see the Royal College taking forward Tommy’s recommendations from our Lancet research in their new care guidelines, so we can prevent more losses wherever possible but also better support those who do sadly lose their babies.

‘We know what to do and how to do it, so now we need a commitment across the NHS to develop these care pathways and improve support for everyone.’

The guidelines are due to be finalised by the end of 2021.

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