Your care after 3 miscarriages

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Testing after recurrent miscarriage

How do I get tested?

Do these guidelines for referral include all types of losses?

What can my GP do?

Your mental health

What kind of tests will I have at a specialist miscarriage clinic?

Tests and treatments that have not been proven useful

What happens next

If you get pregnant again
 

Testing after recurrent miscarriage

There are tests available to try and find out why you have had multiple pregnancy losses.

Sadly, these tests may not always be able to find out why you lost your baby. No cause is found in about half of cases. 

If a cause is found, it may be possible to treat the issue and reduce your risk of miscarriage in your next pregnancy. But sometimes an issue may be found that is not treatable. Sometimes, the treatment may not work. There are also some known causes of miscarriage that cannot be changed, such as age. Find out more about the known causes of miscarriage.

The whole process of getting tested and having treatment can cause anxiety. But try to keep in mind that most people are likely to have a successful pregnancy in the future, even after 3 miscarriages in a row. 

We have a Miscarriage Support Tool that you can use to get personalised support and find out your chance of a successful next pregnancy.

How do I get tested?

The NHS follows guidelines that say your GP will refer you to a doctor who specialises in miscarriage after you have had 3 early miscarriages (recurrent miscarriage) or 1 late miscarriage.

Different areas have different rules. Some hospitals may be able to investigate after 2 miscarriages. It is worth talking to your GP, explain how you are feeling and ask to be referred.

Find out more about getting referred to a specialist after a miscarriage. 

"I never thought I’d go on to have the complications I did." Read Nina's story here.

Do these guidelines for referral include all types of losses?

Some people consider losses such as ectopic pregnancy or molar pregnancy as a miscarriage. This is completely understandable, as these pregnancies end in loss.

But you may not be referred to a miscarriage specialist after 2 or 3 miscarriages that include these types of losses. For example, if you’ve had 1 ectopic pregnancy and 2 miscarriages where the cause was unknown, you may not be accepted for specialist miscarriage care in some areas.

This can be upsetting. But it is because we know what causes ectopic pregnancy or molar pregnancy, so further tests are not medically necessary.

Again, different areas have different rules. So it is worth talking to your GP about getting referred for specialist care if you have experienced other types of pregnancy loss. 

If you’ve had an ectopic pregnancy or molar pregnancy before, you should be offered an extra scan at 6 to 8 weeks in your next pregnancy to check that the baby is developing in the right place.

Find out about types of miscarriage. 

What can my GP do?

As well as organise your referral to a specialist, your GP can help you in other ways.

For example, they can help you access any support or services you may need to make sure you are as healthy as possible before you try to get pregnant again. For example, they can help you access support to stop smoking, access to a dietitian or treatments for mental health problems.  

They can also help you manage any long-term conditions or refer you to a specialist who can help. 

Your GP can also do blood tests, including a full blood count (FBC) to check for things like anaemia or coeliac disease. 

Vitamin D deficiency testing

Your GP may be able test for a vitamin D deficiency. Recent research found that women with low vitamin D levels are at significantly increased risk of miscarriage.   

You may be at risk of not having enough vitamin D (known as Vitamin D deficiency) if:

• you have dark skin (for example, if you're of African, African Caribbean or south Asian origin)
• you cover your skin when outside or spend a lot of time inside
• your diet is low in vitamin D-rich foods such as eggs, meat, vitamin D-fortified margarine or breakfast cereal.
• your BMI is above 30. 

A 10 microgram (or 400 IU) vitamin D supplement a day will be enough for most people to get enough vitamin D. However, if you are found to have very low levels, your doctor may prescribe a higher dose.

Your mental health

Losing a baby is heartbreaking and can cause overwhelming feelings. 

It is possible to develop mental health problems because of this kind of grief and stress. Depression and anxiety are common, but some people may develop other issues, such as post-traumatic stress disorder (PTSD) or perinatal obsessive compulsive disorder (OCD). 

Talk to your GP if you are worried about how you or someone else is feeling. There is support available and mental health problems are treatable.

You can also talk to a Tommy’s midwife free of charge from 9am–5pm, Monday to Friday on 0800 0147 800 or you can email them at [email protected]. 

You can also join the Tommy's Baby Loss Support Group on Facebook for those who have experienced any type of baby loss. You can also join the Tommy's Pregnancy and Parenting After Loss Support Group on Facebook if you want to speak to people about trying again or pregnancy after loss. 

You can also refer yourself directly for talking or psychological therapies using the NHS talking therapies services known as Improving Access to Psychological Therapies (IAPT) services.

Some recurrent miscarriage clinics have bereavement counselling available. Your specialist may be able to tell you what’s available where you are.

Find out more about your feelings and emotions after miscarriage.

We also have information about baby loss support specifically for dads and partners. 

What kind of tests will I have at a specialist miscarriage clinic?

You and your partner should be seen together by a specialist health professional.

This is a list of tests you may have after 3 miscarriages. It’s unlikely you will need every test and not every miscarriage clinic will have every test available. 
If a cause has been found, possible treatment options will be offered to you to improve your chance of a successful pregnancy.

Blood testing 

Your blood can be checked for anticardiolipin antibodies (aCa) and lupus anticoagulant. This test should be done when you're not pregnant. If the first result is out of the normal range, it should be tested again 12 weeks later. If the tests confirm the positive result you may be diagnosed with antiphospholipid syndrome (APS). This is an immune system disorder that may increase the risk of miscarriage as tiny blood clots restrict the blood flow to the pregnancy.

APS may be treated with low-dose aspirin and heparin injections to thin the blood, and will only be used during pregnancy. These are safe to take in pregnancy if you have been diagnosed with APS but do not take them unless they have been prescribed by a healthcare professional. You’ll also be carefully monitored during pregnancy.  

If you had a late miscarriage you should be offered a blood test for thrombophilia. This is a condition that raises your risk of blood clots in pregnancy. This should be treated with heparin. This will reduce your risk of a blood clot during pregnancy, although there is not enough evidence to say if it will reduce your risk of miscarriage. 

Tests for infection

If you have had a late miscarriage, tests such as blood samples and vaginal swabs may have been taken at the time of your miscarriage to look for any source of infection. 

Natural killer cells (NK cells)

Natural killer cells (NK cells) form part of the body’s immune system. They help the body fight infection and cancer. Every organ has NK cells to protect it, including the uterus (womb).

NK cells in the uterus are known as uNK cells. Too many or too few uNK cells are both associated with infertility and miscarriage.

It is possible to have tests to measure your level of NK cells. This is not usually available on the NHS (although some people have told us that they have had these tests through their NHS recurrent miscarriage clinic). Some fertility clinics offer tests, but not all. If they do, you will have to pay for it. This can be expensive and will vary from clinic to clinic. 

It’s important to know that the Royal College of Obstetricians and Gynaecologists (RCOG) says that there is not enough evidence that treatments for abnormal levels of NK cells are effective. Your specialist can tell you more.

Find out more about Natural killer cells (NK cells).

Thyroid function test

The thyroid gland is a small butterfly-shaped gland in the neck, just in front of the windpipe.

It produces hormones that regulate the speed at which your body cells and organs work. If there are too many hormones, the body cells and organs work faster. If there are too little hormones, the cells and organs may be slower.

Thyroid problems can cause complications in pregnancy, including miscarriage. 

If your GP hasn’t already done so, your specialist may offer a thyroid function test (a blood test) can check if your hormones are within range. If they are not, you may need treatment. Ideally, he thyroid to be working well before pregnancy. If you are prescribed medication to help your thyroid you should be seen by a specialist when you are pregnant. 

Tests for chromosome abnormalities in the baby

If you have had 3 miscarriages, you should be offered tests to check for abnormalities in your baby’s chromosomes (blocks of DNA which contain instructions for developing every part of a person). This is not always possible but may help to determine your chance of miscarrying again.

You may also be offered a postmortem examination of your baby if you have had a late miscarriage. This does not happen without your permission (consent). 

Parental karyotyping

If a genetic abnormality is found in your baby, this may not be something which has been passed on from you or the baby’s father. However, if there is a chance that it could have been passed on from you or the father, then the clinic will suggest testing you both for chromosome abnormalities. This is known as parental karyotyping.

If any problems are found, you will be referred to a clinical geneticist who can talk to you about your options for getting pregnant again. This is called genetic counselling. Find out more about conception and your baby's genes.

Tests for abnormalities in the shape of your uterus

A transvaginal ultrasound can check your womb for any structural abnormalities. This will most likely be a 3D ultrasound scan that will look for any abnormalities in the womb and pelvis.

If an abnormality is found, your doctor should talk you through the findings and you may be offered surgery. Find out more about uterine abnormality. 

Test for weak cervix

A transvaginal ultrasound scan can also check if you have a weak cervix (also known as cervical incompetence or cervical insufficiency). This test can usually only be carried out when you get pregnant again. Usually, you’ll be asked to come for a scan when you are between 10 and 12 weeks pregnant. 

If you are diagnosed with a weak cervix, you may be offered a cervical stitch (these are also used to prevent premature birth). 

Find out more about weak cervix.

Tests and treatments that have not been proven useful

• Partner compatibility testing
• Immunity testing
• Paternal cell immunisation, third-party donor leucocytes, trophoblast membranes and intravenous immunoglobulin 
• hCG supplements
• Metformin treatment
• Pre-implantation genetic diagnosis
• Treatment with steroids.

Low-dose aspirin

Low dose aspirin (LDA) is a useful treatment for antiphospholipid syndrome when used in combination with low-dose heparin.

But current evidence suggests that LDA on its own is not beneficial for women with unexplained recurrent miscarriage so is not recommended, as it may be harmful.

Aspirin should not be taken around the time you get pregnant as it interferes with implantation of the pregnancy. If your healthcare professional thinks you should take aspirin, they will prescribe it and explain when to take it.  

What happens next

If your tests don’t provide any answers

About half of people will not get an answer as to why they have experienced recurrent miscarriage after all the testing. This is known as ‘unexplained’ recurrent miscarriage. 

This can be very upsetting and might make you feel very anxious about trying again. But try to keep in mind that most couples are likely to have a successful pregnancy in the future, even after 3 miscarriages in a row. 

We are here to support you. 

If you get pregnant again

Supportive antenatal care 

Women and birthing people who get supportive care from the beginning of a pregnancy have a better chance of successful birth. 

If you get pregnant again, some miscarriage clinics will provide specialist antenatal care for you. This will likely include early pregnancy scans.   

For couples where no cause for recurrent miscarriage has been found, 75 in 100 (75%) will have a successful pregnancy with this care. 

Progesterone

You may have also heard about the use of progesterone in early pregnancy. We have more information about this.