We have had a miscarriage, or more than one

One miscarriage in the first twelve weeks is common. It is so common that it is treated as part of the ordinary range of what happens to pregnancies, and no tests are needed after it, because there is rarely anything to find. The usual reason is a chance error in the way the chromosomes came together in that one embryo. It is not inherited, it is not repeated on purpose by the body, and it says nothing about the next pregnancy.

Two miscarriages in a row is where a conversation is worth having, and three is where tests earn their place. Even then, in many couples nothing is found, and the next pregnancy is still usually fine. When something is found it is usually one of a short list: a thyroid or a sugar level that is off, a clotting tendency that is treated with a daily tablet or injection through the next pregnancy, a shape of the uterus that can be corrected, or, less often, a chromosome arrangement in one partner that changes the advice about how to try.

A miscarriage later, after twelve weeks, is rarer and is looked into after the first one, because the reasons are different and more of them are treatable.

There is no hurry in this consultation. The story, at whatever pace you want to tell it: each pregnancy, how far it got, how it ended, what was done afterwards. Your periods, your health, medicines, and his health too. Whether you want to try again soon, later, or are not sure. Bring any reports and scan pictures from the pregnancies, however painful they are to hold; they answer questions that would otherwise need repeating.

Then an examination, and a scan of the uterus and ovaries, which looks at the shape of the cavity and at the lining. Where tests are called for, they are listed with a reason for each one, in the order they are worth doing, and you are told which results would change anything and which are being done to rule things out.

You leave with a plan for the next pregnancy, whenever it comes, even if the plan is “no tests, try when you are ready, and come the day the test is positive”.

• Time, and being allowed to grieve. Physically you can try again after one normal period; there is no medical reason to wait longer. Emotionally the right time is when you both feel ready, and that is allowed to be months.
• Folic acid from now, whenever you plan to try.
• Putting right what the tests found. A thyroid corrected with a tablet. Sugar brought under control before conceiving. Both are simple and both matter.
• A daily low-dose aspirin, and sometimes a daily injection, through the next pregnancy where a clotting tendency has been found on two separate tests. This is the one treatment with a clear reason behind it, and it is used only where the reason exists.
• Progesterone in early pregnancy for some women with recurrent loss, started the day the test is positive. Whether it is worth it for you is discussed before, not during.
• A small procedure to correct the cavity of the uterus where the scan shows a septum or a polyp, done before the next attempt.
• Early and frequent scans in the next pregnancy, more for reassurance than for treatment, because waiting until twelve weeks is not something anyone should have to do twice.

It happened last week. Rest as much as you want and no more than you want. Bleeding like a heavy period for up to two weeks is expected; bleeding that soaks a pad an hour, fever, or pain that is getting worse is not, and needs to be seen the same day. Come in for a visit in two or three weeks, when you are ready to talk about it, and not before.

You want to try again and you are afraid. Come and say so. The fear is reasonable and it does not go away by being told the odds; it eases with a plan, a scan booked for the first weeks, and a number you can call. That is what the visit is for.

You have been told it is your age. Age raises the chance of a chance error in an embryo, and that is all it does. It is a reason to be seen sooner and to move between steps a little faster if help is needed. It is not a verdict, and anyone who used it as one was wrong to.

• Heavy bleeding, fever, or worsening pain after a miscarriage: the same day
• A positive test after a previous miscarriage: in the first week, for an early scan
• Two or more miscarriages, before trying again
• A miscarriage after twelve weeks
• A miscarriage in a pregnancy that came after fertility treatment
• Any pregnancy where you have had pain on one side

After a miscarriage that has not completed on its own, the pregnancy tissue is sometimes removed with a short procedure under anaesthetic, or with tablets, or the body is given time; which of the three is right for you is a choice, explained, and yours. Where the scan shows a septum in the uterus or a polyp, it is corrected through the cervix with a hysteroscope before the next attempt. If an operation is the right answer, you are told who will do it and where, before anything is booked.