Thinking about another pregnancy

Miscarriage* can be a very unhappy and frightening experience. Even some time later you may still be coping with feelings of shock and great sadness. You may also be feeling anxious about the future – especially about trying again.

This leaflet looks at feelings and some of the facts about pregnancy after miscarriage. It talks about deciding whether to try again, and about timing. It also gives some information that may help you and your partner before and during another pregnancy.

Reasons for and against You may want to try again because: • You simply want a baby – or another baby if you already have one. Even if you didn’t plan the last pregnancy, the miscarriage may have made you realise that’s what you want • It seems the best way to get over the ‘empty’ feeling that is common after miscarriage • You feel confident that the next pregnancy will go well • It’s important to your partner • You feel it’s your last chance – if you are an older mother, for example.

Should we try again?
You may feel quite confident about trying for another baby. But you may be very anxious about having another miscarriage. Or you may be worried about whether you will manage to conceive.

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You feel so desperately empty after the loss and want to fill that void…

* We generally use the word ‘miscarriage’ to cover early and late miscarriage, ectopic pregnancy and molar pregnancy.

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You may want to put off trying again because: • You fear the next pregnancy will end badly too • You don’t think you’ll be able to cope with another miscarriage • You think you’re unlikely to conceive – because of age, or fertility problems or relationship issues • You are worried about how your anxiety will affect another pregnancy • You are worried about how a stressful pregnancy, and maybe another miscarriage, will affect your partner and family.

Other things to consider Deciding whether to try again is not always easy. Other things that might influence you include: • Your partner’s feelings about another pregnancy • What your family and friends have to say • What your doctor says about the risk of another miscarriage • Any tests and treatment you might need • Work and career pressures • Money issues, especially if fertility treatment is involved. You may not be ready to decide either way. But if you are not sure, it may help to read our leaflet ‘When the Trying Stops’.

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Part of me desperately wants to be pregnant again, and the other part of me is just too terrified of going through the same thing again.

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When’s the best time?
There is no right answer to this. You may want to get pregnant again as soon as possible; or you may want to wait a while, particularly if the thought of another pregnancy makes you anxious. You may need time to recover physically. You and your partner may both need time to come to terms with your loss and to grieve for your baby. Women and their partners often have mixed feelings about the next pregnancy: hope mixed with fear and excitement mixed with worry. Now or later? You may want to get pregnant as soon as possible if: • You think another pregnancy will help you to cope with your loss and move forward • You want to be pregnant by the time the baby you lost would have been due • You have no time to waste because of age or fertility problems • You can’t bear not being pregnant.

You may want to wait if: • You don’t feel well enough yet • You are too upset or anxious to even think about another baby • You are still being followed up after surgery or a molar or ectopic pregnancy • You are still waiting for medical tests or results • You want to wait until after the baby you lost would have been due, or some other important date • You are on a waiting list for fertility treatment • There are practical reasons, such as your partner being away from home.

I recently miscarried at 11 weeks. I would dearly love to conceive again but I’m getting conflicting information on how long we should wait.

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I feel like I am in limbo and I will not be able to enjoy life again until I am pregnant again.

How soon can we start? Doctors usually advise against having sex after miscarriage until all the bleeding has stopped. This is to avoid infection. They often advise having at least one period before trying for another baby. This is because the first menstrual cycle after miscarriage is often much longer or shorter than usual. If you get pregnant during that cycle, it may be difficult to work out when you conceived. So you may think you are eight weeks pregnant, say, when a scan shows a sixweek pregnancy. If you’ve already had a miscarriage that involved confusion over dates, that kind of uncertainty can be very hard to deal with.

If you do get pregnant in that first cycle, that’s not going to make you more likely to miscarry. There is even some evidence that conceiving in the first six months after a miscarriage actually lowers your risk of miscarriage next time.1 Usually you and your partner are the best judges of how soon to try again. But you may be advised to wait longer if: • you’ve had a molar or ectopic pregnancy • you’ve had a late miscarriage • you are having tests after recurrent miscarriage. It can be very frustrating to have the decision about when to try again taken out of your hands.

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When I first realised I would have to wait at least six months, I cried for about a week. Life seemed so unfair and to have no control over when I could try for a baby was awful.

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Will it happen again?
No one can say for sure. What we do know is that you are much more likely to have a healthy pregnancy than another loss after: • one or two miscarriages • an ectopic pregnancy • a molar pregnancy. The odds are still on your side after three or even four miscarriages. But age is a factor too; and the older you are, the higher your risk of miscarriage, particularly over 40. The risk of having another ectopic pregnancy is lower than you might expect, though being older increases the risk. But the state of your tubes is more important: if one or both are blocked or damaged, your risk may be higher. You may want to talk more about this to one of the doctors who treated you in hospital. After a molar pregnancy you will be advised not to get pregnant until you have finished follow-up. Then your risk of a second molar pregnancy is very low. You can see your risk of another loss in percentage terms in the box opposite.

Your percentage risk of another pregnancy loss Previous loss Miscarriage2 1 miscarriage 2 miscarriages 3 miscarriages Ectopic pregnancy3 1 ectopic pregnancy 2 ectopic pregnancies Molar pregnancy4 1 molar pregnancy 2 molar pregnancies under 2% 17% 2-10% 16-20% 20% 28% 43% Risk of recurrence

What do those numbers mean for me? Lots of people want to know about their percentage risk of miscarriage. But even with the numbers in front of you, it can be hard to make sense of them. You may be able to see that your risk is very low (after one molar pregnancy) or fairly high (after three miscarriages). But that won’t tell you what you really want to know: will I be okay next time – or not?

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Can I reduce my risk of another miscarriage?
There may be things you can do and we’ll explain about some of these in the next sections. But it’s important to know that however hard you try, you can’t completely rule out the chance of another miscarriage. It’s helpful to know the difference between a risk and a cause. Take alcohol for example: we know that regular or heavy drinking in pregnancy raises the risk of miscarriage5; but even if you drank a lot in your last pregnancy, that doesn’t mean it caused your miscarriage. Even so, you might decide to cut down or stop drinking altogether next time.

So what can I do? You and your partner may be able to take steps to improve your general health, diet and lifestyle. This can make a difference to your chances of getting pregnant and having a healthy pregnancy. We don’t know why these improvements make a difference; or why they help some people more than others. As we said earlier, there are no guarantees. But you might find the information in the next pages helpful.

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It was quite a comfort when the midwife said that lots of women who have two miscarriages go on to have a good next pregnancy, but that doesn’t change the fact that that might not be me! Statistics are all very well but the chances for you personally are either 100% or 0%.

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Eat a healthy diet
A well-balanced diet, including food from the four main groups below, seems to reduce the risk of miscarriage: • Fruit and vegetables – fresh or frozen is best – 5 portions a day if you can – wash fresh fruit and salad thoroughly. • Meat, fish, eggs, lentils, soya, tofu – cook meat and eggs thoroughly – avoid pâté and foods made with raw eggs – don’t eat liver more than once a week. • Milk, cheese or vegan alternatives – avoid unpasteurised milk or cheese – avoid mould-ripened cheese like Brie, Camembert and blue cheeses – cream and cottage cheeses are fine. • Cereal, breads and grains, including: – rice and pasta – breakfast cereals, which often have added vitamins and minerals.

Think about vitamins and minerals A well balanced diet should give you all the vitamins and minerals you need. But there is some evidence that a multivitamin supplement specifically designed for pregnancy can reduce the risk of miscarriage5 and of having a baby that is small for gestational age (SGA: a baby that is smaller than it should be at that stage).6 If you are trying to conceive, or you’re in the first 12 weeks of pregnancy, it’s good to take folic acid supplements. These reduce the risk of neural tube defects like spina bifida (where the baby’s spinal cord doesn’t develop normally). Once you are pregnant they are prescribed free of charge.

Aim for a reasonable weight
You may be slender, curvy or somewhere in between. But whatever your shape it is best to avoid: • being very underweight. This means having a body mass index (BMI) of less than 18.5 • being very overweight. This means having a BMI of more than 30. You may want to talk to your doctor if you are worried about your weight, diet or appetite, or if you don’t know how to measure your BMI. Your doctor might refer you to a dietician for advice on how to lose or gain weight safely before you get pregnant.

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Cut down on alcohol, smoking and caffeine
Research shows that even moderate drinking, smoking or caffeine consumption can increase the risk of miscarriage. The guidance below might help you reduce your risk: Alcohol The miscarriage risk is highest for women who drink every day and/or more than 14 units per week. Heavy drinking by your partner can reduce the quantity and quality of his sperm. An occasional drink is unlikely to be harmful. But the usual advice is to stick to just one or two units a week, or stop drinking altogether before you conceive and during pregnancy.

Smoking Researchers don’t all agree about how much smoking affects the risk of miscarriage; but it is probably safest to give up in pregnancy or cut down as much as you can. This will reduce your risk of miscarriage and of having a very small baby. Caffeine Pregnant women are advised to limit caffeine to 200mg a day – equal to about two mugs of coffee. Be aware, though, that caffeine is also found in: • tea • ‘energy drinks’ and some soft drinks • some medicines, such as cold and ‘flu remedies • chocolate – there is about 6mg in a 30g bar of milk chocolate. Women often go off coffee and tea in early pregnancy, especially if they are feeling sick; so cutting down may not be a problem for you.

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Take care with medicine and drugs
The general advice is to avoid all medicines and drugs unless your doctor or pharmacist says they are safe when you are trying to conceive or pregnant. This applies to prescribed medicines as well as those you can buy over the counter, including herbal remedies. If you are already taking tablets or other forms of medication, the guidance below should help when trying to conceive: Treatment after miscarriage, such as antibiotics for infection. Wait until you have finished the course and any infection has cleared up. Treatment for ectopic pregnancy. The usual advice is to wait three months after methotrexate treatment. Short-term treatment for another illness or infection. It may be best to wait until you have finished the course. Treatment for chronic or long-term illness, such as epilepsy, diabetes or depression. Talk to your GP or consultant about safety when you are trying to conceive or pregnant. You also need to know about any risks to you – and possibly your baby – from stopping treatment or reducing the dose.

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Treatment prescribed to reduce your risk of miscarriage. Talk to your GP or consultant before trying to conceive. Treatment bought privately, eg over the internet. Paying for medicine that is prescribed privately should be fine. But you should not buy medicine from other sources because you’ve heard it might reduce your risk of miscarriage; there are risks with medicines obtained through the internet or other unofficial sources. It is best to avoid using street drugs like cannabis, heroin, crack and cocaine before and during pregnancy. Your doctor should be able to advise you and refer you on for help and support if necessary.

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I thought herbal remedies would be safer than prescription drugs, but even with those, it’s impossible to know what’s safe and what isn’t…

Treating and avoiding infection
Some infections can increase your risk of miscarriage or harm your baby in pregnancy; so it is worth avoiding or treatment them before you get pregnant if you can. That’s not always possible because some infections have no signs or symptoms and you only know you are infected if you have a test. Infections that can increase the risk of miscarriage include: Chlamydia This is a sexually transmitted infection (STI) that often has no symptoms. If there is a chance that you or your partner is infected, it is a good idea for both of you to be tested. Then you can be treated, if necessary, before you get pregnant. You can arrange this through your GP or by visiting your local GUM (genitourinary medicine) clinic. Your GUM clinic can also check you for signs of other STIs. Chlamydia psittaci This is a rare form of Chlamydia that you can catch through contact with infected sheep or cattle during lambing or calving. If possible, avoid touching these animals if you are trying to conceive or pregnant.

Other infections of the vagina or uterus (womb) If you are worried that you might have an infection you could ask to be tested. Again, these infections don’t always have symptoms. Listeria This is caused by consuming unpasteurised cheese or milk. See page 8 for a list of what to avoid. Toxoplasmosis You can avoid this by cooking meat thoroughly and washing fresh fruit and salad. Cats can carry this infection in their guts; so it’s best to wear gloves when cleaning out litter trays and when gardening. Parvovirus This is a viral infection, which is sometimes called ‘slap-cheek’. Although it can cause late miscarriage, most women who are infected have a normal pregnancy.

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Exercising and relaxing
Exercise in moderation won’t do you or the baby any harm. On the plus side, it can improve your mood. If you need help relaxing, yoga or meditation might help; or you could try a treatment like massage or reflexology. But always tell the teacher or therapist if you are trying to conceive or already pregnant.

You may find it helps to do one or more of the things suggested here: Talk to your partner about how you are both feeling. You may be able to find ways to support each other before and during the next pregnancy. Talk to family and friends. They may be able to help in practical ways or just by listening. Talk to your manager or colleagues about reducing stress at work. This might mean changing your hours or the way you work; or it could be about arranging time off for extra GP or hospital appointments before and during the next pregnancy. Remember that you are protected by employment law when you are pregnant (see our leaflet ‘Miscarriage and the Workplace’). Talk to other people who have been through miscarriage. You can do this by: • contacting our helpline (see page 15) • talking to one of our telephone contacts • going to a support group meeting • joining our online support forum.

Coping with stress and anxiety
We all feel stressed or anxious at times. And this is particularly likely when you are facing pregnancy after miscarriage. We can’t say whether stress on its own actually causes miscarriage. But we do know that women under a lot of stress are more likely to miscarry; and the more stressful events they have to cope with, the higher the risk. Work that is demanding and very stressful may also increase the risk of miscarriage, especially if the stress goes on for a long time. On the other hand, we know that good care and support after miscarriage can increase the chances of things going well next time. That may be because your stress is reduced.

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Talk to your GP about any questions and worries you have about another pregnancy. Or you could try the local early pregnancy unit, or our helpline. Ask about extra care, such as an early scan. This is especially important after an ectopic pregnancy, to check that the baby is growing in your uterus. But early scans – or extra scans at critical times – can be reassuring after any loss. This may not be true for you if the thought of a scan makes you more anxious rather than less.

Thinking about another pregnancy: a summary
It is natural and normal to feel anxious about pregnancy after miscarriage. You may be worried about trying to conceive or about what will happen if you can’t. You may feel most anxious at the stage when you miscarried before. Or you may worry more as your due date gets closer. We hope that that the information in this leaflet will help you to feel calmer and more confident about the next pregnancy. And we wish you well for the future.

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My employer allowed me to work from home for a while, which really took the pressure off. At a very stressful time I was able to avoid the stress of the workplace.

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Sources of information and support
The Miscarriage Association Our helpline, volunteers and online support forum can provide support and information: • after miscarriage, ectopic or molar pregnancy • when you’re thinking about trying again • during pregnancy after miscarriage Tel: 01924 200799; www.miscarriageassociation.org.uk 17 Wentworth Terrace, Wakefield WF1 3QW NHS pre-conception care clinics These are run by some hospitals and health centres. Your GP or hospital staff should be able to tell you if there is one in your area. You may be referred for specialist pre-conception care if you have a long-term medical condition, such as diabetes. Well-woman clinics These can give useful advice, especially if you want to see a woman doctor. Some of them offer a pre-conception check-up.

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I would love to have another baby. The thought of having another miscarriage fills me with dread, but I know that we will try again and won’t give up. Because although there will be a chance that I will miscarry, there is also a chance that everything will be OK this time.

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It is so nice to hear from other people who understand what I am going through. I was starting to feel like I am going mad!

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Helpful publications
Although there is no guaranteed method for ensuring a healthy pregnancy, you may find the following publications useful for general guidance. Please note that the Miscarriage Association is not able to endorse all that is in these publications and therefore does not accept responsibility for their contents. Foods to avoid in pregnancy A useful guide provided by NHS Choices, published online at. http://www.nhs.uk/conditions/ pregnancy-and-baby/pages/foods-toavoid-pregnant.aspx#close Planning a baby? A complete guide to pre-conceptual care by Dr Sarah Brewer Published by Vermilion (2004) ISBN: 009189848X

Love E, Bhattacharya S, Smith NC, Bhattacharya S. Effect of interpregnancy interval on outcomes of pregnancy after miscarriage: retrospective analysis of hospital episode statistics in Scotland BMJ 2010; 341:c3967 2 Regan L, Braude PR and Trembath PL 1989 Influence of past reproductive performance on risk of spontaneous abortion BMJ 299, 541-5 3 Prof JJ Walker, personal communication 4 Information from Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital 5 Maconochie N, Doyle P, Prior S, Simmons R. Risk factors for first trimester miscarriage: results from a UK-population-based case-control study. BJOG, 2007; 114(2): 170-186 6 Brough L, Rees G, Crawford M, Morton RH, Dorman E (2010). Effect of multiple-micronutrient supplementation on maternal nutrient status, infant birth weight and gestational age at birth in a lowincome, multi-ethnic population. British Journal of Nutrition, 104, pp 437-445 doi: 10.1017/50007114510000747
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References

Need to talk to someone who understands? Call our support line on 01924 200799. Monday to Friday, 9am-4pm Or email info@miscarriageassociation.org.uk

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The Miscarriage Association 17 Wentworth Terrace Wakefield WF1 3QW Telephone: 01924 200799 e-mail: info@miscarriageassociation.org.uk www.miscarriageassociation.org.uk

© The Miscarriage Association 2013 Registered Charity Number 1076829 (England & Wales) SC039790 (Scotland) A company limited by guarantee, number 3779123 Registered in England and Wales Thinking/04/13

Our sincere thanks to Vitabiotics Pregnacare for sponsoring production of this leaflet.