An estimated one in four known pregnancies end in miscarriage. For up to 3pc of women, however, the devastating loss of a wanted baby is compounded by numerous subsequent losses, often unexplained. “It’s such a complex predicament, so deeply personal yet such a profound human experience,” says Dr Cathy Allen, consultant in charge of the recurring miscarriage service at the National Maternity Hospital.
It can be a major challenge for patients, as well as those of us looking after them. It’s extremely frustrating; there’s this information gap that hovers over what might happen in future pregnancies. There’s an expectation that when a person who has been through repeated losses gets pregnant, they should be happy and everything is cured, but I think it’s unfair to everybody not to recognise the heightened anxiety, which can lead to stress and depression. It’s a complex adjustment, it’s often very hard to believe there’ll be a successful outcome,” Dr Allen adds.
“Cathy is the reason I have my two children,” says Ann-Marie Herbert, an accountant from Leopardstown. To say that she has had a tough fertility journey would be a severe understatement. “We started trying about five years ago and got pregnant straight away but had a very early loss,” she says. “I personally took that very hard. I didn’t want to speak to anyone about it, and it’s something I struggled with for months. I think that first loss you take very hard no matter what stage you’re at.”
When she got pregnant again, her guard was up. “I didn’t want to acknowledge it,” she recalls. It resulted in another early loss but was a very different experience. “With that first loss, I could tell you the first day of my last period, the date I lost it, everything. With the second, I don’t remember anything.”
Ann-Marie and her husband, Mark, decided to go and get checked to see if everything was as it should be, but all tests came back fine. On the eve of an appointment with a fertility expert, they found out they were expecting again.
“We had an eight-week scan in a private clinic because of the previous losses, and there was a great heartbeat. Everything was perfect,” says Ann-Marie. “Then we went back for a 12-week scan, and we got an awful shock. The baby’s heartbeat had stopped just a few days prior to the scan. I was 12 weeks, the baby was measuring 12 weeks, and the nurse who did the scan couldn’t identify anything that wasn’t right.”
They called the maternity hospital and were told to go in for a second scan to confirm. “I remember sitting in the waiting room at the foetal assessment unit, surrounded by pregnant women. Mark recognised someone from school he hadn’t seen in 20 years,” says Ann-Marie. “They must’ve known by the look of us when we came out after the scan that something was wrong.”
The recurrent miscarriage service has been around for a long time, investigating and treating women who have suffered recurrent pregnancy loss, defined as three consecutive miscarriages before 20 weeks. In subsequent pregnancies, the aim is to treat those patients somewhat like VIPs, in Dr Allen’s own words. “In Holles St, we have strived to provide protected time for the medical review, and ensure that the patient has easy access to midwifery support, especially our bereavement specialist midwives,” she explains.
The pandemic, however, brought about new challenges. “Pre-Covid, the antenatal clinic was extremely busy, with 10,000 maternity patients registered every year. That’s a huge volume of patients going in and out. Like everyone, we had to reduce footfall, and since our return we’ve tried to restart in a more effective way.”
While a woman having experienced recurrent pregnancy loss would’ve always been offered regular scans, what’s changed is that there’s now a dedicated time slot every Friday morning as part of the new TLC Pregnancy Clinic, which concentrates on recurrent pregnancy loss patients and their needs during the first trimester. “We’ve made sure that they don’t have to sit at eight weeks in a room full of full-term bumps when they’re fearful that they mightn’t even make it to 12 weeks,” Dr Allen says.
“We can see them promptly, there’s a chance for discussion and reassurance, and they get to see that little heartbeat on a screen every week. Many of these women live week to week, and they won’t let their guard down until well into the second trimester. When they come to the TLC Clinic, they know that any other woman sitting there is in the same boat as them. There’s a bit of solidarity in that.”
It was after her third loss that Ann-Marie’s GP rang Holles St and was told that Dr Allen would be a good consultant to see. “I got pregnant quickly again and went to see Cathy early on. Then we had scans every week until 13 weeks, and every other week after that,” she says. “It wasn’t an easy pregnancy. We’d been in that position before and seen the heartbeat. We knew how it could go. Every time the transducer went onto my stomach, I was holding my breath until I saw a heartbeat. It was only around 24 weeks, when I knew the pregnancy would be viable, that I started to enjoy it.”
In April 2018, Ann-Marie’s first son was born by C-section at 36 weeks, after his growth had slowed on two occasions and the consultants decided that he was better out than in. “I think in the back of my mind, I expected that he might not be OK. I didn’t really, truly believe that he would be OK until he was born,” she says.
Considering what they had already been through, and knowing that they wanted another child, Ann-Marie and Mark started trying again just over a year later. “People think you’ve had one now so you’ll be grand, but that’s not the case,” she says. After another three pregnancies and early losses and a few hard months, genetic and compatibility testing in consultation with Dr Allen showed once more that everything was fine. “I’d always felt that it was my body that had a difficulty,” says Ann-Marie. “I don’t know why I felt that, but I just did.”
Did she ever consider giving up? “It was something we discussed because of the toll it was taking. Knowing that the odds are against you, trying to make it to the point where you can have a scan, going in holding your breath — it’s always difficult. So we decided we would only give it one last try,” she says. But that one last try was worth it. By March, Ann-Marie was pregnant again and supported by the TLC Clinic from the get-go.
The experience this time around was very different, naturally, as a result of the pandemic. Mark missed out on all the appointments, including scans. “I remember going in holding my breath, and the midwife saying to me ‘there’s the heartbeat — can you see it?’ I was so relieved, and she was so relieved for me,” Ann-Marie recalls. “It was particularly difficult because I had to drive myself in as the creche was closed and Mark had to mind the toddler, and I was thinking, if something happens I have to drive myself home.”
When Ann-Marie went into labour, again Mark couldn’t come. “When he was on his way in, I knew that he wasn’t going to make it in time, but Cathy said, ‘look, we’re all here for you, we’re all here with you’. I never once felt that I was on my own. Not once did I feel that I was alone,” says Ann-Marie, who gave birth to her second son via C-section at the end of last November. “Even on the antenatal ward, one of the midwives held my hand all the way and stayed with me in theatre until the very minute she had to go, when someone else took over. I always felt listened to and knew I was fully supported.”
Dr Allen emphasises the importance of recognising the psychological impact of recurrent miscarriage, adding that more research into the area is essential. “I would encourage those struggling to stick with evidence-based medicine, even when no cause is identified,” she says. “Read from reliable, non-commercial sources such as the NICE guidelines. Shared decision-making and patient involvement are central to us, and we abide by the medical tenet of ‘first, do no harm’ very seriously when it comes to medications in early pregnancy.”
She adds there is reason to be optimistic. “At least 50% of people who suffer recurrent pregnancy loss come back and have healthy, ongoing pregnancies, so it’s important to keep the faith,” she says. “We’re not providing a magic cure. Medically significant issues are managed closely, but for the majority the ‘therapy’ acknowledges the unique situation and provides serial reassurance.”
For more information see nmh.ie.