Written by C. Peony Khoo, MD

Early pregnancy loss (EPL) – also called miscarriage or spontaneous abortion – is the spontaneous loss of a pregnancy before 13 weeks’ gestation. EPL is common, occurring in up to 15% of clinically recognized pregnancies, and nearly one in four people capable of pregnancy will experience EPL in their lifetime.¹ Given the prevalence of EPL, clinicians should be prepared to counsel patients who are trying to conceive after EPL.

Most people will become pregnant after a miscarriage, regardless of management method. About 80% of people attempting pregnancy after a miscarriage will go on to have a live birth within five years. In the miscarriage treatment (MIST) randomised controlled trial, this rate did not vary significantly with expectant (79%), medical (79%), or surgical (82%) management.²

There is no benefit in delaying pregnancy attempts after pregnancy loss. While a 2005 World Health Organization report on birth spacing recommended a minimum interpregnancy interval of at least six months after a miscarriage or induced abortion, more recent data suggests that a shorter interpregnancy interval less than three months may result in a higher likelihood of live birth and possibly fewer adverse pregnancy outcomes (e.g., small for gestational age, gestational diabetes) when compared to longer interpregnancy intervals.^3-5

Use shared decision making regarding low dose aspirin to prevent EPL in patients with a history of one or two prior EPL. The EAGeR trial found that preconception-initiated low-dose aspirin (LDA) did not significantly alter live birth or repeat pregnancy loss in patients with a history of one or two prior losses,⁶ however, a per-protocol analysis of EAGeR published in 2021 found that LDA use preconception through 36 weeks may improve pregnancy outcomes, particularly when started early and with maximal daily adherence.⁷ While the 2018 ACOG guidance does not recommend LDA to prevent EPL,⁸ it was published prior to the per-protocol analysis.

Providing mental health support is important following EPL. Pregnancy loss is associated with depression, anxiety, and post-traumatic stress disorder. A multicenter study found that the risk of major depressive symptoms 30 days after treatment for EPL was twice as high for Black patients compared to non-Black patients.⁹ People with prior miscarriage also had higher pregnancy-related fear and anxiety during subsequent pregnancy.¹⁰ Clinicians should remind patients that the pregnancy loss is not the result of something they did, offer emotional support, make referrals to therapists as needed to help process emotions and experiences, and use a validated screener like PHQ-9 or the Edinburgh Postnatal Depression Scale and follow-up with patients who screen positive for symptoms of depression.^11,12

Clinicians should be prepared with evidence-based recommendations to support patients trying to conceive following EPL.

RHAP Resources:

What is an Early Pregnancy Loss (Miscarriage)?

Partner Resources:

ACOG Finding Emotional Support After Pregnancy Loss
ACOG Practice Bulletin No. 200: Early Pregnancy Loss
ACOG Early Pregnancy Loss FAQs
Share Pregnancy and Infant Loss
Postpartum Support International: Loss and Grief in Pregnancy and Postpartum
March of Dimes: Miscarriage, Loss, and Grief

Sources:

1. Prine LW, MacNaughton H. Office management of early pregnancy loss. Am Fam Physician. 2011 Jul 1;84(1):75-82.
https://www.aafp.org/pubs/afp/issues/2011/0701/p75.html.

2. Smith LF, Ewings PD, Quinlan C. Incidence of pregnancy after expectant, medical, or surgical management of spontaneous first trimester miscarriage: long term follow-up of miscarriage treatment (MIST) randomised controlled trial. BMJ. 2009 Oct 8;339:b3827. doi:10.1136/bmj.b3827.

3. Kangatharan C, Labram S, Bhattacharya S. Interpregnancy interval following miscarriage and adverse pregnancy outcomes: systematic review and meta-analysis. Hum Reprod Update. 2017 Mar 1;23(2):221-231. doi:10.1093/humupd/dmw043.

4. Schliep KC, Mitchell EM, Mumford SL, Radin RG, Zarek SM, Sjaarda L, Schisterman EF. Trying to Conceive After an Early Pregnancy Loss: An Assessment on How Long Couples Should Wait. Obstet Gynecol. 2016 Feb;127(2):204-12. doi:10.1097/AOG.0000000000001159.

5. Tessema GA, Håberg SE, Pereira G, Regan AK, Dunne J, Magnus MC. Interpregnancy interval and adverse pregnancy outcomes among pregnancies following miscarriages or induced abortions in Norway (2008-2016): A cohort study. PLoS Med. 2022 Nov 22;19(11):e1004129. doi:10.1371/journal.pmed.1004129.

6. Schisterman EF, Silver RM, Lesher LL, Faraggi D, Wactawski-Wende J, Townsend JM, Lynch AM, Perkins NJ, Mumford SL, Galai N. Preconception low-dose aspirin and pregnancy outcomes: results from the EAGeR randomised trial. Lancet. 2014 Jul 5;384(9937):29-36. doi:10.1016/S0140-6736(14)60157-4.

7. Naimi AI, Perkins NJ, Sjaarda LA, Mumford SL, Platt RW, Silver RM, Schisterman EF. The Effect of Preconception-Initiated Low-Dose Aspirin on Human Chorionic Gonadotropin-Detected Pregnancy, Pregnancy Loss, and Live Birth : Per Protocol Analysis of a Randomized Trial. Ann Intern Med. 2021 May;174(5):595-601. doi:10.7326/M20-0469.

8. Early pregnancy loss. ACOG Practice Bulletin No. 200. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132:e197-207. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/11/early-pregnancy-loss.

9. Shorter JM, Koelper N, Sonalkar S, Oquendo MA, Sammel MD, Schreiber CA. Racial Disparities in Mental Health Outcomes Among Women With Early Pregnancy Loss. Obstet Gynecol. 2021;137(1):156-163. doi:10.1097/AOG.0000000000004212.

10. Fertl KI, Bergner A, Beyer R, Klapp BF, Rauchfuss M. Levels and effects of different forms of anxiety during pregnancy after a prior miscarriage. Eur J Obstet Gynecol Reprod Biol. 2009;142(1):23-29. doi:10.1016/j.ejogrb.2008.09.009.

11. Levis B, Negeri Z, Sun Y, Benedetti A, Thombs BD; DEPRESsion Screening Data (DEPRESSD) EPDS Group. Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data. BMJ. 2020;371:m4022. Published 2020 Nov 11. doi:10.1136/bmj.m4022.

12. Wang, S., Wang, Y., Tong, L. et al. Association between pregnancy loss and depressive symptoms in women: a population-based study. BMC Psychiatry 24, 526 (2024). doi:10.1186/s12888-024-05948-0.

Pharma-free: The Reproductive Health Access Project does not accept funding from pharmaceutical companies. We do not promote specific brands of medication or products. The information in the Insights is unbiased, based on science alone.

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