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Epidemiology
Aberdeen, Aberdeen, UK c Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen Maternity Hospital, Aberdeen, UK
Correspondence: Dr S Bhattacharya, Dugald Baird Centre for Research on Women’s Health, Aberdeen Maternity Hospital, Cornhill Road, Aberdeen
AB25 2ZL, UK. Email sohinee.bhattacharya@abdn.ac.uk
Objective To explore pregnancy outcomes in women following an Aberdeen Maternity and Neonatal Databank between 1986 and
initial miscarriage. 2000.
Design Retrospective Cohort Study. Results We identified 1561 women who had a first miscarriage
(1404 in the first trimester and 157 in the second trimester),
Setting Aberdeen Maternity Hospital, Aberdeen, Scotland.
10 549 who had had a previous live birth (group A) and 21 118
Population All women living in the Grampian region of Scotland primigravidae (group B). The miscarriage group faced a higher risk
with a pregnancy recorded in the Aberdeen Maternity and of pre-eclampsia (adj OR 3.3, 99% CI 2.6–4.6), threatened
Neonatal Databank between 1986 and 2000. miscarriage (adj OR 1.7, 99% CI 1.5–2.0), induced labour (adj OR
2.2, 99% CI 1.9–2.5), instrumental delivery (adj OR 5.9, 99% CI
Main outcome measures (A) Maternal outcomes: Pre-eclampsia,
5.0–6.9), preterm delivery (adj OR 2.1, 99% CI 1.6–2.8) and low
antepartum haemorrhage, threatened miscarriage, malpresenation,
birthweight (adj OR 1.6, 99% CI 1.3–2.1) than group A. They were
induced labour, instrumental delivery, Caesarean delivery,
more likely to have threatened miscarriage (adj OR 1.5, 99% CI
postpartum haemorrhage and manual removal of placenta. (B)
1.4–1.7), induced labour (adj OR 1.3, 99% CI 1.2–1.5), postpartum
Perinatal outcomes: preterm delivery, low birth weight, stillbirth,
haemorrhage (adj OR 1.4, 99% CI 1.2–1.6) and preterm delivery
neonatal death, Apgar score at 5 minutes.
(adj OR 1.5, 99% CI 1.2–1.8) than group B.
Methods Retrospective cohort study comparing women with
Conclusion An initial miscarriage is associated with a higher risk
a first pregnancy miscarriage with (a) women with one previous
of obstetric complications.
successful pregnancy and (b) primigravid women. Data were
extracted on perinatal outcomes in all women from the Keywords Maternal outcomes, miscarriage, perinatal outcomes.
Please cite this paper as: Bhattacharya S, Townend J, Shetty A, Campbell D, Bhattacharya S. Does miscarriage in an initial pregnancy lead to adverse obstetric and
perinatal outcomes in the next continuing pregnancy? BJOG 2008;115:1623–1629.
ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 1623
Bhattacharya et al.
no differences in the incidence of hypertensive disorders of ther miscarriage, ectopic pregnancy or termination in their
pregnancy or diabetes. next pregnancy were excluded. Although multiple births were
In this study, we aimed to compare maternal and perinatal excluded from the original cohorts, 17 women, all belonging
outcomes in the next continuing pregnancy in women with to the first control group (group A), had twin deliveries in
and without a spontaneous miscarriage in their first preg- their second pregnancy and were also excluded. The flow
nancy using data from the Aberdeen Maternity and Neonatal chart showing loss to follow up of the exposed cohort and
Databank (AMND). comparison group A is presented in Figure 1.
Sociodemographic characteristics of the women in the
three groups were compared to assess any differences.
Subjects and methods
As regards maternal outcomes, data were obtained on the
Since 1950, the AMND has recorded and stored information incidence of threatened miscarriage (defined as first-trimester
on all pregnancy-related events occurring in a geographically bleeding with ultrasound evidence of fetal cardiac activity),
defined population living in the Grampian region of Scotland. pre-eclampsia, antepartum haemorrhage including placenta
It is possible to link all pregnancy records of individual praevia, abruption and unclassified APH and postpartum
women. It therefore offers the ideal opportunity to study haemorrhage in the exposed and unexposed cohorts. Pre-
the effects of an initial miscarriage on subsequent continuing eclampsia, eclampsia and gestational hypertension are coded
pregnancies in Aberdeen, which has a relatively stable popu- in the AMND according to the International Society for the
lation, minimising loss to follow up. Completeness of the Study of Hypertension in Pregnancy (ISSHP) definition as
database is checked against the number of deliveries recorded follows: Gestational hypertension is defined as a diastolic
in the National Health Service records office at the end of each blood pressure of ‡110 mmHg on any one occasion or dia-
year. There are numerous consistency checks in place to stolic blood pressure of ‡90 mmHg on any two or more
ensure validity of data entry. Although there is no formal occasions at least 4 hours apart; and pre-eclampsia as hyper-
quality assurance mechanism in place for checking the reli- tension as above with proteinuria ‡300 mg/24 hours or pro-
ability of the entire database, several previous surveys and ad teinuria found in two urine specimens collected at least 4
hoc case note reviews have found the data to be more than hours apart. Antepartum haemorrhage is defined as vaginal
90% accurate with regard to the variables studied. The back- bleeding occurring in pregnancy after 28 weeks of gestation
ground and details of the database are described in the website warranting hospital consultation. Further subclassification
www.abdn.ac.uk/amnd.
Variables are coded in the AMND according to the Inter-
national Classification of Diseases (9th Revision). All miscar- First miscarriage (P0+1) First livebirth (P1+0)
riages that warrant a hospital visit are recorded, but those exposed cohort unexposed group A
n =3860 n=20047
occurring at home may be missed.
Formal ethical approval was not considered necessary by
the North of Scotland Research Ethics Committee as only No further pregnancies
No further pregnancies
anonymised routinely collected data were used for the re- recorded
recorded
7742 (39.6%)
search. Permission was obtained from the Caldicott guardians 1161 (30.8%)
of the AMND.
In this retrospective cohort study, data were extracted on Miscarriage in second
Further miscarriage
all women who had a primary pregnancy event between 1986 656 (17.0%) pregnancy
and 2000 from the AMND. Women with multiple pregnan- 728 (3.3%)
cies and major congenital abnormalities diagnosed by ultra-
sound were excluded. Women who had had a spontaneous Ectopic pregnancy
Ectopic pregnancy
204 (1%)
miscarriage resulting in pregnancy loss before 24 completed 262 (6.8%)
weeks of gestation constituted the exposed cohort. There were
two control groups or unexposed cohorts for this study. The
Termination of second Termination of second
first group consisted of women who had had a live birth pregnancy pregnancy
beyond 24 weeks in their first pregnancy (P1+0)—group A. 120 (3.1%) 847 (4.6%)
The second group comprised women in their first continuing
pregnancy (P0+0) beyond 24 weeks during the study period— Second continuing Second continuing
group B. Women in the exposed cohort and group A of the pregnancy pregnancy
1561 (40.4%) 10 549 (52.6%)
unexposed cohort were followed up to 5 years after their
initial pregnancy to identify any subsequent pregnancies. Figure 1. Flow chart showing loss to follow up of exposed and unexposed
Those who did not have any further pregnancies or had a fur- (group A) cohorts.
1624 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
Pregnancy outcomes subsequent to initial miscarriage
Table 1. Comparison of characteristics between women with a first-trimester miscarriage in their first pregnancy and groups A and B
Age at second pregnancy event (years) 28.7 (4.9) <0.001 27.4 (5.3) 26.0 (5.2) <0.001
Interpregnancy interval (years) 2.9 (0.2) <0.001 0.27 (0.04) N/A
Height (cm) 162.8 (6.4) 0.790 162.9 (6.3) 162.6 (6.3) 0.38
Body mass index (Kg/m2) 24.20 (2.61) 0.013 25.53 (1.92) 24.11 (2.1) 0.011
Married or cohabiting 8513 (80.7%) <0.001 1197 (85.1%) 16976 (80.4%) <0.001
Husband/partner’s social class (I/II) 4039 (38.3%) <0.001 316 (22.5%) 5357 (25.4%) 0.02
Smokers 3597 (34.1%) <0.001 702 (50.0%) 7802 (33.6%) <0.001
Diabetes (type 1) 32 (0.3%) 0.502 7 (0.3%) 56 (0.2%) <0.001
Chronic hypertension 157 (1.0%) 0.600 16 (1.1%) 245 (1.2%) 0.528
Infertility treatment 225 (1.4%) 0.053 28 (2.0%) 336 (1.6%) 0.081
ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 1625
Bhattacharya et al.
than in group B. The women in the miscarriage group had Exposed cohort versus group B
a higher body mass index than the women in both compar- In comparison with primigravidae (group B), threatened mis-
ison groups. The average heights of women in the three carriage (adjusted OR 1.5 [99% CI 1.4–1.7]), induction of
groups were comparable. labour (adjusted OR 1.3 [99% CI 1.2–1.5]) and postpartum
The risks of obstetric complications were different in the haemorrhage (adjusted OR 1.4 [99% CI 1.2–1.6]) were more
two comparison groups. common in the miscarriage group. These findings are pre-
sented in Table 4.
Exposed cohort versus group A In terms of perinatal complication (Table 5), preterm
In comparison with women who had had a previous delivery, delivery after 34 weeks of gestation (adjusted OR 1.5 [99%
women with an initial miscarriage were 3.3 times (99% CI CI 1.2–1.8]) was higher in the exposed cohort after adjusting
2.6–4.6) more likely to suffer from pre-eclampsia, 1.7 times for confounders.
(99% CI 1.5–2.0) more likely to have threatened miscarriage The median gestational period of miscarriage in the
and 1.3 times (99% CI 1.1–1.6) more prone to have nonspe- exposed cohort was 9 weeks. We conducted a subgroup anal-
cific antepartum haemorrhage. Women with an initial mis- ysis of all outcomes (data shown in additional files) comparing
carriage were also more likely to have induction of labour (adj them between women who had had a first-trimester miscar-
OR 2.2 [99% CI 1.7–2.6]), instrumental vaginal delivery (adj riage with those who had a miscarriage in their second trimes-
OR 5.9 [99% CI 5.0–6.9]) and manual removal of placenta ter. There were no statistically significant differences in the
(adjusted OR 1.5 [99% CI 1.1–2.1]). Elective caesarean sec- outcomes in the two subgroups studied except that the risk
tion was, however, more common in women who had had of preterm delivery was higher in the women with second-
a previous delivery. These findings are shown in Table 2. trimester miscarriage (adjusted OR 2.8 [95% CI 1.2–3.6]).
Table 3 shows the risks of perinatal complications in the
exposed cohort (P0+1) in comparison with group A (P1+0).
Preterm delivery, after 34 weeks of gestation (adjusted OR 1.6
Discussion
[99% CI 1.2–2.0]), was more common in the miscarriage In comparison with women with a previous successful preg-
group, as was malpresentation (adjusted OR 1.7 [99% CI nancy, our data suggest that women with an initial miscar-
1.5–1.8]). After adjusting for gestational age and sex of the riage have an increased risk of some obstetric complications.
baby, babies with birthweight <2500 g were 1.6 times more These include pre-eclampsia, threatened miscarriage, nonspe-
common (99% CI 1.3–2.1) in mothers who had had a pre- cific antepartum haemorrhage, induced labour, instrumental
vious miscarriage. delivery and manual removal of placenta. They are also more
Table 2. Risk of subsequent obstetric complications and interventions in women with miscarriage compared with women with a pregnancy
beyond 24 weeks in their first pregnancy (group A)
Complications Miscarriage* Group A (P110)* Crude OR (99% CI) Adjusted OR** (99% CI)
(n 5 1404) (n 5 10 549)
1626 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
Pregnancy outcomes subsequent to initial miscarriage
Table 3. Risk of subsequent perinatal complications in women with a miscarriage compared with women with a pregnancy beyond 24 weeks in
their first pregnancy (group A)
Complications Miscarriage* Group A (P110)* Crude OR (99% CI) Adjusted OR** (99% CI)
(n 5 1404) (n 5 10 549)
Preterm delivery*** 128 (9.1) 540 (3.4%) 2.8 (2.3–3.5) 2.1 (1.6–2.8)
,34 weeks 39 (2.8) 162 (1.0%) 2.8 (2.0–3.5) 1.5 (1.1–2.2)
.34 weeks 89 (6.3) 378 (2.4%) 2.8 (2.2–3.5) 1.6 (1.2–2.0)
Spontaneous preterm delivery 19 (1.4) 234 (1.1%) 1.1 (0.9–2.1)
<34 weeks
Spontaneous preterm delivery 53 (3.8) 591 (2.8%) 1.4 (1.1–1.8)
>34 weeks
Stillbirth 14 (1.0) 42 (0.3%) 3.6 (2.0–6.5) 1.9 (1.1–3.6)
Neonatal death**** 11 (0.8) 24 (0.2%) 5.1 (2.5–10.1) 2.3 (1.1–4.8)
Birthweight <2500 g***** 120 (8.5) 472 (4.6%) 1.9 (1.6–2.4) 1.6 (1.3–2.1)
Apgar at 5 minutes ,7 48 (3.3) 597 (3.8) 1.1 (0.8–1.7)
prone to preterm delivery, malpresentation and low birth- labour, postpartum haemorrhage and preterm delivery
weight. Many of these risks, however, are no higher than those were higher in women with an initial miscarriage. The
in primigravidae. Thus, women who have an initial early results of our study leave no room for doubt that women
pregnancy loss behave like ‘virtual primigravidae’ in their with a first miscarriage have a higher risk of adverse out-
next pregnancy not only in terms of their labour and delivery comes in the subsequent pregnancy compared with
characteristics but also with regard to pregnancy complica- women who have a successful first pregnancy. When com-
tions and neonatal outcomes. pared with primigravidae, however, interpretation of our
In comparison with primigravid women in a continuing findings is not so straightforward. Although there is some
pregnancy, the risk of threatened miscarriage, induced evidence of incremental risk of selected complications,
Table 4. Risk of obstetric complications and interventions in women with miscarriage in their first pregnancy compared with primigravidae
(group B)
Complications Miscarriage* (n 5 1404) Group B* (n 5 21 118) Unadjusted OR (99% CI) Adjusted OR** (99% CI)
ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 1627
Bhattacharya et al.
Table 5. Risk of perinatal complications in women with miscarriage in their first pregnancy compared with primigravidae (group B)
Complications Miscarriage* Group B* Unadjusted OR (99% CI) Adjusted OR** (99% CI)
(n 5 1404) (n 5 21 118)
the absolute risk is small and may not be clinically In addition, we were only able to capture miscarriages that led
important. to hospital contact and as such cannot generalise our findings
Despite an extensive literature search, we were unable to to all women with a first miscarriage. As we have studied
find any papers that had specifically looked at pregnancy out- women over a long time period (15 years), changes in obstet-
comes following a single miscarriage. Thus, to our knowledge, ric practice are bound to have influenced the outcomes. How-
this is the only population-based study of its kind. The AMND ever, as the unexposed cohort were identified from the same
records information contemporaneously as the obstetric events setting and similar time period, this is unlikely to have a sig-
occur, thereby minimising recall bias. Stringent coding criteria nificant effect. Moreover, we entered the year of delivery as an
and consistency checks are in place adding to the reliability of independent variable in the logistic regression model to adjust
the data. Most previous studies in this area have used an for this. It was not possible to do any subgroup analyses on
unselected population attending a particular hospital during the basis of aetiology of miscarriage because of unavailability
a specified time period as their control group. We compared of data. Furthermore, miscarriages occurring in the second
our exposed cohort with two control groups—primigravidae trimester are usually of a different aetiology, and any subse-
and second gravidae. The influence of parity when looking at quent pregnancies are likely to have different outcomes com-
certain obstetric complications like pre-eclampsia is obvious.8 pared with those occurring in the first trimester. As our
Jivraj et al.6 divided the women with history of recurrent miscarriage group consisted mainly of first-trimester loss,
miscarriage into two groups: primary, that is nulliparous, we did a subgroup analysis with second-trimester miscar-
and secondary, that is parous, and compared the outcomes. riages. This group showed a higher risk of preterm delivery.
They suggest that the control population should ideally be Lastly, multiple comparisons using a large data set invariably
matched on age and parity with the exposed cohort. The show some associations that may or may not be clinically
parity of women who miscarry in their first pregnancy is significant. We set alpha at 0.01 level to take this into account.
debatable. In epidemiological terms, these women are multi- Our results show that any pregnancy following an initial
gravidae and should therefore be compared with multigravid miscarriage is associated with a degree of increased obstetric
controls. In clinical terms, they could be expected to behave and perinatal risk. This study questions the evidence behind the
like primiparae and should therefore be matched with nullip- attribution of risk only to women who have had three or more
arous women.9 We have performed both, adding strength and consequent miscarriages (recurrent miscarriage). At the same
validity to our conclusions. time, the magnitude of this risk is likely to be small as women
Like other observational studies of its kind, this study has with a history of recurrent miscarriage achieve good preg-
several limitations. Its retrospective nature could result in nancy outcomes with support from an early pregnancy unit.10
selection bias, and the tertiary referral centre setting could Unfortunately, we could not find any other study in the
have influenced the prevalence of some of the outcomes. This literature that had attempted to quantify the obstetric risks
is, however, likely to be minimal as only women residing in following a single miscarriage that could corroborate or refute
Aberdeen city and district were selected as the control pop- our findings. Our findings agree with those presented in some
ulation. As Aberdeen Maternity Hospital is the only hospital studies that examined these risks in women with recurrent
in the area, it provides secondary as well as tertiary level care. miscarriage. Perinatal adverse outcomes such as preterm
1628 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
Pregnancy outcomes subsequent to initial miscarriage
ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 1629