Risk factors for miscarriage among women attending an early pregnancy assessment unit (EPAU): a prospective cohort study

  • Indra San Lazaro CampilloEmail author
  • Sarah Meaney
  • Paul Corcoran
  • Niamh Spillane
  • Keelin O’Donoghue
Original Article



Miscarriage is the most common adverse outcome in early pregnancy; however, high proportion of miscarriages are classified as unexplained. In addition, pregnant women attending early pregnancy assessment units might be more vulnerable.


The purpose of this study was to explore the risk factors that might be associated with miscarriage among women attending an early pregnancy assessment unit (EPAU).


A prospective cohort study was undertaken. The study was conducted on women attending an EPAU at a large, tertiary hospital. A detailed lifestyle questionnaire was completed. In addition, data from validated psychometric scales were collected. Participants were followed up to determine pregnancy outcome. The relative risk was calculated to estimate the probability of having a miscarriage for all independent variables.


A total sample of 293 women were included in this study. Well-established risk factors for miscarriage were found in this group including advanced maternal age and high-risk pregnancy (i.e. threatened miscarriage and recurrent miscarriage). In addition, lack of emotional wellbeing did contribute to an increased risk of miscarriage. Conversely, presenting with nausea or low-medium energy levels early in pregnancy were associated with a decreased risk of miscarriage. Finally, our results did not find any association between stressful life events, general health and lifestyle factors in this group.


Our findings indicated that maternal, psychological and obstetric factors may have an influence on miscarriage among women attending an EPAU. The insight of a relationship between emotional wellbeing and miscarriage opens a window for prevention in this area.


Early pregnancy assessment unit Emotional wellbeing Miscarriage Perceived stress Pregnancy history 



We are grateful to the women for participating in the study and giving of their time freely.


This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Supplementary material

11845_2018_1955_MOESM1_ESM.docx (43 kb)
ESM 1 (DOCX 42 kb)


  1. 1.
    Royal College of Physicians of Ireland (2010) Ultrasound diagnosis of early pregnancy miscarriage. RCPI, Republic of IrelandGoogle Scholar
  2. 2.
    Royal College of Physicians of Ireland (2017) The management of second trimester miscarriage. RCPI, Republic of IrelandGoogle Scholar
  3. 3.
    Macklon NS, Geraedts JPM, Fauser BCJM (2002) Conception to ongoing pregnancy: the ‘black box’ of early pregnancy loss. Hum Reprod Update 8(4):333–343CrossRefGoogle Scholar
  4. 4.
    Zinaman MJ, Clegg ED, Brown CC, O’Connor J, Selevan SG (1996) Estimates of human fertility and pregnancy loss. Fertil Steril 65(3):503–509CrossRefGoogle Scholar
  5. 5.
    Morris A, Meaney S, Spillane N, O'donoghue K (2015) 611: the postnatal morbidity associated with second-trimester miscarriage. Am J Obstet Gynecol 212(1):S303–S304 -65CrossRefGoogle Scholar
  6. 6.
    Royal College of Obstetricians and Gynaecologists. The investigation and treatment of couples with recurrent first-trimester and second-trimester miscarriage. No 17, Green-top Guideline. Royal College of Obstetricians and Gynaecologists; 2011Google Scholar
  7. 7.
    Zhang T, Sun Y, Chen Z, Li T (2018) Traditional and molecular chromosomal abnormality analysis of products of conception in spontaneous and recurrent miscarriage. BJOG 125(4):414–420CrossRefGoogle Scholar
  8. 8.
    Zhou H, Liu YP, Liu L, Zhang M, Chen XZ, Qi YL (2016) Maternal pre-pregnancy risk factors for miscarriage from a prevention perspective: a cohort study in China. Eur J Obstet Gyn R B 206:57–63CrossRefGoogle Scholar
  9. 9.
    Prior M, Bagness C, Brewin J, Coomarasamy A, Easthope L, Hepworth-Jones B, Hinshaw K, O'Toole E, Orford J, Regan L, Raine-Fenning N (2017) Priorities for research in miscarriage: a priority setting partnership between people affected by miscarriage and professionals following the James Lind Alliance methodology. BMJ Open 7(8):e016571CrossRefGoogle Scholar
  10. 10.
    Maconochie N, Doyle P, Prior S, Simmons R (2007) Risk factors for first trimester miscarriage—results from a UK-population-based case–control study. BJOG 114(2):170–186CrossRefGoogle Scholar
  11. 11.
    Feodor Nilsson S, Andersen PK, Strandberg-Larsen K, Nybo Andersen AM (2014) Risk factors for miscarriage from a prevention perspective: a nationwide follow-up study. BJOG 121(11):1375–1385CrossRefGoogle Scholar
  12. 12.
    Hemming K (2014) Causation or association: running before we can walk? BJOG 121(11):1385PubMedGoogle Scholar
  13. 13.
    Turner MJ, Fattah C, O’Connor N, Farah N, Kennelly M, Stuart B (2010) Body mass index and spontaneous miscarriage. Eur J Obstet Gynecol Reprod Biol 151(2):168–170CrossRefGoogle Scholar
  14. 14.
    Louis GMB, Sapra KJ, Schisterman EF, Lynch CD, Maisog JM, Grantz KL et al (2016) Lifestyle and pregnancy loss in a contemporary cohort of women recruited before conception: the LIFE study. Fertil Steril 106(1):180–188CrossRefGoogle Scholar
  15. 15.
    Farren J, Mitchell-Jones N, Verbakel JY, Timmerman D, Jalmbrant M, Bourne T (2018) The psychological impact of early pregnancy loss. Hum Reprod Update 24:731–749CrossRefGoogle Scholar
  16. 16.
    Alder J, Fink N, Bitzer J, Hösli I, Holzgreve W (2009) Depression and anxiety during pregnancy: a risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature. J Matern Fetal Med 20(3):189–209CrossRefGoogle Scholar
  17. 17.
    Mitchell J, Goodman J Comparative effects of antidepressant medications and untreated major depression on pregnancy outcomes: a systematic review. Arch Womens Ment Health 21(5):505–516Google Scholar
  18. 18.
    Arck PC, Rucke M, Rose M, Szekeres-Bartho J, Douglas AJ, Pritsch M et al (2008) Early risk factors for miscarriage: a prospective cohort study in pregnant women. Reprod BioMed Online 17(1):101–113CrossRefGoogle Scholar
  19. 19.
    Milad MP, Klock SC, Moses S, Chatterton R (1998) Stress and anxiety do not result in pregnancy wastage. Hum Reprod 13(8):2296–2300CrossRefGoogle Scholar
  20. 20.
    Nelson DB, Grisso JA, Joffe MM, Brensinger C, Shaw L, Datner E (2003) Does stress influence early pregnancy loss? Ann Epidemiol 13(4):223–229CrossRefGoogle Scholar
  21. 21.
    Lynch CD, Sundaram R, Maisog JM, Sweeney AM, Buck Louis GM (2014) Preconception stress increases the risk of infertility: results from a couple-based prospective cohort study—the LIFE study. Hum Reprod 29(5):1067–1075CrossRefGoogle Scholar
  22. 22.
    Lynch CD, Sundaram R, Buck Louis GM (2018) Biomarkers of preconception stress and the incidence of pregnancy loss. Hum Reprod 33:728–735CrossRefGoogle Scholar
  23. 23.
    Bigrigg MA, Read MD (1991) Management of women referred to early pregnancy assessment unit: care and cost effectiveness. BMJ 302(6776):577–579CrossRefGoogle Scholar
  24. 24.
    O'Keeffe LM, Kearney PM, Greene RA (2013) Surveillance during pregnancy: methods and response rates from a hospital based pilot study of the pregnancy risk assessment monitoring system in Ireland. BMC Pregnancy Childbirth 13:180CrossRefGoogle Scholar
  25. 25.
    Cohen S, Kamarck T, Mermelstein R (1983) A global measure of perceived stress. J Health Soc Behav 24:385–396CrossRefGoogle Scholar
  26. 26.
    Hays RD, Morales LS (2001) The RAND-36 measure of health-related quality of life. Ann Med 33(5):350–357CrossRefGoogle Scholar
  27. 27.
    Steward AL, Sherbourne C, Hayes RD et al (1992) Summary and discussion of MOS measures. In: Stewart AL, Ware JE (eds) Measuring functioning and well-being: the medical outcome study approach. Duke University Press, Durham, NC, pp 345–371CrossRefGoogle Scholar
  28. 28.
    Webster J, Linnane JW, Dibley LM, Hinson JK, Starrenburg SE, Roberts JA (2000) Measuring social support in pregnancy: can it be simple and meaningful? Birth 27(2):97–101CrossRefGoogle Scholar
  29. 29.
    Scheier MF, Carver CS, Bridges MW (1994) Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): a reevaluation of the life orientation test. J Pers Soc Psychol 67(6):1063–1078CrossRefGoogle Scholar
  30. 30.
    Tunde-Byass M, Cheung VY (2009) The value of the early pregnancy assessment clinic in the management of early pregnancy complications. J Obstet Gynaecol Can 31(9):841–844CrossRefGoogle Scholar
  31. 31.
    Andersen AMN, Wohlfahrt J, Christens P, Olsen J, Melbye M (2000) Maternal age and fetal loss: population based register linkage study. BMJ 320(7251):1708–1712CrossRefGoogle Scholar
  32. 32.
    Saraswat L, Bhattacharya S, Maheshwari A (2010) Maternal and perinatal outcome in women with threatened miscarriage in the first trimester: a systematic review. BJOG 117(3):245–257CrossRefGoogle Scholar
  33. 33.
    Kenny LC, Lavender T, McNamee R, O’Neill SM, Mills T, Khashan AS (2013) Advanced maternal age and adverse pregnancy outcome: evidence from a large contemporary cohort. PLoS One 8(2):e56583CrossRefGoogle Scholar
  34. 34.
    Hasan R, Baird DD, Herring AH, Olshan AF, Funk ML, Hartmann KE (2010) Patterns and predictors of vaginal bleeding in the first trimester of pregnancy. Ann Epidemiol 20(7):524–531CrossRefGoogle Scholar
  35. 35.
    Bruckner TA, Mortensen LH, Catalano RA (2016) Spontaneous pregnancy loss in Denmark following economic downturns. Am J Epidemiol 183(8):701–708CrossRefGoogle Scholar
  36. 36.
    Armstrong BG, Mcdonald AD, Sloan M (1992) Cigarette, alcohol, and coffee consumption and spontaneous-abortion. Am J Public Health 82(1):85–87CrossRefGoogle Scholar
  37. 37.
    Wisborg K, Kesmodel U, Henriksen TB, Hedegaard M, Secher NJ (2003) A prospective study of maternal smoking and spontaneous abortion. Acta Obstet Gynecol Scand 82(10):936–941CrossRefGoogle Scholar
  38. 38.
    Lee KA, Zaffke M (1999) Longitudinal changes in fatigue and energy during pregnancy and the postpartum period. J Obstet Gynecol Neonatal Nurs 28(2):183–191CrossRefGoogle Scholar
  39. 39.
    Nakamura K, Sheps S, Arck PC (2008) Stress and reproductive failure: past notions, present insights and future directions. J Assist Reprod Genet 25(2–3):47–62CrossRefGoogle Scholar
  40. 40.
    Qu F, Wu Y, Zhu YH, Barry J, Ding T, Baio G, Muscat R, Todd BK, Wang FF, Hardiman PJ (2017) The association between psychological stress and miscarriage: a systematic review and meta-analysis. Sci Rep 7(1):1731CrossRefGoogle Scholar
  41. 41.
    National Health System (2018) Causes: miscarriage United Kingdown: National Health System; [Available from: Accessed 7 Feb 2018
  42. 42.
    Meaney S, Corcoran P, Gallagher S, Lutomski JE, Spillane N, O'Donoghue K (2014) Perceived maternal stress and emotional wellbeing as risk factors for miscarriage. Arch Dis Child Fetal Neonatal Ed 99:A1–A180CrossRefGoogle Scholar
  43. 43.
    Bailey S, Bailey C, Boivin J, Cheong Y, Reading I, Macklon N (2015) A feasibility study for a randomised controlled trial of the positive reappraisal coping intervention, a novel supportive technique for recurrent miscarriage. BMJ Open 5(4):e007322CrossRefGoogle Scholar
  44. 44.
    Campillo IS, Meaney S, McNamara K, O'Donoghue K (2017) Psychological and support interventions to reduce levels of stress, anxiety or depression on women’s subsequent pregnancy with a history of miscarriage: an empty systematic review. BMJ Open 7(9):e017802CrossRefGoogle Scholar

Copyright information

© Royal Academy of Medicine in Ireland 2019

Authors and Affiliations

  1. 1.Pregnancy Loss Research Group, Department of Obstetrics and GynaecologyUniversity College CorkCorkIreland
  2. 2.Department of Obstetrics and Gynaecology, Cork University Maternity HospitalUniversity College CorkCorkIreland
  3. 3.National Perinatal Epidemiology CentreUniversity College CorkCorkIreland
  4. 4.School of Public HealthUniversity College CorkCorkIreland
  5. 5.The Irish Centre for Fetal and Neonatal Translational Research (INFANT)University College CorkCorkIreland

Personalised recommendations