About the Miscarriage Clinic
The Aim of the Clinic
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To provide an integrated and comprehensive support service for the investigation and treatment of recurrent pregnancy loss. We also aim to provide support throughout pregnancy for those women who have been referred to us.
There are several sessions held throughout the week for this specialist clinic. They are as follows;
Monday: Held in Gynaecology Outpatients
Tuesday: Held in the Antenatal clinic
Thursday: Nurse Led Screening Clinic
Friday: Held in Gynaecology Outpatients
Personnel
Two consultants run the miscarriage clinics:
1. Mr Roy G Farquharson, MBCHB, FRCOG, MD (Consultant Gynaecologist)
2. Miss Feroza Dawood, MBCHB, MRCOG, MD (Consultant Obstetrician/Gynaecologist)
The clinic is also supported by a miscarriage nurse: Mrs. Ann Maria Ellard
History
The Miscarriage Clinic was originally started in 1986 and the aim was to specifically deal with women who suffer recurring pregnancy loss. Over the years, it has run on a basis of interested Clinicians and Research Fellows sponsored by research monies and, in the past, Trust Fund monies, based at the Liverpool Women's NHS Foundation Trust . Recent analysis shows that a considerable number of patients are referred from outside our catchment area and it now receives regular referrals from the North of England and from the rest of England.
Audit
As a consequence of a recent audit, a process flow has been developed, so that the picture of the entire patient contact can be drawn.
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Research is actively pursued in our clinic. Research activity based in the clinic is considerable and this has produced a number of publications and presentations at national and international meetings. Research grant applications are continuously constructed and submitted. Recent successful research grants have been awarded by the National Osteoporosis Society, NHS Research and Development (North West and Lupus UK. We also collaborate with other centers in the UK to enhance research. As a consequence we also have research fellows who form part of the clinical team.
Current Research
PROMISE - Progesterone in Recurrent Miscarriage Study
The National Institute of Health Research (NIHR) has funded this multicentre study that has been organized by Imperial College, London. The principal investigator for this study at our Hospital is Miss Feroza Dawood.
What is the Purpose of the Study?
The purpose of this study is to determine whether treating women with history of recurrent miscarriage with progesterone, a natural pregnancy hormone, from the time of a positive pregnancy test until 12 weeks of pregnancy decreases their chance of miscarrying.
Patients who have had recurrent miscarriage, for which no underlying cause has been identified, will be invited to participate in this study. Further information is available from the miscarriage clinic.
Patient Referral
We accept referrals of all patients who have suffered three or more early pregnancy losses. We also accept referrals of patients who have had one or more second trimester losses (i.e between 12 and 24 weeks. Sixty percent (60%) of referrals arrive from outside Liverpool. The commonest source of referral is through General Practitioners, as well as Consultant colleagues from other hospitals. The Miscarriage Association often uses our clinic for referral of patients and also assists in information distribution and patient education, also the EPAU Association Ectopic Society.
Investigations
A wide variety of diagnostic investigations are needed to ensure a screen that covers all the known possible causes of recurrent miscarriage. Following audit of the clinic we have identified that all patients referred should have blood tests for the following:
- Tests for antiphospholipid and anticardiolipin antibodies
- Thrombophophilias Download PDF document "Lupus Anticoagulant"
- Autoimmune screen
- ABO grouping and Rh. grouping
- Haemoglobin :white cell count and platelets
- Hormonal blood tests including thyroid function
- Viral screen
- Random blood sugar
- Vaginal Swabs if history warrants it
Patients who suffer a mid-trimester loss (history of pregnancy loss between 12 and 24 weeks gestation), will require additional tests:
1. A day case hysteroscopy
2. Vaginal Swabs for bacerial vaginosis and cervical mycoplasma/chlamydia
Treatments for mid-trimester loss history
Following detailed blood investigation and hysteroscopy, some patients may require a cervical suture to prevent a further mid-trimester loss. This is usually inserted vaginally between 10 to 14 weeks. Some patients may require a transabdominal cerclage. It is our current practice to insert this type of suture preconceptually (before a subsequent pregnancy). Further information including patient information leaflets regarding these procedures are available from the miscarriage clinic.
Chromosomes / Cytogenetics Analysis if Further Miscarriage
Most patients will have had chromosomal analysis performed before she and her partner arrive at clinic and we delay routine request for this, unless the patient suffers a further loss of products within our Miscarriage Clinic. We endeavor to send off miscarried products for detailed cytogenetic analysis by FISH or even microarray analysis. Counselling appointments are arranged for patients who have had a further pregnancy loss usually at our Monday clinic.
First Visit (Thursday p.m.)
(Based at the Outpatients, Liverpool Women's NHS Foundation Trust , Nurse-led clinic)
The first point of contact is with the miscarriage nurse, Ann Maria Hughes who will give information about the other members of the team, the blood tests and the reasons for testing and preliminary history taking. A full interview occurs with history taking, especially details of previous miscarriages and associated adverse effects. A full medical history is also taken. The first visit takes, on average, 40 minutes. The vast majority of patients require time for emotional support and answering many questions they bring with them. They have often undertaken a journey of one or two hours to get to the clinic and it is not in anyone's interest to give them a less than 30 minute consultation.
Second Visit (Monday p.m.)
(Based at the Outpatients, Liverpool Women's NHS Foundation Trust , Consultant-led clinic)
The next interview is with one of the consultants and this takes place in 6-8 week's time, when a list of the investigation screen results are discussed and decoded, in a way that the couple understands. Over 30% will have an identifiable cause and this will take time to explain. Thereafter, a plan for a future pregnancy is made and the relevant management explained. There may be opportunities for the patient to be enrolled into a research trial.
Early Pregnancy Surveillance Clinics (Thursday pm. or Friday am.)
(Based at the GOPD, Liverpool Women's NHS Foundation Trust, Consultant-led Clinic)
We offer early pregnancy surveillance as soon as the patient is pregnant. The patient needs to telephone Kayleigh Bleasdale in patient services on 0151 7089988 Ext. 1194/4080, who will arrange an appointment either on Thursday pm or Friday am. At this clinic, ultrasound scanning is provided on a fortnightly basis until 10 - 12 weeks gestation, when the patient’s care is transferred to our Pregnancy Support Antenatal Clinic. During the very early stages of pregnancy, between 4 and 7 weeks, blood tests may be taken for biochemical monitoring of early pregnancy development. Repeat testing for antiphospholipid syndrome may be necessary at this stage and a treatment plan for the remainder of pregnancy is drawn-up and instigated.
Pregnancy Support Antenatal Clinic (Tuesday pm.)
(Based at the Antenatal Clinic, Liverpool Women's NHS Foundation Trust, Consultant-led Clinic)/newimg_076.jpg)
The Pregnancy Support Antenatal Clinic aims to provide a seamless transition and continuity of care for patients who have attended the miscarriage clinic. Patients receive care during the antenatal period by the same clinicians they’ve met in early pregnancy. Patients are booked under Miss Feroza Dawood. Both Mr. Farquharson & Ann Maria also provide care at this clinic. GP’s are encouraged to send requests for antenatal booking to this clinic.
Patients who have had a vaginal suture or a trans-abdominal suture inserted are closely monitored in this clinic.
Miscarriage Association
Over the years we have forged strong links with the association and are mutually supportive in the interests of our patients/members. We do encourage our patients to make contact and this can be done by writing to:
The Miscarriage Association
c/o Clayton Hospital
Northgate
Wakefield
West Yorkshire WF1 3JS
Phoning the helpline: 01924 200799 (Mon-Fri, 9am - 4pm)
faxing: 01924 298834
e-mail:info@miscarriageassociation.org.uk
