The Miscarriage Clinic
Aim
To provide an integrated and comprehensive support service for the investigation, treatment and pregnancy surveillance of women who suffer recurring miscarriage.
Setting
Fetal Centre, Outpatient Clinic and Antenatal Clinic, Liverpool Women’s Hospital.
Demand

Approximately 200 new patients are referred every year.

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Personnel

Core : Mr Roy G Farquharson (Consultant) Dr Kath Moore (Clinical Assistant) Dr Leanne Bricker (Clinical Research Fellow) Miss Ann-Maria Hughes (Nurse)

Introduction
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 Hospital. 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, occasionally, from the rest of England. 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. It should be emphasised that research activity based in the clinic is considerable and this, in turn, has raised 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.
Patient Referral

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 help in information distribution and patient education.
The type and severity of pathology is as follows :-

Causes Incidence (%) Treatment in Pregnancy Idiopathic 50 Regular ultrasound (USS) Antiphospholipid 30 Thromboprophylaxis & USS Antibody Syndrome Cervical Incompetence 10 Vaginal/abdominal suture & USS Bacterial Vaginosis >4 Antibiotics & USS Hypothyroidism 3 Replacement therapy & USS Anatomical Anomaly 3 ? Surgery & USS

Chromosome abnormality, maternal TORCH infection, diabetes and thrombophilic states remain rare causes. Most patients will have had chromosomal analysis performed on the patient and her partner prior to arrival and we delay routine request for this, unless the patient suffers a further loss within our Miscarriage Clinic.

An information leaflet, derived from the Miscarriage Association, is available and patients are encouraged to contact the Association if they have not already done so.
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First Visit (Wednesday PM)

(Based at the Outpatients, Liverpool Women’s Hospital, Nurse-led clinic)

The first point of contact is with the nurse, when information is provided about clinical personnel, the investigation screen and the reasons for testing and preliminary history taking. If pregnant, an ultrasound scan is organised and fortnightly follow-up is arranged. 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, even by streamlining the process of essential patient data capture and, more importantly, counselling.

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 PM)

(Based at the Outpatients, Liverpool Women’s Hospital, Consultant-led clinic)

A second interview is organised in 6 week’s time, when a list of the investigation screen results are discussed and decoded, in a way that the couple understand, the nature of the tests and the significance of the results. 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.

If the patient has a negative screen, they are discharged back to their base unit, on the premise that they may contact us for early ultrasound reassurance up to 12 weeks gestation, before deciding on the remainder of their antenatal care and place of delivery. It is not our policy to "hold onto" patients to our clinic, unless there is a clear reason to do so.

The patient with a positive screen has a clear idea of what is involved during a future pregnancy. This information is also set out in a discharge letter to the referring General Practitioner or Consultant Obstetrician.
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Early Pregnancy Assessment Clinic (Friday AM)

(Based at the Fetal Centre, Liverpool Women’s Hospital, Consultant-led clinic)

As soon as the patient has completed her investigation screen and subsequently falls pregnant, she can contact the dedicated Miscarriage Clinic Nurse (Ann-Maria Hughes, ( 0151 702 4263) to make an immediate appointment to be seen on a Friday morning for early pregnancy assessment. At this clinic, ultrasound scanning is provided on a fortnightly basis until 10 weeks gestation, when the patient is transferred to the Pregnancy Support Antenatal Clinic. During the very early stages of pregnancy, between 4 and 7 weeks, blood tests are taken for biochemical monitoring of early pregnancy development, prior to the use of fetal heart activity visualisation. Repeat testing for antiphospholipid syndrome should always occur 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 Hospital, Consultant-led clinic)

The Pregnancy Support Antenatal Clinic was established to cope with the overflow caused by the pressure of number attending the Friday morning Miscarriage Clinic in the Fetal Centre. The Pregnancy Support Antenatal Clinic provides continuity of antenatal care and a place of delivery for a large number of women from outside our catchment area and region.

Investigations

First trimester loss history :

Full blood count, blood group and antibodies, thyroid function tests, random blood sugar, chromosome analysis, auto-antibody, antiphospholipid and thrombophilia screen, TORCH screen and endocrine profile.

Mid trimester loss history :

As above, plus day case hysteroscopy and cervical resistance studies. Infection screen for bacterial vaginosis and cervical mycoplasma/Chlamydia.

There is also a Miscarrige Support Group offering help and support to women and their partners.
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