The aim of the clinic
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 GynaecologyOutpatients
Tuesday: Held in the Antenatal clinic
Wednesday: Held in GynaecologyOutpatients
Friday: Held in Fetal Centre,

Demand
Approximately 200 new patients are referred every year.

Personnel
There is a core of specialist staff who attend this clinic
Mr Roy G Farquharson (Consultant)
Dr Kath Moore (Clinical Assistant)
Miss Ann-Maria Hughes (Miscarriage Nurse)
In addition there is a Research Fellow and members of Mr Farquharson's medical team.

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 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.

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.

Research
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.

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

In addition all patients will have a bone mineral density and/or ultrasound investigation.

Mid-trimester loss (history of pregnancy loss between 12 and 24 weeks gestation)
In addition to the above tests, patients will have:

• a day case hysteroscopy
  
• vaginal swabs for bacterial vaginosis and cervical mycoplasma/chlamydia

Chromosomes
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 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.

First Visit (Wednesday p.m.)
(Based at the Outpatients, Liverpool Women's Hospital, 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. 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. 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 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.

Negative screen
If the couple have a negative screen, they are discharged back to their referring doctor. They are advised that they can contact us for early ultrasound reassurance up to 12 weeks of pregnancy. They are able to choose whether or not to continue their antenatal care and place of delivery with us. It is not our policy to "hold onto" patients to our clinic, unless there is a clear reason to do so.

Positive screen
Patients with a positive screen will be given information on the treatment options open to them. The management of future pregnancies is discussed with them and a detailed letter is sent to the referring the referring General Practitioner or Consultant Obstetrician.

Assessment Clinic (Friday a.m.)
(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). An appointment for the next Friday morning clinic is made 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. 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 p.m.)
(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 numbers attending the Friday morning miscarriage clinic in the Fetal Centre. This clinic provides continuity of antenatal care and a place of delivery for a large number of women from outside the Merseyside region.

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