Pregnancy Loss Symposium 2024 PDF

PREGNANCY LOSS SYMPOSIUM 2024 Year 2 Module 203 Dr Katie Fraser MBBS MRCOG BSc(Hons) Consultant Obstetrics and Gynaecology Princess Royal Hospital | Brighton and Sussex University Hospital Please Log On to www.Pollev.com/katiefraser440 Aims for the Session Understand terminology and definitions used...

PREGNANCY LOSS SYMPOSIUM 2024 Year 2 Module 203 Dr Katie Fraser MBBS MRCOG BSc(Hons) Consultant Obstetrics and Gynaecology Princess Royal Hospital | Brighton and Sussex University Hospital Please Log On to www.Pollev.com/katiefraser440 Aims for the Session Understand terminology and definitions used in pregnancy loss Understand the management of pregnancy loss at each trimester Understand possible causes of pregnancy loss and prevention Consider the emotional impact of pregnancy loss Understand how to discuss pregnancy loss with patients and their families Explore our own feelings and fears towards breaking bad news Layout of the Session 12.00 Lecture – Early Pregnancy Loss - Break 12.45 Lecture – Mid – late trimester pregnancy loss 13.20 Patient Experience – Gemma Kybert - Break 13.55 - Break out sessions – 4 groups (including a break session) Session A (GA) – Fiona / Katie – Early Pregnancy Loss and Case discussions Session B (3.07A) – Gemma Kybert – Oscar’s wish and patient perspective Session C (Lecture Theatre) – Sariah – role of the bereavement team Session D (Foyer) - Break Session How does the subject make you feel? How do you feel about being a healthcare professional managing a patient with a miscarriage? https://PollEv.com/free_text_polls/iACUh7fFkVrQX1ifJ875f/web Why Is Pregnancy Loss Important? It is common – 1 in 5 pregnancies end in miscarriage (UK) It is a major cause of death in women worldwide Long-lasting emotional and mental health impact Affects most women and their families at some point in their life Taboo subject – hidden misery Some causes (many) can be prevented First Trimester Miscarriage Miscarriage is the death of a fetus upto 24-weeks of pregnancy 1st trimester - up to 12 weeks Accounts for 85% of pregnancy loss Approx 50% of first trimester miscarriages will have chromosomal abnormality 1-2% of couple suffer recurrent miscarriage Women who–died < 24 weeks Maternal Mortality MBRACCE Report 2021 Terminology Miscarriage is a diagnosis made on ultrasound Complete miscarriage – no tissue remaining Incomplete miscarriage – symptoms of bleeding, usually the cervical os open, some tissue remaining Missed miscarriage (early fetal demise/ anembryonic pregnancy) – diagnosed at scan with no symptoms Molar pregnancy - fetus doesn't develop properly - abnormal cells develop instead of a normal fetus. Known as hydatidiform mole. More seriously can develop into choriocarcinoma. complete mole - mass of abnormal cells in the womb and no fetus develops partial mole, an abnormal fetus starts to form, but it cannot survive or develop into a baby Clinical Presentation Bleeding Pain Found at time of routine scan (i.e. missed miscarriage) (Loss of pregnancy symptoms) Acute collapse Cervical shock, hypotension, tachycardia, bleeding Sepsis Pyrexia, hypotension, tachycardia, raised resp rate, confusion Diagnosing Miscarriage The diagnosis of miscarriage cannot be made following 1 ultrasound scan alone (particularly at very early gestational ages). When performing an ultrasound scan to determine the viability of an intrauterine pregnancy, first look to identify a fetal heartbeat. If there is no visible heartbeat but there is a visible fetal pole, measure the crown– rump length. (Only measure the mean gestational sac diameter if the fetal pole is not visible) If the crown–rump length is < 7.0 mm, or gestational sac is 7.0 mm or gestational sac >25mm (TVUSS) and there is no visible heartbeat, seek a second opinion on the viability of the pregnancy and/or perform a second scan a minimum of 7 days after the first before making a diagnosis. Give women a 24‑hour contact telephone number Ultrasound Images in Early Pregnancy Incomplete m/c Intrauterine pregnancy FH at 6-weeks Viable fetus Threatened miscarriage Advise a woman with a confirmed intrauterine pregnancy with a fetal heartbeat who presents with vaginal bleeding, but has no history of previous miscarriage, that: if her bleeding gets worse, or persists beyond 14 days, she should return for further assessment if the bleeding stops, she should start or continue routine antenatal care Offer vaginal progesterone pessaries to women with an intrauterine pregnancy confirmed by a scan, if they have vaginal bleeding and have previously had a miscarriage. (continue progesterone until 16 completed weeks of pregnancy) Factors Affecting Risk of Miscarriage Age Obesity 25% increase risk with BMI > 30 compared with normal BMI Antiphospholipid syndrome / SLE Parental chromosomal translocation Poorly controlled diabetes Alcohol, smoking, recreational drug use Uterine anomaly (High levels of natural killer cells – limited evidence) Age 20 Miscarriage Risk 15% 30 18% 40 38% 45 70% NB double the risk from 30 to 40… Management of Miscarriage Conservative / expectant (40-80% success) Medical management – misoprostol - can be managed at home or on the ward dependent on size of pregnancy (CRL length) / patient preference Patients must be counselled re: expectations for bleeding and discomfort, potential risk of retained tissue and the potential need for surgical mgmt later Surgical management (SMM) Surgical risks include infection, bleeding, uterine perforation, cervical damage, retained tissue and need for repeat procedure. Follow up - support/counselling, www.miscarriageassociation.org.uk Future pregnancy - Offer vaginal progesterone 400 mg twice daily to women with an intrauterine pregnancy confirmed by a scan, if they have vaginal bleeding and have previously had a miscarriage. (Nice guidance 2022) Recurrent Miscarriage 3 consecutive pregnancy losses less than 24 weeks Affects 1% of couples Investigations / Management: On third (or later) miscarriage offer karyotyping of the tissue (Chromosomal abnormalities- 2-5% of couples. Most common: balanced translocation) Recurrent miscarriage clinic Blood tests - thrombophilia screen, anti-cardiolipin antibodies, lupus anticoagulant Anti Phospholipid syndrome- 15% of patients with recurrent miscarriage. Treatment (Aspirin and LMWH) improves outcome Uterine anomalies: Ultrasound scan (3D scan) or hysteroscopy/laparoscopy Women with recurrent miscarriages (3 consecutive) will need it* from 5 weeks to 16 weeks – (new Nice 2022) Recurrent Miscarriage https://www.youtube.com/watch?v=2bPNLiCOhr4&feature=youtu.be Ectopic pregnancy Pregnancy developing outside the uterine cavity 97% in fallopian tube 2% interstitial Affects 11 per 1000 pregnancies (12000 in UK each year) Heterotopic pregnancy 1 in 30000 (much higher with IVF) Mortality 0.2 per 1000 ectopic pregnancies Risk factors for ectopic pregnancy are only present in 25-50% of women with an ectopic pregnancy Image: Sites for implantation of ectopic pregnancy Risk Factors for Ectopic Pregnancy Previous ectopic pregnancy (15% risk after one) Tubal damage Previous tubal surgery History of pelvic infection / PID History of endometriosis History of subfertility/ IVF Presence of IUCD Use of progesterone only contraception Cystic fibrosis Clinical presentation of ectopic pregnancy ‘Classic’ presentation  Pain and bleeding 6-8 weeks gestation  Positive pregnancy test  Empty uterus on TV ultrasound scan  Given options for conservative / expectant , medical (methotrexate), or surgical management ‘Modern’ presentation  Seen with EPAU minor symptoms in early pregnancy  May be monitored over 48 hours to confirm diagnosis (using scans and hcg levels)  Expectant management / medical / elective surgical Emergency presentation ! Collapsed patient in A and E ! Hypotension, tachycardia, acute abdomen ! Managed with emergency surgery (laparoscopy vs. laparotomy) Diagnosis and Treatment ALWAYS be suspicious of ectopic for any patient who presents with pelvic pain +/bleeding + positive pregnancy test and ALWAYS perform more investigations to rule out ectopic Diagnosis may be From a visualised ectopic on USS At laparoscopy (eg. following previous suspicious investigations) After the patient has collapsed Treatment Conservative Medical – methotrexate injections Surgical (salpingectomy, salpingotomy) Image: Right tubal ectopic Suspected ectopic / pregnancy of unknown location (PUL) Human chorionic gonadotrophin (hCG) monitoring hCG is a pregnancy hormone released from the placenta Detectable in urine 10-11 days post fertilisation and is used in modern pregnancy tests neg/pos Detectable in blood a few days earlier (quantitative testing) < 20 pmol/l unlikely to be normally developing pregnancy Can usually visualise intrauterine pregnancy on scan when hCG > 1000iu/l For a normal intra uterine pregnancy, hCG would be expected to double in concentration every 48-hours In a pregnancy of unknown location (i.e. not visible on the USS) a sub-optimal rise (i.e not double in 48-hours) should provoke strong suspicion of ectopic Time for … a Break Second Trimester Miscarriage Loss of baby between 12-24 weeks May be due to death of the baby in utero or due to premature labour / delivery VERY PRE-TERM LABOUR caused by INTRA-UTERINE DEATH caused by Fetal abnormality – structural / chromosomal Infection Placental dysfunction, growth restriction SLE / anti phospholipid syndrome Cervical weakness / incompetence (e.g. due to multiple LLETZ) anomaly vs. acquired inflammatory response causing uterine irritability and contractions Uterine abnormality Infection Rupture of membranes can be a result of infection e.g. from placenta = abruption (emergency) Bleeding Second trimester miscarriage History – what are we asking about? Bleeding and contractions Ruptured membranes (infection or bleeding?) Any invasive procedures? Screening for fetal abnormality? Chromosomal or structural Previous cervical surgery? Uterine anatomy? Examination Speculum- cervix, bleeding, swabs Scan / dopplers for fetal heart Investigations post-loss Tissue for karyotyping Post mortem? Screening for infection and APS Cervical Sutures Indications  Past history of mid-trimester pregnancy loss  Past history of cervical surgery  Known uterine anomaly  Cervical dilatation noted - on speculum examination or TV scan Elective  Usually inserted after 12 weeks gestation  Can be inserted pre pregnancy  Transvaginal (most) or transabdominal Emergency ! Usually 12-24 weeks but occasionally later ! RCOG evidence that can prolong pregnancy (upto 6-weeks) ! Risk of infection Stillbirth A stillbirth is when a baby dies before or during labour, after 24 completed weeks of pregnancy. Stillbirth statistics In 2021, 1 in every 250 pregnancies ended in stillbirth 2,866 babies were stillborn in 2021 in the UK The stillbirth rate in England and Wales is 4.1 stillbirths per 1,000 total births, up from 3.8 in 2020 Approximately 8 babies were stillborn every day Stillbirth / Neonatal Death Causes for stillbirth Stillbirth Baby delivered with no signs of life after 24 completed weeks  Antepartum/ intrapartum bleeding  Intrauterine growth restriction (eg. caused by maternal medical problems)  Fetal abnormality- structural/ chromosomal  Placental insufficiency  Infection  Poorly controlled diabetes Neonatal Death Early neonatal death: baby dies within 7 days of delivery Late neonatal death: baby dies within 7-28 completed days Causes of NND  Prematurity  Congenital abnormalities  Infection  Intrapartum asphyxia Stillbirth – Who is at Risk Increasing Maternal Age: Offer delivery for women over 40 at 39-40-weeks Raised BMI: In women with a BMI over 26, the risk of stillbirth increases by around 20% with every 5 extra BMI points on the scale ​Smoking The risk of stillbirth goes up depending on how much is smoked during pregnancy :​ the risk of stillbirth is 52% higher in pregnant women who smoked 10 or more​ the risk of stillbirth was 9% higher for those smoking 1 to 9 cigarettes a day.​ Previous stillbirth The risk of another increases 4 times, from 1% to 2.5%​​ Stillbirth – what happens next? The patient is shocked, emotional, tearful, angry, in denial The information they hear is variable Be clear and provide written information where available Give choice Give time Be gentle, be honest, be calm, give facts, give condolences, be caring. In majority of cases, should advise induction of labour for vaginal delivery Mifepristone (anti-progesterone) is first line, after which can go home Give written contact details and provide support at home Advise to return 48 hours later for misoprostol Offer safe place to deliver, bereavement room or suite if available, offer analgesia After a Stillbirth Offer investigations – bloods to rule in / out potential causes (APL) if not known, full infection screen Post-mortem – complete or incomplete, +/- genetics Placental histology Creating memories Funeral options On going support Follow up with consultant to go through investigations and plan for the future Next pregnancy – make a plan SANDS teardrop stickers Legal Certification All stillbirths are registered by certification to the Registrar of Births and Deaths by the parents No certification under 24 weeks if born without signs of life All neonatal deaths have a notification of a live birth and then a death certification Have to be registered by the parents to the Registrar of Births and Deaths Bereavement Suite at PRH Stickers for notes in subsequent pregnancies SANDS Charity – Supporting parents, healthcare professionals, chairty and fundraising, promoting research How Can We Reduce StillBirth Rates Saving Babies’ Lives Care Bundle – is part of a national drive to halve the rate of still births from 4.7 per thousand to 2.3 per thousand Majority of women receive high quality care, but there is ~25% variation in the stillbirth rates across England. The Saving Babies’ Lives Care Bundle addresses this variation The package was developed by groups brought together by NHS England, including midwives, obstetricians and representatives from stillbirth charities KEY FOCUS POINTS: Reducing smoking in pregnancy Improving risk assessment and surveillance for fetal growth restriction Raising awareness of reduced fetal movement Effective fetal monitoring during labour Managing diabetes effectively Perinatal Mortality Review Tool A collaboration led by MBRRACE-UK to develop and establish a national standardised review tool Systematic, multidisciplinary, high quality reviews of the circumstances and care leading up to and surrounding each stillbirth and neonatal death A structured process of review, learning, reporting and actions to improve future care Active communication with parents – informed of the review and how to be involved Coming to a clear understanding of why each baby died, accepting that this may not always be possible even when full clinical investigations have been undertaken; Grading of the care provided Production of a clinical report for which includes a meaningful, plain English explanation of why their baby died and whether, with different actions, the death of their baby might have been prevented Production of national reports of the themes and trends associated with perinatal deaths to enable national lessons to be learned from the nationwide system of reviews; HSIB - Healthcare Safety Investigations Branch - External maternity investigations for babies with poorer outcomes across all Trusts - National action plan to make maternity care safer. We are undertaking approximately 1,000 independent maternity safety investigations to identify common themes and influence systemic change. Use a standardised approach to maternity investigations without attributing blame or liability. Work with families to make sure we understand from their perspective what has happened when an incident has occurred. Work with NHS staff and support local trust teams to improve maternity safety investigations. Bring together the findings from 1,000 reports to identify themes and influence change across the national maternity healthcare system. Break Out Sessions 1. Katie Fraser: The role of the professional in pregnancy loss 2. Gemma Kybert: Oscar’s Story and Creating Memories 3. Jenny Divine: Post-bereavement care – the role of the bereavement midwife BREAK session Patient Perspective Over to Gemma. https://www.youtube.com/watch?v=UAReyHRKMXU&feature=youtu.be Oscars Wish Foundation - Set up 14th February 2015  OWF Bereavement support bags given to families following the stillbirth or passing of their baby after 24 weeks (items included are to enable families to make memories, offer support and information and dignity for their baby)  Miscarriage support bags given to families who use the EPU and are given the news that baby has psssed/ is passing or med management is needed. Other support that OWF provides parents and families and resources to support this counselling  first Christmas personalised decoration  first birthday card  care packs for parents  love-a-best memory bear for children  love-a-best memory bear for parents  Brian and the shiny star book (2 age formats)  Brian and the shiny star audio for children with visual impairment http://www.oscarswishfoundation.co.uk OWF offers the following online support Dads grieve too online support group (private)  Open dads grieve too information and awareness page  Owf website  Oscar’s Wish Foundation social media awareness platforms- public spaces and information and awareness- fb , Twitter and Instagram  Little Stars private online support group (for losses below 14 week gestation)  Shooting Stars private online support group (for losses between 14 weeks-24 weeks gestation  Mummies private online support group for loss before, during or shortly after birth Looking after yourself!