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wolverine
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Joined: 16 Jan 2007
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 Posted: Tue Apr 24, 2007 9:48 pm Post subject: Ante-natal booking, previous late fetal loss |
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You are undertaking a antenatal clinic and you are about to see a new patient. The referral letter by her midwife is as follows:
"Dear doctor,
Could you please review and advice Mrs Carol McDonald who is 14 weeks pregnant by her LMP. She had a miscarriage in her previous pregnancy at 22 weeks.
Thank you,
Janet Slow SM"
You are expected to take a history (8 marks) and discuss a management plan with her (12 marks).
Easy peasy |
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Nick Raine-Fenning
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| Posted: Wed Apr 25, 2007 11:58 am Post subject: |
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Nice question - another version of this is for her to have had one late miscarriage or two early miscarriages before and to present with a missed / silent at 12 weeks. She is unaware. Counsel and formulate a management plan.
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Abik
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| Posted: Wed Apr 25, 2007 8:45 pm Post subject: |
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Easy peasy!!!!??
Getting a bit cocky Wolverine?
History -
age?
prev miscarriage and details of delivery - ?suggestion of cx incomp.
did they find any reason?
other pregnancies (exp. STOP)
cx smear hx ?treatment
this preg - folic acid?
pvb?
USS and ?NT/ screening yet?
planned/happy/worried/depressed
PMH & PSH
see your GP regularly for anything!! etc.!
DH ( incl illicit drug use) allergies
SH
who else?
work/smoking/alcohol/stress
FH - clots, diabetes, heart disease
Management (depends on hx)
Start with reassurance - unlikely to happen again
general preg stuff - stop smoking/teratogens
anomaly scan at 20 weeks
hospital management of pregnancy
check rubella, booking bloods
cervical length assessment by USS?
another scan at 22 weeks
thrombophilia screen if necessary
aspirin/clexane if APLS
can't think of anything else!
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wolverine
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| Posted: Thu Apr 26, 2007 1:56 am Post subject: |
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| Quote: | can't think of anything else!
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Maybe cos there isn't anything else! Apart from checking MSU and LVS. And maybe a fibronectin swab later? very arguable! Can anybody add something else?
Actually I was thinking of Ms McDonald being 25 year old houswife (ex hairdresser) happily married to a policeman.
She had a STOP at 12 weeks when she was 16 but nobody knows about that including her husband Mr Shirodkhar.
She also had a smear test just before she got pregnant and last month she recieved a letter from her GP to repeat it because it showed some abnormality.
She is quite scared that she might loose this pregnancy like the previous one last year, although her first pregnancy 3 years ago was fine and she delivered her daughter Amy at 37 weeks by forceps because her heart beat dropped suddenly just after she started pushing. She then had to go to theatres to be stiched as she was bleeding quite heavily and she was told that there was a tear on the neck of the womb.
From last year she remembers a few things. She gets very upset when she is asked and she says that she almost flushed her baby in the toilet and burst into tears. She had no idea on what was going on until she felt some urge to go to the toilet and to her great surprise she passed the whole sac with the baby!
She is on antidepressants and folic acid, fit and well, no allergies, smokes 10/day and is a social drinker. Her mother had a stroke when she was 45 and she has quite bad varicose veins. She also had her tonsils removed when she was a child.
General examination is normal BP 100/70, pulse 68, BMI 27, gross varicose veins... |
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Abik
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| Posted: Thu Apr 26, 2007 12:23 pm Post subject: |
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Is this a mate of yours?!!
Very detailed imagination you have, Wolverine. I think I'd have got all that? |
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wolverine
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| Posted: Thu Apr 26, 2007 9:21 pm Post subject: |
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No she is not a mate of mine! But sitting on labour ward all night your imagination flies!
Yes I think you could have got the gold metal with this one!! |
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Nick Raine-Fenning
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| Posted: Fri Apr 27, 2007 7:29 am Post subject: |
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| wolverine wrote: | | Yes I think you could have got the gold metal with this one!! |
Is that different to the "Gold Medal"? 
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rpwalavalkar
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| Posted: Fri Apr 27, 2007 8:52 am Post subject: |
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i think the metal bit was vangelis typing in a hurry!!
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EMAK
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| Posted: Fri Apr 27, 2007 12:48 pm Post subject: |
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may I add :
If there is features of cervical incompetence whether from the history of previuos miscarriage[ sudden rupture of membrane with painless dilatation ] or she underwent investigations after miscarriage by using Foly's catheter, Higars Dilator or doing HSG, so the patient adviced about prophylactic cervical suture[ MacCdonald suture] in addition to other prophylactic precausions.
If her history is not conclusive, we can follow her by using TV/US for dilatation of internal os, funnelling or progressive shortenning of cervical canal, also we can get benefit from fetal fibronectin. In such circumstanse if there is any sign of Cx incompetence, an emergency cerclage is inserted, sometimes with reduction of membranes can be done.
Cases with short or scared cervix, a trans-abdominal cerclage is adviced.
Further management will be accordingly.
Antenatal corticosterois is advised if there is sign of immenant preterm labour.
If every thing goes well, the cerclage should be removed at 36 weeks gestation and vaginal delivery is allowed.
For the abdominal cerculage, CS is indicated and the cerculage can be left for future pregnancy. |
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wolverine
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Posts: 394
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| Posted: Fri Apr 27, 2007 5:23 pm Post subject: |
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| No it wasn't! It is my Greek virus who stroke again! In Greek Medal is "metalio" the same roote with the word metalic etc. Sorry! I still wonder how I managed the written part with all these spelling mistakes... |
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Abik
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Posts: 243
Location: Poole
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| Posted: Sun Apr 29, 2007 10:39 am Post subject: |
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The consideration of cervical cerclage is difficult.
It's very dificult to confirm cervical incompetence and the evidence for prophylactic cerclage is ('scuse my french) crap.
Following with USS and putting a rescue cerclage in has better evidence. The risks and benefits for this woman would be extremely difficult to counsel on with respect to prophylactic cerclage.
We had a woman in clinic the other day who had 2 stops then came in at 24 weeks fully dilated (silently) spent a week on her back then SROMed and delivered. The baby died of GBS septicaemia after a rocky course. SHe then had USS monitoring from about 16 weeks and the cervix began to shorten at around 23 weeks so she had a shirodkar. It was removed at 36 weeks and she delivered quickly a week later.
Sounds pretty conclusive to me?
However, my consultant found it very difficult to advise her (at 10 weeks next preg) and she was in floods of tears not knowing whether to have a prophylactic cerclage because of the lack of evidence and the known risk of SRM and infection. She eventually opted to go ahead as she found the idea of miscarriage early from SRM better than the idea of delivering just at viability again.
VERY tricky! |
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wolverine
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| Posted: Sun Apr 29, 2007 10:58 pm Post subject: |
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| Couldn't she have the same as in her previous pregnancy? Serial cervical lengths, any signs of shortenning/funneling for a rescue cerclage. |
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Abik
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| Posted: Mon Apr 30, 2007 10:28 am Post subject: |
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| yes, we offered that too but then the risk is of missing the boat. how often to scan? |
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wolverine
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| Posted: Mon Apr 30, 2007 4:58 pm Post subject: |
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| I don't think there is an answer to that! Most consultants I think would scan every week up to 24weeks |
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Abik
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| Posted: Tue May 01, 2007 3:57 pm Post subject: |
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| She had her stitch yesterday - so far, so good! |
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Nick Raine-Fenning
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Location: Nottingham
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| Posted: Tue May 01, 2007 4:47 pm Post subject: |
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| wolverine wrote: | | I don't think there is an answer to that! Most consultants I think would scan every week up to 24weeks |
You should scan at 22 weeks ideally. If it is normal you can be reassured. It's a bit like a fibronectin tests in that the specificity helps determine management. Not sure if you need to rescan but it would seem safe and sensible to do so prior to the time of the last delivery and possibly 4 to 6 weeks after the baseline scan. If there is no chnage and the patient is asymptomatic leave her alone. Rescan if symptroms develop.
Have a look at the Fetal Medicine Foundation website as they offer training and certification in this. I have read their guidance but cannot remembe rit off the top of my head.
Remember it is not what your consultant would do but the consensus opinion of a scientific body which look at randomised controlled trials, metanalyses, and observational studies. If the College or NICE do not offer guidance go to other key bodies such as the FMF, BSGE, HFEA etc but never ever your consultant!!
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