Dear
Thank you for your Freedom of Information request concerning .
The Trust can provide the following information:
1. Please provide copies of all current versions (currently handed to patients or in use by clinical staff)
of the following documents where available:
a. Consent forms for patients for all kinds of pregnancy terminations
b. Advice sheets and leaflets provided to patients for all kinds of pregnancy terminations
c. Consent forms concerning retention and disposal of fetal tissue and remains following terminations
d. Advice sheets and leaflets concerning retention and disposal of fetal tissue and remains following
terminations
e. Trust or staff policy on informing patients of terminations on the disposal of fetal tissue and
remains, including any scripts or guidance on advice/information staff must provide
2. Please provide copies of all current versions (currently handed to patients or in use by clinical staff)
of the following documents where available:
a. Consent forms for patients for all kinds of procedures relating to miscarriages (for example, manual
vacuum aspiration or medical miscarriage, etc.)
b. Advice sheets and leaflets provided to patients for all kinds of procedures relating to miscarriages
(for example, manual vacuum aspiration or medical miscarriage, etc.)
c. Consent forms concerning retention and disposal of fetal tissue and remains following all kinds of
procedures relating to miscarriages (for example, manual vacuum aspiration or medical miscarriage,
etc.)
d. Advice sheets and leaflets concerning retention and disposal of fetal tissue and remains following
all kinds of procedures relating to miscarriages (for example, manual vacuum aspiration or medical
miscarriage, etc.)
e. Trust or staff policy on informing patients of all kinds of procedures relating to miscarriages on the
disposal of fetal tissue and remains, including any scripts or guidance on advice/information staff must
provide
PLEASE SEE ATTACHMENTS
If you have any queries about this response please contact the information governance
manager at foi@homerton.nhs.uk , in the first instance. If, following that, you still have
any concerns, you may contact the Information Commissioner either by letter, FOI/EIR
Complaints resolution, Wycliffe House, Water Lane, Wilmslow, Cheshire SM9 5AF, or by
email www.informationcommissioner.gov.uk to take them further.
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PERMISSION FOR OWN DISPOSAL OF PREGNANCY TISSUE
Name
____________________________________________
Hospital number ____________________________________________
Address
____________________________________________
I wish to make my own arrangements for disposal of the fetal tissue and I
am taking the remains away from the hospital with me.
Date
______________________
Signature of client
_________________________________
Name of health professional
____________________________________
Signature of health professional ____________________________________
Copy for notes
OmC April 2004
PERMISSION FOR DISPOSAL OF FETAL TISSUE AFTER
TERMINATION OF PREGNACNY
Name
____________________________________________
Hospital number ____________________________________________
Address
____________________________________________
I request Homerton University Hospital NHS Foundation Trust to arrange
sensitive disposal of the tissue after the termination of pregnancy
procedure.
Some information about me (name, hospital number) will be released to the
funeral director and crematorium for identification.
I wish for other arrangements to be made.
Date
______________________
Signature of client
_________________________________
Name of health professional
____________________________________
Signature of health professional ____________________________________
Copy for notes
Copy to mortuary
LS April 2004
Homerton Row
London E9 6SR
Directorate of Services for Children, Women and Sexual Health
Department of Community Gynaecology
Secretary/office Tel: 020 510 7609
Appointments: 020 8510 7445
Women’s Outpatients: 020 8510 7505
Fax: 020 8510 7358
Information for women attending for an early medical termination of pregnancy
Telephone numbers:
ON CALL NURSE
07769303995
Womens OPD
0208 510 7445 (secure answerphone)
Day Stay Unit
0208 5107548 (secure answerphone)
Liz
07976134287
First Appointment for Mifepristone tablet
Please come to Day Stay Unit / Womens OPD
on ______________________________________________________at__________________________
Food and Drink Try and eat about 1 hour prior to arrival. You will be given a tablet and asked to stay
for 10 minutes. You may then leave and resume normal activities.
Your decision After you have taken this tablet it is not advisable to change your mind about having the
abortion. If you are still considering keeping the pregnancy, you should not take the tablet. We do not
know the effect it might have on your baby if you continue the pregnancy.
Bleeding Some women do get period pain and bleeding before the second appointment. We advise that
you carry a pad with you .
Nausea and vomiting Some women experience increased nausea and vomiting the day after taking the
tablet. If you vomit within 1 hour of taking the tablet you may need to take another.
Pain Killers Take any painkillers you have if needed
.
The Homerton ~ The Hospital for Hackney
-2-
Second Appointment for prostaglandin tablets
Please come to Day Stay Unit / Womens OPD
on ____________________________________________________at ______________________
Food and Drink Try and eat before coming to the hospital.
Treatment You will be given 4 prostaglandin tablets by mouth.
You are advised to wear a pad because it is unpredictable when the bleeding will start.
You may then go home as long as the following criteria are satisfied:
• You have an adult with you at home
• You can arrange to come back to the hospital if necessary
• You have access to a phone for incoming and outgoing calls
• You feel confident that you can manage the pain and bleeding at home
The abortion Bleeding and period pains usually start soon after the tablets have been given. The pain
can be severe, but in most cases is not worse than a normal period pain. Some women feel faint or dizzy
during the procedure. You will pass the pregnancy like a blood clot usually within 6 hours. The bleeding
can be heavy with clots, but once the abortion is complete the bleeding and pain settle quickly. For some
people the pain and bleeding do not start until much later.
Tablets You will be given pain killing tablets at the start of treatment and some to take home.
Antibiotics You will be given antibiotic tablets to take afterwards. We also test for infection at your
clinic visit and will give you the results when you attend for the treatment.
Risks Having this procedure is usually straightforward although some women find it difficult to go
through. The tablets that we use sometimes give side effects such as allergies, diarrhoea and vomiting.
Rarely a small operation is needed to empty the womb (the medical name for this is ‘evacuation of
retained products of conception’ or ERPC, often known as a scrape or curettage). Very rarely blood loss
is heavy and needs some other treatment. Most women have normal fertility after a medical abortion but
very rarely there can be complications that reduce fertility.
Contact with the hospital You will be given the mobile number of the nurse on call and can use this at
any time during the day. She will arrange to contact you in the evening.
Follow up You will be given an appointment for a follow up scan.
If you do not attend this appointment there is a risk of the pregnancy continuing.
After the abortion You are advised to rest until the next day. You will experience some period pain and
bleeding for up to 14 days.You should not use tampons and avoid sex for 2 weeks.You will be given the
results of all your tests when you attend for the tablets.
LS Jun 13
CLINICAL GUIDELINES
FOR THE
EARLY PREGNANCY ASSESSMENT UNIT
HOMERTON UNIVERSITY HOSPITAL
Authors
Miss S J Watson
Lead Consultant for Acute Gynaecology
Miss Carron Weekes
Nurse Consultant
Gynaecology
Version
Draft 1
Version Date
June 2012
Implementation Date
Review Date
File Reference
June 2015
Table of Contents
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
12.0
13.0
14.0
15.0
16.0
17.0
18.0
19.0
20.0
21.0
22.0
23.0
24.0
Summary………………………………………...……………………………………page 3
Introduction…………………………………………………………………………..page 3
Development Process………………………………………………………………page 3
Objectives…………………………………………………………………………….page 3
Target Population……………………………………………………………………page 4
Audience………………………………………………………………………………page 4
Referral Criteria ............................................................................................. page 4
Indications for Assessment in the EPAU or by the Gynaecology Team ….page 4
Clinical and Ultrasound Assessment…………………………………………....page 6
Hygiene Guidelines………………………………………………………………….page 7
Diagnosis and Management of Early Pregnancy Problems ……..………….page 8
Management of incomplete and missed miscarriage…………………………page 10
Ectopic Pregnancy…………………………………………………………………page 13
Management of Ectopic Pregnancy…………………………………………….page 13
Pregnancy of unknown location……………..………………………...……….page 16
Rare Pregnancies………………………………...……………………………..…page 17
Beta-HCG and Progesterone Levels……………………………………………page 17
Management of Molar Pregnancies…………………………………………….page 18
Late Miscarriages…………………………………………………………...……..page 19
Management of Recurrent Miscarriage…………………...…………………..page 20
Anti-D Prophylaxis……………...…………………………………………………page 21
Disposal of Fetal Tissue………………...………………………………………..page 22
References………………………………………………………………...………..page 22
Appendices…………………………………………………...…………………….page 25
2
1.0 SUMMARY
These clinical guidelines concern the procedures within the Early Pregnancy Assessment
Unit at the Homerton University Hospital NHS Foundation Trust. All staff involved in caring
for women with early pregnancy complications should adhere to these guidelines.
2.0 INTRODUCTION
Early pregnancy complications represent a significant number of attendances both to
primary care and hospital emergency departments. One in four pregnant women will suffer
a first trimester miscarriage and up to one in 50 will have an ectopic pregnancy. The setting
up of early pregnancy assessment units in all acute hospitals was recommended by the
Royal College of Obstetricians & Gynaecologists, to be accessible by other hospital
departments, general practitioners and women themselves 1. The rapid identification,
management and aftercare of such women as a result of the development of early
pregnancy services has been of considerable benefit to women’s wellbeing as well as an
effective use of resources.
The early pregnancy assessment unit (EPAU) at the Homerton is located on the first floor,
between Priestley Ward and 2012 Ward. It was the first service within the Acute
Gynaecology Unit to be set up in 1994. This service operates alongside the Emergency
Gynaecology Service and the Acute Gynaecology Clinics.
The aim of the unit is to provide a rapid-access and comprehensive service for women in
Hackney with early pregnancy problems. The unit is staffed by specialist nurses,
sonographers, the duty gynaecology team, and is supported at senior level by the duty
consultant gynaecologist, a consultant nurse and the lead consultant in acute gynaecology.
The sonography service is available from 9am to 4.30pm on weekdays and is provided by
experienced sonographers. Specialist nurses staff the unit from 8.30 to 20.00 on weekdays.
The duty gynaecology team is available 24 hours per day for the assessment of women with
early pregnancy problems.
3.0 DEVELOPMENT PROCESS
The previous EPAU guidelines were reviewed and updated then circulated to all the relevant
trust staff for comments before being approved by Clinical Board. All relevant national, Royal
College of Obstetricians & Gynaecologists and other specialist guidelines and research were
consulted, as well as relevant trust policies. Recommendations are graded in the usual way
based on evidence available.
4.0 OBJECTIVES
The aim of these guidelines is to ensure women who attend the unit with early pregnancy
problems are treated safely, effectively and with high standards of care.
3
5.0 TARGET POPULATION
Women within City & Hackney and surrounding areas who have early pregnancy complaints
(under 18 week’s gestation).
6.0 AUDIENCE
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
Nurses in the Acute Gynaecology Unit, 2012 Ward, the Acute Care Unit and Surgical
Centre
Sonographers within the Trust
Gynaecology medical staff
Accident and & Emergency medical and nursing staff
Midwives in the Trust
General Practitioners and Practice Nurses
Staff in the Termination of Pregnancy Service & Department of Sexual Health
All staff within the Trust
7.0
REFERRAL CRITERIA
7.1
Positive Urine HCG and estimated gestation < 18 weeks
The gestation can be estimated from the date of the first day of the last
menstrual period OR from a previous ultrasound report in this pregnancy.
7.2
Referrals are not accepted if:
7.2.1 Negative urine HCG.
7.2.2 No clinical symptoms relating to pregnancy.
7.2.3 Dating scan request.
7.2.4 Normal early pregnancy seen on a scan performed within the last 7 days unless new
bleeding has occurred.
7.2.5 Women who are over 18 weeks gestation (they should be referred to the Obstetric
Assessment Unit or the duty obstetric team).
8.0
INDICATIONS FOR ASSESSMENT WITHIN THE EPAU AND/OR BY THE ONCALL GYNAECOLOGY TEAM
8.1
Indications for immediate assessment in the A&E Department by the duty
gynaecology team. These patients should normally be in the Resuscitation
Room in A&E. The Gynaecology Registrar must see the patient in A&E with
the junior gynaecology doctor.
8.1.1
Signs of hypovolaemic shock secondary to either vaginal bleeding (e.g. due to
miscarriage) or intra-abdominal bleeding (e.g. due to ruptured ectopic pregnancy).
8.1.2
Signs of cervical shock (due to miscarriage).
8.1.3
These patients must be stabilised as much as possible in A&E first with appropriate
intravenous (iv) lines (two large-bore cannulae), iv fluid resuscitation and
4
investigations such as pregnancy test, Full Blood Count and Cross Match. Patients
with hypovolaemia due to massive blood loss may require direct transfer to the
operating theatre without prior assessment in the Acute Gynaecology Unit.
8.1.4
Women in the A&E Department with miscarriage who are bleeding heavily and
show signs of hypovolaemia or cervical shock should have a speculum examination
in A&E. It may be possible to remove products of conception from the cervical os,
which will reduce bleeding and will immediately lead to an increase in pulse rate in a
patient with cervical shock. This may be performed by either a Gynaecology doctor
or an experienced A&E doctor. Any of the following drugs may be given to reduce
bleeding once miscarriage is confirmed. The drug used will depend upon availability.
First line:
misoprostol, 800 mcg rectally
Second line: syntometrine, 1 ampoule, intramuscularly (im)
Third line:
ergometrine 250-500mcg im
8.2
Indications for urgent assessment (normally within 4 hours) in the EPAU. A
urine pregnancy test must be performed in A&E before referral to the unit.
Most of the referrals from A&E will fall in this category. The Specialist Nurse
(bleep 295) should be informed of the patient during the weekday, otherwise
the Gynaecology Registrar (bleep 005) or ST1-2/FY2 (bleep 004) should be
informed. Referrals from General Practitioners or other community locations
should be made by telephoning the unit on 0208 510 7861.
8.2.1
Early Pregnancy pelvic pain and/or vaginal bleeding. The important investigation in
these women is an ultrasound to locate and to determine the viability of the
pregnancy.
8.2.2
The following investigations should be performed in A&E, especially if bleeding
heavily or if the patient is seen during the night or weekend and the ultrasound scan
is booked for the following day: full blood count, group and save, (beta-HCG and
serum progesterone level ONLY if an ectopic pregnancy is suspected).
8.2.3
Where miscarriage or ectopic pregnancy has been diagnosed on a routine antenatal
scan or prior to planned termination of pregnancy.
8.3
Indications for non-urgent assessment (see within 48 hours during week,
usually on same day; up to 60 hours at weekend).
8.3.1
Women in early pregnancy who are asymptomatic, but who have an increased risk of
ectopic pregnancy: previous ectopic pregnancy, history of pelvic inflammatory
disease, pregnancy following a sterilisation procedure or with an intrauterine
contraceptive device in situ. These women require an ultrasound in order to locate
the pregnancy. These women may self-refer to the unit, or may be referred by their
GP or practice nurse.
8.3.2
Women with a history of previous miscarriage or molar pregnancy who are
asymptomatic in a new pregnancy. These women may self-refer or may be referred
by their GP or practice nurse.
5
8.4
Indications for referral to Consultant Early Pregnancy Clinic
8.4.1
Recurrent miscarriage (3 consecutive miscarriages if under 37 years old, or 2
consecutive miscarriages if over 37 years old).
8.4.2
Women with histology showing molar pregnancy who require referral to Charing
Cross Hospital Gestational Trophoblastic Tumour Screening Unit.
8.4.3
Women with pregnancy of unknown location with increasing beta-HCG levels.
8.4.4
Women with rare ectopic pregnancies (See Section 17).
8.4.5
Women being followed up after medical/conservative management of ectopic
pregnancy.
8.4.6
Women who request manual vacuum aspiration.
9.0
CLINICAL & ULTRASOUND ASSESSMENT
9.1
All women should have a clinical history taken by a gynaecology nurse or a member
of the gynaecology team, prior to ultrasonography. The history should include: the
date of the last menstrual period (LMP), the cycle length and regularity of the
periods, the time of onset and severity of vaginal bleeding and/or pelvic pain and
whether or not products of conception have been passed. Previous obstetric and
gynaecological history, including early pregnancy problems, method of family
planning, pelvic inflammatory disease and gynaecological operations should also be
noted.
9.2
All patients with very heavy vaginal bleeding or severe pelvic pain, or who are faint or
collapsed should first be assessed by a gynaecology doctor. The appropriate
actions must be taken prior to scanning in these patients: to gain intravenous access,
to begin fluid resuscitation and to ensure full blood count and a group and save/cross
match samples are taken. If the cervical os is open, products of conception should
be removed if possible.
9.3
All women should have given their verbal consent to have a clinical and/or
ultrasound examination in advance 2.
9.4
All women having clinical examinations and TV scans must be offered a chaperone,
regardless of the gender of the examiner 3.
9.5
No other person should enter the room during a TV scan or clinical examination,
apart from a senior member of the team who is supervising, training or providing a
second opinion of the ultrasound or examination findings.
9.6
Both transvaginal (TV) and transabdominal (TA) ultrasound modalities should be
used according to the clinical indication. TV scanning provides greater diagnostic
accuracy and is the default modality for early pregnancy problems. If a live
6
intrauterine pregnancy is NOT seen on TA ultrasound, a TV scan must be performed
for diagnosis of miscarriage or ectopic pregnancy.
9.7
It must be fully documented on the scan report and in the patient’s notes if TV
ultrasound is declined by the patient, and the images obtained with TA scanning are
unclear. The Lead Clinician or Clinical Nurse Specialist should be made aware of the
patient.
9.8
However, in some situations TV scanning is contraindicated. These patients should
be scanned transabdominally with a full bladder.
9.9
Patients’ details must be entered onto the ultrasound machine prior to scanning, so
that images printed out are identifiable.
9.10
All ultrasound examinations should be entered onto the Viewpoint database and
patient encounters, investigations and diagnoses must be recorded on EPR.
9.11
All pregnant women attending the Acute Gynaecology Unit must be offered
screening for Chlamydia and Gonorrhoea if not screened in the last 1 year or if
clinically indicated. Patients may take their own vulval swab or cervical swabs may
be taken at the time of speculum examination. This policy is in accordance with the
DOH Chlamydia screening programme 4.
9.12
All investigations (swabs, blood tests, histology and cytology samples) must be
recorded and the results checked by the Gynaecology Nurse Specialist or
gynaecology team within 24 hours of the result being available. If an ectopic
pregnancy is suspected, the results must be checked before the patient is
discharged home and a plan of management and/or follow up made.
9.13
The specialist nurse should see the patient following the ultrasound scan in order to
counsel the patient regarding management options, to arrange follow up as
necessary and to give general health and lifestyle advice. Information given to the
patient and patient choice of management options should be clearly documented.
9.14
The duty gynaecology team must be informed of any patient with pregnancy of
unknown location, ectopic pregnancy or patients who opt for surgical evacuation.
10.0
HYGIENE GUIDELINES
10.1
Hands should be washed and/or cleaned with alcohol gel before and after each
examination and non-sterile gloves should be worn for TV scanning 5 (Grade A).
10.2
The ultrasound probe should be cleaned with disinfectant cleaning solution before
and after each patient.
10.3
A new latex probe cover with gel must be placed over the transvaginal probe before
each examination.
10.4
If a woman is allergic to latex, a non-latex probe cover and non-latex gloves must
be used.
7
10.5
Used probe covers should be immediately disposed of in a clinical waste bin.
10.6
The examination and consultation rooms should be clean and tidy at all times. All
blood spills must be mopped up immediately and the area cleaned with
disinfectant.
10.7
All cytotoxic-contaminated materials should be disposed of in the dedicated
container. Gloves and aprons must be worn when administering Methotrexate and
must be disposed of in the dedicated container 6.
11.0
DIAGNOSIS AND MANAGEMENT OF EARLY PREGNANCY PROBLEMS
Following a scan, one of the following diagnoses should be given in accordance with
recent guidelines from the RCOG and Association of Early Pregnancy Units 7,8.
Outdated terminology including “abortion”, “anembryonic pregnancy” and “blighted
ovum” should be avoided 7.
1. Viable intrauterine pregnancy
2. Intrauterine pregnancy of uncertain viability
3. Complete miscarriage
4. Incomplete miscarriage
5. Missed miscarriage or early fetal demise
6. Ectopic pregnancy
7. Pregnancy of unknown location (PUL)
11.1
Viable Intrauterine Pregnancy
11.1.1
Viable intrauterine pregnancy is defined as an intrauterine gestation sac with
a fetal pole and fetal heart movements seen on ultrasound.
11.1.2
Management consists of reassurance. The patient should be encouraged to
arrange antenatal booking either directly by filling a self-booking form in the
Antenatal Clinic or via her GP.
11.1.3
The use of folic acid in the first 12 weeks of pregnancy should be encouraged
to prevent neural tube defects 9.
11.1.4
No follow up scan should be arranged. However, if the patient experiences
further bleeding, she should be advised to contact the EPAU for advice.
11.1.5
The anti-D protocol should be followed (see Section 22).
11.2
Intrauterine Pregnancy of Uncertain Viability
11.2.1
Diagnosis: The presence on transvaginal ultrasound of an intrauterine
gestational sac < 25 mm in diameter, with a yolk sac but no fetal pole
or a fetal pole < 7mm in length with no fetal heart pulsations seen (10,11).
8
11.2.2
Management: Rescan in 7-10 days to assess viability. These women
do not need to have serial beta-HCG levels.
11.3
Complete Miscarriage
11.3.1
Women with a complete miscarriage will have a history of heavy vaginal
bleeding, usually with clots and crampy, period-like pain which has now
settled. There may be a history of passing tissue or a gestation sac.
11.3.2
Assessment of the endometrial cavity on ultrasound can determine whether a
miscarriage is complete or incomplete. The absence of products of
conception, which appear as mixed echogenic tissue within the endometrial
cavity, suggests a complete miscarriage.
11.3.3
Patients with a presumed complete miscarriage should have a urine
pregnancy test. If this is negative, no further follow up is required. If this is
positive, and there is a history of passing products of conception, or a
previous scan report of an intrauterine pregnancy, the patient should be
managed conservatively and followed up by the Specialist Nurse in 2-3
weeks. The patient should be followed up until the pregnancy test is negative
and the bleeding has stopped. If there is no definite evidence of a
miscarriage, then the patient should be investigated as for Pregnancy of
Unknown Location.
11.4
Incomplete miscarriage
11.5.1
Incomplete miscarriage is diagnosed when there are products of conception
visible on ultrasound. Products of conception appear as echogenic tissue
within the endometrial cavity.
11.5.2
Women with incomplete miscarriage who are not bleeding heavily have a
high rate of spontaneous resolution and lower complication rates when
managed conservatively compared with surgery 12 (Grade A).
11.5.2
However, many women prefer the options of medical or surgical management
and they should be given the choice of management option as outlined
below.
11.5.3
Absolute indications for surgical management of incomplete miscarriage: a
large amount of retained products of conception (>50mm anterior-posterior
diameter), very heavy bleeding with tachycardia or hypotension and women
with signs of infection 8.
11.3
Missed Miscarriage/early fetal demise
11.3.1
Diagnosis: Intrauterine gestation sac >25 mm in mean diameter is seen on
transvaginal ultrasound with a yolk sac but no fetal pole, or a fetal pole >7mm
9
is seen with no fetal heart beat. There may or may not be a history of vaginal
bleeding.
11.3.2
Management: The options of conservative, medical and surgical
management should be discussed with the patient.
12.0
MANAGEMENT OF INCOMPLETE AND MISSED MISCARRIAGE
For most women with missed and incomplete miscarriage, all three options of
expectant,
medical
and
surgical
management
under
local
anaesthetic/analgesia or general anaesthetic can be given. The pros and
cons of each method should be discussed with the patient. Reassuringly, all
three methods have been shown to be safe and well-tolerated 13.
Reviews of published randomised controlled trials have shown that surgical
management is the most successful at achieving complete uterine
evacuation, while medical management is more successful than expectant
management 14,15,16 (Grade A). Expectant and medical management is more
successful if a longer time is allowed before further intervention.
Surgical management may have a higher risk of infection 16 (Grade A),
although a large UK-based randomised trial did not show any difference in
rates of infection following expectant, medical and surgical management 17.
Patients managed expectantly have the longest duration of bleeding, but this
is not reflected in a measurably lower Haemoglobin concentration or
haematocrit at 10-14 days 17. No difference in fertility has been detected
following surgical or expectant management 18.
12.1
Expectant management of miscarriage
12.1.1
Expectant management has been shown to be safe and can be continued as
long as the patient is willing. Most miscarriages with an intact gestation sac
will occur within three weeks but a minority continue up to 6-8 weeks 8.
Expectant management aims to avoid the need for anaesthesia, hospital
admission and side effects from medication.
12.1.2
The patient should be informed of what to expect: the likely amount of blood
and pain, what analgesics to be taken, what sort of sanitary protection to be
used. Patient information leaflets should be given, together with the
telephone numbers of Priestley Ward and the EPAU. Patients should be
encouraged to telephone for advice if they are worried by pain or bleeding.
12.1.3
Patients opting for expectant management should be given a follow-up
appointment with the Specialist Nurse in 2 weeks. Further management
depends on whether the pregnancy test is still positive or not and whether
bleeding has settled or not.
10
12.1.4
Negative pregnancy test: discharge patient. Counsel regarding likely
duration of bleeding, onset of normal periods and plans for future pregnancy
or family planning.
12.1.5
Positive pregnancy test: arrange ultrasound. If there are products of
conception present, the patient is again given the options of conservative,
medical or surgical management. If the patient opts for conservative or
medical management, a further follow up appointment should be given in 2
weeks. If the patient opts for surgical management, this should be arranged.
12.2
Medical management of miscarriage
12.2.1
Medical management of miscarriage using either the anti-progesterone agent
mifepristone or the prostaglandin E1 analogue misoprostol or a combination
of the two has been shown to be effective and safe. Evidence to date
suggests that combination therapy is no more successful than misoprostol
alone 15,19,20.
12.2.2
For incomplete and early missed miscarriage, misoprostol alone should be
used. The regime is 800mcg misoprostol vaginally followed by up to 4 oral
doses of 400mcg, 3 hourly. Medical management may be undertaken either
as an in-patient or as an outpatient. Outpatient management should only be
offered if the patient understands English, has someone at home and has
access to a telephone and transport in case of heavy bleeding.
12.2.3
Patients who are likely to bleed heavily (e.g. those with late miscarriages)
should be admitted to the ward for in-patient management.
12.2.4
Contraindications to medical management are: 8
Absolute:
Adrenal insufficiency
Long-term glucocorticoid therapy
Haemoglobinopathies/anticoagulant therapy
Anaemia (Hb <9g/dl)
Porphyria
Mitral stenosis
Glaucoma
Relative:
hypertension
severe asthma
12.2.5
Consent form 1 must be signed. The risk of heavy bleeding must be stated
clearly, as well as the risk of failure or requirement for surgical evacuation.
12.2.6
Patients managed as out-patients may be given misoprostol to take at home
and analgesics.
12.3
Surgical management of miscarriage
12.3.1
Surgical management results in the highest resolution and the shortest
duration of bleeding. Risks include uterine perforation (1%), cervical tears,
11
intra-abdominal trauma (0.1%), intrauterine adhesions, haemorrhage and the
same risk of infection as expectant or medical management (2-3%).
12.3.2
Indications: Patient choice, heavy vaginal bleeding, severe pain, infection
and persistent bleeding.
12.3.3
All patients requesting surgical evacuation must be seen by the duty
gynaecology doctor. The “Evacuation of Retained Products of Conception
(ERPC) Checklist” must be completed (see Appendix). The following must be
performed: clerking, consent, swabs taken by the patient herself or on
speculum examination for Chlamydia and Gonorrhoea, FBC and group and
save sample. All patients with intact gestation sacs and no bleeding must be
prescribed misoprostol 800 mcg vaginally 1-2 hours pre-operatively for
cervical preparation.
12.3.4
The procedure should be described as: “Surgical Treatment for Miscarriage”
or similar, as a more sensitive term than ERPC.
12.3.5
ERPC should be performed using vacuum aspiration (Grade A) 7. Vacuum
aspiration is associated with significantly less blood loss, less pain and
shorter duration of the procedure compared with sharp curettage 21.
12.3.6
Currently there is no evidence to support routine prophylactic antibiotics for
surgical evacuation (Grade A) 7. However, women with a history of pelvic
inflammatory disease should receive prophylactic antibiotics, such as
azithromycin 1g stat and metronidazole 400mg tds for 5 days 7.
12.3.7
Women who present with signs of infection (raised temperature, offensive
vaginal loss, raised white cell count and C-Reactive Protein level) should be
given intravenous broad-spectrum antibiotics prior to and following surgical
evacuation.
12.3.8
The Anti-D protocol must be followed (See Section 22).
12.4 Manual Vacuum Aspiration
12.4.1
A variation of ERPC, using vacuum created using a hand held aspirator, may
be performed in the EPAU by suitably trained consultants and Registrars in
gynaecology. This technique was first described in 1973 22 and has
successfully been used worldwide for the treatment of miscarriage and
termination of pregnancy since its introduction 23.
12.4.2
This is an extremely successful technique and can be performed under local
anaesthetic (paracervical/intracervical block) and oral/rectal analgesia. The
amount of suction achieved by the hand held aspirator is the same as in
ERPC, but there is a lower risk of perforation. There has been shown to be
good patient satisfaction with this technique 24. The RCOG guideline
recommends consideration of this procedure for suitable patients 7.
12
12.4.2
For both ERPC and MVA, a scan should be performed if available to check
the cavity is empty at the end of the procedure.
12.4.3
Products of conception should be sent for karyotyping in 3rd and successive
miscarriages, or following IVF.
13.0
ECTOPIC PREGNANCY
13.1
Diagnosis: An ectopic pregnancy is located outside the uterus. The most
common location is within the fallopian tube, but other possible locations are
within the cervix, the interstitial portion of the tube, the ovary, within a
Caesarean scar or within the abdominal cavity. Ectopic pregnancies account
for 11 per 1,000 pregnancies 25.
Ectopic gestations are potentially life-threatening because of the risk of
rupture and massive intra-abdominal haemorrhage. Traditionally they were
diagnosed at laparotomy performed for maternal collapse, but more recently,
with rapid and accurate testing for beta-HCG and transvaginal ultrasound,
they are diagnosed early, when more conservative methods of treatment may
be used.
Ectopic pregnancy is an important cause of maternal mortality. There were 10
maternal deaths due to ruptured ectopic pregnancies reported in the last
maternal mortality report 25. Seven of these 10 deaths were associated with
substandard care. Four patients presented with atypical symptoms of
diarrhea and vomiting and were misdiagnosed.
The usual symptoms of an ectopic pregnancy are 6-8 weeks of amenorrhoea,
lower abdominal pain, shoulder-tip pain and vaginal bleeding. The patient
may also report atypical symptoms such as diarrhea, vomiting and fainting
episodes 25.
13.2
Ultrasound features: an adnexal mass, an adnexal gestation sac and/or free
fluid within the pelvis with no signs of an intrauterine pregnancy.
13.3
Clinical signs of rupture: tachycardia, hypotension, pallor, clammy
peripheries, abdominal distension, abdominal and pelvic tenderness.
13.4
Investigations: FBC, Group and Save or Cross Match, serum beta-HCG and
progesterone. The management should be based on severity of symptoms,
ultrasound findings and HCG levels. Management should be discussed with
the lead clinician or consultant on call.
14.0
MANAGEMENT OF ECTOPIC PREGNANCY
14.1
Conservative management
A small proportion of women with ectopic pregnancy are suitable for
conservative management 8.
13
14.1.1
Indications: Minimal/no symptoms, low initial beta-HCG level (<1000 iu/l),
and declining or static beta-HCG level after 48 hours.
14.1.2
Contraindications: Significant pain or signs of rupture, high initial levels of
beta-HCG and rising levels after 48 hours, fetal heart beat on scan, large
ectopic mass seen on ultrasound (>2cm diameter) or evidence of free fluid
seen on ultrasound.
14.1.3
Management: The patient must be warned about the small risk of rupture
and need for surgery. There is also a risk of pain secondary to tubal
miscarriage. The patient must be able to come to the EPAU for follow up and
at least weekly beta-HCG levels until the pregnancy test is negative.
14.2
Medical Management of ectopic pregnancy
14.2.1
Some patients with ectopic pregnancy are suitable for medical management
with the antimetabolite methotrexate 8,26 (Grade B). Methotrexate is highly
effective and, if successful, avoids the need for surgery and the associated
surgical and anaesthetic risks.
14.2.2
Indications: Patients with no or minimal pelvic pain, with low initial betaHCG (<3000 iu/l) which is increasing less than 85% over 48 hours 8. Patients
must come for follow up on days 4 and 7 after the injection, and then on a
weekly basis, or whenever indicated until beta-HCG <25 iu/l. The period of
follow up may last for 1-3 months.
14.2.3
Contraindications 8:
1. Unstable vital signs, severe pain or abdominal or pelvic tenderness
or cervical excitation.
2. Patient is unable/unwilling to attend for follow up or chooses
surgical management.
3. Medical contraindications to medical management:
Abnormal liver or renal function
Anaemia, leucopenia, thrombocytopenia
(Hb < 10g/dL, WCC < 2, platelets < 100)
4. Beta-HCG > 3000iu/l.
5. Fetal heart activity on scan.
6. Large ectopic mass seen on scan (>2.5cm).
7. Significant free fluid seen on scan (>100ml).
14.2.4
Possible adverse effects: sore mouth, nausea, diarrhea, photosensitivity,
rashes, abnormal liver function. These are temporary and resolve quickly.
14.2.5
Patient advice to be given:
The patient should be warned about the follow up period (up to 3 months)
with regular blood tests and the possibility of requiring surgery (approx. 7%)
or a second dose of methotrexate (approx. 15%) 27. These patients should
be warned about the possibility of developing pain (3-5 days post-injection)
because of tubal miscarriage. These patients have direct access to the EPAU
14
and if they attend A&E, they should be seen urgently by the gynaecology
Registrar on duty.
14.2.6
Consent Form 1 should be signed after a full explanation of the risks and
benefits of the treatment by a Registrar or Consultant. The patient
information leaflet should be given.
14.2.7
Methotrexate is given at a dose of 50mg/m2 body surface area by
intramuscular injection. The Trust policy for the administration of cytotoxic
drugs and the disposal of contaminated material should be followed 6.
14.2.8
The required blood tests pre and post-injection are as follows:
Before treatment: FBC, U&Es, LFTs., HCG, progesterone, Group and Save
Day 4: HCG
Day 7: HCG, FBC, U&Es, LFTs.
If the decline is more than 15% between days 4 and 7, beta-HCG levels are
checked on a weekly basis until < 25u/l or pregnancy test is negative. A
decline of less than 15% indicates an inadequate response and a second
dose of methotrexate or surgical management should be considered.
14.2.10
The following drugs should be avoided for one week after treatment: folic
acid, nonsteroidal anti-inflammatory drugs, trimethoprim, co-trimoxazole and
penicillins.
14.2.11
Overall, the success rate of single-dose Methotrexate is 80-90% with a tubal
patency rate of 80% 8, which compares favourably with conservative tubal
surgery.
14.2.12
Reliable contraception should be used for 3 months following the treatment to
prevent teratogenic effects on a new pregnancy from Methotrexate.
14.3
Surgical Management
14.3.1
Indications: Symptoms and signs of rupture, where conservative or
medical management is contraindicated. Surgery is the
default method of management.
14.3.3
Investigations: All patients must have a FBC and Group and Save or Cross
Match sample as well as a beta-HCG level and progesterone level. High
vaginal and endocervical swabs must be taken.
14.3.2
Surgical Method: Choice of surgical technique depends on the clinical
scenario and operative findings, as well as surgical expertise. In a stable
patient, laparoscopic surgery should be the surgical method of choice 26
(Grade A). The choices of salpingectomy or salpingotomy are available. In
the presence of a healthy contralateral tube, there is no clear evidence that
salpingotomy should be used in preference to salpingectomy 8,26,27 (Grade B).
If salpingotomy is performed, serum beta-HCG should be measured
15
postoperatively until it declines to <25iu/l to exclude persistent ectopic
trophoblast. In the event that the beta-HCG level does not fall as expected,
methotrexate may be given.
14.3.2
Laparoscopic salpingotomy should be considered the surgical treatment of
choice in women who have a damaged contralateral tube 26 (Grade B). The
increased risk of a further ectopic pregnancy should be explained to the
patient.
14.3.3
The Anti-D protocol should be followed after medical or surgical management
of ectopic pregnancy (see Section 22).
15.0
PREGNANCY OF UNKNOWN LOCATION
15.1
Definition: No obvious intrauterine or ectopic pregnancy is seen on
ultrasound with a positive pregnancy test and there is no history of a
complete miscarriage 7.
15.2
The patient must be seen and examined by the gynaecology team. Vaginal
and speculum examination must be performed to detect pelvic tenderness
and cervical excitation and to detect whether the cervical os is open. Swabs
must be taken.
15.3
Blood should be taken for FBC, G&S, beta-HCG and serum progesterone. If
the patient is asymptomatic and stable, follow up should be arranged in 48
hours for a repeat beta-HCG level.
15.4
If the HCG is declining, the diagnosis is of either a resolving ectopic
pregnancy or miscarriage. These patients should be offered a review in 7
days with a further beta-HCG level or urine pregnancy test.
15.5
If the beta-HCG levels are increasing over 48 hours, the patient should be
asked to attend for a further ultrasound scan and assessment within 5 days.
The differential diagnosis is an ectopic pregnancy or early intrauterine
pregnancy. The serum progesterone is useful in this situation. If the
progesterone level is high (>60 mmol/l) then an intrauterine pregnancy is
more likely and the presence of an intrauterine gestation sac should be
confirmed when the beta-HCG is above 1000iu/l. A lower progesterone level
raises the suspicion of an ectopic pregnancy. See Appendix for flow chart.
15.6
It is occasionally appropriate to perform both laparoscopy and ERPC in
women in whom the location of the pregnancy is uncertain if surgical
management is required (e.g. for pelvic pain, signs of bleeding). If an ectopic
pregnancy is not identified, and if a viable intrauterine pregnancy can be
excluded, then ERPC should be performed to remove any products of
conception from the uterine cavity.
16
16.0
RARE PREGNANCIES
16.1
Heterotopic Pregnancy: The incidence of a simultaneous intrauterine and
ectopic pregnancy is around 1:30,000, but is up to 1% in assisted conception.
Therefore the presence of an intrauterine gestation sac or confirmed products
of conception makes the diagnosis of ectopic pregnancy very unlikely.
Patients with heterotopic pregnancies must be discussed with the lead
consultant or duty consultant in order to decide on further management.
16.2
Cervical Pregnancy: This diagnosis requires the following criteria: an empty
uterus, a barrel-shaped cervix, a gestation sac below the level of the uterine
arteries, the use of colour Doppler to demonstrate blood flow to the sac, and
a negative sliding sac sign 28. The lead consultant or duty consultant must be
informed of the patient. Serum beta-HCG must be taken and management
should be based on serum HCG level, size and viability of the pregnancy and
the amount of bleeding. The options of expectant management, local
injection of methotrexate and/or potassium chloride (KCl), systemic
methotrexate or surgery should be decided at a consultant level.
16.3
Caesarean Scar Pregnancy: The gestation sac will be seen to be implanted
within a previous Caesarean scar and may bulge into the bladder, with only a
thin layer of myometrium separating it from the bladder. These pregnancies
may be carried to term but are associated with significant morbidity and
mortality associated with placenta praevia, accreta or percreta, with the risk
of massive postpartum haemorrhage and Caesarean hysterectomy.
Management depends on patient symptoms, bleeding, viability, gestation and
the wishes of the patient 29. They include systemic methotrexate, local
injection of methotrexate and/or KCl, surgical evacuation under ultrasound
guidance, laparoscopic resection or expectant management if the patient
declines intervention during early pregnancy. These patients should be
referred to the lead consultant or duty consultant for further management.
16.4
Interstitial Pregnancy: The gestation sac is located in the interstitial portion
of the tube. Ultrasound features include the interstitial line sign (gestation sac
seen laterally with lumen of tube in continuum with endometrial cavity). These
pregnancies rupture relatively late and thus are associated with more severe
blood loss and higher mortality 28. Management should be decided on
symptoms, signs, size of the pregnancy and beta-HCG level and include
laparoscopy or laparotomy, and systemic methotexate. In general,
asymptomatic women with early interstitial pregnancies should be managed
medically in view of the risks to future pregnancies 26.
17.0
BETA-HCG AND PROGESTERONE LEVELS
17.1
Beta-HCG
17.1.1
HCG is a hormone produced by trophoblast (early placenta). Most
commercially available monoclonal antibody–based urine tests can
17
detect the presence of HCG at a level above 25 iu/l, which corresponds to
day 24-25 of a 28 day menstrual cycle in which conception has occurred.
17.1.2
The level of HCG correlates well with the amount of viable trophoblast. In
intrauterine pregnancy, the level doubles every 48 hours until 1200 iu/l and
thereafter every 72 hours. Ectopic pregnancies usually have a longer
doubling time, therefore the rate of increase of beta HCG are used to
investigate suspected ectopic pregnancies 7 (Grade B). However, 15% of
normal pregnancies have a longer doubling time, and 13% of ectopic
pregnancies have a normal doubling time 8, therefore HCG ratios and
doubling times cannot be used exclusively to locate pregnancies.
17.1.3
After a pregnancy has been expelled or removed, the HCG level falls with
a half life of 36 hours.
17.1.4
Beta-HCG should only be used in the investigation and monitoring of
confirmed ectopic pregnancies and pregnancies of unknown location.
17.2
Serum Progesterone
17.2.1
In very early pregnancy (<7 weeks gestation), progesterone is produced by
the corpus luteum and thereafter by the placenta. The level of progesterone
is determined by the rate of increase of HCG, which in turn depends on the
speed of trophoblast proliferation. Serum progesterone is also useful in the
investigation of pregnancy of unknown location 7 (Grade B).
17.2.2
A low level of progesterone (<20 mmol/l) strongly suggests a miscarriage or
failing ectopic pregnancy, particularly if associated with falling beta-HCG
levels.
17.2.3
A higher level of progesterone (20-60mmol/l), with beta-HCG levels that
do not rise at the expected rate, is suggestive of an ectopic pregnancy.
17.2.4
High progesterone levels (>60mmol/l) are consistent with either a viable
intrauterine pregnancy or a viable ectopic pregnancy.
18.0
MANAGEMENT OF MOLAR PREGNANCIES
Molar pregnancies account for 1 in 714 live births 30 but the incidence is
double in Asian women. Molar pregnancies are caused by either duplication
of sperm following fertilization or dispermic fertilization. Persistent gestational
trophoblastic disease, which may cause serious morbidity as well as maternal
mortality, may follow molar pregnancy, a non-molar pregnancy or a live birth.
Registration should be made via the website: nww.h-mole.nhs.uk. The
nearest Trophoblastic Tumour Screening & Treatment Centre is at Charing
Cross Hospital.
18
Diagnosis is usually made on histology of products of conception following
miscarriage. The diagnosis may be suspected on ultrasound appearances of
multiple cystic spaces within the trophoblast tissue.
If a molar pregnancy is suspected with a non-viable pregnancy, then surgical
evacuation should be performed 30 (Grade C). Medical management of molar
pregnancies, including cervical preparation prior to suction evacuation, is not
recommended. Oxytocic agents should only be used once the uterus has
been completely evacuated 30 (Grade C).
Patients with viable pregnancies who are suspected on ultrasound to have
partial moles should be followed up. Rescan should be arranged in 7-14
days as there is an increased risk of miscarriage in these patients.
As ultrasound has low sensitivity in the diagnosis of molar pregnancy, it is
recommended that all products of conception from all surgical evacuations
should be sent for histological examination 30 (Grade C).
If products of
conception are available from medical management or spontaneous
miscarriage, then this should also be sent for histological examination.
Patients with histologically confirmed molar pregnancy should have a follow
up appointment in Miss Watson’s Early Pregnancy Clinic. The patient should
be advised not to become pregnant or to use hormonal contraception for 6
months, when they will usually be discharged from follow up 30 (Grade C).
HCG levels will also be checked 6 and 10 weeks following a future
pregnancy. See Appendix 25.6 for further guidance.
19.0
LATE MISCARRIAGES
19.1
Women with late miscarriage (>14 weeks) should be managed medically.
Misoprostol should be given according to the protocol (800mcg pv, then 3
hourly oral doses of 400mcg). These women should be admitted, because of
the possibility of heavy bleeding and infection.
19.2
Those with signs of infection should be given iv broad-spectrum antibiotics for
24 hours prior to ERPC if required but misoprostol can be given concurrently
with antibiotics.
19.3
Women with an incomplete late miscarriage can be considered for ERPC,
MVA or medical management according to clinical scenario and amount of
retained tissue.
19.4
Women who miscarry after 14 weeks of gestation should be offered a follow
up appointment after 6 weeks with the consultant in charge of the patient or
with Miss Watson in the EPAU.
This should be arranged via the
bereavement midwives if over 16 weeks or EPAU if under 16 weeks of
gestation.
19
19.5
The following investigations should be performed: HVS and endocervical
swabs, placental swab, karyotyping of the fetus (send dry specimen from
placenta and cord), RPOCs for histology and maternal blood to be sent for
antiphospholipid antibodies and inherited thrombophilia (Factor V Leiden,
Prothrombin gene mutation and protein S deficiency 31. Consideration should
be made for 3D ultrasound to check for congenital uterine abnormalities.
19.6
Management of future pregnancies should be individualised and consultantled. These women should be referred early for first trimester ultrasound and
combined screening if desired. Consideration should be given to screening
for bacterial vaginosis, the elective insertion of a cervical suture and/or
cervical length ultrasound monitoring or progesterone therapy.
20.0
MANAGEMENT OF RECURRENT MISCARRIAGE
20.1
Recurrent miscarriage (RM) is defined as three consecutive miscarriages.
The incidence is 1%, which is approximately 3 times higher than the expected
incidence. Several conditions are now known to be associated with RM and
may have a causative role. Treatment of these conditions has been shown to
dramatically increase the success of subsequent pregnancies.
20.2
Women with 3 or more recurrent miscarriages should be referred to Miss
Watson’s Early Pregnancy Clinic so that the appropriate investigations can be
carried out and a plan for management of future pregnancies can be made.
Women over 37 made be referred for investigation following 2 recurrent
miscarriages.
20.3
The risk of subsequent miscarriage following 3 consecutive miscarriages is
about 43%. In the majority of cases (> 70 %), no underlying cause is found
and the most of these women will eventually proceed to a full term pregnancy
with support during early pregnancy 8,31. Increasing maternal age is an
independent risk factor for further miscarriages due to a decline in the
number and quality of remaining oocytes. Advanced paternal age has also
been identified as a risk factor for miscarriage 31. In addition, lifestyle factors
have also been identified in increasing the risk of sporadic miscarriage,
including cigarette smoking, caffeine, alcohol and raised Body Mass Index.
Well-controlled diabetes or thyroid dysfunction are not associated with
recurrent miscarriage.
20.4
Investigations for Recurrent Miscarriage
Mother’s blood for:
Antiphospholipid antibodies:
anti-Cardiolipin antibodies
lupus anticoagulant
beta 2 glycoprotein antibodies
If one/more antibody is positive, repeat testing must take place 12 weeks later
to exclude transient positivity secondary to infections etc.
20
Other maternal blood investigations according to history: thrombophilia
screen if previous history of thrombosis, or in second trimester miscarriage,
HbA1c or thyroid function if any suggestive history.
3D transvaginal ultrasound to exclude congenital uterine abnormalities.
Parental karyotypes should only be performed in couples with
documented unbalanced translocation in a previous miscarriage.
20.5
Management of Recurrent Miscarriage and late miscarriage
20.5.1
Couples with unexplained recurrent miscarriage should be managed by serial
ultrasound and supportive care in the next pregnancy in the EPAU. This
alone increases the success of the next pregnancy 32,33 (Grade A).
20.5.2
If anti-phospholipid syndrome (APS) is diagnosed, then the regimen is aspirin
75mg and enoxaparin 40mg s/c od from early pregnancy. Treatment with
aspirin and heparin reduced the pregnancy losses by 54% compared with
aspirin alone in women with antiphospholipid antibodies 34,35 (Grade A). No
difference has been demonstrated between unfractionated heparin and lowmolecular weight heparin in recurrent miscarriage associated with APS and
therefore enoxaparin should be used, due to the associated benefits.
20.5.3
In APS, treatment should be continued to term as there is a high risk of
complications in all three trimesters.
20.5.4
Women with congenital uterine abnormalities should be counseled regarding
the implications for the exact abnormality found and treatment options
available.
20.5.5
If a balanced translocation is found in either parent then the couple should be
referred for genetic counseling.
20.5.6
Women with late miscarriage who are found to carry an inherited
thrombophilia should be treated with enoxaparin 40mg/day 31 (Grade A). This
has been shown to increase the live birth rate 36. There is insufficient
evidence to evaluate the effect of heparin in pregnancy to prevent recurrent
first trimester miscarriages in women with thrombophilia (Grade C) 31.
20.5.7
If subsequent pregnancies are miscarried, then products of conception
should be sent for karyotyping. Follow up should be arranged in Early
Pregnancy Clinic.
21.0
ANTI – D PROPHYLAXIS IN EARLY PREGNANCY
21.1
All pregnant women who attend the unit who have any vaginal bleeding or
who are diagnosed with miscarriage or ectopic pregnancy should have blood
taken for group and save regardless of the gestational age of the pregnancy.
21
21.2
Women who are under 12 weeks gestation and are Rhesus Negative and
non-sensitised need to be given Anti–D only if they undergo surgical
evacuation of the pregnancy or if they have an ectopic pregnancy 37 (Grade
B).
21.3
All Rhesus Negative women over 12 weeks gestation require Anti-D if
they present with any bleeding 37 (Grade B).
21.4
The dose of Anti-D is 250 iu given intramuscularly to the deltoid. This should
be obtained from Blood Transfusion after a sample has been sent for typing.
Anti-D should be given within 72 hours of any bleeding or surgery.
21.5
Women should not normally be sent home prior to receiving the Blood Group
result and ascertaining whether or not Anti-D is required.
22.0
DISPOSAL OF FETAL TISSUE
22.1
The Trust policy for disposal of fetal tissue should be followed at all times.
If recognizable fetal tissue is passed, patients may either request to take
the tissue home for private burial or cremation or they may request a
hospital communal cremation. All requests to take tissue home should be
respected and dealt with sensitively according to the personal, religious
and cultural needs of the patient and her partner 8,38. The appropriate
consent form for removal of products of conception should be signed by
the patient.
22.2
Patients must not be given the products of conception if they have not
requested to take them home and have not signed the form.
22.3
Under no circumstances should products of conception be disposed of
except by incineration (or cremation if recognizable fetus is delivered). The
“Sensitive Disposal of Pregnancy Tissue” form should be signed.
22.4
Recognizable fetal tissue should not be sent for histological examination.
23.0
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27.
Hajenius PJ et al. Interventions for tubal ectoic pregnancy. Cochrane
Database
Syst Rev. 2000 (2): CD000324.
28.
Kirk E. Managing non-tube ectopic pregnancy: interstitial and cervical
pregnancy. In Handbook of Early Pregnancy Care. Informa. Abingdon. UK.
2006.
29.
Bottomley C. Caesarean Scar Pregnancy. In: Handbook of Early Pregnancy
Care. Informa. Abingdon. UK. 2006.
30.
The management of gestational trophoblastic neoplasia. Green-Top Guideline
No. 38. RCOG, London. 2004.
24
31.
The investigation and treatment of couples with recurrent first trimester and
second trimester miscarriage. Green-Top Guideline No.17. RCOG, London.
2011.
32.
Clifford K, Rai R, Regan L. Future pregnancy outcome in unexplained
recurrent first trimester miscarriage. Hum Reprod 1997;12:387-9.
33.
Brigham SA, Conlon C, Farquharson RG. A longitudinal study of pregnancy
outcome following idiopathic recurrent miscarriage. Hum Reprod
1999;14:2868-71.
34.
Rai R, Cohen H, Dave M, Regan L. Randomised controlled trial of aspirin and
aspirin plus heparin in pregnant women with recurrent miscarriage associated
with phospholipid syndrome (or antiphospholipid antibodies). BMJ
1997;314:253-7.
35.
Empson M et al. Prevention of recurrent miscarriage for women with
antiphospholipid antibody or lupus anticoagulant. . Cochrane Database Syst
Rev 2005;(2):CD002859.
36.
Gris JC et al. Low-molecular weight heparin versus low-dose aspirin in
women with one fetql loss and constitutional thrombophilic disorder. Blood
2004;103:3695-9.
37.
Royal College of Obstetricians and gynaecologists. Use of Anti-D Immunoglobulin for
Rhesus Prophylaxis. Clinical Green Top Guideline No 22. 2002
38.
RCOG Good Practice No. 5. Disposal following pregnancy loss before 24 weeks of
gestation. RCOG. 2005.
24.0
APPENDICES
24.1
Grades of Recommendations
Requires at least one randomised control trial as part of the body of literature of overall good
A quality and consistency addressing the specific recommendation)
Requires availability of well-conducted clinical studies but no randomised clinical trials on the
B topic of recommendation
Requires evidence from expert committee reports or opinions and/ or clinical experience of
C respected authorities. Indicates absence of directly applicable studies of good quality
25
24.2 EPAU Flow Chart
Positive HCG
TV (TA) SCAN
Intrauterine
pregnancy
(IUP)
Viable
Antenatal
booking
Ectopic
Pregnancy
(EP)
Nonviable
Stable
Pregnancy of
unknown location
(PUL)
HCG/progesterone
and rescan to
establish diagnosis
Non-Stable
Miscarriage
management
protocol
Laparotomy
HCG 0 and
48 hours,
progesterone
IUP
EP
Failing PUL
Medical or
Surgical
management
(Laparoscopy)
Follow up
HCG to ensure
resolution
26
24.3 Intrauterine pregnancy diagnoses and management
PV Bleeding < 18
weeks, HCG +ve
TV or TA scan
Viable
IUP
Pregnancy of
uncertain viability
GS <
25mm, no
Fetal Pole
FH+
Advise folic
acid, antenatal
booking, 12
week scan or
antenatal follow
up accordingly.
CRL <
7mm
no FH
Missed
Miscarriage
Incomplete
Miscarriage
Complete
miscarriage
Empty sac >
25mm or no FH
if CRL > 7mm
Rescan in 7-10
days
Expectant, medical or
surgical management of
miscarriage
If expectant or medical
management, EPAU nurse
review in 2-3 weeks to
check HCG +/- scan.
Additional medical or
ERPC/MVA can be
arranged at this time.
Referral for investigations if
recurrent miscarriage.
Pregnancy of
uncertain
location
See Appendix
25.3
27
24.4
ERPC and MVA Checklist
To be completed by Nurse and Doctor
Miscarriage confirmed on scan?
Yes
No
Type of miscarriage
Incomplete
Missed
Yes
No
Yes
No
Yes
No
Yes
No
Cervical preparation required (missed misc, mole not
suspected)
Blood taken for G&S, FBC
Blood Group if known……………………………
Yes
No
Yes
No
Karyotype if 3rd or more miscarriage
Fill form
Yes
No
Theatre informed
Yes
No
Booked on EPR?
Yes
No
Patient given letter/informed of where/when to attend,
NBM instructions
Yes
No
Follow up required in Early Pregnancy Clinic in 6
weeks?
e.g. if 3rd/more miscarriage
Yes
No
Gestation/size of pregnancy
Swabs taken
Hx of PID
Antibiotic prescribed
Consent
Any other significant information?
Nurse signature…………………………Name…………………………… Date…………….
Doctor signature……………………… Name…………………………..…Date…………….
28
24.5
Flow Diagram for management of tubal ectopic pregnancy
Ectopic diagnosed
on scan
Pain +, or HCG
>3000, signs of
rupture/intraperitone
al bleeding or fetal
heart beat: for
surgery
No/minimal pain: 0 and 48
hour HCG and
progesterone level
Increase in HCG
>85%
Surgery
Decrease in HCG
<85%
Expectant
management
(repeat HCG 48
hours)
Methotrexate 50mg/m2
>15% decrease
HCG day 4-7
Repeat
weekly until
<25 iu/l
<15% decrease
HCG day 4-7
Further
methotrexate
or surgery
HCG
increasing
HCG
decreasing
Weekly HCG
until <25 iu/l
29
24.6 Information regarding referral and follow up for molar pregnancy.
30
25.7
Anti-D Prophylaxis in early pregnancy
Patient Rhesus
Negative with no
Rhesus antibodies
Medical/Expectant
Management of
Miscarriage < 12 weeks
No Anti-D
required
Any bleeding > 12
weeks or surgical
evacuation
Ectopic pregnancy
Give 250 iu Anti-D by intramuscular
injection within 72 hours
31
CLINICAL GUIDELINES
FOR THE
EARLY PREGNANCY ASSESSMENT UNIT
HOMERTON UNIVERSITY HOSPITAL
1 Document Progress Sheet
This form to be completed by the Lead Clinician at all relevant stages
Clinical Guidelines for The Early Pregnancy Assessment Unit.
Policy Title
Lead
“home”
Directorate
Informed
Miss S J Watson, Lead Consultant for Acute Gynaecology
Development of guidelines approved by “home” Directorate or Expert Group
Minutes attached
Date ___________________
Registered
via Clinical
Governance
Facilitator
yes  / no 
Initial: ___________________
___________________
CGF Initial:
Date: _____________________
Version
number
_Final Draft
circulated
Attach a complete list of those on circulation list
Date: _____________________
Expert Group or Trust Committee
Version
number
Group Name ___________________________Initial: ___________________
_____
circulated
Group Name __________________________ Initial: ___________________
Final
version
_____
approved
Final version of guidelines approved by “home” Directorate or Expert Group Minutes
attached
yes  / no 
Date ________________________
32
2 Document Control Summary
Clinical Guidelines for The Early Pregnancy Assessment Unit.
Document Title
Author (s)
Sandra Watson
Lead Consultant for Acute Gynaecology
Carron Weekes
Nurse Consultant, Gynaecology
Department
Directorate of Services for Children, Women and Sexual Heath
Date of Production
June 2012
Purpose of Document
Circulated to
Status
To describe and facilitate the management of women with early
pregnancy problems in the Early Pregnancy Assessment Unit and
by the Gynaecology duty team.
All of the Obs & Gynae Consultants
All of the A&E Consultants
Please see attachment below
Final Draft 2012
Version Reference
File Reference / Address
(Author)
File Reference / Address
(Trust network/Intranet)
Update Frequency
Every 3 years
Next Review Date
June 2015
Approved By
Signatures
Clinical Director: __________________________
Clinical Governance Chair: _____________________
Clinical Board Chair: _____________________
33
Gynae Nursing Team
Katharine Thompson
Carron Weekes
Denise Brown
Obs & Gynae Consultants
Mr Y Akinfenwa
Mr C Barnick
Ms K Erskine
Mr E Dorman
Ms C Roberts
Ms L Stacey
Miss S Watson
Mr A Shah
Mr A Gudi
Miss M Parisei
Miss C Kingman
34
Disposal of pregnancy tissue /
Products Of Conception
(POC) after a miscarriage
(under 16 weeks)
Patient information
This leaflet has been produced by
Acute Gynaecology Unit / Early Pregnancy Assessment Unit
Homerton University Hospital
Homerton Row
London
E9 6SR
020 8510 7861
Incorporating hospital and community health services, teaching and research
This leaflet will give you information about what happens to the
pregnancy tissue, usually called Products Of Conception and
abbreviated to POC following a miscarriage.
If the POC are passed or removed in the hospital or are brought to the
hospital, then we will arrange disposal unless you wish to make your
own arrangements.
Laboratory analysis
In most cases a sample of the tissue will be sent to the laboratory for
testing to identify whether any abnormal changes can be identified
within it that may have contributed to the miscarriage. This cannot
identify all causes of miscarriage. If anything abnormal is detected,
you will be contacted to attend for results.
Sensitive disposal – hospital arrangements
In early miscarriages, where the foetus or embryo (baby) cannot be
identified within the POC, then the tissue is sent to the mortuary for
incineration.
In more advanced pregnancies where a recognizable foetus or embryo
is passed, then the mortuary will arrange for communal cremation.
This is done in a local crematorium and you will need to sign a consent
form for this to happen. This involves the release of some information
about you (full name, initial and hospital number) to a funeral director
and the crematorium.
Sensitive disposal – own arrangements
If you wish to make your own arrangements for disposal then this is
possible. You will need to sign a release form. You can arrange a
private burial or cremation through a funeral director but you will incur
the costs for this.
You can also arrange a burial outside a cemetery as long as the
following requirements are met:
-
It must not cause danger to others
It must not interfere with any rights other people may have on the
land
There must be no danger to water supplies or water courses
There must be no chance of bodily fluids leaking into or onto
adjoining land
The tissue must be buried at a depth of at least 18 inches (45cm)
Permission must be obtained from the landowner if you do not
own the land
If considering a burial in a garden, careful thought must be given
to what would happen if you moved home or the land was used
for new purposes in the future
Where can I get more information?
If you require any further information about any of these options,
please discuss this with your nurse.
Useful Contacts
Institute of Cemetery and Crematorium Management (ICCM)
Tel: 020 8989 4661
Website: www.iccm-uk.com
Miscarriage Association
Tel: 01924 200 799
Website: www.miscarriageassociation.org.uk
Stillbirth and Neonatal Death Society (SANDS)
Tel: 020 7436 7940 (details of local SANDS groups)
020 7436 5881 (helpline)
Website: www.uk-sands.org
Jane Steele, Women’s & Couples Councillor at Homerton University
Hospital NHS Foundation Trust
Tel: 020 8510 7198
Acute Gynaecology Unit / Early Pregnancy Assessment Unit (EPAU)
Tel: 020 8510 7861
Patient Advice and Liaison Team (PALS)
PALS provide information and support to patients and carers and will
listen to your concerns, suggestions or queries. The service is
available between 9am and 5pm. Telephone 0208 510 7315 or email:
pals@homerton.nhs.uk
For information on the references used to produce this leaflet, please
ring 0208 510 5302/5144 or email
patientinformation@homerton.nhs.uk
If you require this information in other languages, large print, audio or
Braille please telephone the Patient Information Team on 0208 510
5302/5144 or email: patientinformation@homerton.nhs.uk
Homerton University Hospital NHS Foundation Trust
Homerton Row, London E9 6SR
T: 0208 510 5555
W: www.homerton.nhs.uk
E: enquiries@homerton.nhs.uk
Date produced: 23rd October 2013
Review date: 23rd October 2015
When to contact the EPAU?
The risks of complications are very small, but
if you have heavy bleeding, severe
abdominal pain, a fever or vaginal discharge,
please call the EPAU and ask to speak to a
nurse. Do come to the A&E Department or or
see your GP if you are very unwell.
This leaflet has been produced by
If you have any questions during or after
your treatment please do not hesitate to
ask the nurse or doctor in the clinic.
The Acute Gynaecology Unit
Homerton Hospital
Homerton Row
London
E9 6SR
020 8510 7861
15.3.12
www.homerton.nhs.uk
Manual Vacuum Aspiration
for Miscarriage
(Clinic procedure to remove pregnancy
tissue from the womb after a miscarriage)
Information Leaflet for Patients
Why have I been given this leaflet?
You have been diagnosed with a miscarriage
and have opted to have or are considering
having MVA in the Early Pregnancy Unit.
What is MVA?
MVA is a procedure to remove the
pregnancy tissue inside the womb in the
clinic with pain killers and local anaesthetic.
It is an alternative procedure to ERPC, which
is a similar procedure done under General
Anaesthetic.
What are the differences between MVA
and ERPC?
1. MVA is done under local anaesthetic and
pain killers. Therefore you will feel periodlike pain during the procedure, but in most
cases this is not severe and wears off quickly
afterwards.
2. Both techniques are very similar and both
result in 98-99% chance of removing all the
tissue from the womb.
3. Both techniques result in reduced bleeding
compared with medical or conservative
management of miscarriage.
4. There is a reduced risk of womb
perforation (accidentally making a hole in the
womb) with MVA compared with ERPC.
5. There is a similar chance of other
complications such as infection with all
management options.
What does the procedure involve?
You will come to the EPAU and will need to
stay on the ward for 2-3 hours. You will be
given some strong painkillers such as co-
codamol by mouth and diclofenac
(Voltarol) suppository. Misoprostol
tablets are then inserted in the vagina
to soften the neck of the womb to
make the procedure easier. You will
have the procedure about 1 hour after
the tablets are given.
Do I need any special preparation?
You do not need to be nil by mouth, so
do eat prior to coming for your
appointment. If you have any allergies
to medications let us know. Please
bring a sanitary towel and have
someone pick you up in case you are
unable to travel home alone.
The alternatives to the procedure in the clinic
are having either the same procedure under
a general anaesthetic or to have tablets
alone or to wait and see if the pregnancy
tissue comes away itself.
Most miscarriages can be managed without
doing anything as the tissue will come away
eventually on its own, but this process may
take several weeks.
Many women prefer to speed up the process
with either tablets or a procedure. Tablets
speed up the process by causing cramps
and bleeding, and are successful in 60-80%
cases.
How long does the procedure take?
The procedure takes about 10
minutes. We will insert a speculum
into the vagina to see the neck of the
womb. We will take swabs to check
for infection if not previously done.
Sometimes surgery is needed after the
tablets to remove pregnancy tissue.
You will have a local anaesthetic
injection into the neck of the womb.
The neck of the womb will be opened
up gently. A plastic tube will be
inserted into the womb and suction will
be applied. The tissue will be gently
removed from the womb. This takes 12 minutes. You will feel cramps during
this part of the procedure. Once all the
tissue is removed, you will have an
ultrasound scan to check the womb is
empty.
What happens after the procedure?
We will keep you in the ward for about an
hour afterwards to check you are well
enough to go home. You will be given pain
killers to help with any ongoing discomfort. If
your blood group is Rhesus Negative, you
will be given an injection of Anti-D. If you
have had an infection in the past, or if you
are likely to have an infection currently, you
may be given antibiotics to take.
What alternatives are there?
How will I feel afterwards?
You will have light bleeding and the cramps
will wear off gradually.
How will I be followed up?
You will be given an appointment to come for
review in the clinic in 2-4 weeks time.
Why have I been referred to
Homerton?
Who can come with me to
my appointment?
You have been given an appointment at Homerton to discuss and
arrange having an abortion.
 You can bring a partner, relative
or friend with you.
 You may want them to come
into the consultation with you –
it is your choice. The doctor or
nurse may need to see you on
your own for some of the time.
 It is best if you do not bring
children into the consultation
with you, because it can be
difficult to concentrate if you are
looking after a child.
If you are unable to come for your
appointment, please ring and let
us know so that we can make
another appointment for you.
Tel 020 8510 7445
Where do I go for my
appointment?
The clinic is based in the Women’s
Outpatients Department. It is signposted from the main corridor.
Please go to the reception in
Women’s Outpatients when you
arrive.
How long will my
appointment take?
You need to allow about two hours
for your appointment. It is important
to arrive on time: if you are late we
may not be able to see you that day.
What do I need to bring with
me?
Please bring any medicines that you
are taking and details of any medical
conditions that you have. This will
help the doctor when she sees you.
How will the abortion be
carried out?
This depends on the size of the
pregnancy, your health and your
wishes. A decision will be made at
your first visit.
 Either you can take tablets
to cause the pregnancy to
miscarry
 Or you can have a small
operation under general
anaesthetic, usually lasting
about ten minutes.
What will happen on my
first visit?
First, you will see a nurse:
 she will take your
medical history and talk
to you about your decision
 she will be able to discuss
any concerns or worries
 she will give you advice and
information about future
contraception.
You may see a counsellor if you
would like more time to think about
any aspect of your decision or your
feelings about it.
You will have a scan to confirm the
gestation (the size of the
pregnancy).
You will see a doctor:
 who will assess your health and
explain the risks and benefits of
the different options available
 who will book you for the
procedure and explain what will
happen
 who will also prescribe any
contraception that you need.
You will be given written
information about the procedure
that you have chosen and your
future appointments.
The abortion will probably take
place within a week of your
appointment but at busy times it
may be up to two weeks later.
What tests will be
carried out in the clinic?
You will have routine blood tests
for:
 anaemia (including sickle and
thalassaemia, if necessary)
 blood group.
 HIV
 Syphillis
You will also be offered tests for
Chlamydia and gonorrhoea.
We do not do cervical smears: if
your smear is due, it is better to have
it done three months after the
abortion.
If you would like to see a
counsellor before or after the
abortion you can either ask a
member of staff to refer you to her
or you can ring her yourself to
make an appointment: Tel: 020
8510 7198
Advocacy
If you need someone to translate
for you, please tell a member of
staff as soon as possible so that
we can book an advocate for your
appointment.
After the abortion
You will be given written information
about the procedure that you have had
done and what to expect afterwards.
If you have questions or
concerns, please ask – we are
happy to help.
Information for women
who have an appointment
at Homerton University
Hospital for abortion
advice
You are advised not to travel out of the
country for at least two weeks after the
abortion, just in case you need to
come back to hospital for further tests
or treatment.
In a small number of cases further
treatment is needed more than two
weeks after the abortion procedure.
Leaflet written by Consultant Gynaecologist
Produced: May 2006
To be reviewed: May 2007
Seeing a counsellor
Women’s Outpatients Department
Tel. 020 8510 7445
PERMISSION FOR OWN DISPOSAL OF FETAL TISSUE
Name
____________________________________________
Hospital number ____________________________________________
Address
____________________________________________
I wish to make my own arrangements for my fetal tissue and I am taking
them away from the hospital with me.
Date
______________________
Signature of client
_________________________________
Name of health professional
____________________________________
Signature of health professional ____________________________________
Copy for notes
Copy to mortuary
OmC April 2004
PERMISSION FOR SENSITIVE DISPOSAL OF FETAL TISSUE
Name
____________________________________________
Hospital number ____________________________________________
Address
____________________________________________
I request Homerton University Hospital NHS Foundation Trust to arrange
sensitive disposal of the fetal tissue following miscarriage.
This will involve release of some information about me ( second name,
initial and hospital number ) to a funeral director and crematorium.
I wish for other arrangements to be made.
(delete as required)
Date
______________________
Signature of client
_________________________________
Name of health professional
____________________________________
Signature of health professional ____________________________________
Copy for notes
Copy to mortuary
OmC April 2004
Directorate of Services for Children, Women and Sexual Health
Cervical preparation before surgical termination of pregnancy
It is sometimes helpful to give women some treatment before a termination of pregnancy to begin to open the
womb. Your clinic doctor will decide whether you need it, depending on your medical history. There are two
types of tablets that are used for this purpose
Misoprostol Some small tablets are inserted into the mouth or vagina two hours before the operation. They
act by making the womb contract, and they may cause period pain or bleeding. These tablets may be given
on their own or as well as Mifepristone.
Mifepristone This is a tablet that is taken by mouth 1- 2 days before the operation. It acts by blocking the
effects of progesterone, a hormone that is need for a pregnancy to continue. Once you have taken this tablet
it would not be advisable to change your mind about having the termination of pregnancy.
The risks of surgical termination of pregnancy
Having a termination of pregnancy is usually a straight forward procedure and most women have no
immediate or long term problems. Every effort is made to ensure that the operation is as safe as possible but
no matter how much care is taken a small number of women have complications. These can be related to the
drugs given, the anaesthetic, the operation itself or the recovery period.
The operation usually lasts 10 – 15 minutes but in about 1 in 500 cases complications arise that make it
necessary to perform a more major procedure. An example of this is when one of the instruments used to
open the womb and remove the pregnancy causes damage to the wall of the womb ( the medical term for this
is perforation of the uterus ). If this occurs there may be heavy bleeding or damage to other parts of the
abdominal cavity and it may be necessary to perform keyhole surgery to look inside or perform a bigger
operation to repair the damage (laparotomy). This would have to be done through a cut in the lower
abdomen (usually a bikini line incision) and would involve a longer stay in hospital and convalescence as for
a major operation. Another rare complication is damage to the cervix requiring stitches. Blood transfusion
and other surgical procedures are very rarely required.
After the operation sometimes women need to stay in hospital because of pain or bleeding, or need to come
back after they have been discharged, for further treatment. This happens in about 1 in 30 cases. In some
cases women develop an infection which causes pain , bleeding and a high temperature and usually gets
better rapidly when antibiotics are given. In other cases there are fragments of the pregnancy still inside the
womb which can cause heavy bleeding, and another anaesthetic is required to allow the womb to be emptied
completely (this is called evacuation of retained products of conception or ERPC).
Most women who have had a termination of pregnancy will have normal fertility in the future. Infertility as
a direct result of having a termination of pregnancy is very rare, however factors not relating to the
termination may cause future fertility problems. It is possible that there is a slightly increased risk of
miscarriage after termination, however the majority of women will have no problems conceiving or carrying
future pregnancies.
Other information
The pregnancy tissue removed at operation will be destroyed unless you wish to make your own arrangements. If
this is the case you must tell the staff before the operation. It is not possible to tell the sex of the fetus at termination.
While you are asleep you will usually be given an antibiotic and a pain killer in the form of a suppository (a
tablet inserted into your back passage).
These are given to reduce complications and to make you
comfortable after the operation. These drugs and the ones used for cervical preparation may cause side
effects such as vomiting or allergies.
September 2009
The Homerton ~ The Hospital for Hackney
Disposal of pregnancy tissue after pregnancy loss before viability –
making your own arrangements.
If you wish to make your own arrangements for disposal of the pregnancy tissue the following
options are available:
Private burial or cremation
You may arrange this through a funeral director but you will incur the costs.
Burial outside a cemetery
You may take the pregnancy tissue home to bury yourself but the following requirements need
to be met.
It must not cause danger to others
It must not interfere with any rights other people may have on the land
There must be no danger to water supplies or water courses
There must be no chance of bodily fluids leaking into or onto adjoining land
The tissue must be buried at a depth of at least 18 inches (45 cms)
Permission must be obtained from the landowner if you do not own the land
If considering burial in a garden careful thought must be given to what would
happen if you moved house.
LS August 2004