RCOG World Congress 2023

Evaluating the Management and Follow-Up Care of Mid-Trimester Miscarriages

Mohamad Barakat, Hassan Shehata, Sasha Ang, Deena Basha, Radhika Viswanatha

Introduction:

Mid-trimester miscarriage is defined as the spontaneous loss of pregnancy between 13+0 to 23+6 weeks
An estimated 1–2% of second- trimester pregnancies end in a miscarriage before reaching 24 weeks of gestation⁽¹⁾
Risk factors include advancing maternal age, medical co-morbidities, inherited thrombophilic defects, previous miscarriages, genetic and anatomical factors (including cervical weakness and congenital uterine malformation)⁽¹⁾

Aims:

To identify risk factors present within our population
Assess the management and follow-up investigations of mid-trimester miscarriages at Epsom and St Helier University Hospitals over a 4-year period
To compare this against the proposed guidance stated by the RCOG Greentop Guidelines No.17⁽¹⁾
Provide recommendations to improve our future practice

Methods:

All women who underwent a mid- trimester miscarriage between January 2018 and January 2022 at Epsom and St Helier University Hospitals were retrospectively identified
Data was collected and analysed on excel regarding risk factors, management and follow-up care provided
This was then compared against pre- defined standards as stated by the RCOG guidelines

Results:

Age Range and BMI:

• Age Range: 19 – 45 years old

Mean- 31 years old
42% ≥ 35 years old

• BMI Range: 18.9 – 52.7 • Mean- 27.1 • 18.5% BMI ≥30

Identified Risk Factors:

61% had 1 or more medical co- morbidities

15.6 % were on recurrent miscarriage treatment regime

7.8 % had previous mid-trimester miscarriages

7.8 % had cervical surgery

42.2 % had PV bleeding

34.4 % had PPROM

Management:

A total of 64 women were identified:

37% underwent expectant management Of which 12.5% required further management

57.8% underwent medical management Of which 18.9% needed further management – MROP or surgical

4.7% underwent surgical management

Follow-Up Care:

Recurrent miscarriages clinic: 36% referred, 64% not referred

Debrief: 64% completed, 31% not completed, 5% declined

Follow-Up Investigations:

Maternal Investigations:

US Pelvis: 17.2% performed, 82.8% not performed

Thrombophilia Screen: 81.2% performed, 18.8% not performed

Antiphospholipid Antibodies: 82.8% performed, 17.2% not performed

Foetal Investigations:

Placental Histology: 76.7% performed, 20.3% not performed, 3.1% declined

Post-Mortem: 57.8% performed, 21.8% not performed, 20.3% declined

Karyotyping: 57.8% performed, 21.8% not performed, 20.3% declined

Longer Term Outcomes:

32.8% of women went on to have a further successful pregnancy

Conclusion:

A multitude of risk factors were identified amongst our population with 42% of women being ≥ 35 years old and 61% of women having 1 or more medical co-morbidities
Most women were managed medically with a small proportion requiring further surgical management
A large proportion of women are not being referred to the recurrent miscarriages clinic or did not have a debrief offered/completed
Further work could be done to ensure that follow-up investigations are performed for these women – particularly ensuring they have an ultrasound pelvis

Recommendations:

To update trust guidelines to ensure all RCOG recommended follow-up investigations are carried out for all women who has had a mid-trimester miscarriage, in particular an ultrasound pelvis to rule out any anatomical malformations
Ensure clear documentation to state if investigations have been offered and if this is declined by the women
Aim for a 100% placental histology rate as patients who decline a post-mortem can still be offered this
Aim for all women to be seen in debrief and recurrent miscarriages clinic within 3 months

References:

(1) The Investigation and Treatment of Couples with Recurrent First- trimester and Second-trimester Miscarriage Green-top Guideline No. 17. Royal College of Obstetricians and Gynaecologists; 2011 [cited 2023 May 27]. Available from: https://www.rcog.org.uk/media/3cbgonl0/gtg_17.pdf

RCOG World Congress 2023

Evaluating the Management and Follow-Up Care of Mid-Trimester Miscarriages

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