Early Pregnancy

The leaflet is detailed below, or you can download the 'Having a Trans-Vaginal (Internal) Scan' leaflet in PDF.

Introduction

You have been booked to attend for a transvaginal (internal scan) to help assess the health of your pregnancy. This leaflet will explain what this involves. It may not answer all your questions, so if you have any queries, please ask the staff who will be performing the scan, who will be happy to help and advise you.

What Is a Transvaginal Ultrasound Examination?

An ultrasound picture is formed by sound waves, which are passed through the body and reflected as an image. Under 12 weeks gestation the Ultrasound examination is performed with a transvaginal scan (internally) as this provides clearer pictures of the womb, ovaries, and surrounding structures.

Why Have I Been Booked for A Trans-Vaginal Scan?

The aim of the scan is to assess the health of your pregnancy.

You may have experienced bleeding, spotting, or pain or you may require a reassurance scan due to a history of recurrent miscarriage or ectopic pregnancy.

Trans vaginal ultrasound is a safe and generally painless procedure. There is no evidence that having a trans-vaginal scan can cause miscarriage or harm a pregnancy.

Sometimes there might be a concern that the pregnancy is in the wrong place, this is called an ectopic pregnancy. In this situation, we would advise a trans-vaginal scan, as ectopic pregnancies may not be visible on a trans-abdominal scan which can delay the clinical diagnosis .

Waiting for your scan

If you are experiencing severe pain or bleeding please attend the Gynaecology Department in person for assessment, do not wait for your appointment.

What Will Happen During the Scan?

You will need to empty your bladder just before the scan and undress from the waist down. The practitioner uses a specially designed ultrasound probe to perform the vaginal scan, this is covered with a protective sheath and lubricating gel. This is gently inserted into the vagina and is then moved into various positions to see the womb and ovaries clearly.

What Happens After the Scan?

If the scan shows a healthy pregnancy, you will be discharged by the Practitioner and advised to continue with routine antenatal care with your doctor or midwife. If the scan shows any abnormalities, such as a miscarriage or ectopic pregnancy, then you will be referred to the Gynaecology Emergency Department for further management, here you will be reviewed by one of the doctors or Advanced Nurse Practitioners. They will discuss the findings and management options with you.

Further information

If you require any further information about your scan, please contact the    

Gynaecology Emergency Department and Early Pregnancy Assessment Unit on

0151 702 4140

Change of appointment – (if booked to attend the Imaging Department) contact the

Access Centre on 0151 702 4328

 

 

 

 

The leaflet is detailed below, or you can download the 'Medical management of ectopic pregnancy and pregnancy of unknown location (PUL)' leaflet in PDF

Why have I been asked to read this leaflet?

You have been given this information leaflet because your doctor or nurse believes that you may be eligible for medical management of an ectopic pregnancy or pregnancy of unknown location (PUL).  We are so sorry that you are having to consider this, and for your loss.   We know that this can be a very confusing and scary time and we encourage you to ask the team here at LWH any questions or queries you may have.

What support is available?

The following charities are an excellent support at a time like this: The Ectopic Pregnancy Trust, which is a national charity, and Cradle, which is a local early pregnancy charity.  We have a bereavement team here at the Women’s – the Honeysuckle team – who are also available for support.

The Ectopic Pregnancy Trust  

Website https://ectopic.org.uk/

Cradle

Contact at info@cradlecharity.org  

Facebook webpage https://www.facebook.com/cradlecharity.org/?ref=py_c

Honeysuckle team

Contact at email honeysuckle@lwh.nhs.uk or telephone, office hours Monday to Friday, 8am to 4pm on 0151 702 4151

Website https://www.liverpoolwomens.nhs.uk/patients/honeysuckle-bereavement-service/

What is an ectopic pregnancy?

An ectopic pregnancy is a pregnancy that is growing outside of the womb, for example the tubes or the ovaries, or in a part of the womb that cannot support a pregnancy such as the cervix or a caesarean section scar.   Up to 90% of ectopic pregnancies occur in the tubes.

 

Sites of ectopic pregnancy^[i]

What is a Pregnancy of unknown location (PUL)?

PUL is diagnosed when we know a woman is pregnant because she has a positive pregnancy test but we cannot see the pregnancy on an ultrasound scan.   Sometimes this is because the pregnancy is outside of the womb, i.e. an ectopic.  It could also be because the pregnancy is too early or when it has sadly miscarried.

What is medical management?

With medical management we give you an injection of a medicine called Methotrexate.  This is a medication that blocks cells from processing folic acid and causes the cells to die.  This is not the same as termination medications which make the womb pass the pregnancy.  We will only consider this medication when we are sure that a pregnancy is not growing in a healthy way that will produce a baby.

How is methotrexate given?

It is given as a single injection into your buttock.

What are the side effects of the medication?

All medications have side effects however, it is important that you know the ones associated with this medication to enable you to make an informed choice

The most common side effects affecting around 1 in 100 people are:

• Loss of appetite, feeling or being sick, stomach-ache or indigestion
• Diarrhoea
• Headaches
• Feeling tired or drowsy
• Hair loss
• Sensitivity to sunlight

Serious but less common (less than 1 in 10,000 people) side effects include:

• Yellowing of your skin and whites of your eyes; this can be a sign of a liver issue
• Persistent cough, chest pain or difficulty breathing
• Swollen hands ankles or feet
• High temperature, chills, muscle aches, sore throat
• Bleeding gums or blood in your urine, bruising
• Rash or blisters to the skin

What checks are done to make sure I am safe to take the medication?

Before we give you the medication your doctor or nurse will check your liver and kidney function on a blood test.  We also take blood to check your full blood count, blood group and rhesus status.

How do you know if it has worked?

Once we have given you the medication we ask you to come back to the gynaecology emergency department (GED) on day 4 and 7 after the injection.  We will check your bHCG (pregnancy) hormone by taking a blood test.  The level may rise initially on day 4 but we expect it to fall by day 7.  If the level is not falling quickly enough, for example less than 15%, we will talk to you about your options of a repeat ultrasound scan, second injection or surgical management.

What are the chances of it working?

There are a couple of factors that affect how well the medical management will work.  Firstly, the size of an ectopic pregnancy, if we have seen one.  If it is over 3.5cm it is less likely to be successful and your doctor or nurse will talk to you about the benefits of surgery versus medical management.

If your pregnancy hormone is high it is less likely to work.  Below is a table that demonstrates the success rates for different ranges of bHCG.  These figures are from the last 3 years at LWH.

Table 1: Success rates for medical management per bHCG range

We also know that a bHCG that is rising >20% in 48 hours is associated with lower success rates.

Please note that we do not routinely offer or advice medical management when the bHCG level is above 3000.  This is an individualised discussion to be had with your GED doctor.  NICE guidance^[i] allows medical management to be used up to 5000, however we believe these group of ladies deserve to have an individualised discussion with their doctor in GED to make the best plan for them.

When is medical management not considered appropriate?

In addition to the issues discussed above, evidence of bleeding inside the tummy, which is referred to as ‘free fluid’ on ultrasound scan, severe pain, or the presence of a heartbeat in the ectopic pregnancy would mean medical management would not be suitable for you.  If you have any concerns as to whether medical management is suitable for you, please do not hesitate to ask your doctor or nurse.  We do not routinely use medical management for ectopic pregnancies that occur in the cervix or the caesarean section scar, but we may discuss this with you as a part of your management.

How will I know it has worked?

The GED team will follow you up with a blood test.  We want to see your pregnancy hormone level decreasing at each appointment although we can see a slight rise on the day 4 blood test.  The team will follow you up until your pregnancy hormone is negative.  The length of time this takes can vary.  It can take up to 8 weeks with weekly attendances for bloods, rarely sometimes longer.

How will I know it has not worked?

We know that there are a proportion of women where medical management will not be successful.  This may be detected by your pregnancy hormone level not falling as we want it to, or you may experience a change in symptoms.  Please contact us as soon as possible if you have any of the following:

• Increase in pain
• Feel unwell
• Experience dizziness or vomiting
• Fainting or collapse
• You are concerned or feel something is not right

Please note that the GED can be contacted by telephone, however we appreciate at times it can be difficult to get through.  If you are concerned or experience any of the symptoms above and cannot get through on the phone, please come straight to the GED and you will be seen by one of the nursing staff.  If you are very unwell and need to call an ambulance, please inform the ambulance control person who speak to you that you are being treated for an ectopic pregnancy in order for them to appreciate your need to come to the GED.

How long does medical management take?

Medical management can take several weeks to completely treat an ectopic pregnancy.  It can be up to 8 weeks of weekly blood tests.  We appreciate this can be very distressing and problematic for women.  We try our best to limit the blood tests we ask you to attend for and we can be flexible with the times to suit your schedule.  If you feel you cannot commit to attending for follow up please let your doctor or nurse know.

What are my other options?

If your bHCG level is low, for example below 1000, you may have the option of conservative management.  This is when we let the body absorb the pregnancy tissue naturally. The GED team will continue to monitor your pregnancy hormone until it has dropped appropriately.

The other option is surgical management.  This is usually done laparoscopically (keyhole surgery).  If the tube that does not have the pregnancy tissue in looks healthy the surgeon will remove the tube with the ectopic.  If you have already had a tube removed or your other tube appears damaged, the surgeon will discuss the option of opening the tube and removing the pregnancy tissue if it is safe to do so.  The reason we do not open the tube when there is another healthy tube is because once a tube has undergone this it will not work as well and you will be at an increased risk of future ectopic pregnancy.  Women who undergo this also need follow up of their pregnancy hormone to ensure all pregnancy tissue has been removed.

Where can I find support and further information?

We appreciate that this is a long leaflet with a lot of information.  Please ask your doctor or nurse if you need anything else clarifying or if you have questions we have not answered through this leaflet.

The Ectopic Pregnancy Trust 

Website https://ectopic.org.uk/

Cradle

Contact at info@cradlecharity.org  

Facebook webpage https://www.facebook.com/cradlecharity.org/?ref=py_c

Honeysuckle team

Contact at email honeysuckle@lwh.nhs.uk or telephone, office hours Monday to Friday, 8am to 4pm on 0151 702 4151

Website https://www.liverpoolwomens.nhs.uk/patients/honeysuckle-bereavement-service/

 

 

 

The leaflet is detailed below, or you can download the 'What to bring with you for your miscarriage management' leaflet in PDF. 

Why have I been given this leaflet?

This leaflet is for women who have suffered a miscarriage and have chosen medical or surgical management that means they will be spending time in the hospital with us.  We appreciate that this is a difficult time and so have come up with some guidance on what to bring with you when you come into us. 

What should I bring for my stay in the hospital?

Although we do not anticipate most women will need to stay overnight it is best to be prepared. We would advise you to bring an overnight bag including toiletries, fresh underwear, and nightwear such as dressing gown, slippers, and pyjamas.

Sanitary pads will be provided on the ward however you may wish to bring your own which you are comfortable wearing.

There are no televisions on the ward but there is accessible Wi-Fi. Most ladies like to bring a Tablet/iPad with pre-downloaded films, games, or music, please charge them before you attend, please don’t forget your earphones. There is an onsite shop for purchasing any magazines if you wish.

If you are taking regular medication, bring them with you and give them to the nurse on admission. You will be provided with these and/or painkillers if and when you require them.

I’ve opted for medical management is there anything else I need to know before I come in?

You can usually eat and drink as normal unless you are told otherwise on the day. Meals will be provided for you, but you may like to bring your own drinks and snacks. Please note there aren’t any fridge storage facilities. There is a WHSmith, a restaurant and a Costa onsite if you wish to purchase refreshments or snacks. It is advised that you don’t leave the ward once treatment has started so it may be better if your support person goes on your behalf. Please advise staff on admission of any specific dietary requirements you may have e.g., gluten free/vegetarian etc. and staff will be able to accommodate as best as possible

You can bring someone with you for the day. Unfortunately, there are currently no facilities for them to stay with you overnight. This however this can be discussed on the day with the Nurse caring for you if there is a need to do so.

I have opted for surgical management is there anything else I need to know before I come in?

You will have been asked not to eat or drink anything before your surgery you will be provided with hot/cold drinks and light diet post-surgery. Please advise staff on admission of any specific dietary requirements you may have e.g., gluten free/vegetarian etc. and staff will be able to accommodate as best as possible

We ask that you do not wear any jewellery, nail varnish or false eyelashes for your surgery so please remove such items before coming in. Please leave any valuables at home.

Partners may stay in the admissions lounge until you are taken to theatre, we will then kindly ask partners /support person to leave. 

There are refreshment areas in the hospital if they wish to stay on site until you are ready for discharge is advised that you bring with you a fully charged mobile phone so you can contact the person who will collect you when you are ready for discharge.

 

 

The leaflet is detailed below, or you can download 'Management of your Miscarriage' leaflet in PDF. 

What is this leaflet about?

We would like to offer our sincere condolences for your pregnancy loss. This leaflet contains information about how we manage your miscarriage here at the Liverpool Women’s.  We understand that this is can be an extremely distressing time and we are here to support you.

Every miscarriage is different and how we manage it is based on your thoughts and wishes. 

Although this leaflet is about the management of miscarriage there are also leaflets available on the support available for you and your family at this difficult time.

The term ‘pregnancy remains’ is used throughout this leaflet for consistency in reference to cases of pregnancy loss up to and including 23 weeks and 6 days gestation. This leaflet has been devised in accordance with Human Tissue Authority guidance.

If after reading this leaflet you have questions or queries please contact us at the Gynaecology Emergency Department (GED) on telephone 0151 7024140

What are the options available to me?

There are three broad options for management of miscarriage and in most cases there is no one “right” answer.  It may be that you, or someone you know, have experienced this before and you may already know what you want to do.  However if not, we hope this leaflet will help you understand your options.

The 3 options are

• Conservative management
• Medical management
• Surgical management

In all 3 options it is reassuring to know that

• The risk of infection or harm are very small with all 3 methods
• Your chance of a healthy pregnancy next time are the same with all 3 methods
• Women cope better when given clear information, good support and a choice of management options

Natural management (also known as conservative or expectant management)

What happens?

In this option we allow time for your body to complete the miscarriage itself.  This can take days or weeks and the amount of bleeding or pain that you experience is difficult to predict.  The further on in pregnancy you are may mean that you have heavier bleeding or stronger cramps but this is not always the case.

You will be provided with painkillers to help with the period cramps that can be associated with miscarriage.

A follow up scan in the Early Pregnancy Assessment Unit (EPAU) will be booked for you for two weeks after your miscarriage is diagnosed.  This way we can advise you whether your miscarriage is complete.  If the miscarriage has not completed we can advise you on your next options.

There is a chance you will experience heavy bleeding you should contact the Gynaecology Emergency Department (GED) on 0151 7024140 if you are worried about the bleeding.  The general advice is to contact us if your bleeding is so heavy that you need to change pads every half hour or if you are feeling unwell, such as feeling dizzy or faint.

We are here for you throughout your natural management should you wish to contact us sooner for advice or if you wish to discuss alternative management.

What are the risks?

• Infection can occur in about 1 in 100 women. Signs to look out for are
• Raised temperature or flu-like illness
• Vaginal loss that changes colour to be darker or smells bad
• Pain that gets worse rather than better
• Bleeding that gets heavier rather than lighter

If you develop any of these symptoms please contact us at the Gynaecology Emergency Department.  We will need to assess you and you may need antibiotics.

• About 1 - 2 in 100 women will have heavy bleeding bad enough to require blood transfusion. Some of these women need to undergo emergency surgery to stop the bleeding and complete the miscarriage.  This is why we ask you to contact us should the bleeding become heavy or you feel unwell.
• Sometimes during a natural miscarriage, the pregnancy does not completely pass even within two to three weeks. This is why we see you for a follow up scan so we can advise on further management options for you.

What are the benefits?

The main benefit is that you are in control of your miscarriage and can avoid intervention.  Some women feel that this helps them deal with the miscarriage better however this is not how everybody feels.  Natural management can be successful in up to 9 out of 10 women therefore avoiding any medical intervention.

What are the disadvantages?

There is an element of waiting for things to happen and some women find this difficult.  Some women do not want to be at home during their miscarriage because they don’t want to worry about getting into hospital if they have heavy bleeding or if they have other children at home who they do not want to be around while miscarrying.

Although over 9 out of 10 women who chose natural management miscarry within 3 weeks it may not happen on its own.  This could mean you require medical or surgical management despite waiting for nature to take its course.

Medical management

Most women are suitable for medical management of miscarriage at home.  There are certain circumstances when we would advise you to have your management with us.  You may already have been made aware of this.  If you have any concerns about management at home please speak to a member of the medical or nursing staff.

What does medical management involve?

Medical management is made of up two parts.  Initially you will receive a medicine called mifepristone that prepares the womb for the miscarriage.  This will be given to you in the GED.  You will be given the second part of the medical management to take home with you along with pain killers.  We ask you to take this medication 48 hours after your first medication.  This medication is called misoprostol and it causes the pregnancy to pass.

We ask you to contact us at the GED after 48 hours if you have not had any bleeding.  This is so we can review you to see if you need a further dose.  If after this second dose there is no bleeding or minimal bleeding after 7 days we will ask you to contact the GED to arrange review.

You can sometimes pass your pregnancy before the second part of the medical management.  If this happens, please contact the GED and tell the nurse that you have had bleeding and think you have passed the pregnancy.  They may ask you further questions about what you have passed and may invite you in for a review.  They may also ask you to bring the pregnancy remains with you if you still have it.  Some women instinctively flush the toilet after passing the pregnancy but some women prefer to remove the remains for a closer look.  We will provide you with an appropriate receptacle at the start of your miscarriage management to bring the remains into us if this is what you wish.

How will the management be different if I need to stay in hospital?

If you need to stay with us for your miscarriage management you will be given a date to attend.  This will be 48 hours after taking your first medication.  There can be a slight delay getting this date as we try and plan your stay at times when the ward is quieter for your privacy.  You will be given the misoprostol medication is separate doses 4 hours apart.  If after two doses you have not passed the pregnancy a member of the team will review you and offer you a third dose.  At this point they will have a discussion about what will happen next.  This will be based upon your circumstances and your wishes.

What are the risks?

• Infection is common affecting about 1 in 10 women
• Bleeding that lasts up to 2 weeks is common but heavy bleeding is uncommon, about 1 in 1000 women

Medical management is successful in 80-90% of women however if it is not successful you may require a further dose of the medicines or be offered surgical management.

What are the benefits?

The main benefit is avoiding a surgical procedure and the associated general anaesthetic.

Some women prefer this option as they feel more in control by choosing when the miscarriage will happen.

As with natural management some women find acknowledging the passing of the pregnancy helps with the grieving process of a miscarriage.

What are the disadvantages?

There are side effects to the medication most commonly tummy cramps and diarrhoea.  Sometimes these pains and the associated bleeding can be quite distressing.

If you chose to manage your miscarriage at home some women worry about having to get back to the hospital if they have heavy bleeding.

Some women have concerns about seeing the baby, particularly if they are more than 10 weeks when the miscarriage occurs.

Bleeding can last for up to 3 weeks. Sometimes this is due to small amounts of tissue remaining and in some cases, it may be necessary to consider surgical management

Surgical Management

This can be done in one of two ways

• Under local anaesthetic while you are awake also known as Manual vacuum aspiration (MVA)
• In theatre with sedation

Both procedures are very similar.  You may have heard it referred to as a D&C which means dilatation and curettage.  Although this is technically a procedure done for heavy periods some people use this term to explain surgical management of miscarriage also.  .

What does and MVA involve?

A doctor will see you and discuss the procedure.

You will be given a medication (misoprostol) to soften the cervix (neck of the womb) prior to the procedure. Some women will experience side effects with these misoprostol tablets. Possible side effects include nausea, vomiting, diarrhoea, abdominal pain, headache, hot flushes and an unpleasant taste in the mouth.  These side effects are reduced by giving the tablets vaginally (ask a member of your healthcare team for more information about this). You may experience some bleeding.

You will have a speculum examination (similar to that at a smear test) by a doctor or nurse with the assistance of another nurse or healthcare assistant. This will allow the doctor or nurse to assess the cervix, which will be numbed with a local anaesthetic injection.

When you feel comfortable and ready, the pregnancy tissue will be removed with a small tube attached to a syringe.  The pregnancy  remains will be sent to histopathology .  This examination will not provide an answer for why your pregnancy miscarried.  For more information on this please see the section below on how my pregnancy is cared for after I have passed and our Histology patient information leaflet.

You will feel some discomfort during the procedure (similar to period pain). Entonox (‘gas and air’) will be available for you to use if you wish.

If you feel pain please let the nurse or doctor know. Additional local anaesthetic may be possible but if you find the procedure too uncomfortable it can be stopped and the treatment abandoned.

Sometimes an ultrasound scan may be repeated to check that all of the pregnancy tissue has been removed.

How long will the MVA take?

The actual procedure takes about 15 minutes.  You will stay for about 30 minutes after the procedure.

What happens afterwards?

We will monitor you for 30 minutes after the procedure. This includes reviewing vaginal bleeding and any pain you are having. You can leave the hospital once you feel well enough to go home.

You can expect some vaginal bleeding after the MVA. This usually settles within seven days but can persist for two weeks.   If you are worried about your bleeding because you feel it is too heavy please contact the GED.

We recommend you use sanitary towels instead of tampons and do not have sexual intercourse until the bleeding has settled. This reduces the risk of infection. You may return to work when you feel able. If your blood group is Rhesus (Rh) Negative you will require anti D

How is the theatre management different?

The procedure is very similar but for the surgical management you will ask to be fasted.  You will be asked to attend the gynaecology unit either early morning or early afternoon depending on what time of day the procedure is to be performed.  You will meet the anaesthetist who will explain the sedation.  You will also meet your surgeon who will explain the procedure.

Once you are sedated in theatre the cervix is gently dilated (stretched) and a narrow suction tube is inserted into the uterus to remove the pregnancy.  The operation only last about 5-10 minutes however you could expect to be in the theatre department for over an hour due to the time taken for the anaesthesia and recover afterwards. 

After the procedure you should be able to go home the same day.  You may have some period pains afterwards.  You may bleed for up to 2-3 weeks which may stop and start but should gradually tail off.  If it ever gets heavier than a period or you are concerned please contact the GED.

What are the risks?

• In 1 in 20 women some of the pregnancy can remain in the womb after the procedure. This may require a second operation or a dose of the medical management to complete the miscarriage
• About 1 in 30 women can develop an infection
• Bleeding that lasts for up to 2 weeks is common but heavy bleeding is uncommon, less than 1 in 500. It is rare that a woman would require a blood transfusion
• Scarring to the inside of the womb can occur rarely, less than 1 in 100 women. The clinical significance of this scarring is unknown.
• Injury to the cervix or rarely – in less than 1 in 200 women the womb can be perforated (a hole made). If this happens there can be injury to the bowel, bladder or blood vessels inside your tummy.  If there is a concern that this has happened the surgeon may perform a laparoscopy (key hole surgery) to look inside the tummy and if necessary they may need to perform a laparotomy (cut on the tummy) to repair any injury.  This is extremely rare.  In most cases if there is a small perforation it will heal itself with some antibiotics to prevent infection and should not affect future pregnancies.
• Very rarely the anaesthetic can cause a severe allergic reaction, about 1 in 10,000 or even death, 1 in 100,000

What are the benefits?

Some women prefer this method of management as they know when the miscarriage will happen and they can plan around it.  Some women also prefer that the miscarriage happens while they are sedated.

What are the disadvantages?

Some women are frightened of going to theatre or staying in hospital.  The anaesthetic may make you feel groggy afterward for a day or so.

What happens after your miscarriage?

How is my pregnancy cared for once I have passed it?

All pregnancy remains are transferred to the care of the honeysuckle bereavement team.

If an embryo/ tiny baby is identified visually by staff caring for you it will not be necessary for any examination to take place. With your signed consent The Honeysuckle Team will then arrange for a communal cremation to take place at a local crematorium. If you wish to discuss the communal cremation in more detail or think you would like to make your own arrangements please contact The Honeysuckle Team on 0151 702 4151 / honeysuckle@lwh.nhs.uk

If an embryo/ tiny baby is not identified by staff caring for you histopathological testing will be requested by medical staff. For more information please see enclosed patient information leaflet

Histology patient information leaflet

If you miscarry at home or outside of the hospital setting you are most likely to pass your pregnancy loss into the toilet.

You may want to retrieve your pregnancy to have a closer look or flush the toilet (many people do this automatically). There is no right or wrong answer. It is important you do what you feel is best for you.

What does miscarriage mean for future pregnancies?

Because miscarriage is sadly a common occurrence in early pregnancy, 1 in 4 early pregnancies is believed to miscarry, it is unlikely that there is any significant medical cause for you miscarriage that would increase your chances of it happening in your next pregnancy.  It is highly likely that your next pregnancy will not end in miscarriage.  We do however, investigate women who have had 3 miscarriages in a row through our recurrent miscarriage clinic.  If this is something you have experienced please ask about referral to this service.

There are no rules about when you can start trying for a baby again and every couple has different feelings about this.  It is best to wait for your next period as it helps us to date the next pregnancy but there would be no harm if you got pregnant before then.

In order to ensure we can offer early pregnancy scans in our EPAU to women who have bleeding or pain in early pregnancy as soon as possible we cannot provide a reassurance scan for women who have suffered a miscarriage unless they have suffered two miscarriages in the last two pregnancies.  We do offer a private service for early pregnancy reassurance scans when you are over 6 weeks that can be booked via the imaging department.  Please contact them at 0151 702 4483

This leaflet has been produced from the Miscarriage Association ‘Management of miscarriage: your options’ leaflet 2016.

Useful resources

Gynaecology Emergency Department

GED telephone: 0151 702 4140

Honeysuckle Team

Telephone number: 0151 702 4151 (Monday to Friday, 8am to 4pm)

Website: www.liverpoolwomens.nhs.uk/patients/honeysuckle-bereavement-service

Email: honeysuckle@lwh.nhs.uk

Miscarriage Association

Telephone: 01924200799

Website: www.miscarriageassociation.org.uk

Email: info@miscarriageassociation.org.uk

The leaflet is detailed below or you can download the 'medical management of miscarriage as an outpatient' leaflet in PDF

Introduction

Following a scan and possibly some further investigations in the Gynaecology Emergency Department (GED) we have unfortunately diagnosed a miscarriage. We would like to offer our sincere condolences for your loss.

After discussion with one of our Doctors, Emergency Nurse Practitioners or nurses where all options were explained to you, you have opted to proceed with the medical form of managing your miscarriage. A consent form for this treatment should have been completed.

Please read this information leaflet and if you have any questions please do not hesitate to ask a member of our team.

What is medical management of miscarriage?

Medical management of miscarriage is where medications are given to speed up the process of miscarriage.

The treatment consists of two parts; the first part being a single tablet taken orally which will be given to you by one of the nurses whilst you are in the Gynaecology Emergency Department. This is called Mifepristone 200mg and acts by blocking the hormone progesterone which is important in maintaining the growth of the pregnancy. Following this tablet you may experience some nausea and this medication may cause some bleeding and period type abdominal pain. We will provide you with advice regarding pain relief and a take home prescription if required.

The second part of the treatment will be provided for you to take home and administer 48 hours later. It is 4 tablets called Misoprostol 200mcg. This medication aims to soften the neck of the womb and causes the womb to contract. These are to be placed into the vagina, as high up as you can get them. This is the preferred method of use for these tablets as you will experience fewer side effects this way. If this is not an option for you, you can place the tablets in your mouth, in between your cheek and gum (2 tablets on each side) and allow these to dissolve. If they have not dissolved in 30 minutes you can swallow what is left with some water.

What should I expect at home?

You will need to take some time off work and make sure you have your partner, friend or relative available for support. If you have young children at home it may be wise to arrange childcare. We would advise you have a supply of large sanitary pads. You are able to eat and drink as normal.

Usually, you will start to bleed and have period type pains 2-4 hours after taking the Misoprostol tablets. The intensity of the pain will vary; for some women it will be quite mild and others it may be very painful. We will have discussed pain relief with you in the hospital to ensure you have a supply of stronger medication for if it is needed. If the pain becomes unbearable at home despite taking adequate pain relief, you can call the Gynaecology Emergency Department on 0151 702 4140 for a telephone consultation to see if an attendance to the GED is needed.

The level of bleeding will also vary; we would expect bleeding like a heavy period with some clots of blood to be passed. Usually you will not pass anything that is recognisable as a pregnancy.  The bleeding at its heaviest rarely lasts for more than a few hours. If the bleeding does become concerning and you are filling large sanitary pads every half hour for more than an hour then again we would advise you call the GED on 0151 702 4140 for an over the phone assessment to see if an attendance to the hospital for examination is needed.

What happens if I don’t start to bleed?

Sometimes the medication will take a little longer to start working. If there has been no bleeding after 24 hours of taking the Misoprostol then we would ask you to ring the Gynaecology Emergency department to discuss this further when potentially a further dose of the medication can be prescribed and arranged to be collected.

What happens next?

A member of staff will ring you after 48 hours to see how you are. We would advise against the use of tampons whilst you are still bleeding as there is a small risk of infection, please continue to use sanitary pads until the bleeding stops. The length of time bleeding lasts will vary; we would expect some bleeding for approximately 2 weeks but this may continue for longer. We would ask you ring the department if the bleeding continues to be heavy or if an offensive smell is noticed from your loss. We would also like to speak to you if at any time you become unwell or notice any fevers / high temperatures.

To ensure the treatment has worked we would ask you perform a home pregnancy test 3 weeks later to ensure this is negative. If at this point the test is positive please call to speak with a member of the team in GED so as a further assessment can be made.

Once a diagnosis of miscarriage has been made, the staff in GED will complete a notification to inform other departments of your loss. This will enable any appointments for antenatal care to be cancelled. 

Returning to normal

You can return to work when you feel ready and able to. If you feel unable to return straight away then you can complete a self – certificate sick note for 7 days or obtain a note from GED or your GP. Letters to confirm our diagnosis and treatment will be sent to them so they are aware of what has happened.

Once the bleeding has stopped it will then vary how long it will take for you normal menstrual cycle to return. Your next period may be a little heavier than normal and your cycles could be a little irregular for a while. 

If you are keen to try again for a pregnancy we would advise you wait until after your next period so you are aware of approximate time of conception which will make things a little easier for the timing of scans and antenatal appointments.

It is quite normal to feel sad at this time and for some time afterwards. We would like to reassure you that our department is open 24 hours a day, 7 days a week for any questions or concerns to be heard. We have also completed a referral to our Honeysuckle team, a dedicated bereavement team at the Liverpool Women’s hospital who can provide support and advice to women and their partners / families following pregnancy loss at any stage of pregnancy. An accompanying leaflet has been provided with further information about this service has been provided.

The leaflet is detailed below, or you can download the 'Experiencing a pregnancy loss under 12 weeks Gestation' leaflet in PDF.

This leaflet explains your option for histopathology testing of the baby / pregnancy remains after early miscarriage (up to 12 weeks’ gestation).

If you have any further questions or concerns, please do not hesitate to discuss with the health professional looking after you or a member of the Gynaecology Emergency Department (24hr number)  0151 702 4438 or The Honeysuckle Bereavement Team:  0151 702 4151 Mon-Fri:  8am-4pm Email : honeysuckle@lwh.nhs.uk

Introduction

The Honeysuckle Team are the dedicated baby bereavement team at Liverpool Women’s Hospital.  We are very sorry you have experienced a miscarriage. We understand that this will be a difficult time for you to make decisions and we hope that the following information will be of help. 

We would like to assure you that The Honeysuckle Team ensure that all babies and the remains of pregnancies are treated with care and respect.

You have been asked to consider giving verbal consent to Histopathological examination of your pregnancy loss.  This information together with the discussions that you will have with the health professionals caring for you will assist you in making the choices that you feel are right for you.

Genetic testing on the pregnancy remains will only be offered if there was a known fetal abnormality or if this is your third or more miscarriage, which is in keeping with national guidelines.

What is Histopathology testing and why is it recommended?

Histopathology is the microscopic examination of the appearance of cells and tissues in very fine detail to exclude any abnormalities.

Histopathology testing is advisable although not compulsory.

We need to examine your pregnancy remains/baby to exclude a rare condition called Molar Pregnancy (Gestational Trophoblast Disease). This is a condition where pregnancy and placental tissue develop abnormally and this can be the cause for your miscarriage - the testing does not give reasons why a miscarriage has occurred nor will it determine the gender of the baby.

There are two types of Molar Pregnancy:

1. A complete mole, where there's a mass of abnormal cells in the womb and no foetus develops or
2. A partial mole, where an abnormal foetus starts to form, but it cannot survive.

Molar Pregnancies can cause the pregnancy hormone in your body to be very high and you may still feel pregnant. If Molar Pregnancy is diagnosed when your pregnancy tissue is examined it allows staff to give you the most appropriate treatment and follow up care in future pregnancies.

Molar pregnancy is a very rare condition and we will only contact you if the examination identifies this condition, or if anything else is found that might affect you.

If you have opted for surgical management of your miscarriage we recommend sending the pregnancy remains for testing. If you have opted for medical management of your miscarriage the health professionals caring for you will check any remains you pass and discuss if they think histopathology testing is advisable with you.

The examination is carried out in the Histopathology Department at The Royal Liverpool University Hospital.

Does this Examination have to be Performed?

It is your decision whether or not to allow this examination. 

Please be aware that results from histopathology examination rarely identify a cause for your miscarriage. We do not routinely contact you with the results unless they are abnormal and results can take up to 3 months to come through.

After histopathology examination

When fetal tissue is identified microscopically, its presence is commented within the pathology report, but as this is embedded in a paraffin block and is part of the diagnostic record, this is not returned unless a patient specifically asks to have the blocks and slides returned.

If no fetal tissue is identified Royal Liverpool University Hospital can make arrangements for respectful disposal of the remaining tissue according to their standard procedure.

When fetal tissue is identified during the examination this is returned to Liverpool Women's NHS Foundation Trust.  The Honeysuckle Team will ensure your pregnancy remains are cared for in accordance with your wishes recorded on the care of pregnancy remains consent form.

Should you wish to discuss the care of your pregnancy remains in further detail please contact The Honeysuckle Team.

The leaflet is detailed below, or you can download the 'Honeysuckle Team - General Patient Information Leaflet' leaflet in PDF.

The Honeysuckle Team are the dedicated baby bereavement team at Liverpool Women's NHS Foundation Trust. The team consists of 2 bereavement support midwives, Marie Kelleher and Pauline McBurnie, and a bereavement support admin officer, Sarah Martin.

The Team’s office is open Monday – Friday 8am-4pm, you are welcome to contact them either by phone 0151 702 4151 or email honeysuckle@lwh.nhs.uk

The Honeysuckle team are very sorry for your loss, we do not wish to be intrusive at this sad time but we would like you to know that we are here to offer support and advice where we can.

We can offer you and your family practical advice and information, help explain some of the formalities involved and guide you through the choices you may face during this difficult time.

Although we do not offer formal counselling we are here if you wish to talk as it may be helpful to talk with someone outside of the family setting. We can provide you with contact details for outside agencies that specialise in bereavement counselling in your local area.

The Honeysuckle Team run a monthly support group for parents and grandparents, with guest speakers, a library of books, craft table and refreshments provided.

Please visit Liverpool Women's NHS Foundation Trust website Honeysuckle Bereavement Service - Liverpool Womens NHS Foundation Trust for up to date information regarding support group sessions.  

The Honeysuckle Team are active on social media. We have our own Facebook page Honeysuckle Bond and two private closed Facebook pages one for families and one for Dads who have suffered the loss of a baby.  To join one of the private groups, request to join Honeysuckle Community Page or Honeysuckle Dads Group.

The Honeysuckle Team arranges an annual remembrance service in October during Baby Loss Awareness Week https://babyloss-awareness.org/  for all families to remember their babies. We will publish details of our service on Liverpool Women’s NHS Foundation Trust website and social media pages.

Liverpool Women's NHS Foundation Trust has a special remembrance garden located in the courtyard behind main reception. Within the garden there is a metal love lock tree where families have placed special locks in memory of a loved one. If you would like to order a lock please visit Ladybugs Picnic Wirral

https://www.etsy.com/uk/shop/LadybugsPicnicWirral  

Contact Details for Honeysuckle Team

marie.kelleher@lwh.nhs.uk – 0151 702 4151

 

pauline.mcburnie@lwh.nhs.uk – 0151 702 4151

 

sarah.martin@lwh.nhs.uk – 0151 702 4151

Facebook – search Honeysuckle Bond or request to join our closed groups Honeysuckle Closed Community Group or Honeysuckle Dads Group.

Twitter - @honeysucklelwh

Helpful organisations

Antenatal Results and Choices ( ARC ) – Offers information and support for parents making decisions around antenatal testing, including when a baby has a significant anomaly. https://www.arc-uk.org/  

 Liverpool Bereavement Services – provides counselling support in Liverpool for all gestations – 0151 236 3932

 

Love Jasmine – provides counselling support in Liverpool for over 22 weeks gestation –  0151 459 4779 /
enquiries@lovejasmine.org.uk

 

Child Bereavement UK 0800 028 8840

 

Child Death Helpline 0800 282 986 / 0808 800 6019

 

Children of Jannah 0161 480 5156

 

The Ectopic Pregnancy Trust 020 7733 2653

ept@ectopic.org.uk

 

The Miscarriage Association 01924 200 799

info@miscarriageassociation.org.uk

 

Muslim Bereavement Support Service 020 3468 7333

info@mbss.org.uk

 

SANDs

Stillbirth and Neonatal Death charity 020 7436 5881

helpline@uk-sands.org

 

SPACE is a Liverpool-based network that offers peer support to women who have experienced miscarriage or infertility – either recently, or at any time in the past. 

The network was started up by a small group of friends who met during their own miscarriage and fertility journeys, and felt inspired to create a local support space for other women facing similar struggles. The network is open to any woman in the Merseyside area who would like to connect with other women for peer support.  

• Small group support - a monthly online drop-in evening (currently online) is held on the final Thursday of each month for women affected by these issues to connect informally for a cuppa and chat  
• 1-2-1 peer support – an option for women who would rather chat to someone else with a similar story in a one-to-one setting, over a phone call/online chat, or face to face for a coffee or walk 
• Website support – online support including a private Facebook space, real stories from local women, and signposting to lots of other recommended resources and support such as helpful books, podcasts and other organisations.  

To find out more or to access the SPACE network, women can visit  www.thereisspaceforyouhere.com 

 

Or email the team directly at: thereisspaceforyouhere@gmail.com 

TAMBA

Twin and Multiple Birth Association

0800 138 0509

asktwinline@tamba.org.uk

The leaflet is detailed below, or you can download 'Sickness & Vomiting in Pregnancy' leaflet in PDF.

Sickness & Vomiting In Pregnancy

Around half of all pregnant women feel sick and vomit during early pregnancy. Symptoms are mild in most cases but in more severe cases an anti-sickness medicine may be recommended by your doctor or midwife.

If your nausea and vomiting is severe you should visit your GP.

Why do you have pregnancy sickness?

Your body goes through some big changes in early pregnancy. The hormones that keep your pregnancy going may also affect your:

• Energy levels (you can feel very tired)
• Emotions (you can easily feel close to tears)
• Gut

You may have a different taste in your mouth. Your saliva can be more acidic. This may be mild, with just some foods tasting different (for example, red meat may taste metallic), or severe with most foods and fluids tasting strange.

The contents of your stomach are more acidic and this can lead to a constant queasiness. Your gut is slower throughout pregnancy.

The muscle at the top of your stomach is more relaxed and you may get reflux of acid into your oesophagus, a feeling of nausea and heartburn.

An empty stomach can make all of these feelings worse, and hunger can actually be felt as nausea.

If your blood sugar drops low, this can also make you feel nauseous and weak. So it is important to try and eat during this time.

You often feel most nauseous first thing in the morning, which is why this condition is often referred to as ‘morning sickness’. This is because your stomach is empty after not eating all night.

Golden Rules for Pregnancy Sickness

EAT OFTEN

This stops your stomach from becoming empty and your blood sugar becoming low.

The move severe the nausea and vomiting, the more frequently you should snack. Eat at least 6 times a day, and as frequently as every 15-20 minutes. The amount you eat will depend on how frequently you snack.

You might try just one mouthful of food or fluid every 15-20 minutes, or a small plateful every 2-3 hours.

Don’t skip meals and snacks. It is important that you keep trying to eat, even if you are still vomiting.

Keep some crackers, dry breakfast cereal, or other dry starchy food near the bed, and try a mouthful to settle your stomach before getting up in the morning. 

DON’T GET DEHYDRATED

Being very dry will make you feel sick and give you a headache. Dehydration is worse for your health at this time than is the weight lost from nausea and vomiting.

Sometimes sickness in pregnancy causes lots of saliva production and you find yourself constantly spitting or swallowing this. You can become quite dry from spitting and should try to sip fluids frequently.

If you are passing little or dark urine, this can be due to dehydration. You need between 1.5 and 2.5 litres (8-10 glasses) of fluid each day. The high amounts are for summer months, or if you are losing a lot of fluid through sweating/spitting.

Try to sip 25ml or ¼ glass of fluid every 15- 20 minutes when vomiting is severe. Some people feel they are less nauseous when they don’t take food and fluid together.

Avoid having your fluid as drinks containing caffeine (like tea, coffee, cola drinks) as these not only make your nausea worse, but will make you pass more urine.

Get fluids from:

• Chilled or hot water with or without lemon or lime slices, mint leave (boil the water then cool it or let water stand in a jug for a few hours to reduce the chlorine smell and taste)
• Ice pops or ice cubes
• Sports drinks

Try drinking through a straw or with a sealed cup.

USE CARBOHYDRATES (starchy foods)

Use these foods to settle your stomach and to provide energy for you and the baby.

The best carbohydrate foods to try are plain starchy foods such as:

• Bread/rolls
• Breakfast cereals
• Potatoes
• Pasta/rice
• Plain biscuits
• Crackers
• Toast
• Crumpet/muffin

Try them dry when vomiting is severe.

What to Do On Bad Days

Try 2 or 3 days without iron supplements (and if this reduces your nausea ask your doctor or midwife if you need to keep taking iron).

Eat mainly carbohydrates. Try them dry when vomiting is severe. Eat very small amounts, very frequently throughout the day. Use only small amounts of proteins (like egg, meat) or fats (butter, margarine, oils) as these take longer to digest.

Suck on ice, ice cubes, crushed ice, ice pops.

• Freeze orange, melon pieces or grapes in cling film
• Freeze fruit juice or cordial in ice cube trays etc, frozen fruit products, like sorbets
• Simple drinks
• Dilute fruit juice
• Weak cordials
• Mineral or soda water
• Ginger beer, lemonade
• Lucozade
• Sports drinks

Good days

You need to catch up a bit! Widen your choices. Make sure you include foods from all food groups. Keep using carbohydrates as the basis for meals.

Rice:

• Topped with kebabs
• Your favourite curry (perhaps ‘not so spicy’)
• Stir-fry with meat, chicken, tofu and/ or vegetables
• Part of a hot dish (e.g. risotto)
• Accompaniment to a meal (e.g. rice pilaff)
• Salad

Potato:

• A side dish (e.g. potato au gratin)
• Stuffed jacket potato

Pasta:

• Topped with a sauce of your choice (go easy with fat or oil)
• A salad (e.g. pasta and tuna salad)

Bread:

• Bruschetta/focaccia, grilled with cheese on top
• Try making pizza our of flat breads
• Pitta bread filled with e.g. hot chicken stir fry or grated cheese, salad and mayonnaise
• Egg or beans on toast

Starting To Feel Better

Try adding some variety; also see if you can tolerate some low fat, protein rich foods:

• Jelly, custard, Angel Delight
• Steamed or boiled vegetables
• Soups made with milk (e.g. cream of chicken)
• Marmite/Vegemite on toast, crackers, crumpets
• Thinly sliced chicken or meat, no skin, no fat
• Pasta with a light sauce
• A sandwich

Try some different drinks

• Milk
• Other fruit juices, nectars or vegetable juices
• Milkshakes
• Marmite, Bovril
• Complan/Build-up

‘Make hay while the sun shines’ or have you thought ahead, making meals and freezing them for not-so-good days. Continue to eat a minimum of 6 small meals over the day. Gradually increase the amount and variety of food you eat over the day. Practice relaxation every day and try to take some walks in the fresh air and when you can, sit outside to eat and drink.

Some Extra Remedies

Ginger

There is some evidence that ginger settles the nausea associated with pregnancy. Ginger has been used in many cultures to relieve indigestion as well as other ailments. Ginger can be taken in the following ways:

• Sip a drink made from half a teaspoon powdered ginger dissolved in herbal tea or weak tea or coffee
• Sip a warm drink made from grated ginger root in a cup of hot water
• Sip on ginger beer
• Chew crystallised or glace ginger
• Eat a ginger flavoured biscuit, like ginger snaps / ginger nuts
• Simmer a large crushed ginger root with 2 cups of water for 20 minutes, strain, add 1 tablespoon of honey, refrigerate and use this as a cordial with mineral water

Ginger is reported to take effect after about 25 minutes and lasts 4 or more hours. Ginger is available at most supermarkets in the herb section or the dried fruit section. Fresh ginger is sold by fruit and vegetable shops.

Peppermint

Some women have found peppermint to be helpful. Peppermint can be taken in the following way:

• Peppermint tea
• Cordial
• Peppermint sweets

Travel Bands

These are available from chemist shops and are worn on the wrist to prevent travel sickness. They work on the principle of acupressure (similar to acupuncture). Some people find that they help to relieve pregnancy sickness. Follow the directions on the packet.

Pregnancy Vitamins

The Department of Health recommends that all low risk pregnant women take 10 micrograms of vitamin D and 400 micrograms of folic acid as a supplement (healthy start or pregnancy vitamins contain this).

It is recommended that folic acid is taken until the end of the 12th week of pregnancy. However, all women in Liverpool should receive healthy start vitamins throughout pregnancy. You should also try to eat plenty of foods containing folate – the natural form of folic acid. Good food sources include broccoli, brussels sprouts, spinach, spring greens, peas, chick peas and granary and wholemeal breads. Folic acid is also added to some foods such breakfast cereals.

Healthy start vitamins are also recommended for women who are breastfeeding.

All women in Liverpool should receive Healthy Start vitamins

Further Information

NHS – www.nhs.uk

British Nutrition Foundation – www.nutrition4baby.co.uk

Healthy Start – www.healthystart.nhs.uk

Patient Information – www.patient.co.uk

Also, you will find more information in your hand held Liverpool Women’s Hospital patient notes.

The leaflet is detailed below, or you can download 'Ondansetron in pregnancy' leaflet in PDF.

What is Ondansetron?

Ondansetron is a medication that we use to treat nausea and vomiting. In pregnancy it is used as third line medication. This means that it is used if two other medications have not helped with the woman’s symptoms.

Is Ondansetron safe in pregnancy?

A large study of over 1.8million pregnancies in 2018 has shown that there is no increased association with heart problems in babies of mum’s who take Ondansetron in pregnancy. There was an increased association of 3 per 10,000 of cleft palate. This means that the number of babies born with cleft palate increased from 11 per 10,000 to 14 per 10,000).

What are the benefits of taking Ondansetron in Pregnancy?

There is a significant risk to women in early pregnancy with severe nausea and vomiting, including and not limited to malnutrition, dehydration, hospital admission, loss of work, blood clots, reduced quality of life, small babies and some women opt to terminate the pregnancy as the sickness is so severe.

Because we use Ondansetron as a third line this means that only women with severe nausea and vomiting are taking the medication.

What does the Pregnancy Sickness Community say?

The pregnancy sickness community has challenged this view that Ondansetron should not be used in the first trimester based upon the trial. The European Medicines Agency (EMA) responded to say that their statement is not referring to women with severe nausea and vomiting in pregnancy. They said that it is up to local units to decide whether to continue to prescribe for women with severe nausea and vomiting in pregnancy.

The advice from the pregnancy sickness community is that we should inform women of the small increased association with cleft lips and palates . If women understand and are willing to accept the risk we should continue to prescribe Ondansetron.

More information

Talk to your doctor for more information or visit the Pregnancy Sickness Support website https://www.pregnancysicknesssupport.org.uk/

i Huybrechts K F, Hernandez-Diaz S, Straub L, Gray K J, Zhu Y, Patrono E, Desai R J, Mogun H, Bateman B T. Association of maternal first trimester Ondansetron use with cardiac malformations and oral cleft palates in offspring. JAMA 2018:320(23);2429-2437
ii Ondansetron update. Pregnancy Sickens Support. Available at https://www.pregnancysicknesssupport.org.uk/news/items/ondansetron-update Accessed 28th November 2019

This leaflet can be made available in different formats on request. If you would like to make any suggestions or comments about the content of this leaflet, then please contact the Patient Experience Team on 0151 702 4353 or by email at pals@lwh.nhs.uk

The leaflet is detailed below, or you can download the 'Corticosteroid treatment in Hyperemesis Gravidarum' leaflet in PDF.

What is Hyperemesis Gravidarum?

Nausea and vomiting in pregnancy are very common, affecting up to 80% of pregnant women.

Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting during pregnancy; this is less common, affecting 1-3 in every 100 pregnant women.  This type of nausea and vomiting in pregnancy is diagnosed by your healthcare practitioner when you have significant dehydration (feeling dry mouthed, very thirsty, drowsy or you have dark urine) and weight loss.

Some women with this condition need to be admitted to hospital for support.  This can include fluids through a drip or medications as injections or through a drip as well as nutritional support.

Why does Hyperemesis Gravidarum happen?

Nausea and vomiting in pregnancy and hyperemesis gravidarum are thought to be due to the pregnancy hormone, human chorionic gonadotrophin (hCG).  There is no clear reason why some women get it worse than others.  It is more likely to occur if you have had it before, you are having twins or triplets or rarely, if you have been diagnosed with a molar pregnancy (where the placenta overgrows and the pregnancy does not form correctly). 

Where can I find out more about Hyperemesis Gravidarum?

The team at the women’s are always happy to discuss HG or any concerns you have.  We have a leaflet about sickness and vomiting in pregnancy on our website that can be found here.

www.liverpoolwomens.nhs.uk/media/2755/die_2018-192-v2-sickness-vomiting-in-pregnancy.pdf

There is also an excellent online support network through the charity Pregnancy Sickness Support.  This can be accessed on the web address below

www.pregnancysicknesssupport.org.uk

We would encourage anyone affected by nausea and vomiting in pregnancy and their families to visit this site as it has a lot of information, advice and support.

What are corticosteroids?

Corticosteroids are strong anti-inflammatory, immunosuppressive and anti-sickness medications. There is increasing evidence that steroids are an effective treatment for hyperemesis gravidarum.

The way they help with anti-sickness is unclear.

Corticosteroids have been used for a long time in pregnancy for other conditions such as acute asthma, inflammatory bowel disease and to speed up lung development in babies at risk of premature birth.

At what point should I be treated with corticosteroids for hyperemesis gravidarum?

Your doctor will consider prescribing you a course of corticosteroid treatment after you have tried other anti-sickness medications, and they have not been effective at reducing or stopping your vomiting symptoms.  This is a medication that is only started in hospital by the specialist early pregnancy team.  Corticosteroids are termed a “third-line” medication which means that you will be prescribed both first- and second-line treatment prior to consideration of this therapy.  See example below:

Table 1.  Recommended anti-sickness therapies (RCOG GTG 69)

Benefits of corticosteroid use in hyperemesis gravidarum

There is good evidence that corticosteroids can dramatically improve the symptoms of severe hyperemesis gravidarum that have not responded to other anti-sickness therapies.   

How will I take corticosteroids?

Corticosteroids are usually started while you are in hospital.  They will be commenced intravenously (through the vein) at a high dose.  When you feel better, they will be given as oral tablets and gradually reduced over several weeks (Table 1) until they are stopped altogether or continued at a low dose.

Are there any side effects?

Side effects of corticosteroids are uncommon - your doctor should prescribe the lowest effective dose for the shortest time possible.

Examples of side effects include some disturbance of mood, developing ulceration of the gastric tract (your stomach and bowel) and muscle breakdown.  Less commonly, changes in your blood pressure, swelling and electrolyte disturbances (the salts in your blood) can occur.  With prolonged use they are associated with diabetes, gestational diabetes, and osteoporosis (bone thinning).

Seek medical attention if you experience visual disturbances for example, blurring of your vision.

Are there any reasons I should not be taking corticosteroids?

This medication should not be used if you have a widespread serious infection.

Are corticosteroids safe for me to take during pregnancy?

Corticosteroids are generally safe to take in pregnancy.  Only a small amount of corticosteroids used for hyperemesis gravidarum pass through to your baby.

There is some association between taking corticosteroids in pregnancy and cleft lip/palate.  Since 2003 no study has proven a significant risk but the rate for cleft lip/palate is believed to be increased from 1.7 to 2.7 per 1,000 babies born to mums who have taken corticosteroids in pregnancy.

It is important to stress that the effects of hyperemesis gravidarum itself on pregnancy can be significant.  HG is associated with low birth weights, preterm birth, dehydration and malnutrition for mum, increased risk of blood clots and in some circumstances families having to make the very difficult and heart-breaking decision to end a pregnancy because they cannot continue with the sickness.

Your obstetrician may recommend that you have a test for gestational diabetes during your pregnancy if corticosteroids are taken long-term.

When will I stop taking corticosteroids in my pregnancy?

Most women will stop corticosteroid treatment by 18-20 weeks of pregnancy.  1 in 5 women may require a low dose for the rest of the pregnancy to control nausea and vomiting, sometimes until delivery.

The most important thing when you stop your steroids is that you do it gradually.  This is usually done by reducing the dose by 5mg (1 tablet) each week.  For some women this causes the nausea and vomiting to return.  If this is the case we would advise you to go back to the dose level that stopped your sickness symptoms.

Who will look after me as my pregnancy progresses?

You will be followed up by a consultant in the antenatal clinic.  They will advise you further on managing your medications and will arrange growth scans for your baby from 30 weeks.

Further information

Liverpool Women’s Hospital website

There are information leaflets on the website for early pregnancy.  Look for the tab for patients, then patient information leaflets.  Select gynaecology and you will see and area for early pregnancy.  Here are all our specific early pregnancy leaflets.  Below is the direct link to the sickness and vomiting in pregnancy leaflet

www.liverpoolwomens.nhs.uk/media/2755/die_2018-192-v2-sickness-vomiting-in-pregnancy.pdf

Pregnancy sickness support

An online charity for women and their families who suffer sickness and vomiting in pregnancy

www.pregnancysicknesssupport.org.uk/get-help/treatments/

Royal college of Obstetricians and Gynaecologists (RCOG)

This is our medical body that produces guidance and support for doctors, nurses and midwives caring for women and their families in pregnancy.   They also write information leaflets for women and their families.  They have information on pregnancy Sickness (nausea and vomiting of pregnancy and hyperemesis gravidarum) accessible at

https://www.rcog.org.uk/en/patients/patient-leaflets/pregnancy-sickness/

 

 

 

 

 

 

 

 

The leaflet is detailed below, or you can download the 'Pregnancy of Unknown Location' leaflet in PDF.

Why am I being asked to read this leaflet?

You will have been asked to read this leaflet because you have had an ultrasound scan that could not identify a pregnancy inside the womb.  We are sorry for the upset and confusion you may be feeling after having this scan and we hope that this information leaflet will help you understand the next steps.  It can be a lot to read all at once.  We hope that this leaflet will provide you and your family with all the information you need to understand what is happening and why.  If you have further questions please do not hesitate to ask a member of the Gynaecology Emergency Department (GED).

What is pregnancy of unknown location?

Pregnancy of Unknown location (PUL) is an ultrasound diagnosis when a woman has a positive pregnancy test and a pregnancy cannot be seen inside or outside the womb on scan.  This can mean one of 3 things

1. The pregnancy is too small to be seen on scan  because we are earlier than 6 weeks
2. The pregnancy has passed and this will be a miscarriage
3. The pregnancy is outside the womb but we cannot see it on scan today.  This is an ectopic pregnancy

What is an ectopic pregnancy?

An ectopic pregnancy is a pregnancy that is developing outside of the womb.  It is usually in the fallopian tube but it can also be on the ovary, at the very top corner of the womb where the tube meets the womb, in the cervix, in a previous caesarean section scar or even in the abdomen.

Why is an ectopic pregnancy different to a PUL?

An ectopic pregnancy is when the ultra sound scan shows that the pregnancy is developing on the outside of the womb such as in the areas described above i.e. it is not in the correct position.  PUL is when the scan cannot demonstrate the pregnancy either inside the womb or outside.   A PUL can still be an ectopic pregnancy that has not yet been identified, as it can sometimes be difficult to see an ectopic pregnancy on a scan.

What do we expect to see in an intrauterine pregnancy?

In early pregnancy the first sign we see is a fluid filled in the womb which looks like a black circle.  Within this we look for a ring which is called the yolk sac.   This is shown in the picture below. 

This confirms a pregnancy in the womb.  If we cannot see this on scan we will talk to you about pregnancy of unknown location or early pregnancy loss.

Why is a yolk sac so important?

In an ectopic pregnancy (a pregnancy outside of the womb) a collection of fluid in the uterus can look like an early pregnancy sac.  This is referred to as a pseudosac or false sac.  The presence of the yolk sac is diagnostic of a pregnancy.  There are other subtle features such as the position of the fluid filled area, the shape etc.  These can be used to help us reach a diagnosis when we have more information from your blood tests, see below.

What happens next?

A member of the gynaecology emergency department (GED) or Early Pregnancy Unit (EPAU) team will explain to you what the scan has shown.  They will take your blood pressure, pulse and temperature.   They will advise you to have a blood test that looks at the pregnancy hormone, bHCG.  This is the same hormone that causes a pregnancy test to be positive when you do a urine test.  The blood test however can give us a number.  If this number is less than 10 it will confirm a miscarriage.  If it is greater than 10 you will be invited for a repeat blood test in 48 hours.  The initial number does not tell us a lot about the prognosis of the pregnancy as it is the change in the number that is important.  If the level is greater than 5000, there is no fluid filled area seen in the uterus and you have not had any heavy bleeding you will be reviewed by one of the senior doctors in the GED.

How do we interpret the change in the pregnancy hormone?

If the number is rising by more than 63% in the first 48 hours it is likely this is an early pregnancy and will arrange a repeat scan in 7-10 days depending how early in pregnancy we think you are.  Ideally we always want to scan after 6 weeks as this is when we are most likely to see a heartbeat that can give you some reassurance

If the number drops by more than 50% we are sorry but it is likely that this will be a miscarriage.  Exactly what happens next will depend upon the initial scan findings and the levels of your pregnancy hormones.  A member of the GED team will discuss this with you and offer support and access to more information about miscarriage.  With any early pregnancy loss we will ask you to do a pregnancy test in 2-3 weeks.  We would expect the test to be negative however if it is still positive we ask that you contact us so we can invite you back for an assessment.

What if I do not fit into either of those two scenarios?

It is quite common that the blood test does not go down or up as we described above.  In this instance what happens next will be discussed with you by a member of the GED team taking into account your history, symptoms and scan findings.  Often we will perform a third blood test to see the trend over a longer period of time.

What are the options for management of a PUL that is not rising or falling as expected?

The management is very dependent upon each woman’s situation and wishes.  If the pregnancy hormone is low, for example below 1000 and is falling we may offer conservative management of watching the pregnancy hormone weekly.

The management may also depend on what we have seen on the ultrasound scan.  If we have seen a fluid filled area without the yolk sac but we think there are other signs this is an intrauterine pregnancy such as the position in the womb, the way the fluid filled area looks, how your pregnancy hormone is behaving we may discuss treatments for miscarriage.  This is because some pregnancies may stop growing before they develop the yolk sac therefore we will only ever see a fluid filled area on scan. This is what is called an early embryonic loss.

When is ectopic pregnancy ruled out?

We will only be able to completely rule out an ectopic pregnancy when we see a pregnancy in the womb on a scan or your pregnancy level becomes negative.  This is why we need you to contact the department immediately if you have increasing abdominal or shoulder tip pain, feel unwell, develop diarrhoea or are concerned.   Even if your pregnancy hormone is rising as we want it to you are still at risk until you have a follow up scan.

What happens if I am diagnosed with an ectopic pregnancy?

In an ectopic pregnancy we can offer conservative, medical or surgical management.  This will be based on your symptoms, the size of the ectopic pregnancy, the level of your pregnancy hormone and your wishes.  Your doctor will discuss these options with you in detail.

How do I access support?

You may feel grief, along with feelings of sadness, confusion and loneliness after your experience. It is important to remember that this is normal, but there are places you can go to for support. We are always available for advice and support through the GED. Our Honeysuckle team is also available for support following pregnancy loss.

GED telephone number 0151 7024140

Honeysuckle Team

Telephone number: 0151 702 4151 (Monday to Friday, 8am to 4pm)

Website : www.liverpoolwomens.nhs.uk/patients/honeysuckle-bereavement-service/

Email: honeysuckle@lwh.nhs.uk

There are national organisations that can also provide invaluable support and advice during this difficult time:

Miscarriage association : www.miscarriageassociation.org.uk

Ectopic pregnancy Trust : www.ectopic.org.uk

Cradle - Local early pregnancy loss Charity : cradle@earlypregnancylos.co.uk

Facebook - Cradle

Twitter - @Cradle_EPL

Instagram - @cradle_epl.

 

The leaflet is detailed below, or you can download the 'Anti-D' leaflet in PDF.

This leaflet aims to give you an overview of anti-D and should answer most of your questions. Please speak to your doctor/nurse if you have any further questions/concerns.

Just as every human being is unique, so are the characteristics of your blood. People can belong to one of four blood groups, A, B, AB and O which are carried on the red blood cells. There is another important difference in people’s blood called rhesus factor, which is also found in the red blood cells. People who are rhesus positive have a substance known as D antigen on the surface of their red blood cells – they are said to be RhD-positive. People who are rhesus negative do not have the D antigen on their blood cells – they are RhD-negative. It is difficult for us to know the blood group of your baby. If you are rhesus negative and your baby is rhesus positive, then there is a risk of a reaction between yours and baby’s blood cells. This may cause the baby to become anemic (low blood count). This is called haemolytic disease in newborn (HDN).  

HDN occurs when the blood types of a mother and baby are incompatible.

• Haemolytic disease is a blood problem, the red blood cells break down at a faster rate than normal. Due to this baby’s red blood cell count becomes deficient, blood cannot carry enough oxygen from the lungs to all parts of the body, causing organs and tissues to struggle. This condition can be prevented by receiving this medicine. This medicine can stop your antibodies from reacting to your baby’s Rh-positive cells.

In the event of potentially sensitizing events listed below an injection of anti-D immunoglobulin is necessary:

• Vaginal bleeding or abdominal trauma/injury in pregnancy 13+ weeks gestation
• Miscarriage > 13 weeks gestation.
• Ectopic pregnancy- surgical intervention at any gestation
• Molar pregnancy- surgical intervention at any gestation
• Termination of pregnancy (abortion)- surgical intervention at any gestation
• Medical termination of pregnancy >10 weeks gestation

To reduce the possible effects of a sensitising event, it is crucial to report any events such as vaginal bleeding or abdominal injury to your health care professional as soon as possible.  Anti-D should be given within 72 hours of a sensitising event. The standard dose is 250IU intramuscularly up to 19+6 weeks gestation.  However, if this is not available a dose of 500 IU will be administered. An increased dose does not cause any harm.  Anti-D Ig usually lasts up to 6 weeks.

What is anti-D immunoglobulin?

Anti-D immunoglobulin is made from a part of the blood called plasma that is collected from donors. The production of Anti-D as a blood product, it is very strictly controlled to ensure the chance of a known virus or blood-borne infections being passed from the donor to the person receiving Anti-D is very low.

How is it given?

A trained healthcare professional will administer the injection with your consent, into the muscle in the upper arm.

You may experience mild discomfort during and for a short time following the injection.

This is completely normal and to be expected.    

Side effects

Some women may develop a slight short term allergic reaction to anti d immunoglobulin, this can include a rash or flu like symptoms. Please get in touch with your GP or healthcare professional if you have any concerns.