WEBVTT - 153. New Miscarriage Guidelines 0:00:04.440 --> 0:00:07.520 Welcome to the Kick Your Expert led podcast, helping you 0:00:07.600 --> 0:00:12.000 explore and learn everything about getting pregnancy, birth, and becoming 0:00:12.039 --> 0:00:12.440 a parent. 0:00:12.760 --> 0:00:16.520 On the podcast and our online pregnancy program grow My Baby, 0:00:16.680 --> 0:00:19.680 we share my experience of helping more than four thousand 0:00:19.720 --> 0:00:21.119 babies to be born and. 0:00:21.040 --> 0:00:24.040 Our experience of running a women's health clinic and parenting 0:00:24.079 --> 0:00:24.680 for boys. 0:00:24.920 --> 0:00:27.880 We're here to help everyone to feel empowered in pregnancy 0:00:28.040 --> 0:00:30.880 and birth with real life, practical information. 0:00:33.800 --> 0:00:35.800 Welcome everyone. I'm Bridget Maloney. 0:00:35.400 --> 0:00:37.839 And I'm obstetrician doctor Patrick Maloney. 0:00:37.440 --> 0:00:40.560 And today we've got a really important podcast to share 0:00:40.600 --> 0:00:41.120 with everybody. 0:00:41.159 --> 0:00:45.880 I think, yeah, recurrent miscarriage is a such a big 0:00:46.720 --> 0:00:51.559 topic within obstetrics. It's such a heartbreaking problem for a 0:00:51.600 --> 0:00:55.720 couple to have. And the interesting thing is that the 0:00:55.760 --> 0:00:59.520 Australian guidelines have just been redone on this topic to 0:00:59.600 --> 0:01:03.400 give us perhaps a more certainty on when we're supposed 0:01:03.440 --> 0:01:07.399 to intervene and what tests are of high value to do, 0:01:08.000 --> 0:01:11.160 and hopefully how we can help people move on from 0:01:11.200 --> 0:01:15.640 our current miscarriage situation to having the family size that 0:01:15.680 --> 0:01:16.400 they desire. 0:01:17.080 --> 0:01:20.280 As we go through the guidelines, it will sound like 0:01:20.480 --> 0:01:23.200 where I read them and thought well, they're kind of 0:01:23.240 --> 0:01:24.600 hedging their bets. 0:01:24.319 --> 0:01:24.840 A little bit. 0:01:24.920 --> 0:01:27.840 Yeah, but can you just describe to the audience what 0:01:28.280 --> 0:01:31.600 are guidelines for and who has developed these guidelines. 0:01:32.120 --> 0:01:35.560 Yeah. So these guidelines are developed by RAN's COG with 0:01:35.920 --> 0:01:40.640 the Australian og College and it's a worthwhile thing to 0:01:40.640 --> 0:01:43.720 do to produce guidelines. It's important that we remember that 0:01:43.720 --> 0:01:47.000 that's all they are. They're guidelines. They're not the law 0:01:47.080 --> 0:01:49.720 that you must intervene at this point or you must 0:01:50.000 --> 0:01:53.400 do these tests. One thing when they produce guidelines is 0:01:53.400 --> 0:01:56.120 that they tend to look at things that have already 0:01:56.160 --> 0:01:58.160 been done in the past, such as a certain test, 0:01:58.440 --> 0:02:01.560 and rate it on the evidence behind actually doing that. 0:02:01.720 --> 0:02:04.480 And sometimes the evidence for something that we've always done 0:02:04.520 --> 0:02:08.720 turns out to be pretty disappointing, and there are a 0:02:08.720 --> 0:02:12.720 couple of potential explanations for that that we have to remember. 0:02:13.280 --> 0:02:17.400 So if a test has very little evidence that it 0:02:17.440 --> 0:02:22.560 actually helps, that just means that the evidence is not there. 0:02:22.880 --> 0:02:26.080 It doesn't mean that it doesn't actually help. It might 0:02:26.160 --> 0:02:30.320 actually be good, but the evidence does not exist to 0:02:30.320 --> 0:02:32.240 say this has been proven to help. 0:02:32.720 --> 0:02:34.800 And I read a lot of them are based on 0:02:34.840 --> 0:02:38.720 the findings of an RCT or a randomized control trial, 0:02:40.040 --> 0:02:41.360 just really quickly, what is that? 0:02:41.560 --> 0:02:47.280 Yeah, So these guidelines always rate a current practice in 0:02:47.400 --> 0:02:50.399 terms of how much evidence there is behind it. And 0:02:50.480 --> 0:02:54.440 there's a scale from excellent evidence, which would be a 0:02:54.520 --> 0:02:59.880 really well constructed, really big randomized control trial where we 0:03:00.080 --> 0:03:02.120 yet half the people with the problem to agree to 0:03:02.160 --> 0:03:05.880 have treatment x and half the people that have the 0:03:05.919 --> 0:03:08.840 problem to agree to have treatment why, and look at 0:03:08.880 --> 0:03:11.959 which group does the better? And obviously we have some 0:03:12.000 --> 0:03:15.200 of those in obstetrics, some really really well constructed ones, 0:03:15.960 --> 0:03:20.360 and lots of what we do in medicine obstetrics is 0:03:20.360 --> 0:03:25.760 no exception. We're looking at evidence way less persuasive than 0:03:25.800 --> 0:03:30.520 a double blinded randomized control trial. So sometimes it might 0:03:30.560 --> 0:03:35.080 say that the evidence behind course of action ABC is 0:03:35.120 --> 0:03:40.520 nowhere near A level evidence. It might be Z level evidence, 0:03:40.760 --> 0:03:43.360 which is just it's the way I was taught by 0:03:43.400 --> 0:03:44.880 my professor Will as a student. 0:03:44.960 --> 0:03:46.960 Yeah, And it's anecdotal and observation. 0:03:47.600 --> 0:03:49.480 Yeah. Yeah, the last time I did this at work, 0:03:50.000 --> 0:03:51.480 therefore I did it the next time. 0:03:51.480 --> 0:03:54.200 It worked again treatment. But it's not a sample size 0:03:54.200 --> 0:03:58.680 that has any you know, real high clarity or high 0:03:58.800 --> 0:03:59.960 level of evidence. 0:03:59.560 --> 0:04:03.640 Absolute, So Whilst we should be Whilst we should always 0:04:03.720 --> 0:04:07.360 be reaching for better levels of evidence in our medical practice, 0:04:07.520 --> 0:04:09.880 we also have to remember that sometimes we have to 0:04:09.880 --> 0:04:12.120 make a decision to do something or not do something, 0:04:12.120 --> 0:04:14.800 and the evidence may be lacking, and then we're going 0:04:14.840 --> 0:04:18.400 to or high grade evidence may be lacking, and then 0:04:18.400 --> 0:04:22.120 we kind of accept whatever evidence there is, remembering, of course, 0:04:22.560 --> 0:04:25.000 there's no randomized control trial that says you could you 0:04:25.080 --> 0:04:26.880 should go to hospital if you cut your legg off. 0:04:27.720 --> 0:04:30.599 And yet it seems like a good idea. Okay, so 0:04:30.800 --> 0:04:33.400 we don't do nothing just because we don't have an RCT. 0:04:33.839 --> 0:04:39.480 So in some circumstances, an RCT may not be approved 0:04:39.520 --> 0:04:42.360 by ethics either, yes, it's actually going to do harm 0:04:42.400 --> 0:04:43.520 to their control group. 0:04:43.440 --> 0:04:46.119 That's right. It might be that you just can't get 0:04:46.240 --> 0:04:48.760 such a study up and going. It might be that 0:04:48.800 --> 0:04:51.279 ethics would never approve it. It might be too much 0:04:51.320 --> 0:04:55.520 to ask of people to be randomized. Often at the 0:04:55.520 --> 0:04:58.520 start of a randomized control study, when you're approaching someone 0:04:58.520 --> 0:05:01.040 to be part of it, we've got two treatments. We're 0:05:01.040 --> 0:05:03.760 trying to work out which is the best one, and 0:05:03.800 --> 0:05:05.719 sometimes the post will just give me the one that 0:05:05.760 --> 0:05:09.720 you think really works, and well we don't know. That's 0:05:09.760 --> 0:05:10.680 why we're doing the trial. 0:05:10.839 --> 0:05:14.039 Good, all right, well let's get into it. I think, firstly, 0:05:14.200 --> 0:05:18.640 how is rans COG now defining what a recurrent miscarriage is? 0:05:18.720 --> 0:05:22.840 Yeah, so that's tightened up a lot, and that's that's 0:05:23.160 --> 0:05:28.440 that's of interest. So we used to really define a 0:05:28.480 --> 0:05:33.039 recurrent miscarriage and certainly intervene when somebody had had three 0:05:33.520 --> 0:05:37.040 in a row. So three early pregnancy losses less than 0:05:37.040 --> 0:05:40.600 twenty weeks in a row, and we would we would 0:05:40.600 --> 0:05:43.680 attach more significance to say, someone who lost an otherwise 0:05:43.720 --> 0:05:46.520 normal pregnancy at fifteen weeks, to somebody who had a 0:05:46.520 --> 0:05:48.840 positive pregnancy test at five weeks and then it was 0:05:48.880 --> 0:05:53.920 gone a week later. But still it was three in 0:05:53.960 --> 0:05:58.080 a row. And now they're saying that we should be 0:05:58.160 --> 0:06:02.080 considering it a recurrent miscarriage hit situation. If a woman's 0:06:02.120 --> 0:06:07.640 lost two pregnancies under twenty weeks under any circumstances, not 0:06:07.800 --> 0:06:08.920 necessarily in a row. 0:06:09.160 --> 0:06:10.880 Gosh, that's a big change, isn't it. 0:06:11.240 --> 0:06:14.160 Yes, so it would it would capture more people, It 0:06:14.800 --> 0:06:20.119 would encapsulate a greater group of women, some of whom 0:06:20.160 --> 0:06:23.600 had been previously told that they didn't reach the criteria 0:06:24.120 --> 0:06:25.599 to have the tests that have. 0:06:25.680 --> 0:06:30.440 Further investigations, and like, if you're thinking about three consecutive miscarriages, 0:06:30.760 --> 0:06:32.520 might have taken that woman a few months to get 0:06:32.640 --> 0:06:34.920 pregnant in the first time, so that in the first place, 0:06:34.960 --> 0:06:36.160 so that could be a few years. 0:06:36.480 --> 0:06:39.880 Yes, yes, and so on the one hand, with the 0:06:39.880 --> 0:06:42.400 old system, we must have been telling some people who 0:06:42.480 --> 0:06:46.760 had a significant issue, don't worry, just try again, and 0:06:47.480 --> 0:06:50.880 they may actually get the necessary tests earlier with the 0:06:50.920 --> 0:06:53.920 new definition. On the other hand, surely with the new 0:06:53.920 --> 0:06:59.160 definition will be investigating some people who don't have much 0:06:59.200 --> 0:07:02.560 wrong with them and would have conceived normally if they 0:07:02.640 --> 0:07:03.279 just tried again. 0:07:03.440 --> 0:07:07.320 Yeah. And this definition is a bit different wherever you 0:07:07.360 --> 0:07:10.280 are in the world. I did see that Europe it's 0:07:10.320 --> 0:07:13.000 a loss of two or more pregnancies, but in the 0:07:13.080 --> 0:07:16.760 UK it's a loss of three or more first trimester losses. Yes, 0:07:17.640 --> 0:07:19.800 all right, before we go on, Patty, can we just 0:07:21.400 --> 0:07:25.640 very basically talk about what does the research say that 0:07:25.840 --> 0:07:28.680 causes recurrent miscarriages? 0:07:29.440 --> 0:07:31.360 Yeah? That's the question at the heart of all of this, 0:07:31.480 --> 0:07:36.200 isn't it. Because if only we knew most of the 0:07:36.320 --> 0:07:41.040 cases we don't identify. Course and that makes guidelines difficult, 0:07:41.560 --> 0:07:47.280 But there are some known causes. It's very relevant maternal 0:07:47.440 --> 0:07:53.480 and paternal age, some lifestyle factors like alcohol and smoking, 0:07:53.960 --> 0:08:01.200 The woman's obstetric history is quite relevant. Medical maternal medical 0:08:01.200 --> 0:08:10.640 conditions like diabetes or hypothyroidism known to be relevant in 0:08:10.720 --> 0:08:13.800 particular if those diseases that are there and are untreated. 0:08:15.360 --> 0:08:18.160 But plenty of cases we never identify exactly what the 0:08:18.160 --> 0:08:18.760 cause is too. 0:08:19.080 --> 0:08:21.720 All right, so someone's just come in and you know 0:08:21.800 --> 0:08:28.480 it's their second miscarriage. What screening tests does rang Skog 0:08:28.800 --> 0:08:31.520 now recommend that you do according to the guidelines. 0:08:32.000 --> 0:08:38.040 So there's a list, But we have to remember that 0:08:38.280 --> 0:08:41.480 this is not a one size fits all problem, and 0:08:41.520 --> 0:08:43.920 we have to remember that the tests that we might 0:08:44.000 --> 0:08:47.840 do for someone who'd lost two very very early pregnancies 0:08:47.880 --> 0:08:51.320 before there was even something seen in the uterus, you know, 0:08:51.400 --> 0:08:54.959 a five and a half week loss might be different 0:08:55.040 --> 0:08:58.920 to someone who's two losses were both at eighteen weeks. 0:09:01.800 --> 0:09:09.319 And that's important that the advice is personalized. But certainly 0:09:10.880 --> 0:09:17.439 the tests that they recommend concentrate on potentially untreated maternal 0:09:19.160 --> 0:09:21.480 Nothing we can do about maternal age or paternal age 0:09:21.480 --> 0:09:27.040 in most cases. But untreated maternal disease is important, and 0:09:27.120 --> 0:09:31.080 of course lifestyle factors are very important. So a test 0:09:31.080 --> 0:09:34.000 for maternal diabet is a test for thyroid disease. 0:09:34.679 --> 0:09:37.640 All right, So we'll get into the screening tests because 0:09:37.679 --> 0:09:40.480 that all depends on the different conditions that they want 0:09:40.480 --> 0:09:42.319 to test for, which have changed a little bit. But 0:09:42.440 --> 0:09:46.560 let's go to this recommendation, which is that in previous 0:09:47.040 --> 0:09:52.560 recommendations in recurrent miscarriages, there was a routine analysis of 0:09:52.600 --> 0:09:55.800 the pregnancy tissue. This has changed is that? 0:09:56.440 --> 0:09:59.319 Well, I think it used to be said that whenever possible, 0:10:00.080 --> 0:10:03.480 if we were doing a curate for a pregnancy loss, then 0:10:03.559 --> 0:10:06.360 if there was a chance to get the tissue that 0:10:06.400 --> 0:10:09.720 was evacuated from the uterus and send it for genetic analysis, 0:10:10.520 --> 0:10:12.840 that that would be that that was a highly worthwhile 0:10:12.840 --> 0:10:15.600 thing to do. The new guidelines aren't so fast about that, 0:10:16.400 --> 0:10:21.319 and suggests that knowing that genetic analysis is rarely important, 0:10:22.720 --> 0:10:26.080 there would be some scenarios where a genetic basis to 0:10:26.120 --> 0:10:31.120 the recurrent miscarriage was strongly suspected, where that might still 0:10:31.160 --> 0:10:36.040 be a worthwhile thing to do. But these guidelines are 0:10:36.040 --> 0:10:38.800 more in favor of a maternal and paternal carrier type 0:10:38.800 --> 0:10:41.600 where the genes of the parents are analyzed rather than 0:10:41.600 --> 0:10:45.480 necessarily going to the lengths of analyzing the genetics of 0:10:45.520 --> 0:10:47.240 the material from the miscarriage. 0:10:47.440 --> 0:10:52.120 So the next recommendation is around thrombophilia. Can we start 0:10:52.160 --> 0:10:52.800 with the definition? 0:10:52.880 --> 0:10:56.160 What is that? Yeah, thrombophilias are a group of conditions, 0:10:56.240 --> 0:11:00.600 quite a big group of conditions where the body is 0:11:00.760 --> 0:11:05.679 more likely to form a blood clot. And when I 0:11:05.720 --> 0:11:08.760 did my training, they were identifying more and more of 0:11:08.800 --> 0:11:14.199 these thrombophilias, and they were getting more and more excited 0:11:14.240 --> 0:11:20.320 about them being an identifiable cause of recurrent miscarriage and 0:11:20.800 --> 0:11:27.280 infertility and a potentially treatable cause. And in a lot 0:11:27.320 --> 0:11:30.480 of cases for these various thrombopelias, it's actually been a 0:11:30.520 --> 0:11:33.400 bit disappointing. It has not panned out quite as it 0:11:33.480 --> 0:11:36.080 was originally thought it would be. They thought they'd found 0:11:36.120 --> 0:11:40.360 the holy grail to early pregnancy loss, and unfortunately it's 0:11:40.400 --> 0:11:43.640 been a bit disappointing. Some of them have not had 0:11:43.679 --> 0:11:47.560 the association with early pregnancy loss that was predicted, and 0:11:47.760 --> 0:11:52.240 others have not had a worthwhile treatment. So whether you've 0:11:52.240 --> 0:11:55.720 got it or not, maybe there may be nothing you 0:11:55.720 --> 0:11:58.400 can do about it either way. There's a group of 0:11:58.440 --> 0:12:04.600 related there's a relate condition called antiphosphilipid syndrome where the 0:12:04.600 --> 0:12:10.959 body makes an immune response that is more likely to 0:12:11.520 --> 0:12:16.360 form clots. And antiphosphilipid syndrome does have good evidence that 0:12:16.840 --> 0:12:21.040 it's involved in pregnancy loss, and so we should definitely 0:12:21.080 --> 0:12:22.400 be testing for that one. 0:12:22.760 --> 0:12:26.400 So of those issues that caused thrombophilia, what were some 0:12:26.480 --> 0:12:27.880 of the changes in the guidelines. 0:12:28.640 --> 0:12:33.800 Yes, that they were less keen for people to be 0:12:33.840 --> 0:12:40.120 tested for conditions like activated protein C resistance, something that's 0:12:41.240 --> 0:12:45.640 caused by by a common genetic phenomenon called factor five light, 0:12:46.600 --> 0:12:50.040 and there are other conditions and protein C protein s 0:12:50.440 --> 0:12:55.920 and these were part of a handful of tests that 0:12:55.960 --> 0:12:58.120 are commonly done and should be done as part of 0:12:58.160 --> 0:13:00.439 the investigation, say of an adult with bug clot in 0:13:00.440 --> 0:13:03.640 their leg, but have not proven as useful as we 0:13:03.640 --> 0:13:05.800 thought they were going to in the investigation of a 0:13:05.880 --> 0:13:06.880 current miscarriage. 0:13:07.360 --> 0:13:10.920 Right, So you mentioned the anti phospholipid What are some 0:13:10.960 --> 0:13:12.680 of the tests that people have for that. 0:13:13.040 --> 0:13:15.800 It's a blood test. Yeah, yeah, test, and that basically 0:13:15.800 --> 0:13:18.720 says yes, I know, Okay. The reason why that one's 0:13:18.760 --> 0:13:20.840 relevant to know about is that it can there is 0:13:20.880 --> 0:13:25.640 a treatment so that particular condition. For example, if you 0:13:25.679 --> 0:13:30.839 go on to low dose aspirin and a powerful blood 0:13:30.880 --> 0:13:34.120 thinner like Colecksain, that does change pregnancy outcomes. 0:13:34.400 --> 0:13:37.920 So, Patty, you already mentioned about genetic testing, what do 0:13:37.960 --> 0:13:39.680 the guidelines say about that now? 0:13:40.559 --> 0:13:46.199 Well, they say that there's value in doing a maternal 0:13:46.200 --> 0:13:48.880 and paternal carrier type so that both both people and 0:13:48.920 --> 0:13:52.840 the couple go and have their genetics analyzed. And occasionally 0:13:52.920 --> 0:13:58.560 some people have a thing called a balanced translocation where 0:13:58.600 --> 0:14:00.920 they may have a little bit of genetic material that 0:14:01.000 --> 0:14:04.559 has broken off one chromosome and attached to another chromosome. 0:14:05.160 --> 0:14:07.720 And while that's fine for them because all the genetic 0:14:07.720 --> 0:14:11.760 material is there, when their cells goes to divide, they 0:14:11.800 --> 0:14:14.480 can wind up with the wrong amount in the sperm 0:14:14.559 --> 0:14:18.640 or the egg that they're creating. Well, and so knowing 0:14:18.679 --> 0:14:22.560 about balanced translocations is relevant, all right. 0:14:22.640 --> 0:14:24.720 So there's a place in the guideline for talking about 0:14:24.720 --> 0:14:26.880 anatomical factors. What's different there? 0:14:27.120 --> 0:14:29.240 Yeah, it's interesting. These are the ones that they thought 0:14:29.360 --> 0:14:33.400 had Some of them had low evidence, a low degree 0:14:33.440 --> 0:14:36.640 of evidence, but some of them would seem to be 0:14:36.640 --> 0:14:39.760 no brainers. For example, if you did an ultrasound and 0:14:39.840 --> 0:14:42.520 you found that Norman's uterus had a number of polyps 0:14:42.640 --> 0:14:45.240 or a big septum down the middle of it, then 0:14:46.200 --> 0:14:49.320 they're saying there's low evidence that intervening to fix those 0:14:49.320 --> 0:14:53.440 things would help. I suspect that there's an absence of evidence, 0:14:54.000 --> 0:14:57.880 not evidence that doing it doesn't help. Does that make sense? Yeah? Yeah, yeah, 0:14:57.960 --> 0:15:03.400 So in general terms, we would do simple things that 0:15:03.960 --> 0:15:06.480 would help correct the intrauterine environment. 0:15:07.080 --> 0:15:12.080 Just quickly go through what some of the common anatomical 0:15:12.160 --> 0:15:14.920 features that they're talking about in the guidelines. Ah. 0:15:15.120 --> 0:15:19.800 Yes, So they're talking about polyps within the uterus, septums 0:15:19.800 --> 0:15:21.920 within the uterus, like where there's a wall down the middle, 0:15:22.760 --> 0:15:26.480 and then other things that really change the size and 0:15:26.520 --> 0:15:29.960 the shape of the uterus like black fibroids. 0:15:30.120 --> 0:15:31.800 Yeah. And adhesions are read too. 0:15:32.160 --> 0:15:36.960 Yeah, intrauterine adhesions where the front and the back of 0:15:36.960 --> 0:15:39.920 the uterine cavity is stuck together, so called Asherman syndrome, 0:15:40.160 --> 0:15:42.560 which can be seen in people who've had recurrent previous 0:15:42.640 --> 0:15:46.720 curetes with someone with recurrent miscarriage might have had. Then 0:15:46.760 --> 0:15:50.080 that would be relevant, and you break those adhesions down 0:15:50.120 --> 0:15:52.560 and try and let a nice clean lining start again. 0:15:53.200 --> 0:15:57.000 And the other interesting one is caesarean scar niche or 0:15:57.080 --> 0:16:02.320 caesarean scar defect, and it's something really interesting. The last 0:16:02.320 --> 0:16:04.760 gynecological conference I went to there were no few of them, 0:16:04.800 --> 0:16:09.400 about five presentations on exactly this. There's definitely a phenomenon 0:16:09.440 --> 0:16:12.400 where a woman has had apparently normal fertility and she's 0:16:12.440 --> 0:16:14.840 had two or three seasons and then trying to have 0:16:14.880 --> 0:16:20.200 another baby and experiencing a secondary infertility or a secondary 0:16:20.560 --> 0:16:24.720 current pregnancy lost situation where she's previously been fined. And 0:16:24.760 --> 0:16:28.480 it's thought that the cesarean section scar might have developed 0:16:28.480 --> 0:16:32.480 a little niche or or sort of a pocket or 0:16:32.600 --> 0:16:36.360 alcove within it, and that might hang on to fluid 0:16:37.440 --> 0:16:42.640 that inhibits the healthy environment within the uterus. And there's 0:16:42.680 --> 0:16:46.120 a procedure where you can cut the scar out, make 0:16:46.160 --> 0:16:48.680 a new one start again. And like a lot of 0:16:48.680 --> 0:16:52.120 these things, the science of making the operation to fix 0:16:52.160 --> 0:16:56.240 it has surged ahead, well ahead of the evidence that 0:16:56.320 --> 0:17:01.560 suggests that that would actually help. But anecdotally it seems 0:17:01.600 --> 0:17:02.600 to be promising. 0:17:03.280 --> 0:17:06.240 So tricky, isn't it, Because like you've got clinical experience 0:17:06.560 --> 0:17:10.439 of this not just the cesareanscarnage, but like all of 0:17:10.440 --> 0:17:14.480 those anatomical issues, and you've had experience where people have 0:17:14.640 --> 0:17:17.439 had that particular surgery to move a fibrod or a 0:17:17.440 --> 0:17:20.560 poll up or something like that, and then subsequently, yeah, 0:17:20.560 --> 0:17:23.840 they're pregnant. It's really it must be really difficult as 0:17:23.840 --> 0:17:26.439 a governing body to go, Okay, well, what we're working 0:17:26.480 --> 0:17:29.840 with is people that perhaps are all different skill levels 0:17:29.920 --> 0:17:33.800 or all access to different services. We've got to make 0:17:33.840 --> 0:17:36.240 something that is the guideline. I'm going to say it 0:17:36.400 --> 0:17:37.560 for the bare minimum. 0:17:37.640 --> 0:17:41.480 Well, yes, and that's that's what guidelines really are. And 0:17:41.840 --> 0:17:44.560 it's important that we remember that if a guideline says 0:17:44.600 --> 0:17:47.640 that there is a poor a low level of evidence 0:17:47.680 --> 0:17:54.240 for a particular intervention, it doesn't mean that they're saying 0:17:54.640 --> 0:17:57.800 it necessarily should be done. They're saying that there's a 0:17:57.840 --> 0:18:00.000 low level of evidence to support it's better. 0:18:00.520 --> 0:18:03.400 Do you think they make these guidelines with any financial 0:18:03.760 --> 0:18:05.960 constraints in mind or thought in mind? 0:18:06.760 --> 0:18:09.520 I don't think so. I think the clinical practice guidelines 0:18:09.560 --> 0:18:13.080 that probably exist somewhat independently of how much these things cost. 0:18:13.680 --> 0:18:15.879 And if you look at the definition, they've tightened it 0:18:15.960 --> 0:18:18.600 up so there's every chance that this will that this 0:18:18.640 --> 0:18:21.280 will result in more money being spent on this problem, 0:18:21.320 --> 0:18:22.239 not less or right. 0:18:22.280 --> 0:18:24.199 There is something in the guidelines which is like a 0:18:24.240 --> 0:18:27.000 strong recommendation, something we can do something about, and that 0:18:27.160 --> 0:18:28.359 is hypothirotism. 0:18:28.520 --> 0:18:32.000 Yeah, that's got good evidence. So we check the thyroid 0:18:32.200 --> 0:18:34.159 and if someone has been walking around with a low 0:18:34.240 --> 0:18:37.439 thyroid and you correct that, you'll improve their chance of 0:18:37.440 --> 0:18:40.479 holding onto the pregnancy. So that's great. We knew that already, 0:18:40.520 --> 0:18:42.520 but it's good that that's known to have good evidence. 0:18:43.280 --> 0:18:45.800 There's an interesting comment in the guidelines about whether we 0:18:45.840 --> 0:18:50.480 should treat asymptomatic where the blood tests are mildly abnormal 0:18:50.480 --> 0:18:53.240 but the woman looks and feels fine. A lot of 0:18:53.280 --> 0:18:59.280 people in a recurrent miscarriage situation would latch onto any 0:18:59.320 --> 0:19:03.080 mild abnormal the one percenter. Let's just try and get 0:19:03.119 --> 0:19:06.200 everything as normal as we can. 0:19:06.640 --> 0:19:11.160 So what about the person who has a subclinical finding 0:19:11.200 --> 0:19:12.120 about their thyroid. 0:19:12.520 --> 0:19:14.879 Yeah, so they look and feel fine, but there's a 0:19:15.000 --> 0:19:20.639 very mild abnormality to the test, and these guidelines are 0:19:20.640 --> 0:19:24.440 suggesting that there's poor evidence to treat that, but that 0:19:24.440 --> 0:19:28.400 that person should have close attention paid to their thyroid 0:19:28.800 --> 0:19:29.280 as soon. 0:19:29.119 --> 0:19:31.800 As they're pregnant, and again during their pregnancy. 0:19:31.880 --> 0:19:34.400 Yeah, well we check anyone with thorroid disease, which gets 0:19:34.400 --> 0:19:35.240 recurrent checks. 0:19:35.320 --> 0:19:39.680 Yep. And there's this thing called antibody positive youth thyroid. 0:19:40.119 --> 0:19:40.600 What is that. 0:19:41.560 --> 0:19:45.600 That's people who've got a normal level of thyroid function, 0:19:45.920 --> 0:19:48.520 but they have a thing called thyroid auto antibodies where 0:19:48.560 --> 0:19:51.800 your body has made antibodies against thyroid tissue. 0:19:51.920 --> 0:19:55.439 Well, that's the Hashimotos and Graves disease. And yeah, and 0:19:55.480 --> 0:19:58.720 that's treated the same, isn't it. It's just tested to 0:19:58.760 --> 0:20:02.160 see if there's any dis function in the pregnancy once 0:20:02.200 --> 0:20:05.439 you're pregnant. Once you're pregnant. I googled all of that 0:20:05.480 --> 0:20:08.520 because it is all new to me, and Google definitely 0:20:08.640 --> 0:20:10.840 says that that is all the cause of miscarriage. So 0:20:12.000 --> 0:20:15.200 this is where the punters get the information from, isn't 0:20:15.240 --> 0:20:16.000 it in the first place? 0:20:16.680 --> 0:20:20.240 Well? Yes, and I think we have to remember that 0:20:20.840 --> 0:20:23.240 there are multiple sources of information. But the point of 0:20:23.280 --> 0:20:27.159 the guideline is to gather the quality evidence from wherever 0:20:27.200 --> 0:20:30.240 it exists in the world and put it together and 0:20:30.720 --> 0:20:34.200 have a go at recommending what best clinical practice is. 0:20:34.400 --> 0:20:38.040 Yeah. Also, if you avidly googling, you might come across 0:20:38.160 --> 0:20:44.040 intravenous immunoglobular therapy. What is that? That is in the guidelines, 0:20:44.640 --> 0:20:46.760 But can you just quickly define that for us? 0:20:47.640 --> 0:20:53.040 Yeah, you know, globulin therapy is an idea that for 0:20:53.080 --> 0:20:57.600 a current miscarriage that doesn't have much scientific merit behind 0:20:57.640 --> 0:21:00.919 it as far as I can see. Where you know, 0:21:01.000 --> 0:21:06.719 im immune substances are purified from blood donation, could be 0:21:07.040 --> 0:21:12.080 could be injected and used in an attempt to treat 0:21:12.119 --> 0:21:14.480 my current miscarriage. And I don't believe that has any 0:21:14.720 --> 0:21:17.119 serious science behind it at this stage. 0:21:17.359 --> 0:21:20.800 I know that currently it's not a approved use of 0:21:20.840 --> 0:21:23.960 donated blood in Yeah, well, and it must cost a 0:21:23.960 --> 0:21:26.960 lot of money. So that's in the guidelines, but there's 0:21:26.960 --> 0:21:27.879 no recommendations. 0:21:28.160 --> 0:21:29.440 They recommend against. 0:21:29.200 --> 0:21:34.119 It, all right. So this leads us to the last recommendation. 0:21:35.160 --> 0:21:38.120 This is the use of progesterone when someone has had 0:21:38.280 --> 0:21:39.480 recurrent miscarriages. 0:21:39.760 --> 0:21:42.280 This is an interesting one because because you've got to 0:21:42.320 --> 0:21:48.600 remember that recurrent miscarriage is one of those heartbreaking conditions. 0:21:48.720 --> 0:21:51.679 It's very frustrating to treat. There's a certain sort of 0:21:51.800 --> 0:21:54.679 randomness about it. It just people seem to just have 0:21:54.720 --> 0:21:57.880 the pregnancy snatch from them, and there's very little we've 0:21:57.920 --> 0:21:59.919 been able to do about that other than in a 0:22:00.080 --> 0:22:03.879 good other than in a kind way suggesting that we 0:22:03.920 --> 0:22:08.320 go home, nurture our bruised body and heart, and then 0:22:08.359 --> 0:22:13.480 try again. So we've latched upon, we've latched on to 0:22:13.600 --> 0:22:16.240 treatments when they've come along in the hope that they 0:22:16.280 --> 0:22:19.240 are the holy graylmen we can really help people. And 0:22:20.040 --> 0:22:26.679 progesterone certainly has a role in a sort of a 0:22:26.720 --> 0:22:33.119 different problem in pregnancy, which is one of cervical insufficiency, 0:22:33.119 --> 0:22:36.000 where the cervix comes open too early and end in 0:22:36.040 --> 0:22:40.679 a sort of a painless second trimester pregnancy loss. Cervix opens, 0:22:40.720 --> 0:22:45.240 baby comes out, and that I think led to its 0:22:45.280 --> 0:22:48.280 to an increasing focus on its use to try and 0:22:48.320 --> 0:22:52.400 help prevent first trimester pregnancy losses. The evidence for that's 0:22:52.440 --> 0:22:56.719 not quite as good, and in this guideline they recommend 0:22:58.400 --> 0:23:03.520 only doing that if there's bleeding, which is not really 0:23:03.560 --> 0:23:08.800 where frequent everyday clinical practice was sitting prior to this guideline, 0:23:08.800 --> 0:23:12.280 So it'll be interesting to see whether that changes practice. Okay, 0:23:12.800 --> 0:23:17.960 because using a little bit of vaginal progesterone pessories in 0:23:18.000 --> 0:23:21.320 a woman with the recurrent pregnancy lost situation has really 0:23:21.359 --> 0:23:25.160 been seen as a as a safe thing to do, 0:23:25.560 --> 0:23:30.600 as something that might help that won't harm. And it's 0:23:31.440 --> 0:23:35.760 for some people the feeling of doing something is a 0:23:35.800 --> 0:23:40.720 lot more satisfactory than the feeling of doing nothing, even 0:23:40.840 --> 0:23:43.920 if the something doesn't have a lot of evidence behind it. Yeah. 0:23:44.880 --> 0:23:47.840 Yeah, and we can see you know, that is where 0:23:47.880 --> 0:23:50.439 people have agency in their life when it comes to 0:23:50.480 --> 0:23:54.080 recurrent miscarriage. You know, they start to look at their 0:23:54.119 --> 0:23:57.800 lifestyle factors and that can also be somewhere where they 0:23:57.920 --> 0:24:02.480 concentrate on. Yes, but for you, does anything in this 0:24:02.560 --> 0:24:04.920 guideline change how you practice as a clinician? 0:24:05.480 --> 0:24:08.280