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There is so much we don't know in medicine that could make a difference, and often we focus on the big things, and the little things get forgotten. To highlight some smaller but important issues, we've put together a series of pearls that the Red Whale found at the bottom of the ocean of knowledge! Miscarriage: frequently asked questions What is the best method for managing miscarriage? The MIST trial (BMJ 2006;332:1235) compared medical, surgical and expectant management in a UK-based RCT of 1200 women. It found no difference in the rate of gynaecological infection. There were more unplanned hospital admissions in the expectant and medical management groups compared with the surgical group (49% vs. 18% vs. 8% respectively). Bleeding stopped sooner in surgical management, but this did not affect Hb levels. Unplanned surgical intervention was required in: 6% (missed), 2% (incomplete) managed surgically. 38% (missed), 29% (incomplete) managed medically. 50% (missed), 25% (incomplete) managed expectantly. Based on this study, the RCOG concluded that: Women who were at high risk of bleeding/infection or molar pregnancy should be offered surgical treatment. All other women should be allowed to choose which option they prefer. NICE has recommended expectant management first line, medical second line and surgery third line on the basis of costeffectiveness. Does choice of method affect future fertility? No! ... Long-term follow-up of the women from the MIST trial showed that the method of miscarriage management does not affect subsequent pregnancy rates (BMJ 2009;339:b3827). Of the initial 1200 women, 762 replied to 5y follow-up, and live birth rates were approximately 80% in all three groups within 5y of the index miscarriage. Older women (>35y) and those with previous miscarriages were less likely to give birth. 1 previous miscarriage – 74% had a live birth at 5y. 2 previous miscarriages – 67% had a live birth at 5y. 3 previous miscarriages – 58% had a live birth at 5y. In view of the number of women who did not respond to the follow-up survey, it is possible that these figures may be overly optimistic. How soon can we try again? I always say as soon as you feel emotionally ready on the basis of common sense and practicality! This large Scottish retrospective cohort study found that women who conceive again within 6m were significantly less likely to have another miscarriage, termination, ectopic pregnancy or complications in pregnancy, compared with women with longer interpregnancy intervals. The worst outcomes were seen with delays of >24m (BMJ 2010;341: c3967 and c4181 (editorial)). As with all retrospective studies, confounding may be a significant factor in the result, e.g. women who take longer to conceive may be more likely to have adverse pregnancy outcomes owing to factors which contribute to fertility itself, rather than interpregnancy duration. Causation cannot be determined. It appears safe to recommend trying again for pregnancy as soon as the woman is ready, and the best outcomes are seen if conception occurs within 6m of the first miscarriage. What can I do to reduce the chance of miscarriage? This article in the NEJM focuses on the causes and management of recurrent miscarriage (NEJM 2010;363:1740). The most common cause of early spontaneous miscarriage is chromosomal aneuploidy (having more or less genetic material than normal). This is a spontaneous event which is more common under the age of 18y and over the age of 35y. There is little that an individual woman can do to prevent it. Poorly controlled diabetes and thyroid disease are associated with increased risk of miscarriage, but well controlled chronic diseases are not. Offer patients with diabetes and thyroid disease a pre-conception review to ensure they are optimally managed prior to becoming pregnant. Do not screen for diabetes and thyroid disease in women who have had a miscarriage, unless there are other clinical indicators for doing so. In the case of recurrent miscarriage (three or more consecutive miscarriages), women should be referred for further investigation, although this review openly acknowledges that the evidence base for these investigations and interventions is poor. With no intervention, 65% of couples with recurrent miscarriage will achieve a future live birth. The role of antithrombotics is controversial and is considered below. Screening for uterine abnormalities, e.g. septate and bicornate uterus, is commonly undertaken, and many experts recommend correction before trying for future pregnancy – but RCT data to support this is lacking. Genetic screening and IVF with pre-implantation genetics does not improve live birth rate compared with spontaneous conception. Lifestyle issues associated with an increased risk of miscarriage include: Obesity. Cigarette smoking. Alcohol use. Moderate to heavy caffeine intake. There is no evidence that sexual activity has any impact on miscarriage. This very large observational study published in the BJOG looked at nine established risk factors for miscarriage in pregnancies included in the Danish National Birth cohort from 1996 to 2002 (BJOG 2014;DOI 10.1111/1471-0528.12694). It found that being underweight or obese prior to conception and age >29y at time of conception increased the risk of miscarriage. During pregnancy, drinking coffee or alcohol, lifting >20kg in weight on a daily basis, and night shift work compared with daytime non-shift work, also increased the miscarriage risk. It concluded that a quarter of miscarriages could be prevented if all women conceived between the ages of 25 and 29y, were a normal weight, did not drink alcohol, did not lift >20kg on a daily basis and only did daytime work. However, the miscarriage rate in the population studied was much lower than expected. This suggests early miscarriages may have been missed, as women were recruited from their first antenatal clinic appointment. There is also a risk of recall bias because 77% of the miscarriages had taken place by the time the woman was interviewed. The study provides further evidence for the increased risk of miscarriage with the lifestyle factors listed above, but more research is needed to determine whether there is a causal link with heavy lifting or night shift work. Antithrombotics and miscarriage Recurrent miscarriage is defined as 3 or more consecutive pregnancy losses before 24w gestation, and affects 1% of women of reproductive age. Women with recurrent miscarriage should be referred to a specialist clinic for further investigation (RCOG green top guideline 17). Identifiable causes include: Antiphospholipid syndrome. Acquired thrombophilia. Heritable thrombophilia, e.g. Factor V Leiden. The risk of miscarriage due to antiphospholipid syndrome has been shown to be reduced by the use of antithrombotic treatment. This has led to speculation that antithrombotic treatment may be helpful in all recurrent miscarriages. This small RCT in the NEJM randomised women with two or more miscarriages to receive placebo, aspirin alone, or aspirin and low molecular weight heparin (NEJM 2010;362:1586). Women entered the trial if they were planning to conceive or were less than 6w pregnant. The outcome was live birth rate. The trial was terminated early because there was no difference in live birth rate between the three groups. Live birth rates were between 50 and 57% across the groups. There were no significant harms, but bruising and swelling at injection sites were reported. The authors concluded that, in unexplained recurrent miscarriage, neither aspirin alone nor aspirin combined with low molecular weight heparin improved live birth rates compared with placebo. The linked editorial (NEJM 2010;362:1630) comments that it is still possible that some groups may benefit more than others, e.g. those with three or more pregnancy losses or heritable thrombophilias, but this study was not powered to detect these sub-group differences. There are ongoing trials specifically focusing on women with heritable thrombophilia. This RCT in America compared pre-conception use of 81mg aspirin daily with placebo during 6 menstrual cycles while trying to conceive and continued until 36w gestation. It included women with one or two previous miscarriages who had no major medical problems (Lancet 2014;384:29). The majority of women had one previous miscarriage, and more than half had one or two previous live births. Live birth rates were higher in the low dose aspirin group (58% vs. 53%), but the difference was not significant. There was no significant difference between groups in pregnancy loss (13% aspirin group vs. 12% placebo group) or other pregnancy complications. Vaginal bleeding was significantly more common in women taking low dose aspirin, but this was not associated with increased pregnancy loss. The authors conclude that low dose aspirin is not indicated for the prevention of pregnancy loss in women with one or two previous miscarriages. Management of miscarriage Method of miscarriage management does not seem to affect future fertility, with 80% of women achieving a live birth within 5y of their first miscarriage. Women aged >35y and with previous miscarriages had lower live birth rates. After one miscarriage, it is safe and desirable to try for a further pregnancy as soon as a woman feels ready. The best pregnancy outcomes are seen in those conceiving within 6m of the initial miscarriage. Maintaining a normal BMI, stopping smoking, cutting out alcohol and reducing caffeine all reduce the risk of miscarriage. There is no evidence that sexual activity has any effect. Lifting >20kg/d and working night shifts may increase the risk of miscarriage, but further research is needed. Ensure diabetes and thyroid disease are well controlled prior to conception. Do not prescribe aspirin and/or low molecular weight heparin to women with recurrent unexplained miscarriage as there is no evidence it improves live birth rates. We make every effort to ensure the information in these pages is accurate and correct at the date of publication, but it is of necessity of a brief and general nature, and this should not replace your own good clinical judgement, or be regarded as a substitute for taking professional advice in appropriate circumstances. In particular check drug doses, side effects and interactions with the British National Formulary. Save insofar as any such liability cannot be excluded at law, we do not accept any liability for loss of any type caused by reliance on the information in these pages. GP Update Limited April 2017 ALL OUR 2017 COURSES Our comprehensive one-day update courses for GPs, GP STs, and General Practice Nurses. We do all the legwork to bring you up to speed on the latest issues and guidance. All our courses are: Relevant Developed and presented by practising GPs and immediately relevant to clinical practice. Challenging Stimulating and thought-provoking. Unbiased Completely free from any pharmaceutical company sponsorship. Humorous and entertaining – without compromising the content! ‘Matt/The Daily Telegraph 2017© Telegraph Media Group Ltd’ Fun! Are they for me? Our courses are designed for: • GPs, trainers and appraisers preparing for appraisal and revalidation or wanting to keep up to date across the whole field of general practice. • GP ST1, 2 & 3, looking for the perfect launch pad into general practice and help with AKT and CSA revision. • GPs who want to be brought up to speed following maternity leave or a career break. • General Practice Nurses, especially those seeing patients with chronic diseases. What’s included? • 6 CPD credits in a lecture-based format, with plenty of time for interaction, humour and video clips, to keep you focussed and awake. • A printed copy of the relevant handbook including the results of the most important research in primary care over the last 5 years and covering the subjects more extensively than possible in the course. • 12 months’ subscription to www.gpcpd.com. With three times the content of the handbook, it allows you to capture CPD credits as you read on the site and use it in consultations! It also comes with Focused Learning Activities online learning activities to provide evidence for your appraisal and earn hundreds of further hours of CPD credits. • Buffet lunch and refreshments throughout the day! What’s not included? Our courses contain NO theorists, NO gurus, NO sponsors, NO reps on the day! Just real-life GPs who will be back at the coal face as soon as the course has finished. www.gp-update.co.uk ALL OUR 2017 COURSES The GP Update Course – our flagship course! With the amount of evidence and literature inundating us, it can be hard to know which bits should change our practice, and how. The GP Update Course is designed to be very relevant to clinical practice and help you meet the requirements for revalidation. We collate and synthesise the evidence for you so you don’t have to! Using a lecture based format, with plenty of time for interaction, the GP presenters discuss the results of the most important evidence and guidance, placing them in the context of what is already known about this topic. The presenters also concentrate on what it means to you and your patients in the consulting room tomorrow. Bristol Exeter London London Newcastle Sheffield Manchester Birmingham Norwich Bedford London Belfast Oxford Southampton Wed 10 May Thur 11 May Fri 12 May Sat 13 May Wed 17 May Thur 18 May Fri 19 May Sat 20 May Tues 23 May Wed 24 May Thur 25 May Wed 7 June Fri 29 Sept Sat 30 Sept Cardiff Exeter London London Leeds Liverpool Manchester Birmingham Cambridge London Nottingham Inverness Edinburgh Glasgow Wed 4 Oct Thur 5 Oct Fri 6 Oct Sat 7 Oct Wed 11 Oct Thur 12 Oct Fri 13 Oct Sat 14 Oct Tues 17 Oct Wed 18 Oct Thur 19 Oct Wed 1 Nov Thur 2 Nov Fri 3 Nov Lead. Manage. Thrive! – The NEW management skills course for GPs Many of us have chosen to be salaried or portfolio GPs yet feel impotent or looked over when it comes to contributing to the effective running of our practices. We become frustrated and feel that we have little or no influence over what happens. It’s not your fault, most GPs (experienced and new) have had very little training in management and leadership skills for clinical practice. Here’s the good news, all of us ‘lead’ whether in an official or unofficial role. Who is this course for? GPs at every stage in their career who aren’t quite sure how to get unstuck! Also highly relevant to anyone who recognises the need to build their personal resilience and leadership skills to meet the demands of modern primary care, i.e. practice managers, nurses, and administrative and support teams. As usual Red Whale has done all the legwork to bring you a concise, practical and actionable one-day course and handbook. Not only have we trawled through lots of relevant management, leadership and development literature, but we have also distilled its content through the lens of real GPs, enabling you to apply it to the reality of your practice. Newcastle Manchester London Southampton Thur 18 May Fri 19 May Wed 24 May Thur 16 Nov Exeter Oxford London Fri 17 Nov Thur 23 Nov Fri 24 Nov The Women’s Health Update Course From the pill to pelvic pain, periods and prolapses, the one day Women’s Health Update course is a comprehensive guide to understanding and managing common gynaecological problems in general practice. Using a case-based approach will give you the skills to manage your female patients in a real surgery. We aim to make the day fun, interactive as well as educational. You will leave the course feeling more confident, knowledgeable and with a much stronger pelvic floor!!! The course is designed for all GPs and GP STs (male and female!) not just those with a special interest, however it does fulfil the CPD criteria for DFSRH/DFFP LoC IUD/SDI. 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This course is able to look in much more detail at the big picture behind the disease perhaps most feared by our patients and, let’s face it, that 1 in 2 of us will be diagnosed with over our lifetime. Leeds Newcastle London Birmingham Nottingham Thur 22 June Fri 23 June Thur 29 June Fri 30 June Thur 9 Nov Manchester Norwich Exeter London Fri 10 Nov Wed 15 Nov Thur 16 Nov Fri 17 Nov Our Consultation Skills Courses One day small group courses designed for GPs, GP STs and General Practice Nurses. The courses have a practical focus and lots of engaging exercises allowing delegates to rehearse the most effective consultation behaviours. But don’t worry, there won’t be any role playing in front of everybody! For more information on each course, please visit www.gp-update.co.uk/courses The Effective Consultation Course Manchester London Wed 10 May Fri 12 May Leeds London Wed 4 Oct Fri 24 Nov The Telephone Consultation Course Leeds Birmingham London Bristol Wed 17 May Fri 19 May Wed 7 June Fri 9 June London Manchester Glasgow Fri 6 Oct Fri 13 Oct Sat 4 Nov The Medically Unexplained Symptoms Course Manchester Thur 18 May London Thur 19 Oct Prices Join the Red Whale pod GP Update Course: GP £195 | GP Registrar £150 | Nurse £150 All other courses: £225 or £210 for members of www.gpcpd.com Plan ahead! Save £60 when you book three courses in 2017. Use discount code 3BUNDLE2017 when booking via www.gp-update.co.uk or by phone 0118 960 7077. (GPCPD members, please log in and then click on the relevant button within the ‘Member information’ box on the right of the home screen to get your discount code) Relevant challenging and fun! GPCPD.com - your appraisal and revalidation all under one roof! Red Whale has joined forces with FourteenFish to bring you a seamless approach to the appraisal and revalidation process. Subscribe to GPCPD to improve your learning journey and take advantage of these partnership benefits: ‘12 months’ access to the course online handbook and focussed learning activities to gain additional credits. Seamless appraisal integration – just link your GPCPD account to FourteenFish and any learning you record in GPCPD will be automatically added to your appraisal. Exclusive 15% off FourteenFish Appraisal Toolkit – switch to this nimble and userfriendly toolkit for only £35.70 a year, and with a free switching service from your existing appraisal system, it’s a real catch! Effortless CPD recording – access to the FourteenFish Learning Diary app, to track your CPD from your smartphone and on the move. Access to surveys and tools for your revalidation – FourteenFish offers quick and simple to set up peer review and patient surveys to help you with revalidation. 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The Telephone Consultation Course (location)............................................................... (date)................................ The Effective Consultation Course (location)............................................................... (date)................................ The Medically Unexplained Symptoms Course (location)............................................................... (date)................................ I can’t attend a course, but would like to order your Handbook or DVD: GP Update Handbook and 12 months’ access to GPCPD £150 GP Update Handbook, DVD and 12 months’ access to GPCPD £225 Women’s Health Update Handbook £70 Cancer Update Handbook £70 Name............................................................................................. 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Please send this form with your cheque payable to GP Update Limited to: Red Whale, University of Reading, Reading Enterprise Centre, Earley Gate Entrance, Whiteknights Road, Reading, Berkshire RG6 6BU GP Update Limited, registered in England and Wales No. 7135974. Registered Office: Prospect House, 58 Queens Road, Reading RG1 4RP Full terms and conditions are available at www.gp-update.co.uk BMJ/010417 Relevant challenging and fun!