Last week's report by the HSE into misdiagnosed miscarriages pinpoints major issues for the women involved who underwent surgery, writes JOANNE HUNT
UP TO ONE IN five pregnant women suffers a miscarriage. All too aware of its frequency, expectant mothers are ever alert to their bodies’ and their babies’ health – and, when things seem amiss, it is to the medical profession they look for reassurance.
Last week’s HSE report into the misdiagnosis of miscarriage in Ireland may do little to reassure women, however. In finding that, of 24 women told they had miscarried, 22 of them went on to have healthy babies, the report leaves more questions than answers.
As human error, rather than ageing scanning machines, was to blame for most of the misdiagnosed miscarriages concerned, better training in early pregnancy ultrasound procedures was a clear recommendation of the report. An over-reliance on ultrasounds to confirm or rule out miscarriages in very early pregnancy was also identified as an issue of concern.
Just as shocking, however, were the experiences of a quarter of those in the review group. After being misdiagnosed as having miscarried, these six women then went on to experience a rollercoaster of events.
Despite undergoing a surgical procedure to evacuate the contents of their uterus and thereby “complete” their miscarriage, all six remained pregnant after the procedure, four of them going on to give birth.
Speaking at the publication of the HSE’s report into miscarriage misdiagnosis last week, review group chair Prof William Ledger, head of the department of obstetrics and gynaecology at the University of Sheffield, admitted he was “shocked” by the double blunder.
“First the pregnancy was misdiagnosed as miscarriage and, second, the attempt to remove the miscarried tissue was not carried out properly,” he said.
“The tissue remained and turned out to be a viable pregnancy.”
Of the six women who underwent the surgical procedure, three were believed at the time to have had an incomplete miscarriage. Two were suspected of having had an ectopic pregnancy – one that occurs outside the womb – while one of the women had a suspected molar pregnancy, which entails the growth of abnormal tissue in the uterus and typically does not involve an embryo.
All of the women underwent an evacuation of retained products of conception (ERPC), commonly referred to, though not the same as, a “DC”. The ERPC to remove the remains of the pregnancy requires general anaesthetic and is just one of the ways in which a miscarriage can be managed.
That four of the women should remain pregnant after such an invasive procedure is “surprising” though not unheard of according to Prof Michael Turner, the Coombe obstetrician leading the HSE’s programme to improve maternity services.
Asked if it was unusual that women who had undergone a procedure to clear out the uterus would go on to have a baby, Turner described it as “highly unusual”, though he did say cases had been documented.
“It is possible to put an instrument into the uterus and not disturb an ongoing pregnancy,” he said, “but it’s very unwise and a risky thing to do obviously.”
Dr Keelin O’Donoghue, a senior lecturer in obstetrics and gynaecology at UCC, concurred. Asked if in her experience it was rare for a woman to give birth following such a procedure, O’Donoghue said, “It is very unusual and hard to see how it happened”.
However, two of the six women who underwent the surgical procedure, though still pregnant after it, later miscarried.
The report can’t but leave them wondering whether the surgery had any effect on the outcome of their pregnancy.
O’Donoghue said that a number of steps could be taken to assess the outcome of an ERPC, including an ultrasound done during or after the procedure to confirm its completeness, a biopsy of placenta-type tissue taken on consent of the patient, or a clinical examination.
While an ultrasound taken after surgery had detected a baby’s heartbeat in both cases, Ledger said it could not be concluded whether or not the later miscarriage in these two cases was a result of the procedure.
“What you can’t say is whether or not the procedure precipitated the later miscarriage,” he said. “It seems to me that if the procedure was likely to have caused the miscarriage, it would have happened almost immediately, but these were cases where time passed.”
While it was “not possible to say” how much time had elapsed between the surgical interventions and the miscarriages, Ledger said: “I hope and I believe that the two events were not related but we can’t be sure . . . it’s impossible to be certain.”
Responding to the findings of the report, Lorcan O’Toole of the Miscarriage Association of Ireland said, “In our experience, it is a very rare event for a woman who has undergone a to then go on to deliver a baby.”
O’Toole said that the association had known the procedure to “result in miscarriage but not a live birth”. However, he added, “as we offer a support service to those who have suffered miscarriage, we would not normally hear about live births in such circumstances.”
While it cannot be said that the two miscarriages were linked to the unnecessary ERPC, the report’s authors are clearly amazed that babies were born in spite of the procedure.
The triumph for Melissa Redmond, the Dublin mother who first brought misdiagnosed miscarriage to the attention of the public, is that not only will an expectant mother’s request for a second ultrasound now be heeded, but also that no surgical procedures can now take place until the result of this second scan is fully known.