Tommy’s standardised text for letters – Intro

Investigations & research 

 

Routine investigations and research 

A member of our research team will contact you following this consultation and arrange an appointment to have all the routine blood tests that we have discussed today. These are: full blood count, thyroid function test, thyroid antibody test and antibody tests for antiphospholipid syndrome (“sticky blood”). We will also arrange for you to have a pelvic ultrasound scan to check the shape of your womb and ovaries. Our research team will also discuss with you the opportunity to have additional tests and to be part of the studies that we are running. 

 

Parental karyotyping (5 or more losses) 

In addition to the routine tests, as you have sadly suffered several miscarriages, we discussed that it would be important for us to look at the genetic makeup of you and your partner. This is done through a blood test. These bloods will be taken at the same time as the routine tests, and your partner will need to come with you to the appointment. 

 

Fetal cytogenetics (offer to all) 

In the unfortunate event that you go on to suffer any further miscarriages, it will be helpful if you can bring in the tissues that you pass so that we can analyse them in the laboratory and see if there is any obvious reason why the pregnancy ended. The pregnancy tissue must be placed in a clean dry pot. Please contact our Tommy’s team to arrange bringing the tissues in if you can. In up to 4 in 10 cases, fetal genetic testing may be inconclusive due to a lack of tissue in the sample sent to the laboratory. 

 

Abnormal results 

 

TPO positive and normal TFT 

Your blood test shows that you have thyroid antibodies. This means that you are at a higher risk of developing a thyroid problem during pregnancy. I have reassured you that you do not require any treatment currently, but we recommend monitoring your thyroid function during pregnancy. This will start at around 6-8 weeks of pregnancy, at the time of your first reassurance scan, with further tests at 16-18 weeks and 28 weeks. If your thyroid results remain normal throughout the pregnancy then nothing further is needed. Depending on the test results we may recommend starting a treatment called levothyroxine. 

 

Abnormal TFT 

Individualised dictation depending on result. 

 

Abnormal USS 

Individualised dictation depending on result. 

 

Abnormal LA/aCL/B2GP1 

If repeat test needed – standard letter already available and repeat test to be arranged. Please counsel women in the first appointment that they may need a repeat test and so could receive a letter indicating this, so it won’t be a surprise/shock if they receive it without warning. 

 

If 2x borderline or positive results – use aspirin and low molecular weight heparin text (see below). 

 

 

Interventions 

 

Progesterone (4 or more losses) 

Since you have suffered with several miscarriages, we would recommend that you take progesterone pessaries in your next pregnancy. These should be started when you become pregnant and your GP should provide you with the prescription. We recommend Utrogestan 400 mg to be inserted vaginally twice a day from the time of a positive pregnancy test until you complete 16 weeks of pregnancy. If you are having difficulty obtaining the prescription from your GP please contact us. 

 

Progesterone (bleeding during pregnancy advice) 

I very much hope your next pregnancy is successful, but if you develop bleeding in the first trimester we would recommend starting progesterone pessaries (Utrogestan 400 mg inserted vaginally twice a day) and to take these until 16 completed weeks of pregnancy. There is some evidence they may help improve the chances of having a live birth. Your GP can prescribe these for you, but if you have difficulty obtaining the prescription please contact us. If the pregnancy does not continue successfully then you will need to stop taking the pessaries. 

 

Aspirin and Clexane 

The results of your tests suggest that you have sticky blood and that this may be causing your miscarriages. Therefore, we recommend that you take medication to help thin the blood when you become pregnant. Your GP should prescribe Aspirin tablets 75mg once daily and Clexane injections (insert dose) once daily, these are to be started when you become pregnant. Your GP will need to refer you to consultant led antenatal care and you will see a Haematology specialist who will discuss how long to continue the medication for. 

 

Metformin 

Today we discussed your diagnosis of polycystic ovary syndrome and how there is some evidence that giving a medication called Metformin may improve your chances of having a successful pregnancy. In view of this, I recommend that you start Metformin tablets 500mg, which should be prescribed by your GP. The dose we recommend starting with is 1 tablet a day for the first week, then increase to 2 tablets a day (morning and evening) in the 2nd week and 3 tablets a day (morning, lunch and evening) in the 3rd week. Taking 1 tablet 3 times a day can then be continued throughout the pregnancy. I also mentioned the common side-effects that may occur (diarrhoea, nausea and vomiting). If you find that you are struggling with side-effects, then you can contact us or your GP and we may suggest reducing the dose. 

 

Thyroid treatment 

Individualised depending on the result. 

 

Closing statement 

A member of our team will discuss the results of all of your tests during your follow-up appointment, which should be in the next couple of months. You will receive an appointment in the post and this will also be a telephone consultation. If you become pregnant before your follow-up appointment, please contact us and we will check all available results and advise you if any action is needed. We will also arrange for you to have a reassurance scan from around 7 weeks of gestation. I have enclosed a card with the details of our Tommy’s team. 

 

I wish you all the very best for the future. 

 

 

 

 

Tommy’s template for dictation for new patients 

 

Brief personalised summary of pertinent points from history 

 

Insert routine investigations & research paragraph and fetal karyotyping 

 

Insert any additional tests (e.g., parental karyotyping) or treatments that will be offered regardless of results (e.g., progesterone/metformin) 

 

Insert closing statement 

 

Suggested standardised text for normal results 

 

It was lovely to speak with you today regarding the results of all the investigations you have had with Tommy’s. I have reassured you that all your test results have come back as normal. This means there is no obvious medical reason for your previous miscarriages.  

 

Please contact us if you become pregnant again and we will be able to offer you scans from around 7 weeks of gestation to monitor your pregnancy. A member of our team is always available during working hours if you need to contact us for advice. 

 

I wish you all the very best for the future and sincerely hope that you go on to have a successful pregnancy.