When a patient's problem mirrors your experience
Jane Andrews, aged 24, comes to see you eight weeks into her first pregnancy. She is very tearful because she has had some vaginal bleeding and thinks she may progress to a miscarriage. In the last year both your wife and your sister in law have had miscarriages at a similar stage. Dr Steve Brown advises.
What are the clinical features of a threatened miscarriage?
There is vaginal bleeding before 24 weeks gestation anything from faint brown discharge to profuse red blood. No products are passed and there is generally no pain, although sometimes there is a dull ache. Clinically the uterus is normal size for dates, and the cervix is closed. The pregnancy test is positive and ultrasound scanning confirms a viable intrauterine pregnancy.
What is the likely outcome of a threatened miscarriage?
About 60 per cent of pregnancies end in miscarriage, although many of these will present as a heavier than normal period. For clinically recognised pregnancies the miscarriage rate is about 15 per cent. However, the overall prognosis is good with 75 per cent of threatened miscarriages resulting in a successful pregnancy.
What is the best management?
Bedrest is often recommended but there is little evidence to show a benefit. Explanation and attention to the emotional consequences of a threatened miscarriage are needed.
How may women miscarry more
than three times?
Some 0.8 per cent of women miscarry more than three times. Even after three miscarriages the prognosis for a successful fourth pregnancy is about 70 per cent.
What feelings may surface during the consultation?
It is vital we acknowledge that certain patients and the conditions they present with can provoke feelings within us during the consultation. Unless we are amazingly lucky, at some point in our GP careers a significant personal or family illness will be mirrored by a patient. We should do our best to prepare ourselves for such an eventuality.
As GPs we might feel angry and bitter during consultations that mirror our own experience. Other feelings provoked could be fear, sorrow, guilt, and worry for the patient. On a more positive note a GP could be protective showing greater understanding and empathy.
How may these feelings affect the consultation?
It may be that the consultation is enhanced by our own experiences. We will know from first-hand experience what the best management should be and how the local hospital department functions.
We could pay more attention to the patient's feelings and be prepared to spend more time in the consultation than before. Alternatively, the consultation may not go well. An angry and bitter GP may not be able to cope with patients' anxieties.
This may mean a shorter consultation for self-protection. The patient's concerns and anxieties may not be met in this instance. A patient who senses their GP is upset may find it more difficult to be open and receive vital emotional support.
How open should we be of our own experiences?
This is a difficult question. Most GPs will not want to be too open. Our own experiences and background and coping mechanisms will probably be very different to the patients' and they will have different ideas and concerns that they will bring to the consultation.
We are aware that if we are too open the focus of the consultation will move away from the patient who has come for help and support.
Experiences will enable us to empathise better and phrases like 'I do know to some extent how you feel' or 'I know that must be difficult' will have a genuine resonance to them. There is nothing wrong in sometimes hinting to patients that 'a relative of mine was in a similar situation'.
What should I do to help me in this
type of consultation?
The GP needs to acknowledge their feelings and be self-aware about how experiences could affect the consultation. It may be useful to discuss the situation with others. Hopefully discussions could take place with some or all of the partners. Other sources of informal support could be a trainers group, a co-mentoring type of network, or a young GPs' group. Such informal support which is usually part of the registrar year sometimes disappears and this is a great pity.
Each of us will want to share with other GPs in different ways and we should be able to find a way that suits our personality and 'openness level'.
What if informal support is not enough?
It may be if consultations are too painful that further help is needed. Your own GP is a good starting point after all, they should be able to understand and empathise. Other sources of help could be the PCT or trust occupational health scheme (if there is one), or the BMA support line. A specific plan of help should be devised. Occasionally, reduced hours or even time off work is needed, coupled with longer-term psychological or counselling input.
I was able to obtain a clear history from Jane and her anxieties were similar to those of my wife.
However, the light nature of the bleeding and a lack of pain suggested a threatened miscarriage and I suspected a good outcome.
A vaginal examination was also reassuring, showing a six-week-sized uterus and a closed cervical os.
I felt relieved and pleased (although slightly envious) that Jane would hopefully not have to go through a miscarriage. An early ultrasound
scan in the early pregnancy unit the next morning showed a viable pregnancy.
· Be aware that personal experiences can provoke feelings in the consultation
· Be ready to talk to your partners
· Build up a support network
· Consider how open to be with patients
· Do not be afraid of seeking formal help
BMA counselling service 08459 200169
The Miscarriage Association www.miscarriageassociation.org.uk