<<The novel blood test protocol pioneered by KKH, which is able to give results within a few hours, allows doctors to identify risks of miscarriage and determine care plans for their patients.>>

A smooth pregnancy and healthy baby is what every mother wishes for throughout her pregnancy journey. However, one in four expectant mothers experiences symptoms such as spotting or vaginal bleeding, fluid or tissue passing from the vagina, abdominal pain or cramps, or a dull pain in the lower back. While these signs can be alarming and may indicate a threatened miscarriage, about 80 to 85 per cent of these symptoms do not result in miscarriages.

Associate Professor Tan Hak Koon, Chairman, Division of Obstetrics and Gynaecology (O&G), KK Women’s and Children’s Hospital (KKH), warned against inferring that a miscarriage would occur based on any one symptom alone. Persistent bleeding or bleeding associated with pain may indicate an underlying problem and medical attention should be sought promptly, said Prof Tan, who is also Senior Consultant, Department of Obstetrics and Gynaecology, Singapore General Hospital.

<<Prof Tan Hak Koon warned against inferring that a miscarriage would occur based on any one symptom alone.>>

With increasing advancements in medical technology, early pregnancy screening helps parents-to-be better understand how the pregnancy is progressing and what they can expect.

Since January 2017, KKH has pioneered the use of a blood test as part of its screening protocol for women with high-risk symptoms of miscarriage. The blood test, which offers results in just a few hours, allows doctors to determine quickly whether a woman has normal or low levels of progesterone, an essential hormone in pregnancy.

KKH is the only known institution in the world to use this novel triage protocol routinely. Prior to this, women with signs of threatened miscarriage at KKH were typically prescribed oral progestogens, a steroid hormone, to stabilise the pregnancy. This remains a common practice in many hospitals around the world.

With this protocol, KKH patients at low risk need not be prescribed progestogens, thereby avoiding potential side effects, such as headaches, vomiting, mood changes and fatigue, which are associated with medical therapy, as well as additional financial costs.

“If the progesterone level is normal, we can reassure the majority of our patients that the risk of miscarriage is low, and that they do not need any further treatment. If the progesterone level is low, we can provide appropriate anticipatory guidance and treat that with progestogens. In so doing, we optimise the appropriate care that every woman receives,” said Dr Ku Chee Wai, Division of O&G, KKH.

“For pregnant women with no known risk factors or symptoms, the incidence of miscarriage is very low and there is no need to undergo this screening protocol,” he added.

Beneficial for all

A study of 1,087 women with threatened miscarriage at KKH’s Urgent O&G Centre has shown this novel protocol to be effective and accurate in predicting pregnancy outcomes at 16 weeks of gestation for two groups — the high-risk group with low progesterone levels and the low-risk group with normal levels.

Early intervention prevented a miscarriage from happening for 70 women in the high-risk group while 847 women in the low-risk category avoided being prescribed progestogens without increasing their risk of miscarriage.

This safe and effective clinical protocol has revolutionised the management of women with threatened miscarriage. Together with his team, Dr Ku, one of the co-principal investigators of the study, is looking for it to be readily adapted for use in other healthcare institutions.

It has garnered much interest from doctors overseas, who have approached KKH to further understand the processes required when implementing this protocol.

The future of testing

Further research is ongoing to develop even better ways to help women at risk of miscarriage. Dr Ku and his team collaborated with researchers at the Nanyang Technological University, Singapore to develop a urine test that takes only 30 minutes to determine the risk of miscarriage.

This method is fast and noninvasive, requiring just a small droplet of urine sample to screen for molecules associated with miscarriage risk. A pilot research study of 40 pregnant women at KKH found that the toolkit was able to accurately identify the pregnancy outcomes of all participants with symptoms of threatened miscarriage.

“These results signal the reliability of this testing method, and we will next validate it further by administering it on a larger population of patients,” Dr Ku said.

Coping with pregnancy loss

The majority of miscarriages occur because of underlying genetic or structural abnormalities, and neither parents are at fault, Dr Ku said.

Dr Choo Chih Huei, Senior Consultant, Women’s Mental Wellness Service, Department of Psychological Medicine, KKH, added that it is normal to grieve over a miscarriage.

“After a pregnancy loss, some may want to consider holding a small memorial service or a symbolic ceremony. Others may find it helpful to hold and touch the foetus or give the foetus a name. Remember to give yourself time and space to grieve,” he said.