INADEQUATE TRAINING in the use of ultrasound machines resulted in 24 women being wrongly told they had miscarried when in fact their unborn babies were still alive, an independent review has found.
Two of the women who were incorrectly told they had miscarried and who had surgical procedures to evacuate their wombs lost their babies at a later stage.
These two women “will never know” if the surgical procedures precipitated their subsequent miscarriages, said the chairman of the review, Prof William Ledger.
The National Miscarriage Misdiagnosis Review report, published yesterday by the HSE, also found four women who had surgical interventions to evacuate their wombs went on to have live births.
The report recommends second ultrasounds after an initial diagnosis of miscarriage.
The report reviews misdiagnoses over the past five years, where drugs or surgery were recommended and where subsequent information showed pregnancy was viable.
Between June and October last year, 409 related calls were received by 19 maternity hospital helplines. Some 136 callers were reassured their concerns were unfounded and 273 clinical files were reviewed by the hospitals. Of these 33 were referred to the clinical review team. Of these one was found to be a duplicate, giving a total of 32 cases. Eight of these did not meet the terms of reference, leaving 24 cases for examination.
Of the 24 women who had been wrongly told they had miscarried, 22 went on to have live births.
In 14 of the cases, the women presented at seven weeks’ gestation or less. The first diagnosis of miscarriage was made by registrars in 13 cases, consultants in six and by senior house officers in five.
While several clinicians reported significant experience in conducting ultrasounds in early pregnancy, “formal training in early pregnancy ultrasound was reported by only three”.
In just three cases the women had requested follow-up scans after being told they had miscarried. Some 21 of the pregnancies were found to be viable in scheduled follow-up scans before or after scheduled interventions.
In 18 of the 24 cases a surgical procedure was conducted or scheduled, while in eight medication to induce evacuation was prescribed.
In six cases a procedure was carried out. Of these there were four live births and two miscarriages.
Prof Ledger said it was “not wise” to rely on a single ultrasound at six or seven weeks’ gestation to determine viability.
Ultrasound equipment in the 16 affected hospitals was found to be “at a generally good level of operation”, though hospitals are reviewing equipment and where machines are older than five years they are being replaced.
