Information about being a carrier

Some women receive a test result that requires further discussion and / or follow up. How this happens will depend upon the type of test that that requires following up. In some cases you will be contacted by your Community Midwife, who will explain the test result to you and tell you what might happen next.

Alternatively you may be contacted by a Specialist Screening Midwife or Fetal Medicine Midwife who will explain things to you and talk to you about the test result and what might happen next. Some women are referred to other specialist services and your Community Midwife or Specialist Midwife will arrange this.

Scan findings are discussed at the time of the scan. If there are any concerns, women will be referred to a fetal Medicine Consultant for further scans and discussion of the findings. (See Fetal Medicine page).

The following link to the government website will direct you to information leaflets relating to a number of conditions. Scroll down the page to find additional information on sickle cell, thalassaemia and other haemoglobin variants; infectious diseases; 11 physical conditions relating to the 20 week scan; diagnostic tests. www.gov.uk

Information for friends and relatives about mechanical clot retrieval for ischaemic stroke at North Bristol NHS Trust. 

What has happened?

Your friend or relative has had an ischaemic stroke and needs an emergency procedure. 

Strokes happen when an artery (blood vessel) is blocked by a clot, cutting off blood flow to part of the brain. Without a blood supply, brain cells can be damaged or destroyed because they may not receive enough oxygen. 

Symptoms may have included numbness or weakness on one side of the body, problems with balance, speech, vision, and/ or swallowing.

What is thrombolysis?

Thrombolysis is a drug treatment which is given within 4 hours of an ischaemic stroke to dissolve the blood clot. 

It is a treatment that is not suitable for everyone and is less effective than mechanical thrombectomy when the clot is large. Certain medications or medical conditions may mean that thrombolysis is not the suitable for all patients.

What is mechanical clot retrieval?

• Mechanical clot retrieval aims to remove the blood clot from the affected artery in the brain, restoring blood flow and minimising brain tissue damage.
• The procedure is often done using general anaesthesia (patient will be asleep).
• A thin tube called a catheter is inserted into an artery, usually in the groin, and moved towards the site of the clot. The clot retrieval device is inserted through the catheter.
• Different devices and methods are used to remove blood clots. The most commonly used device is called a stent retriever, which traps and removes the clot.
• The aim is to remove the clot as soon as possible, within a few hours of the stroke to restore blood flow to the affected area of the brain.

The procedure is only suitable for some patients, a healthcare team experienced in managing acute ischaemic stroke will decide if you are suitable for this procedure. The following will factors will be taken into consideration:

• The vessel the blood clot is in.
• The time the stroke happened.
• Other medical conditions.
• The patients ability to care for themselves.

Stent retrieval of a clot 

Clot that has been removed

Who will do the procedure?

External transfers to Southmead Hospital

What are the benefits of mechanical clot retrieval?

What are the risks of mechanical clot retrieval?

What happens after the procedure?

What happens after the procedure?

References and further information

© North Bristol NHS Trust. This edition published July 2024. Review due July 2027. NBT003017.

The purpose of ISARIC CCP-UK (International Severe Acute Respiratory and emerging Infection Consortium Clinical Characterisation Protocol United Kingdom) is to prevent illness and deaths from infectious disease outbreaks.

It is a global federation of clinical research networks, providing a proficient, co-ordinated, and agile research response to outbreak-prone infectious diseases. The Clinical Characterisation protocol (CCP) is designed for any severe or potentially severe acute infection of public health interest and feeds into the data collated by ISARIC.

The protocol allows data and biological samples to be collected rapidly in a globally-harmonised manner. It has been previously initiated in response to other acute infections, including MERS-CoV and Ebolavirus, and has now been initiated in 2020 for COVID-19.

All patients admitted to the Trust with a diagnosis of COVID-19 are enrolled with data collected on demographics, co-morbidities, signs, symptoms, treatments and outcomes.

A subset of patients will be consented into sub studies which will include additional biological sampling. This data can be combined globally to provide information on those most at risk, common signs and symptoms and also help establish treatments.

The GenOMICC (Genetics of Susceptibility and Mortality in Critical Care) study seeks to identify the specific genes that cause some people to be susceptible to specific infections and consequences of severe injury.

When a patient is already sick, different genetic factors determine how likely they are to survive, and our genes are what determine how susceptible we are to life-threatening infection.

Susceptibility to COVID-19 is almost certainly, in part, genetic. By identifying these genes, we should be able to determine the best use of existing treatments, and design new treatments to help people survive critical illness. This will be achieved by comparing DNA and cells from carefully selected patients with samples from healthy people.

GenOMICC was designed for this crisis. Since 2016, the open, global GenOMICC collaboration has been recruiting patients with emerging infections, including COVID-19. All patients with confirmed COVID-19 in critical care are eligible for this study.

GenOMICC is prioritised as an NIHR Urgent Public Health Study in the UK.

North Bristol Trust: Thrombectomy Referral Criteria – External Hospitals

Thrombectomy service for patients from the Severn region, England operate 24/7.

Referrals from outside Severn and Wales should be discussed with your nearest thrombectomy centre. If the referral time falls outside operating hours for your nearest thrombectomy centre then please discuss with us via referapatient. 

Referrals should be made via Homepage (referapatient.org) to North Bristol Trust in the first instance

   (Search ‘Mechanical Thrombectomy’ and ‘Southmead Hospital’)

If no response is received in 10 minutes, please phone the thrombectomy phone directly

 07784 359723

In case of difficulties, alternative contacts are stroke registrar bleep 1490, or ANPs 0117 9549092.

Before referral, the following should have been carried out:

• Upload of all new brain imaging to cloud portal (Biotronics 3Dnet).
• Input all referral information via: Homepage (referapatient.org)
• Where intravenous thrombolysis is indicated this should not be delayed.

Referrals should fulfil all of the following criteria:

Clinical

• NIHSS >= 6 or disabling/fluctuating deficit
• Independent before the index stroke (modified Rankin Scale 0-2).
• Fit for emergency transfer. If concerns exist regarding patients being safe for inter-hospital transfer seek advice from local anaesthetic / critical care team
• Sufficiently well to benefit from treatment. This includes co-morbidities and frailty; while age influences fitness for treatment age does not by itself limit capacity to benefit.

Radiological

• All patients should undergo a NCCT and CTA with coverage from aortic arch to the vertex*
  • This should be uploaded to Biotronics 3DNet routinely,
  • This should have a local diagnosis of an LVO (carotid-T, M1, proximal M2 or tandem occlusions) via a consultant radiologist or automated post processing tool such as Rapid or Brainomix.

*Multi or dual phase CT angiography is preferred.

• For patients arriving at Southmead within 6 hours:
  • NCCT and CT angiography is required.

 

• For patients arriving at Southmead within 12 hours:
  • NCCT and CT angiography is required. 
  • Minimal early ischaemic change required (defined as NCCT ASPECTS >= 3 if perfusion imaging is not available locally).
  • Additional CT perfusion with automated post processing is preferable.

 

• For patients arriving at Southmead between 12 and 24 hours:
  • NCCT, CT angiography and CT perfusion is required. 

NOTE:   If a patient does not fulfil the above criteria but it is felt that they would benefit from treatment, for example young patient with large ischaemic core, basilar occlusion, referrals will still be considered

Please ensure a ReSPECT  form has been completed prior to transfer

 

What is diabetes?

Diabetes means the body can no longer control the level of glucose (sugar) in the blood. Our bodies make insulin (a hormone) which allows glucose in the blood to be used by the body for energy. In diabetes:

• The body doesn’t produce any insulin, or        
• The body doesn’t produce enough insulin, or            
• The body cannot use insulin efficiently (most common)

The body particularly struggles to use insulin when you are unwell. 

Aims of this page

When a person with diabetes is unwell, glucose levels often rise as a result of the illness.  High glucose levels can lead to further problems and a longer stay in hospital.  For this reason, your diabetes medication may need to be adjusted. You will have help to do this in hospital. It is also important that you continue to follow a healthy balanced diet.

The information on this page is designed to help you to:

• Understand the importance of a healthy balanced diet in diabetes
• Understand North Bristol NHS Trust’s menus
• Understand the importance of making an individualised choice at mealtimes

Does it matter what I eat?

Yes. What you eat affects the levels of glucose and fat in your blood, your blood pressure and your weight. It is therefore important to follow a healthy, balanced diet. The below recommendations are the same as for the general population. 

Healthy eating involves:

• If you are overweight, try to lose some weight (when you are well).
• Eat at regular intervals during the day i.e. breakfast, midday and evening meal. Don’t miss meals.
• Include starchy food (carbohydrate) at each meal (approximately one quarter to one third of the plate). Aim to have about the same amount of starchy food each day. Go for wholegrain, high fibre options where possible.
• Have two or three portions of vegetables each day.
• Have two or three portions of fruit spread throughout the day.
• Limit foods with a high fat content.
• Cut down on sugar, sugary foods and sugary drinks (this includes smoothies and fruit juice).
• Drink alcohol in moderation.
• Cut down on salt.
• Special diabetic foods are not necessary.

Further information is available on healthy eating with diabetes.

Is there a diabetes specific menu in hospital?

No. Healthy eating recommendations are the same as for the general population. There is no need for a specific ‘diabetes menu’ or meal options to be coded as ‘suitable for individuals with diabetes’. The main menu at Southmead Hospital offers a variety of options that allows a person to eat a balanced diet. 

Please note some main courses from the menu already contain a portion of starchy carbohydrates. For example, cheese and potato pie already has a portion of carbohydrate in it in the form of potato. In this instance, you may wish to choose two vegetable side dishes rather than a further potato, pasta or rice accompaniment.

Menu options which contain high amounts of sugar should be limited

Some options on the menu are higher in calories and sugar. Examples include: fruit crumbles, sticky toffee pudding, bread pudding or parkin cake, sponge puddings, rice pudding, chocolate crunch etc

Due to their high sugar content, these options may significantly increase blood glucose levels. Intake of these options should be limited. Small portions of these can be enjoyed occasionally.

Lower sugar and calorie alternatives include:

• Fruit in natural juices
• A portion of stewed fruit
• A small pot of yoghurt

Some patients in hospital may be identified as being at ‘higher nutritional risk’:

• If the patient is underweight.
• If the patient has recently lost weight.
• If the patient has a poor appetite and intake (how much food they eat).

These patients are encouraged to increase the amount of food they eat. They will benefit from having some of the higher calorie and sugar options, as noted above. This is not the case for everyone in hospital and meals should be chosen on an individual basis. Please ask the ward staff for support if you are unsure.

Hospital meal times

Meal times in hospital may be at different times to at home. Depending on the type of medication or insulin you take to manage your diabetes, the difference in meal times could increase your risk of having a ‘hypo’ (blood glucose less than 4mmol/L). 

If you take rapid-acting insulin (NovoRapid™, Humalog™, Apidra™ or Fiasp™) with meals, it is advised that you wait until your meal has been served to you before injecting your insulin. This reduces your risk of having a hypo if the meal is delayed, is different to what you ordered, or you don’t expect to eat the full portion.

Snacks such as cereal, toast, sweet biscuits and milky drinks are routinely available on the ward. Please ask a member of ward staff if you require a snack to prevent a hypo if your meal is delayed, at a different time to home, or, if you have been advised to have a snack before bed.

References

North Bristol NHS Trust Healthy Eating with Diabetes

British Dietetic Association:  The Nutrition and Hydration Digest: Improving Outcomes through Food and Beverage Services (PDF). 2nd Edition. Last updated July 2019. 

Diabetes UK (May 2011) Evidence-based Nutrition Guidelines for the prevention and management of diabetes (PDF).

National Institute of Clinical Excellence. NICE. (Last updated July 2016) Type 1 diabetes in adults: diagnosis and management

National Institute of Clinical Excellence. NICE. (Last updated May 2017). Type 2 diabetes in adults: management

How to contact us

See your appointment letter for the number to phone with any queries you may have.

If you or the individual you are caring for need support reading this leaflet please ask a member of staff for advice.

If you’re an overseas visitor, you may need to pay for your treatment or you could face fraud or bribery charges, so please contact the overseas office:

• Telephone: 0117 414 3764
• Email: overseas.patients@nbt.nhs.uk

Promoting a culture of supporting and working in partnership with carers within our hospitals

North Bristol NHS Trust (NBT) and University Hospitals Bristol and Weston NHS Foundation Trust (UHBW) value the vital work done by those with unpaid caring responsibilities (referred to as ‘carers’ within this charter) and are committed to working together with them as expert partners in care.

A carer is someone who provides care for someone else who, due to illness, mental health problems, substance misuse, physical and learning disability, old age or frailty, is unable to care for themselves without their support. This charter includes young carers and parent carers.

Carers as equal partners

We will ensure that the role you have, as a carer, is valued by all staff and will make sure that we respect, listen to and understand carers and what they do. We will identify carers as early as possible.

Supporting carers

We will inform you as a carer of your right to an assessment under the Care Act 2014 and the Children & Families Act 2014, providing information about the range of support and advice services available to you as a carer. We recognise the importance of your needs being met and will support you to have breaks away from the ward when you need them.

Young carers

We will ensure that we involve young carers and will work to support you and recognise the valuable role you play in the health of our patients.

Sharing information

With the relevant consent obtained, we will provide information that is timely, appropriate and accessible. We will involve you in decision making, with the patient wherever possible, whilst respecting the need for confidentiality.

Having a voice

We will ensure that you have an easily accessible means of giving feedback, that this is responded to and that you are involved in the planning and development of our services.

Discharge planning

We will begin discharge planning as soon after admission as possible. We will help you understand the processes, including you in all discussions, respecting your detailed knowledge of what happens outside the hospital. With the relevant consent obtained, we will include you in all discussions on all aspects of care and medication. 

To contact us

For Southmead and the BRI:

• Southmead 0117 937 5626
• BRI 0117 435 0188 or 0117 435 0193

or email carerliaison@carersbsg.org.uk

For Weston-super-Mare:

• 01934 636363 and ask for extension 3193

or email hospitalteam@alliancehomes.org.uk

This information is for patients who have been directed to this page as you are starting, or already taking, a medicine, known as enoxaparin. It is most likely that the enoxaparin brand you will be using is called Inhixa®. Enoxaparin is part of a group of medicines called anticoagulants. An anticoagulant medicine prevents blood clots forming in your blood vessels by making your blood take longer to clot.

Enoxaparin contains a product derived from pigs. If you have any ethical objections to the use of animal products please discuss this with a healthcare professional before using enoxaparin.

Enoxaparin reduces blood clot risk

A blood clot can develop in the large veins of the body, usually in the legs. This is called a deep vein thrombosis (DVT). 

Sometimes, a blood clot can break free and travel through your blood vessels. If a clot lodges in the blood vessels of your lungs it is called a pulmonary embolism (PE). A PE can cause chest pain and difficulty in breathing and, if severe, can cause death. Rarely, a clot may move to the brain and cause a stroke. 

After surgery there is an increased risk of blood clots forming. Evidence shows that following some types of surgery, an extended period of treatment with enoxaparin reduces this risk. You will usually need to inject enoxaparin for between 10 and 28 days after your surgery.

Why do I need enoxaparin?

There are lots of reasons why you may be at higher risk of blood clots. Here are some of the most common ones:

• Age over 40, as the risk increases with age.
• Taking any kind of oral contraceptive pill (OCP).
• Taking hormone replacement therapy (HRT).
• Some heart problems.
• Severe breathing difficulties.
• Varicose veins.
• Obesity .
• If you have had a DVT before.
• If you have a family history of DVT.
• If you have previously suffered a stroke.
• The type of surgery, such as knee or hip replacement or abdominal surgery.

How can I tell if I have a DVT or PE?

Early signs of a deep vein thrombosis (DVT)

Early signs of a pulmonary embolism (PE)

How should I inject enoxaparin?

You need to inject Inhixa® under the skin (a ‘subcutaneous injection’). You should have the injection at the same time every day. 

A healthcare professional will have shown you how to inject yourself using the Inhixa® syringe. They should also tell you how long the treatment will be for. It is important that you know the correct technique before you try to inject yourself. If you are unsure, you should ask a healthcare professional for advice.

Step-by-step instructions for injecting Inhixa®

Things to look out for

Heparin-induced thrombocytopenia (HIT)

Dos

Don'ts

Your questions answered

After discharge from hospital who can I contact for help or advice?

The patient information leaflet that came with enoxaparin advises against using a particular medicine that I am taking. Is this okay?

Can I inject anywhere other than my stomach?

Where should I keep the enoxaparin syringes?

What should I do if there is an air bubble in the syringe?

What should I do if I have injected too much enoxaparin?

What should I do if I miss an enoxaparin injection?

How can I find out more about enoxaparin?

What should I do with my used syringes?

© North Bristol NHS Trust. This edition published January 2024. Review due January 2027. NBT002719

Key points

• A miscarriage is the early loss of a pregnancy.
• Recurrent miscarriage is when this happens three or more times.
• Around 1% of women have recurrent miscarriages.
• Most couples who have had recurrent miscarriages still have a good chance of a successful pregnancy in the future.
• If you have had recurrent miscarriages, you may be offered blood tests and a pelvic ultrasound scan to try and identify the reason for them.
• Despite careful investigations, it is often not possible to find a reason for recurrent miscarriage.
• Your doctors will not be able to tell you for certain what the outcome will be if you become pregnant again.

About this information

This information is for women and couples who have had three or more miscarriages. It is based on the Royal College of Obstetricians and Gynaecologists (RCOG) guidance, last reviewed in 2011. It explains:

• Some of the known reasons for recurrent miscarriage;
• The most effective ways of investigating and treating women who have experienced recurrent miscarriages.

National guidance aims to help you and your healthcare team make the best decisions about your care. It is not meant to replace advice from a doctor or midwife about your own situation.

This guidance does not look at reasons or treatment for a single miscarriage.

What is recurrent miscarriage?

A miscarriage is the loss of a pregnancy at some point during the first 23 weeks. There is a 10 - 15% chance of miscarriage with any pregnancy, and most miscarriages occur within the first 12 weeks.

Recurrent miscarriage is when three or more pregnancies end in miscarriage. 1% of couples who are trying to conceive have recurrent miscarriages, and for women and their partners it can be an incredibly distressing situation.

For some women experiencing recurrent miscarriage, there is a specific reason for their losses. For others, however, their repeated miscarriages may be due to chance alone.

For around half of women who have recurrent miscarriages, no underlying cause is found.

What are the reasons for recurrent miscarriage?

A number of factors may play a part in recurrent miscarriage. It is a complicated problem and more research is still needed.

Abnormalities in the embryo

An embryo is a fertilised egg. An abnormality in the embryo is the most common reason for single miscarriages. However, the more miscarriages you have, the less likely this is to be the cause of them.

Your age and past pregnancies

The older you are when you become pregnant, the greater your risk of having an abnormality in the embryo and therefore the greater your chance of having a miscarriage.

Having multiple miscarriages in the past may also increase the likelihood of having another one.

Lifestyle factors and weight

Smoking, excessive alcohol or caffeine intake, and having a body mass index (BMI) above 25 are all associated with increased risk of miscarriage, and may therefore be a factor in recurrent miscarriage for some women.

Genetic factors

For around 3 - 5% of women who have recurrent miscarriages, they or their partner have an abnormality in one of their chromosomes (the structures within our cells that contain our DNA and therefore determine the genetic features we inherit from our parents).

Although such abnormalities may cause no problem for you or your partner, they may sometimes cause problems if passed on to your baby, and therefore be a reason for recurrent miscarriage.

Autoimmune factors

Antibodies are substances produced in our blood in order to fight off infection. Some people produce antibodies that react against the body’s own tissues; this is known as an autoimmune response.

Antiphospholipid antibodies (aPL) are an example of antibodies that react against the body’s own tissue and are strongly associated with recurrent miscarriage.

About 15% of women who have had recurrent miscarriages have antiphospholipid antibodies in their blood, compared to fewer than 2% of women who have normal pregnancies. If you have antiphospholipid antibodies and a history of recurrent miscarriage, your chances of a successful pregnancy may be reduced.

Abnormalities in womb structure

It is not clear how far major irregularities in the structure of your womb can affect the risk of recurrent miscarriage. Women with serious anatomical abnormalities affecting their womb, and who do not have treatment for them, appear to have a higher risk of miscarrying or giving birth early.

Minor variations in the structure of your womb do not cause miscarriage.

Weak cervix

In some women, the entrance to the womb (the cervix) opens too early in the pregnancy and results in a miscarriage. This is known as a weak cervix, and is only recognised as a possible cause of miscarriage in the second and third trimester (from 13 weeks onwards).

Polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common condition in which an imbalance of hormones causes symptoms including irregular or absent periods, or changes in aspects of your appearance.

It is sometimes, but not always, associated with ovaries that appear larger than normal on an ultrasound scan and have more follicles (fluid filled spaces containing developing eggs) than normal ovaries. Having polycystic ovaries on an ultrasound scan does not necessarily mean you have PCOS, and not all women with PCOS have polycystic ovaries.

Having a diagnosis of PCOS has been linked with having an increased chance of miscarriage, however the exact association with recurrent miscarriage isn’t clear.

Diabetes and thyroid problems

Diabetes or thyroid disorders can be factors in single miscarriages. They do not cause recurrent miscarriage, as long as they are treated and kept well controlled.

What can be done to investigate and treat recurrent miscarriage?

Supportive pregnancy care

Women who have supportive care from the beginning of a pregnancy have a better chance of a successful birth.

There is some evidence that being under the care of a dedicated recurrent miscarriage service can reduce the risk of further miscarriage.

Blood tests

Hormone levels on day 2 - 3 of your first period after your most recent miscarriage may be measured. If this falls at a weekend, please attend the early pregnancy clinic (EPC) after the weekend, as these blood tests can be taken on day 1 - 5 of your period.

Other blood tests are carried out 6 weeks after your most recent miscarriage.

Hormone treatment

It has been suggested that taking progesterone early in pregnancy could help prevent a miscarriage. This may be offered to you in the recurrent miscarriage clinic depending on the results of your tests.

Treatment for antiphospholipid antibodies

There is some evidence that if you have aPL antibodies and a history of recurrent miscarriages, treatment with low-dose aspirin tablets and low-dose heparin injections (blood thinner) in the early part of your pregnancy may improve your chances of a live birth.

Screening for abnormalities in the embryo

If you have a history of recurrent miscarriage and you lose your next pregnancy, your doctors or the early pregnancy clinic may suggest checking for abnormalities in the embryo or the placenta afterwards.

They will do this by checking the chromosomes of the embryo through a process called karyotyping (although it is not always possible to get a result). They may also examine the placenta through a microscope.

The results of these tests may help them to identify and discuss with you your possible choices and treatment.

Screening for abnormalities in the structure of your womb

You will be offered a pelvic ultrasound scan to check for and assess any abnormalities in the structure of your womb, so that they can be treated if necessary.

Tests and treatment for a weak cervix

If there is a suspicion of a weak cervix based on your previous pregnancy history, you will be referred to the preterm labour clinic.

At the clinic, scans of your cervix will be undertaken in the second trimester of your pregnancy, and treatment may be offered if a weak cervix is confirmed.

Immunotherapy

Treatment to prevent or change the response of the immune system (known as immunotherapy) is not routinely recommended for women with recurrent miscarriage. It has not been proven to work, does not improve the chances of a live birth and can be associated with certain risks.

What could it mean for me in future?

Your doctors will not be able to tell you for sure what will happen if you become pregnant again.

However, even if they have not found a definite reason for your miscarriages, you still have a good chance (75%) of a healthy birth.

What to expect following a referral to the recurrent miscarriage clinic

• Whilst you are waiting for your first appointment in the recurrent miscarriage clinic, you are advised to avoid pregnancy if possible.
• It will not be possible to offer any additional treatment, scans or advice beyond routine pregnancy and miscarriage care, if you do become pregnant before being seen.
• When you come to the clinic, your investigations and possible treatment options will be discussed.
• After you have been seen, you may be offered any necessary treatment as well as repeat reassurance scans during the first trimester of future pregnancies, as part of your ongoing care.

Further information and support

You can find more information and support around recurrent miscarriage through the following organisations.

Tommy’s foundation

www.tommys.org/baby-loss-support/miscarriage-information-and-support/recurrent-miscarriage

Miscarriage association

www.miscarriageassociation.org.uk/information/miscarriage/recurrent-miscarriage

How to contact us

Early Pregnancy Clinic

0117 414 6778

www.nbt.nhs.uk/epac

If you or the individual you are caring for need support reading this leaflet please ask a member of staff for advice.

If you’re an overseas visitor, you may need to pay for your treatment or you could face fraud or bribery charges, so please contact the overseas office:

Tel: 0117 414 3764

Email: overseas.patients@nbt.nhs.uk

© North Bristol NHS Trust. This edition published May 2024. Review due May 2027. NBT002544.