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Early Pregnancy Assessment Unit
that provides efficient
management, counselling and access to appropriate information.
At all times women will be
supported in making informed choices
about their care
and
management.
The Association of Early Pregnancy Units Executive
Committee have
set out a 10 point Charter for service provision and these include:
1. Referral Guidelines and
Operational Policy that are clear to patient.
2. Recognition of Patient
choice in management.
3. Dedicated area with quiet
room for breaking bad news.
4. Availability of facility and
opening hours.
5. Competence at Scanning
6. Same day Serum HCG Service.
7. Written information leaflets
for patient care
8. Acknowledgement of patient
privacy and dignity
9. Bereavement counselling
availability
10.
Free pregnancy testing
Contents
I Guidelines for Service Organisation
² Site, Access, Facilities and Staffing 5
²
Referral Guidelines 6
II Clinical Guidelines
² General Patient management 8
²
Guidelines for Rhesus prophylaxis 9
² Record Keeping and Data Collection 10
² Ultrasound scanning: RCOG Criteria 11
Ultrasound features of early
pregnancy 12
Ultrasound features of early
pregnancy and management 13
² Viable Intra-uterine Pregnancy 15
² Non Viable Pregnancy 16
Incomplete miscarriage
Missed miscarriage
Conservative management 17
Medical management 19
Surgical management 20
²
ß-HCG Assay 22
²
Management of Pregnancy of Unknown Location (PUL) 23
²
Ectopic Pregnancy 25
Expectant Management
Medical Management
Surgical Management
² Management of Recurrent Miscarriage
34
²
Management of Gestational Trophoblastic disease 38
III Supportive Guidelines
²
Support and follow-up after a miscarriage 39
²
Disposal of fetal remains (< 24 weeks) and funeral services 41
I Guidelines for Service Organisation
Site
² It should be located in a dedicated area.
² The surroundings should be pleasant and comfortable with
toilets near at hand.
Access
² The gold standard is to have a unit open seven days a week
from 8.00am until 5.00 pm
²
The minimum requirement would be to have a unit open for five days,
mornings only from Monday to Friday.
²
Patient access to AEPU Website (earlypregnacy.org.uk) will give details
of nearest EPU to patient within UK and contact number.
Facilities
² Good quality ultrasound equipment
² A simple system of sensitive urine pregnancy testing should
be available in the unit
² There should be access to ß-hCG assay with results within 24
hours
² Rhesus grouping and Anti-D should be considered if gestation
is >12 weeks
² It is important to bear in mind that some patients may
require other gynaecological procedures
such as infection screen.
Staffing
² Varies between the units.
Minimum requirement would be:
a receptionist/secretary
a midwife/nurse
a gynaecologist and a sonographer
² Attitude of the staff involved should be caring and
sympathetic
² Clear and consistent verbal and written information
² Initial support and informal counselling should be provided
by all health professionals involved
² There should be access to formal counselling sessions where
necessary (this may be needed occasinally)
Referral Guidelines
Who
may be referred:
·
Women in first trimester who have had a positive pregnancy test
and a) abdominal pain
b)
vaginal bleeding
c) previous ectopic
d)
previous tubal surgery
e)
two or more previous miscarriages
f)
intrauterine contraceptive device in-situ
·
Women with a non-viable pregnancy diagnosed in ante-natal booking
clinic.
·
Women between 13-20 weeks, with pain and/or bleeding, either restricted
access to only inpatients or open to all outpatient referrals depending on the
resources of a unit
·
Post evacuation/termination with persistent bleeding.
Sources of Referral
·
Primary Care Doctors
·
Accident & Emergency Departments
·
Wards
·
Nurse Led Primary Care Drop In Centres
·
Self referral
Referral Procedure
Referral
booking is via Co-ordinator between 9 am and 5 pm and via the Gynae SHO/Senior
Gynae nurse at night.
·
The appointment book or Electronic Diary should be available on gynae
ward after 5.00pm. to enter referrals
·
Details of patient’s name, address, date of birth, name of GP and
reason for referral should be noted and a n appointment time given
·
GPs to be advised to tell the patients that :
a) a
transvaginal scan is likely
b)
as it is an emergency clinic the appointment time cannot be guaranteed
and
delays are likely
·
GPs to be encouraged to send a letter either with the patient or by fax
A
patient information leaflet on what to expect should be available in the
waiting area.
Caution
Women
referred to the unit are, by definition, stable and can be given an appointment
for the next working day.
Women
who are unwell, bleeding heavily or in whom an ectopic pregnancy is suspected
should be admitted through the usual channels and not asked to wait for an
appointment on the unit. There will also
be a proportion of women who are frightened by the loss or who are socially and
geographically isolated and prefer admission.
II Clinical Guidelines
Guidelines for
General Patient Management
·
A brief history is taken on the standardised proforma in accordance
with RCOG/RCG guidelines including:
i) Previous
obstetric history, LMP, pregnancy test in this pregnancy
ii) Pain
- description
iii) Bleeding
- amount
iv)
Passage of POC
·
Clinical examination should be considered if appropriate
·
Transvaginal scan (TVU) is performed if less than 7-8 weeks and also in
some circumstances at more than 8 weeks, with patient option to see what is
seen on the screen
·
Patient’s wishes should be respected if strongly declines a TVS
·
A clear explanation should be given by the Gynaecologist/Sonographer
performing the scan as to the possible or likely diagnosis/diagnoses.
·
Appropriate pictures are taken for the patient’s records. Pictures are not usually given to patients in
EPAU except when asked by a patient.
·
All items on the proforma should be checked
·
A plan of management should be formulated based on the guidelines
·
A pregnancy test should be performed if a pregnancy is not clearly
visible
·
Consideration for a ß-hCG assay should be given if a pregnancy test is
positive
·
Support should be given where the pregnancy is non-viable and a second,
independent observer must confirm the diagnosis. A quiet room should be
available
·
Follow up should be arranged before the woman leaves the clinic
·
Appropriate written advice and telephone numbers for contact should be
given
RCOG Guidelines for Rh
Prophylaxis
Confirmed miscariage: Anti-D immunoglobulin should be given to all
non-sensitised Rh negative women who miscarry after 12 weeks, whether complete
or incomplete and to those who miscarry below 12 weeks when the uterus is
evacuated (either surgically or medically).
Threatened miscarriage: Anti-D should be given to
all non-sensitised Rh negative women with threatened miscarriage after 12
weeks. Routine administration of anti-D is not required below 12 weeks when the
fetus is viable, unless the bleeding is heavy or associated with abdominal
pain.
Ectopic
pregnancy:
All Rh negative women with ectopic pregnancies whether managed surgically or
medically should be given anti-D. The recommended dose before 20 weeks of pregnancy is
250IU.
Documentation from
the EPAU should clearly state whether or not anti-D was given in the
Clinic.
Reference:
Use of anti-D immunoglobulin for Rh prophylaxis. RCOG ‘Green –top’ Guideline no. 22,
1999.
Guidelines on Record keeping
and Data Collection
Until
such time as computer based records are developed in the early pregnancy
assessment units, data should be maintained in hand-written registers.
Accurate
record keeping is needed to ensure that pregnancy outcome is recorded with
sufficient detail and that feedback is comprehensive.
The
training of appropriate support staff to maintain high standards of
record-keeping should be encouraged.
----------------------------------------------------------------------------------------------------------------
Guidance on maintaining
Registers
The
monitoring of the management protocols in terms of acceptance and outcome can
only be achieved through maintaining accurate registers. The following issues are important to
establish the diagnosis and its management.
1. All first visit scans should be given a diagnosis and grouped
under respective diagnostic groups,
such as:
Viable pregnancy or Threatened miscarriage if
associated with bleeding,
Complete
Miscarriage,
Incomplete
Miscarriage,
Missed
Miscarriage,
Ectopic
Pregnancy,
2. Those scans that do not fit into any of
the above diagnostic categories because a gestation
sac is either too small or not visible, should be grouped under:
EGS (early gestational sac)
with/without YS (yolk sac), when no embryo is visible and
Pregnancy
of Unknown Location (PUL) if an intrauterine or
extrauterine pregnancy can not be demonstrated on scan.
3. Pregnancy of unknown location (PUL): At a subsequent scan when a diagnosis becomes
possible they are placed under the respective groups as mentioned above. A pregnancy, which does not fit
into any of the above diagnostic groups, is still classified as Pregnancy of unknown location (PUL).
4.
Scans that are performed after a diagnosis has been allocated to an
individual patient so as to avoid counting the same patient twice in a
diagnostic category.
5. All Incomplete/Missed miscarriages should be further grouped according to the method of treatment and their outcome recorded.
6. All ectopic pregnancies should be grouped according to the method of treatment and their outcome recorded.
7. Monthly statistics should be entered on a Data sheet.
Guidelines for Scanning
RCOG Criteria
If
the gestation sac has a mean diameter greater than 20mm, with no evidence of an
embryo or yolk sac, this is highly suggestive of a silent miscarriage.
If
the embryo has a crown rump length greater than 6mm, with no evidence of heart
pulsations, this is highly suggestive of a silent miscarriage.
When
the mean gestation sac is less than 20mm or the crown rump length is less than
6mm a repeat examination should be performed at least one week later both to
assess growth of the gestation sac and embryo and to establish whether heart
activity exists.
If
the gestation sac is smaller than expected for gestational age the possibility
of incorrect dates should always be considered, especially in the absence of
clinical features suggestive of a threatened miscarriage.
In
all of the above instances a repeat scan should be undertaken in 7 days. This is necessary to confirm the diagnosis. A
second independent observer needs to confirm the findings of pregnancy loss if
fetal death is apparent.
All scans should be
performed by experienced personnel.
The
following individuals are suitably trained to perform ultrasound:
Radiographers/midwives
with the Diploma in Medical Ultrasound (DMU)/PGDip
Radiologists
with ultrasound training and experience as recommended by the Royal College of
Radiologists.
Obstetricians
and Radiologists who have completed the joint obstetric ultrasound training
scheme of the Royal College of Obstetricians and Gynaecologists and The Royal
College of Radiologists, or alternatively who have appropriate experience and
training in obstetric ultrasound.
All
personnel should have appropriate peer review of their ultrasound practice.
Information should be
recorded including:
i)
number of sacs and mean gestation sac diameter
ii)
regularity of the outline of sac and its location
ii) presence
of haematoma
iii) presence
of a yolk sac
iv) presence
of a fetal pole
v) CRL
measurement (mm)
vi)
presence of fetal heart pulsation
vii)
extra uterine observations – ovaries, adnexal mass, fluid in the Pouch
of Douglas (P.O.D.)
Guidelines
for Ultrasound Features of Early Pregnancy
|
Gestational age |
Anatomical landmarks |
Comments |
|
4
weeks 2 days |
Eccentrically
placed Gestational
sac GSD
2-3mm |
May
represent pseudosac 10-20%
of ectopic pregnancies have an intrauterine pseudo GS |
|
5th
week |