Association of Early Pregnancy Units
 
 
 
   
 
Frequently Asked Questions

 

GUIDELINES

 

 

Organisational

Clinical

Supportive

2004

 

 

All women with early pregnancy problems will have prompt access to a dedicated

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