The Management of Ectopic Pregnancy

	Antenatal Guidelines
No.43   Women who present with early pregnancy pain +/- bleeding, or early pregnancy loss within EPU dept.

1. Introduction

Women with early pregnancy problems have access to a dedicated Early Pregnancy Unit that provides efficient management , counselling and access to appropriate information.

Facilities of EPU

·         EPU is an outpatient department with an appointment system.

·         The EPU provides a morning only session, Monday to Friday.

·         There are 10 dedicated slots.

·         In addition, inpatients will also be seen as an emergency if deemed appropriate.

·         Access of Beta-hCG assay with results within 24 hours.

·         Rhesus grouping and provision of anti D as appropriate.(see guideline)

Staffing

Gynaecologist/ Obstetrician and Nurse Sonographers

Midwife /MCA

Receptionist

2. Indications for early pregnancy assessment

1. Exclusion of Ectopic pregnancy .

·              Identification of intrauterine implantation

·              Detection of an extra-uterine implantation

2. Confirm ongoing pregnancy in the setting of vaginal bleeding and pain.

3. In presence of hyperemesis requiring hospital admission and treatment

·              Exclude multiple pregnancy and Hydatiditiform Mole

                  pregnancy

3. Reasons for Referral

Women in the first trimester who have had a positive pregnancy test and

1.    abdominal pain

2.    Vaginal bleeding

3.    previous ectopic

4.    previous tubal surgery

5.    Intrauterine contraceptive devise in situ.

6.    Previous Molar pregnancy.

7.    Women referred via the antenatal screening/ dating department.

4. Sources of referral

1. Gynae SHO/Reg
2. Emergency Department
3. Primary Care Doctors
4. Midwives (in presence of bleeding only)

5. Referral Procedure

Referral bookings are made via the Woman Day Services department within the hours of 0800 -2000, Monday to Friday .Outside these hours the book is held in Maternity Reception (ext 53651)

Details of patients name, date of birth, hospital number (if available), name of person who referred and date of referral  to be recorded and an appointment time given

If the patient is considered to be clinically stable, they are given next available       appointment as outpatient.

If the patient is considered to be clinically unstable and cannot remain in the home setting until the appointment, they must be clinically assessed by the gynae SHO/Reg, who will decide whether there is an indication  for woman to be an inpatient, i.e. in severe pain, bleeding heavily or are unwell.

·         Doctors to advise patients that a Transvaginal scan (TVS) is likely and that as the EPU is an emergency clinic the appointment time and duration  cannot be guaranteed and delays are possible.

·         For TVS the patient will require an empty bladder.

·         Requests for appointments are monitored by midwives to ensure pathways are appropriate.

6. General Management

·         The woman should be welcomed to the unit / ward and sat in appropriate waiting area.

·         The midwife will take a history in a side room to ensure confidentiality and privacy.

The brief  Clinical history includes:

1. LMP, menstrual cycle ,planned pregnancy / contraception, date of first positive pregnancy test  and previous obstetric history.
2. abdominal Pain –description
3. Bleeding –amount and colour. Light / heavy / prolonged
4. Passage of Products of conception (POC)
5. Allergies / Medications (check for Latex allergy)
6. Any previous medical or relevant social history.

• A urine pregnancy test may be preformed if deemed necessary.
• Explanations regarding the ultrasound scan are given.
• The majority of ultrasound scans will be transvaginal in order to optimise images and confirm diagnosis. Patients wishes are respected if strongly declines TVS.
• A clear explanation is given by the Gynaecologist /Sonographer performing

            the scan regarding the confirmed; possible or likely diagnosis.

• A plan of management is then formulated . In the case of poor outcomes the patient will be counselled and pathways explained.
• Blood test are taken as deemed appropriate, and results are reviewed alongside USS reports and clinical history by experienced senior midwives/ nurses  and  seek advice from gynaecologists with specialist interest in EPU if any concerns.
• Follow up appointments are made as deemed appropriate with appropriate written advise sheets and telephone contact numbers.

N.B.Careful consideration of clinical history, risk factors, ultrasound scan findings and serum BhCG levels and serum progesterone must always be paramount especially in absence of viable ongoing pregnancy.

If the woman appears clinically unstable, i.e. if the woman is bleeding heavily and/or has severe pain, contact Gynae SHO ‘on call’ immediately. Ensure the patient has been stabilised and has IV access  before attempting to scan.

7. Clinical Management

7.1 Viable intrauterine pregnancy

If scan confirms a live intrauterine pregnancy and fetal heart is present the woman may be discharged with general advise to book with midwife.

7.2 Intrauterine pregnancy but unable to confirm viability.

·         Intrauterine sac is <25mm mean sac diameter(MSD) with / without obvious yolk sac.

OR

·         Fetal pole<7 mm crown rump length (CRL) with no obvious fetal heart, Viability cannot be confirmed

N.B. Where the gestational sac is smaller than expected for the gestational age and is less than 25mm(MSD) the possibility of incorrect dates should always be considered, especially in the absence of clinical features of threatened miscarriage.

In order to confirm or refute viability , a repeat scan 14 days later is arranged.

If there is no change in development, ie. Gestational sac/ yolk sac and/or fetal heart have not developed by second scan ,then this confirms diagnosis of missed miscarriage.

If there has been no vaginal bleeding and scan confirms an IU pregnancy  there is no indication for rescan and patient may be discharge and await dating scan.

7.3 Non-viable intrauterine pregnancy

Complete miscarriage  

• History of heavy PV bleeding with crampy lower abdominal pain and expulsion of  Products of conception (POC)
• Scan shows empty uterus with endometrial thickness less than 15mm in longitudinal section.  This is a presumptive diagnosis and needs to exclude an ectopic pregnancy unless there has been a previous scan confirming an IU Pregnancy or confirmed passage of POC. If so confirmed then no FU is needed.
• To check for an ectopic pregnancy take blood to check Serum BhCG and Progesterone and follow guideline for Pregnancy of unknown location.(see below)  
• Advise re: bleeding and risk of infection. Provide written information leaflet and offer psychological support as needed.

Incomplete Miscarriage

• Scan shows mixed echogenic Intrauterine tissue with diameter more than 15mm
• Discuss Management options – expectant / medical and surgical

• Provide information leaflet and support as above

Missed Miscarriage –

• If the gestation sac has mean sac diameter (MSD) greater than 25mm ,with no evidence of embryo or yolk sac,
• If the embryo has a crown rump length greater than 7 mm, with no heart pulsation

Inevitable Miscarriage .

·         Dilated cervix Os with cramping pelvic pains and bleeding. Miscarriage is imminent or in the process of occurring and/or ruptured membranes.

7.3.1 The management pathway options are:

1.Expectant Management.

2.Medical Management:

3.Surgical management

 7.4 Pregnancy of unknown Location (PUL)

Scan shows no signs of either intra- or extra uterine pregnancy with a positive pregnancy test.

• Ensure serum bHCG and Progesterone is taken and sent to lab.

Review results

• If BHCG is less than 25iul no further follow up is required.
• If BHCG is equal or more than 2000iul for review by doctor with EPU interest or Consultant  week on service.
• Progesterone – if progesterone is equal to or less than 10ng/ml  and BHCG is equal to or less than 500iul – repeat BHCG in 2 weeks
• Progesterone is equal to or less than 10ng/ml and BHCG is over 500iul – repeat 48-72 hrs
• If serum progesterone > 10 ng/ml and BHCG over 25iul – repeat 48-72 hrs
• Rescan if necessary – rising BHCG or static (suspected EP)

N.B. Progesterone level to be done at initial visit only i.e. do not repeat unless specifically  requested by EPU specialist Doctors.

7.4.1 Follow up

Follow up should occur until:

Intrauterine pregnancy identified

            OR

Miscarriage confirmed

            OR

Active intervention required (Ectopic confirmed or persistent suboptimal BhCG level rises)

            OR

BhCG levels falls to less than 25iul.

7.5 Suspected or confirmed tubal ectopic.

In addition, please refer to antenatal guideline 20: Management  of ectopic pregnancy.

8. Fetal heart Auscultated

If clinician is able to auscultate fetal heart and women not in severe/ significant pain then an ultrasound not necessarily indicated.

9. Rh negative women

Give anti-D if necessary – see antenatal guideline 3: Anti-D administration.

10. Notification of outcome

 If viable intrauterine:

• Send letter and copy of scan to GP. Copy of  letter and scan to be filed in notes.
• Copy of scan report to patients hand held notes if appropriate

If non viable:

• Ensure patient have relevant information sheets as appropriate.

• Complete notification of miscarriage forms.
• Notify General Practitioner by letter with  copy of scan enclosed. Copy of letter and scan to be filed in notes.

 11. Recurrent Miscarriage

Definition - 3 or more consecutive miscarriages.  May be referred by G.P. to Recurrent Miscarriage Clinic, Ocean Suite.

12. Record Keeping

Ensure all information is filed appropriately in the patients hospital notes. All documentation must  be clear, contemporaneous and  chronological when entered  by any healthcare professionals as per Hospital Trust Policy. This is in keeping with standards set by professional colleges, i.e. NMC and RCOG.

All entries must have the date and time together with signature and printed name.

Monitoring and Audit Auditable standards: Patient satisfaction with EPU Appropriate use of anti-D prophylaxis Appropriate use of serum hCG / progesterone assessments Uptake rates for medical / surgical / expectant interventions Complications of various interventions, i.e. failure rates Patient choice of treatment Number of visits to reach definitive diagnosis Standards of documentation Please refer to audit tool, location: ‘Maternity on cl2-file11’, Guidelines Reports to: Clinical Effectiveness Committee – responsible for action plan and implementation of recommendations from audit Clinical Governance & Risk Management Committee Frequency of audit: Annual Responsible person: Womens’ day services manager
Cross references Antenatal Guideline 3 – Administration of Anti-D immunoglobulin Antenatal Guideline 20 - The Management of Ectopic Pregnancy, Including the use of methotrexate Antenatal Guideline 31 - Maternity Hand Held Notes, Hospital Records and Record Keeping Antenatal Guideline 44 – Guideline Development within the Maternity Services
References
Author	Guideline Committee, Liza Rose
Work Address	Maternity Unit, Derriford Hospital, Plymouth, PL6 8DH
Version	3
Changes	Timely update
Date Ratified	Jul 12	Valid Until Date	Jul 15