Early Pregnancy Assessment Unit EPAU

Transcription

1 Early Pregnancy Assessment Unit EPAU

2 Introduction Miscarriage occurs in 20 30% of clinical pregnancies and accounts for 55,000 couples experiencing early pregnancy loss each year in Australia. With the advent of more refined diagnostic techniques and therapeutic interventions, treatment is now provided more and more on an outpatient basis. Both RCOG 1 & WHA 2 (Women s Hospitals Australasia) have published guidelines recommending setting up of EPAU to manage of women with threatened or actual early pregnancy loss, Research showed that EPAU improves the efficiency of the service and quality of care. Admission to hospital was shown to be avoided in the UK by 40% of women, with a further 20% requiring shorter hospital stay. 1.

3 The inadvertent use by medical professionals of inappropriate terms such as pregnancy failure, or incompetent cervix can contribute to women s negative self-perceptions and worsen any sense of failure, shame, guilt and insecurity related to the miscarriage. These are the WHA s recommendations: Previous term Spontaneous abortion Threatened abortion Inevitable abortion Incomplete abortion Complete abortion Missed abortion anembryonic pregnancy/ blighted ovum Septic abortion Recurrent abortion Incompetent cervix Recommended term Miscarriage Threatened miscarriage Inevitable miscarriage Incomplete miscarriage Complete miscarriage Missed miscarriage/silent miscarriage Early fetal demise/delayed miscarriage Miscarriage with infection (sepsis) Recurrent miscarriage Cervical weakness

4 The European Society for Human Reproduction Special Interest Group for Early Pregnancy has published revised nomenclature for use in early pregnancy loss in order to improve clarity and consistency. The following are some of the pertinent recommendations: Term Biochemical pregnancy loss Empty sac Fetal loss Early pregnancy loss Delayed miscarriage Late pregnancy loss Pregnancy of unknown location Definition Pregnancy not located on scan Sac with absent or minimal structures Previous CRL measurement with subsequent loss of fetal heart activity (FHA) Confirmed empty sac or sac with fetus but no FHA 12 weeks As early pregnancy loss Loss of FHA 12 weeks No identifiable pregnancy on scan with positive hcg

5 In addition to the obvious medical (and possibly surgical) implications of miscarriage, research over the last two decades indicates that significant psychological effects can occur in women who suffer a miscarriage, while further research has shown that appropriate support during and after the event can have positive, lasting effects. The EPAU allows close collaboration and liaison among, social workers, bereavement officer, pastoral care, medical and nursing staff; and ensure a holistic approach to the patient s care. Gynaecologist GP Emergency Department Nurses EPAU Pastoral Care Operating Theatre MFM & Radiology Social Worker

6 Working in EPAU EPAU is located level 7 Mater Mothers Hospital EPAU operating hours are from hours Monday to Friday The EPAU Co-ordinator is contactable Monday to Friday on Out-of-hours there is an answering machine with a detailed message advising women how to access assistance after hours for a variety of presenting complaints.

7 Referral Process Women may be referred to the EPAU by their GP or O&G Specialist or may self-refer Any area within the Mater may refer patients to EPAU via either a phone call or to the Co-ordinator. Women should be given the options of either attending the Emergency Department immediately or waiting for the next available appointment in the EPAU Women electing to be seen in EPAU should be advised to re-present to ED sooner if significant bleeding (taking less than 30 minutes to soak a pad) or significant pain (unrelieved by simple analgesia) A maximum of 6 women can be booked into the Ultrasound clinic and 2 women into the lunch time Nurse Clinic on any one day

8 Inclusion Criteria Women may be referred to the EPAU who have: A positive pregnancy test or suspected pregnancy. A pregnancy less than 20 weeks completed gestation. Pain or vaginal bleeding but are clinically stable. No bleeding but with a non viable pregnancy. A confirmed stable ectopic pregnancy to be treated conservatively. Pregnancy of unknown location, stable, and requiring follow-up.

9 Exclusion Criteria Women are not eligible for EPAU referral who are: More than 20 weeks completed gestation. A Triage Category 1 or 2 or 3. Haemodynamically unstable/ heavy Bleeding (taking less than 30minutes to soak a pad) In pain which exceeds normal period pain and/or is unrelieved by simple analgesia Pulse 100; any postural drop For routine pregnancy confirmation. For routine pregnancy dating scans Presenting with nausea/vomiting in pregnancy Presenting with other acute gynaecological conditions or other medical/surgical conditions in early pregnancy Unhappy with returning to the Hospital on another occasion for assessment in the EPAU

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12 1. Meet with Nurse Co-ordinator Assessment Procedure Explain the nature of the service Confirm woman meets inclusion criteria by asking prescribed questions and performing observations. Woman considered unsuitable for EPAU should be promptly escorted from the Unit to ED Triage desk for more appropriate assessment and management. Standardised history taken using online form LNMP, cycle length and regularity, contraception, breast feeding, Spontaneous or assisted conception, date of +ve pregnancy test Pain, bleeding, passage of POC, or other symptoms Obstetric history Gynaecological history Relevant medical, surgical history Medications, allergies Obtain results of recently performed HCG and blood group. Collect blood for these investigations if not already performed and deemed necessary. Referral for Ultrasound scan, TA > 10 weeks, TA and TV < 10 weeks.

13 Assessment Procedure 2. Ultrasound scan a. Scans should only be performed by suitably trained and experienced personnel b. Scans will also be performed by O&G Registrars, Radiology Registrars and Trainee sonographers under appropriate supervision c. A transvaginal USS is advised however the woman s wishes should be respected if she declines such an investigation. It should be noted that the algorithms provided are based on observations following a TV-USS d. Scans are reviewed and reported on by MFM specialists prior to patients discharge from the Clinic.

14 Assessment Procedure o o o o The presence of a fetal pole 6mm without a fetal heartbeat is considered diagnostic of a missed miscarriage In the setting of unusual or unexpected scan findings (specifically in situations of a pregnancy of unknown location), the case should be discussed with the duty MFM Specialist in the adjacent MFM Department at the time. Responsibility for management decisions remain with the Gynaecology Consultant on-call Anti D is given when the woman has a negative blood group and an early pregnancy loss or a threatened miscarriage > 12 weeks. In line with Mater Policy, anti D does not need to be given for threatened miscarriage < 12 weeks.

15 Assessment Procedure HCG a. Serum hcg levels double approximately every two days in early (<8 weeks) normal intrauterine pregnancy until a peak at around 8-10 weeks. It is normal for HCG to fall after this gestation. A falling HCG in early pregnancy is suggestive of a failing intrauterine (or extrauterine) pregnancy. b. A lesser increase (<66% over 48 hours) is associated with ectopic pregnancy and miscarriage. However 15% of normal pregnancies will have an abnormal doubling time and a similar proportion of ectopic pregnancies will have a normal doubling time. c. The doubling time is particularly useful in early pregnancy (i.e. before 5.5 weeks or when the serum hcg level is <5000IU/L). d. The recommendation for serial HCG means that the woman be given 3 request slips for serum ßHCG and be asked to have blood collected every 48 hours. The Co-ordinator books follow up phone call with patient and records the results in Viewpoint, liaising with the Gynaecology Registrar as required.

16 Assessment Procedure CAUTION i. In multiple pregnancies the level of hcg needs to be a little higher before sacs become visible. ii. The possibility of a heterotopic pregnancy should be kept in mind (1 in of spontaneous conceptions and 1% - 3% of assisted conceptions). iii. Falling HCG does not exclude an ectopic pregnancy. A fall of less than 15% over 48h is more suggestive of an ectopic than a failing intrauterine pregnancy. iv. A diagnosis of ectopic pregnancy is more likely whenever an intrauterine pregnancy is not detected by ultrasound at serum hcg concentration above ~1500IU/L.

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18 Early pregnancy loss Early pregnancy loss encompasses the diagnoses of: delayed miscarriage/anembryonic Pregnancy (previously known as blighted ovum) Missed miscarraige Ectopic pregnancy Molar pregnancy, Spontaneous miscarriage

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22 Medical Rx for Ectopic Pregnancy In selected stable cases, methotrexate can be considered as an effective alternative to surgical options for the management of ectopic pregnancies. The most common indications would include: Un-ruptured tubal ectopic pregnancy; stable woman Persistent ectopic following conservative tubal surgery for ectopic Case-reports suggest Methotrexate could also be considered for management of pregnancies in the ovary, cervix, and interstitium Most authorities recommend a single intramuscular injection of methotrexate as opposed to multi-dose therapy

23 Gestational trophoblastic disease Molar pregnancies occur in approx 1 in 1200 pregnancies and are formed when a normal egg is ferilised concurrently by 2 sperm (partial mole) or an empty egg with no genetic material is fertilised by a sperm (complete mole). Partial molar pregnancies are usually not identified until a histological examination of products of conception is performed. Complete molar pregnancies are more likely to be identified by their characteristic USS features. MMH EPAU provide counselling and follow up services for ladies with a diagnosis of molar pregnancy and register them on the GTD register at the RBH. Women are followed with weekly then monthly hcg levels to confirm that levels are dropping and remain at zero for a minimum of 6 mth. Women who go on to develop persisting GTD are referred to RBG for management

24 Best Practice Guidelines for counseling patient Re: Mx options The Cochrane review (Nanda et al; Apr 2006): 5 trials, n=689. Expectant management led to a higher risk of incomplete miscarriage, need for surgical emptying of the uterus, and bleeding. None of these were serious. In contrast, surgical evacuation was associated with a significantly higher risk of infection. Given the lack of clear superiority of either approach, the woman's preference should play a dominant role in decision making. Medical management has added choices for women and their clinicians, but these were not reviewed here. MIST Trial (Trinder et al.; BMJ; May 2006): RCT, n=1200 (largest to date). The incidence of gynaecological infection after surgical, expectant, and medical management of first trimester miscarriage is low (2-3%), and no evidence exists of a difference by the method of management. However, significantly more unplanned admissions and unplanned surgical curettage occurred after expectant management and medical management than after surgical management.

25 Bereavement Support Package Miscarriage is a complex biological and psychological event, for many representing the loss of a desired and loved child. The sense of grief and sadness can be overwhelming and the classic stages of bereavement often follow this sad event. These are normal reactions and women and their families need to be able to work through them in their own time. It is essential that the loss is acknowledged and that parents are able to talk about it for as long as it takes. A central component of an exceptional EPAU service at MHS is a greater level of sensitivity and understanding offered to all women accessing care, and recognition of their anxieties and emotions by all of the professionals involved.

26 Bereavement Support Package For most women miscarriage is a difficult and vulnerable experience where the threatened loss, repeated tests and the uncertainties arising from this lead to significant anxiety, challenging emotional safety and any sense of control. The provision of a sensitive and timely, woman centred service will in itself be effective in addressing a woman s emotional needs. Continuity of carer, privacy and recognition of these anxieties and potential loss will be sufficient in the majority of cases to enable women and their partners to move through a normal process and prevent a potential emotional crisis. This algorithm pertains to all presentations to MHS where there is the possibility of an early pregnancy loss. Those women who present with a history of a threatened miscarriage will require the same level of emotional support even when there is a positive outcome. Clinical care will be provided in collaboration with the relevant protocols.