Care of women;miscarriage and ectopic pregnancy Belinda Champion- Gynae Oncology Clinical Nurse Specialist and Clinical Nurse Lead in Sexual Health Lewisham & Greenwich NHS TRUST May 2014 Email: bchampion@nhs.net
Overview Increase awareness of the extended role of the Nurse Sonographer within the emergency gynae setting Describe some of the emerging trends in the management of miscarriage and ectopic pregnancy Discuss the implications of the NICE guidance on ectopic pregnancy and miscarriage management and how these guidelines impact upon current local and national practice.
Nurse Sonographer-Advanced role Making a difference (NHS Plan, 1999) proposed a new career framework for nurses to incorporate newly developed roles CNO key roles for nurses; To manage patient caseloads To run clinics
The Scope of the Nurse Sonographer s Role Clinical expert in gynaecology and ultrasound practice Act autonomously and within the MDT Develop innovative ways to improve the patients journey Contribute to meeting government targets Nurse led care is safe and effective as well as cost effective Provide expert advise, training and support to trainee sonographers and doctors
Improving women s experience Dedicated practitioner Rapid diagnosis and reasurrance Improve access to care Continuity of care Evidence-based care Shorter waiting times More information, more choice
Impact on services Higher turnover of patient s Efficient patient throughput Reduced length of stay Reduced emergency admissions Delivery of cost-effective, efficient services leading to cost reduction
Nurse Sonographer-The way forward The role of the NURSE SONOGRAPHER will CHAMPION benefits to the patients journey making it more accessible and seamless
Miscarriage ultrasound diagnosis RCOG Revised Guidelines(October 2011) Delayed miscarriage ( TV scan in all cases) Ultrasound diagnosis of a miscarriage should only be considered with a mean sac diameter >/=25mm (with no obvious yolk sac), or With a fetal pole with crown rump length >/=7mm (without fetal heart activity)
30 yr old woman G1P0 Case 1 10 weeks by gestational age Noticed an episode of brown pv spotting 1/52 ago and mild crampy pains NT scan due in 1/52
Delayed Miscarriage 10weeks by dates 7+5/40 by Scan
Empty gestation sac >25mm
NICE Guidelines- Diagnosis and initial management of ectopic pregnancy and miscarriage ( Dec, 2012) Summary of key points: NICE say 2 operators are required to diagnose a miscarriage on TVS the same day or the same clinician 7days later. If TA rescan in 14days. In practice, we routinely offer second opinion for the diagnosis of miscarriage and document clearly if this is declined on the ultrasound report
TVS- one scan fits all? Is there a gestational cut-off for TVS? Is TVS appropriate for all women? Why are we performing an intimate examination for all women? Are we taking into account women s choice? How are we implementing the guidance locally?
Management of Miscarriage-current options Expectant management- wait & see Medical management Surgical management- ERPC
New Developments management of miscarriage Manual Vacuum Aspiration
Manual Vacuum Aspiration (MVA) ERPC under LA. Default option in some trusts Performed under ultrasound guidance CRL up to 23mm or RPOC up to 5cm Not suitable for post natal, post STOP, suspected molar or complex uterine structure ie fibroids
MVA Cervical priming with misoprostol 400mcg sublingually 3hrs pre procedure If under 25yrs old screen for chlamydia or azithromycin stat dose offered PR diclofenac self administered 1hr pre procedure Anaesthetic gel and local anaesthetic injection to the cervix Reassure throughout the procedure
MVA 15minute obs for the first half hour then half hourly To be observed in hospital for 2hours post procedure Anti-D if rhesus negative POC sent to histology No follow up routinely booked To return if prolonged pvb (>2weeks) or signs of infection
Why do women choose MVA? Available sooner than GA Avoiding a GA Feel more in control Quicker recovery Recommended by friends and family
Patient Satisfaction Survey-Women s positive experiences of MVA All nurses and the consultant have all been extremely friendly, professional and kind throughout my stay. A special thank you to the Romanian nurse. Thank you to the staff at EPAGU I was made to feel comfortable and felt as though I had the support and kindness shown through this time. The medical team was very supportive. Lumi showed absolute concern and care. She is just wonderful. The other nurses and consultant were also fantastic. They made my healing/recovery process faster!!!
Medical Management- A change in practice NICE recommend that mifepristone is no longer offered as a treatment for delayed or incomplete miscarriages
Huge! Impact on Women? Anecdotally-women are walking with their feet Offers more flexibility in terms of taking time off work Reduced number of follow up visits Women want their care closer to home
Management of PUL s and ectopic pregnancies
Ectopic Gestation- management options Ultrasound diagnosis with a clinically useful report will aid in the decision making process of the following management options: Expectant management ( wait and see) Medical management ( methotrexate) Surgical ( laparoscopy/laparotomy)
27 yr old woman Case 2 G3P1+1 ( SVD) and previous STOP 7 weeks by gestational age. Irregular cycle varies- 5 to 6wks 2/7 history of slight dark brown spotting and pain in LIF Past history of PID in the past and previous Appendicetomy
Case 2-ultrasound appearances
Expectant management of Ectopic Wait and see approach: Pregnancy Lead Consultant decision only Less than 10% of all ectopic gestations can be safely managed through close observation Initial BHCG < 1000 and decreasing No blood in pelvis on USS
Expectant Management - NICE do not recommend expectant management of ectopic pregnancy Locally, our unit have good supporting data to continue with expectant miscarriage
Thank you!
Acknowledgements My Husband, Jon and my Daughter Georgina for their patience and encouragement Debbie Holloway, Nurse Consultant in Gynaecology, Guy s and St Thomas NHS Foundation Trust Joanne Fletcher, Nurse Consultant in Gynaecology, Sheffield Shirley Bogle, Sister, colleague and friend, Early Pregnancy unit at Lewisham Hospital Dr Judith Hamilton, Consultant Gynaecologist and Lead for EPAGU