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Bushra's NICE guidline > Ectopic pregnancy and miscarriage: diagnosis and initial management > Flashcards

Ectopic pregnancy and miscarriage: diagnosis and initial management Flashcards

1
Q

Support and information giving to early prenancy loss

demeanor

A
  • Treat with dignity and respect.
  • women will react to complications or loss in different ways.
  • information & support in sensitive manner, taking into account individual circumstances & emotional response.

.

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2
Q

Support and information giving to early prenancy loss

HCP & non technical staff training

A

HCP providing care:

    • aware that early pregnancy complications cause significant distress
    • given training in how to communicate sensitively and breaking bad news.

Non-clinical staff such as receptionists
– given training on how to communicate sensitively with early pregnancy complications

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3
Q

Throughout a woman’s care, give her and (with agreement) her partner specific evidence-based information in a variety of formats. This should include (as appropriate):

A

EMERENCY:- When & how to seek help if existing symptoms worsen or new symptoms develop, including 24-hour contact telephone number.

WAITING US: - What to expect during time she is waiting for US scan.

EXPECTANT MX: - What to expect

  • potential length & extent of pain &/or bleeding, &
  • possible side effects.
  • information tailored to care she receives.

SURERY: - Information about post-operative care.

RECOVERY: - What to expect –

  • when to resume sexual activity
  • &/or try to conceive again, &
  • what to do if she becomes pregnant again.
  • information tailored to care she receives.

FUTURE FERTILITY:- Information about likely impact of her treatment.

INFORMATION: - Where to access support & counselling services, including leaflets, web addresses and helpline numbers for support organisations.

SUFFICIENT TIME: - Ensure
- arrange additional appointment if more time needed

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4
Q

After early pregnancy loss, offer option of follow-up appointment with

A

a healthcare professional of her choice.

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5
Q

Early pregnancy assessment services

A
  • Regional services organised so that early pregnancy assessment service is available 7/7 for early pregnancy complications, where scanning & decisions about MX made.
  • An early pregnancy assessment service should:
      • dedicated service provided by HCP competent to diagnose and care for women with pain and/or bleeding in early pregnancy and
      • offer US & assessment of serum hCG levels and
      • HCP with training in sensitive communication & breaking bad news.
  • accept self-referrals with recurrent miscarriage or a previous ectopic or molar pregnancy.
  • All other with pain and/or bleeding assessed by HCP (as GP, A&E doctor, midwife or nurse) before referral to an early pregnancy assessment service.
  • system in place to enable women referred to their local early pregnancy assessment service to attend within 24 hours if clinical situation warrants this.
  • If service is not available, & clinical symptoms warrant further assessment, refer women to nearest accessible facility that offers specialist clinical assessment & US scanning (as gynaecology ward or A&E service with access to specialist gynaecology support).
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6
Q

Symptoms and signs of ectopic pregnancy and initial assessment

A
  • Refer women who are haemodynamically unstable, or in whom there is significant concern about the degree of pain or bleeding, directly to A&E.
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7
Q

Symptoms and signs of ectopic pregnancy and initial assessment

A
  • Be aware that atypical presentation for ectopic pregnancy is common.
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8
Q

Symptoms and signs of ectopic pregnancy and initial assessment
SYMPTOMS common & other

A
  • can present with variety of symptoms. Even if symptom is less common, it may still be significant. Symptoms of ectopic pregnancy include:

common symptoms:
1 - abdominal or pelvic pain
2 - amenorrhoea or missed period
3 - vaginal bleeding with or without clots

other reported symptoms:
1 - breast tenderness
2 - gastrointestinal symptoms
3 - dizziness, fainting or syncope
4 - shoulder tip pain
5 - urinary symptoms
6 - passage of tissue
7 - rectal pressure or pain on defecation.
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9
Q

Symptoms and signs of ectopic pregnancy and initial assessment
SIGNS common & other

A

Be aware that ectopic pregnancy can present with a variety of signs on examination by a healthcare professional. Signs of ectopic pregnancy include:

more common signs:
1 - pelvic tenderness
2 - adnexal tenderness
3 - abdominal tenderness

other reported signs:
1 - cervical motion tenderness
2 - rebound tenderness or peritoneal signs
3 - pallor
4 - abdominal distension
5 - enlarged uterus
6 - tachycardia (more than 100 beats per minute) or
7 - hypotension (less than 100/60 mmHg)
8 - shock or collapse
9 - orthostatic hypotension.
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10
Q

During clinical assessment of women of reproductive age, be aware that:

A
  • They may be pregnant, and think about offering a pregnancy test even when symptoms are non-specific and

the symptoms and signs of ectopic pregnancy can resemble the common symptoms and signs of other conditions – for example, gastrointestinal conditions or urinary tract infection..

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11
Q
  • All HCP involved in care of women of reproductive age should have access to
A
  • pregnancy tests.
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12
Q
  • Refer immediately to early pregnancy assessment service (or out-of-hours gynaecology service if EPAS not available) for further assessment with positive PT & following on examination:
A

1 - pain and abdominal tenderness or
2 - pelvic tenderness or
3 - cervical motion tendernes

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13
Q

ectopic & risk factors

A

Exclude possibility of ectopic pregnancy, even in absence of risk factors (as previous ectopic pregnancy), b/c about third of women with ectopic pregnancy will have no known risk factors.

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14
Q
  • Refer immediately to early pregnancy assessment service (or out-of-hours gynaecology service if EPAS not available) for further assessment with bleeding or other symptoms and signs of early pregnancy complications who have:
A

1 - pain or
2 - pregnancy of 6 weeks gestation or more or
3 - pregnancy of uncertain gestation.

  • urgency of this referral depends on clinical situation.
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15
Q

Use expectant management for women with a pregnancy of less than 6 weeks gestation who are bleeding but not in pain. Advise these women:

A
  • to repeat a urine pregnancy test after 7–10 days and to return if it is positive
  • negative pregnancy test means that the pregnancy has miscarried
  • to return if their symptoms continue or worsen.
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16
Q

1.3.11 Refer women who return with worsening symptoms and signs that could suggest an ectopic pregnancy to an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available) for further assessment.

A

The decision about whether she should be seen immediately or within 24 hours will depend on the clinical situation.

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17
Q

1.3.12 If a woman is referred to an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available),

A

explain the reasons for the referral and what she can expect when she arrives there.

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18
Q

1.4 Diagnosis of viable intrauterine pregnancy and of ectopic pregnancy
Using ultrasound for diagnosis
TVS or TAS

A
  • Offer: attend EPAS (or out-of-hours gynae service if EPAS not available) TVS to identify location of pregnancy & fetal pole and heartbeat.
  • Consider: TAS scan for enlarged uterus or other pelvic pathology, as fibroids or ovarian cyst.
  • If TVS unacceptable, offer TAS & explain limitations of this method of scanning.
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19
Q

1.4 Diagnosis of viable intrauterine pregnancy and of ectopic pregnancy
Using ultrasound for diagnosis

Viability
Heart, pole, or GS

A
  • Inform that diagnosis of miscarriage using 1 US cannot be guaranteed to be 100% accurate & small chance that diagnosis may be incorrect, particularly at very early gestational ages.
  • performing US to determine viability of IUP, first look to identify fetal heartbeat. If there is no visible heartbeat but there is a visible fetal pole, measure CRL.
  • Only measure mean GS diameter if fetal pole is not visible.
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20
Q

1.4 Diagnosis of viable intrauterine pregnancy and of ectopic pregnancy
Using ultrasound for diagnosis

CRL

A
  • If CRL < 7.0 mm with TVS & no visible heartbeat, perform second scan minimum of 7 days after first before making diagnosis. Further scans may be needed before diagnosis can be made.
  • If CRL >/ = 7.0 mm with TVS & no visible heartbeat:
      • seek second opinion on viability of pregnancy and/or
      • perform second scan minimum of 7 days after first before making diagnosis.
  • If no visible heartbeat when CRL measured by TAS:
      • record size of CRL and
      • perform second scan minimum of 14 days after first before making diagnosis.
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21
Q
  • Diagnosis of viable intrauterine pregnancy and of ectopic pregnancy
    Using ultrasound for diagnosis

GS

A
  • If mean GS diameter < 25.0 mm with TVS & no visible fetal pole, perform second scan minimum of 7 days after first before making diagnosis.
  • Further scans may be needed before a diagnosis can be made.
  • If mean GS diameter >/ = 25.0 mm by TVS & no visible fetal pole:
      • seek second opinion on viability of pregnancy and/or
      • perform second scan minimum of 7 days after first before making diagnosis.
  • If no visible fetal pole & mean GS diameter by TAS:
      • record size of mean GS diameter and
      • perform second scan minimum of 14 days after first before making a diagnosis.
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22
Q

LMP and early pregnancy

A
  • Do not use gest age from LMP alone to determine whether fetal heartbeat should be visible.
  • Inform women that date of LMP may not give accurate representation of gestational age because of variability in menstrual cycle.
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23
Q

Early penancy and at home anxiety

A
  • Inform: what to expect while waiting for repeat scan and waiting has no detrimental effects on outcome of pregnancy.
  • Give 24-hour contact telephone number so that they can speak to someone with experience of caring for with early pregnancy complications who understands their needs and can advise on appropriate care.
24
Q
  • When diagnosing complete miscarriage on US, in absence of previous scan confirming IUP,
A
  • always be aware of possibility of ectopic pregnancy.

- Advise these women to return for further review if their symptoms persist.

25
Q

Who should review scan of early prenancy

A
  • All US should be performed and reviewed by someone with training in, and experience of, diagnosing ectopic pregnancies.
26
Q

Human chorionic gonadotrophin measurements in women with pregnancy of unknown location

A
  • PUL could have an ectopic pregnancy until the location is determined.
  • Do not use serum hCG measurements to determine location of pregnancy.
  • In PUL, place more importance on clinical symptoms than on serum hCG results, and review woman’s condition if any of her symptoms change, regardless of previous results and assessments.
27
Q

HCG,

A
  • Use serum hCG measurements only for assessing trophoblastic proliferation to help to determine subsequent management.
28
Q

serial BHCG

A
  • Take 2 serum hCG measurements as near as possible to 48 hours apart (but no earlier) to determine subsequent MX of PUL. Take further measurements only after review by senior healthcare professional.
29
Q

PUL information

A
  • Regardless of serum hCG levels, give women with a pregnancy of unknown location written information about what to do if they experience any new or worsening symptoms, including details about how to access emergency care 24 hours a day. Advise women to return if there are new symptoms or if existing symptoms worsen.
30
Q
  • For increase in serum hCG concentration > 63% after 48 hours:
A
    • Inform her that she is likely to have a developing IUP (possibility of ectopic pregnancy cannot be excluded).
      • Offer: TVS to determine location of pregnancy b/w 7 and 14 days later. Consider earlier scan with serum hCG level > /= 1500 IU/litre.
      • If viable iIUP confirmed, offer routine antenatal care
      • If viable IUP not confirmed, refer her for immediate clinical review by senior gynaecologist.
31
Q
  • For decrease in serum hCG concentration > 50% after 48 hours:
A
    • inform that pregnancy is unlikely to continue but that this is not confirmed and
      • provide with oral and written information about where she can access support and counselling services and
      • ask her to take a urine pregnancy test 14 days after second serum hCG test, and explain that:
        • if test negative, no further action is necessary
        • if test positive, return to EPAS for clinical review within 24 hours.
32
Q

Threatened miscarriage MX

A
  • Advise: with vaginal bleeding & confirmed IUP with fetal heartbeat that:
      • if bleeding gets worse, or persists beyond 14 days, she should return for further assessment
      • if bleeding stops, start or continue routine antenatal care.
33
Q

Expectant MX

A
  • Use expectant MX for 7–14 days as first-line MX strategy for confirmed diagnosis of miscarriage.
  • Explore MX options other than expectant MX if:
    1 – at increased risk of haemorrhage (for example, she is in the late first trimester) or
    2 – previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage) or
    3 – increased risk from effects of haemorrhage (for example, if she has coagulopathies or is unable to have a blood transfusion) or
    4 – there is evidence of infection.
34
Q

Expectant MX

A
  • Use expectant MX for 7–14 days as first-line MX strategy for confirmed diagnosis of miscarriage.

Explore MX options other than expectant MX if:
1 – at increased risk of haemorrhage (for example, she is in the late first trimester) or
2 – previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage) or
3 – increased risk from effects of haemorrhage (for example, if she has coagulopathies or is unable to have a blood transfusion) or
4 – there is evidence of infection.

35
Q

Expectant MX Miscarriage

A
  • Use expectant MX for 7–14 days as first-line MX strategy for confirmed diagnosis of miscarriage.

Explore MX options other than expectant MX if:
1 – at increased risk of haemorrhage (for example, she is in the late first trimester) or
2 – previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage) or
3 – increased risk from effects of haemorrhage (for example, if she has coagulopathies or is unable to have a blood transfusion) or
4 – there is evidence of infection.

36
Q

When to offer directly medical manaemnt without expectant in miscarriage

A

Offer medical management to women with a confirmed diagnosis of miscarriage if expectant management is not acceptable to the woman.

37
Q

counselling for expectant MX in miscarriae

A
  • Explain what expectant management involves and that most women will need no further treatment. Also provide women with oral and written information about further treatment options.
  • Give all women undergoing expectant management of miscarriage oral and written information about what to expect throughout the process, advice on pain relief and where and when to get help in an emergency[3].
38
Q

how to decide complete abortion in expectant MX

A
  • If resolution of bleeding & pain indicate that miscarriage has completed during 7–14 days of expectant MX, advise to take urine PT after 3 weeks, & to return for individualised care if it is positive.
39
Q

Offer a repeat scan if after the period of expectant management the bleeding and pain:

A
  • Have not started (suggesting that the process of miscarriage has not begun) or
  • are persisting and/or increasing (suggesting incomplete miscarriage).

Discuss all treatment options (continued expectant management, medical management, and surgical management) with the woman to allow her to make an informed choice.

40
Q
  • Review condition of woman who opts for continued expectant management of miscarriage at a minimum of
A
  • Review condition of woman who opts for continued expectant management of miscarriage at a minimum of 14 days after the first follow-up appointment.
41
Q

Medical management of miscarriage and mifepristone

A
  • Do not offer mifepristone as a treatment for missed or incomplete miscarriage.
42
Q

Medical management of miscarriage and Misoprostol

A
  • Offer vaginal misoprostol for medical TX of missed or incomplete miscarriage.
  • Oral administration acceptable alternative if woman’s preference.
  • For missed miscarriage, use single dose of 800 mcg misoprostol.
  • Advise: if bleeding not started 24 hours after treatment, contact HCP to determine ongoing individualised care.
  • For incomplete miscarriage, use single dose of 600 mcg of misoprostol. (800 mcg can be used as an alternative to allow alignment of treatment protocols for both missed and incomplete miscarriage.
43
Q

Medical management of miscarriage and other meds

A

Offer all women receiving medical management of miscarriage pain relief and anti-emetics as needed.

44
Q

Medical management of miscarriage and Misoprostol and expectations

A
  • Inform women undergoing medical MX of miscarriage about what to expect throughout process, including length and extent of bleeding and potential side effects of treatment including pain, diarrhoea and vomiting.
45
Q

Medical management of miscarriage and Follow up

A
  • Advise: urine pregnancy test 3 weeks after medical MX of miscarriage unless they experience worsening symptoms, in which case advise them to return to HCP responsible for providing their medical MX.
  • Advise: with positive urine PT after 3 weeks to return for review by HCP to ensure that there is no molar or ectopic pregnancy.
46
Q

Surgical management of miscarriage

A
  • Where clinically appropriate, offer women undergoing a miscarriage a choice of:
      • manual vacuum aspiration under local anaesthetic in an outpatient or clinic setting or
      • surgical management in a theatre under general anaesthetic.
  • Provide oral and written information to all women undergoing surgical management of miscarriage about the treatment options available and what to expect during and after the procedure
47
Q

Management of ectopic pregnancy
Surgical and medical management
self referral

A
  • Inform: HX of ectopic pregnancy that they can self-refer to EPAS in future pregnancies if any early concern.
48
Q

Management of ectopic pregnancy
Surgical and medical management

Counselling

A
  • Give all women with ectopic pregnancy oral & written information about:
      • how they can contact healthcare professional for post-operative advice if needed, & who this will be and
      • where and when to get help in an emergency.
49
Q

Management of ectopic pregnancy

medical management

A
  • Offer systemic methotrexate as first-line treatment to, who are able to return for follow-up & who have all of following:
    1 - no significant pain
    2 - unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat
    3 - serum hCG level less than 1500 IU/litre
    4 - no intrauterine pregnancy (as confirmed on US.
50
Q

Management of ectopic pregnancy

Surgical management

A
  • Offer surgery where treatment with methotrexate is not acceptable to the woman.
  • Offer surgery as first-line treatment to who are unable to return for follow-up after methotrexate treatment or who have any of following:
    1 - ectopic pregnancy and significant pain
    2 - ectopic with adnexal mass of 35 mm or larger
    3 - ectopic with fetal heartbeat visible on US.
    4 - ectopic and serum hCG >/= 5000 IU/litre.
51
Q

Management of ectopic pregnancy

Surgical VS medical management

A
  • Offer choice of either MTX or surgical MX with ectopic pregnancy who have hCG of at least 1500 IU/litre and less than 5000 IU/litre, who are able to return for follow-up and who meet all of the following criteria:
    1 - no significant pain
    2 - unruptured ectopic pregnancy with adnexal mass smaller than 35 mm with no visible heartbeat
    3 - no IUP (as confirmed on ultrasound scan).

Advise women who choose methotrexate that their chance of needing further intervention is increased and they may need to be urgently admitted if their condition deteriorates.

52
Q

Management of ectopic pregnancy

Surgical and medical management

A
  • ectopic pregnancy who have had MTX, take 2 serum hCG in first week (days 4 and 7) after treatment & then 1 hCG measurement per week until a negative result is obtained. If hCG levels plateau or rise, reassess the woman’s condition for further treatment
53
Q

Management of ectopic pregnancy
Surgical and medical management

Performing laparoscopy

A
  • When surgical treatment is indicated for women with an ectopic pregnancy, it should be performed laparoscopically whenever possible, taking into account the condition of the woman and the complexity of the surgical procedure.
  • Surgeons providing care to ectopic should be competent to perform laparoscopic surgery.
  • Commissioners and managers should ensure that equipment for laparoscopic surgery is available
54
Q

Management of ectopic pregnancy
Surgical and medical management

Salpingectomy and salpingotomy

A
  • Offer salpingectomy: surgery for ectopic unless they have other risk factors for infertility.
  • Consider salpingotomy as alternative to salpingectomy with risk factors for infertility such as contralateral tube damage.
  • Inform having salpingotomy that up to 1 in 5 may need further treatment. This treatment may include MTX and/or a salpingectomy.
  • had a salpingotomy, take 1 serum hCG at 7 days after surgery, then 1 serum hCG per week until negative result is obtained.
  • Advise had a salpingectomy that they should take urine pregnancy test after 3 weeks. Advise women to return for further assessment if the test is positive.
55
Q

Management of ectopic pregnancy
Surgical and medical management

Anti-D rhesus prophylaxis

A
  • Offer anti-D rhesus prophylaxis at dose of 250 IU (50 micrograms) to all rhesus negative women who have a surgical procedure to manage ectopic or miscarriage.
  • Do not offer anti-D rhesus prophylaxis to women who:
    1 - receive solely medical MX for ectopic or miscarriage or
    2 - have threatened miscarriage or
    3 - have complete miscarriage or
    4 - have PUL
  • Do not use Kleihauer test for quantifying feto–maternal haemorrhage.

Bushra's NICE guidline (2 decks)

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