For us, this guideline doesn’t change management a lot. It will have implications for secondary care, as it specifies that assessment services must be available 7 days a week and women should be seen within 24 hrs or referral.
Useful bits of information:
- Expectant Management – see below – this is good for us to know.
- Presentation of Ectopic Pregnancy. Remember that presentation can be nebulous.
- Pregnancy Tests. All surgeries should have pregnancy tests available (at the moment I would suggest that only a minority have them – should we think about carrying them?).
- Emergency Contact Numbers. Ensure women know who to contact if symptoms worsen (NICE doesn’t advise who – but GP or OOH would probably be appropriate initially).
Refer Immediately patients who have a positive pregnancy test AND:
- Abdo pain AND tenderness OR
- Pelvic tenderness OR
- Cervical Motion tenderness
NB – this is different to current local practice, where patients are generally booked into the next available slot, but this could be several days away.
Refer with urgency dependent upon clinical presentation patients with a positive pregnancy test AND Bleeding or other signs and symptoms of early pregnancy complications AND
- Pain OR
- Pregnancy 6/40 or more OR
- Pregnancy of uncertain gestation
Expectant Management for patients:
- < 6/40
- Bleeding but no pain
Where you are managing patients expectantly, advise them to repeat a pregnancy test after 7 to 10d. If it is positive, they need review. If it is negative, they have had a miscarriage. Also warn patients that you are managing expectantly, to come back if symptoms worsen or continue.
Management of Complete Miscarriage:
Most women will be managed conservatively. If bleeding has settled within 14d, they will be advised to do a pregnancy test after 3/52. If it is still positive, they will need further review. They will not necessarily need further scanning.
Management of Threatened Miscarriage:
Advise women that if the bleeding hasn’t settled after 7 to 14d, that they need review.
Notes about Hospital Investigations that we need to know about:
Beware a diagnosis of ‘complete miscarriage’ when no previous intrauterine pregnancy has been seen. There is a possibility of it being ectopic.
bHCG levels are done 48 hrs apart (NB progesterone should no longer be used):
- A rise of 63% or more, suggests a developing intrauterine pregnancy. Repeat scan after 1 to 2/52
- A decline of 50% or more, suggests a pregnancy that is unlikely to continue. Women should repeat a pregnancy test after 1 to 2/52. If positive, they will need review.
Management of Ectopic Pregnancy:
These will be managed in hospital.
Only give if they have had surgical management, not otherwise. Patients do not need it for threatened or complete miscarriages. Further guidance on use of anti-D is available.