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1. Introduction
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The Women's has a dedicated Early Pregnancy Assessment Service (EPAS) to provide coordinated assessment, scanning, diagnosis and management-planning for women who experience pain and/or bleeding in early pregnancy.
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2. Purpose
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The purpose of this CPG is to standardise the processes used by EPAS staff for:
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- assessing women attending the Women's EPAS
- making a diagnosis following EPAS assessment
- arranging the next stage of care.
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3. Definition of Terms
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EPAS – Early Pregnancy Assessment Service. This service runs Monday – Friday mornings in the Well Women’s Clinic.
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Early pregnancy – all gestations up to 16 completed weeks. (Note: Women with pregnancy of gestation >16 completed weeks should be referred to the obstetric unit).
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POC – Products of Conception (avoid using the term “products of conception” with women and their families – from their perspective, they have lost their baby).
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4. EPAS Care Pathway
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4.1 Initial Assessment
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- Obtain history and review notes from referrer (if any).
- Assess vital signs and general wellbeing.
- Urinary pregnancy test (unless already provided).
- Establish gestation, based on LMP.
- Advise that the majority of women will require a transvaginal scan and reassure woman regarding the tolerability and safety of the procedure.
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4.2 Ultrasound Scan
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- The Ultrasound scan should only be performed by EPAS staff, who are appropriately qualified or credentialed in first trimester scanning.
- All scanning should comply with the CPG: first trimester ultrasound scanning.
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- Record the following findings onto Viewpoint.
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1) The mean gestation sac diameter
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| 7) The presence / absence of fetal heart activity
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| 2) The number of sacs / fetal number
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| 8) The appearance of the ovaries
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| 3) The regularity of the outline of the sac
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| 9) The presence of any ovarian cysts
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| 4) The presence of a yolk sac
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| 10) The presence and size of any tubal mass
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| 5) The presence of a fetal pole
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| 11) The presence of haematoma / other anatomy
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| 6) The CRL / gestational dates
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| 12) The presence of any fluid in the P.O.D
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If the ultrasound images are difficult to interpret, or a second opinion is required, contact the ultrasound “floating doctor” to view the images prior to making diagnosis.
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4.3 Diagnosis
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- To determine diagnosis, refer to
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4.4 Additional diagnostic tests
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- Perform additional investigations as needed to inform ongoing planning, including:
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 | - Blood tests – to obtain blood group, antibody status, full blood count and ßhCG level
- Abdominal palpation
- Speculum assessment.
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- Consider chlamydia swabs for women aged under 25yrs, or according to individual circumstances.
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4.5 Discuss the diagnosis with the woman:
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- Inform the woman of the assessment findings and diagnosis, and provide consumer information.
- Provide reassurance, and be aware of the potential for psychological trauma - adequate time should be allowed for the woman to make decisions.
- Provide access to formal counseling when necessary. Appropriate support can result in significant positive psychological gain.
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4.6 Management planning
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- Plan the next steps of care, as per table below:
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| | | | Viable pregnancy
| - Intrauterine gest. sac seen
- Fetal pole seen
- Fetal heart beat seen
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| - Provide reassurance and discharge to antenatal care provider or PAS as requested.
- If not booked for antenatal care, arrange a Women's ANC appointment.
- Check the need for Anti-D, as per the Women's CPG: Rh D Immunoglobulin in Obstetrics
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| | Missed miscarriage
| - Intrauterine gest. sac seen
- Fetal pole seen.
- Fetal heart beat not seen.
- CRL is >6mm
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| - Refer to CPG: Miscarriage: management
- Check the need for Anti-D, as per the Women's CPG: Rh D Immunoglobulin in Obstetrics
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| | Inconclusive (possible viable)
| - Intrauterine gest. sac seen,
- Fetal pole seen.
- Fetal heart beat not seen.
- CRL is <6mm
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| OR
| - Intrauterine gest. sac seen,
- Fetal pole not seen.
- Gestational sac <20mm
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| - Obtain blood for ßhCG.
- Check the need for Anti D.
- Ensure woman clinically stable.
- Discharge and repeat ßhCG in 48 hrs.
- Repeat scan in EPAS in 1 week.
- If viable pregnancy subsequently confirmed, follow plan of management [A] above (if not, follow [B]).
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| | Missed miscarriage
| - Intrauterine gest. sac seen
- Fetal pole not seen.
- Gestational sac >20mm
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| - Refer to CPG: Miscarriage: management
- Check the need for Anti-D, as per the Women's CPG: Rh D Immunoglobulin in Obstetrics
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| | Ectopic pregnancy
| - Intrauterine gest. sac not seen
- Ovarian / fallopian mass seen
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| - Obtain bloods (i.e. ßhCG, group and hold, FBC).
| - Refer to CPG: Ectopic Pregnancy: Management
- Check the need for Anti-D, as per the Women's CPG: Rh D Immunoglobulin in Obstetrics
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| | Pregnancy of unknown location
| - Intrauterine gest. sac not seen
- No ovarian / fallopian mass
- No POC passed
- No POC seen in uterus
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| - Obtain blood for ßhCG.
- Refer to CPG: Pregnancy of an Unknown Location.
- Check the need for Anti-D, as per the Women's CPG: Rh D Immunoglobulin in Obstetrics
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| | Complete miscarriage
| - Intrauterine gest. sac not seen
- No ovarian / fallopian mass
- POC have passed (if in doubt, treat as per ‘F’).
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| - Refer to CPG: Miscarriage: management
- Check the need for Anti-D, as per the Women's CPG: Rh D Immunoglobulin in Obstetrics
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| | Incomplete miscarriage
| - Intrauterine gest. sac not seen
- No ovarian / fallopian mass
- POC have passed
- POC seen in uterus
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| - Obtain blood for ßhCG.
- Refer to CPG: Miscarriage: management
- Check the need for Anti-D, as per the Women's CPG: Rh D Immunoglobulin in Obstetrics
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- If co-existing pathology is noted in scan (e.g. complex ovarian cyst, undiagnosed fibroids) contact Gynaecology Registrar.
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5. Records and Data Collection
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- The EPAS Record sheet should be used to document details of the attendance. This should be filed in the Women's patient record.
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- Ultrasound findings should be recorded onto Viewpoint and the report printed, signed by Sonologist and filed in the Women's patient record.
- Additional progress notes can be added to the patient record.
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- GPs will be sent an attendance letter including investigations performed and management plan.
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6. Refer also to the following Women's resources:
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Clinical Practice Guidelines (CPGs)
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Policies and Procedures
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7. References
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The content of this CPG is based on:
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- Royal College of Obstetricians and Gynaecologists - RCOG (2006) Greentop Guideline number 25: The Management of Early Pregnancy Loss, http://www.rcog.org.uk/index.asp?PageID=515
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- Royal College of Obstetricians and Gynaecologists - RCOG (2004) Greentop Guideline number 21: The Management of Tubal Pregnancy, http://www.rcog.org.uk/index.asp?PageID=537
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- The Association of Early Pregnancy Units – AEPU (2004) Organisational, Clinical and Supportive Guidelines, http://www.earlypregnancy.org.uk/guidelines.asp
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Additional information has been drawn from:
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- Goodhope Hospital NHS Trust: Operational Policy and Guidelines
- Sheffield NHS Foundation Trust: Management of early pregnancy problems
- Sheffield NHS Foundation Trust: Guidance notes for the EPAU
- Cambridge University NHS Foundation Trust: Guidelines for the management of women presenting with bleeding and or pain in early pregnancy
- Cambridge University NHS Foundation Trust: Algorithm for management of patients with ultrasound scan findings consistent with an intrauterine pregnancy
- Cambridge University NHS Foundation Trust: Algorithm for management of patients with ultrasound scan findings showing an empty uterus
- Gold Coast Health Services EPAC – Guidelines for an admission to EPAS
- Gold Coast Health Services EPAC – Guidelines for management of pain and bleeding in early pregnancy
- Gold Coast Health Services EPAC – Guidelines for EPAC ultrasound scan
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Evidence table
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2 August 2007
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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