1. An audit of the ectopic pregnancy pathway at a district general hospital
Mr M Patwardhan, Dr M Allan, Dr N Ramskill Queen Elizabeth Hospital, South London healthcare Trust, Woolwich, London, UK
Objectives
Methods
Results
Conclusions
Maternal deaths are thankfully extremely rare in the United Kingdom. The maternal mortality rate for calculated from all maternal deaths directly or indirectly due to pregnancy identified by the CEMACH enquiry was 14 per 100,000 maternities. 10/1000 were due to ectopic pregnancy with a total of 32,100 ectopic pregnancies diagnosed in the UK during this time period.
The definition of ectopic pregnancy is a conceptus implanting outside the uterine endometrium. Most commonly this is within the fallopian tube (95.5%), followed by ovarian (3.2%), and abdominal (1.3%) sites.
In the management of suspected ectopic pregnancy there is a serum hCG level at which it is assumed that all viable intrauterine pregnancies will be visualised by transvaginal ultrasound. This is referred to as the discriminatory zone. When serum hCG levels are below the discriminatory zone (<1000 iu) and there is no pregnancy (intra- or extrauterine) visible on transvaginal ultrasound scan, the pregnancy can be described as being of unknown location.
In a patient with a PUL or a suspected ectopic who is stable and comfortable, expectant management can be considered will 48 hour follow up of hCG levels. Non-sensitised women who are rhesus negative with a confirmed or suspected ectopic pregnancy should receive anti-D immunoglobulin.
Management of a confirmed ectopic pregnancy depends on an initial assessment of whether the patient is haemodynamically stable. The RCOG greentop guideline recommends a laparoscopic approach to the surgical management of tubal pregnancy in this group of women.
Our study was a two-part retrospective audit comparing the management of ectopic pregnancy with local and national guidelines at a district general hospital in London. It was devised in two parts.
PART 1
Part 1 of the study looked at several aspects of the management of women admitted to accident and emergency with a suspected ectopic pregnancy.
We wanted to look at:
the consistency of recording serial hCG levels and rhesus status
whether anti-D therapy was appropriately administered for those women found to be rhesus negative
the length of stay waiting for a pelvic ultrasound
PART 2
Part 2 looked at the management and outcome of women who had a salpingectomy for a diagnosed ectopic pregnancy.
In both instances, local and national guidelines were observed in order to compare our performance with the “Gold-Standard”.
PART 1
138 cases of suspected ectopic pregnancy presenting to the accident and emergency department between January and August 2011 were reviewed. These patients were given an initial diagnosis of ectopic pregnancy and either admitted to hospital or referred to the Early Pregnancy Assessment Unit (EPAU) for scan and hCG follow up.
The following local audit standards were examined:
How frequently were we performing a hCG in woman undergoing expectant management? The standard - at least 48 hours apart in 100% of the patient.
How many patients were being followed up until HCG dropped below 50? The standard - 100% of women.
How many women had their blood group documented in their notes with Anti – D then being given to those with a negative blood group? The standard – 100% of women.
PART 2
100 women were identified as having had a salpingectomy for diagnosed ectopic pregnancy between January and August Their notes were reviewed and the following audit standards were addressed:
What was our rate of women having a seemingly “normal” laparoscopy with no ectopic pregnancy identified, and was it comparable to the national rate in the UK.
Were patients being followed up until their serum hCG level dropped below 50? The standard – 100% of women.
Was their blood group documented and Anti – D given to eligible women? The standard – 100% of women.
The results from both parts of the study were then collated into a spreadsheet and interpreted for conclusion.
PART 1
PART 2
PART 1
26 women were managed expectantly during the period of study. Of these women, only 6 were followed up with frequent hCG levels until it dropped below 50, equating to 23%. The reason for this may be that it simple was not practical to monitor women for this length of time. The addition of a large group of women returning for frequent hCG levels would place an immense strain on an already stretched EPAU. Some women also preferred not to go back for follow up, and the outcome of these women is not known.
80% of women managed expectantly however had at least one 48 hour hCG. The remaining 20% may have been lost when the 48 hour period fell on a weekend or bank holiday, or if it simply was not convenient for the woman. The A&E department could take up this task, however they are also severely overstretched, and it would also rely on a thorough hand-over between medical staff and a motivated patient. Women should be counselled about the importance of close follow up in order to be fully informed about the gravity of their decision to have frequent tests or not.
Administration of anti-D to rhesus negative women was also not 100% compliant. The two women who did not have anti-D had a pregnancy of unknown location – should these women even need anti-D administration at all?
PART 2
10% of women had a negative laparoscopy following a positive transvaginal ultrasound scan. There are currently no national guidelines for the rate at which this should occur in any given hospital. Is 10% too much? Should we been more reserved in taking a patient to theatre in order to reduce potential morbidity and mortality in our patients?
77% of women were given anti-D following their procedure. This is unacceptable and adequate training should be to all staff involved in order to improve this.
Audit Standard to be Evaluated
Number
Standard to be achieved
Percentage
Numbers of women with suspected ectopic pregnancy
138 -
Numbers of women with suspected ectopic or pregnancy of unknown location on US 41
30%
Managed expectantly
26/41
63%
Women with at least one 48 hour hCG levels
20/26
100%
80%
Women followed up until hCG levels dropped to <50
6/26
23%
Blood group documented
37/41
90%
Women with rhesus negative blood group
3/41 7%
Treatment with Anti-D
1/3
33%
Audit Standard to be Evaluated
Number
Standard to be achieved
Percentage
Numbers of women undergoing laparoscopy
100 -
Negative laparoscopy
10/100
unknown
10%
Blood group documented
99/100
100%
99%
Women with rhesus negative blood group
13/100
Treatment with Anti-D
10/13
77%
References
Bouyer J, Coste J, Fernandez H, et al. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod 2002;17:3224–3230
Lewis, G (ed) The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH.
Royal College of Obstetricians and Gynaecologists. The management of tubal ectopic pregnancies. Greentop Guideline 21. RCOG; London: 2004.
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