Early Pregnancy Cerclage – vvaaggiinnaall oorr aabbddoommiinnaall?? Roy Farquharson MD FRCOG Gynaecologist Liverpool Women’s Hospital, UK [email protected] • Setting the scene • Early pregnancy figures in UK • Trends and shifts •• CCaarree pprroovviissiioonn • New horizons UK Figures (2008) • 700,000 births per annum in UK • 200,000 terminations • >250,000 miscarriages •• 1155,,000000 eeccttooppiicc pprreeggnnaanncciieess • Reference: CEMACH report, 2008, RCOG Press, London Trends and Shifts • Increasing average maternal age • Increasing demand for all EP events • Increasing knowledge about early pprreeggnnaannccyy eevveennttss ((1177,,550000,,000000 eennttrriieess oonn Google) • Patient Choice an important driver for management and shared decision making based on evidence based practice Standards in Early Pregnancy + Ectopic Pregnancy + Recurring Miscarriage AEPU/RCOG Joint Document (2007) RCOG Standards in Gynaecology (2008) AEPU Roy Farquharson, Chair, Association of Early Pregnancy Units Lesley Regan, Hon President, AEPU Website: earlypregnancy.org.uk rcog.org.uk/standards June 2008 2 Early pregnancy loss 3. Ectopic pregnancy 4. Recurring Miscarriage Standard CORE Aspirational Patient Designated Reception Area Dedicated staff constantly at reception desk to provide greeting, obtain Information Universal use of clear, understandable patient details and explain structure and triage function of EPU terminology by all staff Patient Choice Education of patient relevant to diagnosis and Dedicated phone line for patient queries and electronic access to protocols In management from outside unit Management Open explanation of expectant, medical and surgical options Dedicated Quiet Room for breaking bad news away from work Single-use room only with soft furnishing and absence of medical Room area equipment Availability of 5 day opening during office hours 7/24 opening and service provision with full staffing and daily scan support Service Competence of Recognised ultrasound training and preceptor Lead Clinician Presence of RCOG/BMUS trainer in EPU Scanning assessment and validation Annual assessment of audited activity ((RRCCOOGG//BBMMUUSS)) Register of staff competent at scanning Blood HCG Laboratory access to blood HCG measurement Same day sampling and result with electronic result link to laboratory level and result within 48 hours of sampling measurement Written Visible open access to written information Online external access to PIL Information leaflets in EPU Leaflets Acknowledgment To provide individualised patient support and Place one to one care as best practice at all times of Privacy acknowledge confidentiality and Dignity Bereavement All staff trained in emotional aspects of early To provide all emotional and psychological counselling requirements Counselling pregnancy loss within EPU and supported by dedicated staff and related agencies To enable access to counselling and provide immediate support Site of EPU Geographically separate from all maternity Own EPU entrance/exit areas What does an Early Pregnancy Clinic/Unit do? • All early pregnancy problems are seen by a multidisciplinary team in a dedicated area with easy patient access and privacy (for breaking bad news) plus good quality scan service and laboratory backup (HCG result computer link) •• AAddaapptteedd ((MMEEWWSS--bbaasseedd)) TTrriiaaggee AAsssseessssmmeenntt oonn presentation (~ 1-2% score>4) • Diagnosis & surveillance of PUL/PUV/ectopic • Treatment & Surveillance of EP loss, ectopic failed PUL/molar pregnancy/hyperemesis • Initiation of Management Plan for Medical/Surgical/Expectant protocols & options Inherited Thrombophilia Tests UK National EPU Survey 2008 (Norrie et al, Brit J Haem, 2009, 144, 241-4) • 70% response rate (115/164 EPU’s) in UK • Heritable Thrombophilias (eg FVL, Prot C, S ) tested for late miscarriage (80%), recurrent mmiissccaarrrriiaaggee ((7766%%)) aanndd ppllaacceennttaall aabbrruuppttiioonn (88%) • Highly variable range of tests between EPU’s which frequently led to heparin/aspirin administration in next pregnancy • Evidence based practice for testing and intervention inconsistent across UK OOppppoorrttuunniittyyiissnnoowwhheerree