Bleeding in Early Pregnancy

Published Date: 19th July 2016

Publication Authors: Graham S, Rao S, Moorcroft LK

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Objectives 

Bleeding in early pregnancy (BEP) creates a significant workload for the emergency department (ED) as women seek help out of hours when other specialist services are closed. Turnover of doctors and nurses is high, ED staff are anxious not to miss an ectopic pregnancy and women attend seeking an immediate scan

or reassurance. Serial serum b-hCG levels can indicate pregnancy loss or ectopic pregnancy and the first measure is not routinely taken by ED staff, delaying the time to diagnosis by specialists. Cases attending the ED at Whiston Hospital were audited according to RCOG guidelines for early pregnancy loss; specifically measuring as a primary outcome the proportion of women with a serum b-hCG level taken. To improve care a patient information leaflet has been implemented as well as a computer ordering system for Triage nurses to automatically request serum b-hCG.

Methods 

One hundred and thirty women attended the ED in 5 weeks January–February 2012 with BEP. A retrospective case note review audited against eight standards of care in these women including the primary outcome of serum b-hCG measurement. Women attending the ED in 5 weeks January–February 2013 with BEP have been audited to validate the interventions.

Results 

Subset analysis revealed differences in care. Sixty-four percent (n = 9) of women referred directly to a gynaecology SHO had the first serum b-hCG measurement taken, compared to 52% (n = 26) of women seen by an ED doctor and none of those women who did not wait to be assessed by a doctor after triage. Twenty-five percent (n = 3) of the women not waiting also did not attend the BEP clinic, so may be an at risk group. Differences were also seen in using the correct nomenclature to describe pregnancy loss, documenting LMP and taking a urine pregnancy test, FBC and blood group.

Conclusions 

Implementing an information leaflet with red flag symptoms for ectopic pregnancy reassures ED staff of a safer discharge awaiting specialist follow-up and reassures women that BEP is a common symptom that does not necessarily lead to pregnancy loss. Automatic ordering to select b-hCG as an investigation for BEP standardises care and ensures women who do not wait to see a doctor out of hours do not also experience unnecessary delay to diagnosis by specialists.

Moorcroft, LK; Rao, S; Graham, S. (2013).  Improving the experience and time to diagnosis of women with bleeding in early pregnancy (BEP) attending the emergency department (ED) at a district general hospital . BJOG: An International Journal of Obstetrics and Gynaecology. 120 (Supplement S1), 436​

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