Ectopic Pregnancy - management of patient presenting to the Emergency Department.
Version
2
Name of responsible (ratifying) committee
Consultant Clinical Lead Early Pregnancy
Lead Nurse Early Pregnancy Service
Clinical Director Emergency Department
Clinical Director Gynaecology
W&C CSC Policies and Guidelines Group
Date ratified
20 January 2011
Document Manager (job title)
Clinical Nurse Specialist Early Pregnancy Unit
Date issued
07.07.2011
Review date
July 2013
Electronic location
Corporate Clinical Guidelines
Related Procedural Documents
Key Words (to aid with searching)
Ectopic Pregnancy; pelvic pain
Ectopic Pregnancy - management of patient presenting to the Emergency Department.
Review date: July 2013
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CONTENTS
QUICK REFERENCE GUIDE……………………………………………………………………………...….2
1.
2.
3.
4.
5.
6.
7.
8.
9.
INTRODUCTION.......................................................................................................................... 3
PURPOSE ................................................................................................................................... 3
SCOPE ........................................................................................................................................ 3
DEFINITIONS .............................................................................................................................. 3
DUTIES AND RESPONSIBILITIES .............................................................................................. 3
PROCESS ................................................................................................................................... 3
TRAINING REQUIREMENTS ...................................................................................................... 4
REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................ 4
MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS .............................................................................................................................. 4
Ectopic Pregnancy - management of patient presenting to the Emergency Department.
Review date: July 2013
Page 2 of 9
1. INTRODUCTION
Patients with an ectopic pregnancy may present with a wide range of symptoms, ranging from
acute collapse to mild vaginal spotting. Classically the complaints are pelvic pain and irregular
or abnormal vaginal bleeding, but only half of the patients with ectopic pregnancy are correctly
diagnosed on the basis of clinical features alone.
Clinicians in primary care and Emergency Departments, in particular, need to be aware of
atypical clinical presentations of ectopic pregnancy and especially of the way in which it may
mimic gastrointestinal disease (CEMACH, 2007).
Signs and Symptoms:
The patient can present with
 Delayed menses or irregular bleeding
 Slightly dark to heavy fresh per vaginum blood loss
 Unilateral or bilateral pain
 Fainting/ dizziness
 Shoulder tip pain
 Pain on defecation, diarrhoea and/or gastrointestinal symptoms (CEMACH, 2007)
2. PURPOSE
To ensure immediate diagnosis and optimal treatment of the client
3. SCOPE
Any woman accessing care in the early stages of pregnancy. To include women of child
bearing age presenting with pain and bleeding and a positive pregnancy test that may not have
planned or suspected that they are pregnant.
Acute -The patient is in shock with pallor, hypotension and rising pulse rate secondary to intraabdominal bleeding. There is associated sudden onset of abdominal pain, and the patient may
collapse and become unresponsive. Shoulder tip pain may occur due to internal haemorrhage
causing diaphragmatic irritation.
Non Acute - Abdominal pain is most common, but the site and severity vary considerably.
There is usually amenorrhoea or an abnormal last menstrual period (light or delayed), and
there may be pregnancy symptoms such as breast tenderness. Vaginal bleeding is common
and varies from a small amount of dark loss to heavier fresh bleeding.
4. DEFINITIONS
Ectopic Pregnancy – is a pregnancy occurring outside the uterus, most frequently occurring in
the fallopian tube.
5. DUTIES AND RESPONSIBILITIES
Clinical Director in Gynae and Emergency Department to ensure Medical staff are informed of
process
Early Pregnancy Assessment Unit Senior Nurse for ensuring nursing staff are informed of
process
6. PROCESS
When a woman presents with any of the above signs and symptoms (contained in scope
section), a rapid urinary pregnancy test should be carried out.
This will be positive in virtually all cases of ectopic pregnancy. If the pregnancy test is positive,
then a provisional diagnosis of possible ectopic pregnancy can be made.
Ectopic Pregnancy - management of patient presenting to the Emergency Department.
Review date: July 2013
Page 3 of 9
To ensure prompt optimal treatment in the Emergency Department (ED) if the patient is
unstable, showing any signs of haemodynamic instability or in severe pain, the patient should
be managed in the resuscitation room and the Duty Gynaecological registrar (bleep 1344)
should be called to see the patient in ED.
Patients who are not acutely unwell and are haemodynamically stable should be discussed
with the Gynaecology Registrar ‘on call’ for Gynae Emergencies (bleep1344).
Patients who are in a stable condition can be transferred to the D8 Gynae Ward.
Prior to transfer the following must be undertaken in case of sudden collapse
I. Ensure adequate Intravenous access has been achieved with at least a size 18 gauge
venflon; blood has been sent for haemoglobin and group and save, Urea and
electrolytes and beta HCG.
II. The patients in ED awaiting transfer to D8 Gynaecology should continue to have regular
15 –30 minutes observations up until departure from the department to ensure they
remain fit for transfer and alert staff to any deterioration in the patient’s condition.
If admitted acutely unwell or there is any change in the condition and patient becomes
acute contact the on call Gynaecology Consultant via switchboard and Gynae Registrar
on Bleep 1344. Ensure adequate venous access in all cases of sudden collapse.
7. TRAINING REQUIREMENTS
Emergency Department, Surgical and Gynaecology medical staff to be informed of process and
transfer pathway during their induction to area.
Gynaecology Ward Manager to inform nursing staff of pathway on their induction to the area.
The Early Pregnancy Assessment Unit or Gynaecology Ward may be contacted for advice or
patient information on Ectopic Pregnancy.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
Confidential Enquiry into Maternal and Child Health (2007). Saving Mothers’ Lives 2003-2005: Improving
the health of Mothers, babies and Children. CEMACH: London.
Further reading;
Royal collage of Obstetricians and Gynaecologists. 2004 May. The Management of Tubal Pregnancy.
Green Top Guideline 21. www.ectopic.org/medical_information/guidelines_for_management.asp
9. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF,
PROCEDURAL DOCUMENTS
In order to provide the Gynaecology and Emergency Department with assurance of
implementation of the guideline and the provision of safe clinical care the following process of
monitoring will be utilised.
There will be with continual monitoring and audit by the Early Pregnancy Assessment Unit
Staff.
Audit findings to be presented annually to the Gynaecology governance group and CD for the
Emergency Department. Any inappropriate actions to be highlighted immediately to the CD for
Gynae & ED.
Monitoring Time Frames
A = Rare events – in these cases individuals case review will occur (e.g. Collapsed rupture
ectopics)
B = Annual audit/ collection of data retrospectively
C = Ongoing prospective audit/data collection
D = Tri annual audit – linked to guideline amendments
Ectopic Pregnancy - management of patient presenting to the Emergency Department.
Review date: July 2013
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Management of possible Ectopic Pregnancies within the Emergency Department
Level of
Monitoring and
Compliance
required
Audit Method
Lead responsible for
audit and repost
submission
Frequency of audit
A
Notes Audit
Admitting Consultant or
CNS EPAU
Within 1 month of
admission
C
30 sets of Notes
Audit
CNS EPAU
Annually
 The audit report will be submitted to the Gynaecology and Emergency Department Governance
Group and Management Forums for monitoring.
 Action plan implementation is the responsibility of the Gynaecology and Emergency Department
Governance and Management Forums.
 Notable practice and lessons learned will be disseminated to Gynaecology and Emergency staff
via departmental and ward governance meetings and departmental newsletter.
 The action plan will remain an agenda item for the Governance, and Management Forum until all
actions have been achieved or barriers to compliance have been identified
 Any barriers to compliance will be risk assessed within 2 months of identification by an appointed
member of the Governance and Management Forum. The resultant risk assessment will populate
the Gynaecology and Emergency Department Risk register and monitored by the Governance
and Management Forum.








Audit
Evidence of observations
Evidence of assessment
Appropriately referred to Gynae Registrar or Consultant.
Venflon inserted prior to transfer
Evidence of observations at 15-30 minute intervals whilst awaiting transfer
If delay in transfer documentation to demonstrate why this has occurred.
If change in condition evidence of escalation and Consultant involvement.
Did the patient go straight to theatre from the Emergency Department.
Ectopic Pregnancy - management of patient presenting to the Emergency Department.
Review date: July 2013
Page 5 of 9
APPENDIX A
Checklist for the Review and Ratification of Procedural Documents and
Consultation and Proposed Implementation Plan
To be completed by the author of the document and attached when the document is
submitted for ratification: a blank template can be found on the Trust Intranet. Home page ->
Policies -> Templates
CHECKLIST FOR REVIEW AND RATIFICATION
TITLE OF DOCUMENT BEING REVIEWED:
1
2
4
5
COMMENTS
Title
Is the title clear and unambiguous?
Yes
Will it enable easy searching/access/retrieval??
Yes
Is it clear whether the document is a policy,
guideline, procedure, protocol or ICP?
Yes
Introduction
Are reasons for the development of the document
clearly stated?
3
YES/NO
N/A
Yes
Content
Is there a standard front cover?
Yes
Is the document in the correct format?
Yes
Is the purpose of the document clear?
Yes
Is the scope clearly stated?
Yes
Does the scope include the paragraph relating to
ability to comply, in the event of an infection
outbreak, flu pandemic or any major incident?
No
Are the definitions clearly explained?
Yes
Are the roles and responsibilities clearly
explained?
Yes
Does it fulfil the requirements of the relevant Risk
Management Standard? (see attached
compliance statement)
Yes
Is it written in clear, unambiguous language?
Yes
Evidence Base
Is the type of evidence to support the document
explicitly identified?
Yes
Are key references cited?
Yes
Are the references cited in full?
Yes
Are associated documents referenced?
N/A
Approval Route
Ectopic Pregnancy - management of patient presenting to the Emergency Department.
Review date: July 2013
Page 6 of 9
Does the document identify which
committee/group will approve it?
6
Yes
Process to Monitor Compliance and
Effectiveness
Are there measurable standards or KPIs to
support the monitoring of compliance with the
effectiveness of the document?
7
Review Date
Is the review date identified?
6
Yes
Dissemination and Implementation
Is a completed proposed implementation plan
attached?
7
Yes
Yes
Equality and Diversity
Is a completed Equality Impact Assessment
attached?
Yes
APPENDIX A
cont……
Checklist for the Review and Ratification of Procedural Documents and
Consultation and Proposed Implementation Plan
CONSULTATION AND PROPOSED IMPLEMENTATION PLAN
Date to ratification committee
Groups /committees / individuals involved in
the development and consultation process
Is training required to support
implementation?
Emergency Department, Surgical and
Gynaecology medical staff to be informed of
process and transfer pathway during their
induction to area.
Gynaecology Ward Manager to inform
nursing staff of pathway on their induction to
the area. The Early Pregnancy Assessment
Unit or Gynaecology Ward may be contacted
for advice or patient information on Ectopic
Pregnancy.
If yes, outline plan to deliver training
As above
Outline any additional activities to support
implementation
None identified
Ectopic Pregnancy - management of patient presenting to the Emergency Department.
Review date: July 2013
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Individual Approval
If, as the author, you are happy that the document complies with Trust policy, please sign
below and send the document, with this paper, the Equality Impact Assessment and NHSLA
checklist (if required) to the chair of the committee/group where it will be ratified. To aid
distribution all documentation should be sent electronically wherever possible.
Name
Janet Birrell
Date Dec 2010
Signature
Committee / Group Approval
If the committee/group is happy to ratify this document, would the chair please sign below
and send the policy together with this document, the Equality Impact Assessment, and
NHSLA checklist (if required) and the relevant section of the minutes to the Trust Policies
Officer. To aid distribution all documentation should be sent electronically wherever
possible.
Name
Date
Signature
If answers to any of the above questions is ‘no’, then please do not send it for ratification.
Ectopic Pregnancy - management of patient presenting to the Emergency Department.
Review date: July 2013
Page 8 of 9
APPENDIX B
EQUALITY IMPACT ASSESSMENT
To be completed by the author of the document and attached when the document is
submitted for ratification: a blank template can be found on the Trust Intranet. Home page ->
Policies -> Templates
Ectopic Pregnancy - management of patient
presenting to the Emergency Department.
Title of document for assessment
Date of assessment
December 2010
Job title of person responsible for Clinical Nurse Specialist
assessment
Division/Service
W&C
Yes/No
Comments
Does the document affect one group less or more favourably than another on the
basis of:
NO
 Race

Gender (including transgender)
Yes

Religion or belief
No

Sexual
orientation,
including Yes
lesbian, gay and bisexual people
No
Age (for HR policies only)

This is a gynaecological condition that
will only effect women including pretransgender re-assignment (female to
male)
As above
Disability – learning disabilities, No
physical
disabilities,
sensory
impairment and mental health
problems
Does this document affect an No
individual’s human rights?

If you have identified potential N/A
discrimination, are the exceptions
valid, legal and/or justified?
If the answers to any of the above questions is ‘yes’ you will need to complete a full Equality
Impact Assessment (available from the Equality and Diversity website) or amend the policy
such that only an disadvantage than can be justified is included. If you require any general
advice please contact staff in the Equality and Diversity Department on 02392 288511
Ectopic Pregnancy - management of patient presenting to the Emergency Department.
Review date: July 2013
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