Enough is enough! Time for a new model of care for women with early pregnancy complications
: Associate Professor George Condous, Acute Gynaecology and Early Pregnancy Unit, Nepean Centre for Perinatal Care, Nepean Clinical School, University of Sydney, Nepean Hospital, Penrith, Sydney, NSW, Australia. Email: email@example.com
Australian women with early pregnancy complications, like their English counterparts, should have access to ultrasound-based early pregnancy units (EPUs) nationwide. This modern approach to women with first trimester problems would not only streamline individual care pathways but also reduce the impact that early pregnancy problems have on already overburdened public emergency departments. Dedicated EPUs, with trained gynaecological sonologists experienced in the management of first trimester complications, should become the benchmark standard of care for Australian women in early pregnancy.
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All women with first trimester complications should be evaluated in an ultrasound-based early pregnancy unit (EPU). EPUs that use ultrasound, and in particular transvaginal ultrasound (TVS), at the clinical interface have been prospectively validated.1–3 The UK has embraced this early pregnancy model of health care. The introduction of such dedicated EPUs throughout the UK has resulted in significant benefits for women with first trimester complications. Ultrasound, especially TVS, has enabled rapid diagnosis of early pregnancy conditions such as miscarriage and ectopic pregnancy. These conditions are seen much earlier in their natural history, and consequently, more conservative treatment modalities have been adopted including expectant and medical management.4–9 Prompt gynaecological input, creation of a sympathetic environment for women and preservation of women's dignity have revolutionised first trimester loss. There has also been a direct financial benefit to the National Health Service (NHS) with a reduction in unnecessary admissions, increase in outpatient-based management and a reduction in overall costs.1–3
Australia has been slow to introduce such units, but now is the time to embrace this more efficient model of early pregnancy care. This approach will not only streamline first trimester management but also reduce the impact of early pregnancy problems on an already overburdened public health-care system. Early pregnancy management should no longer be the ‘scraps’ for unsupported junior Obstetric and Gynaecology (O&G) residents in the setting of a busy emergency department (ED). Instead, it is time to acknowledge that early complications require consultant lead care by appropriately ultrasound-trained gynaecological specialists in a dedicated EPU.
Traditional model of early pregnancy care
Historically, first trimester pregnant women experiencing any lower abdominal pain or vaginal bleeding attend their general practitioner (GP) or the ED. After an initial assessment with or without vaginal examination, referral to the on-call gynaecologist would occur. Further assessment and vaginal examination would take place, and depending on the experience of the junior doctor, a further senior opinion would often be sought before other investigations were arranged. Admission of the woman because of lack of access to outpatient ultrasound facilities would often occur. Any serum investigations ordered could potentially take more time thus contributing to an already prolonged hospital stay. Should surgery be necessary, a further wait on the emergency operating list could be expected resulting in prolonged fasting times until the operation was possible. This was a totally unacceptable experience physically, mentally and financially. As a consequence, the Royal College of Obstetricians and Gynaecologists introduced a guideline recommending the setting up of a dedicated EPU in all hospitals that was accessible by GPs, women and other hospital departments. This guideline stipulated that the facility should be available on a daily basis or during normal working hours as a minimum.1
Unfortunately, most Australian women with early pregnancy complications are still subject to this antiquated care pathway. The uncertainty and anxiety generated by the potential loss of a pregnancy is compounded by often ambiguous ultrasound conclusions and unclear management plans. It is therefore not surprising that this clinical scenario is often the source of hospital-based patient complaints. It is time that Australia adopted a new model of early pregnancy care to the management of early pregnancy complications.
New model of early pregnancy care
The EPU provides a flexible ‘women-centred’ model of service delivery, where women in early pregnancy gain timely access to be assessed and treated for complications, and receive appropriate counselling and follow-up care by experienced expert doctors. This modern service also provides appropriate ultrasound-based assessment and subsequent management of women with early pregnancy problems. This new service functions very effectively and assists in the reduction of access block in the ED as well as providing early intervention, counselling and support to women at a very sensitive time. Early intervention in the early pregnancy population means that non-surgical approaches to miscarriage and ectopic pregnancy can be and are safely offered to women with these complications. This also has the added benefit of maximising outpatient management and minimising unnecessary inpatient theatre allocation.
This model of care has the potential to be extended to women with acute gynaecological complications including acute pelvic pain, acute pelvic inflammatory disease, ovarian cyst accidents, severe menorrhagia and acute postmenopausal bleeding. There are limited data available on the introduction of acute gynaecology units (AGUs) which also utilise ultrasound at the initial clinical interface.10 More studies are required in order to assess the impact of AGUs on admission rates, occupied bed days and outpatient attendances.
I propose a ‘one-stop’ ultrasound-based11 approach to women with early pregnancy complications including miscarriage and ectopic pregnancy. This means that a woman should have her history, clinical examination and ultrasound performed in the one dedicated facility. In order to optimise a woman's management plan, ultrasound and in particular transvaginal ultrasound, should be available at the initial clinical interface such that the clinician is able to interpret the real-time ultrasound findings in the context of the woman's clinical picture. I believe that the clinician who makes the decision in the woman's care should also perform the scan. This will ensure that important information, both clinically and ultrasonographically, is not overlooked in the workup. Streamlining women's care, reducing long waiting times in the ED, reducing admission rates and subsequent occupied bed stays are all achievable with this new model of care. Dedicated EPUs, with trained ultrasonographers and gynaecologists experienced in the management of first trimester complications, should become the benchmark standard of care for Australian women in early pregnancy complications.