Over the 8 month period from 1st July 2018 to 28th February 2019 2920 patient episodes were recorded, including patients attending as initial new referrals and follow up appointments. 1932 of these episodes were new patients and 988 were returning patient episodes.
The mean age of patients presenting to the clinic was 31.1 years (range of 13 to 51 years).
The mean gestation of pregnancy gestation was 8.1 weeks (range 4-16 weeks).
The mean waiting time from referral to being seen for an appointment in clinic was 1.28 days (range 0-14). Patients were seen on the same day for urgent referrals, and the longest wait times were 2 weeks to comply with clinic protocols for some patients requiring repeat scans..
Referrals were classified into self, GP, A&E, and gynaecology ward referrals. 58.8% of referrals were self- referrals by patients. GPs made 20.3% of referrals, the hospital gynaecology ward referred 7.5%, and A&E made 3.8% of referrals. Other sources contributed 9.58% of referrals, which were from midwives, antenatal radiology clinic, and from local termination and fertility services.
The commonest initial presentation to EPAU was with bleeding 43.5%, 22.5% presented with pain and bleeding, 19.8% with pain, and 14.2% for other reasons such as previous ectopic pregnancy.
Referrals from EPAU clinic to hospital
Data was collected on the number of patients referred onwards from the EPAU into hospital. During the 8 month period a total of 113 patients were referred into hospital. Reasons for further referral were suspected ectopic pregnancy, diagnosed ectopic, heavy bleeding, severe pain, molar pregnancy, and for the management of retained products of conception. One patient was referred for urgent removal of intrauterine coil. Elective referrals for surgical management are not included in this data.
Following clinic attendance 72.2% of patients were diagnosed with a viable intrauterine pregnancy. 389 miscarriages were diagnosed, of these 84.1% were missed or incomplete miscarriages, 15.9% were complete miscarriages.
Management of confirmed miscarriage
We reviewed each diagnosed miscarriage from the EPAU to find out what type of management the patient chose after the initial diagnosis. 48.6% chose to have conservative management, 19.9% chose medical management, and 31.5% chose surgical management.
During July 2018 to February 2019 there were 25 ambulance transfers from EPAU to the John Radcliffe Hospital. The mean rate of transfers per month was 3.13 (range 0-10). The highest figure of 10 was found in July 2018, the first month of the community clinic, then falls to a steady state between 1 and 4 per month.
Fig1. Graph ambulance transfers by month.
Six patients were transferred because a ruptured ectopic pregnancy was diagnosed on ultrasound. Four stable patients with suspected ectopic pregnancies or bleeding were transferred by ambulance as they were alone with no transport to get to hospital. Eight patients were transferred due to ectopic or suspected ectopic diagnosis. Seven patients were transferred for heavy bleeding or collapse with a diagnosis of miscarriage or PUL. These figures exclude stable ectopic patients as the ambulance transfer protocol allows them to be driven to hospital if accompanied.
Unplanned admission of patients seen in the community EPAU was collected for the months December 2018- April 2019. During this time there were 32 admissions to gynaecology ward of patients who had been seen or in contact with EPAU and had either self referred to the ward or attended via A&E. These account for 2.7% of all patients seen in EPAU during this time period. Three referrals were self referrals, two were from GPs, and one was from paramedics, the remaining 24 were from A&E. 23 (71.8%) of the patients were patients seen in EPAU and then developed worsening symptoms of pain and bleeding so attended A&E or the gynaecology ward. 3 patients booked appointments for EPAU but attended A&E/gynaecology ward due to symptoms before appointment. Two patients were referred to secondary care by their GP after the patient spoke to EPAU.
10 patients who had not been to the EPAU presented to A&E during this time period with an ectopic pregnancy.
Ectopic Pregnancy Outcomes
58 patients had ultrasonographically confirmed or suspected ectopic pregnancies out of 1932 new patients (3%). 17 of these patients were managed conservatively (BHCG<1000), of those 5 went on to have surgical management of non-ruptured ectopic pregnancies.
Fig2. Flow diagram of ectopic pregnancy outcomes.
5 patients who met local guidelines for medical management were treated with methotrexate. 2 of these patients went on to have surgical management- one of which was a suspected ectopic and operated on out of hours.
27 patients were managed surgically with laparoscopic salpingectomy once confirmed. One patient had a negative laparoscopy (3.7%).
8 patients had no evidence of intrauterine or extrauterine pregnancy on ultrasound scan, but based on clinical symptoms went on to have laparoscopy. 3 of these patients had a negative laparoscopy.
Patient feedback data
85 patient feedback surveys were collected in the year that the new clinic opened. We also collected 40 surveys from the hospital based EPAU clinic prior to moving location. In the community clinic quality of care rated excellent increased from 60% to 89%, emotional support rated excellent improved from 50% to 74.7%, and overall experience rated excellent improved from 57.5% to 81.7%. The average waiting time improved from 65% seen within 1-2 days and none seen same day, to 70.7% seen in 1-2 days and 9.8% seen same day.