central qld emergency medicine education and …

CQ EMET ROCKHAMPTON OCTOBER 2014

CQ EMET Oct ’14 Managing Emergencies of Early Pregnancy in the ED

Most pregnancies progress relatively smoothly and our role as the clinician to provide advice/ support but often minimal need to intervene with the natural process over the nine months. However, during early pregnancy approximately one in four women will experience vaginal spotting or bleeding. This can often result in great distress to the patient and her partner/ family. It is crucial that the Emergency clinician managing the patient is able to efficiently identify the life threatening presentation with those that may impact future fertility and those that are more benign. The clear and concise sharing of information to the patient so that they are aware, knowledgeable, informed and empowered is crucial to how the patient will value the experience of this care. The key diagnoses to detect are:

1. Implantation Bleeding (IB) 2. Subchorionic Haemorrhage (SH) 3. Spontaneous Abortion (SA) 4. Ectopic Pregnancy (EP) 5. Heterotopic Pregnancy (HP) 6. Anembryonic Pregnancy (AP) 7. Hyperemesis Gravidarum (HG) 8. Gestational Trophoblastic Disease (GTD) 9. Round Ligament Syndrome (RLS)

IB occurs when the blastocyst (fertilized ovum) attaches to the uterine lining and on average this is approx. 9 days (6-12) after ovulation and fertilization. There is usually scant pink/ brown discharge. It is not similar in character or volume to the usual menses. Usually no symptoms are experienced with the discharge. Rarely women may experience mild cramping or spotting. At this time the key differential for such a presentation remains broad including SA, EP, SH, HP and AP. Once these have been excluded using ultrasound and serial B-hCG then the management of IB is expectant with reassurance essential. SA or miscarriage is relatively common with between 15-35% of pregnancies affected. 80% of all miscarriages occur within the first 12 weeks (first trimester) so the initial assessment and ability to review the patient is important at this time. This is often before the patient has linked in with a specialist care so the Emergency Physician is mainly the clinician who will be involved in the diagnostic and information-sharing phase of care so again clarity and consistency is important. Increasing maternal age does increase the risk of miscarriage as does smoking, obesity and genetic/ chromosomal abnormalities. Miscarriages can progress from threatened miscarriage to inevitable to complete and our understanding of where the patient is during this process is important to clarify if we are to avoid the upset that occurs when a patient miscarries unexpectedly. Women presenting who are less than 20 weeks pregnant with vaginal bleeding and no cervical dilatation or effacement are experiencing a threatened miscarriage. This bleeding may vary from spotting to severe bleeding lasting one to several days. Some patients experience cramping but not all so do not be falsely reassured if the lady has no discomfort. Ultrasound is the key intervention that we can initiate in the Emergency Department. Identification of a gestational sac can occur from 6 weeks on transabdominal ultrasound. An abnormal gestational sac size, small embryo for the dates provided and a slow foetal heart rate can indicate a likely failing pregnancy. Continued over the page.

OCTOBER 2014 NEWS: EMET AIMS 1.1 Providing quality Emergency Medical Care is an aim for all healthcare workers.

1.2 Support clinicians across Central QLD. Have a questions? Need a question answered?

What educational needs do you require?

Contact Sue Davey. on the email

1.3

Simulation and scenario practice: Contact Michael Guerin: [email protected]

1.4 If you have questions or ideas to share contact us on:

[email protected]

If interested in ultrasound, skills training or simulation scenarios - Tell us what you wish to learn?

CENTRAL QLD EMERGENCY MEDICINE EDUCATION AND TRAINING COMMUNICATION OCTOBER 2014


Emergencies of early pregnancy continued. The clinical situation of a threatened miscarriage is emotionally charged- take the time to clarify the potential course for the patient. Arrange for a clinical review either within the ED or with O+G within 48-72 hours so that serial assessment clinically and with ultrasound and B-hCG can occur. Any increase in bleeding, light-headedness fever or increase in pain should result in an emergency review and admission to hospital. Some patients will already have an open cervical os at this stage and are having an inevitable miscarriage. The option for these patients is either for an observant more natural progression or intervention with a dilatation and curettage (D+C). This requires a detailed discussion with the patient along the lines of the ‘shared model of decision making’ previously described so that the various perspectives and options can be considered. The patients who have experienced a total miscarriage have no conception products seen on ultrasound and have no additional symptoms. These patients should be advised to follow up with their GP +/- an obstetrician to discuss fertility issues and consider if there are options to optimise their likelihood of a successful pregnancy. Those patients in whom symptoms have resolved but products are visualized on ultrasound have an incomplete miscarriage. These patients can again be managed either expectantly or with intervention through a D+C. They do require a planned review if intervention is not progressed at this time due to the increased risk of infection that can occur. AP or blighted ovum occurs when the gestation sac develops without any embryonic structures. Patients can present with abdominal pain and bleeding. AP is diagnosed through ultrasound when a gestational sac >13mm is identified without a yolk sac or a gestational sac >18 mm without an embryonic pole. EP is the diagnosis that creates most clinical concern and relates to the implantation of a fertilized ovum outside the uterine cavity, occurring in 2% of pregnancies. This remains the leading cause of first trimester maternal death. There are risk factors from the history and these include- a previous ectopic pregnancy, previous tubal surgery, tubal disease (STD/PID), smoking and current use of IUD. Patients present with either a ruptured or unruptured ectopic. If ruptured then this is a gynaecological surgical emergency as the woman is either in shock or will be imminently- tachycardia, hypotension, guarding or peritonism on examination. Urgent resuscitation and progression to theatre is required. For woman with an unruptured ectopic the presentation can be variable-a recent study looking at 147 such presentations found that the most common symptom was abdominal pain, then amenorrhoea and lastly irregular bleeding. Physical examination most reliably found abdominal pain and adnexal tenderness. However both symptoms and signs can be variable so a high index of suspicion is required and the identification of the potential risk factors. As with each of these clinical presentations the early use of ultrasound and B-hCG is imperative in the clinical management of these women. Within the ED an abdominal ultrasound can confirm the presence of an intrauterine pregnancy from about 7 weeks. The risk of a co-existing ectopic (heterotopic pregnancy) is approximately 1:30,000 for spontaneous pregnancies but does increase to the order of 1:100 in assisted conception so clarifying this fact is essential from the start. The use of B-hCG and the discriminatory zone 1500-2500 mIU/mL suggesting that visualisation with ultrasound should be possible is also important. Ideally, we would like to be able to identify the ectopic but often we need to be guided through the lack of an IUP at a stage and level of B-hCG when we would expect to see a pregnancy. Treatment of an unruptured ectopic can medical or surgical. Methotrexate remains the mainstay of medical treatment and requires a Haemodynamically stable patient with no signs of bleeding or haemoperitonism together a patient desire for future fertility. Ideally treatment with methotrexate suits an unruptured mass of less than 3.5cm in its greatest dimension together with no foetal cardiac activity and a low B-hCG level. Absolute contraindications include impaired renal or liver function, known sensitivity, pulmonary disease, immunodeficiency, breast feeding and peptic ulcer dx.

Rhesus Immune Globulin

A Rh –ve pregnant woman who is exposed to Rh +ve blood is at risk for iso-immunisation. Future exposures to Rh +ve antigen may result in the production of Rh IG (immunoglobulin G) antibodies

which can cause fœtal morbidity and demise. The

administration of RhIG is effective in reducing the maternal sensitisation and consequent morbidity/ mortality during the third trimester. However, its use in the first trimester remains controversial with little concrete evidence available to support its routine use. However, it has become standard practice with RANZCOG providing a policy based upon previous Cochrane reviews. The details of the guidelines for the use of Rh (D) IG or Anti-D in obstetrics within Australia are outlined at the end of this document.

CQ EMET COMMUNICATION 12-18 NOVEMBER 2012 CENTRAL QLD EMERGENCY MEDICINE EDUCATION AND TRAINING COMMUNICATION OCTOBER 2014


Q&A... Some questions on Patient Safety and what you can do


What are the principles for patient safety that I should know? Firstly, it is important for us all to acknowledge that no member of staff wishes to hurt or harm a patient. Errors occur that can be either ‘latent’- hidden within the system of care that we work in through poor protocol design, insufficient training, limited resource or staffing etc. which we do not control and also ‘active’ errors when we as clinicians either do something or omit doing something that can result in harm. Human factors play a large part in how we respond to these situations and if we optimise our understanding of these factors we can make progress in reducing error. We have to accept as individuals and as an organisation that we all do make mistakes. This is regardless of our training, level of experience or seniority. Every one of us is human and that means that we can never be 100% perfect, 100% of the time. Acknowledge this and act in a way that helps to optimise the way that we work together as a team. What are the Human Factors that I should know? There are many factors that can be described but they mostly fall into one of the following categories: 1. Cognition and mental workload 2. Distractions 3. The physical environment 4. Physical demands 5. Device/product design 6. Teamwork 7. Process design We shall go over each of these during the next few issues. Firstly, we can briefly look at category 1 in regard to cognition and mental workload. We bring our whole self to work so it is important to consider if stressors exist outside of work. How will this be affected by the expectation at work? Is there likely to be a lack of focus or concentration? Be self aware and consider if you can make additional time to focus on specific high risk areas? Similarly, if you are in an Emergency take the extra few seconds to double check instruments, drugs or actions. Do you have checklists available to assist in this process? Can you have different prompts or cues to specific actions required? Can you inform colleagues of team members if you feel more stressed and consider re-allocation of tasks or role. Maintain self awareness and help others be self aware through sharing of insights. Simulation is a training technique that does help an individual understand some of these cognition and workload issues. Use the opportunity to have simulation within your own work environment to understand the impact of the physical layout. Do this as a team- your team working constructively to improve a shared aim or outcome. The human brain can only have a few things at its forefront at any one time. IF you are lucky it may be about 7-8 different things or facts. However, often our roles in healthcare require many more pieces of information to be available and readily accessible. Do not rely on vigilance, working harder or memory. Use checklists and visible permanent reminders of actions that are brought into day-to-day working practice. Avoid the common error of ‘involuntary automaticity’. This is when you tend to see what it is that you wish or expect to see. Calculations occur often in healthcare and especially in Emergency or high stress situations and when complex can easily result in error. All environments where this can occur should have a pre-calculated list available. This can be checked and rechecked in the ‘cool light’ of objectivity before any urgent or emergency need arises. Use prefilled syringes whenever possible to avoid error. Ensure that there are consistent ampoule strengths for other drugs. Avoid distractions when calculating and check separately. These are just some examples of the cognitive and mental workload issues- think of others in your area and make efforts to share your awareness with others so that they can be improved.


Continuation of Anti-D / RhIG use.

All Rh D negative women (who have not actively formed their own Anti-D) should be offered Anti-D.

First Trimester indications – CSL 250IU for

Chorionic Villus sampling, miscarriage, temrination of pregnancy or ectopic pregnancy.

2nd and 3rd Trmester indications- CSL 625IU for obstetric bleeding, amniocentesis and cordocentesis as well as external cephalic version of a breech presentation (whether successful or not) and importantly any abdominal trauma or other suspected intra-uterine bleeding or sensitising event.

All women should have the magnitude of potential fetomaternal haemorrhage assessed and quantified. Additional doses of RIG may be required following asssessment.

All Rh-ve women who have not actively formed their own Anti D at approximately 28 weeks of gestation and again at 34 weeks

gestation : 625IU.

Post-natally, within 72 hours. All women who deliver an Rh(D)+ve baby should have quantification of feto-maternal haemorrhage to guide the appropriate dose of anti-D prophylaxis.

Blood should be taken for Rh antibody titre prior to the administration of Anti-D so as to detect those already immunised. Rhesus IgG (RIG) should not be provided to women with preformed Anti-D antibodies except when these are due to the antenatal administration of RIG. If it is unsure whether the Anti-D detected in the

mother’s blood is passive or preformed then

clinical review is required and if continuing doubt exists it is better to asdminister the RIG.

The evidence for this is from the Cochrane reviews. A reduction in alloimmunisation of between 70-78% for antenatal use. At 28 and 34 weeks the administration of RIG reduces alloimmunisation from 1.0 to 0.3 %.


Organisation Factors in Patient Safety: Culture: There has been a lot written and said in regard to organizational and management factors in patient safety- this relates across the whole sphere of patient experience. However, what is regarded as the sentinel step is creating a positive safety culture within the organisation. This sounds quite easy- but as we all know it is not. Why not? We all have the same interest at heart- to ensure the patient is well cared for in a respectful and dignified manner and that information is provided in such a way as to empower the patient and family in decision-making. The organisation needs to be open, just and informed, with learning from errors the norm of how we function. Below is described some of these attributes to an organisation. Does it sound like your workplace? If so then share the ways in which this happens. If not consider how it can improve. An open culture where staff feel comfortable discussing safety issues/ errors with colleagues and senior managers. A just culture where patients and carers are treated fairly, with empathy and consideration when they have been involved in a patient safety event. A reporting culture that staff have confidence in so that it can be used constructively. Is the process of reporting easy? Is constructive feedback provided following an incident report? Are staff involved in a positive way- avoiding blame and punishment- which have no place in patient safety. The concept of fair blame which can result from appropriate discussion, reflection and review is appropriate and needs to be fostered by executive and senior clinical staff so that effective role modeling occurs. A learning culture where lessons are taken on board by the organisation, shared to those across the organisation and remembered by the organisation for future benefit. An informed culture where the organisation has learnt from previous episodes or reports from either within its own organisation or more broadly from the literature. Through this process of learning the organisation is able to implement change and mitigate future incidents demonstrating a mature and informed environment in which to work and share clinical experience. Some actions that the organisation can take to help improve, sustain or develop culture includes the following: structured and planned safety walkarounds, impromptu discussions with staff about safety, focus groups to help in ‘measuring the culture’ of a clinical area/ dept/ hospital. Sharing of experiences at clinical meetings so as to provide the opportunity to reflect and consider appropriate outcomes and actions. Monitor the number of ‘near miss’ reports- ideally it is good to have a high percentage of these as they can provide the stimulus for effective change- with no bad outcome. Encourage and reward staff for reporting. Possibly set targets for departments and professional groups.

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