Roles and services provided

According to the Royal College of Obstetricians and Gynaecologists (RCOG), all antenatal units should provide an early pregnancy service with direct access for GPs and patients.

This service is provided through an Early Pregnancy Assessment Unit, or EPAU, which is available to diagnose and treat women experiencing early pregnancy problems. According to the RCOG, an EPAU should ideally be situated in a dedicated area with appropriate staffing and it should be available on a daily basis (at least during the normal working week). This is because, unlike previous methods, a dedicated clinic can streamline the management of women with early pregnancy bleeding and pain, thereby improving the quality of care they receive. Previously, women had to wait days for an ultrasound scan. All women referred to the clinic should be offered thorough and prompt assessment and a confirmed diagnosis.

An EPAU should be able to provide counselling, should have up-to-date ultrasound equipment and should be easily able to send samples for laboratory testing (for example to test for rhesus antibody status). GPs and other practitioners, such as nurses, midwives and health visitors should have direct access to the appointments system. Patients with previous history of early pregnancy problems such as ectopic pregnancy and recurrent miscarriage should be able to access the unit themselves for self-referral.

One of the main priorities of assessment of early pregnancy symptoms of pain and bleeding is to exclude an ectopic pregnancy as this is a life-threatening condition. Around one in 300 pregnancies (rising to one in 100 in inner city areas) of pregnancies are ectopic, that is, developing outside the womb (usually in one of the fallopian tubes).

Detailed information on the general roles and services an EPAU should provide is available in the RCOG guidelines The management of early pregnancy loss. However, EPAUs are managed locally, so if you require information on a specific area or unit, you should be able to obtain this from your local health authority.

Websites associated with EPAU services

Pregnancycare is a pregnancy information website for patients, students and doctors, and is provided by a consultant and senior lecturer in obstetrics and gynaecology.
www.pregnancycare.co.uk

The Scottish Executive website details the framework of maternity services in Scotland, is aimed at healthcare professionals, and covers pre-conception, pregnancy and childbirth.
www.scotland.gov.uk

Planning pregnancy

A woman wishing to become pregnant should try and optimise her health and fitness levels, as this is seen as increasingly important in the health and development of her baby. Women should be encouraged to make a pre-conception appointment with their GP so that their lifestyle, health and fitness may be assessed, and so that areas that could be improved can be identified. They should also be informed of the importance of taking a daily 0.4 mg of folic acid supplement to reduce the risk of the baby developing a neural tube defect such as spina bifida. For further information on pre-conception advice, click here.

Websites associated with planning a pregnancy

The 2004 PRODIGY guidance on pre-conceptual counselling aims to help professionals provide the information a woman and her partner need in order to make informed choices about planning a pregnancy and ensuring the best possible outcome.
There are links to relevant patient information leaflets.
www.prodigy.nhs.uk

The Scotland NHS Ready Steady Baby website provides parents with information on pregnancy and childcare.
www.readysteadybaby.org

NHS Direct has a ‘frequently asked questions’ section concerning pregnancy and childbirth.
www.nhsdirect.nhs.uk

The Scottish Executive website details the framework of maternity services in Scotland, is aimed at healthcare professionals, and covers pre-conception, pregnancy and childbirth.
www.scotland.gov.uk

The Royal College of Obstetricians and Gynaecologists website has a specific ‘information for patients’ area that provides pregnancy-related information, addresses, queries and links to other useful on-line resources.
www.rcog.org.uk

Emma’s Diary, produced by The Royal College of General Practitioners, is a week-by-week pregnancy guide.
www.emmasdiary.co.uk

The National Childbirth Trust offers support in pregnancy, childbirth and early parenthood and aims to give every parent the chance to make informed choices.
www.nctpregnancyandbabycare.com

Pregnancycare is a pregnancy information website for patients, students and doctors, and is provided by a consultant and senior lecturer in obstetrics and gynaecology.
www.pregnancycare.co.uk

The WellBeing of Women charity website offers a useful leaflet for patients on pregnancy and labour. The leaflet gives information on preparing for pregnancy, diet, complications and antenatal tests.
www.wellbeingofwomen.org.uk

BabyCentre is a parenting resource offering practical advice from expert sources, such as obstetricians, paediatricians, doctors, midwives and parents.
www.babycentre.co.uk

The BBC Lifestyle web pages on Parenting guide parents-to-be through the stages of pregnancy.
www.bbc.co.uk/parenting

The National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Women and Children's Health have published guidelines for the NHS in England and Wales on the assessment and treatment of people with fertility problems. It lists some guidance about how a couple can improve its chances of becoming pregnant.
www.nice.org.uk

Being healthy

Optimising health and fitness levels in preparation for pregnancy is seen as increasingly important in the development of a baby. A woman who wishes to become pregnant should have an assessment of her lifestyle, health and fitness in order to identify areas for improvement.

Areas which may be addressed include:

• an unhealthy diet
• lack of exercise
• daily stress
• other factors, such as smoking or drug use.

A woman should also be informed of the importance of taking folic acid whilst she is trying to conceive and during pregnancy, in order to prevent neural tube defects in the baby, such as spina bifida.

There is a lot of advice that can be given to a woman who is planning a pregnancy or in the early stages. Click here for further information on pre-conception advice and associated web links.

Pregnant women should be advised to have a varied, healthy diet that contains sufficient iron, calcium and folate, as well as the other essential vitamins and minerals to ensure a healthy pregnancy. They should avoid taking vitamin A supplements. Pregnant women should minimise their alcohol and caffeine intake and should avoid foods that are likely to cause food poisoning. Women should also be advised that staying active will help promote general health and wellbeing.

Further information and web links on maternal nutrition can be found on the British Nutrition Foundation website.

Websites associated with health in pregnancy

The Scotland NHS Ready Steady Baby website provides parents with information on pregnancy and childcare.
www.readysteadybaby.org

The Scottish Executive website details the framework of maternity services in Scotland, is aimed at healthcare professionals, and covers pre-conception, pregnancy and childbirth.
www.scotland.gov.uk

NHS Direct has a ‘frequently asked questions’ section concerning pregnancy and childbirth.
www.nhsdirect.nhs.uk

The Royal College of Obstetricians and Gynaecologists website has a specific ‘information for patients’ area that provides pregnancy-related information, addresses, queries and links to other useful on-line resources.
www.rcog.org.uk

Emma’s Diary, produced by The Royal College of General Practitioners, is a week-by-week pregnancy guide.
www.emmasdiary.co.uk

The National Childbirth Trust offers support in pregnancy, childbirth and early parenthood and aims to give every parent the chance to make informed choices.
www.nctpregnancyandbabycare.com

Pregnancycare is a pregnancy information website for patients, students and doctors, and is provided by a consultant and senior lecturer in obstetrics and gynaecology.
www.pregnancycare.co.uk

The WellBeing of Women charity website offers a useful leaflet for patients on pregnancy and labour. The leaflet gives information on preparing for pregnancy, diet, complications and antenatal tests.
www.wellbeingofwomen.org.uk

BabyCentre is a parenting resource offering practical advice from expert sources, such as obstetricians, paediatricians, doctors, midwives and parents.
www.babycentre.co.uk

The BBC Lifestyle pages on Parenting guide parents-to-be through the stages of pregnancy.
www.bbc.co.uk/parenting

Ectopic pregnancy

Ectopic pregnancies occur when the fertilised egg attaches itself outside the uterus, most commonly in the fallopian tubes, but also an ovary, the cervix (neck of the uterus) or another organ within the pelvis. In most cases, an ectopic pregnancy will end spontaneously (miscarry). The majority of women diagnosed with an ectopic pregnancy have to be treated; either with surgery or medication (methotrexate, which decreases the growth of the foetus such that it eventually disappears, although this is an unlicensed indication). Women with an ectopic pregnancy will often experience vaginal bleeding and lower abdominal pain and can feel faint. A pregnancy test will show positive.

An ectopic pregnancy initially develops as a normal pregnancy would, and may present with the same symptoms, such as nausea and breast tenderness. Some women however, have no symptoms and are unaware that they are pregnant. As the pregnancy progresses, the woman may start to experience vaginal bleeding. Any woman experiencing this should seek urgent medical advice as an ectopic pregnancy can be life-threatening. This is because if left untreated, it may cause the fallopian tube to rupture, which leads to very heavy bleeding. A doctor or midwife should refer her straight to an Early Pregnancy Assessment Unit (EPAU).

Factors that increase a woman’s risk of having an ectopic pregnancy:

• a previous ectopic pregnancy
• becoming pregnant whilst an intrauterine device (IUD) is in place
• previous damage to the fallopian tubes (for example as a result of surgery or previous inflammation
• becoming pregnant as a result of in vitro fertilisation (IVF).

Investigations will usually include an abdominal examination along with an internal pelvic examination. The most useful investigation is the ultrasound scan, which will show if the embryo or foetus is inside the uterus or is ectopic, and whether it has a heart beat.

The Royal College of Obstetricians and Gynaecologists guidelines on the management of early pregnancy loss refer to ectopic pregnancy and can be found on its website.

Click here to view the Royal College of Obstetricians and Gynaecologists clinical guidelines on the management of ectopic pregnancy.

Websites associated with ectopic pregnancy

The Ectopic Pregnancy Trust was established in 1998 in memory of Sophie Winter, to raise awareness of ectopic pregnancies amongst women of childbearing age, the medical profession and the general public. The site contains guidelines for the management of ectopic pregnancy.
http://www.ectopic.org

NetDoctor is an on-line collaboration between doctors, healthcare professionals, information specialists and patients providing, wherever possible, quality-assessed information on the basis of the principles of evidence-based medicine. It contains a section on ectopic pregnancy.
www.netdoctor.co.uk

The BBC News web pages contain a medical section in which there is information on ectopic pregnancy.
http://.news.bbc.co.uk

NHS Direct has a section on ectopic pregnancy.
www.nhsdirect.nhs.uk/en

The Miscarriage Association provides support and information for those suffering from pregnancy loss. It has leaflets on ectopic pregnancy.
www.miscarriageassociation.org.uk

Women’s Health is a UK website written by a doctor in the field of obstetrics and gynaecology. It covers a wide range of obstetric and gynaecological issues and has a section on ectopic pregnancy.
www.womens-health.co.uk

Miscarriage

Around a quarter of all pregnancies end in miscarriage, however it is often difficult to determine the cause. The main causes are:

• genetic problems: around half of all early miscarriages are due to chromosome abnormalities in the embryo (for example due to unequal division of chromosome pairs during cell division and growth)
• hormone problems: women with hormonal imbalances generally find it harder to conceive and are more likely to miscarry when they do
• the immune system: problems with the maternal immune system can sometimes cause the woman’s body to reject the baby, which leads to miscarriage
• infections: infections that cause very high temperatures can cause a woman to miscarry. Specific infections in pregnancy, such as rubella (German measles) can also increase the risk of miscarriage. Details of infections important in pregnancy can be found in our Pregnancy and Childbirth website
• problems with the uterus: for example a weak cervix (neck of the womb) can cause it to open as the pregnancy progresses and the uterus becomes heavier. A uterus that has an irregular shape can mean that there is not enough room for the baby to grow later in the pregnancy.

Some pregnancies are lost because they are ectopic that is, growing outside the uterus, usually in the fallopian tubes.

The most common symptom of miscarriage is bleeding from the vagina, often accompanied by lower abdominal pain. Some women have no symptoms (that is, they have a ‘silent miscarriage’) and only find out they have miscarried when they are given a routine antenatal ultrasound scan.

Any woman experiencing vaginal bleeding, with or without pain, should consult her doctor, and should be referred to an Early Pregnancy Assessment Unit. Women who are bleeding heavily (soaking at least one sanitary towel every hour), who are weak or faint, who are experiencing severe abdominal pain (a sign of an ectopic pregnancy) or who have a fever, are shivering or who have foul smelling vaginal discharge (a sign of infection) should seek medical attention immediately.

Investigations will usually include an abdominal examination along with an internal pelvic examination, which may establish whether the woman is experiencing a miscarriage or if it is possible the pregnancy may continue. The most useful investigation is the ultrasound scan, which will show if the embryo or foetus is still inside the uterus and has a heart beat.

After a woman has had a miscarriage, she may suffer from fatigue, lack of appetite, insomnia and headaches. She should be advised to rest for a few days. She will probably be experiencing strong emotions and may need someone to talk her feelings over with. It is often helpful for her to return to a normal daily routine after this period of rest.

Women experiencing three miscarriages in a row (known as recurrent spontaneous miscarriage) should be referred to a gynaecologist. If the investigations subsequently performed are negative, the woman should be reassured that her next pregnancy has a 70% chance of being successful.

The Royal College of Obstetricians and Gynaecologists has produced guidelines on the management of early pregnancy loss, and guidelines on the management of couples with recurrent miscarriage.

Websites associated with miscarriage

The Miscarriage Association provides support and information for those suffering from pregnancy loss.
www.miscarriageassociation.org.uk

NetDoctor is an on-line collaboration between doctors, healthcare professionals, information specialists and patients providing, wherever possible, quality-assessed information on the basis of the principles of evidence-based medicine. It contains a section on miscarriage.
www.netdoctor.co.uk

BabyCentre is a parenting resource offering practical advice from expert sources, such as obstetricians, paediatricians, doctors, midwives and parents. There is lots of information and advice on miscarriage.
www.babycentre.co.uk

The NHS Direct on-line health encyclopaedia contains a section about miscarriage.
www.nhsdirect.nhs.uk/en

St Mary’s is a world class hospital based in Paddington, which has a recurrent miscarriage clinic. It has information on its website and a booklet to download.
www.st-marys.nhs.uk

Miscarriage Support is a Scottish organisation providing information, care and support to people who have suffered miscarriage.
www.connectedscotland.org.uk

DirectGov contains a section on miscarriage.
www.direct.gov.uk

Patient UK provides evidence-based information on health, disease and related issues, written by GPs. It contains information on miscarriage.
www.patient.co.uk

The National Library for Health website contains a section on miscarriage.
www.library.nhs.uk/womenshealth

AIMS, Association for Improvements in the Maternity Services, has an article titled Miscarriage: the loss of a baby.
www.aims.org.uk