The Role Ultrasound in Early Pregnancy
The Role Ultrasound in Early Pregnancy
The Role Ultrasound in Early Pregnancy
2
Theroleofultrasoundinearlypregnancy
Geneva,Switzerland
2July2017
Organisedby
theSpecialInterestGroupImplantationandEarlyPregnancy
Contents
Coursecoordination,coursetype,coursedescription,targetaudience,
educationalneedsandexpectedoutcomes Page3
Programme Page4
Speakerscontributions
Introductiontoearlypregnancyultrasound
EmmaKirk,UnitedKingdom Page5
Thenormalearlyintrauterinepregnancy411weeks
PetyaChaveeva,Bulgaria Page 16
Diagnosingmiscarriage
CeciliaBottomley,UnitedKingdom Page 28
Pregnancyofunknownlocation
TomBourne,UnitedKingdom Page 60
Ectopicpregnancy
EmmaKirk,UnitedKingdom Page 87
Theadnexaandotherpathology
WouterFroyman,Belgium Page 107
Earlydetectionofcongenitalandchromosomalabnormalities
PetyaChaveeva,Bulgaria Page 136
Breakingbadnews
Rachel Small, United Kingdom Page 148
Page 2 of 166
Coursecoordination
SiobhanQuenby(UnitedKingdom)andEmmaKirk(UnitedKingdom)
Coursetype
Basicandadvanced
Coursedescription
Thiscoursewillinvolvetheoreticaltrainingonultrasoundinearlypregnancy.
Targetaudience
SeniorandJuniordoctorsandnurseswhowanttolearnmoreaboutultrasonsographyinpractice
fromthosewhoneverscannedtoexperiencedultrasonographerswhowanttogetbetter.
Educationalneedsandexpectedoutcomes
TheearlypregnancyCSGyoungermembershavediscussedthisideawithjuniordoctorsinseveral
Europeancountries,UK,Netherlands,Denmarkandagreedtherewasagreatneedforthiscoursein
Europe.
Page 3 of 166
Scientificprogramme
Chairmen: SiobhanQuenby,UnitedKingdom
EmmaKirk,UnitedKingdom
09:0009:25 Introductiontoearlypregnancyultrasound
EmmaKirk,UnitedKingdom
09:2509:30 Discussion
09:3009:55 Thenormalearlyintrauterinepregnancy411weeks
PetyaChaveeva,Bulgaria
09:5510:00 Discussion
10:0010:25 Diagnosingmiscarriage
CeciliaBottomley,UnitedKingdom
10:2510:30 Discussion
10:3011:00 Coffeebreak
Chairmen: PetyaChaveeva,Bulgaria
MerelvandenBerg,TheNetherlands
11:0011:25 Pregnancyofunknownlocation
TomBourne,UnitedKingdom
11:2512:00 Discussion
12:0012:25 Ectopicpregnancy
EmmaKirk,UnitedKingdom
12:2512:30 Discussion
12:3013:30 Lunchbreak
Chairmen: EmmaKirk,UnitedKingdom
CeciliaBottomley,UnitedKingdom
13:3014:00 Theadnexaandotherpathology
WouterFroyman,Belgium
14:0014:15 Discussion
14:1514:45 Earlydetectionofcongenitalandchromosomalabnormalities
PetyaChaveeva,Bulgaria
14:4515:00 Discussion
15:0015:30 Coffeebreak
Chairmen: SiobhanQuenby,UnitedKingdom
MerelvandenBerg,TheNetherlands
15:3017:00 Workshops
15:3016:00CaseexamplesAllspeakers,leadbyEmmaKirk
16:0016:30DiagnosticdilemmasAllspeakers,leadbyCeciliaBottomley
16:3017:00BreakingbadnewsRachelSmall,UnitedKingdom
Page 4 of 166
IntroductiontoEarly
PregnancyUltrasound
EmmaKirk
MRCOGMD
Conflict of Interest
None
Page 5 of 166
Objectives
To understand:
Indicationsforultrasoundassessmentin
earlypregnancy
Safetyinearlypregnancy
TransvaginalversesTransabdominal
Ultrasound
Systematicapproachtoexamination
Page 6 of 166
Aims of the Early Pregnancy USS
Presence of an intrauterine
pregnancy
Establish viability
TVS
70-90% 10-30%
Diagnostic Non-diagnostic
Page 7 of 166
Setting for the USS
Specialist Units:
RCOG requirement
Separate to a routine antenatal clinic
Immediate access to USS facilities
Page 8 of 166
Safety Indices
Scanning Modes
B-mode is safe in early pregnancy
Page 9 of 166
Scanning Routes
Advantages Disadvantages
Transvaginal
(TVS) Higherfrequencies(upto7.5MHz) Depthofpenetrationislimiteddueto
Superiorresolutionofimages highfrequencyoftheultrasound
Requiresanemptybladder,sooften Lackofprobemobility.
morecomfortable.
Theprobecanbeusedtotouchthe
pelvicorganstotestforpain.
Thepelvicorganscanbemoved
withtheprobetoseeiftheyslide
easily.
Theprobecanbemovedinandout
ofthevaginatoadjustthedepthof
theorgansonthescreen.
Allowsbetterimaginginobese
patients.
Transabdominal
(TAS) Mayallowbettervisualisationof Decreasedresolution.
pregnanciesinalargefibroiduterus.
Oftenrequiresafullbladder.
Poorviewsinobesepatients.
Ultrasound Technique
Imageorientation:
Imageoptimisation:
Depth
Magnification
Focus
Gain
Page 10 of 166
Systematic Approach
Longitudinal View of the Uterus
Systematic Approach
Longitudinal View of the Uterus
Page 11 of 166
Systematic Approach
Longitudinal View of the Uterus
Systematic Approach
Longitudinal View of the Uterus
Page 12 of 166
Systematic Approach
Longitudinal View of the Uterus
Systematic Approach
Longitudinal View of the Uterus
Page 13 of 166
Systematic Approach
Longitudinal View of the Uterus
Systematic Approach
Longitudinal View of the Uterus
Page 14 of 166
Systematic Approach
Longitudinal View of the Uterus
Other sites
Summary
An early pregnancy scan aims to confirm
pregnancy location, establish viability, determine
number of embryos and determine gestational
age
Ultrasound used in standard presets for clinical
reasons < 10 weeks is safe
A transvaginal ultrasound has a number of
advantages over a transabdominal scan in early
pregnancy
It is essential to provide a structured written report
Page 15 of 166
The Fetal Medicine Precongress Course
Foundation
The role of ultrasound in Early Pregnancy
Petya Chaveeva
Consultant in Fetal Medicine
Ob/Gyn Shterev Hospital, Sofia, Bulgaria
Page 16 of 166
The Fetal Medicine
Foundation
Learning Objectives
Transvaginal Transabdominal
Page 17 of 166
The Fetal Medicine
Foundation
Gestational sac
Amnion
Page 18 of 166
The Fetal Medicine
Foundation
Yolk sac
Schats R, Jansen CAM, Wladimiroff WT: Embryonic heart activity: appearance and development in early
human pregnancy. Br J Obstet Gynaecol 1990;97:989994.
Page 19 of 166
The Fetal Medicine
Foundation Assess the viability
Days 1-3
Morula
Days 4-8
Blastocyst
Days 9-12
Implanted
blastocyst
Days >12
Embyonic
disk formed
Page 20 of 166
The Fetal Medicine
Multiple pregnancy
Foundation
Chorionicity and zygocity
9 twins
2/3 1/3
6 Dizygotic 3 Monozygotic
7 Dichorionic 2 Monochorionic
Multiple pregnancy
Number of yolk sacs usually = Number of amnions
Page 21 of 166
The Fetal Medicine
Foundation
Marton V, zadori J, Kozinszky Z, KereszturiA: Prevalences and pregnancy outcome of vanishing twin pregnancies
achieved by in vitro fertilization versus natural conception. Fertil Steril. 2016 Nov;106(6):1399-1406.
Page 22 of 166
The Fetal Medicine
Foundation
Multiple pregnancy
TRAP sequence
0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 90 100
Survival rate with 95% CI (%) Survival rate with 95% CI (%)
Chaveeva P, Poon LC, Sotiriadis A, Kosinski P, Nicolaides KH. Optimal method and timing of intrauterine intervention in twin
reversed arterial perfusion sequence: case study and meta-analysis. Fetal Diagn Ther 2014;35:267-79.
Page 23 of 166
The Fetal Medicine Fetal therapy
Foundation
Coelocentesis
Needle
Amniotic cavity
F
Celomic cavity
Trophoblast
Jurkovic D, Jauniaux E, Campbell S, Pandya P, Cardy D, Nicolaides KH. Coelocentesis: a new technique for early
prenatal diagnosis. Lancet 1993; 341:1623-4.
Giambona A, Damiani G, Leto F, Jakil C, Renda D, Cigna V, Schillaci G, Picciotto F, Nicolaides KH, Passarello C, Makrydimas
G, Maggio A. Embryo-fetal erythroid cell selection from celomic fluid allows earlier antenatal diagnosis of hemoglobinopathies.
Prenat Diagn 2016 Feb 18. doi: 10.1002/pd.4793.
Page 24 of 166
The Fetal Medicine
Foundation
Page 25 of 166
The Fetal Medicine
Foundation
Page 26 of 166
The Fetal Medicine
Foundation In Summary
Thank you
Page 27 of 166
DIAGNOSIS OF MISCARRIAGE
ESHRE PRE-CONGRESS COURSE
2017
Declaration
Page 28 of 166
Learning Objectives
To:
miscarriage
Miscarriage Definition
Spontaneous loss of pregnancy before the embryo/fetus
reaches viability
Majority <12/40
Incidence decreases with gestation
3% at end of first trimester
Page 29 of 166
Miscarriage
He/she
Page 30 of 166
Clinical examination vs USS
50% misdiagnosis on
clinical examination
alone
Stable woman
USS primary diagnostic
tool
Unstable
Speculum for open cervix,
products in os
WieringadeWaard etal.2002
Page 31 of 166
Ultrasounddiagnosisofmiscarriage
Completemiscarriage
Incompletemiscarriage
Missedmiscarriage
Inhomogenous echoeswithin Nonviableintrauterine
Emptyuterus
theendometrialcavity gestationsac
Previouslyvisualised
Meansacdiameter>25mm
intrauterinepregnancy
withnoembryo
Or
Embryogreaterthan7mm
withnocardiacactivity
Or
Sacdiameter<25mmor
embryo<7mmbutnochange
after714d
TerminologyforEarlyPregnancyEvents
AdaptedfromFarquharson2005andRCOG2006
Biochemicalpregnancyloss Historyofpositivepregnancytestfollowedby
negativetest,withoutanultrasound assessment
havingbeenperformed
Empty sac Gestationsacwithabsentembryonicstructures
Fetalloss Previousidentificationofembryoorfetusand heart
activityfollowedbylossofheartactivity
EarlyPregnancyloss/Delayedmiscarriage/ Intrauterinepregnancywithevidenceoflostfetal
Missedmiscarriage heartactivityand/orfailureofCRLtoincreaseover
oneweek
Or
Persisting presenceofemptysacatlessthan12weeks
gestation
Latepregnancyloss Heartactivity lostafter12weeksgestation
Avoidterm abortion/spontaneousabortionasmay beconfusedwiththerapeutictermination
Embryo<10weeks Fetus>10 weeks
Variationinterminologyforresearch purposesincludese.g.yolksacmiscarriage(Kolte 2015)
Page 32 of 166
International guidelines for diagnosis of
miscarriage
DelayedMiscarriage
Page 33 of 166
DelayedMiscarriage
TRANSVAGINALSCAN
Embryo>7mmandnovisibleheartbeat
Or
Mean gestationsacdiameter(MSD)>25mm
andnoembryonicstructure
Or
Embryo<7mmorMSD<25mmandnoheart
beatafteratleast714days*
*variationinternationally dependsonpresenceofyolksacorembryoon
firstscan.14daysisSAFE
Previous guidance:
USA: 16mm GSD, 5mm CRL
UK: 20mm GSD, 6mm CRL
Page 34 of 166
Intraobserver variability
CRL MSD
CRL1 of first 95% PI for CRL1 MSD of first 95% PI for MSD of
observer (mm) of second observer (mm) observer (mm) second observer (mm)
5 [4.5-5.6] 17 [14.3-21.0]
6 [5.4-6.7] 18 [15.1-22.2]
7 [6.3-7.9] 19 [16.0-23.4]
10 [8.9-11.2] 20 [16.8-24.5]
20 [17.9-22.4] 21 [17.6-25.7]
30 [26.7-33.5] 22 [18.4-26.9]
PI = prediction interval
Pexsters 2011
Page 35 of 166
Miscarriage:Embryo>7mmandnovisibleheartbeat
CRL21.4mm
Dopplerultrasoundcanbeusedtoconfirm
(notessentialfordiagnosis)
Page 36 of 166
Miscarriage:Meangestationsacdiameter(MSD)
>25mmandnoembryonicstructure
Sacmaybeseentobecollapsing
Page 37 of 166
Miscarriage:Embryo<7mmorMSD<25mmandno
changeafter714days
YS
only
Small CRL
GS only
Page 38 of 166
The IPUVI Problem
Bottomley 2009
Page 39 of 166
RCOG/NICE2012
IfCRL>7mmorMSD>25mmandnoFH
Seekasecondopinionontheviabilityofthe
pregnancyand/orperformasecondscana
minimumof7daysafterthefirstbeforemakinga
diagnosis
Ifrepeatscanindicatedafter7days
Furtherscansmaystillberequiredifembryonic
developmentbutnoFHyetvisible
RCOG/NICE2012
Recommendtransvaginal ultrasound
Consideratransabdominalultrasoundscanfor
womenwithanenlargeduterusorotherpelvic
pathology,suchasfibroidsoranovariancyst.
Differentcriteriafordiagnosisofmiscarriage
usingtransabdominalscan
Page 40 of 166
IF ANY POSSIBLE DOUBT ABOUT
MISCARRIAGE DIAGNOSIS
do nothing
IncompleteMiscarriage
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Diagnosis of incomplete miscarriage
Sawyer 2007
Page 42 of 166
Doppler flow = retained products (incomplete miscarriage)
No Doppler flow does not rule out RPOC but less likely
Colour Doppler
ColourDopplerusefultofacilitate
differentialdiagnosisbetweenRPOC
andbloodclotswithinthecavity.
RPOCareusuallywellperfused,
whilstnoDopplersignalsarefound
originatinginbloodclots.
Page 43 of 166
Complete miscarriage
Complete miscarriage
Condous 2005
Page 44 of 166
Miscarriage prediction: Clinical features
Bleeding
55% miscarriage rate
Everett 1997
Age
35yr 20% miscarriage
42yr 55% miscarriage
Andersen 2000
Page 45 of 166
Miscarriage prediction ultrasound markers
Increased CRL:GS ratio
Initially viable pregnancies
CRL
GS size
YS size
GS to CRL ratio
Regularity of GS
Subchorionic haematoma
Embryonic heart rate
Models
IVF women: MSD, CRL, FHR, maternal age, gestational age (AUC
0.87)
Choong 2003
Ultrasound , bleeding, demographics prediction rate for miscarriage of
85.7% (at a false positive rate of 30%)
Papaioannou 2011
80
70
60
+2SD
40 -2SD
Viable
30
Non viable
20
10
0
28 38 48 58 68 78 88
GA (days from LMP)
Page 46 of 166
Miscarriage prediction Slow embryonic heart rate
Page 47 of 166
Miscarriage prediction Subchorionic haematoma
Subchorionic haematoma
Page 48 of 166
Miscarriage prediction
Sana 2013
Page 49 of 166
Summary so far
Diagnostic challenges
1. IncompletemiscarriageorPregnancyofUnknownLocation?
2. Incompletemiscarriageorbloodclot?
3. Incompletemiscarriageorcervical/scarpregnancy?
Page 50 of 166
Incomplete or PUL?
Firstpresentation.8weeksgestation.Moderatebleeding.
Incomplete or PUL?
Ifindoubt,treataspregnancyofunknownlocationandfollow
upwithserialhCG
Page 51 of 166
Diagnostic challenges
1. IncompletemiscarriageorPregnancyofUnknownLocation?
2. Incompletemiscarriageorbloodclot?
3. Incompletemiscarriageorcervical/scarpregnancy?
Page 52 of 166
Colour Doppler
ColourDopplerusefultofacilitate
differentialdiagnosisbetweenRPOC
andbloodclotswithinthecavity.
RPOCareusuallywellperfused,
whilstnoDopplersignalsarefound
originatinginbloodclots
HoweversomeRPOCareavascular
sosubjectiveappearancealso
important
Diagnostic challenges
1. IncompletemiscarriageorPregnancyofUnknownLocation?
2. Incompletemiscarriageorbloodclot?
3. Incompletemiscarriageorcervical/scarpregnancy?
Page 53 of 166
Gestation sac in cervix
Dont forget.sepsis
Leading cause of maternal deaths (CEMACE Saving
Mothers' Lives 2006 2008)
Page 54 of 166
Summary
Do not use endometrial thickness when referring to RPOC
Think sepsis
FAQs
Page 55 of 166
Does 3D help in diagnosis of miscarriage?
No evidence for role of 3D imaging in diagnosis of
miscarriage
Page 56 of 166
Practical tips: What to say in practice?
Page 57 of 166
Practical tips: Information leaflets
Gives patients time to adjust to the
news before having to decide on
treatment
THANK YOU
Questions?
Page 58 of 166
Bibliography
Threatened miscarriage in general practice: diagnostic value of history taking and physical examination. Wieringa-de Waard et
al.,Br J Gen Pract. 2002 Oct;52(483):825-9
Terminology for pregnancy loss prior to viability: a consensus statement from the ESHRE early pregnancy special interest group.
Kolte AM1, Bernardi LA2, Christiansen OB3, Quenby S4, Farquharson RG5, Goddijn M6, Stephenson MD7; ESHRE Special
Interest Group, Early Pregnancy. Hum Reprod. 2015 Mar;30(3):495-8.
The value of measuring endometrial thickness and volume on transvaginal ultrasound scan for the diagnosis of incomplete
miscarriage. Sawyer et al. Ultrasound Obstet Gynecol 2007 Feb; 29(2): 205209.
Do we need to follow up complete miscarriages with serum human chorionic gonadotrophin levels? Condous G, Okaro E, Khalid
A, Bourne T. BJOG. 2005 Jun;112(6):827-9.
The optimal timing of an ultrasound scan to assess the location and viability of an early pregnancy.Bottomley C, Van Belle V,
Mukri F, Kirk E, Van Huffel S, Timmerman D, Bourne T.
Hum Reprod. 2009 Aug;24(8):1811-7
Clinical implications of intra- and interobserver reproducibility of transvaginal sonographic measurement of gestational sac and
crown-rump length at 6-9 weeks' gestation. Pexsters A, Luts J, Van Schoubroeck D, Bottomley C, Van Calster B, Van Huffel S,
Abdallah Y, D'Hooghe T, Lees C, Timmerman D, Bourne T. Ultrasound Obstet Gynecol. 2011 Nov;38(5):510-5
Incidence and outcome of bleeding before the 20th week of pregnancy: prospective study from general practice.Everett C. BMJ.
1997 Jul 5;315(7099):32-4.
Page 59 of 166
Pregnancyofunknownlocation(PUL)
ProfessorTomBourne
TommysNationalCentreforMiscarriageResearch
ImperialCollegeLondon
TomBourne:Disclosureofspeakersinterests
ResearchFundingandEquipment
SamsungMedison
RocheDiagnostics
SpeakingHonoraria
SamsungMedison
CharityFunding
ImperialCollegeCharity
KULeuven
TommysCharity
Accenture
Relevantcommittees
BoardInternationalSocietyforUltrasoundinObstetricsandGynecology(ISUOG)
ScientificcommitteeRoyalCollegeObstetriciansandGynaecologists (RCOG)
UltrasoundAdvisorycommitteeoftheRCOG
PresidentoftheAssociationofEarlyPregnancyUnits(AEPU)
BoardTommysNationalCentreforMiscarriageResearch
Page 60 of 166
LearningObjectives
Bytheendofthissessionyoushouldbeabletounderstandthe
evidencebasedmanagementofPregnancyofUnknownLocation:
ThecommonprogesteronebasedprotocolsusedtomanagePUL
ThecommonhCGbasedprotocolsusedtomanagePUL
HowhCGandprogesteronecanbecombinedinatwostepprotocol
includingaprediction model tobettermanagePUL
What is a PUL?
UK US
Emptyuterus,nosignsofan Yes Yes
IUPorEP truePUL
Possibleearlyintrauterine No Yes
gestationalsac
Possibleextrauterine No Yes
inhomogeneousmass
Page 61 of 166
PUL
Followcanbechaoticwith
multiplevisits
multiplebloodtests
multiplescans
especiallyifpatientsareseenoutofhours
Thereneedtobestrict,evidencebased
managementprotocolsinplace
Manydifferentmanagementprotocolsexist
Page 62 of 166
Sensitivehomepregnancyteststhatdate
Earlierscans:theopportunityforerrorisincreased
At2834days 70%PULrate
Bottomley,BourneetalHR2009
Currentbiomarkersinclinicaluse
progesterone
hCG
Page 63 of 166
Progesterone
singlevisitstrategy
Dayetal(UOG2009)
n=1110,prospective,1centre
Dischargedifprogesteroneatday010nmol/l 47%
12ectopics withaprogesterone10nmol/l
6/12ectopics neededintervention
Cordina etal(BJOG2011)
n=252,prospective,1centre
Dischargedifprogesteroneatday010nmol/l 37%
5ectopics (2neededsurgery)
Overallinterventionrate=1.6%
10%losttof/u
Page 64 of 166
Currentbiomarkersinclinicaluse
progesterone
hCG
Discriminatoryzoneisanoutdatedconcept
n=527consecutivePULattendinganEPU
Page 65 of 166
PUL Results: n = 518
78%ofectopicsmissedhCG<1000U/L
Prog
hCG
FailingPUL ViableIUP Ectopic
hCG
hCG ratio
hCG 48hours/hCG 0hours
hCG ratio
hCG ratio hCG ratio
0.87
<0.87 >1.66
1.66
Page 66 of 166
PregnancyofUnknown
Location
triage
LOWrisk(6090%) HIGHrisk(1040%)
Intrauterine Ectopic
FailingPUL PPUL
PredictionmodelsutilisinghCG:
InitialhCG
M4model
hCG ratio
Page 67 of 166
Guha etal(HR2014)
n=1271,prospective,3centres
Comparedperformanceofprogesteronecutoffsv.hCG ratiov.M4model
Percentageclassifiedashighrisk
Data Prog hCG ratio M4model
Outcome (<10nmol/L) (0.87x1.66) (riskEP5%)
FailedPUL 24% (2028%) 10% (812%) 14% (1117%)
Guha etal(HR2014)
n=1271,prospective,3centres
Comparedperformanceofprogesteronecutoffsv.hCG ratiov.M4model
Percentageclassifiedashighrisk
Data Prog hCG ratio M4model
Outcome (<10nmol/L) (0.87x1.66) (riskEP5%)
FailedPUL 24% (2028%) 10% (812%) 14% (1117%)
Onevisit Twovisits
Page 68 of 166
Arepredictionmodelsthewayforward?
hCG progesterone
2stepmodel
Methods
Diagnosticaccuracystudy
Secondaryanalysisofprospectively,consecutivelycollecteddata
EPAUattwoLondonbaseduniversityteachinghospitals:
StGeorges:07/2003 02/2007
QueenCharlottes&Chelsea:04/2009 12/2013
Datausedtodevelopa2stepriskpredictionmodel
Page 69 of 166
Data Failed PUL I UP Ectopic Total
All 1450 (52.7%) 1002 (36.4%) 301 (10.9%) 2753
Development data
All 785 (54.2%) 501 (34.6%) 163 (11.2%) 1449
SGH 455 (49.4%) 375 (40.7%) 91 (9.9%) 921
QCCH 330 (62.5%) 126 (23.9%) 72 (13.6%) 528
Validation data
All 665 (51.0%) 501 (38.4%) 138 (10.6%) 1304
SGH 443 (51.2%) 344 (39.8%) 78 (9.0%) 865
QCCH 222 (50.6%) 157 (35.8%) 60 (13.7%) 439
STEP 1:
Progesterone 2?
YES NO
DO NOT perform
48 hr HCG
UPT in 2 weeks
Page 70 of 166
STEP 1:
Progesterone 2? Go to STEP 2
YES NO
DO NOT perform
48 hr HCG
UPT in 2 weeks
STEP 1: STEP 2:
DO NOT perform
48 hr HCG
UPT in 2 weeks
Page 71 of 166
STEP 1: STEP 2:
DO NOT perform
48 hr HCG Model states Model states
Model states
LOW RISK LOW RISK
HI GH RI SK
FPUL IUP
UPT in 2 weeks
STEP1:progesteronecutoffs
Page 72 of 166
STEP1:progesteronecutoffs
Cut-off to define PUL classified Negative EP classified Non-EP classified
low-risk as at low-risk predictive value as at high-risk as at high-risk
Prog 2 200/1449, 13.8% 197/200, 98.5% 160/163, 98.2% 1089/1286, 84.7%
Prog 3 293/1449, 20.2% 286/293, 97.6% 156/163, 95.7% 1000/1286, 77.8%
Prog 4 377/1449, 26.0% 367/377, 97.3% 153/163, 93.9% 919/1286, 71.5%
Prog 5 445/1449, 30.7% 429/445, 96.4% 147/163, 90.2% 857/1286, 66.6%
Prog 6 505/1449, 34.8% 486/505, 96.2% 144/163, 88.3% 800/1286, 62.2%
Prog 7 549/1449, 37.9% 526/549, 95.8% 140/163, 85.8% 760/1286, 59.1%
Prog 8 583/1449, 40.2% 555/583, 95.3% 136/163, 83.3% 731/1286, 56.8%
Prog 9 609/1449, 42.0% 579/609, 95.2% 134/163, 81.9% 707/1286, 55.0%
Prog 10 636/1449, 43.9% 603/636, 94.9% 130/163, 79.9% 683/1286, 53.1%
STEP2:M6model
M6P M6NP
(modelwithprogesterone) (modelwithnoprogesterone)
InitialhCG InitialhCG
Initialprogesterone hCG ratio
hCG ratio
Page 73 of 166
Testperformancedata
Negative
Data PUL classified Sensitivity for False positive
predictive
Classification approach as low-risk EP rate
value
Validation data
210/1304, 206/210, 134/138, 960/1166,
Step 1 only:
Progesterone cut-off
16.1% 98.1% 97.1% 82.3%
(14.2-18.2) (95.0-99.3) (92.4-98.9) (80.0-84.5)
789/1304, 782/789, 131/138, 384/1166,
M6P model in isolation 60.5% 99.1% 94.9% 32.9%
(57.1-63.8) (98.1-99.6) (89.4-97.6) (29.5-36.5)
716/1304, 706/716, 128/138, 460/1166,
M6NP model in isolation 54.5% 98.6% 92.5% 39.9%
(49.8-59.2) (97.3-99.2) (86.4-96.1) (35.0-45.1)
810/1304, 799/810, 127/138, 367/1166,
Two-step protocol:
Step 1 + M6P model 62.1% 98.6% 92.0% 31.5%
(58.8-65.3) (97.5-99.3) (85.9-95.6) (28.1-35.0)
754/1304, 740/754, 124/138, 426/1166,
Two-step protocol:
57.7% 98.1% 89.6% 36.6%
Step 1 + M6NP model
(53.2-62.1) (96.8-98.9) (83.0-93.9) (32.0-41.5)
921/1304, 895/921, 112/138, 271/1166,
M4-based triage 70.6% 97.2% 81.4% 23.2%
(68.0-73.1) (95.9-98.1) (73.9-87.2) (20.8-25.8)
572/1304, 542/572, 108/138, 625/1166,
Single visit prog 10nmol/l 43.8% 94.7% 78.1% 53.6%
(41.1-46.6) (92.5-96.3) (70.3-84.3) (50.7-56.5)
Results(gaugeplots)
M4based 2stepwithM6P
~17%atstep1
~45%atstep2
%Lowrisk
71% 62%
NPV(%)
97% 99%
SensitivityEP(%)
81% 92%
Page 74 of 166
Diagnosticaccuracy
study
Clinical
study
2stepclinicalstudy
Multicentre prospectivecohortstudy
2645PUL
117(4.4%)incomplete
outcomedata
2528PUL
260(16.7%)LFU
2268PUL
Page 75 of 166
EP/PPULmisclassifications:SUMMARY
STEP1 STEP2
(prog cutoffs) (M6model)
PROGCUTOFF2
&10ATWMUH PROGCUTOFF2
24.1%(563/2333) 19.5%(455/2333) 54.9%(990/1802)
PULaslowrisk PULaslowrisk PULaslowrisk
3.0%(17/563) 2.2%(10/455)
INCORRECT INCORRECT
Page 76 of 166
Page 77 of 166
Page 78 of 166
Page 79 of 166
Page 80 of 166
Summary
ThereisaclinicalneedtorationalizethemanagementofPUL
SeveralmanagementprotocolsbasedonhCG andprogesteroneareusedincurrentclinical
practice
Thetestperformanceofanyprotocolwillbeinfluencedbythecountry,legalramifications,
qualityofscanning,PULrate..
ThereremainsaquestionmarkovertherelevanceofmisclassifyingsomeEPaslowriskPUL
The2stepmodelutilizinghCG andprogesteronelevelsisoneofthelargestdatasetsonPUL
todate
Wearecurrentlyperformingamulticentre interventionstudytoassessitsutilityinclinical
practice
Wehavedevelopedthemodelintoauserfriendlyappforsmartphones
Page 81 of 166
Acknowledgments
MissJessicaFarren ProfessorBenVanCalster
MissNicolaMitchellJones ProfessorTomBourne
Mr FrancisAyim ProfessorDirkTimmerman
MissBaljinder Chohan MissCeciliaBottomley
MissBramara Guruwadahyarhalli MissAnjaliKothari
MissSayanti Ghosh Mr Vathanan Veluppillai
MissMelodyTaheri MissSharmistha Guha
Mr OsamaAbughazza MissDeborahGould
MissMayaAlMemar MissShahla Ahmed
MissCatriona Stalder MissSophieTapp
App:searchearlypregnancyLeuvenintheappstore
Freewebsite:www.earlypregnancycare.org
Furtherreadingandreferences
TheclinicalperformanceoftheM4decisionsupportmodeltotriagewomenwithapregnancyofunknownlocationas
atloworhighriskofcomplications. BobdiwalaS,GuhaS,VanCalsterB,Ayim F,MitchellJonesN,AlMemarM,Mitchell
H,StalderC,BottomleyC,KothariA,TimmermanD,BourneT.Hum Reprod.2016Jul;31(7):535.
ManagingpregnancyofunknownlocationbasedoninitialserumprogesteroneandserialserumhCGlevels:
developmentandvalidationofatwosteptriageprotocol. VanCalsterB,BobdiwalaS,GuhaS,VanHoorde K,AlMemar
M,HarveyR,FarrenJ,KirkE,CondousG,SurS,StalderC,TimmermanD,BourneT.UltrasoundObstetGynecol.2016
Nov;48(5):642649.
Triagingpregnanciesofunknownlocation:theperformanceofprotocolsbasedonsingleserumprogesteroneor
repeatedserumhCGlevels. GuhaS,Ayim F,LudlowJ,SayasnehA,CondousG,KirkE,StalderC,TimmermanD,Bourne
T,VanCalsterB.HumReprod.2014May;29(5):93845.
Rationalizingthemanagementofpregnanciesofunknownlocation:temporalandexternalvalidationofarisk
predictionmodelon1962pregnancies. VanCalsterB,AbdallahY,GuhaS,KirkE,VanHoorde K,CondousG,
PreislerJ,Hoo W,StalderC,BottomleyC,TimmermanD,BourneT.HumReprod.2013Mar;28(3):60916.
ClassificationofpregnanciesofunknownlocationaccordingtofourdifferenthCGbasedprotocols. Fistouris J,BerghC,
Strandell A.HumReprod.2016Oct;31(10):220311.
Diagnosingectopicpregnancy andcurrentconceptsinthemanagementofpregnancyofunknownlocation.
KirkE,BottomleyC,BourneT.HumReprodUpdate.2014MarApr;20(2):25061
Introductionofasinglevisitprotocolinthemanagementofselectedpatientswithpregnancyofunknown
location:aprospectivestudy. CordinaM,SchrammGajraj K,RossJA,Lautman K,JurkovicD.BJOG.2011
May;118(6):6937.
Theoptimaltimingofanultrasoundscantoassessthelocationandviabilityofanearlypregnancy. Bottomley
C,VanBelleV,MukriF,KirkE,VanHuffelS,TimmermanD,BourneT.HumReprod.2009Aug;24(8):18117.
Page 82 of 166
AdditionalSlides notused
ROCcurvesfordiscriminatingEPfromFPUL/IUP.
Theperformanceattheriskthresholdof5%isindicatedbyblackdots
Page 83 of 166
N=1900PUL
hCGratio>1.66
ViableIUP>3000
SerumhCG@3000
EP<1000
PULtriagebyM4:
HighriskareaM4isa
Simplemathematical
Modelthatgivesarisk
basedontheinitialserum
hCGratio<0.8
hCGandthehCGratio
Results(differentvisualization)
M4based 2stepwithM6P
FPUL/IUP orEP
classifiedasat
lowriskafter
1visit
FPUL/IUP orEP
classifiedasat
lowriskafter
2nd visit
FPUL/IUP orEP
classifiedasat
Highriskafter
2nd visit
Page 84 of 166
TheissuecomesdowntowhetherEPlabeledlowriskaredangerous
andvalueofaoneortwovisitstrategy
DependsonwhichcasesarebeinglabeledasaPUL
dopublishedstudiesreflectrealworld?
Dependsonqualityofthescanning soaresome
unitsEPintheirPULpopulationriskierthanothers?
Dependsonthecultureandcountry perceivedrisk
ofmissedectopicpregnancy
Naturalhistoryofectopicpregnancy
HowmanynewpatientsdoyouseeinyourEPUeachyear?
WhatisyourPULrate? i.e.the%ofnewpatientslabeledaPUL
OfyourPULhowmanyturnouttobeectopicpregnancies?
ConsidermissedEP:
Arewetalkingaboutthesamepopulations?
PULrateinliteraturerangesfrom5to42%
PULrateinbetterknownpapersis810%(KirkandCordina)
132of354PULwereEP
(37%)
133of1271PULwereEP
(10.5%)
85outof1110PULwereEP
(7.6%)
284outof1400wereEP
(20%)
Page 85 of 166
App
53
Page 86 of 166
EctopicPregnancy
EmmaKirk
MRCOGMD
Conflict of Interest
None
Page 87 of 166
Objectives
Page 88 of 166
Ultrasound Diagnosis
TVS
70-90% 10-30%
Diagnostic Non-diagnostic
Page 89 of 166
Diagnosis on the initial USS
Page 90 of 166
Sensitivity of TVS to detect ectopic pregnancy
Kirketal.,2007.HumReprod
5318cases,122ectopicpregnancies
Initial TVS:
Sensitivity 73.9% (95% CI: 55.7 81.2%)
Specificity 99.9% (99.8-100.0%)
PPV 96.7% (91.6 99.2%)
NPV 99.4% (99.1 99.6%)
Page 91 of 166
Why are some ectopic pregnancies missed
on the initial TVS?
Initial TVS
Page 92 of 166
Initial TVS
TVS to diagnose EP
hCG IU/L Median (IQR) 1286 (3384, 473-3826) 1259 (2657, 340-2997) 0.2431
Prog nmol/L Median 19 (27, 9-36) 20 (17, 11-28) 0.7334
(IQR)
Appearance on TVS:
Inhomogeneous mass 222 (62.9) 25 (71.4)
n (%) 0.1029
Empty gestational sac 77 (21.8) 9 (25.7)
n (%)
Gestational sac with 54 (15.3) 1 (2.9)
yolk sac/fetal pole n (%)
Mean size of ectopic 22.2 (9.3) 15.4 (5.3) <0.0001
mass mm (SD)
Page 93 of 166
Why are some ectopic pregnancies missed
on the initial TVS?
Lower mean gestational age
Lower mean initial hCG
Higher mean progesterone level at presentation
1. Demographics
2. Presentingcomplaints
3. SerumBiochemistry
4. USSfindings
Endometrium
FreePelvicFluid
Visualizationofanectopicmass
Page 94 of 166
Demographics
Medianmaternalage31years(1645years)
MediangestationalageaccordingtoLMP44days(11104days)
Gestationalage<6/40 30.6%
Parity0(07)
Historyof1miscarriage18.5%
Historyof1termination19.4%
Historyof1ectopicpregnancy9.5%
*Datafrom422consecutivetubalectopicpregnanciesKirketal.,2008
Presenting Complaints
1/3rd havenoclinicalsignsandupto10%noclinicalsymptoms(Tay
etal.,2000,Kaplanetal.,1996)
Painandbleeding41.7%
Painalone20.3%
Bleedingalone23.2%
Datafrom422consecutivetubalectopicpregnanciesKirketal.,2008
Page 95 of 166
Serum Biochemistry
InitialserumhCGlevel1299IU/L(6129,956IU/L)
InitialserumhCGlevel<500IU/L24.9%
InitialserumhCGlevel<1000IU/L41.7%
InitialserumhCGlevel<1500IU/L51.4%
Initialprogesteronelevel19nmol/L(1178nmol/L)
*Datafrom422consecutivetubalectopicpregnanciesKirketal.,2008
Serum Biochemistry
InitialserumhCGlevel1299IU/L(6129,956IU/L)
InitialserumhCGlevel<500IU/L24.9%
InitialserumhCGlevel<1000IU/L41.7% *45%
InitialserumhCGlevel<1500IU/L51.4%
Initialprogesteronelevel19nmol/L(1178nmol/L)
*hCG<1000IU/L 72%visualisedontheinitialTVS
*hCG>1000IU/L 83%visualisedontheinitialTVS
*Datafrom697consecutivetubalectopicpregnancies unpublished
* Datafrom422consecutivetubalectopicpregnanciesKirketal.,2008
Page 96 of 166
Empty uterus.
Endometrium
Nospecificendometrialappearancethatcanbe
usedtodiagnoseanectopicpregnancy
*ET9.3mm(1.7 36.0mm)
*24.1%Disrupted75.8%Intact
Pseudosacreportedinupto20%ofcases
Mayoccasionallycontaininternaldebris ?embryonic
structures
*Datafrom422consecutivetubalectopicpregnanciesKirketal.,2008
Page 97 of 166
Endometrium
Free Fluid..
Page 98 of 166
Free Fluid
Smallamountofanechoicfluidcommoninintra and
extrauterinepregnancies
Echogenicfluidpresentin2856% (Nybergetal.,1991,
Fleischeretal.,1990)
*Anechoicfreefluidin19.5%
*Echogenicfluidin35.8%
AmountoffluidfoundonTVScorrelateswellwith
operativefindings
Significantifreachesfundusofuterus,isinutero
vesicalpouchorMorrisonspouch
*Datafrom422consecutivetubalectopicpregnanciesKirketal.,2008
MedianhCG9072IU/L
*19% *Cardiacactivityin29%
*5.5%ofallvisualisedEPs
Range378 129,956IU/L
Page 99 of 166
Tubal Ectopic Pregnancy
Gestational sac and CRL or yolk sac
MedianhCG1576IU/L
Range63 47,302IU/L
*20%
MedianhCG667IU/L
Range10 31,169IU/L
*62%
Gestational sac or
trophoblastic mass located in
the interstitial area
surrounded by a continuous
rim of myometrium
1in76,000pregnancies
A gestational sac or
trophoblastic mass mobile 0.27%ofallectopics
and separate from the main
uterine body but surrounded
by myometrium
Gestational sac or
trophoblastic mass located
anteriorly at the level of the
internal os covering the
visible or presumed site of
the previous lower uterine
segment caesarean section
scar
Evidence of peritrophoblastic
flow on color Doppler 1in1800pregnancies
examiantion
6%ofectopicsinwomen
withapreviousLSCS
Gestational sac or
trophoblastic mass with
a wide echogenic ring
on or within the ovary,
generally seen
surrounded by ovarian
cortex and seen
separately from the
corpus luteum Upto3%ofallectopic
pregnancies
Gestational sac or
trophoblastic mass
completely surrounded by
myometrium and separate to
the endometrial cavity
Rare
Riskfactors:IVF,adenomyosis,
uterinetraumafrom
instrumentation
Heterotopic Pregnancy
An ectopic pregnancy with an
intra-uterine pregnancy
1 in 7,500 - 30,000
spontaneous conceptions
No evidence of a dilated
Fallopian tube or complex
adnexal mass
Summary
TVS has a high sensitivity for the detection of
ectopic pregnancy:
Wouter Froyman, MD
Unilocular
Unilocular
-solid
Multilocular-
solid
Multilocular
Solid
Anovulatory follicles
Unilocular, thin-walled, anechoic
<8-10 cm
Resolve spontaneously
11
Ovulation
Thick-walled, ring of fire, spider web
appearance
Resolve after 14-16 weeks of gestation
13
Haemorrhagic cysts
14
15
Haemorrhagic cysts
16
Luteoma of pregnancy
Luteoma of pregnancy
Imagescourtesy ofProf.LilValentin 18
Theca-lutein cysts
Hyperreactio luteinalis
Bilateral thin-walled multilocular cysts
(spoke wheel appearance)
Asymptomatic or pain (pressure, torsion,
haemorrhage)
Virilisation (25%)
Regress later in pregnancy or after delivery
Theca-lutein cysts
23
Theca-lutein cysts
24
25
Theca-lutein cysts
26
29
30
Endometrioma
Endometrioma
32
33
Endometrioma
34
35
Cystadenomas
Cystadenofibromas
Fibromas/fibrothecomas
Relatively rare
Round or oval, solid, regular lining, stripy
or fan-shaped shadows, vascularity
peripheral and limited
39
Fibromas/fibrothecomas
40
Hydrosalpinx
43
Hydrosalpinx
44
Para-ovarian cysts
Broad ligament
Thin-walled, unilocular, anechogenic
Separable from the ovary
Minimal vascularisation
No clinical significance
Peritoneal pseudocysts
Leiomyomas/fibroids
Appendicitis
Pelvic kidney
Peritoneal pseudocysts
Peritoneal
pseudocyst
50
Leiomyomas/fibroids
Appendicitis
Imagescourtesy ofProf.LilValentin 53
Pelvic kidney
55
3. Conclusions
57
Petya Chaveeva
Ob/Gyn Shterev Hospital, Sofia
12w
Specialist
care 12-34w 22w
32 or 36w
41w
12w
Specialist
care 12-34w 22w
ANEUPLOIDY
32 or 36w FETAL DEFECTS
PREECLAMPSIA
GESTATIONAL DIABETES
41w
PRETERM BIRTH
FETAL SURGERY
11-13+6 weeks
CRL 45-84 mm
Midsagital section
Magnification
Nutral position
Avoid amnion
Calliper on-to-on
Largest measurment
BS
Brain stem
4th ventricle BS BSOB
Cisterna BSOB
magna
Chaoui R, Benoit B, Mitkowska-Wozniak H, Heling KS, Nicolaides KH. Assessment of intracranial translucency in
detection of spina bifida at 11-13 weeks. UOG 2009
Early detection of
Clefts
Chaoui R, Orosz G , heling KD, Heling KS, Sarut-Lopez A,Nicolaides
KH. Maxillary gap at 11-13 weeks' gestation: marker of cleft lip
and palate. UOG 2015
80
70
60
50
40
30
20
10
Expectant management
Amnio 1% Livebirth n = 33,310; Miscarriage n = 404 (1.2%)
CVS 1-2% Regression model to predict miscarriage
Variable OR 95% CI
Age (per year) 0.870 0.766-0.988
Delta nuchal translucency 1.778 1.496-2.114
Amnio 0.3-0.5% Ductus venosus: reversed a-wave 2.208 1.508-3.232
Akolekar R, Bower S, Flack N, Bilardo K, Nicolaides KH: Prediction of miscarriage and stillbirth at 11-13 weeks and the
contribution of chorionic villus sampling. Prenat Diagn 2011:31:38.
100
Combined screening at 11-13 wks
90 1 in 1000
(age, fetal NT, serum -hCG & PAPP-A) 98%
20
+ve -ve
10
0
Invasive test Nothing else 0 3 10 13 20 30
Screen positive rate (%)
Santorum M, Wright D, Syngelaki A, Karagioti N, Nicolaides KH. Accuracy of first trimester combined test in screening for trisomies 21, 18 and 13.
Ultrasound Obstet Gynecol 2016; doi 10.1002/uog.17283
Cardiac defects
Major defects Lethal skeletal dysplasias
8.0 Diaphragmatic hernia
Exomphalos
45%
Nuchal translucency (mm)
7.0 Megacystis
0 Dyserythropoietic anaemia
45 55 65 75 85 Thalassaemia-a
CRL (mm) Parvovirus B19 infection
Souka AP, Snijders RJ, Novakov A, Soares W, Nicolaides KH. Defects and syndromes in chromosomally normal fetuses with increased nuchal
translucency thickness at 10-14 weeks of gestation. Ultrasound Obstet Gynecol 1998; 11:391-400. 1082.
Spina bifida
Facial clefts 5-14%
Syngelaki A, Chelemen T, Dagklis T, Allan L, Nicolaides KH. Challenges in the diagnosis of fetal non-chromosomal abnormalities at 11-13 weeks.
Prenat Diagn 2011; 31:90-102.
100
100 100
Tricuspid regurgitation
50 & DV reversed a-wave
90
0
<1.5 2 3 4 5 >6 80
80
Risk of major cardiac defect (%)
NT (mm)
TR 70 75%
Detection rate (%)
60
60
DVr 50
40
40
30
20
10%
20
10
0
0 History 4CV /
Normal Doppler Markers
-2.0 0 2.0 4.0 6.0 Hyet 1999; Atzei 2004; Cheleman 2011;
Pereira 2011; Rembouskos 2011
Delta NT (mm)
Campbell S et al: Anencephaly, early ultrasound diagnosis and active management. Lancet 1972
Campbell S et al: Ultrasound in the diagnosis of spina bifida. Lancet 1975
Rodeck CH, Campbell S. Prenatal diagnosis of neural-tube defects by ultrasound-guided fetoscopy. Lancet 1978
Wald et al: Maternal serum AFP in antenatal screening for anencephaly and spina bifida. Lancet 1977 DR 80% FPR 3%
Sphenoid bone
Prevalence: 1: 1350
Chromosomal abnormalities: 19%;
Trisomy 18 and trisomy 13
Bladder length:
7-15 (19%), resolution 90%
>15 (17%), resolution 0%
Syngelaki A, Guerra L, Ceccacci I, Efeturk T, Nicolaides KH: Impact of holoprosencephaly, exomphalos, megacystis and high NT in first
trimester screening for chromosomal abnormalities. Ultrasound Obstet Gynecol. 2016 . doi: 10.1002/uog.17286.
Holoprosencephaly: alobar
Prevalence: 1: 2950
Chromosomal abnormalities: 78%;
Trisomy 13
Syngeaki et al., 2016
Exomphalos
Prevalence: 1: 2950
Chromosomal abnormalities: 41%;
Trisomy 18
Bowel only
CRL of 45-54.9 mm: 1 in 114
CRL of 55-64.9 mm: 1 in 953
Liver : 1 in 3 300
Resolution by 20 wks
Bowel: 90%
Liver : 0%
Thank you
RachelSmall,BSc(Hons)1,RM,RGN
LeadMidwifeforEarlyPregnancy&MiscarriageCare
HEFT,UK
ChairofAssociationOfEarlyPregnancyUnits
NoconflictofInterest
HaveanunderstandingofwhatBadNewsisandits
occurrenceintheEarlyPregnancySetting
Toolstoassistyoutobreakbadnewsofapregnancy
loss
Tools/mechanismsofstayingresilientwhencarrying
outthisroledaily
DefinitionofBreakingBadNews
Badnewscanbedefinedasanynegativeinformation
thatadverselyandseriouslyaltersanindividualsviewof
theirfutureorexpectations.
(NationalInstitutesofHealth,2010)
Miscarriage
EctopicPregnancy
Abnormalityofbaby
Abnormalincidentalpathology
OngoingPregnancy
MultiplePregnancy
BreakingBadNewsinanEarlyPregnancyunitcanbean
everydayevent
IncidenceofBreakingbadnewsin
EarlyPregnancy
1:4firsttrimestermiscarriage
1:45congenitalanomaly
1:60ectopicpregnancy
1:100latetrimestermiscarriage
1:100womenhaveRecurrentMiscarriage
(OfficeforNationalStatistics)
Disclosingbadnewsinanearlypregnancysettingis
unavoidable,itisanessentialskillforthisarea.
HealthProfessionalscanfinditstressfulandabsenceof
effectivetrainingmayleadthemtoadoptinappropriate
techniquesofbreakingbadnews
Badrolemodelscanperpetuatebadpractice
(Seamanetal,2014)
Guidance
NICE(2012)PainandBleedinginEarlyPregnancy
recommendedformaltrainingforallhealthprofessional
workinginEarlyPregnancy
GMCrecommendedenhancedcommunicationskilltraining
inundergraduatesisrequiredsince1993butthisisnot
specificallyforbreakingbadnews.
Thereisnonationalguidanceonhowtobreakbadnewsin
earlypregnancyunits,yetisitanessentialskillandlearning
comesthroughtrialanderrorandlearningonthejob.
Increaseanxiety/stress
Increaseinpain
Brokendownrelationshipwithhealthprofessional
Notconformingtotreatment
Confusion
Dissatisfaction,increaseincomplaints
Increaseinlitigation
Increaseinalastingimpactontheirabilitytoadaptand
adjust
(Fallowfield&Jenkins,2004)
Increasesnegativepsychosocialoutcome
1:5situationaldepression
1:10clinicaldepression
1:8ofclinicaldepressiongroupwillstillhaveit3years
on(Seamanetal,2014)
Bourneetal(2016)4:10womenreportedPTSD3
monthsafterpregnancyloss
Resilience
Worth
Haveyourfacts
Showcompassion
Provideasafeenvironmentwhereyouwontbe
interrupted
Understandatthestartwhatyoupatients
understandingis
Recogniseandrespondtothepatientsemotions
Embracetheawkward
Bepreparedfortheunexpected
Assesscapacity
Speakatthepatientlanguage
Acknowledgetheirfeelings
Haveanawarenessofyourownfeelings,remember
youcannotfixthis,thingsaren'tok.
SPIKES6stepprotocol
Settingthescene
Perceptionofwoman
Invitation
Knowledge
Empathy
Summarising
(BaileWFetal2000)
CompassionFatigueSymptoms
Alwaystired
Hopelessness
Noenjoymentofanyhobbies
Decreaseinproductivity
Inabilitytofocus
overinvolved
Dreadingwork
Insensitivitywithpatients
Abrupt
Lackofmemory
Unabletosleep
USAstudyof73medicsreportedthat42%
indicatedthatstresstheyexperiencedingiving
badnewslastedseveralhoursupto3days
followingtheconsultation.(Ptaceketal,2001)
HowtopreventCompassionFatigue
Establishroutines
Havedowntime takeyourleave
Knowwhatmakesyouhappy
Acceptyourlimits&createprofessionalboundaries
Clarifymajorenergythieves
Valueyourself
Getsupportandperspective
Askforhelp
Thankyou
anyQuestions?
NationalInstitutesofhealthwww.ncbi.nih.gov 2010
Officefornationalstatisticswww.ons.gov.uk/healthandsocial
Communicatingsad,badanddifficultnewsinmedicine
FallowfieldL&JenkinsVTheLancetVol363Jan24,2004,p312
319
PtacekJT,PtacekJJ,EllisonNMI'msorrytotellyou
physiciansreportofbreakingbadnewsJbehaveMed2001:
24:20517
Posttraumaticstress,anxietyanddepressionfollowinga
miscarriageorectopicpregancyJessicaFarrenMariaJalmbrant,
LievekeAmeye,KarenJoash,NicolaMitchellJones,Sophie
Tapp,DirkTimmerman,TomBourne
http://bmjopen.bmj.com/content/6/11/e011864.full