SDMS ID: P2010/0310-001 WACSClinProc1.

20 Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Pregnancy Assessment Clinic Referral New guideline Criteria for referral to the Pregnancy Assessment Clinic and Early Pregnancy Assessment Midwives, nurses, medical officers, QVMU and DEM Pregnancy assessment, early pregnancy loss P2010/0480-001 Early Pregnancy Loss P2010/0309-001 Ectopic Pregnancy P2010/0324-001 Nausea and Vomiting in Pregnancy Purpose: The pregnancy assessment clinic (PAC) allows women with complications in pregnancy to be assessed, monitored and treated on an outpatient basis reducing the need for admission to hospital. Pregnancy Assessment Clinic (PAC): The pregnancy assessment clinic does not provide a triage service. Women should be triaged (by Department of Emergency Medicine, general practitioner or Ward 4B) and if appropriate then referred to the pregnancy assessment clinic. The pregnancy assessment clinic is available on weekdays from 0900 to 1700 by appointment. Women who are in labour, have pain or active bleeding after 14 weeks gestation or who have preterm (<37 weeks) prelabour rupture of membranes should be assessed in 4B. Pregnant women who have been involved in a motor vehicle accident with significant injury or major trauma should be assessed in DEM. Fetal monitoring should be performed in DEM as per Fetal Monitoring Following Trauma in Pregnancy WACSClinProc1.8. Criteria for Early Pregnancy Assessment in PAC Eligible women must have a diagnosed pregnancy and: are booked for confinement at the QVMU be referred by their general practitioner be referred by a private obstetrician be referred by the triage nurse or senior midwife in 4B. Self referral by women not booked for confinement will not be accepted. Women who do not have a confirmed pregnancy by either: serum or documented urinary BHCG, ultrasound or clinical means (>20 weeks), will not be seen in PAC. Appropriate Indications for Early Pregnancy Assessment in PAC: Under 20 weeks gestation: Bleeding and or pain in early pregnancy (following appropriate triage) BHCG monitoring
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Non viable pregnancy detected on USS Ectopic pregnancy being treated as an outpatient with methotrexate Women who have had a miscarriage and require non-surgical management Hyperemesis Suspected ectopic pregnancy

Exclusion Criteria: Non confirmed pregnancy Routine pregnancy dating scan or pregnancy confirmation Haemodynamically unstable/ heavy bleeding In significant pain and/or requiring narcotic administration Women categorised as triage categories 1 and 2 Appropriate Indications for PAC Referral Over 20 Weeks Gestation: Reduced fetal movement Fetal monitoring Fetal surveillance Monitoring of pregnancy induced hypertension Term spontaneous rupture of membranes not in labour Minor falls during pregnancy External cephalic version Iron transfusion > 36 weeks Appointments The Pregnancy Assessment Clinic is available Monday to Friday from 0900 to 1700, by appointment. Appointments for the Pregnancy Assessment Clinic can be made through the antenatal clinic administration staff during office hours (6348 8980) or after hours a message can be left on the answering machine (6348 8946). Written referrals can be faxed to the Pregnancy Assessment Clinic (6348 8899).

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Attachments Attachment 1 Attachment 2 Attachment 3 Attachment 4 Attachment 6

DEM Referral Process to PAC Flowchart DEM Referral to PAC PAC Referral Form General Practitioner Referral to PAC References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _1 August 2008_____

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ATTACHMENT 1 DEM REFERRAL TO PAC PAC phone: 8946 Fax: 8899 History LMP Relevant history eg. previous ectopic, prior presentations, collapse prior to presentation Confirmation of Pregnancy By either documented serum BHCG or ultrasound confirming pregnancy Otherwise perform urinary or serum BHCG Assessment of Pain and Bleeding Vital Signs BP, pulse, temperature If BP < 90/50, pulse > 100 or temperature > 37.5C then manage in DEM Assess PV loss If soaking a sanitary pad in 40 mins or passing large clots then manage in DEM Assess pain If pain is absent or central cramping pain then PAC referral If pain is moderate or severe or adnexal then consider an ectopic and manage in DEM Pathology Blood group and antibody screen Hb if heavy or prolonged bleeding or history of anaemia Quantitative serum BHCG Ultrasound Complete radiology request form for ultrasound scan appointment ASAP PAC Referral Phone 8946 to make an appointment or leave a message with the womans name, UR, contact number and preliminary diagnosis Fax referral to PAC (8899) Provide patient with the relevant information sheet and business card Discharge home for follow up with PAC Afterhours an appointment (ideally immediately after ultrasound scan) can be made by DEM using the HOMER system (PAC 434)

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ATTACHMENT 2 FLOWCHART - DEM Referral to PAC

History
LMP Relevant previous history or presentations Confirmation of pregnancy urinary or serum BHCG or ultrasound scan

DEM
BP < 90/50, HR>100 or T >37.5C Soaking a sanitary pad in 40 minutes or large clots Moderate/severe/adnexal (consider ectopic)

Assessment
Vital Signs PV loss Pain

PAC
Normal Small to moderate Absent, cramping/central location

Investigations
Pathology Blood group and antibody screen Hb if bleeding heavy or prolonged or history of anaemia Quantitative BHCG Ultrasound Complete ultrasound request form

PAC Referral
Phone 8946 to book appointment or leave a message with the womans name, UR, contact number and preliminary diagnosis or arrange PAC appointment using HOMER. Fax referral to PAC 8899 Provide patient with PAC business card with contact phone numbers Provide patient with the relevant information sheet Discharge home for follow up with PAC

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Pregnancy Assessment Clinic

Addressograph label

Referral Form
FAX 8899
Shaded area to be completed by patient

Alternative contact number: eg mobile or partners mobile: What was the date of your last period? How many pregnancies have you had? How many babies have you had? How many miscarriages have you had? How many terminations have you had? Is this an IVF pregnancy? Have you ever had an ectopic (tubal) pregnancy? How would you describe your bleeding? spotting like a period flooding How would you rate your pain? None like a period moderate Have you fainted in the last 24 hours? Do you know your blood group? Do you have private health insurance? If yes which specialist would you like to care for you? Observations BP Pregnancy Confirmed Yes severe Unknown?

HR

Urinary BHCG

Serum BHCG

Ultrasound Scan

Pathology Quantative BHCG taken Blood group and antibody screening (if unknown) Anti D given if required FBC (if bleeding heavy or prolonged or history of anaemia) Investigations USS appointment booked

Yes Yes Yes Yes

No No No No

N/A

Date:

Time:

Not yet arranged

Follow Up Arranged PAC appointment made Date: Written information sheet given to patient Nominated Specialist: Signed: Name:
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Time:

Date:
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ATTACHMENT 4 General Practitioner Referral to Pregnancy Assessment Clinic (PAC) PAC phone number: 6348 8946 Fax: 6348 8899 The Pregnancy Assessment Clinic is available to manage women with early pregnancy bleeding (<20 weeks gestation). It is also the appropriate referral point for women with a confirmed non-viable pregnancy. The Pregnancy Assessment Clinic is available Monday to Friday between 0900 and 1700. The service is unavailable on public holidays. For women who are stable, after hours referral should follow the referral process outlined below. Unstable women should be referred immediately to the Department of Emergency Medicine if less than 14 weeks gestation or if greater than 14 weeks gestation to Ward 4B. Referral Process Use current QV OPD referral form and nominate specialist History LMP Relevant history eg. previous ectopic, prior presentations, collapse prior to presentation Confirmation of Pregnancy By either documented serum or urinary BHCG or ultrasound confirming pregnancy Otherwise perform urinary or serum BHCG Assessment of Pain and Bleeding Vital Signs BP, pulse, temperature If BP < 90/50, pulse > 100 or temperature > 37.5C then refer to DEM Assess PV loss If soaking a sanitary pad in 40 mins or passing large clots then refer to DEM Assess pain If pain is absent or central cramping pain then PAC referral If pain is moderate or severe or adnexal then refer to DEM Referral to PAC Phone 6348 8946 - an answer phone is available after hours Fax referral and results of any relevant investigations (FBC, blood group or prior USS results) 6348 8899 Please indicate nominated specialists for private patients mark Private Patient

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ATTACHMENT 5 REFERENCES Royal College of Obstetricians 2006, The management of early pregnancy loss, online: http://www.rcog.org.uk/index.asp?PageID=515 Womens Hospitals Australasia Clinical Practice Guideline 2008, Management of early pregnancy loss, Canberra.
www.wcha.asn.au/docs_library/Mgt%20of%20Early%20Pregnancy%20Loss%20CPG.pdf

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