Management of bleeding in early pregnancy in accident and emergency departments
BMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6954.574a (Published 03 September 1994) Cite this as: BMJ 1994;309:574
- G Gilling-Smith,
- P Toozs-Hobson,
- D J Potts,
- R Touquet,
- R W Beard
- Correspondence to: Miss C Gilling-Smith, Department of Obstetrics and Gynaecology, St Mary's Hospital, London W2 1PG.
- Accepted 3 March 1994
Vaginal bleeding occurs in up to 20% of all pregnancies.1 Many women present to accident and emergency departments, rather than to general practitioners or antenatal clinics, because they provide open access on a 24 hour basis. Doctors in accident and emergency receive little training, however, in the management of gynaecological emergencies. We previously showed that the use of management guidelines and the provision of advisory leaflets to patients on discharge significantly enhanced the service provided to women with such bleeding, both by improving diagnostic accuracy and by reducing the numbers of unnecessary admissions or referrals.2 We examined the facilities provided by other accident and emergency departments in such cases.
Patients, methods, and results
We sent a questionnaire to 109 accident and emergency departments in England and Wales treating more than 20 000 new patients a year. We asked them whether they saw women with bleeding in early pregnancy and, if so, to answer a further 11 questions requiring a yes or no answer on the facilities available and the management policy used. After the first 21 questionnaires had been sent, a question on the availability of ergometrine and oxytocin was added to the remaining 88 questionnaires. Consultants or senior medical or nursing staff completed the questionnaires, which were analysed with a X2 test.
We received completed questionnaires from 94 departments. The table shows the questions asked and replies received. There were no significant relations between the answers. Although 88 (94%) of the 94 departments dealt with bleeding in early pregnancy, only 64 (73%) of these had gynaecological staff on site. Forty one departments (47%) did not expect their doctors to perform vaginal examinations despite the fact that nine (22%) of these did not have gynaecology staff on site. Eight (20%) of the 40 departments in which doctors performed pelvic examinations did not provide an examination room with a door. Of the 86 departments with ultrasound facilities on site, 40 (47%) could not obtain an ultrasound scan outside normal working hours. Nine (56%) of the 16 departments that did not stock either ergometrine or oxytocin had no gynaecology staff on site.
Replies to postal questionnaire by 88 accident and emergency departments managing women with bleeding in early pregnancy
Comment
This study showed that over 90% of accident and emergency departments see women with bleeding in early pregnancy. The questions referred to the minimum facilities we believed should be provided for such women. Overall, the service provided was poor.
Visualisation of the fetal heart by ultrasound scanning differentiates between a woman with a viable pregnancy, who can be discharged, and a woman with a non-viable or ectopic pregnancy, who requires admission and definitive treatment. Although access to ultrasound scanning was good, in half the departments this service was not available outside normal working hours. A similar number of departments did not have a portable Doppler ultrasound scanner (Sonicaid), a cheap and quick alternative means of detecting a fetal heart at gestations greater than 12 weeks. Bleeding in threatened abortion can lead to immunisation of a Rh negative mother with a Rh positive fetus. These women must be given anti-D immunoglobulin.3, 4 Although most departments had access to Rh blood typing facilities, 77% had no policy for administering anti-D immunoglobulin when appropriate.
One in four units did not have gynaecology staff on site, of which 22% did not expect their doctors to perform vaginal examinations. Failure to stock either ergometrine or oxytocin in these departments was particularly worrying. Speculum examination allows the cervix to be visualised and products of conception obstructing the so to be removed, while oxytocic drugs promote uterine contraction. Both reduce blood loss and are key resuscitative measures, particularly if the patient is to be transferred to another site for surgery.
This study confirms that in many accident and emergency departments the service provided to women presenting with bleeding in early pregnancy falls short of reasonable standards. Facilities for examining women in privacy must be provided, management protocols implemented, access to basic investigations improved, and practical advice given to patients discharged home.5