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George-Carey R, Memtsa M, Kent-Nye FE, Magee LA, Oza M, Burgess K, Goodhart V, Jurković D, Silverio SA. Women's experiences of early pregnancy loss services during the pandemic: A qualitative investigation. Women Birth 2024; 37:394-402. [PMID: 38184398 DOI: 10.1016/j.wombi.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/19/2023] [Accepted: 12/19/2023] [Indexed: 01/08/2024]
Abstract
PROBLEM Early pregnancy losses [EPL] are common, varied, and require different courses of management and care. BACKGROUND In the UK, women who suspect or suffer a pregnancy loss are usually provided specialist care in early pregnancy assessment units [EPAUs]. Their configuration has recently been evaluated, but recommendations for change in-line with best practice for optimum outcomes were unable to be implemented due to the COVID-19 pandemic health system shock. AIM To compare women's experiences of EPAUs during the pandemic to themes previously found in qualitative work undertaken with women who utilised EPAUs before the pandemic. METHODS We conducted semi-structured virtual interviews, with women (N = 32) who suffered an early pregnancy loss during the pandemic; analysing transcripts using Template Analysis, based on findings about women's (pre-pandemic) experiences of EPAU from The VESPA Study. FINDINGS We report on seven key themes: Barriers to Accessing Services; Communication & Information; Retention of Relational Care; Involvement in Care Decisions; Staffs' Attitude or Approach; Efficiency of Service Delivery; Sensitive Patient Management. DISCUSSION Sensitive patient management and woman-staff interactions in EPAU settings remain a fundamental issue. Women also reported their experiences of EPAUs were comparatively worse during the pandemic. CONCLUSIONS Women valued the care provided by EPAUs and found services to be efficient, despite pandemic-related restrictions. However, psychological recognition surrounding EPL and appropriate, sensitive, relational care and support continue to be areas in need of improvement. Our recommendation is to implement the improvements suggested by VESPA as a priority to ameliorate present sub-optimal experiences and prevent further deterioration.
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Affiliation(s)
- Rhiannon George-Carey
- Gynaecology Services, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Maria Memtsa
- Gynaecology Service, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, United Kingdom; Elizabeth Garrett Anderson Institute for Women's Health, Faculty of Population Health Sciences, School of Life and Medical Sciences, University College London, London, United Kingdom
| | - Flora E Kent-Nye
- Department of Women & Children's Health, School of Life Course & Population Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Laura A Magee
- Department of Women & Children's Health, School of Life Course & Population Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Munira Oza
- The Ectopic Pregnancy Trust, London, United Kingdom
| | - Karen Burgess
- Petals: The Baby Loss Counselling Charity, Cambridge, United Kingdom
| | - Venetia Goodhart
- Gynaecology Diagnostic and Treatment Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Davor Jurković
- Gynaecology Diagnostic and Treatment Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, United Kingdom; Elizabeth Garrett Anderson Institute for Women's Health, Faculty of Population Health Sciences, School of Life and Medical Sciences, University College London, London, United Kingdom
| | - Sergio A Silverio
- Department of Women & Children's Health, School of Life Course & Population Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom.
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Ridout AE, Moses FL, Herm-Singh S, Turienzo CF, Seed PT, Goodhart V, Vousden N, Sam B, Momoh M, Kamara D, Kuhrt K, Samura S, Beoku-Betts C, Hurrell A, Bramham K, Kenneh S, Smart F, Chappell L, Sandall J, Shennan A. CRADLE-5: a stepped-wedge type 2 hybrid implementation-effectiveness cluster randomised controlled trial to evaluate the real-world scale-up of the CRADLE Vital Signs Alert intervention into routine maternity care in Sierra Leone-study protocol. Trials 2023; 24:590. [PMID: 37723530 PMCID: PMC10506317 DOI: 10.1186/s13063-023-07587-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/16/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND The CRADLE Vital Signs Alert intervention (an accurate easy-to-use device that measures blood pressure and pulse with inbuilt traffic-light early warning system, and focused training package) was associated with reduced rates of eclampsia and maternal death when trialled in urban areas in Sierra Leone. Subsequently, implementation was successfully piloted as evidenced by measures of fidelity, feasibility and adoption. The CRADLE-5 trial will examine whether national scale-up, including in the most rural areas, will reduce a composite outcome of maternal and fetal mortality and maternal morbidity and will evaluate how the CRADLE package can be embedded sustainably into routine clinical pathways. METHODS CRADLE-5 is a stepped-wedge cluster-randomised controlled trial of the CRADLE intervention compared to routine maternity care across eight rural districts in Sierra Leone (Bonthe, Falaba, Karene, Kailahun, Koinadugu, Kono, Moyamba, Tonkolili). Each district will cross from control to intervention at six-weekly intervals over the course of 1 year (May 2022 to June 2023). All women identified as pregnant or within six-weeks postpartum presenting for maternity care in the district are included. Primary outcome data (composite rate of maternal death, stillbirth, eclampsia and emergency hysterectomy) will be collected. A mixed-methods process and scale-up evaluation (informed by Medical Research Council guidance for complex interventions and the World Health Organization ExpandNet tools) will explore implementation outcomes of fidelity, adoption, adaptation and scale-up outcomes of reach, maintenance, sustainability and integration. Mechanisms of change and contextual factors (barriers and facilitators) will be assessed. A concurrent cost-effectiveness analysis will be undertaken. DISCUSSION International guidance recommends that all pregnant and postpartum women have regular blood pressure assessment, and healthcare staff are adequately trained to respond to abnormalities. Clinical effectiveness to improve maternal and perinatal health in more rural areas, and ease of integration and sustainability of the CRADLE intervention at scale has yet to be investigated. This trial will explore whether national scale-up of the CRADLE intervention reduces maternal and fetal mortality and severe maternal adverse outcomes and understand the strategies for adoption, integration and sustainability in low-resource settings. If successful, the aim is to develop an adaptable, evidence-based scale-up roadmap to improve maternal and infant outcomes. TRIAL REGISTRATION ISRCTN 94429427. Registered on 20 April 2022.
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Affiliation(s)
- Alexandra E Ridout
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Francis L Moses
- Reproductive Health and Family Planning, Ministry of Health and Sanitation, Freetown, Sierra Leone
| | | | - Cristina Fernandez Turienzo
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | | | - Nicola Vousden
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Betty Sam
- Welbodi Partnership, Freetown, Sierra Leone
| | - Mariama Momoh
- Reproductive Health and Family Planning, Ministry of Health and Sanitation, Freetown, Sierra Leone
| | | | - Katy Kuhrt
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Sorie Samura
- National Emergency Medical Service, Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Candace Beoku-Betts
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Alice Hurrell
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Kate Bramham
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Sartie Kenneh
- Reproductive Health and Family Planning, Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Francis Smart
- Reproductive Health and Family Planning, Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Lucy Chappell
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Jane Sandall
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Andrew Shennan
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
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3
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Turienzo CF, November L, Kamara M, Kamara P, Goodhart V, Ridout A, Sam B, Thomas S, Williams PT, Sandall J, Shennan AH. Innovations to reduce maternal mortality and improve health and wellbeing of adolescent girls and their babies in Sierra Leone. Lancet Child Adolesc Health 2023; 7:151-153. [PMID: 36442481 DOI: 10.1016/s2352-4642(22)00322-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 10/22/2022] [Accepted: 11/02/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Cristina Fernandez Turienzo
- Department of Women & Children's Health, School of Life Course & Population Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK.
| | - Lucy November
- Department of Women & Children's Health, School of Life Course & Population Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | | | | | | | - Alexandra Ridout
- Department of Women & Children's Health, School of Life Course & Population Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Betty Sam
- Welbodi Partnership, Freetown, Sierra Leone
| | | | | | - Jane Sandall
- Department of Women & Children's Health, School of Life Course & Population Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Andrew H Shennan
- Department of Women & Children's Health, School of Life Course & Population Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
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Bright S, Moses F, Ridout A, Sam B, Momoh M, Goodhart V, Smart F, Mannah M, Issa S, Herm-Singh S, Reid F, Seed PT, Bunn J, Shennan A, Augustin K, Sandall J. Scale-up of a novel vital signs alert device to improve maternity care in Sierra Leone: a mixed methods evaluation of adoption. Reprod Health 2023; 20:6. [PMID: 36609353 PMCID: PMC9817393 DOI: 10.1186/s12978-022-01551-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 12/13/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The CRADLE (Community blood pressure monitoring in Rural Africa: Detection of underLying pre-Eclampsia) Vital Signs Alert device-designed specifically to improve maternity care in low resource settings-had varying impact when trialled in different countries. To better understand the contextual factors that may contribute to this variation, this study retrospectively evaluated the adoption of CRADLE, during scale-up in Sierra Leone. METHODS This was a mixed methods study. A quantitative indicator of adoption (the proportion of facilities trained per district) was calculated from existing training records, then focus groups were held with 'CRADLE Champions' in each district (n = 32), to explore adoption qualitatively. Template Analysis was used to deductively interpret qualitative data, guided by the NASSS (non-adoption, abandonment, scale-up, spread, sustainability) Framework. FINDINGS Substantial but non-significant variation was found in the proportion of facilities trained in each district (range 59-90%) [X2 (7, N = 8) = 10.419, p = 0.166]. Qualitative data identified complexity in two NASSS domains that may have contributed to this variation: 'the technology' (for example, charging issues, difficulty interpreting device output and concerns about ongoing procurement) and 'the organisation' (for example, logistical barriers to implementing training, infighting and high staff turnover). Key strategies mentioned to mitigate against these issues included: transparent communication at all levels; encouraging localised adaptations during implementation (including the involvement of community leaders); and selecting Champions with strong soft skills (particularly conflict resolution and problem solving). CONCLUSIONS Complexity related to the technology and the organisational context were found to influence the adoption of CRADLE in Sierra Leone, with substantial inter-district variation. These findings emphasise the importance of gaining an in-depth understanding of the specific system and context in which a new healthcare technology is being implemented. This study has implications for the ongoing scale-up of CRADLE, and for those implementing or evaluating other health technologies in similar contexts.
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Affiliation(s)
- Sophie Bright
- grid.11835.3e0000 0004 1936 9262School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Francis Moses
- Reproductive Health and Family Planning, MoHS, Freetown, Sierra Leone.
| | - Alex Ridout
- grid.13097.3c0000 0001 2322 6764King’s College London (KCL), London, England
| | - Betty Sam
- Welbodi Partnership, Freetown, Sierra Leone
| | - Mariama Momoh
- grid.463455.50000 0004 1799 2069Ministry of Health and Sanitation (MoHS), Freetown, Sierra Leone
| | | | - Francis Smart
- Planning and Information, MoHS, Freetown, Sierra Leone
| | | | - Sattu Issa
- Reproductive Health and Family Planning, MoHS, Freetown, Sierra Leone
| | | | - Fiona Reid
- grid.13097.3c0000 0001 2322 6764Department of Population Health Sciences, KCL, London, England
| | - Paul T. Seed
- grid.13097.3c0000 0001 2322 6764Department of Women and Children’s Health, KCL, London, England
| | - James Bunn
- World Health Organization, Freetown, Sierra Leone
| | - Andrew Shennan
- grid.13097.3c0000 0001 2322 6764Department of Women and Children’s Health, KCL, London, England
| | - Katrin Augustin
- grid.13097.3c0000 0001 2322 6764School of Population Health and Environmental Sciences, KCL, London, England
| | - Jane Sandall
- grid.13097.3c0000 0001 2322 6764Women’s Health Academic Centre, KCL, London, England
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5
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Silverio SA, Memtsa M, Barrett G, Goodhart V, Stephenson J, Jurković D, Hall JA. Emotional experiences of women who access early pregnancy assessment units: a qualitative investigation. J Psychosom Obstet Gynaecol 2022; 43:574-584. [PMID: 36094423 DOI: 10.1080/0167482x.2022.2119958] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Purpose: Early pregnancy complications are common and often result in pregnancy loss, which can be emotionally challenging for women. Research on the emotional experiences of those attending Early Pregnancy Assessment Units [EPAUs] is scarce. This analysis explored the emotions which women spontaneously reported when being interviewed about their experiences of using EPAU services.Materials and methods: Semi-structured telephone interviews were conducted with a purposive sample of 38 women. Using Thematic Framework Analysis, we identified six unique emotional typologies which mapped onto women's clinical journeys.Results: Women with ongoing pregnancies were characterized as having: "Anxious Presentation" or "Sustained Anxiety due to Diagnostic Uncertainty", dependent on whether their initial scan result was inconclusive. Women with pregnancy loss had one of four emotional typologies, varying by diagnostic timing and required interventions: "Anxious-Upset"; "Anxious-Upset after Diagnostic Uncertainty"; "Anxious-Upset with Procedural Uncertainty"; "Anxious with Sustained Uncertainty".Conclusions: We provide insights into the distinct emotions associated with different clinical pathways through EPAU services. Our findings could be used to facilitate wider recognition of women's emotional journeys through early pregnancy complications and stimulate research into how best to support women and their partners, in these difficult times.
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Affiliation(s)
- Sergio A Silverio
- Department of Women & Children's Health, King's College London, London, UK.,Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Maria Memtsa
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Women's Health Services, University College London Hospitals NHS Foundation Trust, London, UK
| | - Geraldine Barrett
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Venetia Goodhart
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Women's Health Services, University College London Hospitals NHS Foundation Trust, London, UK
| | - Judith Stephenson
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Davor Jurković
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Gynaecology Diagnostic and Outpatient Treatment Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jennifer A Hall
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
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Keeney E, Memtsa M, Goodhart V, Jurkovic D, Ambler G, Khan N, Round J. An observational cohort study of health outcomes and costs associated with early pregnancy assessment units in the UK. BMC Health Serv Res 2022; 22:319. [PMID: 35264163 PMCID: PMC8905996 DOI: 10.1186/s12913-022-07709-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 02/18/2022] [Indexed: 11/14/2022] Open
Abstract
Background The objective of this study was to assess the impact of consultant presence, volume of patients seen and weekend opening on the health and cost-related outcomes associated with different Early Pregnancy Assessment Unit (EPAU) configurations. Methods This was an observational study with a prospective cohort design. Six thousand six hundred six pregnant women (16 years of age and over) attending EPAUs because of suspected early pregnancy complications were recruited from 44 EPAUs across the UK. The main outcome measures were quality of life, costs, and anxiety. Results Costs, quality of life and anxiety scores were similar across configurations with little evidence to suggest an impact of consultant presence, weekend opening or volume of patients seen. Mean overall costs varied from £92 (95% CI £85 - £98) for a diagnosis of normally developing pregnancy to £1793 (95% CI £1346 - £2240) for a molar pregnancy. EQ-5D-5L score increased from 0.85 (95% CI 0.84–0.86) at baseline to 0.91 (95% CI 0.90–0.92) at 4 weeks for the 573 women who completed questionnaires at both time points, largely due to improvements in the pain/discomfort and anxiety/depression dimensions. 78% of women reported a decrease in their anxiety score immediately following their EPAU appointment. Conclusions EPAU configuration, as specified in this study, had limited impact on any of the outcomes examined. However, it is clear that care provided in the EPAU has a positive overall effect on women’s health and emotional wellbeing, with significant improvements in EQ-5D and anxiety shown following an EPAU visit. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07709-9.
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Affiliation(s)
- Edna Keeney
- Health Economics Bristol, Population Health Sciences, University of Bristol, Bristol, UK.
| | - Maria Memtsa
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Venetia Goodhart
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Davor Jurkovic
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Nazim Khan
- Modelling and Analytical Systems Solutions Ltd, Edinburgh, UK
| | - Jeff Round
- Institute of Health Economics, Edmonton, Alberta, Canada.,Faculty of Medicine and Dentistry, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Memtsa M, Goodhart V, Ambler G, Brocklehurst P, Keeney E, Silverio SA, Anastasiou Z, Round J, Khan N, Hall J, Barrett G, Bender-Atik R, Stephenson J, Jurkovic D. Differences in the organisation of early pregnancy units and the effect of senior clinician presence, volume of patients and weekend opening on emergency hospital admissions: Findings from the VESPA Study. PLoS One 2021; 16:e0260534. [PMID: 34847201 PMCID: PMC8631630 DOI: 10.1371/journal.pone.0260534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 11/11/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To determine whether the participation of consultant gynaecologists in delivering early pregnancy care results in a lower rate of acute hospital admissions. DESIGN Prospective cohort study and emergency hospital care audit; data were collected as part of the national prospective mixed-methods VESPA study on the "Variations in the organization of EPAUs in the UK and their effects on clinical, Service and PAtient-centred outcomes". SETTING 44 Early Pregnancy Assessment Units (EPAUs) across the UK randomly selected in balanced numbers from eight pre-defined mutually exclusive strata. PARTICIPANTS 6606 pregnant women (≥16 years old) with suspected first trimester pregnancy complications attending the participating EPAUs or Emergency Departments (ED) from December 2016 to July 2017. EXPOSURES Planned and actual senior clinician presence, unit size, and weekend opening. MAIN OUTCOME MEASURES Unplanned admissions to hospital following any visit for investigations or treatment for first trimester complications as a proportion of women attending EPAUs. RESULTS 205/6397 (3.2%; 95% CI 2.8-3.7) women were admitted following their EPAU attendance. The admission rate among 44 units ranged from 0% to 13.7% (median 2.8). Neither planned senior clinician presence (p = 0.874) nor unit volume (p = 0.247) were associated with lower admission rates from EPAU, whilst EPAU opening over the weekend resulted in lower admission rates (p = 0.027). 1445/5464 (26.4%; 95%CI 25.3 to 27.6) women were admitted from ED. There was little evidence of an association with planned senior clinician time (p = 0.280) or unit volume (p = 0.647). Keeping an EPAU open over the weekend for an additional hour was associated with 2.4% (95% CI 0.1% to 4.7%) lower odds of an emergency admission from ED. CONCLUSIONS Involvement of senior clinicians in delivering early pregnancy care has no significant impact on emergency hospital admissions for early pregnancy complications. Weekend opening, however, may be an effective way of reducing emergency admissions from ED.
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Affiliation(s)
- Maria Memtsa
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom
| | - Venetia Goodhart
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, United Kingdom
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Sergio A Silverio
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom.,Department of Women and Children's Health, King's College London, London, United Kingdom
| | - Zacharias Anastasiou
- Department of Statistical Science, University College London, London, United Kingdom
| | - Jeff Round
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom.,Institute of Health Economics, Edmonton, Canada
| | - Nazim Khan
- Modelling and Analytical Systems Solutions (MASS) Ltd, Edinburgh, United Kingdom
| | - Jennifer Hall
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom
| | - Geraldine Barrett
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom
| | | | - Judith Stephenson
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom
| | - Davor Jurkovic
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom
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8
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Hall JA, Silverio SA, Barrett G, Memtsa M, Goodhart V, Bender-Atik R, Stephenson J, Jurkovic D. Women's experiences of early pregnancy assessment unit services: a qualitative investigation. BJOG 2021; 128:2116-2125. [PMID: 34407281 PMCID: PMC9292489 DOI: 10.1111/1471-0528.16866] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/20/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To explore the experiences of women who had used an Early Pregnancy Assessment Unit (EPAU) service in the UK and make recommendations for their improvement. DESIGN Qualitative interview study. SETTING Early Pregnancy Assessment Units in the UK. SAMPLE A maximum variation sample of women who had consented to be interviewed having attended one of 26 EPAUs involved in the VESPA study in 2018. METHODS In-depth telephone interviews with 38 women. A thematic framework analysis was conducted, with a focus on how experiences varied according to EPAU service configuration and clinical pathway. MAIN OUTCOME MEASURES Women's experiences of EPAU services. RESULTS We found that EPAUs are highly valued, and women's experiences were generally positive. However, women reported a range of issues that negatively affected their experience. These included difficulties accessing the service, insensitive management of the investigation and treatment options of pregnancy loss, poor communication, insufficient information and a lack of support for their psychological health. These issues were not strongly associated with EPAU configuration or clinical pathway. CONCLUSIONS Recommendations to improve women's experiences include the separation of EPAUs from general maternity services, and we make suggestions on how to remove barriers to access by reviewing opening hours, how to provide sensitive patient management, such as automatically cancelling appointments and scans following pregnancy loss, and how to improve communication, both with women and their partners as well as with other parts of the health service.
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Affiliation(s)
- J A Hall
- Faculty of Population Health Sciences, Elizabeth Garrett Anderson Institute for Women's Health, School of Life and Medical Sciences, University College London, London, UK
| | - S A Silverio
- Department of Women & Children's Health, Faculty of Life Sciences & Medicine, School of Life Course Sciences, King's College London, St Thomas' Hospital, London, UK
| | - G Barrett
- Faculty of Population Health Sciences, Elizabeth Garrett Anderson Institute for Women's Health, School of Life and Medical Sciences, University College London, London, UK
| | - M Memtsa
- Faculty of Population Health Sciences, Elizabeth Garrett Anderson Institute for Women's Health, School of Life and Medical Sciences, University College London, London, UK.,Women's Health Services, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - V Goodhart
- Faculty of Population Health Sciences, Elizabeth Garrett Anderson Institute for Women's Health, School of Life and Medical Sciences, University College London, London, UK.,Women's Health Services, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - J Stephenson
- Faculty of Population Health Sciences, Elizabeth Garrett Anderson Institute for Women's Health, School of Life and Medical Sciences, University College London, London, UK
| | - D Jurkovic
- Faculty of Population Health Sciences, Elizabeth Garrett Anderson Institute for Women's Health, School of Life and Medical Sciences, University College London, London, UK.,Gynaecology Diagnostic and Outpatient Treatment Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
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9
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Amin TN, Wong M, Foo X, Pointer SL, Goodhart V, Jurkovic D. The effect of pelvic pathology on uterine vein diameters. Ultrasound J 2021; 13:7. [PMID: 33599877 PMCID: PMC7892655 DOI: 10.1186/s13089-021-00212-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 02/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transvaginal ultrasound (TVS) is a sensitive tool for detecting various conditions that contribute to pelvic pain. TVS can be also used to assess blood flow and measure the size of pelvic veins. Pelvic venous congestion (PVC) is characterised by enlargement of the pelvic veins and has been recognised as a cause of chronic pelvic pain. The reference ranges for uterine venous diameter in women with normal pelvic organs have been established, but there is no information regarding the potential effect of pelvic pathology on the uterine venous diameters. The aim of this study was to examine the size of uterine venous plexus in women with evidence of pelvic abnormalities on TVS and to determine whether the reference ranges need to be adjusted in the presence of pelvic pathology. A prospective, observational study was conducted in our gynaecological outpatient clinic. Morphological characteristics of all pelvic abnormalities detected on TVS and their sizes were recorded. The uterine veins were identified and their diameters were measured in all cases. The primary outcome measure was the uterine venous diameter. Regression analyses were performed to determine factors affecting the uterine venous size in women with pelvic pathology. RESULTS A total of 1500 women were included into the study, 1014 (67%) of whom were diagnosed with pelvic abnormalities. Women with pelvic pathology had significantly larger uterine venous diameters than women with normal pelvic organs (p < 0.01). Multivariable analysis showed that pre-menopausal status, high parity, presence of fibroids (p < 0.001) and Black ethnicity were all associated with significantly larger uterine vein diameters. Based on these findings modified reference ranges for uterine venous diameters have been designed which could be used for the diagnosis of PVC in women with uterine fibroids. CONCLUSIONS Our findings show that of all pelvic pathology detected on TVS, only fibroids are significantly associated with uterine venous enlargement. Factors known to be associated with enlarged veins in women with normal pelvic organs, namely parity and menopausal status, also apply in patients with pelvic pathology. Future studies of uterine venous circulation should take into account the presence and size of uterine fibroids when assessing women for the signs of PVC.
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Affiliation(s)
- T N Amin
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK.
| | - M Wong
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - X Foo
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - S-L Pointer
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - V Goodhart
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - D Jurkovic
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
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Memtsa M, Goodhart V, Ambler G, Brocklehurst P, Keeney E, Silverio S, Anastasiou Z, Round J, Khan N, Hall J, Barrett G, Bender-Atik R, Stephenson J, Jurkovic D. Variations in the organisation of and outcomes from Early Pregnancy Assessment Units: the VESPA mixed-methods study. Health Serv Deliv Res 2020. [DOI: 10.3310/hsdr08460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background
Early pregnancy complications are common and account for the largest proportion of emergency work in gynaecology. Although early pregnancy assessment units operate in most UK acute hospitals, recent National Institute of Health and Care Excellence guidance emphasised the need for more research to identify configurations that provide the optimal balance between cost-effectiveness, clinical effectiveness and service- and patient-centred outcomes [National Institute for Health and Care Excellence (NICE). Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management. URL: http://guidance.nice.org.uk/CG154 (accessed 23 March 2016)].
Objectives
The primary aim was to test the hypothesis that the rate of hospital admissions for early pregnancy complications is lower in early pregnancy assessment units with high consultant presence than in units with low consultant presence. The key secondary objectives were to assess the effect of increased consultant presence on other clinical outcomes, to explore patient satisfaction with the quality of care and to make evidence-based recommendations about the future configuration of UK early pregnancy assessment units.
Design
The Variations in the organisations of Early Pregnancy Assessment Units in the UK and their effects on clinical, Service and PAtient-centred outcomes (VESPA) study employed a multimethods approach and included a prospective cohort study of women attending early pregnancy assessment units to measure clinical outcomes, an economic evaluation, a patient satisfaction survey, qualitative interviews with service users, an early pregnancy assessment unit staff survey and a hospital emergency care audit.
Setting
The study was conducted in 44 early pregnancy assessment units across the UK.
Participants
Participants were pregnant women (aged ≥ 16 years) attending the early pregnancy assessment units or other hospital emergency services because of suspected early pregnancy complications. Staff members directly involved in providing early pregnancy care completed the staff survey.
Main outcome measure
Emergency hospital admissions as a proportion of women attending the participating early pregnancy assessment units.
Methods
Data sources – demographic and routine clinical data were collected from all women attending the early pregnancy assessment units. For women who provided consent to complete the questionnaires, clinical data and questionnaires were linked using the women’s study number. Data analysis and results reporting – the relationships between clinical outcomes and consultant presence, unit volume and weekend opening hours were investigated using appropriate regression models. Qualitative interviews with women, and patient and staff satisfaction, health economic and workforce analyses were also undertaken, accounting for consultant presence, unit volume and weekend opening hours.
Results
We collected clinical data from 6606 women. There was no evidence of an association between admission rate and consultant presence (p = 0.497). Health economic evaluation and workforce analysis data strands indicated that lower-volume units with no consultant presence were associated with lower costs than their alternatives.
Limitations
The relatively low level of direct consultant involvement could explain the lack of significant impact on quality of care. We were also unable to estimate the potential impact of factors such as scanning practices, level of supervision, quality of ultrasound equipment and clinical care pathway protocols.
Conclusions
We have shown that consultant presence in the early pregnancy assessment unit has no significant impact on key outcomes, such as the proportion of women admitted to hospital as an emergency, pregnancy of unknown location rates, ratio of new to follow-up visits, negative laparoscopy rate and patient satisfaction. All data strands indicate that low-volume units run by senior or specialist nurses and supported by sonographers and consultants may represent the optimal early pregnancy assessment unit configuration.
Future work
Our results show that further research is needed to assess the potential impact of enhanced clinical and ultrasound training on the performance of all disciplines working in early pregnancy assessment units.
Trial registration
Current Controlled Trials ISRCTN10728897.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 46. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Maria Memtsa
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Venetia Goodhart
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sergio Silverio
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
- Department of Women and Children’s Health, King’s College London, St Thomas’ Hospital, London, UK
| | | | - Jeff Round
- Institute of Health Economics, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Nazim Khan
- Modelling and Analytical Systems Solutions Ltd, Edinburgh, UK
| | - Jennifer Hall
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Geraldine Barrett
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | | | - Judith Stephenson
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Davor Jurkovic
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
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Amin T, Cohen H, Wong M, Goodhart V, Pointer SL, Jurkovic D. The prevalence of incidental uterine venous plexus thrombosis in women attending a gynecology clinic. J Thromb Haemost 2020; 18:2557-2565. [PMID: 32638480 DOI: 10.1111/jth.14989] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/31/2020] [Accepted: 07/01/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND The uterine venous plexus (UVP) is an unusual site for venous thrombosis (VT). Our aim was to determine the prevalence of UVP thrombosis (UVPT) and identify associated risk factors. METHODS We conducted a cross-sectional study on consecutive nonpregnant women attending our general gynecology clinic with a wide variety of presenting symptoms over a 16-month period. All women underwent a transvaginal ultrasound scan which involved detailed examination of the uterine venous plexus. Women diagnosed with incidental UVPT had thrombophilia screening, lower limb venous duplex imaging, and specialist hematological review. Logistic regression was used to examine associations between various risk factors and UVPT. RESULTS We screened 1383 women, 39 of whom had an incidental UVPT, giving a prevalence of 3.0% (95% confidence interval [CI], 2.1%-4.1%). Multivariate analysis showed positive associations between multiparity (odds ratio [OR] 5.75 [95% CI 2.10, 15.7]), recent surgery (OR 3.10 [95% CI 1.19, 8.07]), presence of leg varicose veins (OR 3.15 [95% CI 1.32, 7.49]), and a family history of venous thromboembolism (OR 8.74 [1.65, 46.4]) and negative associations between postmenopausal status (OR 0.36 [95% CI 0.13, 0.95]) and the development of UVPT. Thrombophilia was detected in 12.8% women diagnosed with UVPT. CONCLUSIONS The prevalence of incidental UVPT in a general gynecology population was 3.0%. Several demographic and clinical factors were found to be associated with UVPT. This could help to identify women at risk of this condition, and facilitate its early detection and development of evidence-based management strategies.
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Affiliation(s)
- Tejal Amin
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, London, UK
| | - Hannah Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Michael Wong
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, London, UK
| | - Venetia Goodhart
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, London, UK
| | - Sara-Louise Pointer
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, London, UK
| | - Davor Jurkovic
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, London, UK
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Amin TN, Wong M, Pointer S, Goodhart V, Bean E, Jurkovic D. Reference ranges for uterine vein dimensions in non-pregnant women with normal pelvic organs. Ultrasound Obstet Gynecol 2019; 54:403-411. [PMID: 30834625 DOI: 10.1002/uog.20254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/25/2019] [Accepted: 02/27/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To establish reference ranges for uterine vein (UtV) diameters in non-pregnant women with normal pelvic organs. METHODS This was a prospective study of all women attending the general gynecological clinic of a university teaching hospital in the UK, between August 2015 and December 2016. All women aged ≥ 18 years underwent a transvaginal ultrasound examination in accordance with the study protocol. In women with normal pelvic organs, the largest trunk of the uterine venous plexus was identified in the transverse plane on each side. The maximum anteroposterior vessel diameter was measured by placing the calipers on the inner walls of the vein, and the mean of three measurements was used as the representative value. Inter- and intraobserver variability was assessed in a subgroup of 30 women. Maximum UtV diameter was compared between right and left UtVs and between pre- and postmenopausal women. Factors associated with UtV diameter were assessed and reference ranges were constructed. RESULTS Of 1500 women examined, 486 (32%) had normal pelvic organs on ultrasound scan and were included in the final analysis. In all women, the uterine venous trunk was clearly visualized and there was no significant difference between the maximum median left and right UtV diameters (P = 0.37). UtV diameters were generally lower in postmenopausal, compared with premenopausal, women, with the difference being statistically significant for the right UtV and the average of left and right UtVs. There was a gradual increase in UtV diameter with advancing age, with a peak observed in women aged 41-50 years and decreasing values in older age groups. Univariable analysis showed that parity, menopausal status and age were associated significantly with UtV diameters (P < 0.01). On multivariable analysis, only higher parity was significantly associated with increasing venous size in both pre- and postmenopausal women. Reference ranges were constructed separately for nulliparous and parous premenopausal women aged between 18 and 45 years. CONCLUSION UtVs can be identified and measured consistently in all women with normal pelvic organs using transvaginal ultrasound. Parity was the main factor influencing the maximum mean UtV diameter, which had to be taken into account when constructing reference ranges. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- T N Amin
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - M Wong
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - S Pointer
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - V Goodhart
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - E Bean
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - D Jurkovic
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
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13
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Rajah K, Goodhart V, Zamora KP, Amin T, Jauniaux E, Jurkovic D. How to measure size of tubal ectopic pregnancy on ultrasound. Ultrasound Obstet Gynecol 2018; 52:103-109. [PMID: 29143993 DOI: 10.1002/uog.18958] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 10/16/2017] [Accepted: 11/05/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To identify the preoperative ultrasound parameters for assessing the size of tubal ectopic pregnancy that correlate best with findings at surgery. METHODS This was a prospective study of all women attending our center who had a conclusive transvaginal ultrasound diagnosis of tubal ectopic pregnancy over a 10-month period. In each case, the total size of the ectopic pregnancy was measured by placing the calipers on the outer edges of the visible trophoblastic tissue. In ectopic pregnancies presenting with a well-defined gestational sac, the size of the celomic (chorionic) cavity was also measured using the inner borders of the trophoblastic ring as reference points. In women with signs of intra-abdominal bleeding, the size of the hematosalpinx and/or hemoperitoneum was measured. Surgeons were blinded to the ultrasound measurements and were asked to estimate the size of the ectopic pregnancy and the amount of hemoperitoneum intraoperatively. RESULTS A total of 105 women were diagnosed with a tubal ectopic pregnancy on ultrasound examination, of whom 71 (67.6%) were managed surgically. A significant (P < 0.01) positive correlation was found between all ultrasound measurements and the size of the tubal ectopic pregnancy as reported during surgery. In the absence of hematosalpinx, the mean total outer diameter of the ectopic pregnancy had the highest positive correlation with the size of the tubal ectopic pregnancy at surgery (r = 0.65, P < 0.001). In cases complicated by hematosalpinx, the mean diameter of the tube was the only variable that correlated significantly with the estimated size of the ectopic pregnancy at surgery (P < 0.001). There was a significant positive association between the amount of hemoperitoneum on ultrasound and the estimated volume of intraperitoneal blood at surgery (P < 0.001). CONCLUSIONS The mean size of a hematosalpinx and the total outer mean diameter of an ectopic pregnancy on ultrasound correlate better with the surgical findings than does the size of the celomic cavity. Our findings show that the standard approach of measuring the size of an intrauterine pregnancy on ultrasound should be adapted to include these additional measurements in women diagnosed with a tubal ectopic pregnancy. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- K Rajah
- Early Pregnancy Unit, Institute for Women's Health, University College Hospital, London, UK
| | - V Goodhart
- Early Pregnancy Unit, Institute for Women's Health, University College Hospital, London, UK
| | - K P Zamora
- Early Pregnancy Unit, Institute for Women's Health, University College Hospital, London, UK
| | - T Amin
- Early Pregnancy Unit, Institute for Women's Health, University College Hospital, London, UK
| | - E Jauniaux
- Early Pregnancy Unit, Institute for Women's Health, University College Hospital, London, UK
| | - D Jurkovic
- Early Pregnancy Unit, Institute for Women's Health, University College Hospital, London, UK
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