Reflective_Practice_on_Ultrasound

|First Trimester Ultrasound- Short Course – Reflective Writing | | | | | |Dr.S.Guruswami | | | |ID – A9042177 | | | |Submission date: March 26th 2010 | | | |Sheffield Hallam University Faculty of Health and Wellbeing | | | |MSc Medical Ultrasound - Level 7 Msc Medical Ultrasound | | | |Assignment Title | | | |First Trimester Ultrasound – Reflective Writing | |An Abnormal Case Study | | | |No. of words - 2197 | | | | | |I would like to reflect on my experience in the department on the early pregnancy | |unit since I have enrolled for the short course on ultrasound in first trimester | |scanning. | |My reflection is based on the Gibb’s model of reflective practice. I have chosen this model as I find it simple and precise and allows me| |to reflect systematically by going through description, evaluation and critical analysis of my experience and thus helps me formulate an | |action plan to change or develop my practice. It is also one of the few models that takes into account feelings and emotions (Gibbs, | |1988). I feel that as a clinician reflecting on my emotions and feelings will greatly influence my practice when confronted with a | |similar situation in future. | |Introduction | |Ectopic pregnancy is a challenging obstetrical entity in terms of diagnosis both for the clinician and the radiologist. It is the leading| |cause of pregnancy related morbidity and mortality in early pregnancy (CEMACH 2003-2005) | |This account is a reflection of an abnormal case study of a patient who was seen on the early pregnancy unit. A diagnosis of complete | |miscarriage was initially made. However she was finally diagnosed to have an ectopic pregnancy. This is a reflection of whether the | |diagnosis of ectopic pregnancy could have been made earlier, what I have learnt from this experience and the steps I would take to | |improve my practice in the future. | | | | | Description A patient was referred to the early pregnancy unit with history of amenorrhoea of eight weeks and abdominal pain. She had a BHcg level of 1200 IU. She was sent home after initial evaluation and was booked for a scan. .She was seen in two days and she had a transabdominal scan which showed thickened endometrium with no adnexal masses and a diagnosis of complete miscarriage was made. However a repeat BHcg was requested which was found to be 2000 IU (48 hours after her initial BHcg). She was readmitted the next day with severe abdominal pain and a repeat transvaginal scan was requested which showed an adnexal mass .She was taken up for laparoscopy and found to have a tubal pregnancy and had a salpingectomy. Feelings At the first visit the patient had reported heavy bleeding. She was anxious and distraught and felt certain that she had lost the pregnancy. I performed a transabominal scan on her and concluded that it was a complete miscarriage. At that time I was quite sure of my diagnosis and did not consider the possibility of of an ectopic pregnancy. In hindsight, I think I was biased even before I started the examination. Having worked as a clinician for several years, I had probably arrived at the diagnosis on the basis of the clinical history and the negative findings on ultrasound. I was prejudiced by my clinical judgement and I probably did not consider an alternate diagnosis at that time. At that time, I wanted to give my patient the answers and thought I had done so. However when I came to know the sequence of events that followed I felt guilty that I had probably missed the diagnosis .In hindsight I could have probably picked it up in the first instance if I had performed transvaginal ultrasound at her scan visit. On looking back, I have realised I should not jump to conclusions until I have investigated thoroughly. In this instance the examination was incomplete as I had not offered her a transvaginal scan. There is always uncertainty in ultrasound and I need to be cautious. It might have been prudent to confirm the diagnosis before declaring to her that she had complete miscarriage. Evaluation Thinking retrospectively. I had wrongly jumped to the conclusion of a complete miscarriage as the ultrasound did not show evidence of an intrauterine pregnancy. I presumed this as she had complained of profuse bleeding. In this instance my judgement was based on my past clinical experience rather that objective evidence on ultrasound. There is a distinct possibility that I still would not have made a diagnosis even if I had done a transvaginal scan at the first visit. Even with expert use of transvaginal scan using agreed criteria, it may not be possible to confirm if a pregnancy is intrauterine or extra uterine in 8–31% of cases at the first visit. (RCOG Guideline 25). In a study (Coudous et al, 2005) of 152 women with a history and transvaginal scan findings suggestive of complete miscarriage, serial Hcg assessment revealed a 5.9% incidence of ectopic pregnancy. Comparing the transabdominal and transvaginal ultrasonographic modalities, it has been said that the diagnostic reliability of transabdominal ultrasonography is around 70%, whereas that of transvaginal scan, under ideal conditions, is more than 90 %.(Gurel et al, 2007).The patient fortunately was not discharged and she was subsequently followed up with a bHcg level. The levels were strongly suggestive of an ectopic pregnancy .She was readmitted and evaluated again. The diagnosis of ectopic was eventually made and patient was managed appropriately. Analysis This patient was seen first in the department for bleeding. She did not have abdominal pain and was stable and comfortable. A diagnosis of complete miscarriage was presumed on the basis of negative finding on transabdominal ultrasound. She had a BHcg level performed that showed a suboptimal rise and strongly in favour of a diagnosis of ectopic pregnancy. Ectopic pregnancy is a life and fertility -threatening condition that is commonly seen in all emergency departments in obstetrics. There were 13 maternal deaths resulting from ectopic pregnancy in the UK during the period 2003-2005. The incidence of ectopic pregnancy has remained static in recent years (11.1/1000 pregnancies) and nearly 32000 ectopic pregnancies are diagnosed in the UK within a three year period. One concern raised in the Confidential Enquiry into Maternal Deaths was the difficulty encountered in diagnosing ectopic pregnancy. Ultrasound has come to play a vital role in the management of early pregnancy problems. Gracia and Barnhart (2001) compared different methods of diagnosing ectopic pregnancy using combinations of transvaginal ultrasound plus biochemistry (serum progesterone and serum beta-Hcg), ultrasound only, and clinical examination without ultrasound. The study found that the most accurate method of diagnosing ectopic pregnancy was using a combination of ultrasound followed by beta-Hcg.This was supported by recently published review by Sawyer and Jurkovic (2007).The superiority of transvaginal ultrasound has been established in several other studies. It has been shown to be an accurate diagnostic test for ectopic pregnancy with a high sensitivity (87.0–99.0%) and specificity (94.0–99.9%) (Braffman et al., 1994[pic]; Shalev et al., 1998; Atri et al., 2003; Condous et al., 2005)Transvaginal scan has been shown to be an acceptable diagnostic procedure for women attending an early pregnancy unit (EPU) with problems such as pain and bleeding in early pregnancy (Dutta and Economides, 2003; Basama et al., 2004). The use of high frequency transvaginal ultrasound has been has been the driving force behind the revolutionary change towards conservative management strategies in ectopic pregnancy care.(Condous 2009) Ultrasound is always used in conjunction with BHcg levels. The concept of discriminatory BHcg levels is used to diagnose ectopic pregnancy. (AEPU Guideline) It refers to a defined level of Hcg above which the gestational sac of an intrauterine pregnancy should be visible on ultrasound. In women with an Hcg result above the discriminatory level, but absence of an intrauterine gestational sac on ultrasound, ectopic pregnancy is a distinct possibility. With the use of high resolution transvaginal ultrasound the discriminatory level has been reported to be around 1000 IU/L. With the evolution in ultrasound technology, the discriminatory threshold has dropped from 6500 IU/L with a transabdominal approach to between 1000 and 2000 IU/L with transvaginal imaging. (Mehta et al). This threshold is user- and machine-dependent and thus will vary slightly from institution to institution. In a normal pregnancy, the first-trimester β-Hcg concentration rapidly increases, doubling about every 2 days. An increase over 48 hours of at least 66% has been used as a cut-off point for viability (Kader et al, 1985). Serum Hcg levels need caution in interpretation. In cases of twin pregnancy or heterotopic pregnancy, a suboptimal rise may be misleading. Both the Hcg levels and the patterns of change of Hcg are helpful in constructing a plan for ectopic pregnancy. The clinical picture should always be considered with Hcg measurements. However 15% of normal pregnancies will have abnormal doubling time and 13% of ectopic pregnancies will have a normal doubling time ( Ling and Stovall, 1994) This patient had a BHcg following her scan which showed as suboptimal rise and was readmitted with pain abdomen. Ectopic pregnancy was strongly suspected and patient had another scan on which the ectopic pregnancy was picked up .In view of severe abdominal pain a laparoscopy was performed. The RCOG guideline on early pregnancy care clearly states that the patient should be offered transvaginal ultrasound if transabdominal scan is inconclusive. In this instance I was guided by my own clinical judgement and failed to follow the guidelines. The second consideration on retrospective analysis was whether the patient would have been suitable for medical treatment and we could have avoided surgery. When the patient attended the unit on her first visit she was quite stable and pain free. If a diagnosis of ectopic pregnancy was confirmed at the first visit she could have been offered medical treatment. One important advantage of medical therapy is the potential for considerable savings in treatment costs. Economic evaluations undertaken alongside randomised trials comparing methotrexate and laparoscopic surgery have shown direct costs for medical therapy to be less than half of those associated with laparoscopy. Indirect costs are also less with women and their carers losing less time from work (Sowter, 2001).In addition medical treatment helps to conserve the tube and avoids the risks of complications of anaesthesia and other surgical risks and subsequent morbidity. I would also like to reflect on the patient’s perspective of the whole event. She was initially informed that she had a complete miscarriage and would have had to deal with the loss of the pregnancy. To add to this, she was subsequently informed that the diagnosis was wrong and that she had an ectopic pregnancy. Now she has to deal with losing her tube in addition. In hindsight, if she had been told that there was the possibility of an ectopic pregnancy at the first visit and that we were not sure and that she would need follow-up, she would probably trust our clinical practice. Giving her conflicting reports may lead to her losing trust in our judgment and may lead to her either seeking another opinion or lodging a complaint. Following my experience with this case, I have been considering the protocol in our department regarding the early pregnancy services provided. This patient was diagnosed to have an ectopic in her third visit. She was initially clinically evaluated and then booked for ultrasound. Management of women with threatened or actual early pregnancy loss can be streamlined, with improvement in the efficiency of the service and quality of care. Bigrigg et al (1991) have shown that admission to hospital can be avoided in 40% of women, with a further 20% requiring shorter hospital stay. If we can consider providing ultrasound to the patient at the first visit, it would improve patient satisfaction and also help to make diagnosis earlier and help to formulate a plan for treatment when she is stable. Conclusion Overall I have learnt a lot during the short period that I have been scanning on the early pregnancy unit. I will start with transbdominal scanning to get a global view of the pelvis. However I will not hesitate to offer transvaginal scanning if the findings are not conclusive. Although we need to consider the clinical picture, we should be unbiased and follow the protocol during ultrasound. Every patient who is being scanned is a potential candidate to have ectopic pregnancy and we have to make every effort to rule out an ectopic pregnancy. We need to consider the patient’s emotional status when she visits the early pregnancy unit. Every patient who attends the early pregnancy unit is concerned about her pregnancy and it is important that we are sure of our diagnosis and not jump to conclusions. This in some instances may involve calling her back for another visit or ordering additional investigations like BHcg and further followup.It is vital for the patient to have confidence in our management and to be honest with them when we are not sure of the findings. I would also like to change the protocol of the department and see if we can do the ultrasound at the first visit itself. This is strongly recommend by the RCOG and AEPU(guidelines)This may help to save time and also satisfy the patient whose purpose of the visit to the hospital to know for sure that everything is alright or otherwise. It would also be safer for the patient as early diagnosis can be made and we can discuss the treatment options which would include the medical treatment if she is stable and asymptomatic. I have devised an action plan to improve my practice in future – See Appendix References Association of Early Pregnancy Units. Guidelines 2007 [www.earlypregnancy.org.uk/documents/AEPUGuidelines2007.pdf Basama FM, Crosfill F, Price A. Women's perception of transvaginal sonography in the first trimester; in an early pregnancy assessment unit. Arch Gynecol Obstet (2004) 269:117–120 Bigrigg MA, Read MD.Management of women referred to early pregnancy assessment unit: care and effectiveness.Br Med J 1991;302:577–9 Condous G, Okaro E, Khalid A, Lu C, Van Huffel S, Timmerman D, Bourne T. The accuracy of transvaginal ultrasonography for the diagnosis of ectopic pregnancy prior to surgery. Hum Reprod (2005a) 20:1404–1409. Condous G, Okaro E, Khalid A, Bourne T. Do we need to follow up complete miscarriages with serum human chorionic gonadotrophin levels' BJOG 2005;112:827–9. Condous G.Ectopic pregnancy: challenging accepted management strategies. Aust N Z J Obstet Gynaecol. 2009 Aug;49(4):346-51. Dutta RL, Economides DL. Patient acceptance of transvaginal sonography in the early pregnancy unit setting. Ultrasound Obstet Gynecol (2003) 22:503–507 Gibbs, G. (1988) Learning by Doing: A guide to teaching and learning methods. Further Education Unit, Oxford Brookes University, Oxford. Gracia C, Barnhart K. Diagnosing ectopic pregnancy: decision analysis comparing six strategies. Obstet Gynecol. 2001;97:464–470. [PubMed] Gurel S, Sarikaya B, Gurel K, Akata D. Role of sonography in the diagnosis of ectopic pregnancy. J Clin Ultrasound. 2007;35:509–517 Kadar N, Caldwell BV, Romero R. A method of screening for ectopic pregnancy and its indications. Obstet Gynecol 1981;58:162-6. [PubMed] Ling and Stovall (1994) Update on the diagnosis and management of ectopic pregnancy, Advances in Obstetrics and Gynaecology, 1, pp 55-83. Chicago: Mosby Year Book, Inc Lewis G, editor. Confidential Enquiry into Maternal and Child Health. Saving Mothers’ Lives – Reviewing maternal deaths to make motherhood safer 2003-2005. London: CEMACH, 2007. Royal College of Obstetricians and Gynaecologists. The Management of Early Pregnancy Loss. Green- top Guideline No. 25. London: RCOG; 2006. Sawyer E, Jurkovic D. Ultrasonography in the diagnosis and management of abnormal early pregnancy. Clin Obstet Gynecol. 2007;50:31–54. [PubMed] Sowter M, Farquhar C, Petrie K, Gudex G. A randomised trial comparing single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured tubal pregnancy. Br J Obstet Gynaecol 2001;108:192–203. APPENDIX |Date |Issue |Action |Date of completion |Evidence | |23/3/2010 |Review of protocols |Get protocols and review |December 2010 |RCOG/AEPU guidelines | | | |literature to justify change of | | | | | |practice | |Royal College of Obstetricians and | | | | | |Gynaecologists – Greentop guideline | | | | | |25 | | | | | |& | | | | | | | | | | | |Association of Early pregnancy unit | | | | | |guidelines | | | | | | | |23/3/2010 |Identify practice in our |Perform an audit of our practice |December 2010 | | | |EPAU(early pregnancy assessment |and reaudit after change of | | | | |unit) |protocol | | | | | | | | | |23/3/2010 |Learning to correlate BHcg Levels|Compare bHcg levels and scan |December 2010 | | | |to gestational age |images | | | | | | | | | | | | | | |