Early Pregnancy Assessment Clinic

Miscarriages and first trimester bleeding and pain are common complications of pregnancy. Overall, 30% of women will experience bleeding and pain during the first half of the pregnancy, 10–20% of pregnancies will miscarry, and 1% will implant in an inappropriate site. 

Early pregnancy assessment clinics are standard in most hospitals in England yet not in Canada. An assessment clinic is a collaborative, interdisciplinary service devoted to providing care for women experiencing pain or bleeding (or both) in the first trimester of pregnancy. It addresses the medical as well as the emotional needs of the patient in an efficient and timely fashion in a one-stop clinic.

EPAC at BC Women’s
The Early Pregnancy Assessment Clinic (EPAC) at BC Women’s Hospital & Health Centre first opened in July 2007 within the Reproductive Med­icine Program. The clinic is staf­fed by nurse clinicians and ultrasound certified obstetrician-gynecologists. 

Services offered include assessment, diagnosis, and management of early pregnancy complications and early pregnancy loss as well as supportive counseling and follow-up care. The clinic is open Monday to Friday from 8 a.m. to 4 p.m. The goal is for all patients to be seen and treated within 1 to 2 business days. 

The clinic sees patients who:
• Have cramping or bleeding and a positive pregnancy test.
• Have a non-viable pregnancy on ultrasound at less than12 weeks of gestational age.

Patients with heavy bleeding, sev­ere abdominal pain, or suspected ectopic pregnancy are not eligible to be seen at EPAC and are directed to their local emergency department.

The patient is contacted by the nurse clinician within 12 to 24 hours (or the following Monday when refer­red on weekends). The clinical information is reviewed over the telephone to ensure that eligibility criteria are met. She is given an appointment usually the same day or the following day (Monday to Friday). 

On arrival, the patient meets with the clinical nurse, and, if needed, the obstetrician-gynecologist performs an ultrasound. The findings are reviewed with the patients along with management options. Involvement of her partner or other support person is welcome at all times.

Patients with a viable pregnancy are referred back to their health care provider. Patients with a non-viable pregnancy are given the following choices:

• Expectant management.
• Medical management with misoprostol (vaginal administration).
• Surgical management with manual vacuum aspiration under local anesthetic at BC Women’s (usually the same day or the following day, Monday to Friday).
• Surgical management with dilatation and curettage with conscious sedation or general anesthetic at BC Women’s.

Emotional support and counseling is an important component of the patient’s experience. Telephone follow-up, when necessary, is provided by the nurse clinician. Written information is also given to the patient. 

A note and ultrasound report, if applicable, are faxed to all health care providers involved in the care of the patient within 24 hours of her visit to EPAC. This outlines the diagnosis, management, and follow-up plan.

Referrals can be made by family phy­sicians, midwifes, obstetrician-gynecologists, emergency departments, and from the assessment room of obstetrical units. Patients can also self-refer by phone and do not have to been assessed by her health care provider first. 

Referring health care providers are asked to fax all relevant patient information available. This may include referral letter and ultrasound and laboratory results such as blood group. After hours and on weekends, health care providers can call the clinic directly and leave a message.

Contact information
Early Pregnancy Assessment Clinic, BC Women’s Hospital & Health Centre, 4500 Oak Street, Vancouver, BC V6H 3N1; phone: 604 875-2592 (Mon­day to Friday, 8 a.m. to 4 p.m.); fax: 604 875-3136; www.bcwomens.ca/services/healthservices/reproductivemedicine/earlypregnancy.
—Nicole Racette, MD, FRCSC
Head, Division of General Gynecology and Obstetrics, UBC

Acknowledgments
Dr Racette would like to acknowledge the contributions of Dr Stephanie Rhone, medical director of the Reproductive Medicine Program, WHC; Ms Edwina Houlihan, program manager of Specialized Women’s Health, WHC; and Ms Lubna Ekramoddoullah, communications specialist at BC Children’s Hospital and BC Women’s Hospital and Health Centre.