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  7. Ectopic Pregnancy Medical Management (116)
Important: please update your RDS app to version 4.7.3

Welcome to the March 2025 update from the RDS team

1.     RDS issues - resolutions

1.1 Stability issues - Tactuum implemented a fix on 24th March which we believe has finally addressed the stability issues experienced over recent weeks.  The issue seems to have been related to the new “Tool export” function making repeated calls for content when new toolkit nodes were opened in Umbraco. No outages have been reported since then, and no performance issues in the logs, so fingers crossed this is now resolved.

1.2 Toolkit URL redirects failing– these were restored manually for the antimicrobial calculators on the 13th March when the issue occurred, and by 15th March for the remainder. The root cause was traced to adding a new hostname for an app migrated from another health board and made live that day. This led to the content management system automatically creating internal duplicate redirects, reaching the maximum number of permitted redirects and most redirects therefore ceasing to function.

This issue should not happen again because:

  • All old apps are now fully migrated to RDS. The large number of migrations has contributed to the high number of automated redirects.
  • If there is any need to change hostnames in future, Tactuum will immediately check for duplicates.

1.3 Gentamicin calculators – Incidents have been reported incidents of people accessing the wrong gentamicin calculator for their health board.  This occurs when clinicians are searching for the gentamicin calculator via an online search engine - e.g. Google - rather than via the health board directed policy route. When accessed via an external search engine, the calculator results are not listed by health board, and the start page for the calculator does not make it clearly visible which health board calculator has been selected.

The Scottish Antimicrobial Prescribing Group has asked health boards to provide targeted communication and education to ensure that clinicians know how to access their health board antimicrobial calculators via the RDS, local Intranet or other local policy route. In terms of RDS amendments, it is not currently possible to change the internet search output, so the following changes are now in progress:

  • The health board name will now be displayed within the calculator and it will be made clear which boards are using the ‘Hartford’ (7mg/kg) higher dose calculator
  • Warning text will be added to the calculator to advise that more than one calculator is in use in NHS Scotland and that clinicians should ensure they access the correct one for their health board. A link to the Right Decision Service list of health board antimicrobial prescribing toolkits will be included with the warning text. Users can then access the correct calculator for their Board via the appropriate toolkit.

We would encourage all editors and users to use the Help and Support standard operating procedure and the Editors’ Teams channel to highlight issues, even if you think they may be temporary or already noted. This helps the RDS team to get a full picture of concerns and issues across the service.

 

2.     New RDS presentation – RDS supporting the patient journey

A new presentation illustrating how RDS supports all partners in the patient journey – multiple disciplines across secondary, primary, community and social care settings – as well as patients and carers through self-management and shared decision-making tools – is now available. You will find it in the Promotion and presentation resources for editors section of the Learning and support toolkit.

3.     User guides

A new user guide is now available in the Guidance and tips section of Resources for providers within the Learning and Support area, explaining how to embed content from Google Calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream and Jotforms into RDS pages. A webinar for editors on using this new functionality is scheduled for 1 May 3-4 pm (booking information below.)

A new checklist to support editors in making all the checks required before making a new toolkit live is now available at the foot of the “Request a new toolkit” standard operating procedure. Completing this checklist is not a mandatory part of the governance process, but we would encourage you to use it to make sure all the critical issues are covered at point of launch – including organisational tags, use of Alias URLs and editorial information.

4.Training sessions for RDS editors

Introductory webinars for RDS editors will take place on:

  • Tuesday 29th April 4-5 pm
  • Thursday 1st May 4-5 pm

Special webinar for RDS editors – 1 May 3-4 pm

This webinar will cover:

  1. a) Use of the new left hand navigation option for RDS toolkits.
  2. b) Integration into RDS pages of content from external sources, including Google Calendar, Google Maps and simple Jotforms calculators.

Running usage statistics reports using Google analytics

  • Wednesday 23rd April 2pm-3pm
  • Thursday 22nd May 2pm-3pm

To book a place on any of these webinars, please contact Olivia.graham@nhs.scot providing your name, role, organisation, title and date of the webinar you wish to attend.

5.New RDS toolkits

The following toolkits were launched during March 2025:

SIGN guideline - Prevention and remission of type 2 diabetes

Valproate – easy read version for people with learning disabilities (Scottish Government Medicines Division)

Obstetrics and gynaecology induction toolkit (NHS Lothian) – password-protected, in pilot stage.

Oral care for care home and care at home services (Public Health Scotland)

Postural care in care homes (NHS Lothian)

Quit Your Way Pregnancy Service (NHS GGC)

 

6.New RDS developments

Release of the redesign of RDS search and browse, archiving and version control functionality, and editing capability for shared content, is now provisionally scheduled for early June.

The Scottish Government Realistic Medicine Policy team is leading development of a national approach to implementation of Patient-Reported Outcome Measures (PROMs) as a key objective within the Value Based Health and Care Action Plan. The Right Decision Service has been commissioned to deliver an initial version of a platform for issuing PROMs questionnaires to patients, making the PROMs reports available from patient record systems, and providing an analytics dashboard to compare outcomes across services.  This work is now underway and we will keep you updated on progress.

The RDS team has supported Scottish Government Effective Prescribing and Therapeutics Division, in partnership with Northern Ireland and Republic of Ireland, in a successful bid for EU funding to test develop, implement and assess new integrated care pathways for polypharmacy, including pharmacogenomics. As part of this project, the RDS will be working with NHS Tayside to test extending the current polypharmacy RDS decision support in the Vision primary care electronic health record system to include pharmacogenomics decision support.

7. Implementation projects

We have just completed a series of three workshops consulting on proposed improvements to the Being a partner in my care: Realistic Medicine together app, following piloting on 10 sites in late 2024. This app has been commissioned by Scottish Government Realistic Medicine to support patients and citizens to become active partners in shared decision-making and encouraging personalised care based on outcomes that matter to the person. We are keen to gather more feedback on this app. Please forward any feedback to ann.wales3@nhs.scot

 

 

Ectopic Pregnancy Medical Management (116)

Warning Warning: This guideline is 285 day(s) past its review date.
Please report any inaccuracies or issues with this guideline using our online form

  1. Antimetabolite and antifolate drug which is an established, effective and safe treatment for unruptured ectopic pregnancy and treatment of PUL.
  2. Success rates are around 80-90%.
  3. Careful patient selection is paramount- consultant review is required.
  4. Avoid aspirin or anti inflammatory drugs for 1 week after administration.
  5. Avoid alcohol, vitamins containing folic acid, intercourse, and travel out with the local area until follow up is complete.
  6. The vast majority of patients who have methotrexate will go on to have a subsequent intra-uterine pregnancy.

  1. Diagnosis of ectopic pregnancy or PUL confirmed according to EPAS guidelines.
  2. Patient clinically stable with minimal or no symptoms.
  3. No contra-indications to medical management.
  4. Patient fully counselled regarding treatment options and wishes medical management.
  5. Patient is able and willing to comply with follow up for several weeks - the average follow up time is 35 days.
  6. Patient agrees to avoid pregnancy until follow - up complete and three months after methotrexate.

  1. Fetal cardiac activity.
  2. Concurrent intrauterine pregnancy (heterotopic pregnancy).
  3. Significant free intraperitoneal fluid.
  4. Serum HCG≥ 5000 iu/l.
  5. Abnormal renal or hepatic function- discuss with consultant if deranged.
  6. Adnexal mass ≥ 4 cm.
  7. Hb ≤ 100g/l, WCC≤ 2 x 109/l , platelets ≤100 x 10 9/ l
  8. Immunodeficiency.
  9. Patient currently breast feeding.
  10. Patient unwilling to avoid pregnancy for 3 months

Most side effects are usually mild:

  • Nausea, diarrhoea, stomatitis.

More serious side effects are rare:

  • Impaired liver function, bone marrow suppression- usually reversible.

Abdominal pain occurs in about 75% of patients 3-7 days after methotrexate. This “separation pain” can be difficult to distinguish from pain due to rupture. If patient presents with concerning symptoms, carry out ultrasound to look for free fluid +/or admit for observation and senior review.

There is a 7% risk of tubal rupture following methotrexate.

  1. Serum HCG
  2. FBC, U+E, LFTs, blood group
  3. Height and weight. Calculate Surface Area-copy and paste the following into a web browser:
    https://www.medicinescomplete.com/#/calculators?calcId=body-surface-area

    (use the Dubois formula, weight in kg and height in centimetres)

  4. Offer Chlamydia screening.
  5. Pharmacy prescription to be completed by senior medical staff.

Day 1. Methotrexate administration day

  1. Ensure patient has had appropriate counselling and information sheet.
  2. Ensure consent form signed.
  3. Ensure patient contact details are clearly documented in notes.
  4. Ensure patient has EPAS contact numbers and gynaecology ward number for out- of -hours advice
  5. Inform GP of diagnosis and treatment- see GP information leaflet.
  6. Administer methotrexate 50 mg/m2  IM-see methotrexate prescription form for dose banding according to surface area.

Day 4. EPAS Review

  1. Check serum HCG

Day 7. EPAS Review

  1. Check serum HCG
  2. If HCG on day 7 has fallen by 15% or more from day 4 levels, check HCG weekly until < 5iu/l.
  3. If HCG has not fallen by at least 15%, discuss with senior medical staff. In carefully selected cases, it may be appropriate to repeat HCG levels on day 10.
  4. If HCG has risen, refer to senior medical staff to discuss option of laparoscopy or a second dose of methotrexate.
  5. Approximately 15% of women will require a second dose of methotrexate.
  6. Very rarely, a third dose may be appropriate- this must be a consultant decision.

Second Dose of Methotrexate

  1. Ensure treatment criteria still fulfilled and discuss case with Consultant
  2. Transvaginal scan.
  3. FBC, U+E, LFT.

  1. Check HCG levels weekly until <5iu/l
  2. If levels plateau or rise, discuss with senior medical staff
  3. Discharge patient when HCG < 5iu/l.

There are no absolute contra-indications to specific forms of contraception after an ectopic, other than usual cautions, but the use of a copper coil should be limited to patients for whom no other methods are suitable.

Advise to attend EPAS early in next pregnancy to confirm location.

Editorial Information

Last reviewed: 23/07/2021

Next review date: 01/07/2024

Author(s): Lynne Thomson.

Version: 4

Approved By: Gynaecology Clinical Governance Group

Document Id: 116

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