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Announcements and latest updates

Welcome to the Right Decision Service (RDS) newsletter for August 2024.

  1. Contingency planning for RDS outages

Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.

We would like to invite you to a webinar on 26th September 3-4 pm on national and local contingency planning for future RDS outages.  Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.

I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.

 

2.National  IV fluid prescribing  calculator

This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids  . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery.  It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.

Please do spread the word about this new calculator and get in touch with any questions.

 

  1. New toolkits

The following toolkits are now live;

  1. Updated guidance on current and future Medical Device Regulations

We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.

 

  1. Guide to six stages of RDS toolkit development

We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit.  We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process.  The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.

 

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:
  • Thursday 5 September 1-2 pm
  • Wednesday 24 September 4-5 pm
  • Friday 27 September 12-1 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

7 Evaluation projects

Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.

We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

 

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

Non-tubal ectopic pregnancies (707)

Objectives

The purpose of this guideline is to aid the management of women diagnosed with a non-tubal ectopic pregnancy.

Please report any inaccuracies or issues with this guideline using our online form

Ectopic pregnancies in locations other than the fallopian tubes are becoming more common. In vitro fertilisation, pelvic inflammatory disease and the rise in the caesarean section rate are known risk factors. Whilst non tubal pregnancies only account for 5% of all ectopic pregnancies they disproportionately account for morbidity and mortality associated with ectopic pregnancy.

Management

An unstable patient should be managed in accordance with emergency protocols.

A stable patient should have a group and save, FBC and if appropriate a βhCG taken.

Initial diagnosis, management and scans or biochemical results of non tubal pregnancies must be discussed with a consultant gynaecologist. A gynaecologist with early pregnancy expertise should be involved in planning ongoing care and management.

Site of ectopic

Ultrasound features

Biochemical investigations

Management options

Cervical pregnancy

Empty uterine cavity

Barrel shaped cervix

Gestational sac (GS) below the level of the internal cervical os

Blood flow around the GS

Absence of sliding signi

Serum βhCG  

Consider systemic methotrexate if:

  • βhCG levels <10000iu
  • absence of fetal cardiac activity
  • <12+0 weeks gestation

Consider systemic methotrexate +/- surgical debulking +/- intracervical methotrexate if:

  • βhCG ≥10000iu
  • Evidence of fetal cardiac activity
  • CRL ≥10 mm

Caesarean ectopic

Empty uterine cavity

GS or trophoblast located anteriorly at the level of the internal cervical os

Embedded at site of previous caesarean section

Thin or absent myometrium between GS and bladder

Evidence of prominent trophoblastic circulation on doppler examination

Empty endocervical canal

Not routinely required

Consider MRI if diagnosis is in doubt

Treatment requires individualised care

1st trimester options:

  • Surgical management is the most effective
  • Consideration of surgical evacuation with Foley catheter insertion for additional haemostasis
  • Local injection of methotrexate into the GS. Risk of haemorrhage remains high from degenerating placental tissue

If the pregnancy continues after the first trimester then the patient must be highlighted to the Obstetric Consultant leading the patient’s care as there is a risk of invasive placentation.

Interstitial pregnancy

Empty uterine cavity

GS located in the intramural part of the fallopian tube

<5mm of myometrium in all planes

Presence of interstitial lineii

Consider sequential βhCG

Consider MRI to aid diagnosis following discussion with gynaecology consultant

Medical management with systemic methotrexate should be considered 1st line

Consider expectant management in those with low initial βhCG levels

Cornual pregnancy

GS mobile and separate from the uterus and surrounded by myometrium

Vascular pedicle adjoining the unicornuate uterus

Consider sequential βhCG 48 hours apart

Surgical management should be 1st line

Removal of the rudimentary horn should be undertaken

Ovarian pregnancy

Empty uterus

Internal anechoic area on the ovary

Consider sequential βhCG 48 hours apart

Laparoscopic management should be 1st line

Abdominal pregnancy

Empty uterus

GS surrounded by loops of bowel and separated from them by peritoneum

Mobile mass when pressing with the transvaginal probe

βhCG

Laparoscopic management should be 1st line.

Heterotopic pregnancy

Intrauterine pregnancy and co-existing ectopic pregnancy

Not required

Management needs to be individualised based on the intrauterine pregnancy and wishes of the patient

Surgical management is 1st line with salpingectomy of the ectopic

Systemic methotrexate should only be used if the intrauterine pregnancy Is non-viable or patient wishes termination

Scan following surgery to assess viability of intrauterine pregnancy

i Sliding sign: the vaginal probe is used to apply pressure onto the cervix. In a miscarriage, the gestational sac slides against the cervical canal, but does not do so in a pregnancy implanted in the endocervix or caesarean section scar.
ii Interstitial line sign: an echogenic line from the mass to the endometrial echo.

Editorial Information

Last reviewed: 26/11/2019

Next review date: 30/11/2024

Author(s): Claire Higgins.

Approved By: Gynaecology Clinical Guidelines Group

Document Id: 707