What happens at an Early Pregnancy Assessment Unit (EPAU)?

Early Pregnancy Assessment Units in the UK are usually based within NHS hospitals. These specialist clinics deal with complications in the first 16 weeks of pregnancy such as pain or bleeding. Early scans are carried out to assess the viability of the pregnancy; if a heartbeat is seen in the embryo, it is growing in the right place, and no concerns are visualized on ultrasound then women are normally discharged to antenatal care and will next be scanned at their 12 week dating scan. If a miscarriage is diagnosed then the EPAU (also sometimes called an EPU) manage any ongoing care or treatment.

How do you get an appointment with an EPAU/EPU?

Most EPAU or EPU departments require a referral from a healthcare professional such as your GP or midwife, so any issues with pain or bleeding should be discussed with them first. Some EPAU clinics do take self referrals, however walk in patients are not accepted; an appointment must be made. To find out where your local EPAU is see  the website for the Association of Early Pregnancy Units at https://www.aepu.org.uk/find-a-unit/. Referrals are usually handled electronically and vetted quickly due to the emergency nature of patient symptoms. Ideally patients are given an appointment the same day, however in reality due to overstretched NHS capabilities this is not always possible, however if referrals are accepted they will be booked in as soon as is feasible based on clinical needs.

Most EPAU clinics allow patients to bring one other adult to accompany them but children and babies are not usually permitted. EPAU departments are run separately to antenatal and maternity services and

Why do EPAUs reject some referrals?

If you are under 6 weeks pregnant then there is a chance that a referral will not be accepted by an EPAU unless there is reason to suspect ectopic pregnancy. Sometimes patients in distress are concerned when a clinic has rejected their referral because they are only 4 weeks pregnant, however it is important to remember that a pregnancy that early is simply too small to be seen on scan so an appointment would not be helpful. If your referral is rejected, the clinician should explain why, and offer advice for your scenario. For example, if it is possible from the referral that a miscarriage has already occurred and symptoms have settled, then the clinician may ask the patient to do a urine pregnancy test in a couple of weeks and call back if the test remains positive at that time. Some EPAU clinics will accept patients with a history of recurrent miscarriage who are very anxious, however this is not always the case as NHS clinics are usually very oversubscribed with patients who require urgent treatment.

What happens at an EPAU appointment?

At the EPAU clinic some history will be taken regarding your general health, details of any previous pregnancies and current symptoms. Patients are then scanned by a Sonographer who may be a Specialist Nurse or a Doctor. The majority of EPAU patients are scanned trans vaginally ie internally. The reason for this is that the pregnancy is still very tiny to assess and views via abdominal scans are often poor at this time because of the amount of layers between the probe and the uterus. Internal scans can get much closer to the pregnancy and usually a much better picture is obtained to ensure a clearer diagnosis. Internal scans do not harm the pregnancy in any way. A small probe goes into the vagina; this is not painful, and an empty bladder is required. If you are uncomfortable with this, please discuss with your clinician prior to your scan and they may try to scan abdominally (which requires a full bladder). There will be another chaperone in the room, often a Nurse or a Health Care Assistant. Within NHS teaching hospitals sometimes you may be asked if you would mind if a medical student or junior doctor is also present while they learn about early pregnancy.

The Sonographer will look to find the gestational sac and where it is growing. If it is visualized then measurements are taken of the sac and anything growing inside it such as a foetal pole (the beginnings of an embryo) and a yolk sac (which feeds the embryo). If an embryo is seen then the Sonographer will also see if it has developed a heartbeat yet (which usually happens during week 5-6.) If no pregnancy sac is seen then a diagnosis of “pregnancy of uncertain location” is made and some blood tests will be taken to help ascertain what is happening. During the scan the Sonographer will also look around the pelvic area to access ovaries, tubes and to check for any abnormal free fluid or areas where bleeding may be present.

If you receive bad news during your scan that you are having (or have had) a miscarriage then the clinician will offer advise and arrange for any follow up which may be appropriate. In the possibility of a missed miscarriage, where the embryo remains in situ, you will have some decisions to make about how to proceed. Your clinician may also provide details of where to find emotional support.  Further information is available via the Miscarriage Association.

Many scans in early pregnancy are inconclusive and require further scanning at a later date, usually because the measurements seen could either mean the embryo has stopped developing OR that it is still developing but it is too early to see a heartbeat. Early Pregnancy Units have to abide by strict protocols here and are not allowed to scan patients again until a certain number of days have passed (depending on measurements seen). At the second scan the Sonographer will be able to compare the measurements between the two scans and hopefully make a firm diagnosis; however sometimes another scan is still necessary. If during a scan a diagnosis arises which requires immediate medical attention such as a ruptured ectopic pregnancy then you will be admitted to the gynaecology ward.

Sometimes no reason for pain or bleeding is found, however the patients will be advised on how to manage their symptoms and if any follow up is required. Further information on Early Pregnancy assessment and guidelines for care can be found via the Association for Early Pregnancy Units https://www.aepu.org.uk/.