If you have bleeding and/or pain in the early stages of pregnancy, you should seek medical advice.

Bleeding and/or pain is common in early pregnancy and does not always mean that there is a problem.

Bleeding and/or pain in early pregnancy can sometimes be a warning sign of a miscarriage. You may be advised to have tests including an ultrasound scan to check your pregnancy.

If you have heavy bleeding, severe pain in your abdomen, pain in your shoulder, dizziness or fainting, you should contact your Early Pregnancy Assessment Service or nearest A&E department immediately.

What does vaginal bleeding and pain mean for me?

Vaginal bleeding and/or cramping pain in the early stages of pregnancy are common and do not always mean that there is a problem. However, bleeding and/or pain can be a warning sign of a miscarriage or, less commonly, of other complications of early pregnancy.

What should I do if I have bleeding and/or pain in the first 3 months?

If you have any bleeding and/or pain, you can get medical help and advice from:

- your GP or midwife, who may advise you to go to hospital

- your nearest Early Pregnancy Assessment Service: details of the unit nearest to you can be found at: www.aepu.org.uk/find-a-unit/

- NHS 111: call 111 when you need medical help fast but it’s not a 999 emergency; the service is available 24 hours a day, 365 days a year, and calls are free from landlines and from mobile phones

- your nearest A&E department if you are bleeding heavily or if your pain is severe.

What will happen when I attend hospital?

You will be asked about your symptoms and the date of your last period. You will also be asked about previous pregnancies and your general health.

You may need to have:

• A urine sample tested to confirm that you are pregnant

• An ultrasound scan. You may be advised to have either a transvaginal scan (where a probe is gently inserted in your vagina) or a transabdominal scan (where the probe is placed on your abdomen) or occasionally both. A transvaginal scan may be recommended as it gives a clearer image. Neither scan increases your risk of having a miscarriage.

• A speculum and/or a vaginal examination to check the neck of the womb for any apparent cause of bleeding and/or pain.

• A test for chlamydia

• Blood test(s) to check your blood group and/or the level of your pregnancy hormone (βhCG).

• A vaginal examination and a transvaginal scan. You should be offered a chaperone (someone to accompany you) or you may also wish to bring someone with to support you during your examination or scan.

What could be causing bleeding and/or pain at this stage of pregnancy?

A threatened miscarriage

If you have had bleeding and/or pain but your ultrasound scan confirms that your pregnancy is progressing normally, this is known as a threatened miscarriage. Many women who bleed at this stage of pregnancy go on to have a healthy baby. You may be offered a follow-up scan.

An early miscarriage

Unfortunately, bleeding and/or pain in early pregnancy can mean that you have had or are having a miscarriage. Sadly, early miscarriages are common. In the first 3 months, one in five women will have a miscarriage, for no apparent reason, following a positive pregnancy test.

However, most miscarriages occur as a one-off event and there is a good chance of having a successful pregnancy in the future.

An ectopic pregnancy

When a pregnancy starts to grow outside the womb, it is called an ectopic pregnancy. In the UK, one in 90 pregnancies is ectopic. Your symptoms, scan findings and blood tests might lead to suspicion that you have an ectopic pregnancy. An ectopic pregnancy can pose a risk to your health. If this is suspected or confirmed, you may be advised to stay in hospital.

A molar pregnancy

A molar pregnancy is an uncommon condition where the placenta is abnormal and the pregnancy does not develop properly. It affects only one in 700 pregnancies. A molar pregnancy is usually diagnosed when you have an ultrasound scan.

A pregnancy of unknown location (PUL)

If you have a positive pregnancy test and your pregnancy cannot be seen clearly on ultrasound scan, it is known as a pregnancy of unknown location (PUL).

Reasons for this may be:

• That your pregnancy is in the womb but it is too small or too early to be seen. Modern pregnancy testing kits are extremely sensitive and can detect the pregnancy hormone just a few days after conception. However, a pregnancy may not be seen on ultrasound until approximately 3 weeks after conception (at least 5 weeks from your last period).

• That an early miscarriage has occurred, particularly if you have had bleeding that has now settled. Pregnancy tests can stay positive for a week or two after a miscarriage.

• An ectopic pregnancy that is too small to be seen. As many as one in five women with a PUL may have an ectopic pregnancy.

I have been told that I have a PUL – what happens next?

It is important that you are followed up to get a diagnosis and to confirm whether your pregnancy is continuing or not. You will be given an appointment to attend your early pregnancy unit for follow-up. You are likely to be asked to come every 2–3 days for a blood test to check the level of your pregnancy hormone (βhCG). The results should help show where the pregnancy is developing. They will also help to guide your follow-up:

In a normal pregnancy, βhCG levels rise significantly. In an ectopic pregnancy, the level will usually rise slightly or stay the same. Once a miscarriage has occurred, the level will fall significantly.

You may also be booked for another ultrasound scan, usually within 1–2 weeks. If an ectopic pregnancy is suspected, a member of staff may contact you with your results and give you advice. This uncertainty will be difficult but it often takes time to come to the right diagnosis. Sometimes this is reached within a few days but it may take up to 2 weeks. The team looking after you will discuss your options at each step.

What symptoms should I be aware of while I am being monitored?

It is important that you are aware of the signs of an ectopic pregnancy (below) and that you seek urgent medical help if you have any of them. Fortunately, most women with a PUL do not have an ectopic pregnancy.

Contact your Early Pregnancy Assessment Service or A&E department immediately if you have any of the following:

Heavy bleeding

Severe pain in your abdomen

Pain in your shoulders

Dizziness

Fainting

Reference- https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/bleeding-andor-pain-in-early-pregnancy-patient-information-leaflet/

For further information

Association of Early Pregnancy Units (AEPU): https://www.aepu.org.uk/

Miscarriage Association: www.miscarriageassociation.org.uk

National Institute for Health and Care Excellence (NICE): Ectopic Pregnancy and Miscarriage: www.nice.org.uk/guidance/cg154/ifp/chapter/About-this-information

NHS 111 service: www.nhs.uk/NHSEngland/AboutNHSservices/Emergencyandurgentcareservices/Pages/ NHS-111.aspx

• Your baby is moving or kicking less than usual. You'll start to feel your baby move when you're about 16 weeks pregnant, and if the frequency of his movements slows down, it could signal a problem. Tell your provider right away if your baby seems quieter than normal. Also, ask your provider whether you should monitor your baby's activity by doing daily "kick counts." She can give you specific instructions on how to count and when to call.

• Vaginal bleeding or spotting. Keep in mind that it's normal to have a little spotting after sex or a vaginal exam.  

• A change in vaginal discharge from milky white to watery, mucousy, or bloody – even if it's only pink or blood-tinged. If you're in your third trimester, know that after 37 weeks an increase in mucous discharge is normal and may indicate your body is preparing for labor.

• Pelvic pressure (A feeling that your baby is pushing down), lower back pain (especially if it's a new problem for you), menstrual-like cramping or stomach pain, or six or more contractions in an hour before 37 weeks (even if they don't hurt) . If you start feeling these symptoms, drink some water and rest to see if they ease up or go away within an hour. If they don't, or if symptoms increase in intensity and last longer than an hour, call your provider.

• Painful or burning urination, feeling the urge to go again minutes after peeing, having little or no urination, and having urine that's cloudy, blood-tinged, or has a strong odor can be signs of a bladder infection. If you are experience any of these symptoms contact your provider as soon as possible as early detection and treatment of bladder infection during pregnancy is very important for the health of both mother and baby.

• Chills or fever of 38 degrees Celsius/ 100.4 degrees Fahrenheit or higher

• Vomiting along with pain or fever

• Sudden vision changes or visual problems, such as double vision, blurring, dimming, flashing lights, auras, or "floaters" (spots in your field of vision). These can be signs of preeclampsia.

• Persistent or severe headache that doesn't go away when you rest or take acetaminophen, or any headache with blurred vision, slurred speech, or numbness

• Persistent swelling in your face or puffiness around your eyes, anything more than a little swelling in your hands, or severe and sudden swelling of your feet or ankles, particularly in the morning. (Swelling is a concern when you press your thumb into your skin, and an indentation remains for a few seconds.)

• Rapid weight gain

• Abdominal injury, such as from a fall or a car accident

• Persistent intense itching of your torso, arms, legs, palms, or soles, or a feeling of itchiness all over your body

• Persistent pain in your upper belly or shoulder, especially under the ribs on your right side

• Flu exposure or symptoms. Let your provider know right away if you've been in close contact with someone who has the flu, or if you have any flu symptoms. These may include fever, sore throat, cough, runny or stuffy nose, exhaustion, and body aches and chills. You may also have vomiting or diarrhea. To minimize your risk of the flu, get the flu shot as soon as it's available in the fall. The flu is very risky for pregnant women.

• Exposure to a communicable disease, like chicken pox or rubella, if you're not immune or show signs of infection. Call your provider to discuss your symptoms before going to the office.

• Depression or severe anxiety. If you feel profoundly sad or hopeless, have panic attacks, feel unable to handle your daily responsibilities, or have thoughts of harming yourself, seek help immediately.

• Any other health problem that you'd ordinarily call your provider about, even if it isn't related to your pregnancy (like worsening asthma or a cold that gets worse rather than better). If you're near your due date, check out the signs of labor so you'll know what to look for and when to call.

• Possible exposure to Zika Virus. If you or your partner live in or have traveled to an area where Zika virus has been reported, tell your healthcare provider right away. It's important to be tested, even if you don't notice any signs of the disease. Most people don't have any symptoms of Zika, but when they do develop can include fever, rash, painful joints, pink eye (conjunctivitis), muscle pain, and headache.

If you are experiencing any of the above please call you GP, go to the A and E or your nearest EPU.

References- https://www.nhs.uk/pregnancy/related-conditions/common-symptoms/common-health-problems/

An ectopic pregnancy is when a fertilised egg implants itself outside of the womb, usually in one of the fallopian tubes.

The fallopian tubes are the tubes connecting the ovaries to the womb. If an egg gets stuck in them, it won't develop into a baby and your health may be at risk if the pregnancy continues. Unfortunately, it's not possible to save the pregnancy. It usually must be removed using medicine or an operation.

Most ectopic pregnancies develop in the fallopian tubes (tubal pregnancy) but, rarely they can occur in other places.

What is pregnancy of unknown location (PUL)?

A pregnancy of unknown location (PUL) means that you have a positive pregnancy test but there is no identified pregnancy on an ultrasound scan. This may be due to three possible reasons:

• You may have a very early pregnancy within the uterus that is too small to be seen on a scan

• You may have miscarried; your pregnancy test can remain positive for up to 2–3 weeks following a miscarriage

• You may have an ectopic pregnancy.

Uncertainty about your pregnancy can be very stressful for you and your family. While it may take time, it is important to reach the correct diagnosis before your doctor discusses your treatment options with you. With a PUL, you will be advised to have regular blood tests to measure your pregnancy hormone levels and your treatment plan will be based on the results of these blood tests, ultrasound scan reports and clinical features.

What are the symptoms of an ectopic pregnancy?

Each woman is affected differently by an ectopic pregnancy. Some women have no symptoms, some have a few symptoms, while others have many symptoms. Most women get physical symptoms in the 6th week of pregnancy (about 2 weeks after a missed period). You may or may not be aware that you are pregnant if your periods are irregular, or if the contraception you are using has failed.

Because symptoms vary so much, it is not always straightforward to reach a diagnosis of an ectopic pregnancy.

The symptoms of an ectopic pregnancy may include:

Pain in your lower abdomen - This may develop suddenly for no apparent reason or may come on gradually over several days. It may be on one side only.

Vaginal bleeding. - You may have some spotting or bleeding that is different from your normal period. The bleeding may be lighter or heavier or darker than normal.

Pain in the tip of your shoulder - This pain is caused by blood leaking into the abdomen and is a sign that the condition is getting worse. This pain is there all the time and may be worse when you are lying down. It is not helped by movement and may not be relieved by painkillers. You should seek urgent medical advice if you experience this.

Upset tummy - You may have diarrhoea or feel pain on opening your bowels.

Severe abdominal pain/collapse - If the fallopian tube bursts (ruptures) and causes internal bleeding, you may develop intense abdominal pain or you may collapse. In rare instances, collapse may be the very first sign of an ectopic pregnancy. This is an emergency, and you should seek urgent medical attention.

Should I seek medical advice immediately?

Yes. An ectopic pregnancy can pose a serious risk to your health. If you have had sex within the last 3 or 4 months (even if you have used contraception) and are experiencing these symptoms, you should get medical help immediately. Seek advice even if you do not think you could be pregnant.

You can get medical advice from:

Your GP or midwife

The A&E department at your local hospital

An Early Pregnancy Assessment Unit (EPAU); details of the unit nearest to you can be found at: www.aepu.org.uk/find-a-unit

NHS 111 (England and Wales) and NHS 24 (Scotland) on 111; support is available 24 hours a day, 365 days a year, by dialing 111; calls are free from landlines and mobile phones.

Am I at increased risk of an ectopic pregnancy?

Any woman of childbearing age could have an ectopic pregnancy. You have an increased risk of an ectopic pregnancy if:

• You have had a previous ectopic pregnancy

• You have a damaged fallopian tube; the main causes of damage are:

• Previous surgery to your fallopian tubes, including sterilisation

• Previous infection in your fallopian tubes

• You become pregnant when you have an intrauterine device (IUD/coil) or if you are on the progesterone-only contraceptive pill (mini pill)

• Your pregnancy is a result of assisted conception, i.e. in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI)

• You smoke.

How is it diagnosed?

Most ectopic pregnancies are suspected between 6 and 10 weeks of pregnancy. Sometimes the diagnosis is made quickly. However, if you are in the early stages of pregnancy, it can take longer (a week or more) to make a diagnosis of an ectopic pregnancy.

Your diagnosis will be made based on the following:

Consultation and examination. Your doctor will ask about your medical history and symptoms and will examine your abdomen. With your consent, your doctor may also do a vaginal (internal) examination. You should be offered a female chaperone (someone to accompany you) for this. You may also wish to bring someone to support you during your examination.

Urine pregnancy test. If you have not already had a positive pregnancy test, you will be asked for a urine sample so that this can be tested for pregnancy. If the pregnancy test is negative, it is very unlikely that your symptoms are due to an ectopic pregnancy.

Ultrasound scan. A transvaginal scan (where a probe is gently inserted in your vagina) is known to be more accurate in diagnosing an ectopic pregnancy than a scan through the tummy (transabdominal scan). Therefore, you will be offered a transvaginal scan to help identify the exact location of your pregnancy. However, if you are in the early stages of pregnancy, it may be difficult to locate the pregnancy on scanning and you may be offered another scan after a few days.

Blood tests. A test for the level of the pregnancy hormone βhCG (beta human chorionic gonadotrophin) or a test every few days to look for changes in the level of this hormone may help to give a diagnosis. This is usually checked every 48 hours because, with a pregnancy in the uterus, the hormone level rises by 63% every 48 hours (known as the ‘doubling time’) whereas, with ectopic pregnancies, the levels are usually lower and rise more slowly or stay the same.

Laparoscopy. If the diagnosis is still unclear, an operation under a general anaesthetic called a laparoscopy may be necessary. The doctor uses a small telescope to look at your pelvis by making a tiny cut, usually into the umbilicus (tummy button). This is also called keyhole surgery. If an ectopic pregnancy is confirmed, treatment may be undertaken as part of the same operation. This would be discussed with you before surgery, unless surgery is necessary due to an acute emergency.

What happens when an ectopic pregnancy is suspected or confirmed?

When an ectopic pregnancy is suspected or confirmed, your doctor will discuss your treatment options with you. The options usually depend on where the ectopic pregnancy is suspected or located.

Make sure that you:

- Fully understand all your options

- Ask for more information if there is something you do not understand

- Raise your concerns, if any

- Understand what each option means for your fertility

- Have enough time to make your decision.

- What are the options for treatment of tubal ectopic pregnancy?

Because an ectopic pregnancy cannot lead to the birth of a baby, all options will end the pregnancy to reduce the risks to your own health.

Your options depend upon:

how many weeks pregnant you are

your symptoms and clinical condition

the level of βhCG

your scan result

your fertility status

your general health

your personal views and preferences – this should involve a discussion about your future pregnancy plans

the options available at your local hospital.

The treatment options for tubal ectopic pregnancy are listed below – not all may be suitable for you, so your healthcare professional should guide you in making an informed decision.

1) Expectant management (wait and see). This is not an option for all women. It is usually only possible when the pregnancy is still in the early stages and when you have only a few or no symptoms. Success rates with expectant management are highly variable and range from 30% to 100%. This mainly depends on your pregnancy hormone levels, with higher serum βhCG levels associated with a lower chance of success

2) Ectopic pregnancies sometimes end on their own – similar to a miscarriage. Depending on your situation, it may be possible to monitor the βhCG levels with blood tests every few days until these are back to normal. Although you do not have to stay in hospital, you should go back to hospital if you have any further symptoms. You should be given a direct contact number for the emergency ward or gynaecology ward at your hospital.

3) Medical treatment In certain circumstances, an ectopic pregnancy may be treated by medication (drugs). The fallopian tube is not removed. A drug (methotrexate) is given as an injection – this prevents the ectopic pregnancy from growing and the ectopic pregnancy gradually disappears. Most women only need one injection of methotrexate for treatment. However, 15 in 100 women (15%) need to have a second injection of methotrexate. If your pregnancy is beyond the very early stages or the βhCG level is high, methotrexate is less likely to succeed. Seven in 100 women (7%) will need surgery even after medical treatment. Many women experience some pain in the first few days after taking the methotrexate, but this usually settles with paracetamol or similar pain relief. Although it is known that long-term treatment with methotrexate for other illnesses can cause significant side effects, this is rarely the case with one or two injections as used to treat ectopic pregnancy. Treatment of ectopic pregnancy with methotrexate is not known to affect the capacity of your ovaries to produce eggs.

You may need to stay in hospital overnight and then return to the clinic or ward a few days later. You will be asked to return sooner if you have any symptoms. It is very important that you attend your follow-up appointments until your pregnancy hormone levels are back to normal. You are also advised to wait for 3 months after the injection before you try for another pregnancy.

4) Surgical treatment. An operation to remove the ectopic pregnancy will involve a general anaesthetic. The surgery will either be:

Laparoscopy (known as keyhole surgery). Your stay in hospital is shorter (24–36 hours) and physical recovery is quicker than after open surgery. Laparoscopy might not be an option for some women and your doctor will discuss this with you.

Open surgery (known as a laparotomy). This is done through a larger cut in your abdomen and may be needed if severe internal bleeding is suspected. You will need to stay in hospital for 2–4 days. It usually takes about 4–6 weeks to recover.

The aim of surgery is to remove the ectopic pregnancy. The type of operation you have will depend on your wishes or plans for a future pregnancy and what your surgeon finds during the operation (laparoscopy).

To have the best chance of a future pregnancy inside your uterus, and to reduce the risk of having another ectopic pregnancy, you will usually be advised to have your affected fallopian tube removed (this is known as a salpingectomy).

If you already have only one fallopian tube or your other tube does not look healthy, your chances of getting pregnant are already affected. In this circumstance, you may be advised to have a salpingotomy that aims to remove the pregnancy without removing the tube. It carries a higher risk of a future ectopic pregnancy but means that you are still able to have a pregnancy in the uterus in the future. You will be advised to have blood tests for checking your pregnancy hormone levels after salpingotomy as part of follow-up. Some women may need further medical treatment or another operation to remove the tube later if the pregnancy has not been completely removed during the salpingotomy. The decision to perform a salpingectomy or salpingotomy may sometimes only be made during laparoscopy under anaesthetic.

There are risks associated with any operation from the surgery itself and from the use of an anaesthetic. Your surgeon and anaesthetist will discuss these risks with you.

What are the options for treatment of non-tubal ectopic pregnancy?

The treatment of a non-tubal ectopic pregnancy depends on where the pregnancy is growing (refer to the various sites of non-tubal ectopic pregnancy in the leaflet). Your doctor will discuss the available treatment options with you based on a number of factors, including the location of the ectopic pregnancy, the levels of the pregnancy hormone βhCG in your blood and the ultrasound scan report.

Treatment options may include expectant management, medical treatment with methotrexate or surgical operation.

In an emergency situation

If the tubal or non-tubal pregnancy has burst, emergency surgery is needed to stop the bleeding. This operation is often life-saving. It is done by removing the ruptured fallopian tube and pregnancy. Your doctors will need to act quickly and this may mean that they have to make a decision on your behalf to operate. In this situation you may need a blood transfusion.

What happens to your pregnancy remains?

To confirm that you have had an ectopic pregnancy, tissue removed at the time of surgery is sent for testing in the laboratory. The healthcare team will discuss with you (and your partner) the options around what happens to your pregnancy remains afterwards.

What happens next?

It is important that you attend your follow-up appointments. The check-ups and tests that you need will depend on the treatment that you had. If you had treatment with methotrexate, you should avoid getting pregnant for at least 3 months after the injection.

How will I feel afterwards?

The impact of an ectopic pregnancy can be very significant. It might mean coming to terms with the loss of your baby, with the potential impact on future fertility, or with the realisation that you could have lost your life. Each woman copes in her own way. An ectopic pregnancy is a very personal experience. This experience may affect your partner and others in your family, as well as close friends.

If you feel you are not coping or not getting back to normal, you should talk to your GP and/ or Chana for support.

It is important to remember that the pregnancy could not have continued without causing a serious risk to your health.

What about future pregnancies?

Before trying for another baby, it is important to wait until you feel ready both physically and emotionally. However traumatic your experience of an ectopic pregnancy has been, it may help to know that the likelihood of a normal pregnancy next time is much greater than that of having another ectopic pregnancy.

The chances of having a successful pregnancy in the future are good. Even if you have only one fallopian tube, your chances of conceiving are only slightly reduced.

For most women an ectopic pregnancy is a ‘one-off’ event. However, you should seek early advice from a healthcare professional when you know you are pregnant again. You may be offered an ultrasound scan at between 6 and 8 weeks to confirm that the pregnancy is developing in the uterus.

If you do not want to become pregnant, seek further advice from your doctor or family planning clinic, as some forms of contraception may be more suitable after an ectopic pregnancy.

References- https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/ectopic-pregnancy-patient-information-leaflet/

https://www.nhs.uk/conditions/ectopic-pregnancy/

Folic acid is the synthetic version of the vitamin folate, also known as vitamin B9. Folate helps the body make healthy red blood cells and is found in certain foods.

Folic acid is used to:

• Treat or prevent folate deficiency anaemia

• Help your baby's brain, skull and spinal cord develop properly in pregnancy, to avoid development problems (called neural tube defects) such as spina bifida

• Help reduce side effects from methotrexate, a medicine used to treat severe arthritis, Crohn's disease or psoriasis

Folic acid is available on prescription. It comes as tablets or as a liquid you swallow. You can also buy lower dose tablets from pharmacies and supermarkets.

Folic acid can also be combined with ferrous fumarate and ferrous sulphate to treat iron deficiency anaemia, or other vitamins and minerals, such as a multivitamin and mineral supplement.

Key facts

You'll usually take folic acid once a day, but sometimes you'll only need to take it once a week. Your doctor will explain how often to take it. Most adults and children can take folic acid.

If you're pregnant or trying to get pregnant, it's recommended you take folic acid until you're 12 weeks pregnant. It helps your baby grow normally. You're unlikely to get side effects with folic acid, but some people feel sick, lose their appetite, get wind or feel bloated. These side effects are usually mild and do not last long.

It's best not to drink alcohol while taking folic acid, as it can stop your folic acid from working as well.

If you or your child have been prescribed folic acid, follow your doctor's instructions about how and when to take it.

If you have bought folic acid from a pharmacy or shop, follow the instructions that come with the medicine.

Dosage

How much folic acid you take and how long you take it for depends on why you need it.

Dose before and during early pregnancy - It is recommended to take folic acid while you're trying for a baby (ideally for 3 months before) and during the first 12 weeks of pregnancy.

The usual dose if you're trying to get pregnant and during the first 12 weeks of pregnancy is 400 micrograms, taken once a day.

Your doctor or midwife may recommend taking folic acid throughout pregnancy, particularly if you are at risk of anaemia or are anaemic.

If you have a higher chance of having a baby with a neural tube defect your doctor will recommend an increased dose of 5mg, taken once a day.

Dose for treating folate deficiency anaemia - To treat anaemia, the usual dose for adults and children over 1 year old is 5mg, taken once a day. Sometimes the dose is increased to 15mg a day. If your child is under 12 months old, the doctor will use your child's weight to work out the right dose.

You'll usually take it for 4 months. But if your folate deficiency anaemia is caused by a long-term problem, you may have to take folic acid for longer, possibly for the rest of your life. Do not stop taking folic acid without talking to your doctor.

Dose for preventing folate deficiency anaemia - To prevent anaemia, the usual dose for adults and children aged 12 years and over is 5mg, taken every 1 to 7 days. The dose may vary depending on your age, diet and any other health conditions you have.

For children under 12, the doctor will use your child's age or weight to work out the right dose.

Dose if you're taking methotrexate - The usual dose for adults and children is 5mg once a week, on a different day of the week to your methotrexate. Some people take 1mg to 5mg once a day, apart from the day when they take their methotrexate. You'll usually take folic acid for as long as you take methotrexate. You may have to take it for a long time, possibly for the rest of your life. Do not stop taking it without talking to your doctor. Stopping means you'll be more likely to get side effects from methotrexate, such as being sick (vomiting) and diarrhoea.

Changes to your dose - Usually your dose will stay the same. Your dose may go up, however, if you're taking folic acid to prevent or treat anaemia and blood tests show you need a higher dose.

How to take it

You can take folic acid with or without food. Swallow the tablets whole with a drink of water. If you're taking folic acid as a liquid, it will come with a plastic syringe or spoon to help you measure out the right dose. If you do not have one, ask your pharmacist for one. Do not use a kitchen teaspoon as it will not measure the right amount.

If you forget to take it

Missing 1 or 2 doses probably will not matter. But if you keep forgetting to take your folic acid, or you do not want to take it, speak to your doctor. If you forget to take folic acid, what to do depends on how often you take it:

Once a day – take your missed dose as soon as you remember, unless it's nearly time for your next dose. In this case skip the missed dose and just take your next dose at the usual time. If you remember on the day you take your methotrexate, wait a day and take your missed dose the following day

Once a week – take your missed dose as soon as you remember, unless you take methotrexate that day. If you remember on the day you take your methotrexate, wait a day and take your missed dose the following day. After this, go back to taking your weekly dose on your usual day

Never take 2 doses to make up for a forgotten one.

If you often forget doses, it may help to set an alarm to remind you. You could also ask your pharmacist for advice on other ways to help you remember to take your medicine.

If you take too much

Folic acid is generally very safe. Taking too much is unlikely to cause any harm. If you're worried, speak to your pharmacist or doctor.

Side effects of folic acid

Like all medicines, folic acid can cause side effects in some people. But many people have no side effects or only minor ones.

Common side effects - There are things you can do to help cope if you get these side effects of folic acid:

Feeling sick (nausea)

Loss of appetite

Bloating or wind

Serious allergic reaction - In rare cases, folic acid can cause a serious allergic reaction (anaphylaxis).

Pregnancy, breastfeeding and fertility while taking folic acid

It's recommended you take folic acid as soon as you start trying for a baby (ideally for 3 months before) and during the first 12 weeks of pregnancy. This will help your baby's brain and spine to develop normally.

You can take folic acid after 12 weeks too. It helps make blood cells. Your doctor or midwife may recommend that you keep taking folic acid throughout pregnancy if you are anaemic or at risk of anaemia.

You'll usually take 400 micrograms a day. Your doctor may advise you to take a higher dose of folic acid (usually 5 mg) if you have a higher chance of having a baby with a neural tube defect (a problem with the brain and/or spine, such as spina bifida).

Your chance of having a baby with a neural tube defect may be higher if:

• You have previously had a pregnancy affected by a neural tube defect

• You or the baby's biological father have a neural tube defect

• You or the baby's biological father have a family history of neural tube defects

• You have diabetes

• You're very overweight

• You have sickle cell disease

• You're taking certain epilepsy medicines

• You're taking antiretroviral medicines for HIV

Folic acid and breastfeeding

It's OK to take folic acid while you're breastfeeding. Folic acid is a normal part of breast milk. When taken as a supplement it passes into breast milk in amounts that are too small to harm your baby.

Folic acid and fertility

There's no evidence that folic acid reduces fertility in either men or women. Folic acid does not help you get pregnant, but it's recommended while you're trying to get pregnant and in the first 12 weeks of pregnancy.

Cautions with other medicines

There are some medicines that may affect how folic acid works. Folic acid can also affect the way other medicines work.

Do not take your folic acid within 2 hours before or after taking indigestion remedies (antacids containing aluminium or magnesium), as they may stop the folic acid being properly absorbed.

Tell your doctor if you're taking any of these medicines before you start taking folic acid:

Methotrexate, a medicine used to treat rheumatoid arthritis, Crohn's disease, psoriasis and some types of cancer

Phenytoin, Fosphenytoin, Phenobarbital or Primidone, medicines used to treat epilepsy

Fluorouracil, capecitabine, raltitrexed or tegafur, medicines used to treat some types of cancer

Antibiotics, medicines used to treat or prevent bacterial infection

Medicines that contain zinc (including throat lozenges and cold remedies)

Sulfasalazine, a medicine used to treat the inflammatory bowel conditions ulcerative colitis and Crohn's disease

Cholestyramine, a medicine used to reduce cholesterol

Taking folic acid with painkillers

You can take folic acid at the same time as everyday painkillers such as paracetamol. Paracetamol is the first choice of painkiller if you're pregnant or breastfeeding.

If you're taking folic acid with methotrexate, talk to your doctor before taking any non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or aspirin.

Mixing folic acid with herbal remedies or supplements

Talk to your pharmacist or doctor before taking any herbal remedies or supplements together with folic acid. Some vitamin and mineral supplements already contain folic acid. It's important not to take more than the recommended daily amount.

Tell your pharmacist or doctor if you take any supplements or remedies that contain zinc. Folic acid can stop zinc working as well as it should.

Common questions asked about folic acid

How long does folic acid take to work?

Folic acid usually starts to work in a few hours. But if you're taking it for folate deficiency anemia, it may be a few weeks before you start to feel better. It's important to keep taking your folic acid for as long as it's recommended.

Are there other sources of folate?

Folate is found naturally in foods, and some foods are fortified with folic acid, which means the vitamin is added to it.

Good sources of folate include: spinach, kale, asparagus, brussels sprouts, cabbage and broccoli, peas, lentils and beans, including chickpeas and black-eyed beans , yeast and beef extracts, including Marmite and Bovril, oranges and orange juice, wheat bran and other wholegrain foods, poultry, liver, fortified foods with added folic acid, including some brands of breakfast cereals

Do I need to take folic acid in pregnancy if I already eat foods that contain folate?

Yes, you still need to take folic acid. You need up to 10 times more folate in pregnancy to help your baby grow. It's unlikely that you would be able to have this much through diet alone.

What happens if I do not take folic acid before getting pregnant or during early pregnancy?

Do not worry if you have not taken folic acid before conceiving or in the first 12 weeks of pregnancy. It is still likely that your baby will develop normally. Routine ultrasound checks at around 12 and 20 weeks will detect if there are any concerns. Your midwife will discuss folic acid with you at your first booking appointment and will be able to advise if you need it or not.

Will it affect my contraception?

Folic acid will not stop any type of contraception working, including the combined pill and emergency contraception.

Can I drink alcohol while taking folic acid?

It's best to avoid drinking alcohol with folic acid as alcohol may stop folic acid being absorbed. Your folic acid may not work as well. It's safer not to drink any alcohol if you're pregnant or trying to get pregnant because it can damage your baby's growth.

Is there any food or drink I need to avoid?

You can eat and drink normally while taking folic acid.

What’s the difference between folate and folic acid?

Although the terms “folate” and “folic acid” are often used interchangeably, they are different forms of the same vitamin: vitamin B9. Folic acid has a different structure than folate and has slightly different effects in your body. “Folate” is the generic name that encompasses all forms of vitamin B9, including folic acid and 5-MTHF. Folic acid is a specific synthetic form of this vitamin.

You can find folate in plant and animal foods like these: spinach , kale, broccoli, avocado, citrus fruits, eggs, beef liver

Folic acid is added to foods such as flour, ready-to-eat breakfast cereals, and breads. It’s also in dietary supplements, such as multivitamins.

What does the body use folate for?

Make and repair DNA

Help cells grow, divide, and work properly

Produce certain proteins

Help red blood cells mature

Folate deficiency can lead to many health problems, including

Anemia

An increased risk of heart disease and certain cancers

Developmental irregularities in infants if pregnant people don’t get enough folate

Treating folate deficiency

Folate deficiency can happen for many reasons. Some possible causes of folate deficiency are:

A lack of folate in your diet

Diseases or surgeries that affect how your body absorbs folate, including celiac disease, short bowel syndrome, and gastric bypass surgery

No stomach acid (achlorhydria) or low stomach acid (hypochlorhydria)

Drugs that affect folate absorption, including methotrexate and sulfasalazine (Azulfadine)

Alcohol use disorder

Pregnancy

Hemolytic anemia

Dialysis

Consuming too little folate can cause complications such as anemia, fetal development issues, mental impairment, impaired immune function, and depression.

Preventing birth defects and pregnancy complications

Folic acid supplements can help to prevent neural tube irregularities, including spina bifida and anencephaly. Getting enough folic acid during pregnancy can reduce the chance that your baby will be born with one of these conditions.

Folic acid supplements not only help prevent fetal development issues but also help lower the risk of pregnancy complications such as preeclampsia.

Maintaining brain health

Low blood folate levels are linked to poor mental function and an increased risk of dementia. Even folate levels that are technically normal but on the low side might increase the risk of mental impairment in older adults.

Adequate folate intake may also help protect against Alzheimer’s disease.

Treating mental health conditions

Folate is involved in the production of brain chemicals called neurotransmitters. Consuming too little folate has been linked to depression, schizophrenia, and other mental health conditions. For example, people with depression may have lower blood levels of folate than people without depression.

Taking folate supplements in addition to antidepressant medication may reduce depression symptoms more than taking antidepressant medication alone.

Reducing heart disease risk factors

Folate-based supplements, including folic acid, may help improve heart health and reduce the risk of heart disease. High levels of the amino acid homocysteine are thought to increase heart disease risk. Because folate helps break down homocysteine, low folate can lead to high homocysteine levels, also known as hyperhomocysteinemia. Folic acid supplements can help bring down homocysteine levels and may lower heart disease risk.

What’s more, using folic acid supplements along with antihypertensive medications may reduce high blood pressure significantly more than antihypertensive medications alone. Folic acid supplements may also improve blood vessel function in people with heart disease.

Other possible benefits

Folic acid supplements may also help with these other health conditions:

Diabetes. Folate supplements may help improve blood sugar regulation and reduce insulin resistance in people with diabetes. Because the diabetes drug metformin can lower folate levels, you may need a supplement if your levels are low.

Fertility issues. Folate can improve egg quality and help eggs grow and implant in the uterus. Taking folate may increase the chance of getting pregnant and carrying a baby to term. People who use assisted reproductive technology to conceive may be more likely to have a baby if they have a higher intake of supplemental folate.

Inflammation. Inflammation plays a role in many diseases. Folic acid and folate supplements have been shown to reduce markers of inflammation such as C-reactive protein.

Kidney disease. The kidneys usually filter waste out of the blood, but when the kidneys are damaged, homocysteine can build up. About 85% of people with chronic kidney disease have too much homocysteine in their blood. Folic acid supplements may help reduce homocysteine levels and heart disease risk in people with kidney disease.

Larger studies are still needed to confirm the benefits of folate supplementation.

This list doesn’t include every possible benefit of folic acid. There are many other reasons people may use folate-based supplements.

References- https://www.nhs.uk/medicines/folic-acid/about-folic-acid/

https://www.healthline.com/nutrition/folic-acid#benefits-uses

Keeping healthy when you are having a baby may depend on both the amount and the type of food you eat before you become pregnant and during your pregnancy. Simply being a correct weight for your height does not necessarily mean that you are eating healthily.

Some foods are best avoided if you are planning to become pregnant or if you are already pregnant, as they may contain substances that could affect your baby’s development.

To eat healthily, you should aim to do the following:

• Base your meals on starchy foods such as potatoes, bread, rice and pasta, choosing wholegrain if possible.

• Eat at least five portions of different fruit and vegetables every day. Potatoes do not count towards your five-a-day target, and a portion of pure fruit juice only counts as one of your five-a-day, no matter how much you drink.

• Eat as little fried food as possible

• Avoid drinks that are high in added sugars and other foods such as sweets, cakes and biscuits that have a high fat or sugar content. Instead, eat fibre-rich foods such as oats, beans, lentils, grains and seeds.

• Eat some protein every day; choose lean meat, and try to eat two portions of fish a week. If you do not eat meat or fish, lentils, beans, nuts, eggs and tofu are also good sources of protein.

• If you feel hungry between meals, chose healthier snacks such as vegetables, small sandwiches, fresh or dried fruit.

• Eat dairy foods for calcium or dairy alternatives, which are calcium-fortified and unsweetened.

• Watch the portion size of your meals and snack. Avoid ‘eating for two’.

• Try to eat breakfast.

• Limit your caffeine intake to as little as possible, and less than 200 milligrams (mg) per day, for example two mugs of instant coffee. Be aware that other drinks such as tea and energy drinks also contain caffeine. Ideally avoid caffeine or switch to decaffeinated versions of tea and coffee. This is because new evidence has shown that caffeine in pregnancy can be linked to pregnancy complications such as low birth weight, miscarriage and stillbirth.

Most women do not need any extra calories during the first six months of pregnancy. It is only in the last 12 weeks that they need to eat a little more, and then only an extra 200 calories a day, which is roughly the same as two slices of bread.

What is a ‘healthy’ weight?

Your BMI (body mass index) is routinely calculated at the start of your pregnancy. This is a measure of your weight in relation to your height. Your healthcare team can work it out for you. Whilst it does not indicate how healthy you are, being overweight (BMI above 30 kg/m2) is correlated with a higher chance of complications in pregnancy.

Your healthcare team will support you to keep well in pregnancy whatever your BMI. They will discuss any concerns they have with you and ensure that you are able to make informed choices about your pregnancy and birth

Is it safe for me to diet while I am pregnant?

Trying to lose weight by dieting during pregnancy is not recommended as it may harm the health of your baby. If you are concerned about your weight, your midwife can advise you and may refer you to a dietician.

Is it safe to eat fish while I am pregnant?

In general, eating fish is a healthy option during pregnancy, but the current advice from the Department of Health is to eat no more than two portions of oily fish, such as mackerel or salmon, a week. This is because too much of a substance found in oily fish (mercury) can be harmful to your baby’s development.

Also, pregnant women should not eat more than two fresh tuna steaks or four medium-sized cans of tuna a week.

I have been told not to eat liver while I am pregnant. Why?

Liver can contain high levels of vitamin A, which in high doses can harm the development of your baby’s nervous system. It is rare for women in developed countries like the UK to be deficient in vitamin A so you should avoid eating foods such as liver and liver products like pâté.

Is it safe to eat peanuts while I am pregnant or breastfeeding?

You can eat peanuts or foods containing peanuts (such as peanut butter) while pregnant or breastfeeding. Eating peanuts does not appear to affect your baby’s chances of developing a peanut allergy. Avoid eating them if you are allergic to them.

How can I reduce the risk of infection from food?

You can pick up some infections, such as listeria, salmonella or toxoplasmosis, from contaminated food. These can harm your baby if you catch these infections while you are pregnant.

To reduce your risk of getting listeriosis:

- Drink only pasteurised or UHT milk

- Avoid eating ripened soft cheese such as Camembert, Brie or blue-veined cheese. Hard cheese varieties such as Cheddar, cottage cheese and processed cheese are safe

- Avoid eating pâté

- Avoid eating undercooked food. Make sure that ready-prepared meals are cooked as per instructions, paying particular attention to making sure that they are piping hot when reheating.

To reduce your risk of getting salmonella:

- Avoid eating raw or partially cooked eggs that have not been produced under the British Lion code (for example in mayonnaise, soufflé or mousse). It is safe to eat these eggs once they are cooked until the white and the yolk are hard.

- Eggs produced under the British Lion Code of Practice are safe for pregnant women to eat raw or partially cooked, because they come from hens that have been vaccinated against salmonella. These eggs will have a red lion stamp on their shell and are safe to eat raw or partially cooked (eg. As soft boiled eggs).

- Avoid eating raw or partially cooked meat, especially poultry.

To reduce your risk of getting toxoplasmosis:

- Always wash your hands before and after handling food

- Wash all fruit and vegetables, including ready-prepared salads

- Cook raw meats and ready-prepared chilled meats thoroughly

- Wear gloves and wash your hands thoroughly after gardening or handling soil

- Avoid contact with cat faeces (in cat litter or in soil) – or, if you must handle it, wear rubber gloves.

Do I need extra vitamins (vitamin supplements) when I am pregnant?

Vitamins are needed for growth and development. There are 13 important vitamins: vitamins A, C, D, E and K and the vitamin B series. Apart from vitamin D, which we get from sunlight, most vitamins come from our diet. In the UK, it is quite common for people to be low in vitamin D and folic acid (vitamin B9). These vitamins are important in pregnancy and you can boost your levels by taking a vitamin supplement. Supplements of other vitamins are not usually routinely advised and Vitamin A may actually be harmful in pregnancy. The various vitamins and whether they are recommended in pregnancy are detailed below.

Folic acid - They are one of the B vitamins and helps to reduce the risk of your baby having a neural tube defect, such as spina bifida. Taking extra folic acid may also reduce the risk of heart or limb defects and some childhood brain tumours. The recommended daily dose is 400 micrograms (µg). Ideally, you should start taking extra folic acid before you become pregnant and continue to take it until you reach your 13th week of pregnancy. If you did not take folic acid before you became pregnant, start taking it as soon as you realise you are expecting a baby.

As well as taking a supplement, it is recommended that you eat foods rich in folic acid (for example, fortified breakfast cereals and yeast extract) and to consume foods and drinks rich in folate (for example, peas, beans and orange juice).

Some women take a higher dose of folic acid. Why?

If your risk of having a baby with a neural tube defect such as spina bifida is higher than average, you will be advised to take a daily dose of 5 milligrams (mg) of folic acid. This is higher than usual and it will need to be prescribed by a doctor. You may be advised to take an increased dose if:

• You have had a previous pregnancy affected by a neural tube defect

• You or your partner have a neural tube defect

• You have epilepsy

• You have coeliac disease

• You have diabetes

• Your BMI is 30 or more

• You have sickle-cell anaemia or thalassaemia; the higher dose of folic acid will also help to prevent and treat anaemia and it is recommended that you take this throughout your pregnancy.

Vitamin D - All pregnant women are advised to take a daily dose of 10 micrograms (µg) of vitamin D when pregnant and breastfeeding. This is because it is common in the UK for people to have low levels of vitamin D. Taking supplements can improve your baby’s growth during their first year of life, and can reduce their risk of developing rickets.

You are at particular risk of having low levels of vitamin D if:

• your family origin is South Asian, African, Caribbean or Middle Eastern

• Your BMI is 30 or more

• You stay indoors a lot

• You usually cover your skin when you go outdoors or usually use sun-protection cream

• Your diet is low in vitamin D-rich foods such as eggs, meat, vitamin D-fortified margarine or breakfast cereal.

If you are in one of these situations, you may be may be advised to take a higher daily dose of vitamin D.

When may I need extra vitamin K?

Vitamin K is needed for our blood to clot properly. New-born babies have low levels of vitamin K, which puts them at risk of bleeding. To prevent this, you will be offered vitamin K for your baby after birth. You do not need to take vitamin K supplements yourself during pregnancy unless it is thought that your baby is at particular risk of bleeding. This could be because you are taking certain medicines for epilepsy or if you have liver disease.

When may I need extra vitamin C?

Although routine supplements of vitamin C are not specifically recommended when you are pregnant, this vitamin helps iron to be absorbed. This may be of benefit because while you are pregnant you are at risk of becoming anaemic.

Vitamins that are not recommended

There are many multivitamin tablets for use in pregnancy that contain a small amount of lots of vitamins. These are safe to take, but avoid taking large doses of the following vitamins unless a doctor prescribes them for a particular reason.

Vitamin A - Too much vitamin A can harm the development of your baby’s nervous system. During pregnancy, avoid any supplements that contain more than 700 micrograms (µg) of vitamin A and don’t eat foods such as liver, liver products (pâté) or fish liver oils that may contain this vitamin in high levels.

Vitamin E - There is currently no evidence to recommend additional vitamin E during pregnancy.

Vitamin B supplements (other than folic acid) You do not need any other vitamin B supplements in pregnancy.

What about extra iron?

Most women do not need to take extra iron during pregnancy. Taking routine iron supplements will not necessarily benefit your health and may cause you unpleasant side effects such as heartburn, constipation or diarrhoea.

Your midwife will check your blood at your booking appointment and at 28 weeks of pregnancy. You will only be advised to take iron if you are found to be anaemic or are at increased risk of becoming anaemic in pregnancy, for example if you are having twins.

Can I get help to buy vitamins?

If you are on certain benefits and/or are under the age of 18 years, help may be available to provide you with free supplements. Find out more about the Healthy Start Scheme: https://www.healthystart.nhs.uk.

You can buy folic acid or pregnancy multivitamins from any pharmacy or supermarket. There is no evidence that expensive brands are any better than cheaper ones.

Reference- https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/healthy-eating-and-vitamin-supplements-in-pregnancy-patient-information-leaflet/

London

Barnet Hospital, Wellhouse Lane Barnet, London, EN5 3DJ EPAGU level 2

Contact details: Tel: 020 8216 5233

Clinic Times: Monday to Friday 8am-6pm with scanning from 9am-4pm, Sunday 8am-5pm for A&E referrals only

Referral: GP or A &E, but walk-ins are taken. Urgent GP referrals are seen on the same day. Non-urgent referrals may be seen on the same or next day.

Chelsea & Westminster Hospital Foundation Trust 369 Fulham Road London SW10 9NH 4th Floor, Lift Bank B

Contact details: Tel: 020 3315 5073 Clinic Times: Mon–Fri, 9am–4pm Saturday 9am-12.30pm (clinic is for early pregnancy complications A&E referrals only)

Referral: GPs, A&E and internal doctors within the hospital. No walk-ins are taken.

Guys and Thomas NHS Foundation Trust Westminster Bridge Road London SE1 7EH 8th Floor North Wing

Contact details: Tel: 020 7188 0864

Clinic Times: Monday-Friday, 8.30am- 6pm Weekend/ bank holidays- 9.30am- 3pm Closed Christmas day

For test results, please call: Monday to Friday, 3pm to 6pm Weekends and bank holiday 1pm to 3pm. We'll call you back within 1 working day.

Referral: Self, GP, A&E or Midwife

UK Homerton University Hospital

Homerton Road Hackney London E9 6SR

Contact details: Tel: 020 8510 7861

Clinic Times: We are open from 9am – 5pm, Monday to Friday.

Referral: GPs, ED (fast track) or other health professionals by emailing the EPAU referral form to huh-tr.epau.referrals@nhs.net

King's College Hospital Denmark Hill London SE5 9RS Suite 8, 3rd floor Golden Jubilee Wing

Contact details: EPU helpline: +44 (0)20 3299 7232

Telephone line opening hours:

Monday to Friday: 9am to 5pm

Weekends and bank holidays: 9am to

Telephone assessment with nurse triage. Appointments are given either the same day or within a few days.

Referral: This is an emergency service for early pregnancy patients only by telephone appointment. We do not accept walk-in gynaecology emergencies; these should be referred to the on-call gynaecology registrar.

Queen Charlotte's & Chelsea Hospital Du Cane Road London W12 0HS

Contact details: Tel: 020 33135220

Clinic Times: Monday- Friday 09.00 to 16.30, Gynaecology clinic: Wednesday mornings

Referral: A&E, GP or other healthcare professionals

Queen Elizabeth Hospital Stadium Road Woolwich London SE18 4QH

Contact details: Tel: 0208 836 4897

Clinic Times: Monday to Friday 8.15am – 4.30pm with scanning from 9am-12.30pm excluding Bank Holidays. Saturday and Sunday – closed.

The EPU operates a telephone triage and referral system. Following triage you may be given advice and informed that attendance is not necessary. Alternatively, you may be asked to attend the Emergency Department (ED) or your GP for further assessment or referred for advice to your midwife.

Referral: GP, A&E and self-referrals over the telephone

Royal Free Hospital NHS Trust Pond Street London NW3 2QG 5th floor, next door to maternity

Contact details: Tel: 020 7472 6374 or 020 7794 0500 ext 38205/31468.

Clinic Times: Monday - Saturday, 7.30am to 8pm with scanning facilities from 9am to 5pm on Monday - Friday.

Assistance outside of these hours attend A& E

Specialist nurses can also provide advice by telephone on numbers above during opening hours.

Referral: No walk-in service. GP, A&E, urgent care centre and health care providers in both the public and private sectors.

Patients with three previous, recurrent miscarriages, a previous ectopic pregnancy or previous molar pregnancy can self-refer to the Royal Free Hospital by contacting unit prior to attendance on the telephone numbers above

St Mary's Hospital Praed Street, Paddington London W2 1NY

Contact details: Maternity Helpline: 02033126135 St Mary’s Hospital: 02033121233

Clinic Times: Monday – Friday 9am-5pm

Referral: A&E, GP or family planning clinics

University College Hospital UCLH Grafton Way, London, WC1E 6DB Gynaecology Diagnostic and Treatment Unit Elizabeth Garrett Anderson Wing, Clinic 3, Lower Ground floor

Contact details: Tel: 020 3447 9411

Clinic Times: Monday to Friday, 9am – 12.30pm and 2pm – 3pm. Christmas Eve and New Year’s Eve (on weekdays), 9am – 1.30pm

We can see women in early pregnancy on Saturday and Sunday between 9am and 12:30pm, but they must attend A&E first.

Referral: Patients in early pregnancy do not need a referral: we operate a walk-in clinic

Watford General Hospital Vicarage Rd, Watford WD18 0HB Maternity building ground floor

Contact details: Tel: 01923 217831

Clinic Times: Monday to Friday – 9am to 5pm

Referral: GP, A&E or other healthcare professional. We do not accept walk-ins.

Whittington Hospital NHS Trust Magdala Avenue, London N19 5NF Women’s Diagnostic Unit, Level 3, Kenwood Wing,

Contact details: Tel: 020 7288 3786

Clinic Times: Monday to Friday- 8am to 6pm (outside of these hours patients who need urgent care will be seen in A&E).

Referral: Morning- walk ins. Afternoon- GP, A&E or self referral only

Royal Sussex County Hospital Eastern Road, Brighton, BN2 5BE, Level 11, Thomas Kemp Tower

Contact details: Tel: 01273 696955 ext. 64402

Referral: GP or A &E.

EARLY PREGNANCY UNITS in Manchester and Gateshead

St. Mary's Hospital EPU is shut and has now been relocated to Wythenshawe Hospital Southmoor Road, Wythenshawe, Manchester M23 9LT, Ward F16

Contact details: Tel:0161 291 2561 For women in the first 16 weeks of pregnancy

Tel: 01612912724 For women who are 16 weeks pregnant onwards.

Clinic times: 24 hour service phone line

Women MUST telephone the department first to discuss their symptoms and concerns with one of our Specialist Nurses, who will decide the best course of action. Should the woman require a face to face consultation, she will need to attend EGU on ward F16

Referral: GP/A&E/Midwife/Self

North Manchester General Hospital Acute Pennine Trust, Delauney’s Road, Crumpsall, Manchester, M8 5RB

Clinic Times: Monday – Friday 7.30am - 8.30pm, Weekend - 8.30am - 4.30pm

Contact details: Tel: 0161 720 2010

Referral: GP/Midwife/A&E

The gynaecology service is available 24/7 for emergency patients

Salford Royal Hospital Stott Lane, Salford, Manchester, M6 8HD,

Contact Details: Tel: 0161 206 1480

Clinic Times: Monday – Friday 8am – 4pm Closed on bank holidays and weekends.

Can be referred directly from GP or do a self-referral over the phone.

Royal Victoria Infirmary Queen Victoria Road Newcastle Upon Tyne, NE1 4LP, Level 4 of the Leazes Wing

Contact Details: Tel: 0191 282 5479

Clinic Times: Monday- Friday 08:00-16:30

The maternity assessment unit is open 24 hours a day, 7 days a week. Trust your instincts. If something doesn’t seem right, seek advice.

Please do not wait to contact us on: Telephone: 0191 282 5748.

Referral: GP/A&E/Midwife/GEAU

Queen Elizabeth Hospital Women's Health Clinic, Sheriff Hill, Gateshead, NE9 6SX

Contact details: Tel: 0191 445 2146

Clinic Times: Monday 13:00-16:30 Tuesday 08.30-12:30 Wednesday 08.30-12.30 Thursday 08.30-5.00 Friday-13:00-16:30

Referral: GP/Midwife/A&E/any healthcare professional

*The information provided is accurate at the current time of publication (2023). We will seek to update them yearly.