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Ectopic pregnancy and miscarriage overview

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Ectopic pregnancy and miscarriage HAI

About

What is covered

This pathway covers the diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage.
Ectopic pregnancy and miscarriage have an adverse effect on the quality of life of many women. Approximately 20% of pregnancies miscarry, and miscarriages can cause considerable distress. Early pregnancy loss accounts for over 50,000 admissions in the UK annually. The rate of ectopic pregnancy is 11 per 1000 pregnancies, with a maternal mortality of 0.2 per 1000 estimated ectopic pregnancies. About two thirds of these deaths are associated with substandard care. Women who do not access medical help readily (such as women who are recent migrants, asylum seekers, refugees, or women who have difficulty reading or speaking English) are particularly vulnerable. Improvement in the diagnosis and management of early pregnancy loss is thus of vital importance, in order to reduce the incidence of the associated psychological morbidity and avoid the unnecessary deaths of women with ectopic pregnancies.

Updates

Updates to this pathway

9 September 2014 – Ectopic pregnancy and miscarriage (NICE quality standard 69) added to this pathway.
26 August 2014 Minor maintenance updates.
17 December 2013 Minor maintenance updates.
19 April 2013 Minor maintenance updates.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

Diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage.

What is covered

This pathway covers the diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage.
Ectopic pregnancy and miscarriage have an adverse effect on the quality of life of many women. Approximately 20% of pregnancies miscarry, and miscarriages can cause considerable distress. Early pregnancy loss accounts for over 50,000 admissions in the UK annually. The rate of ectopic pregnancy is 11 per 1000 pregnancies, with a maternal mortality of 0.2 per 1000 estimated ectopic pregnancies. About two thirds of these deaths are associated with substandard care. Women who do not access medical help readily (such as women who are recent migrants, asylum seekers, refugees, or women who have difficulty reading or speaking English) are particularly vulnerable. Improvement in the diagnosis and management of early pregnancy loss is thus of vital importance, in order to reduce the incidence of the associated psychological morbidity and avoid the unnecessary deaths of women with ectopic pregnancies.

Updates

Updates to this pathway

9 September 2014 – Ectopic pregnancy and miscarriage (NICE quality standard 69) added to this pathway.
26 August 2014 Minor maintenance updates.
17 December 2013 Minor maintenance updates.
19 April 2013 Minor maintenance updates.

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Ectopic pregnancy and miscarriage. NICE clinical guideline 154 (2012)

Quality standards

Ectopic pregnancy and miscarriage

These quality statements are taken from the ectopic pregnancy and miscarriage quality standard. The quality standard defines clinical best practice for ectopic pregnancy and miscarriage care and should be read in full.

Quality statements

Timely referral to early pregnancy assessment services

This quality statement is taken from the ectopic pregnancy and miscarriage quality standard. The quality standard defines clinical best practice in ectopic pregnancy and miscarriage care and should be read in full.

Quality statement

Women referred to early pregnancy assessment services are seen by the service at least within 24 hours of referral.

Rationale

Women with a suspected ectopic pregnancy or miscarriage should be referred to an early pregnancy assessment service for diagnosis and management based on an initial clinical assessment. Women should always be seen within 24 hours of referral. However, depending on the clinical assessment, some women may need to be seen immediately to avoid adverse incidents, such as the rupture of a fallopian tube in an ectopic pregnancy. In addition, some women should be referred directly to an accident and emergency department, for example if they are haemodynamically unstable. It is important that appropriate measures are put in place to ensure the safety of the woman.

Quality measures

Structure
Evidence of local arrangements to ensure that women referred to early pregnancy assessment services are seen by the service at least within 24 hours of referral.
Data source: Local data collection.
Process
Proportion of women referred to early pregnancy assessment services who are seen by the service at least within 24 hours of referral.
Numerator – the number in the denominator who are seen in early pregnancy assessment services at least within 24 hours of referral.
Denominator – the number of women referred to early pregnancy assessment.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care services) ensure that a system is in place to enable women referred to early pregnancy assessment services to be seen by the service at least within 24 hours of referral.
Healthcare professionals (such as consultant obstetricians, gynaecologists and ultrasonographers) see women in an early pregnancy assessment service at least within 24 hours of referral.
Commissioners (clinical commissioning groups for secondary care) ensure that early pregnancy assessment services are able to see women at least within 24 hours of referral. They may also work with NHS England area teams to raise awareness and ensure clear that protocols and referral pathways are in place.

What the quality statement means for patients, service users and carers

Women who are referred to a hospital early pregnancy assessment service are seen within 24 hours of referral. They may be referred by a healthcare professional (for example, their GP, midwife or nurse, or an emergency department doctor) or, if they have had an ectopic pregnancy in the past, or 3 or more miscarriages, they should be able to book an appointment themselves.

Source guidance

Definitions of terms used in this quality statement

Early pregnancy assessment services
An early pregnancy assessment service can be located in a dedicated early pregnancy assessment unit or within a hospital gynaecology ward. All early pregnancy assessment services should:
  • be a dedicated service provided by healthcare professionals competent to diagnose and care for women with pain and/or bleeding in early pregnancy and
  • offer transvaginal ultrasound and assessment of serum human chorionic gonadotrophin (hCG) levels and
  • be staffed by healthcare professionals with training in sensitive communication and breaking bad news. [Adapted from NICE clinical guideline 154, recommendation 1.2.2]
Referral
Women can be referred by a healthcare professional (such as a GP, emergency department doctor, midwife or nurse) who has made a clinical decision about whether the woman should be seen immediately or within 24 hours of the referral. [NICE clinical guideline 154, recommendations 1.2.3 and 1.3.11]
Women who have had recurrent miscarriage (the loss of 3 or more pregnancies before 24 weeks of gestation) or a previous ectopic pregnancy can self refer to an early pregnancy assessment service. [NICE clinical guideline 154, recommendation 1.2.3]

Equality and diversity considerations

Appropriate care may depend on the ability of a woman to access services quickly, which may be difficult for some groups of women, such as women who are recent migrants, asylum seekers, refugees, or women who have difficulty reading or speaking English. It is important to ensure that services are easily accessible to women from these groups.

Ultrasound assessment

This quality statement is taken from the ectopic pregnancy and miscarriage quality standard. The quality standard defines clinical best practice in ectopic pregnancy and miscarriage care and should be read in full.

Quality statement

Women who are referred with suspected ectopic pregnancy or miscarriage are offered a transvaginal ultrasound scan to identify the location and viability of the pregnancy.

Rationale

An initial ultrasound scan should be performed to diagnose an ectopic pregnancy or assess for miscarriage. A transvaginal ultrasound scan provides the best quality imaging and is more effective than a transabdominal scan because it can offer clearer pictures of the womb, ovaries and surrounding areas. However, a single transvaginal ultrasound scan may not always accurately diagnose miscarriage.

Quality measures

Structure
Evidence of local arrangements to ensure that women who are referred with suspected ectopic pregnancy or miscarriage are offered a transvaginal ultrasound scan to identify the location and viability of the pregnancy.
Data source: Local data collection.
Process
a) Proportion of women who are referred with a suspected ectopic pregnancy and who receive a transvaginal ultrasound scan to identify the location and viability of the pregnancy.
Numerator – the number in the denominator who receive a transvaginal ultrasound scan to identify the location and viability of the pregnancy.
Denominator – the number of women who are referred with a suspected ectopic pregnancy.
Data source: Local data collection. Data can be collected using the NICE Ectopic pregnancy and miscarriage: ultrasound for determining viable intrauterine pregnancy clinical audit tool, audit standard 2.
b) Proportion of women who are referred with a suspected miscarriage and who receive a transvaginal ultrasound scan to identify the location and viability of the pregnancy.
Numerator – the number in the denominator who receive a transvaginal ultrasound scan to identify the location and viability of the pregnancy.
Denominator – the number of women who are referred with a suspected miscarriage.
Data source: Local data collection. Data can be collected using the NICE Ectopic pregnancy and miscarriage: ultrasound for determining viable intrauterine pregnancy clinical audit tool, audit standard 2.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care services) ensure that protocols and equipment are in place for transvaginal ultrasound scans to be offered to women with a suspected ectopic pregnancy or miscarriage to identify the location and viability of the pregnancy.
Healthcare professionals (such as consultant obstetricians, gynaecologists and ultrasonographers) offer women with a suspected ectopic pregnancy or miscarriage a transvaginal ultrasound scan to identify the location of the pregnancy and viability of the pregnancy.
Commissioners (clinical commissioning groups for secondary care) ensure that protocols and equipment are in place to offer transvaginal ultrasound for the diagnosis of ectopic pregnancy and miscarriage, and ensure that they monitor the provision of transvaginal ultrasound by relevant service providers.

What the quality statement means for patients, service users and carers

Women with a suspected ectopic pregnancy (when a fertilised egg is outside the womb) or a suspected miscarriage are offered a scan called a transvaginal ultrasound scan (where a small probe is inserted into the vagina) to check whether the pregnancy is in the womb and if it is continuing.

Source guidance

Definitions of terms used in this quality statement

Suspected ectopic pregnancy
The symptoms and signs of ectopic pregnancy are outlined in NICE clinical guideline 154, recommendations 1.3.3 and 1.3.4.
Suspected miscarriage
Women with bleeding or other symptoms and signs of early pregnancy complications who have:
  • pain or
  • a pregnancy of 6 weeks’ gestation or more or
  • a pregnancy of uncertain gestation. [NICE clinical guideline 154, recommendation 1.3.9]
Transvaginal ultrasound scan
In a transvaginal ultrasound scan, a small probe is inserted into the vagina to check whether the pregnancy is in the womb and if it is continuing. The use of transvaginal ultrasound scanning is outlined in NICE clinical guideline 154, recommendations 1.4.5–1.4.7, 1.4.9 and 1.4.10.

Equality and diversity considerations

When offering a transvaginal ultrasound scan, healthcare professionals should provide information about the scan that is sensitive to the woman’s religious, ethnic or cultural needs and takes into account whether the woman has learning disabilities, or difficulties in communication or reading. Women provided with information should have access to an interpreter or advocate if needed.
If a transvaginal ultrasound scan is unacceptable to the woman, healthcare professionals should offer a transabdominal ultrasound scan and explain the limitations of this method.
All women should have the option to be examined by a female member of staff if requested. This may be particularly important for women from certain cultural or religious groups.

Confirming a diagnosis of miscarriage

This quality statement is taken from the ectopic pregnancy and miscarriage quality standard. The quality standard defines clinical best practice in ectopic pregnancy and miscarriage care and should be read in full.

Quality statement

Women with a suspected miscarriage who have had an initial transvaginal ultrasound scan are offered a second assessment to confirm the diagnosis.

Rationale

A single transvaginal ultrasound scan may not always accurately diagnose miscarriage, and so a second assessment should be offered to confirm the diagnosis in women with suspected miscarriage. Treatment for miscarriage should not start until the site and viability of the pregnancy have been confirmed by a second assessment.

Quality measures

Structure
Evidence of local arrangements to ensure that women with a suspected miscarriage who have had an initial transvaginal ultrasound scan are offered a second assessment to confirm the diagnosis.
Data source: Local data collection.
Process
Proportion of women with a suspected miscarriage who have had an initial transvaginal ultrasound scan and are offered a second assessment to confirm the diagnosis.
Numerator – the number in the denominator who receive a second assessment to confirm the diagnosis.
Denominator – the number of women with a suspected miscarriage who have had an initial transvaginal ultrasound scan.
Data source: Local data collection. Data can be collected using the NICE Ectopic pregnancy and miscarriage: ultrasound for determining viable intrauterine pregnancy clinical audit tool, audit standards 3b, 3c, 4b and 4c.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care services) ensure that procedures and protocols are in place for women with a suspected miscarriage who have had an initial transvaginal ultrasound scan to be offered a second assessment to confirm the diagnosis.
Healthcare professionals (such as consultant obstetricians, gynaecologists and ultrasonographers) offer women with a suspected miscarriage who have had an initial transvaginal ultrasound scan a second assessment to confirm the diagnosis.
Commissioners (clinical commissioning groups for secondary care) ensure that they monitor service providers to make sure they are offering second assessments to women with a suspected miscarriage who have had an initial transvaginal ultrasound scan to confirm the diagnosis.

What the quality statement means for patients, service users and carers

Women with a suspected miscarriage who have had a transvaginal ultrasound scan (where a small probe is inserted into the vagina) are offered a second assessment to confirm the diagnosis. This may involve a second opinion from another healthcare professional and/or a second scan 1 or 2 weeks after the first.

Source guidance

Definitions of terms used in this quality statement

Suspected miscarriage
Women with bleeding or other symptoms and signs of early pregnancy complications who have:
  • pain or
  • a pregnancy of 6 weeks’ gestation or more or
  • a pregnancy of uncertain gestation. [NICE clinical guideline 154, recommendation 1.3.9]
Second assessment
Confirming a diagnosis of miscarriage with a second assessment is outlined in NICE clinical guideline 154, recommendations 1.4.6, 1.4.7, 1.4.9 and 1.4.10. This includes seeking a second opinion on the viability of the pregnancy and/or offering a repeat transvaginal ultrasound scan at either a minimum of 7 days or a minimum of 14 days after the initial scan to confirm diagnosis (depending on the clinical situation).

Equality and diversity considerations

When offering a repeat transvaginal ultrasound scan, healthcare professionals should provide information about the scan that is sensitive to the woman’s religious, ethnic or cultural needs and takes into account whether the woman has learning disabilities, or difficulties in communication or reading. Women provided with information should have access to an interpreter or advocate if needed.
If a transvaginal ultrasound scan is unacceptable to the woman, healthcare professionals should offer a transabdominal ultrasound scan and explain the limitations of this method.
All women should have the option to be examined by a female member of staff if requested. This may be particularly important for women from certain cultural or religious groups.

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Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Information for the public

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NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

Symptoms and signs of ectopic pregnancy

Symptoms of ectopic pregnancy include:
  • common symptoms:
    • abdominal or pelvic pain
    • amenorrhoea or missed period
    • vaginal bleeding with or without clots.
  • other reported symptoms:
    • breast tenderness
    • gastrointestinal symptoms
    • dizziness, fainting or syncope
    • shoulder tip pain
    • urinary symptoms
    • passage of tissue
    • rectal pressure or pain on defecation.
Signs of ectopic pregnancy include:
  • more common signs:
    • pelvic tenderness
    • adnexal tenderness
    • abdominal tenderness
  • other reported signs:
    • cervical motion tenderness
    • rebound tenderness or peritoneal signs
    • pallor
    • abdominal distension
    • enlarged uterus
    • tachycardia (more than 100 beats per minute) or hypotension (less than 100/60 mmHg)
    • shock or collapse
    • orthostatic hypotension.
Offer anti-D rhesus prophylaxis at a dose of 250 IU (50 micrograms) to all rhesus negative women who have a surgical procedure to manage an ectopic pregnancy or a miscarriage.

Glossary

Accident and emergency.
Immunoglobulin that binds to, and causes the removal of, any Rhesus D positive red blood cells that have passed from the fetus into the maternal circulation.
Pregnancy in the first trimester – that is, up to 13 completed weeks of pregnancy.
A service for women with early pregnancy complications, where scanning can be carried out and decisions about management made. For example, it could be an early pregnancy assessment unit or specialist gynaecology service.
A pregnancy located outside of the uterine cavity, usually in the fallopian tube.
A management approach in which a patient is closely monitored (for example, with observations, scans or blood tests) but treatment is not administered, with the aim of seeing whether the condition will resolve naturally.
Human chorionic gonadotrophin.
A descriptive term used to classify a pregnancy when a woman has a positive pregnancy test but no pregnancy can be seen on ultrasound scan.
Surgical removal of the fallopian tube.
Surgical incision of a fallopian tube to remove an ectopic pregnancy.

Paths in this pathway

Pathway created: December 2012 Last updated: September 2014

© NICE 2014

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