Ectopic pregnancy and miscarriage

Short Text

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

Introduction

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.

Source guidance

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

Quality standards

Quality statements

Effective interventions library

Successful effective interventions library details

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.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on ectopic pregnancy and miscarriage.

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.

Updates to this pathway

17 December 2013 Minor maintenance updates.
19 April 2013 Minor maintenance updates

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.

Woman presents with pain and/or bleeding

Woman presents with pain and/or bleeding, or symptoms of early pregnancy problems, including unusual symptoms of ectopic pregnancy

Refer women who are haemodynamically unstable

Refer women who are haemodynamically unstable, or in whom there is significant concern about the degree of pain or bleeding, directly to accident and emergency

Giving information and support

Giving information and support

Giving information and support

Emotional support

Treat all women with early pregnancy complications with dignity and respect. Be aware that women will react to complications or the loss of a pregnancy in different ways. Provide all women with information and support in a sensitive manner, taking into account their individual circumstances and emotional responseFor further guidance about providing information, see the patient experience in adult NHS services pathway..
Healthcare professionals providing care for women with early pregnancy complications in any setting should be aware that early pregnancy complications can cause significant distress for some women and their partners. Healthcare professionals providing care for these women should be given training in how to communicate sensitively and breaking bad news. Non-clinical staff such as receptionists working in settings where early pregnancy care is provided should also be given training on how to communicate sensitively with women who experience early pregnancy complications.

Information throughout a woman's care

Throughout a woman's care, give her and (with agreement) her partner specific evidence-based information in a variety of formats. This should include (as appropriate):
  • When and how to seek help if existing symptoms worsen or new symptoms develop, including a 24-hour contact telephone number.
  • What to expect during the time she is waiting for an ultrasound scan.
  • What to expect during the course of her care (including expectant management), such as the potential length and extent of pain and/or bleeding, and possible side effects. This information should be tailored to the care she receives.
  • Information about post-operative care (for women undergoing surgery).
  • What to expect during the recovery period – for example, when it is possible to resume sexual activity and/or try to conceive again, and what to do if she becomes pregnant again. This information should be tailored to the care she receives.
  • Information about the likely impact of her treatment on future fertility.
  • Where to access support and counselling services, including leaflets, web addresses and helpline numbers for support organisations.
Ensure that sufficient time is available to discuss these issues with women during the course of their care and arrange an additional appointment if more time is needed.
After an early pregnancy loss, offer the woman the option of a follow-up appointment with a healthcare professional of her choice.
NICE has written information for the public explaining the guidance on ectopic pregnancy and miscarriage.

Source guidance

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Symptoms and signs of ectopic pregnancy

Symptoms and signs of ectopic pregnancy

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.

Source guidance

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Think about the possibility of ectopic pregnancy and offer a pregnancy test

Think about the possibility of ectopic pregnancy and offer a pregnancy test

Think about the possibility of ectopic pregnancy and offer a pregnancy test

Be aware that:
During clinical assessment of women of reproductive age, be aware that:
  • they may be pregnant, and think about offering a pregnancy test even when symptoms are non-specific and
  • the symptoms and signs of ectopic pregnancy can resemble the common symptoms and signs of other conditions – for example, gastrointestinal conditions or urinary tract infection.
All healthcare professionals involved in the care of women of reproductive age should have access to pregnancy tests.
Exclude the possibility of ectopic pregnancy, even in the absence of risk factors (such as previous ectopic pregnancy), because about a third of women with an ectopic pregnancy will have no known risk factors.

Source guidance

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Positive pregnancy test

Positive pregnancy test or woman already knows she is pregnant

Pelvic tenderness, cervical motion tenderness, or pain and abdominal tenderness

Pelvic tenderness, cervical motion tenderness, or pain and abdominal tenderness on examination

Pelvic tenderness, cervical motion tenderness, or pain and abdominal tenderness on examination

Refer immediately to an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available) for further assessment women with a positive pregnancy test and the following on examination:
  • pain and abdominal tenderness or
  • pelvic tenderness or
  • cervical motion tenderness.

Source guidance

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Immediate referral

Immediate referral

No pelvic tenderness

No pelvic tenderness, cervical motion tenderness, or abdominal tenderness on examination

No pelvic tenderness, cervical motion tenderness, or abdominal tenderness on examination

Refer to an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available) 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.
The urgency of this referral depends on the clinical situation.
Use expectant management for women with a pregnancy of less than 6 weeks gestation who are bleeding but not in pain. Advise these women:
  • to repeat a urine pregnancy test after 7–10 days and to return if it is positive
  • a negative pregnancy test means that the pregnancy has miscarried
  • to return if their symptoms continue or worsen.

Source guidance

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Expectant management

Expectant management

Women with worsening symptoms and signs

Women with worsening symptoms and signs

Women with worsening symptoms and signs

Refer women who return with worsening symptoms and signs that could suggest an ectopic pregnancy to an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available) for further assessment. The decision about whether she should be seen immediately or within 24 hours will depend on the clinical situation.

Source guidance

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Referral to an early pregnancy assessment service

Referral to an early pregnancy assessment service

Referral to an early pregnancy assessment service

If a woman is referred to an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available), explain the reasons for the referral and what she can expect when she arrives there.

Source guidance

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Offer an ultrasound scan

Offer an ultrasound scan

Offer an ultrasound scan

Offer women who attend an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available) a transvaginal ultrasound scan to identify the location of the pregnancy and whether there is a fetal pole and heartbeat.
Consider a transabdominal ultrasound scan for women with an enlarged uterus or other pelvic pathology, such as fibroids or an ovarian cyst.
If a transvaginal ultrasound scan is unacceptable to the woman, offer a transabdominal ultrasound scan and explain the limitations of this method of scanning.
Inform women that the diagnosis of miscarriage using 1 ultrasound scan cannot be guaranteed to be 100% accurate and there is a small chance that the diagnosis may be incorrect, particularly at very early gestational ages.
When diagnosing complete miscarriage on an ultrasound scan, in the absence of a previous scan confirming an intrauterine pregnancy, always be aware of the possibility of ectopic pregnancy. Advise these women to return for further review if their symptoms persist.

Source guidance

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Management of pregnancy of unknown location

View the 'Management of pregnancy of unknown location' path

Management of ectopic pregnancy

View the 'Management of ectopic pregnancy' path

Early pregnancy assessment services

Organisation of early pregnancy assessment services

Organisation of early pregnancy assessment services

Regional services should be organised so that an early pregnancy assessment service is available 7 days a week for women with early pregnancy complications, where scanning can be carried out and decisions about management made.
An early pregnancy assessment service 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 ultrasound and assessment of serum hCG levels and
  • be staffed by healthcare professionals with training in sensitive communication and breaking bad news.
Early pregnancy assessment services should accept self-referrals from women who have had recurrent miscarriageAlthough additional care for women with recurrent miscarriage is not included in the scope of the guideline, the Guideline Development group recognised that it is common clinical practice to allow these women to self-refer to an early pregnancy assessment service and wished this to remain the case. or a previous ectopic pregnancy or molar pregnancy. All other women with pain and/or bleeding should be assessed by a healthcare professional (such as a GP, A&E doctor, midwife or nurse) before referral to an early pregnancy assessment service.
Ensure that a system is in place to enable women referred to their local early pregnancy assessment service to attend within 24 hours if the clinical situation warrants this. If the service is not available, and the clinical symptoms warrant further assessment, refer women to the nearest accessible facility that offers specialist clinical assessment and ultrasound scanning (such as a gynaecology ward or A&E service with access to specialist gynaecology support).
All ultrasound scans should be performed and reviewed by someone with training in, and experience of, diagnosing ectopic pregnancies.

Implementation tools

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[[Ectopic pregnancy and miscarriage: ultrasound for determining viable intrauterine pregnancy: electronic audit]

Source guidance

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Patient experience in adult NHS services pathway

View the 'Patient experience in adult NHS services overview' path

Paths in this pathway

Pathway created: December 2012 Last updated: December 2013

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