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28 December 2012

UK: Dedicated NHS service recommended for women with a suspected miscarriage or ectopic pregnancy

The NHS should consider setting up dedicated services for pregnant women who may have an ectopic pregnancy or who experience pain or bleeding before 13 weeks gestation, according to a new guideline published in December by the National Institute for Health and Clinical Excellence (NICE) on the diagnosis and management of ectopic pregnancy and miscarriage in early pregnancy.

NICE’s press release notes that while the majority of pregnancies progress successfully, around one in five will result in a miscarriage. Ectopic pregnancies occur in 11 per 1,000 pregnancies. Between 2006 and 2008, there were 35,495 confirmed cases of ectopic pregnancies and, of these, six women died during their first trimester as a direct result of their pregnancy. About two-thirds of deaths caused by ectopic pregnancy are associated with substandard care, due to missed or late diagnosis.

Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: “It can be very distressing and, in some cases, frightening to experience a miscarriage or be told your pregnancy is ectopic. It’s vital that women and their families receive good, consistent, timely and effective care and support that addresses their needs and enables them to make informed decisions. We know that not every woman is receiving this level of treatment at the moment but this guideline will address that inconsistency and ensure all women receive excellent care, no matter where they live.”

The guideline recommends regional services should be organised so that an early pregnancy assessment service is available seven days a week for women with early pregnancy complications, where scanning can be carried out and decisions made about how their pregnancy should be managed.

The guideline was developed for NICE by a group of clinical experts and lay members. Professor Mary Ann Lumsden, Professor of Gynaecology and Medical Education at Glasgow University, chaired the group and said: “The provision of early pregnancy assessment services will go a long way towards promoting good, timely diagnoses of ectopic pregnancies and miscarriage and will help to ensure all women in England and Wales receive excellent care. Some areas will already have dedicated early pregnancy assessment services but in those localities that do not, it is likely that a reorganisationof current resources will be all that is necessary.

“There may be some cost involved in setting up a seven-day specialist service but, in the long term, it is likely to be cheaper and is certainly better for the woman to have scan facilities and staff with the expertise to assess a woman than it is to treat her in theatre or on a hospital ward after she has collapsed from an ectopic pregnancy or excessive bleeding.”

The new guideline also includes advice for GPs on the signs and symptoms of ectopic pregnancy which can often be general and non-specific. These can include pain and/or bleeding (although not always), pelvic or breast tenderness, dizziness or gut upset. The guideline also makes recommendations on when GPs should refer women to a specialist assessment service.

Dr Nicola Davies, a GP who helped to develop the guideline, said: “It can be difficult for GPs to diagnose an ectopic pregnancy, particularly when some symptoms are very general and women may not even be aware they are pregnant. I have seen two cases where an ectopic pregnancy was diagnosed but the women in question had no idea they were pregnant. By producing a list of potential signs and symptoms and also recommending that healthcare professionals should have access to pregnancy tests for women of reproductive age, the guideline promotes earlier diagnosis of ectopic pregnancy. This will mean that women receive appropriate care sooner and avoid serious complications.”

Other recommendations include:

Signs and symptoms of ectopic pregnancy: 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.

Ultrasound for diagnosis: 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 (TVU) scan to identify the location of the pregnancy and whether there is a fetal pole[3]and heartbeat. If a TVU is not acceptable to the woman, a transabdominal ultrasound (TAU) should be offered as an alternative.

Management of miscarriage: Expectant management for 7-14 days should be the first line management strategy following confirmed diagnosis of a non-viable pregnancy [where appropriate - see the NICE guideline for details]. Offer medical management to women with a confirmed diagnosis of miscarriage if expectant management is not acceptable to the woman.

Emotional support and information giving: 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 including a 24-hour contact telephone number, what to expect during the course of her care, what to expect during the recovery period, information about the likely impact of her treatment on future fertility and where to access support and counselling services, including leaflets, web addresses and helpline numbers for support organisations.

Julie Orford, Chair of the Birth Trauma Association who helped to develop the guideline, said: “I have experienced two miscarriages and know how upsetting and traumatic it can be. I was fortunate to receive generally good NHS care but I know that not all women do. Every woman who experiences early pregnancy complications and faces the possibility of losing her baby deserves the best possible care and support and I really believe this NICE guideline will help to provide this. The recommendations around how miscarriage is managed in particular will help to standardise the care that women receive. While it’s important not to overmedicalise what is essentially a natural process it’s crucial that women are still given a choice about how their miscarriage is managed. My first miscarriage was particularly traumatic and it’s vital that women get good information and support to help them make informed decisions on their care.”

The guideline on diagnosing and managing ectopic pregnancy and miscarriage is available from the NICE website, here.

This guideline focuses on the treatment and care of women who experience a suspected miscarriage or ectopic pregnancy or miscarriage in the first 13 weeks of pregnancy. This includes women who are found to have had a missed miscarriage (confirmed via an ultrasound scan) despite no obvious symptoms. The guideline does not make recommendations about suspected miscarriage or ectopic pregnancy in expectant mothers after the first 13 weeks of pregnancy. It also does not cover the issue of recurrent miscarriage, because these require more specific investigation, management and treatment.

Approximately 20% of pregnancies miscarry; this equates to roughly 168,000 miscarriages per year in England, with 143,000 of these occurring in the first trimester. In England during 2010-11, a total of 54,162 women had either a miscarriage or ectopic pregnancy which resulted in an NHS hospital stay (43,005 cases of miscarriage and 11,157 cases of ectopic pregnancy).

It is anticipated that by implementing this guideline, the NHS would experience a decrease in emergency admissions to hospital of women in need of emergency care caused by early pregnancy complications. This would generate some savings for the health service, as well as utilising resources most wisely and ensuring women receive effective and timely care before any complication becomes too serious, or potentially puts the woman’s life at risk.

Other pregnancy-related clinical guidelines published by NICE include antenatal care, pregnancy and complex social factors and multiple pregnancy. NICE has also published a quality standard on antenatal care.

NICE recommends dedicated NHS service for women with a suspected miscarriage or ectopic pregnancy. National Institute for Health and Clinical Excellence, 11 December 2012