NumberRecommendationSee section
Emotional support and information giving
1Treat 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 response.*4.2
2Healthcare 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.4.2
3Throughout 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.
4.2
4After an early pregnancy loss, offer the woman the option of a follow-up appointment with a healthcare professional of her choice.4.2
Early pregnancy assessment services
5Regional 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.5.3
6An 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 human chorionic gonadotrophin (hCG) levels and
  • be staffed by healthcare professionals with training in sensitive communication and breaking bad news.
5.3
7Early pregnancy assessment services should accept self-referrals from women who have had recurrent miscarriage or a previous ectopic or molar pregnancy. All other women with pain and/or bleeding should be assessed by a healthcare professional (such as a GP, accident and emergency [A&E] doctor, midwife or nurse) before referral to an early pregnancy assessment service.5.3
8Ensure 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).5.3
Signs and symptoms of ectopic pregnancy
9Refer women who are haemodynamically unstable, or in whom there is significant concern about the degree of pain or bleeding, directly to A&E.6.1
10Be aware that atypical presentation for ectopic pregnancy is common.6.1
11Be aware that ectopic pregnancy can present with a variety of symptoms. Even if a symptom is less common, it may still be significant. 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.
6.1
12Be aware that ectopic pregnancy can present with a variety of signs on examination by a healthcare professional. 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.
6.1
13During 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.
6.1
14All healthcare professionals involved in the care of women of reproductive age should have access to pregnancy tests.6.1
15Refer 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.
6.1
16Exclude 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.6.1
17Refer 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.
6.1
18Use 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.
6.1
19Refer 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.6.1
20If 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.6.1
Using ultrasound for diagnosis
21Offer 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.6.3
22Consider a transabdominal ultrasound scan for women with an enlarged uterus or other pelvic pathology, such as fibroids or an ovarian cyst.6.3
23If a transvaginal ultrasound scan is unacceptable to the woman, offer a transabdominal ultrasound scan and explain the limitations of this method of scanning.6.3
24Inform 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.6.3
25When performing an ultrasound scan to determine the viability of an intrauterine pregnancy, first look to identify a fetal heartbeat. If there is no visible heartbeat but there is a visible fetal pole, measure the crown–rump length. only measure the mean gestational sac diameter if the fetal pole is not visible.6.3
26If the crown–rump length is less than 7.0 mm with a transvaginal ultrasound scan and there is no visible heartbeat, perform a second scan a minimum of 7 days after the first before making a diagnosis. Further scans may be needed before a diagnosis can be made.6.3
27If the crown–rump length is 7.0 mm or more with a transvaginal ultrasound scan and there is no visible heartbeat:
  • seek a second opinion on the viability of the pregnancy and/or
  • perform a second scan a minimum of 7 days after the first before making a diagnosis.
6.3
28If there is no visible heartbeat when the crown–rump length is measured using a transabdominal ultrasound scan:
  • record the size of the crown–rump length and
  • perform a second scan a minimum of 14 days after the first before making a diagnosis.
6.3
29If the mean gestational sac diameter is less than 25.0 mm with a transvaginal ultrasound scan and there is no visible fetal pole, perform a second scan a minimum of 7 days after the first before making a diagnosis. Further scans may be needed before a diagnosis can be made.6.3
30If the mean gestational sac diameter is 25.0 mm or more using a transvaginal ultrasound scan and there is no visible fetal pole:
  • seek a second opinion on the viability of the pregnancy and/or
  • perform a second scan a minimum of 7 days after the first before making a diagnosis.
6.3
31If there is no visible fetal pole and the mean gestational sac diameter is measured using a transabdominal ultrasound scan:
  • record the size of the mean gestational sac diameter and
  • perform a second scan a minimum of 14 days after the first before making a diagnosis.
6.3
32Do not use gestational age from the last menstrual period alone to determine whether a fetal heartbeat should be visible.6.3
33Inform women that the date of their last menstrual period may not give an accurate representation of gestational age because of variability in the menstrual cycle.6.3
34Inform women what to expect while waiting for a repeat scan and that waiting for a repeat scan has no detrimental effects on the outcome of the pregnancy.6.3
35Give women a 24-hour contact telephone number so that they can speak to someone with experience of caring for women with early pregnancy complications who understands their needs and can advise on appropriate care.6.3
36When 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.6.3
37All ultrasound scans should be performed and reviewed by someone with training in, and experience of, diagnosing ectopic pregnancies.6.3
Human chorionic gonadotrophin measurements in women with pregnancy of unknown location
38Be aware that women with a pregnancy of unknown location could have an ectopic pregnancy until the location is determined.6.7
39Do not use serum hCG measurements to determine the location of the pregnancy.6.7
40In a woman with a pregnancy of unknown location, place more importance on clinical symptoms than on serum hCG results, and review the woman's condition if any of her symptoms change, regardless of previous results and assessments.6.7
41Use serum hCG measurements only for assessing trophoblastic proliferation to help to determine subsequent management.6.7
42Take 2 serum hCG measurements as near as possible to 48 hours apart (but no earlier) to determine subsequent management of a pregnancy of unknown location. Take further measurements only after review by a senior healthcare professional.6.7
43Regardless of serum hCG levels, give women with a pregnancy of unknown location written information about what to do if they experience any new or worsening symptoms, including details about how to access emergency care 24 hours a day. Advise women to return if there are new symptoms or if existing symptoms worsen.6.7
44For a woman with an increase in serum hCG concentration greater than 63% after 48 hours:
  • Inform her that she is likely to have a developing intrauterine pregnancy (although the possibility of an ectopic pregnancy cannot be excluded).
  • offer her a transvaginal ultrasound scan to determine the location of the pregnancy between 7 and 14 days later. Consider an earlier scan for women with a serum hCG level greater than or equal to 1500 IU/litre.
    • If a viable intrauterine pregnancy is confirmed, offer her routine antenatal care§
    • If a viable intrauterine pregnancy is not confirmed, refer her for immediate clinical review by a senior gynaecologist.
6.7
45For a woman with a decrease in serum hCG concentration greater than 50% after 48 hours:
  • inform her that the pregnancy is unlikely to continue but that this is not confirmed and
  • provide her with oral and written information about where she can access support and counselling services** and
  • ask her to take a urine pregnancy test 14 days after the second serum hCG test, and explain that:
    • if the test is negative, no further action is necessary
    • if the test is positive, she should return to the early pregnancy assessment service for clinical review within 24 hours.
6.7
46For a woman with a change in serum hCG concentration between a 50% decline and 63% rise inclusive, refer her for clinical review in the early pregnancy assessment service within 24 hours.6.7
47For women with a pregnancy of unknown location, when using serial serum hCG measurements, do not use serum progesterone measurements as an adjunct to diagnose either viable intrauterine pregnancy or ectopic pregnancy.6.7
Threatened miscarriage
48Advise a woman with vaginal bleeding and a confirmed intrauterine pregnancy with a fetal heartbeat that:
  • if her bleeding gets worse, or persists beyond 14 days, she should return for further assessment
  • if the bleeding stops, she should start or continue routine antenatal care.
7.2
Expectant management of miscarriage
49Use expectant management for 7–14 days as the first-line management strategy for women with a confirmed diagnosis of miscarriage. Explore management options other than expectant management if:
  • the woman is at increased risk of haemorrhage (for example, she is in the late first trimester) or
  • she has previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage) or
  • she is at increased risk from the effects of haemorrhage (for example, if she has coagulopathies or is unable to have a blood transfusion) or
  • there is evidence of infection.
7.4
50Offer medical management to women with a confirmed diagnosis of miscarriage if expectant management is not acceptable to the woman.7.4
51Explain what expectant management involves and that most women will need no further treatment. Also provide women with oral and written information about further treatment options.7.4
52Give all women undergoing expectant management of miscarriage oral and written information about what to expect throughout the process, advice on pain relief and where and when to get help in an emergency.††7.4
53If the resolution of bleeding and pain indicate that the miscarriage has completed during 7–14 days of expectant management, advise the woman to take a urine pregnancy test after 3 weeks, and to return for individualised care if it is positive.7.4
54Offer a repeat scan if after the period of expectant management the bleeding and pain:
  • have not started (suggesting that the process of miscarriage has not begun) or
  • are persisting and/or increasing (suggesting incomplete miscarriage).
Discuss all treatment options (continued expectant management, medical management, and surgical management) with the woman to allow her to make an informed choice.
7.4
55Review the condition of a woman who opts for continued expectant management of miscarriage at a minimum of 14 days after the first follow-up appointment.7.4
Medical management of miscarriage
56Do not offer mifepristone as a treatment for missed or incomplete miscarriage.7.5
57Offer vaginal misoprostol for the medical treatment of missed or incomplete miscarriage. oral administration is an acceptable alternative if this is the woman's preference.‡‡7.5
58For women with a missed miscarriage, use a single dose of 800 micrograms of misoprostol.‡‡7.5
59Advise the woman that if bleeding has not started 24 hours after treatment, she should contact her healthcare professional to determine ongoing individualised care.7.5
60For women with an incomplete miscarriage, use a single dose of 600 micrograms of misoprostol. (800 micrograms can be used as an alternative to allow alignment of treatment protocols for both missed and incomplete miscarriage.)‡‡7.5
61Offer all women receiving medical management of miscarriage pain relief and anti-emetics as needed.7.5
62Inform women undergoing medical management of miscarriage about what to expect throughout the process, including the length and extent of bleeding and the potential side effects of treatment including pain, diarrhoea and vomiting.7.5
63Advise women to take a urine pregnancy test 3 weeks after medical management of miscarriage unless they experience worsening symptoms, in which case advise them to return to the healthcare professional responsible for providing their medical management.7.5
64Advise women with a positive urine pregnancy test after 3 weeks to return for a review by a healthcare professional to ensure that there is no molar or ectopic pregnancy.7.5
Surgical management of miscarriage
65Where clinically appropriate, offer women undergoing a miscarriage a choice of:
  • manual vacuum aspiration under local anaesthetic in an outpatient or clinic setting or
  • surgical management in a theatre under general anaesthetic.
7.6
66Provide oral and written information to all women undergoing surgical management of miscarriage about the treatment options available and what to expect during and after the procedure.§§7.6
Surgical and medical management of ectopic pregnancy
67Inform women who have had an ectopic pregnancy that they can self-refer to an early pregnancy assessment service in future pregnancies if they have any early concerns.8.2
68Give all women with an ectopic pregnancy oral and written information about:
  • how they can contact a healthcare professional for post-operative advice if needed, and who this will be and
  • where and when to get help in an emergency.§§
8.2
69Offer systemic methotrexate*** as a first-line treatment to women who are able to return for follow-up and who have all of the following:
  • no significant pain
  • an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat
  • a serum hCG level less than 1500 IU/litre
  • no intrauterine pregnancy (as confirmed on an ultrasound scan).
Offer surgery where treatment with methotrexate is not acceptable to the woman.
8.2
70Offer surgery as a first-line treatment to women who are unable to return for follow-up after methotrexate treatment or who have any of the following:
  • an ectopic pregnancy and significant pain
  • an ectopic pregnancy with an adnexal mass of 35 mm or larger
  • an ectopic pregnancy with a fetal heartbeat visible on an ultrasound scan
  • an ectopic pregnancy and a serum hCG level of 5000 IU/litre or more.
8.2
71Offer the choice of either methotrexate††† or surgical management to women with an ectopic pregnancy who have a serum hCG level of at least 1500 IU/litre and less than 5000 IU/litre, who are able to return for follow-up and who meet all of the following criteria:
  • no significant pain
  • an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat
  • no intrauterine pregnancy (as confirmed on an ultrasound scan).
Advise women who choose methotrexate that their chance of needing further intervention is increased and they may need to be urgently admitted if their condition deteriorates.
8.2
72For women with ectopic pregnancy who have had methotrexate, take 2 serum hCG measurements in the first week (days 4 and 7) after treatment and then 1 serum hCG measurement per week until a negative result is obtained. If hCG levels plateau or rise, reassess the woman's condition for further treatment.8.2
Performing laparoscopy
73When surgical treatment is indicated for women with an ectopic pregnancy, it should be performed laparoscopically whenever possible, taking into account the condition of the woman and the complexity of the surgical procedure.8.3
74Surgeons providing care to women with ectopic pregnancy should be competent to perform laparoscopic surgery.8.3
75Commissioners and managers should ensure that equipment for laparoscopic surgery is available.8.3
Salpingectomy and salpingotomy
76Offer a salpingectomy to women undergoing surgery for an ectopic pregnancy unless they have other risk factors for infertility.8.4
77Consider salpingotomy as an alternative to salpingectomy for women with risk factors for infertility such as contralateral tube damage.8.4
78Inform women having a salpingotomy that up to 1 in 5 women may need further treatment. This treatment may include methotrexate and/or a salpingectomy.8.4
79For women who have had a salpingotomy, take 1 serum hCG measurement at 7 days after surgery, then 1 serum hCG measurement per week until a negative result is obtained.8.4
80Advise women who have had a salpingectomy that they should take a urine pregnancy test after 3 weeks. Advise women to return for further assessment if the test is positive.8.4
Anti-D rhesus prophylaxis
81Offer 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.9.3
82Do not offer anti-D rhesus prophylaxis to women who:
  • receive solely medical management for an ectopic pregnancy or miscarriage or
  • have a threatened miscarriage or
  • have a complete miscarriage or
  • have a pregnancy of unknown location.
9.3
83Do not use a Kleihauer test for quantifying feto–maternal haemorrhage.9.3
*

For further guidance about providing information, see Patient experience in adult NHS services (NICE clinical guidance 138)

Although 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.

See also recommendation 3 for details of further information that should be provided.

§

See Antenatal care (NICE clinical guideline 62)

**

See recommendation 3 for details of further information that should be provided

††

See also recommendation 3 for details of further information that should be provided.

‡‡

Although this use is common in UK clinical practice, at the time of publication (December 2012), misoprostol did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing medicines – guidance for doctors for further information.

§§

See also recommendation 3 for details of further information that should be provided.

***

Although this use is common in UK clinical practice, at the time of publication (December 2012), methotrexate did not have UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing medicines – guidance for doctors for further information.

†††

Although this use is common in UK clinical practice, at the time of publication (December 2012), methotrexate did not have UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing medicines – guidance for doctors for further information.

For further guidance about providing information, see Patient experience in adult NHS services (NICE clinical guidance 138)

Although 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.

See also recommendation 3 for details of further information that should be provided.

See Antenatal care (NICE clinical guideline 62)

See recommendation 3 for details of further information that should be provided

See also recommendation 3 for details of further information that should be provided.

Although this use is common in UK clinical practice, at the time of publication (December 2012), misoprostol did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing medicines – guidance for doctors for further information.

See also recommendation 3 for details of further information that should be provided.

Although this use is common in UK clinical practice, at the time of publication (December 2012), methotrexate did not have UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing medicines – guidance for doctors for further information.

Although this use is common in UK clinical practice, at the time of publication (December 2012), methotrexate did not have UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing medicines – guidance for doctors for further information.

From: 1, Guideline summary

Cover of Ectopic Pregnancy and Miscarriage
Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management in Early Pregnancy of Ectopic Pregnancy and Miscarriage.
NICE Clinical Guidelines, No. 154.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG; 2012 Dec.
Copyright © 2012, National Collaborating Centre for Women's and Children's Health.

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