This is an updated guideline on ectopic pregnancy and miscarriage from NICE (published Apr 19). It was last updated in 2012 when I originally wrote this blog post.
The 2019 update doesn't add very much to what we were already doing. There are two new elements:
- Expectant management of women with a miscarriage before 6/40. They have amended this to add that you should only use expectant management if there are no risk factors for ectopic pregnancy (eg a previous ectopic).
- Expectant management of ectopic pregnancy. This is a new section. It is really most relevant for secondary care, but it is useful for us to know a bit about it.
Useful bits of information:
- Expectant Management – see below – this is good for us to know.
- Presentation of Ectopic Pregnancy. Remember that presentation can be nebulous.
- Pregnancy Tests. All surgeries should have pregnancy tests available (at the moment I would suggest that only a minority have them – should we think about carrying them?).
- Emergency Contact Numbers. Ensure women know who to contact if symptoms worsen.
Refer immediately patients who have a positive pregnancy test AND:
- Abdo pain AND tenderness OR
- Pelvic tenderness OR
- Cervical Motion tenderness
NB – this is different to current local practice, where patients are generally booked into the next available slot, but this could be several days away.
Refer with urgency dependent upon clinical presentation patients with a positive pregnancy test AND Bleeding or other signs and symptoms of early pregnancy complications AND
- Pain OR
- Pregnancy 6/40 or more OR
- Pregnancy of uncertain gestation
Expectant Management for patients:
- < 6/40
- Bleeding but no pain
- With no risk risk factors for an ectopic pregnancy (eg a previous ectopic pregnancy).
Where you are managing patients expectantly, advise them to repeat a pregnancy test after 7 to 10d. If it is positive, they need review. If it is negative, they have had a miscarriage. Also warn patients that you are managing expectantly, to come back if symptoms worsen or continue.
Management of Complete Miscarriage
Most women will be managed conservatively. If bleeding has settled within 14d, they will be advised to do a pregnancy test after 3/52. If it is still positive, they will need further review. They will not necessarily need further scanning.
Management of Threatened Miscarriage
Advise women that if the bleeding hasn’t settled after 7 to 14d, that they need review.
Notes about Hospital Investigations that we need to know about
Beware a diagnosis of ‘complete miscarriage’ when no previous intrauterine pregnancy has been seen. There is a possibility of it being ectopic.
bHCG levels are done 48 hrs apart (NB progesterone should no longer be used):
- A rise of 63% or more, suggests a developing intrauterine pregnancy. Repeat scan after 1 to 2/52
- A decline of 50% or more, suggests a pregnancy that is unlikely to continue. Women should repeat a pregnancy test after 1 to 2/52. If positive, they will need review.
Management of Ectopic Pregnancy
Ladies with an ectopic pregnancy will be managed in hospital.
In the 2019 guideline there is information about which patients can have expectant management. NICE advises that expectant management should be offered to women who:
- are clinically stable AND
- pain free AND
- have a tubal ectopic pregnancy <35mm big with no visible heart beat on
- transvaginal scan AND
- have serum hCG levels < 1000 IU/ml AND
- are able to return for follow up.
If serum hCG levels are > 1000 but < 1500 IU/ml, expectant management can be considered.
Women who have expectant management will be followed up with serial hCG levels.
There is no difference between medical management and expectant management in the group of women above in terms of the rate of pregnancies ending naturally, the risk of tubal rupture, the need for additional treatment and other health status scores (eg anxiety).
NICE advises that we only need to give anti-D Ig if they have had surgical management, not otherwise. Patients do not need it for threatened or complete miscarriages.
It is worth noting that the British Society of Haematology would advise that anti-D be given if there is a threatened miscarriage when bleeding is heavy or repeated or where there is abdominal pain associated, especially as the gestation approaches 12/40. They would also advise that it be given for ectopic pregnancies, regardless of whether they are managed medically or surgically.