Management of Ectopic pregnancy and miscarriage: NICE 2019 Guidelines
NICE has released its 2019 guidelines on diagnosis and initial management of Ectopic pregnancy and miscarriage.
This guideline covers diagnosing and managing tubal ectopic pregnancy and miscarriage in women with complications, such as pain and bleeding, in early pregnancy (that is, up to 13 completed weeks of pregnancy). It aims to improve how early pregnancy loss is diagnosed and managed to reduce the incidence of the associated psychological morbidity and improve the support women are given.
The areas to be updated as part of this guideline update are:
- Using ultrasound for the diagnosis of tubal ectopic pregnancy
- Expectant management of tubal ectopic pregnancy
Following are the major recommendations:
1. Management of miscarriage
Threatened miscarriage
- Advise 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. [2012]
Expectant management
- Use expectant management for 7 to 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. [2012]
- 1.5.3Offer medical management to women with a confirmed diagnosis of miscarriage if expectant management is not acceptable to the woman. [2012]
- Explain 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. [2012]
- Give 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.[2012]
- If the resolution of bleeding and pain indicate that the miscarriage has completed during 7 to 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. [2012]
- Offer 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. [2012]
- Review 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. [2012]
Medical management
- Do not offer mifepristone as a treatment for missed or incomplete miscarriage. [2012]
- Offer vaginal misoprostol for the medical treatment of missed or incomplete miscarriage. Oral administration is an acceptable alternative if this is the woman's preference. [2012]
- For women with a missed miscarriage, use a single dose of 800 micrograms of misoprostol. [2012]
- Advise the woman that if bleeding has not started 24 hours after treatment, she should contact her healthcare professional to determine ongoing individualised care. [2012]
- For 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). [2012]
- Offer all women receiving medical management of miscarriage pain relief and anti-emetics as needed. [2012]
- Inform 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. [2012]
- Advise 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. [2012]
- Advise 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. [2012]
Surgical management
- Where 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. [2012]
- Provide 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.[2012]
2. Management of tubal ectopic pregnancy
- Give all women with an ectopic pregnancy oral and written information about:
- the treatment options and what to expect during and after treatment
- how they can contact a healthcare professional for advice after treatment if needed, and who this will be
- where and when to get help in an emergency.
- Inform 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. [2012]
Expectant management
- Offer expectant management as an option to women who:
- are clinically stable and pain free and
- have a tubal ectopic pregnancy measuring less than 35 mm with no visible heartbeat on transvaginal ultrasound scan and
- have serum hCG levels of 1,000 IU/L or less and
- are able to return for follow-up. [2019]
- Consider expectant management as an option for women who:
- are clinically stable and pain free and
- have a tubal ectopic pregnancy measuring less than 35 mm with no visible heartbeat on transvaginal ultrasound scan and
- have serum hCG levels above 1,000 IU/L and below 1,500 IU/L and
- are able to return for follow-up. [2019]
- For women with a tubal ectopic pregnancy being managed expectantly, repeat hCG levels on days 2, 4 and 7 after the original test and:
- if hCG levels drop by 15% or more from the previous value on days 2, 4 and 7, then repeat weekly until a negative result (less than 20 IU/L) is obtained or
- if hCG levels do not fall by 15%, stay the same or rise from the previous value, review the woman's clinical condition and seek senior advice to help decide further management. [2019]
- Advise women that, based on limited evidence, there seems to be no difference following expectant or medical management in:
- the rate of ectopic pregnancies ending naturally
- the risk of tubal rupture
- the need for additional treatment, but that they might need to be admitted urgently if their condition deteriorates
- health status, depression or anxiety scores. [2019]
- Advise women that the time taken for ectopic pregnancies to resolve and future fertility outcomes are likely to be the same with either expectant or medical management. [2019]
Medical and surgical management
- Offer systemic methotrexate to women who:
- have no significant pain and
- have an unruptured tubal ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat and
- have a serum hCG level less than 1,500 IU/litre and
- do not have an intrauterine pregnancy (as confirmed on an ultrasound scan) and
- are able to return for follow-up.Methotrexate should only be offered on a first visit when there is a definitive diagnosis of an ectopic pregnancy, and a viable intrauterine pregnancy has been excluded. Offer surgery where treatment with methotrexate is not acceptable to the woman. [2012, amended 2019]
- Offer 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 5,000 IU/litre or more. [2012]
- Offer the choice of either methotrexate or surgical management to women with an ectopic pregnancy who have a serum hCG level of at least 1,500 IU/litre and less than 5,000 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. [2012]
- For 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. [2012]
Performing laparoscopy
- When 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. [2012]
- Surgeons providing care to women with ectopic pregnancy should be competent to perform laparoscopic surgery. [2012]
- Commissioners and managers should ensure that equipment for laparoscopic surgery is available. [2012]
Salpingectomy and salpingotomy
- Offer a salpingectomy to women undergoing surgery for an ectopic pregnancy unless they have other risk factors for infertility. [2012]
- Consider salpingotomy as an alternative to salpingectomy for women with risk factors for infertility such as contralateral tube damage. [2012]
- Inform women having a salpingotomy that up to 1 in 5 women may need further treatment. This treatment may include methotrexate and/or a salpingectomy. [2012]
- For 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. [2012]
- Advise 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. [2012]
3. Anti-D rhesus prophylaxis
- 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. [2012]
- Do 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. [2012]
- Do not use a Kleihauer test for quantifying feto-maternal haemorrhage. [2012]
For further reference log on to :
https://www.nice.org.uk/guidance/indevelopment/gid-ng10080/consultation/html-content
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