Our comments on new NICE guidelines on the treatment of ectopic pregnancy and miscarriage

The Ectopic Pregnancy Trust (EPT) supports the drive for greater awareness of the symptoms of ectopic pregnancy and miscarriage, which are published in today’s NICE Guidelines.

The EPT is pleased that the guidelines begin the process of putting the issues of women and their partners who are suffering an ectopic pregnancy or early miscarriage at the forefront of gynaecological health care.   The trust is also pleased to see that NICE supports the provision of comprehensive early pregnancy services in the NHS and that they champion a good, caring, enviroment, where the needs of the patient are met.   The highlighting of the need for communication to be undertaken in a sensitive manner between medical staff, the patient and their partners, is most welcome. Ensuring that patients receive emotional support and information, as well as providing 24 hour contact details and explaining what to expect during the course of her care and recovery period, is a change for the better.

We also applaud the recommendation that women are given 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.  NICE also recognises there may be a need for training of staff and the Ectopic Pregnancy Trust is offering training workshops to provide this to medical professionals.

Although most hospitals in the UK have an Early Pregnancy Unit already, the recommendation to introduce a dedicated regional seven day service is warmly welcomed by the EPT. However, we have concerns that there is no mention in the guidelines regarding funding for these services, training provision or standards of care in the proposed services.  Also, the guideline recommends that only women with a previous ectopic pregnancy or multiple miscarriages should have direct access to early pregnancy services and that all others will need to be seen by another healthcare professional first. The guidelines have also recommended that women with vaginal bleeding who are less than 6 weeks pregnant should not be referred for a scan. The EPT are aware that there are already some EPUs that go beyond the recommendations and provide opportunities for self referral and where this is possible we applaud it.  The EPT are concerned that this places barriers to women from receiving prompt attention and early diagnosis, particularly given that women’s estimated dates are often inaccurate if they have had irregular bleeding.

The trust also supports the provision of appropriate equipment and training to deal with the surgical management of ectopic pregnancy.  We would also call for extending availability of expertise in ultrasonography to diagnose ectopic pregnancy and this is entirely dependant on adequate investment in training so we believe this is a missed opportunity.

The EPT have additional concerns and cannot support some significant and specific parts of the guidance.

  1. In our view the guidelines restrict choice for women who suffer a miscarriage. NICE state that all women with a miscarriage should be offered expectant (watch and wait) or medical treatment.  These can be offered as an outpatient.  However they state that surgery is not a first line option except for a select group of women.  While we applaud the provision of outpatient therapies, some women will prefer surgical treatment and this option should be made available to all women who want it.
  2.  The EPT has major concerns about the treatment suggested for ectopic pregnancy.  NICE suggest that providing certain criteria are met, all women should be offered the drug Methotrexate for treatment. No consideration is given to adopting a watch and wait approach with monitoring. We believe this guidance will lead to a number of women receiving Methotrexate when their ectopic pregnancy would have resolved without intervention.  A  further problem with Methotrexate arises with the misdiagnosis of a presumed ectopic pregnancy.   If the drug is given in error to a pregnancy that is in fact correctly located in the uterus, the result is either miscarriage or the potential for serious abnormalities in the baby if it survives.  This scenario has been of such concern in the USA that a consensus conference was held recently to try to stem the tide of these cases.   We would like to see further detail and clarification on its suggested use.

We welcome the interest NICE has taken in early pregnancy care. However, we are disappointed to see the fact of what we see as an erosion of choice in the care of women with early pregnancy problems. There was an opportunity to say something about the need to make the care of early pregnancy problems a ‘Specialist field’ in Gynaecology, to promote training and to encourage commissioners to support the use of computerised reporting in early pregnancy utits to facilitate audit, better knowledge of outcome and drive up standards. Unfortunately they have failed to do this.