Reports

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• Saving Lives, Improving Mothers’ Care Surveillance of maternal deaths in the UK 2012–14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–14 (Published December 2016).

Key points:

2016 MBRRACE Maternal Deaths and Morbidity Report 2009-14 states:

“The presenting symptoms and physical signs can be confusing especially when a woman presents collapsed and in a state of clinical shock. In women of reproductive age simple bedside tests, a urinary pregnancy test, and a FAST scan, are valuable aids in making the correct diagnosis. They will also guard against giving potentially dangerous treatments, such as thrombolysis, to women who have intra-abdominal bleeding from a ruptured ectopic pregnancy. Women of reproductive age who are found collapsed in the community from an unknown cause need rapid transfer to hospital. Resuscitation by paramedics in the community will not stop a woman bleeding to death from a ruptured ectopic pregnancy. Definitive surgical intervention is the only way to arrest the bleeding and avoid death in these situations.

Women of reproductive age who present in the community in a state of shock and/or collapse with no obvious cause should be transferred to a hospital Emergency Department without delay for urgent assessment and treatment.

In several instances, the time spent by paramedics in the community attempting resuscitation was considered by the assessors to be too long to be of any practical benefit to these women. For resuscitation and treatment to be life-saving in collapsed women with ruptured ectopic pregnancies, the bleeding must be stopped and the only way to do this is surgically… A ‘scoop and run’ policy is the best approach for shocked women of reproductive age so that in those with an ectopic pregnancy the bleeding can be stopped as rapidly as possible.”

• Saving Lives, Improving Mothers’ Care Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015-17 (Published November 2019).

Key points:

2019 MBRRACE Maternal Deaths and Morbidity Report 2015-17 states:

“Six women died from early pregnancy problems, five of whom had ectopic pregnancies. All five women with ectopic pregnancies died within 48 hours of presentation and three of the six women who died (half) were from Black or other ethnic minority groups.

A diagnosis of ectopic pregnancy should be considered in any woman of reproductive age presenting to the emergency department with collapse, acute abdominal/pelvic pain or gastrointestinal symptoms, particularly diarrhoea, vomiting and dizziness, regardless of whether or not she is known to be pregnant. A bedside pregnancy test should always be performed in these women if necessary catheterising to obtain urine. (Existing guidance)

Women of reproductive age presenting to the Emergency Department collapsed, in whom a pulmonary embolism is suspected, should have a Focused Assessment with Sonography in Trauma (FAST) scan to exclude intra-abdominal bleeding from a ruptured ectopic pregnancy especially in the presence of anaemia. (Existing guidance)

Women of reproductive age who present in the community in a state of shock and/or collapse with no obvious cause should be transferred urgently to a hospital Emergency Department without delay for rapid assessment and treatment. (Existing guidance)”

2019 recommendations: “When a woman collapses out of hospital, good communication should ensure senior review at admission and multidisciplinary involvement to determine the diagnosis promptly and enable rapid appropriate treatment. 

Early pregnancy assessment services should ensure processes are in place to review and act upon the results of investigations promptly. 

Any facility performing laparoscopic surgery in pregnancy should have blood immediately available, staff should be able to perform measures to control haemorrhage prior to definitive treatment and an escalation protocol for rapid assistance should be in place.

In maternal resuscitation, if there is no response to CPR after 5 minutes, undertake a TIME CRITICAL transfer to the nearest Emergency Department, ideally with an obstetric unit attached. In the event of collapse in the community in early pregnancy, if TIME CRITICAL features are present, transfer to the nearest appropriate destination, which may be the emergency department or early pregnancy unit, with a pre-alert stating the emergency. If significant shock or compromise, consider the emergency department in the first instance. JRCALC Clinical Practice Supplementary Guidelines 2017 (Joint Royal Colleges Ambulance Liaison Committee and Association of Ambulance Chief Executives 2017).”

• Saving Lives, Improving Mothers’ Care Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018–20 (Published November 2022).

2022 MBRRACE Maternal Deaths and Morbidity Report 2018-20 states:

“Women are still dying from early pregnancy problems. In this report almost all women died from ectopic pregnancy, which remains as frequent a cause of maternal death as other pregnancy problems such as hypertensive disorders.

Women with pregnancy of unknown location warrant particularly close attention and it is essential to adhere to national guidance (National Institute for Health and Care Excellence 2019).

Vulnerable and young women remain disproportionately represented amongst those who have died from ectopic pregnancy. They need additional safety measures incorporated into their care, for example, enhanced follow-up pathways.

As previously recommended a pregnancy test and a FAST scan should be undertaken before thrombolysis in all women of reproductive age.

With improved patient and clinician awareness regarding the symptoms of ectopic pregnancy more extrauterine pregnancies could be identified earlier and before collapse occurs. Where women of reproductive age, who may or may not be known to be pregnant, present with collapse, an ectopic pregnancy must be excluded as venous thromboembolism and cardiac disease must not be considered as the only causes.”

Read The EPT’s statement on MBRRACE-UK Report 2022.

• Healthcare Safety Investigation Branch report on the diagnosis of ectopic pregnancy

This patient safety investigation explores the diagnosis of ectopic pregnancy.

Key points:

The report sets out four safety recommendations focused on:

• Updating clinical information to include ectopic pregnancy as a possible alternative/serious diagnosis to lower urinary tract infection.
• Standardising the information that women receive on discharge from the emergency department.
• Providing expert guidance on the type and level of information that EPUs should collect to identify those at risk.
• Including assessment on early pregnancy services especially relating to potential complications in CQC inspections.

• Post-traumatic stress, anxiety and depression following miscarriage and ectopic pregnancy
• Differences in post-traumatic stress, anxiety and depression following miscarriage or ectopic pregnancy between women and their partners 

These studies investigate post-traumatic stress, anxiety and depression in the nine months following early pregnancy loss through miscarriage or ectopic pregnancy.

• Miscarriage Matters Series, The Lancet 2021

This series reviews the evidence on miscarriage and challenges misconceptions.

Key points:

The series calls on the Government to implement three key changes:

• Act to ensure that designated miscarriage services are available 24/7 to all, taking into account local conditions and resources.
• Treatment and care must be standardised and equitable. Appropriate care must be given to everyone after 1, 2 and 3 miscarriages in line with a ‘graded model’ of care.
• To acknowledge that miscarriage matters to parents and take steps to record every miscarriage in England.

• Pregnancy Loss Review

A vision for improving the care and support available to families when baby loss occurs before 24 weeks’ gestation. There are 73 recommendations and The EPT was part of the stakeholder group and is now on the oversight group for implementation.