This information explains the advice about ectopic pregnancy and miscarriage in early pregnancy that is set out in NICE clinical guideline 154.

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1 Information for the public Published: 1 December 2012 nice.org.uk About this information NICE clinical guidelines advise the NHS on caring for people with specific conditions or diseases and the treatments they should receive. e. The information applies to people using the NHS in England and Wales. This information explains the advice about ectopic pregnancy and miscarriage in early pregnancy that is set out in NICE clinical guideline 154. All of the treatment and care that NICE recommends is in line with the NHS Constitution ( NICE has also produced advice on improving the experience of care for adults using the NHS. For more information see 'About care in the NHS' on our website ( Does this information apply to me? Yes, if you: have pain and/or bleeding in the first trimester of pregnancy (that is, less than 13 weeks) do not have pain and bleeding but have a positive pregnancy test and other symptoms (for example, symptoms of a urinary infection or stomach upset) are found to have a missed miscarriage (where an ultrasound scan has confirmed that the pregnancy will not continue to term, but you have had no pain and bleeding) NICE All rights reserved. Page 1 of 13

2 have a positive pregnancy test, have had an ectopic or molar pregnancy in the past and have concerns in the first trimester of pregnancy. It does not cover: pain and/or bleeding after the first trimester (13 or more weeks of pregnancy) tumours of the placenta (molar pregnancy or trophoblastic disease a rare complication of pregnancy where the baby does not grow and the afterbirth develops abnormally) pain and/or bleeding unrelated to pregnancy. Ectopic pregnancy and miscarriage in early pregnancy Early pregnancy complications can be very upsetting. Many women have vaginal bleeding in the early stages of pregnancy and in most cases it is nothing to worry about. However, pain and bleeding can also be a sign of problems with the pregnancy such as an ectopic pregnancy or miscarriage. Some women don't have pain or bleeding, but have other symptoms which may indicate an ectopic pregnancy. There is more information on early pregnancy problems in Signs and symptoms of early pregnancy problems. This information describes the tests and investigations you may be offered if you have pregnancy complications in the first 3 months of pregnancy, and the different options for your care. Your healthcare team The various types of treatment described may be provided by a range of healthcare professionals who specialise in different treatments. These could include doctors (including gynaecologists and obstetricians), nurses, midwives and ultrasonographers (someone who performs ultrasound scans). All of these healthcare professionals should have been trained to communicate sensitively. A member of your healthcare team should discuss ectopic pregnancy and miscarriage in early pregnancy with you and explain the tests and options available to you in detail. You should have the opportunity to ask any questions you have there is a list of questions you might like to ask to help you with this. Some treatments described may not be suitable for you, depending on your exact circumstances. If you think that your treatment or care does not match this advice, talk to your healthcare team. NICE All rights reserved. Page 2 of 13

3 Giving you support You should be treated at all times with dignity and respect. The healthcare professionals caring for you will be aware that problems in early pregnancy can cause great distress for women and their partners. They should take into account your individual circumstances when giving you support and information, and should be sensitive to how you are feeling. Finding out what's wrong at your GP surgery Signs and symptoms of early pregnancy problems, including ectopic pregnancy If you are having signs and symptoms of early pregnancy problems, your doctor will want to find out what is causing them. For example, it may mean you are having a miscarriage or have an ectopic pregnancy. An ectopic pregnancy is where the baby develops outside of the womb, usually in the fallopian tubes (which lie between the womb and the ovaries). It is very important to make an accurate diagnosis of an ectopic pregnancy because if left untreated it can rupture and cause serious complications. Ectopic pregnancy can be mistaken for other conditions because the symptoms are sometimes similar for example, a stomach upset or urinary infection. But in the case of an ectopic pregnancy, there will be a positive pregnancy test. Therefore, if you have gone to see your GP with symptoms and you haven't taken a pregnancy test recently, your GP may offer you one because they want to rule out an ectopic pregnancy. Common signs and symptoms of an ectopic pregnancy can include pain or tenderness (or both) in the abdomen or pelvis, 1 or more missed periods and vaginal bleeding. Other symptoms can include a fast heartbeat (over 100 beats a minute), dizziness or fainting. If you have pelvic tenderness or pain and abdominal tenderness and your GP thinks you may have an ectopic pregnancy, he or she should refer you straight away to an early pregnancy assessment service for further tests. If it is outside of working hours and the service is closed you should be able to go to an out-of-hours gynaecology service, such as a hospital gynaecology ward. There is more information on early pregnancy assessment services in Finding out what's wrong at an early pregnancy assessment service. You may also be offered an appointment at an early pregnancy assessment service if you have symptoms suggesting early pregnancy problems and you are at least 6 weeks pregnant or it's not clear how long you have been pregnant. NICE All rights reserved. Page 3 of 13

4 If you are offered an appointment at an early pregnancy assessment service you should be told why, and what to expect when you get there. If you have symptoms or signs of early pregnancy problems when you visit an accident and emergency department or antenatal service, the doctor,, midwife or nurse will also be able to refer you to an early pregnancy assessment service. You may need to go straight to an accident and emergency department if your blood pressure is very low or your GP is very concerned about the level of pain or bleeding. If your GP tells you to wait It is often difficult to know how the pregnancy is going to progress if you identify problems before 6 weeks. Therefore, if you are bleeding but not in pain your GP should advise you to take a home pregnancy test after 7 10 days. You should return if the test shows that you are pregnant, or your symptoms continue. If symptoms get worse you will need to return sooner. If you return to your GP and he or she thinks you may have an ectopic pregnancy or are having a miscarriage, you should be referred to an early pregnancy assessment service. A negative pregnancy test means that the pregnancy has miscarried. If you have had a miscarriage you should be given information on where to get support and help from counselling services. If you have had an early pregnancy loss you should be offered a follow-up appointment and be able to choose which healthcare professional you see. Finding out what's wrong at an early pregnancy assessment service An early pregnancy assessment service (EPAS) is a special service to help women with problems in early pregnancy. Healthcare professionals at the service will diagnose the problem through a series of ultrasound scans and you may be offered blood tests. This will help them to decide on the most appropriate treatment for you. Your GP will usually arrange your appointment at the early pregnancy assessment service. But if you have had 3 or more previous miscarriages, or had a previous ectopic pregnancy or molar pregnancy, you should be able to book an appointment directly yourself. The service should be available 7 days a week and you should be able to see someone within 24 hours if your condition warrants it. If the service is not open and you need help urgently, you should be referred to an out-of-hours gynaecology service. NICE All rights reserved. Page 4 of 13

5 Having an ultrasound scan At your appointment at the early pregnancy assessment service (or out-of-hours gynaecology service) you should be offered an ultrasound scan. What does the scan show? The scan will help to show whether the pregnancy is in the womb or another place. If the pregnancy is in the womb, the scan may be able to show if it is continuing. How is the scan done? The scan is usually done using a small device called a probe which is inserted into the vagina (this is called a transvaginal ultrasound scan), as this method provides the most accurate results. But, if you prefer, you could have a transabdominal ultrasound scan instead, where a probe is moved over the surface of the abdomen. Your healthcare professional should explain to you that they may not be able to see the pregnancy as well with a transabdominal scan. But in some cases your healthcare professional may think that a transabdominal scan would be better for you for example, if you have an enlarged womb, fibroids or an ovarian cyst. Fibroids are non-cancerous growths that develop in the wall of the womb, and an ovarian cyst is a fluid-filled sac that develops in the ovary. Your healthcare professional may be able to tell from the transvaginal ultrasound scan whether you are having (or are likely to have) a miscarriage. However, they should explain that it is not always possible to confirm this from a single scan, especially very early in a pregnancy; therefore you may need a second scan. What will the healthcare professional look for at the scan? When you have a scan your healthcare professional will look for a fetal heartbeat. This can be very difficult to see in early pregnancy. They should also explain that the date of your last period is not always reliable for working out the age of the pregnancy because some women have longer menstrual cycles than others. Results of the scan Pregnancy in the womb with a visible heartbeat If the scan shows a fetal heartbeat, this means the baby is alive. If you are bleeding and it gets worse, or continues for more than 14 days, you should return for more checks. If the bleeding stops, NICE All rights reserved. Page 5 of 13

6 you will be able to have routine antenatal care. (For more information on antenatal care see the NICE clinical guideline on antenatal care, available from Pregnancy in the womb with no visible heartbeat If there is no visible heartbeat this does not always mean there is a problem it may just be too early to see. Your healthcare professional will look for the 'fetal pole' (the name given to the earliest sign of a developing baby that is visible by scan). If the fetal pole is visible, your healthcare professional should measure it. If it is not visible, he or she should measure the fetal sac (where the fetal pole develops). Having no visible fetal pole does not necessarily mean you will have a miscarriage. Your healthcare professional may ask a colleague for a second opinion, or do a second scan, or both. The second scan should happen at least 7 days after the first (or at least 14 days after if you have had a transabdominal scan). Some women may need to have more than 2 scans. You should be told what to expect while waiting for a repeat scan, and that waiting will not alter the outcome of the pregnancy. You should be given a 24-hour telephone number so you can phone for advice in an emergency. Pregnancy not visible on scan If your pregnancy isn't visible on the scan, your healthcare professional should measure the level of a hormone in your blood called human chorionic gonadotrophin (hcg), which is produced during pregnancy. This will involve having a blood test followed by another one at least 48 hours later. It will show whether the pregnancy is likely to be developing. You should be given written information on what to do if you have any new or worsening symptoms, which should include information on how to make use of 24-hour emergency care. If there is a large rise in hcg levels between the first and second blood tests, the pregnancy is unlikely to be ectopic. You should be offered a scan 7 14 days later to confirm this, or sooner if your hcg levels are very high. If the pregnancy is not ectopic, you should be able to have routine antenatal care (for more information on antenatal care see But if a healthy pregnancy in the womb cannot be confirmed at this scan, you should be offered an appointment with a gynaecologist straight away to rule out an ectopic pregnancy. If there is a large drop in hcg levels the pregnancy is unlikely to continue. If this happens, your healthcare professional should give you information about where you can get support and counselling. Your healthcare professional should advise you to take a home pregnancy test 14 days after the blood test to confirm the test results. If the test shows you are not pregnant, NICE All rights reserved. Page 6 of 13

7 you will not need to do anything else, as it means the pregnancy has miscarried. If it still shows you are pregnant, you should return to the early pregnancy assessment service within 24 hours. If it is not clear from the blood tests whether your pregnancy is developing in the womb, you should be given an appointment to see a healthcare professional within 24 hours. Complete miscarriage If you have been diagnosed with a complete miscarriage on an ultrasound scan, your healthcare professional should tell you to come back for further assessment if your symptoms continue, so that they can rule out an ectopic pregnancy. Giving you information during your care You and, if you agree, your partner should be given information based on the best research, including (as appropriate): When and how to seek help if symptoms worsen or new symptoms develop, including a 24-hour contact telephone number. What to expect while you are waiting for an ultrasound scan. What to expect during your care, such as the potential length and extent of pain and/or bleeding and possible side effects. 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 you become pregnant again. Information about the likely impact of your treatment on future fertility. Where to find support and counselling services, including leaflets, web addresses and helpline numbers for support organisations. You should be given enough time to discuss these issues with your healthcare professional and be able to make an additional appointment if you need more time. NICE All rights reserved. Page 7 of 13

8 Treatment for miscarriage Letting nature take its course If you are having a miscarriage, your healthcare professional should advise you to wait for 7 14 days for the miscarriage to occur naturally. They should explain exactly what will happen when you miscarry naturally and that most women will need no further treatment. But if waiting isn't acceptable to you, you should be offered drugs instead to help the miscarriage process. There is more information on drug treatment in Having treatment with drugs. You should be given written information about what usually happens during a miscarriage. This should include advice on pain relief, and where and when to get help in an emergency. You should also be given information about other treatment options. There is more information on treatment options in Having treatment with drugs and Having an operation. If the pain and bleeding have lessened or stopped completely within the 7 14 days, this may mean that the miscarriage has finished. You should be advised to take a home pregnancy test after 3 weeks. If the test shows you are still pregnant, you may need to have further tests to make sure that you don't have a molar pregnancy or an ectopic pregnancy. If the pain and bleeding haven't started within the 7 14 days, or are continuing or getting worse, this could mean that the miscarriage hasn't begun, or that it hasn't finished. In this case you should be offered another scan. Your healthcare professional should discuss with you the different options available, to help you choose the one that is right for you. You may decide to continue to wait for the miscarriage to occur naturally, or to have drug treatment or surgery. If you choose to continue to wait, your healthcare professional should check your condition again at least 14 days later. Your healthcare professional will explore other options with you if: you are at increased risk of bleeding you have had a previous difficult or traumatic experience during pregnancy, such as a miscarriage, stillbirth or bleeding later in pregnancy you are at increased risk from the effects of heavy bleeding for example, you are unable to have a blood transfusion or you have an infection. There is more information on treatment options in Having treatment with drugs and Having an operation. NICE All rights reserved. Page 8 of 13

9 Having treatment with drugs You may be offered a drug called misoprostol to help you pass any tissue that is left in your womb if you have: a missed miscarriage (where an ultrasound scan has confirmed that the pregnancy cannot continue to term, but you have had no pain and bleeding), also known as a 'delayed' or 'silent' miscarriage or an incomplete miscarriage (where a miscarriage has started but there is still some pregnancy tissue in the womb). Misoprostol is usually taken vaginally, but you should be able to have the oral form (to take by mouth) if you prefer. This form of treatment can cause pain and vomiting, so you should be offered drugs to help with this. You should not be offered a different drug called mifepristone for a missed or incomplete miscarriage. You should be given information about what to expect throughout the process, including how long the bleeding is likely to last and how heavy it will be, and the possible side effects of treatment including pain, diarrhoea and vomiting. You should be advised to take a home pregnancy test 3 weeks after taking the misoprostol. However, if your symptoms get worse during this time, you should return to the healthcare professional who gave you the misoprostol. If the pregnancy test shows you are still pregnant, you may need to have further tests to make sure that you don't have a molar pregnancy or an ectopic pregnancy. If bleeding hasn't started within 24 hours of taking the misoprostol, you should contact your healthcare professional, who will advise you about what care would be best for you. Having an operation Some women are offered surgery for a missed miscarriage or an incomplete miscarriage. The procedure involves removing any remaining tissue from inside the womb using a suction device. If it is clinically appropriate you should be offered the choice of having a local anaesthetic (where the womb and surrounding area is made numb) in an outpatient clinic, or having a general anaesthetic (where you will be unconscious) in an operating theatre. Your healthcare professional should give you information (including written information) about these treatment options and what to expect NICE All rights reserved. Page 9 of 13

10 during and after the procedure. If your blood group is rhesus D negative you should be offered anti- D injections. Treatment for ectopic pregnancy If you have been told you have an ectopic pregnancy, your healthcare professional should take into account your hcg levels, the size of the pregnancy and whether there is a visible heartbeat. They will also ask you if you are in any pain. They will then recommend treatment based on this information. This will be either surgery or a drug called methotrexate, or in some circumstances you may be given the choice. You should be given information on how you can contact a healthcare professional for advice and about what happens after the procedure (if you have surgery), and where and when to get help in an emergency. Your doctor should tell you that you can go straight to an early pregnancy assessment service without waiting for a doctor's referral in future pregnancies if you have any early problems. Having treatment with drugs You should only be offered methotrexate if you are able to come back for your follow-up appointments, otherwise you should be offered surgery. If you have significant pain, surgery is the treatment of choice. If you decide to have methotrexate, you will need to have the hcg hormone levels in your blood measured twice in the first week after treatment, then once a week until it shows there is no longer any hcg in your blood. If your hcg levels aren't decreasing or they're increasing, you should be assessed for further treatment. If you have strong reasons for not wanting to take methotrexate, surgery may be an option (see below). Having an operation If you are offered surgery, it should be done using a procedure called a salpingectomy to remove 1 of your fallopian tubes, unless there are risk factors for infertility. The surgeons should use laparoscopic (keyhole) surgery if possible. If you have laparoscopic surgery it usually means you spend less time in hospital and recover more quickly than with conventional surgery. If you are rhesus D negative you should be offered anti-d injections. You should be advised to take a home pregnancy test 3 weeks after the procedure. If the test shows that you are still pregnant, you should return for further checks. If you have risk factors for infertility for example, if your fallopian tubes are damaged you may be offered a procedure called a salpingotomy to remove the ectopic pregnancy by making a cut in NICE All rights reserved. Page 10 of 13

11 the fallopian tube. Your healthcare professional should tell you that up to 1 in 5 women may need further treatment after this procedure. This could include methotrexate or a salpingectomy, or both of these. If you decide to have a salpingotomy, you should have your hcg levels checked 7 days after surgery, then once a week after that until it shows there is no longer any hcg in your blood. Choosing between drug treatment and surgery If you fulfil certain criteria you may be offered a choice of either methotrexate or surgery. If you choose methotrexate, you should be advised that there's a chance that you may still need emergency surgery despite methotrexate treatment. Questions to ask about ectopic pregnancy and miscarriage These questions may help you discuss your condition or the treatments you have been offered with your healthcare team. Finding out what's wrong (diagnosis) Can you tell me more about the tests/investigations you've offered me? What do these tests involve? Where will these be carried out? Will I need to have them in hospital? How long will I have to wait until I have these tests? How long will it take to get the results of these tests? About your condition Can you tell me more about ectopic pregnancy and miscarriage? Are there any support organisations in my local area? Can you provide any information for my family/carers? Treatments Can you tell me why you have decided to offer me this particular type of treatment? What are the pros and cons of this treatment? NICE All rights reserved. Page 11 of 13

12 What will it involve? How will it help me? What effect will it have on my symptoms and everyday life? What sort of improvements might I expect? How long will it take to have an effect? Are there any risks associated with this treatment? What are my options for taking treatments other than the one you have offered me? Is there some other information (like a leaflet, DVD or a website I can go to) about the treatment that I can have? Side effects What should I do if I get any side effects? (For example, should I call my GP, or go to the emergency department at a hospital or the early pregnancy assessment service?) Are there any long-term effects of taking this treatment? For family members, friends or carers What can I/we do to help and support the person with ectopic pregnancy or miscarriage in early pregnancy? Is there any additional support that I/we as carer(s) might benefit from or be entitled to? Following up on your treatment When should I start to feel better and what should I do if I don't start to feel better by then? Are there different treatments that I could try? Who do I call in an emergency? Sources of advice and support The Miscarriage Association, The Ectopic Pregnancy Trust, NICE All rights reserved. Page 12 of 13

13 The Birth Trauma Association, You can also go to NHS Choices ( for more information. NICE is not responsible for the quality or accuracy of any information or advice provided by these organisations. Other NICE guidance Routine antenatal care for healthy pregnant women. NICE clinical guideline 62 (2008). See Accreditation NICE All rights reserved. Page 13 of 13

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