Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management

Overview

This Guidelines summary on the topic of ectopic pregnancy and miscarriage includes recommendations on support and information, early pregnancy assessment services, symptoms and signs, initial assessment, and management of miscarriage.

This summary is intended for use by primary care health professionals, and therefore does not include recommendations on diagnosis of viable intrauterine pregnancy; medical or surgical management of miscarriage; diagnosis and management of tubal ectopic pregnancy; or anti-D immunoglobulin prophylaxis. For recommendations in these areas, refer to the full guideline.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Support and Information Giving

• Treat all women with early pregnancy complications with dignity and respect. Be aware that women will react to complications or the loss of a pregnancy in different ways. Provide all women with information and support in a sensitive manner, taking into account their individual circumstances and emotional response. For more guidance about providing information, see the NICE guideline on patient experience in adult NHS services.
• Healthcare professionals providing care for women with early pregnancy complications in any setting should be aware that early pregnancy complications can cause significant distress for some women and their partners. Healthcare professionals providing care for these women should be given training in how to communicate sensitively and breaking bad news. Non-clinical staff such as receptionists working in settings where early pregnancy care is provided should also be given training on how to communicate sensitively with women who experience early pregnancy complications. For more guidance about support, see the recommendation on traumatic birth, stillbirth, and miscarriage in the NICE guideline on antenatal and postnatal mental health.
• Throughout a woman's care, provide the woman and (with her consent) her partner specific evidence-based information in a variety of formats. This should include (as appropriate):
  • when and how to seek help if existing symptoms worsen or new symptoms develop, including a 24-hour contact telephone number
  • what to expect during the time she is waiting for an ultrasound scan
  • what to expect during the course of her care (including expectant management), such as the potential length and extent of pain and/or bleeding, and possible side effects; this information should be tailored to the care she receives
  • information about postoperative care (for women undergoing surgery)
  • 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 she becomes pregnant again; this information should be tailored to the care she receives
  • information about the likely impact of her treatment on future fertility
  • where to access support and counselling services, including leaflets, web addresses and helpline numbers for support organisations.

    Ensure that sufficient time is available to discuss these issues with women during the course of her care and arrange an additional appointment if more time is needed.

• After an early pregnancy loss, offer the woman the option of a follow-up appointment with a healthcare professional of her choice.

Early Pregnancy Assessment Services

• Regional services should be organised so that an early pregnancy assessment service is available 7 days a week for women with early pregnancy complications, where scanning can be carried out and decisions about management made.
• An early pregnancy assessment service should:
  • be a dedicated service provided by healthcare professionals competent to diagnose and care for women with pain and/or bleeding in early pregnancy and
  • offer ultrasound and assessment of serum human chorionic gonadotrophin (hCG) levels and
  • be staffed by healthcare professionals with training in sensitive communication and breaking bad news.
• Early pregnancy assessment services should accept self-referrals from women who have had recurrent miscarriage or a previous ectopic or molar pregnancy. All other women with pain and/or bleeding should be assessed by a healthcare professional (such as a GP, accident and emergency [A&E] doctor, midwife or nurse) before referral to an early pregnancy assessment service.
• Ensure that a system is in place to enable women referred to their local early pregnancy assessment service to attend within 24 hours if the clinical situation warrants this. If the service is not available, and the clinical symptoms warrant further assessment, refer women to the nearest accessible facility that offers specialist clinical assessment and ultrasound scanning (such as a gynaecology ward or A&E service with access to specialist gynaecology support).

Symptoms and Signs of Ectopic Pregnancy and Initial Assessment

• Refer women who are haemodynamically unstable, or in whom there is significant concern about the degree of pain or bleeding, directly to A&E
• Be aware that atypical presentation for ectopic pregnancy is common.
• Be aware that ectopic pregnancy can present with a variety of symptoms. Even if a symptom is less common, it may still be significant. Symptoms of ectopic pregnancy include:
  • common symptoms:
    • abdominal or pelvic pain
    • amenorrhoea or missed period
    • vaginal bleeding with or without clots.
  • other reported symptoms:
    • breast tenderness
    • gastrointestinal symptoms
    • dizziness, fainting or syncope
    • shoulder tip pain
    • urinary symptoms
    • passage of tissue
    • rectal pressure or pain on defecation.
• Be aware that ectopic pregnancy can present with a variety of signs on examination by a healthcare professional. Signs of ectopic pregnancy include:
  • more common signs:
    • pelvic tenderness
    • adnexal tenderness
    • abdominal tenderness.
  • other reported signs:
    • cervical motion tenderness
    • rebound tenderness or peritoneal signs
    • pallor
    • abdominal distension
    • enlarged uterus
    • tachycardia (more than 100 beats per minute) or hypotension (less than 100/60 mmHg)
    • shock or collapse
    • orthostatic hypotension.
• During clinical assessment of women of reproductive age, be aware that:
  • they may be pregnant, and think about offering a pregnancy test even when symptoms are non-specific and
  • the symptoms and signs of ectopic pregnancy can resemble the common symptoms and signs of other conditions – for example, gastrointestinal conditions or urinary tract infection.
• All healthcare professionals involved in the care of women of reproductive age should have access to pregnancy tests.
• Refer immediately to an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available) for further assessment of women with a positive pregnancy test and the following on examination:
  • pain and abdominal tenderness or
  • pelvic tenderness or
  • cervical motion tenderness.
• Exclude the possibility of ectopic pregnancy, even in the absence of risk factors (such as previous ectopic pregnancy), because about a third of women with an ectopic pregnancy will have no known risk factors.
• Refer to an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available) women with bleeding or other symptoms and signs of early pregnancy complications who have:
  • pain or
  • a pregnancy of 6 weeks' gestation or more or
  • a pregnancy of uncertain gestation.
    
    The urgency of this referral depends on the clinical situation.
• Use expectant management for women with a pregnancy of less than 6 weeks' gestation who are bleeding but not in pain, and who have no risk factors, such as a previous ectopic pregnancy. Advise these women:
  • to return if bleeding continues or pain develops
  • to repeat a urine pregnancy test after 7 to 10 days and to return if it is positive
  • a negative pregnancy test means that the pregnancy has miscarried.
• Refer women who return with worsening symptoms and signs that could suggest an ectopic pregnancy to an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available) for further assessment. The decision about whether she should be seen immediately or within 24 hours will depend on the clinical situation.
• If a woman is referred to an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available), explain the reasons for the referral and what she can expect when she arrives there.

Management of Miscarriage

Threatened Miscarriage

• Advise a woman with a confirmed intrauterine pregnancy with a fetal heartbeat who presents with vaginal bleeding, but has no history of previous miscarriage, 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.
• Offer vaginal micronised progesterone 400 mg twice daily to women with an intrauterine pregnancy confirmed by a scan, if they have vaginal bleeding and have previously had a miscarriage.
• If a fetal heartbeat is confirmed, continue progesterone until 16 completed weeks of pregnancy.
  
  In November 2021, this was an off-label use of vaginal micronised progesterone. See NICE's information on prescribing medicines.

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.
• Offer medical management to women with a confirmed diagnosis of miscarriage if expectant management is not acceptable to the woman.
• 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.
• 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. See also the third recommendation in the section Support and Information Giving for details of further information that should be provided.
• If the resolution of bleeding and pain indicate that the miscarriage has completed during 7 to 14 days of expectant management, provide the woman or person with a urine pregnancy test to carry out at home 3 weeks after their miscarriage, and advise them to return for individualised care if it is positive.
• 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.
• 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.

For recommendations on medical and surgical management of miscarriage, and on management of tubal ectopic pregnancy and anti-D immunoglobulin prophylaxis, refer to the full guideline.