Letters NICE on ectopic pregnancy and miscarriage

NICE guidance on ectopic pregnancy and miscarriage restricts access and choice and may be clinically unsafe

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f197 (Published 22 January 2013) Cite this as: BMJ 2013;346:f197
  1. Tom Bourne, consultant gynaecologist1,
  2. Kurt Barnhart, professor of obstetrics and gynecology and epidemiology2,
  3. Carol B Benson, professor of radiology3,
  4. Jan Brosens, professor of obstetrics and gynaecology4,
  5. Ben Van Calster, professor in medical statistics5,
  6. George Condous, associate professor of gynaecology6,
  7. Arri Coomerasamy, professor of gynaecology7,
  8. Peter M Doubilet, professor of radiology3,
  9. Steven R Goldstein, professor of obstetrics and gynecology8,
  10. Deborah Gould, consultant obstetrician and gynaecologist9,
  11. Emma Kirk, specialist registrar in obstetrics and gynaecology10,
  12. Ben Willem Mol, professor of obstetrics and gynaecology and clinical epidemiology11,
  13. Nicholas Raine-Fenning, clinical associate professor and reader in reproductive medicine and surgery 12,
  14. Catriona Stalder, consultant in emergency gynaecology13,
  15. Dirk Timmerman, professor in obstetrics and gynaecology5
  1. 1Queen Charlotte’s and Chelsea Hospital, Imperial College, London, UK, and Department of Development and Regeneration, University Hospitals, KU Leuven, Belgium
  2. 2Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
  3. 3Harvard Medical School, Boston, USA
  4. 4Division of Reproductive Health, Warwick Medical School, University of Warwick, Coventry, UK
  5. 5Department of Development and Regeneration, KU Leuven, Belgium
  6. 6University of Sydney, Sydney, Australia
  7. 7School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
  8. 8New York University Medical Center, New York, USA
  9. 9St Mary’s Hospital, Imperial College NHS Trust, London, UK
  10. 10Whittington Hospital, London, UK
  11. 11AMC, Amsterdam, Netherlands
  12. 12Faculty of Medicine and Health Sciences, Queen’s Medical Centre, Nottingham, UK
  13. 13Queen Charlotte’s and Chelsea Hospital, Imperial College NHS Trust, London, UK
  1. t.bourne{at}imperial.ac.uk

We welcome National Institute for Health and Clinical Excellence (NICE) guidance on wider use of pregnancy tests in primary care and its focus on considering ectopic pregnancy (EP), but we are worried about recommendations that restrict access, limit choice, and may be clinically unsafe.1

  • 1 Women should not have access to care restricted. We cannot exclude EP in symptomatic women less than six weeks’ pregnant, and many women have inaccurate dates.2 NICE stipulates that women see another clinician before accessing early pregnancy assessment. This is illogical and without ultrasonography will delay appropriate care and duplicate intimate examinations.

  • 2 NICE suggests women with pregnancy of unknown location and human chorionic gonadotrophin (HCG) changes over 48 hours between −50% and 63% are “at risk” for EP. Using this algorithm, 20% of women with EP would be classified as low risk and not be referred for ultrasonography. Such missed cases will often have high HCG ratios, which may be very dangerous.3

  • 3 NICE recommends initial expectant management for miscarriage. However women must be informed of medical and surgical treatment at diagnosis. Women’s choices about managing their pregnancy loss should not be rationed.

  • 4 NICE recommends methotrexate as first line treatment of EP and does not consider expectant management. Optimal management of unruptured EP is unclear and this recommendation may lead to inappropriate methotrexate use, with inherent morbidity. Errors with methotrexate occur when pregnancy location and viability are misdiagnosed; miscarriage and fetal abnormalities in survivors are possible if the pregnancy is intrauterine. NICE recommendations could result in women with normal pregnancies being more likely to receive methotrexate, and this is being reported more often, particularly in the US.4 Avoiding this depends on ultrasound quality and correct interpretation of serum biochemistry.

  • 5 The Irish Health Service Executive miscarriage misdiagnosis inquiry and triennial report into maternal deaths shows that poor training has lethal consequences.5 Lack of ultrasonography competence and appropriate supervision are the main problems in early pregnancy care.

  • 6 Seven day cover has financial implications. Extra staff and training are needed to deliver such services.

  • 7 In cities, rationalising units to provide weekend cover makes sense. Elsewhere, failing to cover weekends may lead to closure of units that provide good local services.

We welcome NICE’s interest in early pregnancy but are worried about erosion of choice and recommendations for potentially unsafe practice. We urge NICE to reconsider aspects of this guidance.


Cite this as: BMJ 2013;346:f197