Clinical Review

Diagnosis and management of first trimester miscarriage

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f3676 (Published 19 June 2013) Cite this as: BMJ 2013;346:f3676

Re: Diagnosis and management of first trimester miscarriage

I am very grateful to Dr Vaughan for her comments. There is little evidence to support the practice of performing vaginal examinations to diagnose ectopic pregnancy. Accuracy of vaginal examination to differentiate between intra- and extrauterine pregnancies is low and some authors have expressed concerns that it could potentially do harm by causing tubal rupture(1). Ruptured ectopic pregnancy should be suspected in all pregnant women presenting with severe abdominal pain or unusual gastro-intestinal symptoms. Abdominal palpation may also help to identify signs of peritonism caused by intra-abdominal bleeding. These women should be referred to the nearest casualty department without delay. It is true that some clinically stable women will also be diagnosed with ectopic pregnancies. In modern clinical practice; however, many unruptured ectopic pregnancies are managed conservatively and clinically stable women are best referred to their local early pregnancy units for ultrasound assessment and advice about the management.

The recent NICE guideline; however, provides ambiguous advice regarding the role of vaginal examination is suspected ectopic pregnancy(2). In the draft document vaginal examination was included in the initial assessment care pathway. After consultation reference to vaginal examination was removed form the final document, but the assessment of cervical motion tenderness was retained. During discussions at the meeting to mark launch of the guideline the majority of experts attending the meeting expressed opinion that vaginal examination should not be routinely performed in the assessment of women with suspected early pregnancy complications.

References
1.Mol BW, Hajenuis P, Engelsbel S, Ankum WM, van der Veen F, Henrika DJ, et al Should patients who are suspected of having an ectopic pregnancy undergo a physical examination? Fertil Steril 1999;71:155-7.

2.National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage. CG154. 2012. http://publications.nice.org.uk/ectopic-pregnancy-and-miscarriage-cg154.

Competing interests: No competing interests

25 June 2013
Davor Jurkovic
Consultant Gynaecologist
University College Hospital
250 Euston Road, London NW1 6BU
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