Ectopic pregnancy and miscarriage: diagnosis and initial management: summary of updated NICE guidance

Diagnosis of tubal ectopic pregnancy

As with the previous version of this guideline, all women presenting with pain or bleeding in early pregnancy are recommended to undergo ultrasound scanning.

• Offer women who attend an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available) a transvaginal ultrasound scan to identify the location of the pregnancy and whether there is a fetal pole and heartbeat. [Based on moderate to very low quality evidence, and the experience and opinion of the Guideline Committee (GC)]

New recommendations have now been added to specifically highlight the ultrasound features that are associated with a tubal ectopic pregnancy. These include some features that are diagnostic of an ectopic pregnancy, as well as features which indicate a high probability or a possibility of ectopic pregnancy. The recommendations highlight the need to consider ultrasound features which indicate a high probability or possibility of an ectopic pregnancy in the context of other features (such as symptoms and signs, and serum human chorionic gonadotropin (hCG) levels) before making a diagnosis.

• When carrying out a transvaginal ultrasound scan in early pregnancy, look for these signs indicating there is a tubal ectopic pregnancy:

  • An adnexal mass, moving separate to the ovary, comprising a gestational sac containing a yolk sac or

  • An adnexal mass, moving separately to the ovary, comprising a gestational sac and fetal pole (with or without fetal heartbeat).

    [Based on low quality evidence and the experience and opinion of the GC]

• When carrying out a transvaginal ultrasound scan in early pregnancy, look for these signs indicating a high probability of a tubal ectopic pregnancy:

  • An adnexal mass, moving separately to the ovary, with an empty gestational sac (sometimes described as a “tubal ring” or “bagel sign”) or

  • A complex, inhomogeneous adnexal mass, moving separate to the ovary.

    If these features are present, take into account other intrauterine and adnexal features on the scan, the woman’s clinical presentation, and serum hCG levels before making a diagnosis. [Based on moderate to very low quality evidence and the experience and opinion of the GC]

• When carrying out a transvaginal ultrasound scan in early pregnancy, look for these signs indicating a possible ectopic pregnancy:

  • An empty uterus or

  • A collection of fluid within the uterine cavity (sometimes described as a pseudo-sac).

    If these features are present, take into account other intrauterine and adnexal features on the scan, the woman’s clinical presentation, and serum hCG levels before making a diagnosis. [Based on moderate to low quality evidence and the experience and opinion of the GC]

• When carrying out a transabdominal or transvaginal ultrasound scan in early pregnancy, look for a moderate to large amount of free fluid in the peritoneal cavity or pouch of Douglas, which might represent haemoperitoneum. If this is present, take into account other intrauterine and adnexal features of the scan, the woman’s clinical presentation, and hCG levels before making a diagnosis. [Based on high to low quality evidence and the experience and opinion of the GC]

The recommendations also describe the importance of checking the uterus and the adnexae when scanning in early pregnancy, to check for a co-existing intrauterine and extrauterine pregnancy (heterotopic pregnancy).

• When carrying out a transabdominal or transvaginal ultrasound scan during early pregnancy, scan the uterus and adnexae to see if there is a heterotopic pregnancy. [Based on the experience and opinion of the GC]

Finally, the recommendations now highlight the need for suitably trained individuals to be involved in the interpretation of early pregnancy ultrasound scans to improve the accuracy of diagnosis.

• All ultrasound scans should be performed or directly supervised and reviewed by appropriately qualified healthcare professionals with training in, and experience of, diagnosing ectopic pregnancies. [Based on the experience and opinion of the GC]

Management of tubal ectopic pregnancy

As with the previous version of the guideline, the options of medical management (using methotrexate) and surgical management (salpingectomy or salpingotomy) are still recommended, and guidance is given for the circumstances in which these should be favoured.

Expectant management of ectopic pregnancy has not previously been recommended as part of the guideline. However, an evidence review identified that expectant management of ectopic pregnancy may be appropriate, safe, and effective in certain circumstances. New recommendations have therefore been added to give guidance on situations in which expectant management may be suitable, and should be offered or considered for women with a confirmed tubal ectopic pregnancy. These include women who are pain-free with a small, tubal ectopic pregnancy and low hCG levels.

• Offer expectant management as an option to women who:

  • Are clinically stable and pain-free and

  • Have a tubal ectopic pregnancy measuring <35 mm with no visible heartbeat on transvaginal ultrasound scan and

  • Have serum hCG levels of ≤1000 IU/L and

  • Are able to return for follow-up.

• Consider expectant management as an option for women who:

  • Are clinically stable and pain-free and

  • Have a tubal ectopic pregnancy measuring <35 mm with no visible heartbeat on transvaginal ultrasound scan and

  • Have serum hCG levels >1000 IU/L and <1500 IU/L and

  • Are able to return for follow up.

    [Based on moderate to very low quality evidence, and the experience and opinion of the GC]

If the criteria above are not met, then women should be offered medical or surgical management of their ectopic pregnancy, according to the existing recommendations.

The guideline also provides recommendations regarding how often hCG levels should be checked, for women receiving expectant management, and how to act on the results:

• For women with a tubal ectopic pregnancy being managed expectantly, repeat hCG levels on days 2, 4, and 7 after the original test, and:

  • If hCG levels drop by ≥15% from the previous value on days 2, 4, and 7, then repeat weekly until a negative result (<20 IU/L) is obtained or

  • If hCG levels do not fall by 15%, stay the same, or rise from the previous value, review the woman’s clinical condition and seek senior advice to help decide further management.

    [Based on the experience and opinion of the GC]

Finally, the recommendations include information to be provided to women about expectant management:

• Advise women that, based on limited evidence, there seems to be no difference following expectant or medical management in:

  • The rate of ectopic pregnancies ending naturally

  • The risk of tubal rupture

  • The need for additional treatment, but that they might need to be admitted urgently if their condition deteriorates

  • Health status, depression or anxiety scores.

    Advise women that the time taken for ectopic pregnancies to resolve and future fertility outcomes are likely to be the same with either expectant or medical management. [Based on moderate to very low quality evidence, and the experience and opinion of the GC]