Introduction

This quality standard covers the diagnosis and initial management of ectopic pregnancy and miscarriage in women in their first trimester (up to 13 completed weeks of pregnancy). For more information see the topic overview.

Why this quality standard is needed

An ectopic pregnancy occurs when a fertilised egg is located outside the womb (uterus), usually in the fallopian tube. The fertilised egg cannot develop properly outside the womb and may need to be removed. Common signs and symptoms of an ectopic pregnancy can include pain or tenderness (or both) in the abdomen or pelvis, often following 1 or more missed periods and accompanied by light vaginal bleeding. Sometimes women with ectopic pregnancy have non‑specific symptoms such as diarrhoea and it may go unrecognised.

The Centre for Maternal and Child Enquiries report Saving mothers' lives: reviewing maternal deaths to make motherhood safer 2006–2008 states that the rate of ectopic pregnancy in the UK was 11 per 1,000 pregnancies between 2006 and 2008, with a maternal mortality rate of 0.2 per 1,000 estimated ectopic pregnancies. As many as two‑thirds of these maternal deaths may have been associated with inadequate care. Women who cannot access medical help quickly (such as women who are recent migrants, asylum seekers or refugees, or women who have difficulty reading or speaking English) are particularly vulnerable.

When a pregnancy spontaneously ends before the 24th week of pregnancy, it is called a miscarriage. Most miscarriages occur in the first trimester of pregnancy and most cannot be prevented. Between 15% and 20% of clinically confirmed pregnancies spontaneously end before the 13th week.

The quality standard is expected to contribute to improvements in the following outcomes:

  • maternal mortality rates

  • women's experiences of maternity services

  • safety incidents involving severe harm.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measureable quality improvements within a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcome frameworks published by the Department of Health:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2014/15

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicator

1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare* (PHOF 4.3)

i Adults

4 Ensuring that people have a positive experience of care

Overarching indicators

4a Patient experience of primary care

4b Patient experience of hospital care

Improvement area

Improving women and their families' experience of maternity services

4.5 Women's experience of maternity services

5 Treating and caring for people in a safe environment and protecting them from avoidable harm

Overarching indicators

5a Patient safety incident reported

5b Safety incident involving severe harm or death

5c Hospital deaths attributable to problems in care

Alignment across the health and social care system

* Indicator complementary with Public Health Outcomes Framework (PHOF)

Table 2 Public Health Outcomes Framework for England 2013–2016

Domain

Objectives and indicators

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

Indicator

4.3 Mortality rate from causes considered preventable* (NHSOF 1a)

Alignment across the health and social care system

* Indicator complementary with NHS Outcomes Framework (NHSOF)

Coordinated services

The quality standard for ectopic pregnancy and miscarriage specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole ectopic pregnancy and miscarriage care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to women experiencing ectopic pregnancy or miscarriage.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high‑quality ectopic pregnancy and miscarriage service are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals involved in assessing, caring for and treating women experiencing an ectopic pregnancy or miscarriage should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting women experiencing an ectopic pregnancy or miscarriage. If appropriate, and with the woman's consent, healthcare professionals should involve family members and carers in the woman's care, but the decision‑making process about investigations, treatment and care should preserve the woman's autonomy.