The diagnosis of ectopic pregnancy

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

National investigation

This patient safety investigation explores the diagnosis of ectopic pregnancy.

An estimated 12,000 women experience an ectopic pregnancy each year in the UK. Ectopic pregnancy occurs when the fertilised egg implants outside the uterus, usually in the Fallopian tube. If it’s left untreated, it can rupture and cause internal bleeding, putting women at risk of severe harm and death. Ectopic pregnancy may also impact on a woman’s fertility.

Most ectopic pregnancies can be diagnosed by a transvaginal ultrasound scan (TVUS). These scans are commonly undertaken in hospital-based early pregnancy units (EPU).

National incident data from the NHS shows that between April 2017 and August 2018 there were 30 missed ectopic pregnancies leading to ‘serious harm’.

Reference event

The reference event in this investigation follows the care of a 26-year-old woman who experienced a delayed diagnosis of an ectopic pregnancy.

She first went to a local minor injuries unit with abdominal pain on a Saturday morning. She was then advised to go to the emergency department with a suspected urinary tract infection. Following a positive pregnancy test, she was suspected by a doctor to have a problem in early pregnancy and was referred to an EPU for a TVUS within 24 hours and discharged home.

She followed up with the EPU over the weekend but, although she remained in a lot of pain, didn’t have a scan until Tuesday. By then she was found to have a ruptured ectopic pregnancy that required emergency surgery for significant blood loss.

Investigation summary

The investigation looks at:

Referral from emergency departments to early pregnancy services.
The provision of early pregnancy services to diagnose and manage ectopic pregnancy.
Information that women receive on discharge from the emergency department.

Safety recommendations

National Institute for Health and Care Excellence

It is recommended that the National Institute for Health and Care Excellence should review and revise the clinical knowledge summary for ‘urinary tract infection (lower) – women’ to include ectopic pregnancy as a category under ‘alternative or serious diagnoses’.

NICE supports the recommendation to review and revise the clinical knowledge summary (CKS) for ‘urinary tract infection (lower) – women’, to include ectopic pregnancy as a category under alternative or serious diagnoses.

We have commissioned the CKS from an organisation called Clarity, and have discussed the HSIB recommendations.

Clarity has amended the topic to add ectopic pregnancy as an alternative or serious diagnosis to the differential diagnosis page in December 2019.

Response received on 11 March 2020.

Royal College of Emergency Medicine

It is recommended that the Royal College of Emergency Medicine should provide standardised discharge information for clinicians to offer to women following discharge from the emergency department with a problem in early pregnancy and while awaiting further assessment by early pregnancy services.

The Royal College of Emergency Medicine (RCEM) is happy to accept the safety recommendation made by HSIB.

The RCEM will be developing a patient leaflet template to be made available on the RCEM website.

The template will form the basis for a discharge advice leaflet. Clinicians can offer the leaflet to women who have been discharged from emergency departments after experiencing a problem in early pregnancy and who need to attend an early pregnancy service at a later date.

Clinicians can adapt the template to reflect their local service arrangements and include relevant details of their local departments.

In addition to the leaflet template, the RCEM will be releasing a safety flash that will reference the event from the HSIB investigation as well as a link to the HSIB report.

The safety flash will also include a link to the RCEM leaflet template and RCEM recommendations on important information to be included in the discharge leaflet.

Response received on 6 January 2021.

Royal College of Obstetricians and Gynaecologists

It is recommended that the Royal College of Obstetricians and Gynaecologists should provide guidance on the information that should be provided during referral to early pregnancy units to standardise and improve the flow of information required to identify those most at risk from ectopic pregnancy and any consequent deterioration

We were very concerned to hear about any missed ectopic pregnancy as the complications are very serious and can be life threatening.

Early diagnosis and treatment is crucial, and more could be done to improve early detection methods and raise awareness of the symptoms so women and their clinicians can recognise that something is wrong as soon as possible.

It is also essential that information between health professionals is shared in a streamlined and efficient fashion during referral to early pregnancy units so action can be taken swiftly.

We acknowledge HSIB’s safety recommendation in the report and we will include it in the next update of our guidance which is currently underway. We will also work with the Royal College of Emergency Medicine to ensure consistency of approach across all acute settings.

Symptoms of ectopic pregnancy can include vaginal bleeding, abdominal pain, shoulder tip pain and discomfort going to the toilet. Women presenting with these symptoms and a positive pregnancy test should be offered referral to a local early pregnancy unit for ongoing care.

We have information for women and their families about ectopic pregnancy on our website, including symptoms, when to seek advice, risks and diagnosis and treatment options. The information is also available in a print and audio leaflet.

We are updating the RCOG Green-top Guideline (no 21) on the Diagnosis and Management of Ectopic Pregnancy to include the information that should be provided during referral to early pregnancy units.

This information standardises and improves the flow of information required to identify those most at risk from ectopic pregnancy and any consequent deterioration. It is expected the guideline will be published during 2023.

Response received on 16 December 2021.

Care Quality Commission

It is recommended that the Care Quality Commission Services Framework for Gynaecology and Termination Services includes an assessment of early pregnancy services, using as a reference the National Institute for Health and Care Excellence Guideline 126, Ectopic pregnancy and miscarriage: diagnosis and initial management.

CQC fully supports HSIB’s safety recommendations.

Implementation was planned for April 2020. This work has been delayed by the impact of the Covid-19 but this important recommendation will be brought into our future framework.

Response received on 10 September 2020.

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