Our national investigation into the diagnosis of ectopic pregnancy found that differing levels of provision and a mismatch between capacity and demand in early pregnancy units (EPUs) heightens the risk that the diagnosis of this time-critical condition is delayed or missed.
Risk of severe harm and death
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. National incident data from the NHS shows that between April 2017 and August 2018 there were 30 missed ectopic pregnancies leading to ‘serious harm’.
In the case that HSIB examined, 26-year old Abby presented at her emergency department (with a suspected urinary tract infection and unable to pass urine) on Saturday. Following a positive pregnancy test, she was referred to an EPU for scan on the same day and discharged home. Abby didn’t have a scan until Tuesday (after following up with the EPU over the weekend). By then, she was found to have a ruptured ectopic pregnancy requiring emergency surgery for significant blood loss.
Difficult to diagnose
There are around 12,000 cases of ectopic pregnancy a year in the UK, but the symptoms are non-specific and can be hard to differentiate from a range of other gynaecological conditions or bladder, bowel, gastrointestinal problems. They can only be reliably diagnosed in an EPU via a transvaginal ultrasound scan (TVUS) and the investigation found that this places pressure on services. Trusts are struggling to meet the seven-day cover needed and provide the level of skilled and experienced sonographers needed to carry out and accurately interpret the scan.
The lack of consistent information is also a key risk factor in delayed diagnosis. Women cannot normally self-refer to EPUs, making it even more important that the information shared in the referral from emergency departments aids EPU staff to assess risk and prioritise patients. The investigation found that currently information given to women on discharge from the emergency department (whilst waiting to be assessed by an EPU) is varied across the country and can create confusion. In Abby’s case, she was given a leaflet about ‘bleeding in early pregnancy’ which didn’t highlight the signs and symptoms to look out for when suffering a ruptured ectopic pregnancy.
Our report sets out four safety recommendations in response to the findings.
They are focused on:
- Updating clinical information to include ectopic pregnancy as a possible alternative/serious diagnosis to lower urinary tract infection.
- Standardising the information that women receive on discharge from the emergency department.
- Providing expert guidance on the type and level of information that EPUs should collect to identify those at risk.
- Including assessment on early pregnancy services especially relating to potential complications in CQC inspections.
Early pregnancy units stretched
Dr Lesley Kay, Deputy Medical Director at HSIB, said: “Ectopic pregnancy is a common cause of death in early pregnancy and, as Abby’s case highlighted, even if not fatal the effects are distressing and far reaching. Women can suffer with long-term psychological trauma and it can impact on their future fertility.
“If an ectopic pregnancy is diagnosed early, it is likely it can be treated effectively and perhaps avoiding the need for invasive surgery. That’s why it’s important that our investigation focused on the factors that lead to delays and highlights where improvements can be made.
“We recognise that early pregnancy units are stretched, and that Trusts are doing what they can to deliver a good level of care to their patients. Through our investigation we offer a national view and our safety recommendations have been made to help improve consistency in care across England. Aiding that diagnostic process will help to reduce the risk of delays and reduce the devastating risk of severe harm or death in early pregnancy.”
Alex Peace-Gadsby, Chair of The Ectopic Pregnancy Trust, said: “The EPT welcomes HSIB’s findings which highlights key information gaps in ectopic pregnancy. We often hear of women being misdiagnosed and taking action on the safety recommendations on diagnosis and discharge information in particular will make a big difference in ensuring women get the right care quickly. Together with effective information gathering and CQC assessment, these recommendations can be game-changing for ectopic pregnancy care.”
Read the report
For more information, including the safety recommendations in full, download and read ‘the diagnosis of ectopic pregnancy’ report.