NICE guidelines on miscarriage and ectopic pregnancy

The Miscarriage Association warmly welcomes the publication today of new guidelines on the diagnosis and management of miscarriage and ectopic pregnancy.

Developed and published by NICE, the guidelines recommend that women who experience miscarriage or ectopic pregnancy should receive “good, consistent, timely and effective care and support that addresses their needs and enables them to make informed decisions.”

Please read our full response below.

The Miscarriage Association warmly welcomes the new NICE[i] guidelines on the diagnosis and management of miscarriage and ectopic pregnancy.

The guidelines give the clear message that care for women who experience pain and bleeding in early pregnancy must be of high quality, evidence-based and effective and that standards should be consistent across the country.

The detailed framework for clinical care includes the importance of providing clear and accurate information and support for patients and their partners.  It also recognises that this may require additional training for the staff who care for them.  The Miscarriage Association is keen to use its resources and experience to support these recommendations.

We fully endorse the following principles and recommendations:

• The need for consistent and high quality care for women who experience pain and bleeding in early pregnancy.
  • At present, standards and care pathways vary considerably

• Dedicated early pregnancy assessment services to be organised to provide specialist services 7 days a week.
  • At present, opening hours and referral systems vary widely

• The importance of timely diagnosis – or ruling out – of ectopic pregnancy to reduce the risk of serious complications
  • Ectopic pregnancy may not be suspected by the woman or her doctor, especially if there are no obvious symptoms

• The recommendation of a second scan, where appropriate, to confirm the diagnosis of miscarriage rather than a viable pregnancy
  • A single scan may not be 100% accurate, especially in early pregnancy

• The need for emotional support and information-giving
  • Dignity, respect, sensitivity and good communication are crucial to every patient (and her partner)
  • Explanations and information must be clear, accurate and understandable
  • Information should take account of individual needs, including language or comprehension difficulties.
  • Medical terminology should be sensitive to patients’ feelings: miscarriage, not abortion; remains of your baby/pregnancy, not products of conception

• Recommendation of high quality research into the effectiveness and risks of progesterone in threatened miscarriage
  • We need to know if progesterone might reduce the risk of miscarriage; and if so, to ensure it has no risks for mother or baby

We cannot, however, endorse the following recommendations/exclusions:

• Expectant management (letting nature take its course, as against medical or surgical management) as the first-line response in confirmed miscarriage
  • This removes patient choice – a crucial component of the patient-centred care which the guideline generally recommends
  • Previous research indicates that most women have a definite preference for one management method or another
  • Enforced waiting once miscarriage is confirmed can be extremely distressing for the woman and her partner

We believe that as long as the woman is clinically stable, offering informed choice of all available and clinically appropriate management options should be the first-line strategy in confirmed diagnosis of non-viable pregnancy.

• The exclusion of molar (hydatidiform mole) pregnancy from the guideline.
  • This form of pregnancy loss is most often diagnosed after surgical management of miscarriage and we believe the guideline should include a general statement regarding recommended means of contact, information and referral.
  • See also http://www.miscarriageassociation.org.uk/wp-content/uploads/2016/10/Molar-Pregnancy.pdf