Excerpt

The guideline covers diagnosis of early pregnancy loss, including the use of ultrasound scanning and biochemical testing. Investigations incur costs and the use of serial measurements may delay decision making. The guideline includes guidance on when senior and/or specialist advice should be sought in order to avoid errors and unnecessary delay.

Treatment for threatened miscarriage has been offered by many clinicians over the years, although it is not freely available to all women. Even though progesterone/progestogen is not licensed for this purpose in the UK, it is commonly prescribed in many countries. The guideline examines the evidence for the risks and benefits of this treatment.

The clinical and cost effectiveness of expectant, surgical and medical management for miscarriage and surgical and medical treatment of ectopic pregnancy are considered, with reviews looking at both the risks and benefits of each strategy in terms of clinical and psychological outcomes. Cost effectiveness is an extremely important component of any guideline, in order to ensure that the limited resources of the National Health Service are used to maximise health benefits for its users. The final advice and selection of first line treatment takes this into account.

The guideline does not cover pregnancy after the first trimester (after 12 completed weeks of pregnancy). It also does not deal with unusual conditions that present with pain and bleeding, such as hydatidiform mole, which require a different form of treatment. Similarly, it does not consider recurrent miscarriage, as this requires more specific investigation and management.

Contents

• 1. Guideline summary
  • 1.1. Guideline development group membership, NCC-WCH staff and acknowledgements
  • 1.2. Care pathway
  • 1.3. Key priorities for implementation
  • 1.4. Recommendations
  • 1.5. Key research recommendations
  • 1.6. Research recommendations
  • 1.7. Schedule for updating the guideline
• 2. Introduction
  • 2.1. Early pregnancy complications
  • 2.2. For whom is this guideline intended
  • 2.3. Related NICE guidance
• 3. Guideline development methodology
  • 3.1. Introduction
  • 3.2. Developing review questions and protocols and identifying evidence
  • 3.3. Reviewing and synthesising evidence
  • 3.4. Emotional support
  • 3.5. Incorporating health economics
  • 3.6. Evidence to recommendations
  • 3.7. Stakeholder involvement
• 4. Emotional support and information giving
  • 4.1. Introduction
  • 4.2. Psychological and emotional support
• 5. Early pregnancy assessment units
  • 5.1. Introduction
  • 5.2. Clinical and cost effectiveness of early pregnancy assessment units
  • 5.3. Model for service organisation and delivery of EPAUs
• 6. Diagnosis of ectopic pregnancy and miscarriage
  • 6.1. Signs and symptoms of ectopic pregnancy
  • 6.2. Ultrasound for determining a viable intrauterine pregnancy
  • 6.3. Accuracy of imaging techniques for diagnosis of an ectopic pregnancy
  • 6.4. Diagnostic accuracy of two or more human chorionic gonadotrophin (hCG) measurements for ectopic pregnancy
  • 6.5. Diagnostic accuracy of two or more hCG measurements plus progesterone for ectopic pregnancy
  • 6.6. Diagnostic accuracy of two or more hCG measurements for viable intrauterine pregnancy
  • 6.7. Diagnostic accuracy of two or more hCG measurements plus progesterone for viable intrauterine pregnancy
• 7. Management of threatened miscarriage and miscarriage
  • 7.1. Introduction
  • 7.2. Progesterone for threatened miscarriage
  • 7.3. Expectant management compared with active treatment of miscarriage
  • 7.4. Surgical management compared with medical management of miscarriage
  • 7.5. Misoprostol and mifepristone for managing miscarriage
  • 7.6. Setting for surgical management of miscarriage
• 8. Management of ectopic pregnancy
  • 8.1. Introduction
  • 8.2. Surgical compared with medical management of ectopic pregnancy
  • 8.3. Laparotomy compared with laparoscopy for ectopic pregnancy
  • 8.4. Salpingectomy compared with salpingotomy for ectopic pregnancy
• 9. Anti-D rhesus prophylaxis
  • 9.1. Introduction
  • 9.2. Anti-D rhesus prophylaxis for threatened miscarriage, miscarriage and ectopic pregnancy
  • 9.3. Anti-D rhesus prophylaxis – dose
• 10. Health economics
  • 10.1. Introduction
  • 10.2. Progesterone for threatened miscarriage
  • 10.3. Management of miscarriage
  • 10.4. Management of ectopic pregnancy
• 11. References
• 12. Abbreviations and glossary
• Appendix A. Scope
• Appendix B. Stakeholders
• Appendix C. Declarations of interest
• Appendix D. Review protocols
• Appendix E. Search strategies
• Appendix F. Summary of identified studies
• Appendix G. Excluded studies
• Appendix H. Evidence tables
• Appendix I. GRADE tables

While every effort has been made to ensure the accuracy of the information contained within this publication, the publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check current indications and accuracy by consulting other pharmaceutical literature and following the guidelines laid down by the manufacturers of specific products and the relevant authorities in the country in which they are practising.

This guideline has been fully funded by NICE. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient.

Implementation of this guidance is the responsibility of local commissioners and/or providers.