Clinical update

Miscarriage and ectopic pregnancy: diagnosis, care and respect

New guidance on miscarriage and ectopic pregnancy focuses on improved diagnosis and management while stressing the need for supportive and sensitive care

New guidance on miscarriage and ectopic pregnancy focuses on improved diagnosis and management while stressing the need for supportive and sensitive care

 Artwork depicting an ectopic pregnancy, when the embryo implants outside
the uterus.
Picture: Science Photo Library

Essential information

Approximately 20% of pregnancies miscarry, often causing considerable distress. Early pregnancy loss accounts for more than 50,000 hospital admissions in the UK annually. Ectopic pregnancy, when a fertilised egg implants outside the womb, occurs in about 11 per 1,000 pregnancies. The condition has a maternal mortality of 0.2 per 1,000 estimated ectopic pregnancies. About two thirds of these deaths are associated with substandard care, according to the National Institute for Health and Care Excellence (NICE).

What’s new?

NICE has published guidelines that update and replace guidance from 2012 on the diagnosis and management of miscarriage and ectopic pregnancy.

The new guidance focuses on improving the diagnosis and management of early pregnancy loss to save lives and reduce psychological harm.

The guidance says pregnant women who are haemodynamically unstable, or for whom there is significant concern about the degree of pain or bleeding, should be referred directly to an emergency department (ED).

During clinical assessment of women of reproductive age, nurses should be aware that the patient may be pregnant and consider offering a pregnancy test even when symptoms are non-specific.

Signs and symptoms

Nurses should be aware that atypical presentation for ectopic pregnancy is common. The symptoms and signs can resemble the common symptoms and signs of other conditions such as gastrointestinal conditions or urinary tract infection.

ED staff should exclude the possibility of ectopic pregnancy, even in the absence of risk factors such as previous ectopic pregnancy, because about one third of women will have no known risk factors.

The guidance stresses that all women being treated for early pregnancy complications should be afforded dignity and respect.

Women who do not access medical help readily, including recent migrants, asylum seekers, refugees, or women who have difficulty reading or speaking English, are particularly at risk of complications and death from ectopic pregnancy.

Expert comment

Rachel Small, lead midwife and nurse for early pregnancy care and miscarriage care, University Hospitals Birmingham NHS Foundation Trust

‘Emergency nurses need to know about miscarriages and ectopic pregnancies, as a woman with significant pain or bleeding will be directed to the local emergency department (ED) by their GP or 111 service. Any woman of childbearing age (12-55), who comes to an ED with abdominal pain should be asked if they have done a pregnancy test.

‘That should be one of the first questions. Pregnancy tests should be easily available in EDs.

‘For women who are pregnant with pain, staff should automatically think about the possibility of an ectopic pregnancy. The next stage is to get a detailed clinical history.

‘The National Institute for Health and Care Excellence guidance emphasises the importance of ED nurses and other staff having training in breaking bad news. Sometimes staff are very good at the physical care of women having early pregnancy complications, but the emotional care is important and may sometimes be forgotten.’

Implications for nurses

  • Treat all women with early pregnancy complications with dignity and respect.
  • Be aware that women will react to complications or pregnancy loss in different ways.
  • Provide information and support in a sensitive manner, considering their individual circumstances and emotional response.
  • Healthcare professionals should be given training in how to communicate sensitively and breaking bad news.
  • After an early pregnancy loss, offer the woman the option of a follow‑up appointment with a healthcare professional of her choice.
  • Throughout their care women should be told when and how to seek help if existing symptoms worsen or new symptoms develop, including a 24‑hour contact telephone number and what to expect while waiting for an ultrasound scan.

Find out more


Erin Dean is a health journalist


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