Enhancing care for women with ectopic pregnancies: Insights from MBRRACE-UK

Ectopic pregnancies, where a pregnancy is implanted outside the uterus, pose significant health risks to women, potentially leading to severe complications or even death. The Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) 2024 report sheds light on the urgent need for improved care and awareness. 

Understanding ectopic pregnancies

Ectopic pregnancies occur in approximately 11 per 1,000 pregnancies in the UK, translating to around 12,000 cases annually. Despite known risk factors such as previous ectopic pregnancies, tubal damage, and fertility treatments, a significant number of women present with no discernible risk factors. Identifying ectopic pregnancy in reproductive-age women is crucial for quick action to avoid severe complications like tubal rupture and life-threatening hypovolemic shock. 

Lessons from the MBRRACE-UK report

The MBRRACE-UK 2024 report, based on a review of maternal deaths from ectopic pregnancies between 2021 and 2022, highlights several areas for improvement in the care and management of these cases. Key recommendations include:

1. Improved Response Times: The report underscores the importance of rapid response by paramedics to 999 calls concerning pregnant women, advocating for a review of ambulance service algorithms to ensure appropriate risk categorisation and management. 
2. Enhanced Communication and Record-Keeping: Emphasising the need for detailed digital maternity records that account for language needs and the use of formal interpreter services to improve interactions and emergency responses.
3. Awareness and Training: Healthcare professionals must be vigilant in considering ectopic pregnancies as a differential diagnosis, especially in women of reproductive age presenting with atypical symptoms. The report calls for comprehensive training and awareness to avoid confirmation bias and ensure timely and accurate diagnosis. For example, the report suggests consideration should be given to referring women to early pregnancy units rather than ordering pregnancy tests or performing ultrasound scans in the emergency department.
4. Access to Early Pregnancy Assessment Units (EPAUs): The report advocates for the availability of EPAUs seven days a week to facilitate prompt scanning and management decisions, highlighting the need for systems that enable women to attend within 24 hours if clinically warranted. The report recommends that if services aren't available 24/7 and women can't be seen within a day, they should be directed to facilities with specialist assessment and ultrasound capabilities, including emergency departments.
5. Appropriate resuscitation response in women with concealed bleeding: The report highlights that women with ruptured ectopic pregnancies often don't know they're pregnant until emergency care is required. Maternal mortality reviews have shown the necessity for better community response to maternal cardiac arrests. The Royal College of Obstetricians and Gynaecologists stresses the importance of an aggressive approach to volume replacement in cases of maternal collapse. The MBRACE-UK 2024 report recognises the importance of ongoing education and improved emergency protocols to safeguard maternal health.
6. Personalised Care for Vulnerable Women: Recognising the disproportionate representation of vulnerable and young women among those who have died from ectopic pregnancies, the report stresses the importance of ensuring care is personalised to provide additional safety measures. This includes ensuring the digital maternity record includes details of language needs, including the use of formal interpreter services, to ensure that these are taken into consideration at all interactions, including emergency situations. 

‘Think ectopic’

The MBRACE-UK 2024 highlights the need to ensure that women and clinicians are aware of the typical symptoms of ectopic pregnancy, which include:

• Pain in the lower abdomen
• A missed period or vaginal bleeding different from a normal period
• Shoulder tip pain (tends to develop with other symptoms)
• Diarrhoea or gastrointestinal upset

Conclusion

Improved awareness of the symptoms of ectopic pregnancy by both women and clinicians can help identify ectopic pregnancies before collapse and improved access to EPAUs can help with earlier identification and intervention. The MBRRACE-UK 2024 report serves as a critical reminder of the challenges and opportunities in the care of women with ectopic pregnancies. By implementing its recommendations, healthcare providers can significantly improve outcomes and save lives.