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Missed diagnosis and delayed treatment for ectopic pregnancies | Signal

Reference number
1140 G
Issue date27 November 2009

This Signal relates to failure or delay in diagnosing and treating women with ectopic pregnancy in emergency departments and elsewhere.


Ectopic pregnancy is well-recognised as a serious and potentially life-threatening condition needing prompt management. Staff in emergency departments and elsewhere are taught to have a high index of suspicion for women of childbearing age presenting with acute abdominal pain (whether or not they know they are pregnant). 


A typical incident reads:


“Patient admitted overnight with abdominal pain and pv bleeding.  Found to have positive pregnancy test in A&E (history of previous tubal surgery).  Attempts made to get a view through USS unable to see anything in uterus.  BHCG came back at 21,544.  Pain settled and patient discharged to come to early pregnancy assessment unit (EPAU) three days later.  USS at EPAU confirmed ectopic pregnancy in right tube and needed emergency theatre.  Near miss that patient did not rupture at home.” 


Following discussion of a severe trigger incident, the wider incident database was reviewed. Fify-nine relevant incidents were identified. Over a third related to inappropriate management (including failure to respond to deteriorating patient) and another third related to delay and failure to diagnose.


The review of incidents showed some failures to treat these patients as priority and breaches in communication between emergency and obstetric/surgical staff. Thirty incidents were reported as severe harm, but there were also serious near-misses in those incidents classified as no harm. 


Some incidents relate to the failure to rescue deteriorating patients, which has been subject of wider work by the National Reporting and Learning Service (NRLS), including a report and training video for staff.


Have you reviewed current practice in A&E? For example:


  • pregnancy tests on all female patients in A&E with presenting symptoms
  • identifying deteriorating patients and understanding of the need to escalate to medical staff where nurses have concern


Let us know if you have learning to share (rrr@npsa.nhs.uk).


Relevant to: pregnancy, emergency medicine.



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