Correspondence

DOI: 10.1111/j.1471-0528.2011.03095.x
www.bjog.org

Deaths in early pregnancy. The eight report of the

confidential enquiries into maternal deaths in the
United Kingdom

Sir,
We read with interest the chapter on deaths in early pregnancy in the latest Report on Confidential Enquiries into
Maternal Deaths.1 Three women, all at 1618 weeks of gestation, died of massive and uncontainable haemorrhage
secondary to morbidly adherent placenta at the site of previous caesarean section scar. These deaths accounted for
more than one-quarter of all early pregnancy deaths and
yet there are no comments or recommendations in the
report to help clinicians with the management of this complex problem.
In recent years there have been a plethora of reports in
medical literature describing the diagnosis and management
of pregnancies implanted into deficient uterine caesarean
section scar; eight of which were published in BJOG alone.
Most publications describe scar implantation during the
first and second trimesters as a form of ectopic pregnancy.2
The authors of the report, however, grouped the deaths
associated with scar implantation together with those which
occurred following miscarriage. This is not only contrary to
the recommendations from the literature, but it also creates
an erroneous impression that nothing can be done to facilitate a correct preoperative diagnosis and safer management
of this condition.
The prevalence of caesarean section scar ectopic pregnancy is approximately 1:2000 pregnancies,3 which is
nearly 20 times less than the estimated prevalence of all
other ectopic pregnancies in the UK grouped together.
Using the figures from this report the estimated mortality rate of caesarean section scar ectopic pregnancy is
191.2 per 100 000 cases, which is more than 11 times
higher than the 16.9 deaths per 100 000 cases with other
ectopic pregnancies. Treatment of caesarean section scar
ectopic pregnancies is often complex and prolonged. As
a result the maternal morbidity is also very high, particularly in women who progress beyond the first trimester.3,4

The criteria for ultrasound diagnosis have been well

described and successful diagnosis has been reported in
both symptomatic and asymptomatic women during the
first trimester.3 The treatment of early caesarean section
scar ectopic pregnancy before 10 weeks of gestation is
relatively simple and highly successful,4 but pregnancies
that progress further are very difficult to manage and are
often complicated by severe bleeding.2,3 An attempt
should always be made to rule out the possibility of scar
implantation in symptomatic women with a history of
previous caesarean section. In all women with second-trimester caesarean section scar ectopic pregnancies a referral to a tertiary centre with expertise in the management
of this condition, access to magnetic resonance imaging
and facilities for interventional radiology should be considered. In women with uncertain diagnosis, clinicians
should consider obtaining expert advice. The Ectopic
Pregnancy Trust UK (www.ectopic.org.uk) has established
a network of early pregnancy specialists working with the
charity to provide advice and help to both women and
clinicians faced with rare or difficult diagnostic and management problems.
We hope that the authors would consider incorporating
some of these suggestions in the addendum of the report
to minimise the risk of further fatalities caused by this rare,
but very severe condition. j

References
1 OHerlihy C. Deaths in early pregnancy. Saving mothers lives. Reviewing maternal deaths to make motherhood safer: 20062008 The
eighth report of the confidential enquiries into maternal deaths in the
United Kingdom. BJOG 2011;118(Suppl. 1):837.
2 Ash A, Smith A, Maxwell D. Caesarean scar pregnancy. BJOG 2007;
114:25363.
3 Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson C. First
trimester diagnosis and management of pregnancies implanted into
the lower uterine segment Cesarean section scar. Ultrasound Obstet
Gynecol 2003;21:24753.
4 Jurkovic D, Ben-Nagi J, Ofilli-Yebovi D, Sawyer E, Helmy S, Yazbek J.
The efficacy of Shirodkar cervical suture in securing haemostasis
following surgical evacuation of Cesarean scar ectopic pregnancy.
Ultrasound Obstet Gynecol 2007;30:95100.

2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG

1401

Correspondence

J Ben-Nagia & D Jurkovicb

a

Assisted Conception Unit, Chelsea and Westminster Hospital, London, UK bGynaecology Diagnostic and Outpatient Treatment Unit,
University College Hospital, London, UK

Accepted 28 April 2011.

DOI: 10.1111/j.1471-0528.2011.03095.x

The term Pregnancy of unknown location

is staying put

Sir,
I recently read with great interest the recently published triennial report into maternal deaths in the UK, Saving Mothers Lives 20062008.1 In Chapter 6, Deaths in early
pregnancy, one of the reports recommendations is that the
term pregnancy of unknown location (PUL) should be
abandoned. This recommendation was made following one
maternal death that occurred in a woman with a ruptured
ectopic pregnancy who was initially classified as a PUL.
I strongly disagree with the reports recommendation to
abandon the use of the term PUL. Such a recommendation would be a retrograde step. I believe that the use of
the term PUL as reported in this maternal death was not
the reason this woman died but rather her death was a
consequence of catastrophic systems failure involving multiple clinicians at two hospitals.
The use of the term PUL is not new; in 2005, when the
European Society for Human Reproduction and Embryology
(ESHRE) Special Interest Group published its revised
nomenclature for use in early pregnancy events the term
PUL was recommended for use in modern practice.2 They
suggested that when there is no identifiable pregnancy on
ultrasound scan in a woman with a positive pregnancy test,
these women should be classified as having a PUL.2 In 2006,
the Royal College of Obstetricians and Gynaecologists
(RCOG) also embraced the term PUL and the same definition which was published by the ESHRE Special Interest
Group for Early Pregnancy (SIGEP).2,3 The RCOG agreed
with the ESHRE SIGEP that it was paramount to align terminology used in the early pregnancy published literature.3
These two authoritative bodies came to such a consensus
after more than a decade of peer-reviewed published evidence on women with a PUL. To date, there has not been a
single maternal mortality in any of these published studies.
The initial use of the term PUL in the woman described
was appropriate but this ultrasound classification did not
trigger the appropriate follow up in management. All Early
Pregnancy Units should have their own evidence-based
guidelines for managing women with a PUL. This should
include serum human chorionic gonadotrophin follow up
and repeat transvaginal ultrasonography when appropriate.

1402

The term pregnancy of unknown location is descriptive

and not a final diagnosis. The use of this terminology is
here to stay and should continue as long as there is an
appreciation for what it really means. To be dismissive of
the term PUL demonstrates a lack of understanding of the
significant work that has been and continues to be carried
out to improve the basic standards in early pregnancy
ultrasound throughout the UK, USA and Australia. Such a
move also undermines ongoing efforts to standardise firsttrimester nomenclature throughout the western world.4
I believe that current nomenclature should not be changed
on the basis of this solitary case report in the most recent
confidential enquiry into maternal deaths. j

References
1 Lewis G (ed.). Saving Mothers lives: reviewing maternal deaths to
make motherhood safer20062008. The eighth report of the confidential enquiries into maternal deaths in the United Kingdom. BJOG
2011;118(Suppl. 1):1205.
2 Farquharson RG, Jauniaux E, Exalto N. ESHRE Special Interest Group
for Early Pregnancy (SIGEP). Updated and revised nomenclature for
description of early pregnancy events. Hum Reprod 2005;20:3008
11.
3 Guidelines and Audit Committee of the Royal College of Obstetricians
and Gynaecologists. The Management of Early Pregnancy Loss: Clinical Green Top Guidelines No. 25. London: RCOG, 2006.
4 Barnhart K, van Mello NM, Bourne T, Kirk E, Van Calster B, Bottomley C, et al. Pregnancy of unknown location: a consensus statement
of nomenclature, definitions, and outcome. Fertil Steril 2011;95:
85766.

G Condous
Acute Gynaecology, Early Pregnancy and Advanced Endosurgery
Unit, Sydney Medical School Nepean, University of Sydney,
Nepean Hospital, Penrith, Sydney, Australia
Accepted 6 May 2011.
DOI: 10.1111/j.1471-0528.2011.03096.x

Saving Mothers Lives. Reviewing maternal deaths to

make motherhood safer: 20062008

Sir,
As a charity providing information, support and education
to those affected by early pregnancy complications, we welcome the majority of the recommendations made in Chapter 6 of the current Centre for Maternal and Child
Enquiries (CMACE) report, Deaths in early pregnancy,1 and
were pleased to see that there were fewer deaths than in
any previous triennia. However, we are concerned that
some of the recommendations do not have any firm evidence base and could potentially lead to over-investigation
and unnecessary surgical intervention in women at low risk
of death or serious complications.

2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG