Reviewing maternal deaths to make motherhood safer: 2006–2008

tion’ based on early pregnancy ultrasound examination should be abandoned. An early pregnancy ultrasound which fails to identify an intrauterine sac should stimulate active exclusion of tubal pregnancy, and even in the presence of a small uterine sac, ectopic pregnancy cannot be excluded’. The term ‘pregnancy of unknown location’ (PUL) is explicit and is recommended by the Royal College of Obstetricians and Gynaecologist. It describes a common situation—anywhere between 5% and 31% of women attending hospital with early pregnancy problems will not have any evidence of an intrauterine or ectopic pregnancy on scan, but only 6–9% of these women will eventually be diagnosed with an ectopic pregnancy. The chapter does not expand upon what is meant by ‘active exclusion’ and we worry that this recommendation could be interpreted as a push to perform more diagnostic laparoscopies that may not be clinically necessary. The case of a PUL described appeared to illustrate a combination of failures including absent or inadequate follow up, inappropriate delegation of surgery to junior staff; poor quality and poorly supervised scanning, and a lack of knowledge about early pregnancy management. We would suggest that these are more important issues to discuss than nomenclature. Approximately one-quarter of women seen in an early pregnancy unit will have an early intrauterine pregnancy or small uterine sac, so this is a very common diagnosis. An ectopic pregnancy cannot be excluded at any time during gestation—illustrated by the death caused by an advanced ectopic pregnancy that was not diagnosed until the third trimester, included in Chapter 4 Haemorrhage. We feel that this could have been an opportunity to emphasise the importance of considering an ectopic whenever a woman has symptoms of recurrent or severe abdominal pain or evidence of intra-abdominal bleeding, even when an ultrasound has shown an intrauterine pregnancy. A report from CMACE published in BJOG is potentially highly influential, and a careful analysis of these tragic deaths is important, any recommendations that follow must be made in conjunction with the evidence base available and not only on the basis of the individual cases. Furthermore, such a report should be subject to the same rigorous peer review that one would expect for any publication associated with or published under the BJOG name, as well as appropriate consultation both with relevant healthcare professionals and patient groups. j