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For examplethe term pregnancy of unknown location 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.2 It describes a
common situationanywhere between 5% and 31%3 of
women attending hospital with early pregnancy problems
will not have any evidence of an intrauterine or ectopic
pregnancy on scan, but only 69%4 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,5 so this is a very
common diagnosis. An ectopic pregnancy cannot be
excluded at any time during gestationillustrated 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
2
3
Authors Reply
Sir,
I would like to thank Drs Ben-Naji, Jurkovic, Condous and
Wilkinson for their interest in the chapter I wrote for the
Eighth Report of the Confidential Enquiries into Maternal
Deaths in the UK, published as a supplement to BJOG in
March 2011. The main difficulty in replying is that all the
case records have now been destroyed following completion
of the Centre for Maternal and Child Enquiries (CMACE)
Enquiry Process as a consequence of the long-standing confidentiality protocols, and it is no longer possible to revisit
the case data to facilitate any further analysis.
However, with regard to the question of ectopic pregnancies located in deficient uterine caesarean section scars,
Professor Gwyneth Lewis reassures me and reinforces my
recollection that there were no caesarean section ectopic
pregnancies associated with any of the maternal deaths.
*Trustees
Ross BSc, MB BS, MRCOG; Julie Price MB BS, FRCOG; Kevin Walker;
Professor Tom Bourne PhD FRCOG. Medical Advisers: Andrew Horne
PhD MRCOG; Cecilia Bottomley BSc MRCOG; Davor Jurkovic PHD MD
MRCOG; Emma Kirk BSc MBBS; Fiona Bottomley: Superintendant Sonographer; Jackie Ross BSc MB BS MRCOG; Janine Elson MD MRCOG; Julie
References
1 Lewis G (ed.). Saving Mothers Lives: reviewing maternal deaths to
make motherhood safer20062008. The Eighth Report of the
Price MB BS FRCOG; Maria Jalmbrant D.Clin.Psy. C.Psychol; Peter Greenhouse MA MB B.CHIR MECOG MFFP; (Ruth) Izzie Oakley RMN RGN;
Professor Siobhan Quenby FRCOG PhD; Professor Tom Bourne FRCOG
PhD.
2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG
1403
Correpondence
Editor-in-Chiefs Reply
Sir,
Helen Wilkinson and her colleagues raise an important
point about the peer review process employed by BJOG.
Papers published in our regular issues are sent to at least
two referees (more if necessary) and considered by a number of editors in consultation, so that all papers sent out
for peer review are rejected or accepted by the majority of
at least five opinions, often more. The same rigorous peer
review process is applied to our special themed issues
appearing in January of each year. However, supplements
(which by definition are not regular BJOG issues and as
such have a different front cover and supplement pagination distinct from that of regular issues) are not peer
reviewed by the normal BJOG process. The content is the
responsibility of the guest editor(s), who will have been
approved for this position by the Editor-in-Chief of BJOG
(in the case of Saving Mothers Lives, this approval was of
necessity retrospective). We also require that the process
for selecting the papers for any supplement should be
clearly described. This may or may not include external
peer review. If there is no formal peer review, then we
require that this is clearly stated at the beginning of the
supplement. This information is therefore transparent to
1404
Reference
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.
Philip Steer
Editor-in-Chief, BJOG
Accepted 16 June 2011.
DOI: 10.1111/j.1471-0528.2011.03098.x
2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG