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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


Confidential Enquiries into Maternal Deaths in the United Kingdom.

BJOG 2011;118(Suppl. 1):1205.
RCOG Green-top Guideline 25. The Management of Early Pregnancy
Loss. London: RCOG, 2006.
Condous G, Timmerman D, Goldstein S, Valentin L, Jurkovic D,
Bourne T. Pregnancies of unknown location: consensus statement.
Ultrasound Obstet Gynecol 2006;28:1212.
Bottomley C, Van BV, Mukri F, Kirk E, Van Huffel S, Timmerman D
et al. The optimal timing of an ultrasound scan to assess the
location and viability of an early pregnancy. Hum Reprod 2009;24:
Condous G, Van Calster B, Kirk E, Haider Z, Timmerman D, Van
Huffel S, et al. Prediction of ectopic pregnancy in women with a
pregnancy of unknown location. Ultrasound Obstet Gynecol 2007;29:

Helen Wilkinson on behalf of the Trustees and

Medical Advisers*
The Ectopic Pregnancy Trust, London, UK
Accepted 25 May 2011.
DOI: 10.1111/j.1471-0528.2011.03097.x

Reviewing maternal deaths to make motherhood

safer: 20062008

Authors Reply
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.


of the EPT: Alex-Peace Gadsby (chair); Chris Woodward; Jackie

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

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

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



With regard to peer review, up to 35 people may have

peer reviewed each of the chapters during the CMACE processall authors in the Report peer reviewed each chapter
and, similarly, each chapter was submitted to at least one
independent reviewer, whose name is appended in the final
Finally, in relation to the question of terminology, I
stand by my view that the expression pregnancy of
unknown location should be abandoned. j
C OHerlihy
UCD School of Medicine and Medical Science, Dublin, Ireland
Accepted 18 July 2011.
DOI: 10.1111/j.1471-0528.2011.03127.x

Saving Mothers Lives. Reviewing maternal deaths to

make motherhood safer: 20062008

Editor-in-Chiefs Reply
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


the readers enabling them to evaluate the content in this

In the case of the latest Centre for Maternal and Child
Enquiries (CMACE) report,1 the report was presented to us
as a comprehensive document prepared over several years.
The Director and Editor, and the substantial number of
central assessors and authors are all highly reputable, and
the process by which the report was compiled is described
clearly. Each individual chapter has been discussed with an
independent assessor(s), named in the Acknowledgements
section, who we recognise as being experts in their field.
There were clear advantages to the report being published
as a noncommercial supplement to BJOG, which included
increased visibility of the report, and the opportunity for it
to be subjected to publicly documented criticism by correspondence from authors such as Ms Wilkinson, which will
appear both in the Journal and online in PubMed.
I agree with your suggestion that the regular confidential
enquiries into maternal deaths that have been carried out,
first in England and now in the UK, from 1952, are highly
influential. It is therefore of concern that on 31 March
2011 the Royal College of Obstetricians and Gynaecologists
(RCOG) stated that The RCOG has been made aware of
the discussions over the future of the confidential enquiries
into mother and child health. The RCOG is extremely concerned that this vital work is now being stalled. (www.rcog.
rcog-statement-future-confidential-enquiries). At BJOG we
strongly support the RCOGs efforts to persuade the UK
Department of Health to continue funding this national
audit, which has over the years had international significance. j

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