كتاب
The diagnosis and management of ectopic pregnancy & pregnancy of unknown location
- Methodology
A comprehensive search for guidelines was done to identify the most relevant ones to consider for adaptation. The inclusion/exclusion criteria that were followed in the search and retrieval of guidelines to be adapted are:
We select guidelines only if they are:
- Evidence-based guidelines
- National and/or international guidelines
- Guidelines published from 2016 to 2025
- Peer reviewed publications
- Guidelines written in English language
We Exclude guidelines that are:
- Written by a single author not on behalf of an organization as guideline to be valid and comprehensive ideally requires multidisciplinary input.
- Published without references as the panel needs to know whether a thorough literature review was conducted and whether the current evidence was used in the preparation of the recommendations.
The following characteristics of the retrieved guidelines were summarized in a table:
- Developing organisation/authors
- Date of publication, posting, and release
- Country/language of publication
- Dates of the search used by the source guideline developers
All retrieved Guidelines were screened and appraised using AGREE II instrument (www.agreetrust.org) by at least three members. The panel decided on a cut-off point or ranked the guidelines (any guideline scoring above 50% on the rigor dimension was retained).
Guidelines used in the adaptation process:
1- Ectopic pregnancy and miscarriage: diagnosis and initial management. National Institute for Health and Care Excellence (NICE), Guideline (126), 2023, NICE 2024, UK. (6)
2- The Diagnosis and Management of Ectopic Pregnancy, Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland, and, Directorate of Clinical Strategy and Programmes, Health Service Executive, Guideline No. 33, 2017, Irland. (7)
3- Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies, Society of Obstetricians and Gynaecologists of Canada (SOGC), Guideline No. 414, 2021, Canada. (8)
4- Cesarean scar ectopic pregnancy, The American College of Obstetricians and Gynecologists (ACOG) and the Society of Family Planning, Consult Series #63, 2022, USA. (9)
5- Elson CJ, Salim R, Potdar N, Chetty M, Ross JA, Kirk EJ on behalf of the Royal College of Obstetricians and Gynaecologists. Diagnosis and management of ectopic pregnancy. BJOG 2016;.123:e15–e55. (10)
6- Fee N, Begley B, McArdle A, Milne S, Freyne A, Armstrong F. National Clinical Practice Guideline: The Diagnosis and Management of Ectopic Pregnancy. National Women and Infants Health Programme and The Institute of Obstetricians and Gynaecologists. May 2024. (11)
Evidence assessment
According to WHO Handbook for Guidelines, we used the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to assess the quality of a body of evidence, develop and report recommendations. GRADE methods are used by WHO because these represent internationally agreed standards for making transparent recommendations. Detailed GRADE information is available on the following sites:
- GRADE working group: https://www.gradeworkinggroup.org/
- GRADE online training modules: http://cebgrade.mcmaster.ca/
Table 1: Quality and Significance of the four levels of evidence in GRADE:
|
Quality |
Definition |
Implications |
|
High |
The guideline development group is very confident that the true effect lies close to that of the estimate of the effect |
Further research is very unlikely to change confidence in the estimate of effect |
|
Moderate |
The guideline development group is moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different |
Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate |
|
Low |
Confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the true effect |
Further research is very likely to have an important impact on confidence in the estimate of effect and is unlikely to change the estimate |
|
Very low |
The group has very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of the effect |
Any estimate of effect is very uncertain |
Table 2; Factors that determine How to upgrade or downgrade the quality of evidence
|
Downgrade in presence of |
Upgrade in presence of |
|
Study limitations - 1 Serious limitations - 2 Very serious limitations |
Dose-response gradient + 1 Evidence of a dose-response gradient |
|
Consistency - 1 Important inconsistency |
Direction of plausible bias + 1 All plausible confounders would have reduced the effect |
|
Directness - 1 Some uncertainty - 2 Major uncertainty |
Magnitude of the effect + 1 Strong, no plausible confounders, consistent and direct evidence + 2 Very strong, no major threats to validity and direct evidence |
|
Precision - 1 Imprecise data |
|
|
Reporting bias - 1 High probability of reporting bias |
|
The strength of recommendations
The strength of a recommendation communicates the importance of adherence to the recommendation.
Strong recommendations: The GDG found that the desirable effects of adherence to the recommendation outweigh the undesirable effects. This means that in most situations the recommendation can be adopted.
Conditional recommendations: This means that the GDG found that there is:
- Greater uncertainty about the strength of evidence, or
- The recommendation may account for a greater variety in patient values and preferences, or
- The resource use makes the intervention suitable for some, but not for other locations.
Conditional recommendations are still the best available evidence to date and it can be adopted if it meets the conditions mentioned with it.
Good Practice Statement: Statements based on opinion of respected authorities, e.g. the RCOG, ACOG, and the guidelines development group.
