title: Severe maternal morbidity in ectopic pregnancy is not associated with maternal factors but may be associated with quality of care.
abstract: OBJECTIVE
  To study the association between patient-related risk factors and severe maternal morbidity in women with tubal ectopic pregnancy (EP). Furthermore, to identify substandard care factors in clinical care management of EP.
  
  
  METHODS
  Case-control study.
  
  
  METHODS
  Not applicable.
  
  
  METHODS
  Case subjects were from the LEMMoN study, a prospective nationwide cohort study. Control subjects were from the ESEP study, an international multicenter randomized controlled trial.
  
  
  METHODS
  Case subjects were women with tubal EP complicated by severe intra-abdominal hemorrhage necessitating blood transfusion of ≥4 units of packed red blood cells peri- or postoperatively. Control subjects were women with tubal EP who were hemodynamically stable and surgically treated.
  
  
  METHODS
  Patient-related risk factors as: maternal age, gestational age, previous EP, Chlamydia infection, pelvic inflammatory disease, assisted reproductive techniques, and serum hCG level. Substandard care categories classified as unawareness of the clinician, misdiagnosis, and nonadherence to the guideline on EP.
  
  
  RESULTS
  Twenty-nine case subjects and 99 control subjects were included. The mean serum hCG level was significantly higher in case subjects compared with control subjects, but we found no reliable cutoff level of serum hCG to rule out maternal morbidity. Other risk factors did not differ significantly. Substandard care was scored more often in case subjects (43%) than in control subjects (14%), mainly concerning misdiagnosis.
  
  
  CONCLUSIONS
  No patient-related risk factors for severe intra-abdominal hemorrhage in women with tubal EP were identified. Our findings underpin the importance of awareness of EP among young fertile women and care providers and clinical care management according to the guidelines to prevent severe maternal morbidity.
authors.affiliation: Department of Obstetrics and Gynecology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands. n.m.vanmello@amc.nl
authors.forename: Norah M
authors.initials: NM
authors.lastname: van Mello
authors.forename: Carlijn S
authors.initials: CS
authors.lastname: Zietse
authors.forename: Femke
authors.initials: F
authors.lastname: Mol
authors.forename: Joost J
authors.initials: JJ
authors.lastname: Zwart
authors.forename: Jos
authors.initials: J
authors.lastname: van Roosmalen
authors.forename: Kitty W
authors.initials: KW
authors.lastname: Bloemenkamp
authors.forename: Willem M
authors.initials: WM
authors.lastname: Ankum
authors.forename: Fulco
authors.initials: F
authors.lastname: van der Veen
authors.forename: Ben Willem J
authors.initials: BW
authors.lastname: Mol
authors.forename: Petra J
authors.initials: PJ
authors.lastname: Hajenius
mesh_terms: D000328:Adult; D016022:Case-Control Studies; D016009:Chi-Square Distribution; D002983:Clinical Competence; D003951:Diagnostic Errors; D017707:Erythrocyte Transfusion; D005260:Female; D019983:Guideline Adherence; D006470:Hemorrhage / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D006801:Humans; D016015:Logistic Models; D015337:Multicenter Studies as Topic; D015999:Multivariate Analysis; D009426:Netherlands / Q000453:epidemiology; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011274:Pregnancy, Tubal / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D011446:Prospective Studies; D011787:Quality of Health Care; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D012307:Risk Factors; D012422:Rupture, Spontaneous; D012720:Severity of Illness Index; D016896:Treatment Outcome