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Ectopic Pregnancy
Ectopic pregnancy occurs in 1–2% of pregnancies, implanting most commonly in the fallopian tube. Risk factors include PID, previous ectopic, IUD, IVF. Presentation ranges from mild pelvic pain to haemorrhagic shock from tubal rupture. Beta-hCG trend…
RCOG Green-top Guideline 21
The pathway
1 · Stabilise if haemodynamically unstable
- Two large-bore IV cannulae, crystalloid bolus, activate MHP
- Emergency laparotomy
- Do not delay for USS in a shocked patient — this is a ruptured ectopic until proven otherwise
2 · Beta-hCG
- Positive pregnancy test + pelvic pain = ectopic until proven otherwise
- Serial beta-hCG 48h apart
- >66% rise in 48h: intrauterine pregnancy likely
- Rising <50% or plateauing: abnormal pregnancy — ectopic or non-viable IUP
3 · Transvaginal ultrasound
- TVUSS: look for intrauterine pregnancy — rules out ectopic in most cases
- Empty uterus + adnexal mass + free fluid = ectopic
- Discriminatory zone: beta-hCG >1500 IU/L — an IUP should be visible
4 · Medical management (methotrexate)
- Criteria: unruptured, beta-hCG <5000 IU/L, haemodynamically stable, size <35mm, no FH on USS, compliant for follow-up
- IM methotrexate 50mg/m²
- Avoid folic acid
- Check beta-hCG days 4 and 7
5 · Surgical management
- Salpingectomy (preferred) or salpingotomy
- Laparoscopic if stable, laparotomy if unstable
- Consider salpingotomy only if contralateral tube damaged
6 · Anti-D
Up to and including 11+6 weeks: do NOT offer anti-D (NG126, June 2026). 12+0 to 12+6 having medical management or a surgical procedure: offer at least 250 IU (50 micrograms) IM. Use the ultrasound gestation if it disagrees with LMP.
Drugs
| Drug | Dose | Route | Notes |
|---|---|---|---|
| Methotrexate | 50mg/m² | IM | Single dose. Avoid conception for 3 months. Avoid NSAIDs, folic acid. |
| Anti-D immunoglobulin | 250 IU | IM | Not below 12+0 weeks. 12+0–12+6 with medical or surgical management: at least 250 IU. Do not use a Kleihauer to quantify here. |
| 0.9% NaCl / Hartmann's | 500ml bolus | IV | For haemodynamic compromise. Activate MHP and proceed to theatre. |
When to escalate
Haemodynamic instability — emergency laparotomy, activate MHP, O-negative blood,Beta-hCG >5000 or rising despite methotrexate — surgical management,Suspected heterotopic pregnancy (IVF) — specialist review,Interstitial ectopic — higher risk of rupture, specialist centre
Reference: RCOG Green-top Guideline No. 21 (Ectopic Pregnancy) 2016
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