Haemodynamic instability, peritonism, or a confirmed ruptured ectopic: resuscitate and get emergency laparoscopy or laparotomy with the major haemorrhage protocol on standby. Any woman of reproductive age with abdominal pain and collapse has an ectopic until proven otherwise.
Risk and features
- Previous ectopic, tubal surgery, PID, IVF, coil in situ, smoking
- Amenorrhoea then pain and bleeding, shoulder-tip pain
- Adnexal tenderness or mass, cervical excitation
- A positive pregnancy test with pain is an ectopic until excluded
Investigation
- Serum beta-hCG (and a repeat in 48 h if the scan is inconclusive)
- Transvaginal USS: empty uterus with an adnexal mass, or free fluid
- Pregnancy of unknown location: track beta-hCG trend
- Group and save; crossmatch if unstable
Expectant / medical
- Stable, low or falling hCG
- Unruptured, no fetal heartbeat
- Methotrexate or monitor
Needs intervention
- Rising hCG, adnexal mass, pain
- Salpingectomy or salpingotomy
- Anti-D if rhesus negative and surgical
Rupture
- Haemodynamic instability, peritonism
- Shoulder-tip pain, collapse
- Resuscitate and immediate surgery
Pathway (stable, by criteria)
1
1. Expectant
For a small, unruptured ectopic with low and falling beta-hCG and minimal symptoms, with close follow-up.
For a small, unruptured ectopic with low and falling beta-hCG and minimal symptoms, with close follow-up.
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2
2. Medical (methotrexate)
If asymptomatic or minimal pain, unruptured, no fetal heartbeat, beta-hCG below the local threshold (often 1500, up to 5000), and able to attend follow-up. Avoid conception for 3 months after.
If asymptomatic or minimal pain, unruptured, no fetal heartbeat, beta-hCG below the local threshold (often 1500, up to 5000), and able to attend follow-up. Avoid conception for 3 months after.
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3
3. Surgery
Laparoscopic salpingectomy (salpingotomy if the other tube is damaged) for significant pain, larger mass, higher beta-hCG, or if unstable.
Laparoscopic salpingectomy (salpingotomy if the other tube is damaged) for significant pain, larger mass, higher beta-hCG, or if unstable.
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4
4. Anti-D and follow-up
Give anti-D to Rh-negative women having surgical management. Track beta-hCG after medical or conservative treatment until negative. Offer support and future-pregnancy advice.
Give anti-D to Rh-negative women having surgical management. Track beta-hCG after medical or conservative treatment until negative. Offer support and future-pregnancy advice.
Safety-net all women
- Return or call if increasing pain, dizziness, shoulder-tip pain or collapse
- Clear plan for follow-up beta-hCG and scans
- Methotrexate: avoid alcohol, NSAIDs and conception, use reliable contraception
Pitfalls
- Missing an ectopic in a woman with a coil or after sterilisation
- Reassurance from a single beta-hCG
- Methotrexate without reliable follow-up
- Delaying surgery in a deteriorating patient
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026