Ectopic pregnancy — rupture resus and methotrexate criteria

Immediate resus (this patient is ruptured until proven otherwise). Resus bay, oxygen, two large-bore IV cannulae, bloods including FBC, VBG/lactate, coagulation, group and crossmatch (activate the major-haemorrhage pathway if she stays shocked). Limited crystalloid then early blood products; tranexamic acid 1 g IV only as local major-haemorrhage protocol — not an ectopic RCT milligram. Urgent gynaecology — simultaneous resuscitation and theatre. Hendriks: peritoneal signs or haemodynamic instability → immediate surgical transfer. ACOG PB 193: unstable tubal ectopic is a surgical emergency. Bedside FAST free fluid supports the decision; do not delay theatre for formal ultrasound. Shoulder-tip pain is a clinical marker of haemoperitoneum.^[1]

Diagnostic pathway (stable patients). Every reproductive-age woman with pain/bleeding needs β-hCG. Transvaginal US locates the pregnancy. NICE 1.8.2: do not use serum hCG to determine location. Hendriks: if a discriminatory zone is used to avoid harming a wanted IUP, a value as high as 3500 IU/L is cited. Yolk sac and/or embryo in the adnexa is definitive ectopic; a central intrauterine fluid collection without yolk sac must not be called an IUP.^[1][4]

Methotrexate (only if she had been stable, unruptured, and follow-up possible). Dose 50 mg/m² IM (Lipscomb; RCOG; Hendriks Table 4). NICE: offer MTX if no significant pain, mass <35 mm, no heartbeat, hCG <1500 IU/L, no IUP. Choice of MTX or surgery at 1500–<5000. Surgery first at hCG ≥5000, mass ≥35 mm, visible heartbeat, significant pain, or inability to return. Day 4/7 hCG then weekly; need a >15% fall days 4–7.^[2][3][4]

Anti-D (NICE NG126 2026). This patient is 6 weeks (≤11+6): do not offer anti-D for ectopic or miscarriage in that window, including after surgery. At 12+0 to 12+6 with medical or surgical management, offer at least 250 IU (50 micrograms). Confirm the local ANZ product; 500 IU for every ruptured ectopic is not a NICE milligram.^[4]