EM · Ectopic pregnancy
Ectopic pregnancy
Also known as Tubal pregnancy · Ruptured ectopic · Extrauterine pregnancy
Ectopic pregnancy is implantation outside the uterine cavity, most often in the fallopian tube. Unstable rupture is simultaneous resuscitation and theatre. Stable selected tubal ectopics may receive intramuscular methotrexate 50 mg per square metre with NICE-banded hCG thresholds. ACEM-primary, globally tagged.
Checked against its sources on 2 Sept 2026
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Target exams
Red flags
- Every woman of reproductive age with abdominal pain or vaginal bleeding needs a pregnancy test — ectopic until a negative beta-hCG or a confirmed intrauterine pregnancy (and after IVF, an intrauterine pregnancy does not exclude a heterotopic)
- Peritoneal signs or haemodynamic instability with a positive beta-hCG is ruptured ectopic until proven otherwise — transfer for surgery now, not a formal ultrasound later
- NICE does not use a serum hCG 'discriminatory zone' to locate the pregnancy; if a laboratory zone is used at all, Hendriks cites a threshold as high as 3500 IU/L to avoid intervening on a potentially viable intrauterine pregnancy
- NICE NG126 (2026) does not offer anti-D for ectopic or miscarriage at or before 11+6 weeks; at 12+0 to 12+6 offer at least 250 IU when medical or surgical management is used
Meet the patient
A 31-year-old woman at 8 weeks by dates collapses at home — severe lower abdominal pain and right shoulder-tip pain, pale, diaphoretic, confused, a rigid abdomen, and a positive bedside urine beta-hCG. Haemoglobin 68 g/L and venous lactate 5.6 mmol/L. This is ruptured ectopic until proven otherwise. Hendriks: peritoneal signs or haemodynamic instability → immediate surgical transfer. ACOG: an unstable tubal ectopic is a medical emergency that requires prompt surgery. Do not wait for a formal pelvic ultrasound or a quantitative hCG.[9][10]
Hold three questions: is she pregnant? (beta-hCG), where is the pregnancy? (transvaginal ultrasound — yolk sac and/or embryo in the adnexa is definitive), and is she bleeding into the peritoneum? (shock, peritonism, shoulder-tip pain from diaphragmatic irritation). Shoulder-tip pain is a clinical warning of haemoperitoneum, not a sourced millilitre count.[9]
References13ShowHide
- [1]Abdullah NA, Hassan RK, Muhammed AK, Muhammed IM Epidemiological study of Ectopic Pregnancy at Sulaimani Maternity Teaching Hospital, Iraq: A cross-sectional study. Medicine (Baltimore), 2026.PMID 42216416
- [2]Adawe MMM, Ibrahim FH, Mudei NM, Elmi AH Conservative Methotrexate Management of Ovarian Ectopic Pregnancy in a Resource-Constrained Setting: A Rare Case Report. Int Med Case Rep J, 2026.PMID 42164425
- [3]Mol F, Mol BW, Ankum WM, et al. Current evidence on surgery, systemic methotrexate and expectant management in the treatment of tubal ectopic pregnancy: a systematic review and meta-analysis. Hum Reprod Update, 2008.PMID 18522946
- [4]Lipscomb GH, Givens VM, Meyer NL, et al. Comparison of multidose and single-dose methotrexate protocols for the treatment of ectopic pregnancy. Am J Obstet Gynecol, 2005.PMID 15970826
- [5]Alur-Gupta S, Cooney LG, Senapati S, et al. Two-dose versus single-dose methotrexate for treatment of ectopic pregnancy: a meta-analysis. Am J Obstet Gynecol, 2019.PMID 30629908
- [6]van Mello NM, Mol F, Verhoeve HR, et al. Methotrexate or expectant management in women with an ectopic pregnancy or pregnancy of unknown location and low serum hCG concentrations? A randomized comparison. Hum Reprod, 2013.PMID 23081873
- [7]Lipscomb GH, Givens VA, Meyer NL, et al. Previous ectopic pregnancy as a predictor of failure of systemic methotrexate therapy. Fertil Steril, 2004.PMID 15136080
- [8]van Mello NM, Mol F, Mol BW, Hajenius PJ Conservative management of tubal ectopic pregnancy. Best Pract Res Clin Obstet Gynaecol, 2009.PMID 19299204
- [9]Hendriks E, Rosenberg R, Prine L. Ectopic Pregnancy: Diagnosis and Management. Am Fam Physician, 2020.PMID 32412215
- [10]American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy. Obstet Gynecol, 2018.PMID 29470343
- [11]Elson CJ, Salim R, Potdar N, Chetty M, Ross JA, Kirk EJ; Royal College of Obstetricians and Gynaecologists Diagnosis and Management of Ectopic Pregnancy: Green-top Guideline No. 21. BJOG, 2016.PMID 27813249
- [12]Practice Committee of American Society for Reproductive Medicine Medical treatment of ectopic pregnancy: a committee opinion. Fertil Steril, 2013.PMID 23849842
- [13]National Institute for Health and Care Excellence Ectopic pregnancy and miscarriage: diagnosis and initial management NICE guideline NG126, 2026.Source