Ectopic pregnancy — PUL, NICE hCG rules and medical management viva

PUL concept. Positive β-hCG without sonographic IUP or definite ectopic = pregnancy of unknown location. NICE: do not use the 2200 IU/L to locate the pregnancy. Free fluid raises concern for leak even if currently stable — gynaecology/EPAU now, not discharge. Hendriks’ discriminatory-zone figure (as high as 3500 IU/L) is to avoid harming a wanted IUP, not a discharge threshold.^[1][3]

Medical therapy (only once an ectopic is diagnosed and she meets criteria). MTX 50 mg/m² IM. NICE offers MTX below 1500 IU/L with mass <35 mm and no heartbeat; this hCG of 2200 sits in the choice band (1500–<5000) if a small unruptured mass is later confirmed. Day 4/7 hCG with a >15% fall; counsel rupture risk until undetectable.^[2][3]

Surgery. Preferred if unstable, hCG ≥5000, mass ≥35 mm, cardiac activity, failed MTX, or unreliable follow-up. Salpingectomy is NICE first-line unless infertility risk factors; salpingotomy has up to 1 in 5 needing further treatment.^[3]

Pitfalls. Pseudosac mistaken for IUP; normal vital signs in young women masking bleed; methotrexate after IVF without excluding a desired heterotopic IUP.^[1]