Ectopic pregnancy

It is 02:00 and a 29-year-old is on a trolley, pale, with shoulder-tip pain and a systolic of 80. She did not know she was pregnant. This is the presentation that kills young women in early pregnancy, and it still does — ectopic pregnancy remains a leading cause of first-trimester maternal death even in countries with universal scanning. The registrar who wins is the one who reaches for the pregnancy test, then the theatre list, in that order.^[3][8]

Overview and definition

An ectopic pregnancy implants anywhere outside the uterine cavity. Around 11 in every 1000 pregnancies are ectopic, and about 95% of those are tubal, with roughly 80% of tubal ectopics in the ampulla. The remaining 5% are the non-tubal ectopics — interstitial, cervical, caesarean scar, ovarian and abdominal — and they are disproportionately dangerous because they are diagnosed later and bleed more.^[9][3]

The whole topic turns on one discipline: locate the pregnancy before you act on the hormone. Every modern error in ectopic care — a terminated wanted intrauterine pregnancy, a delayed rupture, a methotrexate given to a viable pregnancy — comes from asking the hCG to answer the question that only the scan can answer.^[8][16]

References22ShowHide

1. [1]Royal College of Obstetricians and Gynaecologists Diagnosis and Management of Ectopic Pregnancy: Green-top Guideline No. 21 BJOG, 2016.PMID 27813249
2. [2]American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy Obstet Gynecol, 2018.PMID 29470343
3. [3]Barnhart KT Clinical practice. Ectopic pregnancy N Engl J Med, 2009.PMID 19625718
4. [4]Mol F, van Mello NM, Strandell A, et al. Salpingotomy versus salpingectomy in women with tubal pregnancy (ESEP study): an open-label, multicentre, randomised controlled trial Lancet, 2014.PMID 24499812
5. [5]Lipscomb GH, Bran D, McCord ML, et al. Analysis of three hundred fifteen ectopic pregnancies treated with single-dose methotrexate Am J Obstet Gynecol, 1998.PMID 9662322
6. [6]Lipscomb GH, McCord ML, Stovall TG, et al. Predictors of success of methotrexate treatment in women with tubal ectopic pregnancies N Engl J Med, 1999.PMID 10607814
7. [7]McCord ML, Muram D, Lipscomb GH, et al. Methotrexate therapy for ectopic pregnancy in adolescents J Pediatr Adolesc Gynecol, 1996.PMID 8795780
8. [8]Barnhart KT Early pregnancy failure: beware of the pitfalls of modern management Fertil Steril, 2012.PMID 23084007
9. [9]Parker VL, Srinivas M Non-tubal ectopic pregnancy Arch Gynecol Obstet, 2016.PMID 27056054
10. [10]Chetty M, Elson J Treating non-tubal ectopic pregnancy Best Pract Res Clin Obstet Gynaecol, 2009.PMID 19230785
11. [11]Long Y, Zhu H, Hu Y, et al. Interventions for non-tubal ectopic pregnancy Cochrane Database Syst Rev, 2020.PMID 32609376
12. [12]Po L, Thomas J, Mills K, et al. Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies J Obstet Gynaecol Can, 2021.PMID 33453378
13. [13]Gulino FA, Ettore C, Ettore G A review on management of caesarean scar pregnancy Curr Opin Obstet Gynecol, 2021.PMID 34325464
14. [14]Ankum WM, Mol BW, Van der Veen F, et al. Risk factors for ectopic pregnancy: a meta-analysis Fertil Steril, 1996.PMID 8641479
15. [15]Barnhart KT, Sammel MD, Rinaudo PF, et al. Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined Obstet Gynecol, 2004.PMID 15229000
16. [16]Bobdiwala S, Kyriacou C, Christodoulou E, et al. Evaluating cut-off levels for progesterone, β human chorionic gonadotropin and β human chorionic gonadotropin ratio to exclude pregnancy viability in women with a pregnancy of unknown location: a prospective multicenter cohort study Acta Obstet Gynecol Scand, 2022.PMID 34817062
17. [17]Farren J, Jalmbrant M, Falconieri N, et al. Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multicenter, prospective, cohort study Am J Obstet Gynecol, 2020.PMID 31953115
18. [18]Kirk E, Bourne T Diagnosis of ectopic pregnancy with ultrasound Best Pract Res Clin Obstet Gynaecol, 2009.PMID 19356985
19. [19]Davenport MJ, Lindquist A, Brownfoot F, et al. Time to resolution of tubal ectopic pregnancy following methotrexate treatment: A retrospective cohort study. PLoS One, 2022.PMID 35609041
20. [20]Principi G, Salvatori MM, Ficarola F, et al. Management of heterotopic cervical pregnancy: a case report and review of the literature. J Med Case Rep, 2026.PMID 41486141
21. [21]Rosh B, Hadad J, Gronich N Timing of conception after methotrexate and subsequent pregnancy outcomes: A retrospective cohort study. Int J Gynaecol Obstet, 2026.PMID 41808516
22. [22]Maurice P, Vigoureux S, Garabedian C, et al. Prevention of RhD alloimmunization in the first trimester of pregnancy: Clinical practice guidelines of the French College of Obstetricians and Gynecologists. Int J Gynaecol Obstet, 2025.PMID 40251923