Ectopic pregnancy recognition and haemodynamic emergency

Ectopic pregnancy is implantation outside the endometrial cavity, most often in the fallopian tube. Less common interstitial, cervical, ovarian, caesarean-scar and abdominal sites require specialist imaging and treatment. Heterotopic pregnancy means simultaneous intrauterine and ectopic pregnancies; it is rare after spontaneous conception but more likely after assisted reproduction, so seeing an intrauterine sac does not always end the adnexal assessment.

Presentations range from no symptoms to profound shock. Ask about the last normal period, pregnancy testing, pain, bleeding, dizziness, fainting, shoulder-tip pain, rectal pressure, diarrhoea, vomiting and urinary symptoms. Establish prior ectopic, pelvic infection, tubal surgery, sterilisation, IVF, IUD use and smoking. Pregnancy with an IUD is rare in absolute terms, but if it occurs a greater proportion is ectopic. Do not use risk-factor absence to reassure.

Assess physiology before pelvic diagnosis. Record respiratory rate, oxygen saturation, pulse, blood pressure, temperature, mental state, capillary refill and urine output. Look for pallor and diaphoresis. Abdominal guarding or rebound indicates peritoneal irritation. Speculum and bimanual examinations may identify bleeding, cervical excitation or adnexal tenderness in a stable patient but are neither sufficiently sensitive nor appropriate before resuscitation in shock.

For suspected rupture, call for help immediately. Give oxygen when clinically indicated, insert two large-bore cannulas, send full blood count, coagulation, renal and liver profile, venous gas and lactate, group-and-save and crossmatch, and begin warmed balanced blood-component resuscitation under the major-haemorrhage protocol. Avoid large crystalloid volumes that dilute clotting factors and delay blood. Keep the patient warm, obtain consent where possible and alert theatre, anaesthesia and blood bank.

Transvaginal ultrasound in a stable patient examines the uterine cavity, both adnexa and pelvic free fluid. A definite tubal ectopic is an adnexal gestational sac with yolk sac or embryo; an adnexal mass moving separately from the ovary is highly suspicious. A large volume of free fluid, especially beyond the pelvis, increases concern for haemoperitoneum. An empty uterus is not by itself diagnostic and creates a PUL pathway if no ectopic is seen.

hCG supports management but must not delay emergency haemorrhage control. A single value cannot locate pregnancy, a normal-looking rise does not exclude ectopic and declining values do not guarantee that rupture cannot occur. In a stable PUL, follow the paired 48-hour NICE thresholds. In a patient with peritonism and shock, operative findings and life-saving control take precedence over serial biochemical certainty.

Emergency surgery is usually laparoscopy when physiology and resources permit, but laparotomy may be necessary for profound instability, rapid control or technical complexity. Remove the ruptured tube and pregnancy, control bleeding and inspect the contralateral tube and pelvis. Use damage-control principles and transfusion support where required. Anti-D practice changed in June 2026: do not offer it through 11+6 weeks; at 12+0 to 12+6 weeks offer at least 250 IU to an RhD-negative patient having surgical or medical ectopic management.

After stabilisation, communicate what occurred and what remains uncertain. Tissue is usually sent for histology. Explain that ectopic pregnancy could not progress safely, that grief and trauma responses vary, and that fertility outcome depends partly on the other tube and underlying tubal disease. Provide a future-pregnancy plan: early contact and location ultrasound around 6–8 weeks or sooner with symptoms. Discuss contraception only when the patient is ready.