Synopsis
Recognise typical and atypical ectopic pregnancy, identify concealed intraperitoneal bleeding and prioritise resuscitation and definitive haemorrhage control over diagnostic delay.
- Consider ectopic pregnancy in anyone with pregnancy potential and abdominal or pelvic pain, vaginal bleeding, amenorrhoea, syncope, gastrointestinal or urinary symptoms, even when pregnancy was not suspected.
- Common features are unilateral pelvic pain, missed period and vaginal bleeding; atypical presentations are common and the classic triad is neither sensitive nor required.
- Check a urine pregnancy test early in reproductive-age abdominal pain or collapse with consent and explain why it changes emergency care.
- Unstable patients go directly to A&E and senior gynaecology; resuscitation, transfusion planning and theatre preparation proceed in parallel.
- Transvaginal ultrasound is the key location test in a stable patient, but bedside detection of major free fluid in shock should accelerate surgery rather than prompt prolonged scanning.
- Risk factors include previous ectopic, tubal surgery, pelvic inflammatory disease, assisted conception, smoking and pregnancy with intrauterine contraception, yet absence of risk factors is common.
- Do not rely on the degree of vaginal bleeding: a ruptured tubal pregnancy can bleed mainly into the peritoneum while external loss remains scant.
- After recovery, explain recurrence risk, future early ultrasound access, the loss itself, treatment effects on fertility and how to seek psychological support.
Key red flags
Collapse, confusion, clammy pallor, tachycardia, hypotension, oliguria or rising lactate indicates haemorrhagic shock and may appear after substantial concealed blood loss.
Shoulder-tip pain, abdominal guarding, rebound, rectal pressure or pain on movement supports intraperitoneal irritation and possible rupture.
A positive pregnancy test with pain after sterilisation, with an IUD, after IVF or after previous ectopic pregnancy carries a high index of suspicion despite atypical bleeding.
A low, normal-rising or falling hCG cannot make a symptomatic patient safe; rupture has been reported across the biochemical range.
Investigation priorities
Rapidly identify pregnancy in abdominal pain, bleeding, collapse or atypical gastrointestinal and urinary presentations.
Management branches
Possible pregnancy coexists with shock, collapse, peritonism or strong concern about pain or bleeding.
- Call senior gynaecology, anaesthesia, theatre and transfusion support; perform ABCDE, gain two large-bore IV accesses, take urgent bloods and keep the patient warm.
- Start blood-component resuscitation and major-haemorrhage protocol when indicated, provide analgesia and avoid delaying definitive treatment for serial hCG or a formal scan.
- Proceed to emergency operative haemorrhage control, using laparoscopy when feasible or laparotomy when instability or complexity demands rapid access.
Pain, bleeding or risk factors occur in a haemodynamically stable pregnant patient.
- Take a focused history, observations and abdominal assessment and arrange early-pregnancy transvaginal ultrasound with serum hCG and baseline bloods.
- Diagnose definite ectopic from appropriate imaging or enter the PUL pathway when location is unresolved, prioritising any change in symptoms over numbers.
- Select expectant, methotrexate or surgical management only after senior review of pain, size, heartbeat, hCG, follow-up reliability, fertility and patient preference.