Synopsis
Select ectopic pregnancy treatment from stability, pain, ultrasound, hCG, follow-up and fertility factors, with exact thresholds and complete biochemical or postoperative follow-up.
- Stability and pain come before hCG: rupture, haemodynamic compromise or significant pain requires surgery irrespective of biochemical concentration.
- Offer expectant management when clinically stable and pain free, tubal ectopic is under 35 mm with no heartbeat, hCG is 1,000 IU/L or less and reliable follow-up is possible.
- Consider expectant management at hCG above 1,000 but below 1,500 IU/L when every other criterion is met.
Key red flags
New severe pain, shoulder-tip pain, dizziness, collapse, hypotension or guarding during expectant or methotrexate care may indicate rupture and needs immediate emergency assessment.
Investigation priorities
Confirm site, mass size, fetal cardiac activity and free fluid before selecting conservative treatment.
Management branches
The patient is unstable, has rupture, peritonism or significant pain and bleeding.
- Resuscitate with senior gynaecology, anaesthetic, theatre and transfusion teams and proceed without waiting for outpatient eligibility tests.
- Perform laparoscopy when feasible or laparotomy when rapid access, instability or complexity requires it, controlling haemorrhage and removing ectopic tissue.
The patient is stable and pain free with mass under 35 mm, no heartbeat, hCG at or below 1,000 IU/L and reliable follow-up.
Key medicines
Methotrexate for tubal ectopic pregnancyAdminister a single intramuscular dose of 50 mg/m² under the specialist ectopic protocol after definitive diagnosis and baseline assessment; repeat treatment is determined by day 4 and day 7 hCG response.