Suspected ectopic pregnancy
Positive pregnancy test with pain, bleeding, dizziness or collapse. Ectopic is possible at any hCG level.
All Pathways
Obstetrics & GynecologyEmergency
Ectopic Pregnancy Management (ACOG 2018)
Ectopic Pregnancy Management (ACOG 2018): Suspected ectopic pregnancy → Assess stability and test at once → Unstable or signs of rupture? → Unstable or ...
Pathway Overview
21 steps
Algorithm Steps
21 total
01Start 02Action Assess stability and test at once
Check for bleeding into the abdomen first. Shock or collapse: go straight to emergency care; do not wait for the scan.
- Pulse, BP, pallor, syncope, abdominal tenderness or guarding
- Normal BP does not exclude major internal bleeding
- Quantitative serum hCG and transvaginal ultrasound (TVUS)
- FBC, blood group and antibody screen (Rh D status)
- Ask about IVF or assisted conception (heterotopic risk)
03Decision Unstable or signs of rupture?
Shock, syncope, peritonism or large free fluid on scan.
- If Yes
04Warning Unstable or ruptured: emergency surgery
Resuscitate. Call the senior gynaecologist and anaesthetist now. Go to theatre; do not wait for more tests.
- Two large-bore IV cannulas; crossmatch; massive transfusion protocol if needed. Declines blood: tell senior team now
- Emergency laparoscopy (laparotomy if needed): salpingectomy
- No theatre on site: resuscitate and call the state retrieval service now (000 if outside hospital)
05Action Rh D negative and no anti-D antibodies: give anti-D
Check blood group and antibody screen in every ectopic pregnancy. Give at diagnosis or treatment; do not wait for hCG to fall.
- Australia (NBA 2024): Rh D immunoglobulin 250 IU (50 micrograms) IM up to 12+6 weeks; 625 IU (125 micrograms) IM after 12+6 weeks
- Give as soon as practical within 72 h; if delayed, up to 10 days after the event
- Not needed if anti-D antibodies are already present
- UK (NICE): 250 IU only after surgical management. US: ACOG and local policy
06Outcome Follow-up and counselling
Follow hCG to negative. After salpingectomy: urine pregnancy test at 3 weeks. After salpingotomy: hCG at 7 days, then weekly. After methotrexate or expectant care: as in that step.
- After methotrexate: avoid pregnancy for 3 months; offer contraception
- Risk of another ectopic after one tubal ectopic: about 5 to 19%
- Next pregnancy: self-refer early to the early pregnancy service for an early scan
- Offer psychological support; distress and depression are common
- Written advice on when and where to get emergency care
If No07Decision Stable: what does TVUS show?
Intrauterine pregnancy, ectopic pregnancy, or no pregnancy seen.
- IUP seen
08Outcome Stable, intrauterine pregnancy seen: ectopic unlikely
Gestational sac with yolk sac or embryo in the uterus. After IVF, look for a heterotopic ectopic. Never give methotrexate.
- IVF or assisted conception: heterotopic pregnancy possible; check both adnexa
- Pain, adnexal mass or free fluid with an IUP: senior review
- Otherwise manage as early pregnancy bleeding or pain
- Ectopic seen
09Action Stable, ectopic seen on TVUS
Extrauterine sac with yolk sac or embryo, or an adnexal mass separate from the ovary.
- Record mass size, fetal heartbeat and free fluid
- Solid adnexal mass on one scan only: confirm with repeat hCG before methotrexate
- An empty uterus is not enough to diagnose ectopic pregnancy
10Warning Stable ectopic: check these before treatment
These change or stop the usual treatment options.
- Caesarean scar, cervical, interstitial, ovarian or abdominal site: senior specialist care
- Heterotopic pregnancy (IUP plus ectopic): no methotrexate; specialist care
- Any chance of a viable IUP: no methotrexate until excluded
11Decision Stable tubal ectopic: choose management
Use pain, mass size, fetal heartbeat, hCG and ability to return for follow-up (NICE NG126).
- Surgery first
12Action Surgery: laparoscopic salpingectomy or salpingotomy
Surgery first if significant pain, mass 35 mm or more, fetal heartbeat, hCG 5,000 IU/L or more, cannot return, or other options not suitable or failed.
- Laparoscopy when possible
- Salpingectomy unless other risk factors for infertility
- Consider salpingotomy if risk factors for infertility (for example damaged other tube); up to 1 in 5 need more treatment
- After salpingotomy: hCG at 7 days, then weekly until negative
- After salpingectomy: urine pregnancy test at 3 weeks; return if positive
- Path rejoins step 05Shared downstream outcome
- Consider methotrexate
13Warning Considering methotrexate: exclude contraindications
Methotrexate is off-label for ectopic pregnancy and is cytotoxic. Stop if any of these apply.
- IUP or possible viable IUP; breastfeeding; rupture or instability; cannot return for follow-up
- Immunodeficiency; moderate or severe anaemia, low WBC or platelets; significant liver or kidney disease
- Active lung disease or peptic ulcer; methotrexate allergy. Relative: declines blood transfusion
14Decision Methotrexate? No significant pain, mass <35 mm, no heartbeat, hCG <5,000 IU/L
NICE: offer if hCG less than 1,500 IU/L; offer a choice with surgery if hCG 1,500 to 4,999 IU/L. hCG 5,000 IU/L or more: surgery.
- If Yes
15Action Methotrexate suitable: single-dose protocol (adult)
Methotrexate 50 mg/m² body surface area IM once on day 1. Use local protocol and pharmacy check. Stop folic acid, NSAIDs and trimethoprim (including co-trimoxazole). Rh D negative: give anti-D now.
- Before the dose: FBC, creatinine, LFTs, blood group and antibody screen, hCG (day 1)
- hCG on days 4 and 7; a rise from day 1 to day 4 is common
- Fall 15% or more from day 4 to day 7: hCG weekly until negative
- Fall less than 15% from day 4 to day 7: senior review for a second dose of 50 mg/m² IM
- Pain on days 2 to 3 is common; severe pain or signs of rupture: urgent review
- Avoid folic acid, NSAIDs, trimethoprim, alcohol and sexual intercourse until hCG is negative
- Avoid pregnancy for 3 months after methotrexate
- Two-dose or multidose regimens: specialist protocol only
- hCG falling
- Path rejoins step 05Shared downstream outcome
- Failing
16Warning Treatment failing or rupture suspected: surgical review
For expectant or methotrexate management. Unstable: emergency surgery.
- Severe or increasing pain, signs of rupture or instability: emergency surgery
- After methotrexate: hCG does not fall after 2 doses: surgery
- Expectant: hCG plateau or rise: senior review for methotrexate or surgery
- Path rejoins step 12Shared downstream outcome
If No- Path rejoins step 12Shared downstream outcome
- Expectant criteria met
17Action Expectant: stable, pain free, mass <35 mm, no heartbeat, hCG ≤1,000 IU/L
Offer if hCG 1,000 IU/L or less. Consider if hCG above 1,000 and below 1,500 IU/L. Must be able to return. Rh D negative: give anti-D now (see anti-D step).
- hCG on days 2, 4 and 7 after the first test
- Each value falls 15% or more: then weekly hCG until less than 20 IU/L
- hCG falls less than 15%, plateaus or rises: senior review
- Pain, bleeding, dizziness or collapse: return at once
- Failing
- Path rejoins step 16Shared downstream outcome
- hCG falling
- Path rejoins step 05Shared downstream outcome
- No pregnancy seen
18Action Stable, no pregnancy seen on TVUS: pregnancy of unknown location (PUL)
Treat as a possible ectopic until the location is known. New or worse pain, bleeding or dizziness: return at once, whatever the hCG.
- No hCG level safely excludes a viable IUP: do not treat on one hCG and one scan
- Repeat serum hCG 48 h after the first (not earlier)
- Rise more than 63%: likely developing IUP; TVUS in 7 to 14 days (earlier if hCG 1,500 IU/L or more)
- Fall more than 50%: pregnancy unlikely to continue; urine pregnancy test 14 days later
- Rise less than 63% or fall less than 50%: early pregnancy service review within 24 h
- A viable IUP can rise by only 33 to 49% in 48 h; hCG trend does not locate the pregnancy
19Decision PUL: result of repeat hCG and TVUS
Pregnancy seen in the uterus, ectopic seen, hCG falling, or still unknown.
- IUP seen
- Path rejoins step 08Shared downstream outcome
- Ectopic seen
- Path rejoins step 10Shared downstream outcome
- hCG falling >50%
20Outcome PUL with hCG falling more than 50%: likely failing pregnancy
Not confirmed. Urine pregnancy test 14 days after the second hCG.
- Negative: no further action
- Positive: return to early pregnancy service within 24 h
- Pain, bleeding or dizziness: return at once
- Still unknown
21Outcome Persisting PUL (hCG plateau, no pregnancy seen): senior review
A senior gynaecologist decides further management. No methotrexate until a viable IUP is excluded.
- Do not give methotrexate until a viable IUP is excluded
- Continue review until hCG is negative or location is known
Guideline Source
ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Tubal ectopic only. Caesarean scar, cervical, interstitial, ovarian, abdominal and heterotopic pregnancy need specialist care.
- Methotrexate for ectopic pregnancy is off-label. Use the local protocol and a pharmacy dose check.
- Anti-D policy differs by country: Australia (NBA 2024) after any ectopic; UK (NICE) only after surgery.
- hCG thresholds (NICE NG126) guide choice of treatment; they do not locate the pregnancy.
Contraindicated Populations
Non-tubal ectopic pregnancy (caesarean scar, cervical, interstitial, ovarian, abdominal)Heterotopic pregnancy (specialist care)
Applicable Regions
AUUKUSEUGlobal
AU: Anti-D per National Blood Authority guideline (2024): 250 IU up to 12+6 weeks, 625 IU after. Emergency: 000.
UK: NICE NG126 (updated 2023): anti-D 250 IU only after surgical management of ectopic pregnancy.
US: ACOG Practice Bulletin 193 (reaffirmed 2025). Rh D immune globulin per ACOG and local policy.
Global: Access to methotrexate, laparoscopy and serial hCG varies. Where follow-up is not possible, surgery is safer.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Ectopic Pregnancy Management (ACOG 2018)?
The Ectopic Pregnancy Management (ACOG 2018) is a emergency clinical algorithm for Obstetrics & Gynecology. It provides a structured decision tree to guide clinical decision-making, based on ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy.
What guideline is the Ectopic Pregnancy Management (ACOG 2018) based on?
This algorithm is based on ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy (DOI: 10.1097/AOG.0000000000002560).
What are the limitations of the Ectopic Pregnancy Management (ACOG 2018)?
Known limitations include: Tubal ectopic only. Caesarean scar, cervical, interstitial, ovarian, abdominal and heterotopic pregnancy need specialist care.; Methotrexate for ectopic pregnancy is off-label. Use the local protocol and a pharmacy dose check.; Anti-D policy differs by country: Australia (NBA 2024) after any ectopic; UK (NICE) only after surgery.; hCG thresholds (NICE NG126) guide choice of treatment; they do not locate the pregnancy.. Individual patient factors may require deviation from these recommendations.
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