Ectopic Pregnancy Management (ACOG 2018)

Algorithm Steps

1. ▶

   Start

   Suspected Ectopic Pregnancy

   Positive pregnancy test + pelvic pain, vaginal bleeding, or risk factors

   1. ●

      Action

      Initial Assessment

      Evaluate stability and obtain diagnostics

      • Vital signs - assess for hemodynamic instability
      • Abdominal exam - peritoneal signs?
      • Pelvic exam - cervical motion tenderness, adnexal mass
      • Quantitative β-hCG
      • Transvaginal ultrasound (TVUS)
      • Blood type and Rh, CBC
      1. ◆

         Decision

         Hemodynamically Stable?

         Signs of rupture or significant bleeding?

         1. ⚠

            Warning

            EMERGENT SURGERY

            Suspected ruptured ectopic - immediate OR

            • Large-bore IV access x2
            • Type and crossmatch 2-4 units
            • Fluid resuscitation
            • Emergency laparoscopy or laparotomy
            • Salpingectomy (usually preferred)
            • Blood products as needed
            1. ●

               Action

               Rh Status Management

               Administer RhIG if Rh-negative

               • All Rh-negative patients should receive RhIG
               • 50 mcg if <12 weeks
               • 300 mcg if ≥12 weeks
               • Administer within 72 hours of diagnosis/treatment
               1. ✓

                  Outcome

                  Follow-Up & Counseling

                  Continued monitoring and future pregnancy planning

                  • Weekly β-hCG until undetectable
                  • Contraception for 3 months post-MTX
                  • Future ectopic risk: 10-15%
                  • Counsel on early ultrasound next pregnancy
                  • Emotional support and counseling
         2. ◆

            Decision

            Transvaginal Ultrasound Findings

            Identify pregnancy location

            1. ✓

               Outcome

               IUP Confirmed

               Intrauterine pregnancy visualized - manage appropriately

               • Gestational sac with yolk sac or embryo in uterus
               • Consider threatened abortion vs. other etiology
               • Heterotopic pregnancy rare but possible with IVF
            2. ●

               Action

               Ectopic Pregnancy Confirmed

               Extrauterine gestational sac or mass with pregnancy features

               • Adnexal mass separate from ovary
               • Extrauterine gestational sac with yolk sac/embryo
               • Ring of fire sign on Doppler
               • Empty uterus with β-hCG above discriminatory zone
               1. ◆

                  Decision

                  Treatment Selection

                  Medical vs. Surgical management

                  1. ◆

                     Decision

                     Methotrexate Candidate?

                     Assess eligibility for medical management

                     • Hemodynamically stable
                     • Unruptured ectopic
                     • β-hCG <5000 mIU/mL (best outcomes)
                     • No fetal cardiac activity
                     • Mass <3.5 cm (better success)
                     • No contraindications to MTX
                     • Able to comply with follow-up
                     1. ●

                        Action

                        Methotrexate Protocol

                        Single-dose preferred for most cases

                        • SINGLE DOSE: MTX 50mg/m² IM day 1
                        • Check β-hCG days 4 and 7
                        • If <15% decline: repeat dose day 7
                        • MULTI-DOSE: MTX 1mg/kg IM + leucovorin alternating
                        • Weekly β-hCG until undetectable
                        • Avoid intercourse, NSAIDs, folic acid during treatment
                        • Ectopic precautions: return if pain, bleeding
                        1. ⚠

                           Warning

                           MTX Failure/Rupture Risk

                           Proceed to surgery if MTX fails or symptoms worsen

                           • Significant abdominal pain
                           • β-hCG rising >day 4
                           • <15% decline despite repeat dose
                           • Signs of rupture
                           • Proceed to laparoscopy
                           1. ●

                              Action

                              Surgical Management

                              Laparoscopic approach preferred

                              • SALPINGECTOMY: Removal of tube (preferred if no fertility concerns)
                              • SALPINGOSTOMY: Tube-sparing (if contralateral tube absent/damaged)
                              • Follow β-hCG post-salpingostomy (persistent trophoblast risk)
                              • Laparoscopy preferred over laparotomy if stable
                              • Consider MTX prophylaxis after salpingostomy
            3. ●

               Action

               Pregnancy of Unknown Location (PUL)

               No IUP or ectopic visualized, positive β-hCG

               • β-hCG below discriminatory zone (1500-3000 mIU/mL)
               • Follow serial β-hCG every 48-72 hours
               • Normal rise: ≥53% in 48h at low levels
               • Abnormal: <53% rise or plateau or decline
               • Repeat TVUS when β-hCG reaches discriminatory zone