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Ectopic pregnancy
Every woman of reproductive age with abdominal pain or bleeding has an ectopic pregnancy until proven otherwise: check hCG, and if transvaginal ultrasound shows no intrauterine pregnancy, the choice between observation, methotrexate and surgery is made by stability, hCG level and the scan.
Why it matters in the exam
Ectopic pregnancy is the main cause of maternal death in the first trimester. Exam questions show a woman with a late period, lower abdominal pain and light bleeding, and ask for the next step or the treatment. The first decision is haemodynamic stability: an unstable woman with free fluid in the abdomen goes to theatre without waiting for further tests. In a stable woman, quantitative hCG is combined with transvaginal ultrasound and the decision follows the criteria.
Candidates are asked about the criteria for methotrexate (stability, no rupture, low hCG, no fetal cardiac activity, a small mass, reliable follow-up) and its contraindications (breastfeeding, liver or kidney disease, immunosuppression, a coexisting intrauterine pregnancy). Understand the follow-up too: hCG on day 4 and day 7, with a fall of at least 15% between them. Risk factors: previous ectopic pregnancy, tubal surgery, pelvic inflammatory disease, IVF and smoking. An intrauterine device lowers pregnancy overall, but if a pregnancy occurs with a device in place, it is much more likely to be ectopic.
Key points
- Abdominal pain or bleeding with a positive pregnancy test = exclude an ectopic pregnancy.
- Unstable → immediate surgery.
- Methotrexate: stable, no rupture, low hCG, no cardiac activity.
- Follow-up: a fall of at least 15% between day 4 and day 7.
- Risk factors: previous ectopic, pelvic inflammatory disease, tubal surgery, IVF.
Summary table
| Situation | Findings | Treatment | Exam notes |
|---|---|---|---|
| Unstable | Hypotension, much free fluid, peritoneal signs | Immediate surgery (laparoscopy or laparotomy) | Do not wait for repeat tests |
| Stable, suitable for methotrexate | No rupture, hCG preferably below 5000, no cardiac activity, mass below 3.5 cm | Methotrexate 50 mg per m² IM | hCG on day 4 and day 7; a fall of at least 15% |
| Stable, not suitable for methotrexate | Fetal cardiac activity, high hCG, large mass or a contraindication | Laparoscopy: salpingectomy, or salpingostomy when the other tube is damaged | After salpingostomy — follow hCG |
| Pregnancy of unknown location (PUL) | Positive hCG, no pregnancy seen on ultrasound | Repeat hCG after 48 hours and ultrasound | A rise of less than 35% in 48 hours suggests an abnormal pregnancy |
| Heterotopic pregnancy | Intrauterine and ectopic pregnancy at the same time | Surgery; methotrexate is forbidden | Rare, but more common after IVF |
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Sources
- ACOG Practice Bulletin No. 193, 2018 — Tubal Ectopic Pregnancy
- NICE guideline NG126, 2019, updated 2023 — Ectopic pregnancy and miscarriage: diagnosis and initial management
- ESHRE working group, 2020 — Terminology for describing normally sited and ectopic pregnancies on ultrasound
- Williams Obstetrics, 26th edition (2022) — Ectopic Pregnancy
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.