← Diagnosis and Management Guides
Ectopic Pregnancy
Key considerations: Ruptured ectopic with hemorrhagic shock, Heterotopic pregnancy
Cannot miss
- Ruptured ectopic with hemorrhagic shock
- Heterotopic pregnancy
Likely diagnoses
- Ectopic pregnancy
- Threatened abortion
- Ovarian cyst
- PID
Red flags
- Hemodynamic instability
- Acute abdomen
- Free fluid on POCUS
- hCG >3000 with no IUP on TVUS
Workup
- history: Last menstrual period, vaginal bleeding, abdominal pain, prior ectopic, PID, IUD; exam: Abdominal tenderness, cervical motion tenderness, adnexal mass/tenderness; labs: Quantitative hCG, type and screen, CBC, Rh status; imaging: Transvaginal ultrasound (IUP should be visible by hCG ~3000); bedside: POCUS: IUP, free fluid, adnexal mass
Management
- immediate: Ruptured: IV fluids, blood products, emergent surgery (salpingectomy); Hemodynamically stable: OR or methotrexate; general: Methotrexate criteria: hemodynamically stable, unruptured, hCG <5000, no fetal cardiac activity; Surgical: salpingectomy (preferred) or salpingostomy; RhoGAM if Rh negative
Disposition
- admit: Ruptured ectopic, hemodynamic instability, need for surgical intervention; discharge: After methotrexate with strict return precautions and serial hCG follow-up (day 4 and 7); consults: OB/GYN
Clinical pearls
- Ectopic is the leading cause of maternal mortality in the first trimester
- hCG discriminatory zone: should see IUP on TVUS by hCG ~3000 — if not, assume ectopic until proven otherwise
Source and review
- ACOG Ectopic Pregnancy PB 2018. Last reviewed: 2024-11-01