Ectopic Pregnancy

Key considerations: Ruptured ectopic with hemoperitoneum, Heterotopic pregnancy (concurrent IUP + ectopic, especially after IVF)

Cannot miss

history: LMP and gestational age; Vaginal bleeding and pain pattern; Risk factors: prior ectopic, PID, IUD, tubal surgery, IVF; Syncope or lightheadedness; exam: Vital signs (tachycardia, hypotension); Abdominal exam (peritoneal signs); Pelvic exam: cervical motion tenderness, adnexal tenderness/mass; Cul-de-sac fullness; labs: Quantitative β-hCG; Type and screen/crossmatch; CBC; Rh status; imaging: Transvaginal ultrasound: no IUP, adnexal mass, free fluid; Discriminatory zone: β-hCG >3000 with no IUP on TVUS = ectopic until proven otherwise; bedside: POCUS for free fluid (Morison pouch, pelvis); POCUS for IUP vs no IUP

immediate: If ruptured: 2 large-bore IVs, aggressive fluid resuscitation, type and crossmatch, STAT OB consult for emergent surgery; RhoGAM if Rh-negative; general: Determine if ruptured vs unruptured; Treatment depends on hemodynamic stability, β-hCG level, and ectopic characteristics; specific: diagnosis: Unruptured (stable, β-hCG <5000, no cardiac activity); steps: Methotrexate 50mg/m² IM (single dose protocol); Contraindications: breastfeeding, immunodeficiency, hepatic/renal disease, thrombocytopenia; Follow β-hCG: expect >15% decline between day 4 and 7; Avoid NSAIDs, folate supplements, intercourse, heavy exercise; diagnosis: Ruptured or Hemodynamically Unstable; steps: Emergent surgery (salpingectomy or salpingostomy); Do NOT delay for imaging if hemodynamically unstable with positive β-hCG; Massive transfusion if needed; diagnosis: Pregnancy of Unknown Location; steps: Serial β-hCG q48h (should rise >35% if normal IUP); Repeat TVUS when β-hCG above discriminatory zone; Ectopic precautions and return instructions

admit: Ruptured ectopic; Hemodynamically unstable; Post-surgical observation; discharge: Stable, unruptured ectopic after methotrexate with reliable follow-up; Pregnancy of unknown location with ectopic precautions and 48h β-hCG follow-up; consults: OB/GYN for all confirmed or suspected ectopic; Surgical consult for ruptured

β-hCG >3000 + empty uterus on TVUS = ectopic until proven otherwise
Ruptured ectopic is the #1 cause of first-trimester maternal death
IVF patients: higher risk of heterotopic pregnancy (~1% vs 1/30,000 in natural conception) — always scan both adnexa
β-hCG that plateaus or rises <35% in 48h = abnormal pregnancy (ectopic or nonviable IUP)