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Ectopic Pregnancy

NICE Guideline [NG126] Ectopic pregnancy and miscarriage: diagnosis and initial management. Last updated: Aug 2023.

Guidelines

Refer immediately to the Early Pregnancy Assessment Service if any of the following 2 scenarios:
  • +ve Pregnancy test AND pain / tenderness in abdomen or pelvis OR cervical motion tenderness
 
  • Per vaginal bleeding AND pain OR >6 weeks gestation OR uncertain gestation

NICE explicitly states to use expectant management if ALL the following:
  • Bleeding but NOT in pain
  • Pregnancy <6 weeks
  • No risk factors (e.g. previous ectopic pregnancy)

Expectant management in the above situation includes;
  • Return if bleeding continues or pain develops
  • Repeat urine pregnancy test after 7-10 days, and return if +ve

Investigation of choice:  TVUS to evaluate the uterus, adnexa and surrounding structures

Alternative: TAUSTrans-abdominal ultrasound
  • can be considered if TVUS is not appropriate
  • Note TAUS  has a lower sensitivity and specificity
  • Can also be used to exclude differential diagnoses (e.g. acute appendicitis) 
 

If ultrasound identifies moderate to large amount of free fluid in the peritoneal cavity or Pouch of Douglas, that is indicative of haemoperitoneum, likely due to a ruptured ectopic pregnancy.



NICE has made the following extensive recommendations regarding TVUS findings in diagnosing ectopic pregnancy.

Interpretation TVUS findings
Diagnosis of ectopic pregnancy
  • Adnexal mass, AND
  • Sliding sign (mass moving separately from the ovary), AND
  • Presence of a gestational sac and a yolk sac OR gestational sac and fetal pole +/- fetal heartbeat
High probability of ectopic pregnancy
  • Adnexal mass AND sliding sign AND tubal ring / bagel sign (empty gestational sac), OR
  • Complex inhomogeneous adnexal mass + sliding sign
Possible ectopic pregnancy
  • Empty uterus, OR
  • Pseudo-sac (collection of fluid within the uterine cavity) - but must be differentiated from an early intrauterine sac (double decidual sign)
 

There are 3 main approaches to managing ectopic pregnancies:
  • Expectant management
  • Medical management
  • Surgical management
 

First, check for any indications to offer surgery as 1st line management. ANY of the following:
  • Significant pain
  • Adnexal mass ≥35mm
  • Fetal heartbeat is visible on US
  • hCG ≥5,000 IU/L
 
  • Ruptured ectopic pregnancy (not explicitly stated by NICE but presumed, as this is a requirement for expectant / medical management)
  • Unable to return for follow-up (not explicitly stated by NICE but presumed, as this is a requirement for expectant / medical management)

Indications for expectant and medical management are similar:
 
Approach Indications (ALL must be met)
Expectant Management
  • Clinically stable + pain free
  • Unruptured adnexal mass <35mm
  • NO visible heartbeat
  • hCG <1,000 IU/L (still can be considered if hCG 1,000-1,500)
  • Able to return for follow-up
Medical Management
  • No significant pain
  • Unruptured adnexal mass <35mm
  • NO visible heartbeat
  • hCG <1500 IU/L
  • Able to return for follow-up
  • No intrauterine pregnancy (confirmed on US)
 

Main differences in indications for expectant and medical management are:

  • Pain level: pain-free for expectant; no significant pain for medical
  • No intrauterine pregnancy on ultrasound is a must for medical management
 

Offer choice of medical OR surgical management if all the following:

  • Serum hCG 1,500-5,000 IU/L
  • Able to attend follow-up
  • No significant pain
  • Unruptured ectopic pregnancy
  • Adnexal mass <35mm
  • No visible heartbeat
  • No intrauterine pregnancy (confirmed on US)

Approach Description
Expectant management
  • Watch and wait
  • Repeat hCG levels on day 2,4,7 after the original test
    • If levels drop by ≥15% on these days → repeat weekly until negative result (<20 IU/L)
    • If not → seek senior advice
Medical management
  • Systemic methotrexate
  • Repeat hCG levels on day 4 and 7, then 1 per week until negative (<20 IU/L)
    • If levels ever plateau or rise → reassess
Surgical management
  • Approach: laparoscopic preferred 
    • 1st line for most patients:  salpingectomy (then urine pregnancy test after 3 weeks)
    • If patient has risk factors for infertility (e.g. contralateral tube damage from surgery / infection / disease):  salpingotomy (then serum hCG 7 days after, then 1 per week until -ve result)
Note that up to 1 in 5 women who received salpingotomy may need further treatment.
 
  • Offer anti-D immunoglobulin prophylaxis to all Rh-ve women

References

Author: Adams Lau
Reviewer:
Last edited: 27/04/25