Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Confirm diagnosis with TVUS+hCG trends; assess stability.
- If candidate → MTX with close follow-up; otherwise surgery.
- Administer RhIg if Rh-negative; counsel on return precautions and contraception.
Clinical Synopsis & Reasoning
Suspect with abdominal pain, vaginal bleeding, and positive pregnancy test. Use transvaginal ultrasound and quantitative hCG trends; manage with single- or multi-dose methotrexate for stable, appropriate candidates or laparoscopic surgery for rupture/contraindications. Administer Rh immunoglobulin to Rh-negative patients.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| TVUS and quantitative hCG algorithm | Diagnosis | Absence of intrauterine gestation above discriminatory zone suggests ectopic | Trend hCG |
| Hemoglobin and type & screen | Safety | Assess bleeding; prepare for OR | — |
| CMP (liver/renal) | Eligibility | MTX contraindications | — |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Hemodynamic instability or ruptured ectopic | Life-threatening hemorrhage | Immediate surgical management |
| hCG >5000–10000 or fetal cardiac activity | MTX failure risk | Prefer surgery |
| Poor follow-up reliability | Safety | Surgical approach |
| Significant hepatic/renal disease or breastfeeding | MTX contraindication | Surgery |
| Rh-negative patient | Isoimmunization risk | Administer RhIg |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Methotrexate single-dose 50 mg/m² IM (selected) | Antimetabolite | Days | For stable, small, non-ruptured ectopic | Follow day 4/7 hCG decline |
| Laparoscopic salpingostomy/salpingectomy (unstable/ruptured) | Surgery | Immediate | Definitive for rupture/contraindications | — |
| Rh immunoglobulin 50–300 µg IM for Rh-negative | Alloimmunization prevention | Hours | Standard prophylaxis | — |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- ACOG ectopic pregnancy guidance — Link