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Ectopic pregnancy
Any woman of reproductive age with pain, bleeding or collapse gets a pregnancy test. Recognise the ruptured ectopic and resuscitate. For the stable patient, the transvaginal scan and serum hCG decide whether it's an intrauterine pregnancy, an ectopic, or a pregnancy of unknown location. Built for revision, not live patient decisions.
Settle them, and check the basics
test · resuscitateRed flags — what each should make you think
Ectopic pregnancy is a great mimic: it can present as diarrhoea and vomiting, urinary symptoms, or a faint. Do a pregnancy test on every woman of childbearing age with abdominal pain or collapse, whatever she thinks the chance of pregnancy is.
If unstable (suspected rupture)
- 🧪Urine pregnancy test
- IVTwo large-bore cannulas
- 🩸Major haemorrhage protocol
- ☎Gynaecology registrar now
- 🔪Theatre
- DRhesus status
Understand the patient
scan + hCGRisk factors (many have none)
- Previous ectopic, tubal surgery or sterilisation
- Pelvic inflammatory disease
- Pregnancy with an IUD in place
- Assisted conception (IVF)
- Smoking, older age
Pregnancy of unknown location (positive test, no pregnancy seen on TVUSS)
- Serum hCG at 0 and 48 h
- Rise of more than 63% → likely developing intrauterine pregnancy — rescan
- Fall of more than 50% → likely failing pregnancy — repeat urine test in 2 weeks
- In between → senior/EPAU review within 24 h
- Admit or review same day if pain or instability
Management of tubal ectopic (NICE NG126)
- Expectant — stable, pain-free, unruptured, under 35 mm, no heartbeat, hCG below 1,000 IU/L (can be offered up to 1,500)
- Methotrexate — no significant pain, unruptured, under 35 mm, no heartbeat, hCG below 1,500 IU/L (offered up to 5,000), able to attend follow-up
- Surgery (laparoscopic salpingectomy, or salpingotomy if contralateral tube damaged) — significant pain, mass 35 mm or more, visible heartbeat, hCG 5,000 IU/L or more, or rupture
- Anti-D — 250 IU for Rhesus-negative women having surgical management (not for medical/expectant management)
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Collapse, hypotension, peritonism, shoulder tip pain, positive pregnancy test.
Clinical; bedside USS may show free fluid.
Resuscitate, MHP, emergency surgery.
IVF pregnancy with an intrauterine pregnancy seen but ongoing pain.
TVUSS by experienced sonographer.
Gynaecology review.
Miscarriage with products in the cervical os, vasovagal bradycardia and hypotension.
Speculum.
Remove products from the os with sponge forceps; resuscitate. See the PV bleeding page.
Sudden unilateral pain with vomiting; migratory RIF pain.
Pregnancy test, USS.
See the relevant pages.
Investigate — what to order, when, and what it tells you
test with a question in mindPregnancy test
TVUSS
Bloods
How the plan comes together
disposition · handoverEPAU follow-up
Stable PUL with appropriate hCG pattern, or ectopic suitable for expectant/medical management: clear plan, written information, 24-hour contact.
theatre / admit
Unstable, significant pain, rupture, or criteria for surgery.
Hand over: hCG, scan findings, haemodynamics, Rhesus status.
Pregnancy test everyone, resuscitate the shocked patient and get them to theatre, and use TVUSS plus serial hCG for the stable ones. Nicely done getting here.
Clerking template
copy or downloadEctopic pregnancy — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 10 knownFrequently asked questions
quick answersWhat are the red flags for ectopic pregnancy?
- Shock, collapse, peritonism — think ruptured ectopic
- Shoulder tip pain — think haemoperitoneum
- Pain + positive test + empty uterus — think ectopic until proven otherwise
- IVF pregnancy — think heterotopic pregnancy possible
- Diarrhoea, dizziness + positive test — think ectopic (atypical)
- Rhesus negative — think anti-D considerations
What is the initial management of ectopic pregnancy?
- Urine pregnancy test — immediately
- Two large-bore cannulas — FBC, G&S/crossmatch, clotting, hCG
- Major haemorrhage protocol — if shocked
- Gynaecology registrar now — —
- Theatre — laparoscopy/laparotomy — don't wait for a scan if unstable
- Rhesus status — anti-D if indicated
Always alongside senior support and your local guideline.
What diagnoses must you not miss in ectopic pregnancy?
- Ruptured ectopic — shock · peritonism
- Heterotopic pregnancy — IVF
- Cervical shock (miscarriage) — bradycardia + bleeding
- Ovarian torsion / appendicitis (mimics) — pain + negative test
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for ectopic pregnancy?
- Pregnancy test — Immediately.
- TVUSS — Intrauterine pregnancy, adnexal mass, free fluid.
- Bloods — FBC, G&S (Rhesus), clotting; LFT/U&E before methotrexate.
Admit or discharge: how is the plan decided for ectopic pregnancy?
- Epau follow-up — Stable PUL with appropriate hCG pattern, or ectopic suitable for expectant/medical management: clear plan, written information, 24-hour contact.
- Theatre / admit — Unstable, significant pain, rupture, or criteria for surgery.
Is there a clerking template for ectopic pregnancy?
Yes — there is a clerking template for ectopic pregnancy on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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