Ectopic pregnancy
Any woman of child-bearing age with belly pain, bleeding or fainting needs a pregnancy test. Positive test, pain and no pregnancy in the uterus: ectopic until proven otherwise.
A 26-year-old woman has had lower left belly pain for two days and some brown spotting. Her period is 3 weeks late. Today she fainted in the bathroom and has pain at the tip of her right shoulder. Pulse 122, BP 86/52. Pregnancy test positive.
What do you do in the next 10 minutes?
- Pregnancy testEvery woman of child-bearing age with belly pain, bleeding or fainting.
- Shocked?Two large cannulas, cross-match, major haemorrhage protocol, gynae registrar and theatre now.
- BloodsCBC, group and cross-match, serum hCG, Rh group.
- Transvaginal ultrasoundIs there a pregnancy in the uterus? Free fluid? A mass next to the ovary?
- Stable with uncertain scanPregnancy of unknown location: repeat hCG at 48 hours, clear safety-net.
- Rh negativeAnti-D if surgery is needed.
- Pain reliefParacetamol, opioid if needed.
- Explain kindlyThis is a loss, even when it is an emergency.
- Collapse, low BP, peritonism
- Shoulder-tip pain
- Pain with positive test and empty uterus
- IVF pregnancy
- Diarrhoea and dizziness with a positive test
- Ruptured ectopic
- Heterotopic pregnancy (after IVF)
- Cervical shock
- Ovarian torsion or appendicitis (mimics)
| Positive test with pain and empty uterus | Ectopic until proven otherwise |
| Shocked | Straight to theatre. Do not wait for the scan if unstable |
| Methotrexate | Only if criteria met, senior decision (see below) |
| Pregnancy of unknown location | Repeat hCG at 48 hours |
| Anti-D | 250 IU IM for Rh-negative women having surgery |
Check every dose against a current drug reference and your hospital protocol.
On this page
What it is
A pregnancy that implants outside the uterus, most often in the fallopian tube. As it grows, the tube can rupture and bleed into the abdomen. Ruptured ectopic is a leading cause of early pregnancy death.
Risk factors: previous ectopic, pelvic infection or tubal surgery, IVF, an IUCD in place, previous tubal ligation (sterilisation failure), smoking. Many women have none.
Recognising it
- Lower abdominal pain, often one-sided, with or without vaginal bleeding (often brown or light).
- Missed period, but some women do not realise they are pregnant.
- Shoulder-tip pain (blood irritating the diaphragm), dizziness, fainting.
- Diarrhoea, pain on opening bowels (blood in the pelvis).
- Signs: tenderness, guarding, cervical motion tenderness, fast pulse. Young women can keep a normal BP until late.
Any woman of child-bearing age with abdominal pain, vaginal bleeding, fainting or "gastroenteritis" with dizziness needs a pregnancy test. Do it before deciding anything else.
Assessment pathway
- Major haemorrhage protocol
- Gynae registrar and anaesthetist
- Theatre now (laparoscopy or laparotomy)
- Transvaginal ultrasound
- Serum hCG
- Rh group
Ectopic very unlikely (except after IVF: heterotopic pregnancy)
- Ectopic pregnancy
- Plan surgery or medical treatment
- Pregnancy of unknown location
- Repeat hCG at 48 hours, review with results
- Safety-net clearly
Pregnancy of unknown location
- A positive test but no pregnancy seen on scan. It may be a very early normal pregnancy, a miscarriage, or an ectopic.
- Serum hCG at 0 and 48 hours:
- Rise of more than 63%: probably a developing pregnancy in the uterus. Scan again in 7–14 days.
- Fall of more than 50%: probably a failing pregnancy. Urine test in 2 weeks.
- Anything in between: ectopic possible. Review by the gynae team within 24 hours.
- Return immediately if: pain worsens, fainting, shoulder-tip pain, heavy bleeding.
Treatment options
- Small, no pain, falling hCG
- Close follow-up with hCG
- No significant pain
- Unruptured, under 35 mm, no heartbeat
- hCG below 1500 IU/L (up to 5000 in selected cases)
- Able to return for follow-up
- Pain, rupture, heartbeat, hCG 5000 or more, or she prefers surgery
- Usually laparoscopic salpingectomy
- After methotrexate: avoid alcohol, folic acid supplements, NSAIDs and sex until hCG is negative. Pain can increase in the first days: return if severe.
Support
- An ectopic pregnancy is a loss. Explain gently what has happened and what comes next.
- Future pregnancies: early scan at 6–8 weeks to confirm the location.
- Contraception advice. Most women go on to have normal pregnancies.
Common mistakes
- No pregnancy test in a woman with belly pain or fainting.
- Reassured by a normal BP in a young woman who is bleeding inside.
- Sending a pregnancy of unknown location home without a clear follow-up plan.
- Missing ectopic because "she is sterilised" or "she has a coil".
- Treating diarrhoea and dizziness as gastroenteritis without a pregnancy test.
Frequently asked questions
What are the symptoms of ectopic pregnancy?
Lower abdominal pain, vaginal bleeding, a missed period, shoulder-tip pain, dizziness or fainting, and sometimes diarrhoea or pain on opening the bowels.
Who can have methotrexate for ectopic pregnancy?
Stable women with no significant pain, an unruptured ectopic under 35 mm with no heartbeat, an hCG below 1500 IU/L (or up to 5000 in selected cases), no pregnancy in the uterus, and who can return for follow-up.
What is a pregnancy of unknown location?
A positive pregnancy test with no pregnancy seen on ultrasound, either inside or outside the uterus. It is followed with serial hCG levels 48 hours apart.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A woman with a positive pregnancy test has shoulder-tip pain and BP 86/52. What is the best management?
Answer: Resuscitate and go to theatre. Suspected ruptured ectopic with shock: major haemorrhage protocol and emergency surgery.
- Discharge with review: Fatal error.
- Methotrexate: Only for stable unruptured ectopic.
- Wait for an ultrasound: Unstable: treat as ruptured ectopic.
- Serial hCG: Not in shock.
2. A stable woman has nothing seen on ultrasound. hCG was 1200, then 1350 at 48 hours. What is the best interpretation?
Answer: Possible ectopic: review in 24 hours. A suboptimal rise or plateau in hCG raises concern for ectopic pregnancy.
- Complete miscarriage: hCG is not falling.
- Normal intrauterine pregnancy: Expected rise is about 63% or more in 48 hours.
- Molar pregnancy: Would be much higher.
- No follow-up needed: Needs follow-up.
3. A stable woman has an unruptured 25 mm ectopic, no fetal heartbeat, hCG 900 and minimal pain. Which treatment is suitable?
Answer: Methotrexate. Methotrexate suits stable women with small unruptured ectopics, low hCG and no heartbeat, with hCG checked on days 4 and 7.
- No follow-up: hCG follow-up is required.
- Emergency laparotomy: Not needed if stable and criteria met.
- Mifepristone: Not for ectopic.
- Misoprostol: Not for ectopic.
4. At 6 weeks by dates, a stable woman with mild pain has β-hCG 1800 IU/L and an empty uterus on TVS with no adnexal mass. What is the next step?
Answer: Repeat hCG in 48 hours. Pregnancy of unknown location: positive test, no pregnancy seen on TVS. Serial hCG 48 h apart: rise ≥ 63–66% suggests viable intrauterine pregnancy (rescan); fall ≥ 50% suggests failing pregnancy; plateau/suboptimal rise suggests ectopic. Discriminatory zone (~1500–3500 IU/L): an intrauterine sac should usually be visible above it. Safety-net advice: return with pain, bleeding, shoulder-tip pain, collapse.
- Methotrexate immediately: The diagnosis is not established.
- Laparotomy: She is stable with no evidence of rupture.
- Discharge: Ectopic pregnancy is not excluded.
5. A stable woman has a 2.5 cm unruptured tubal ectopic without fetal heartbeat, minimal pain and β-hCG 1500 IU/L. Which treatment is suitable?
Answer: Single-dose methotrexate. Methotrexate (50 mg/m² IM) suits stable women with unruptured ectopic, low hCG (< 1500–5000 IU/L), mass < 3.5 cm, no fetal heartbeat, minimal pain and reliable follow-up (hCG days 4 and 7; ≥ 15% fall). Surgery (laparoscopic salpingectomy, or salpingotomy if contralateral tube damaged) for rupture, haemodynamic instability, significant pain, high hCG or heartbeat. Avoid folate supplements and pregnancy for 3 months after methotrexate.
- Laparotomy and salpingectomy: Surgery is not needed for a stable, small ectopic with low hCG.
- Expectant only with hCG 15 000: An hCG of 15,000 is too high for expectant management.
- Misoprostol: Misoprostol is for intrauterine pregnancy loss.
6. Which antidiabetic drug commonly causes fluid retention and is avoided in heart failure?
Answer: Pioglitazone. Pioglitazone (a thiazolidinedione) activates PPAR-γ, improving insulin sensitivity, but increases renal sodium and water retention, causing oedema and worsening heart failure. It also raises fracture risk and has been linked to bladder cancer. Other drugs causing fluid retention include NSAIDs, steroids and calcium channel blockers (ankle oedema).
- Metformin: No fluid retention; risk of lactic acidosis.
- Gliclazide: Hypoglycaemia, weight gain.
- Sitagliptin: Weight neutral; rare pancreatitis.
- Acarbose: Flatulence.
7. Which pairing of poison and antidote is correct?
Answer: Iron — desferrioxamine. Antidotes: iron → desferrioxamine; paracetamol → N-acetylcysteine; opioids → naloxone; benzodiazepines → flumazenil; organophosphates → atropine and pralidoxime; methanol/ethylene glycol → fomepizole or ethanol; digoxin → digoxin Fab; heparin → protamine; warfarin → vitamin K; cyanide → hydroxocobalamin; lead → chelation (EDTA, DMSA).
- Paracetamol — naloxone: Paracetamol → N-acetylcysteine.
- Organophosphate — flumazenil: Organophosphate → atropine + pralidoxime.
- Methanol — vitamin K: Methanol → fomepizole.
- Digoxin — protamine: Digoxin → digoxin Fab.
References and dose sources
- NICE NG126: Ectopic pregnancy and miscarriage
- RCOG/AEPU Green-top Guideline 21: Diagnosis and management of ectopic pregnancy
- RCOG — Green-top guidelines
- Methotrexate dosing: Drugs.com: Methotrexate dosage (see also our methotrexate dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.