Ectopic Pregnancy

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Ectopic Pregnancy — Diagnosis, Treatment & Follow-up

Ectopic pregnancy is a time-critical emergency in early pregnancy. This guide covers risk factors, diagnosis with ultrasound and hCG, the Indian standard treatment guideline, expectant, medical and surgical care, special sites, and follow-up, using the ECTOPIC approach.

🎯 AT A GLANCE — ECTOPIC PREGNANCY

An ectopic pregnancy implants outside the endometrial cavity — about 95–97% in the fallopian tube (mostly the ampulla); incidence is about 1–2% of pregnancies (1–3% in the Indian guideline)

It remains a leading cause of first-trimester maternal death; the classic triad is amenorrhoea, pain, and vaginal bleeding, but many women have no risk factor

Diagnosis rests on a transvaginal ultrasound (TVS) and serial serum β-hCG (human chorionic gonadotropin)

Treatment is expectant, medical (methotrexate), or surgical, chosen by stability, hCG level, mass size, fetal heart activity, and follow-up reliability

Think of ectopic pregnancy in every woman of reproductive age with pain or bleeding and a positive pregnancy test — until an intrauterine pregnancy is proven.

🚨 EMERGENCY — SUSPECT A RUPTURED ECTOPIC

Shock: pallor, tachycardia, low blood pressure, fainting, or collapse

Severe or sudden lower abdominal pain, shoulder-tip pain, rebound tenderness, or a distended abdomen

Free fluid in the pouch of Douglas or Morison's pouch on ultrasound, or a positive pregnancy test with cervical motion tenderness

Action: two large IV lines, group and cross-match, resuscitate, call a senior and the anaesthetist, and go to theatre without waiting for hCG

🗺️ THE PATHWAY AT A GLANCE

1 · SuspectPain, bleeding, amenorrhoea, or a positive test; risk factors raise suspicion

2 · StabilisePulse, blood pressure, pallor, and signs of shock; IV access, blood group, cross-match

3 · ImageTransvaginal ultrasound to find the gestational sac and adnexal mass

4 · MeasureSerum β-hCG now and at 48 hours if the location is unknown

5 · TreatSurgery if unstable; otherwise expectant, methotrexate, or surgery by criteria

6 · Follow uphCG to negative, anti-D if Rh-negative, and counsel for the next pregnancy

STEP 1 · RECOGNISE — risk factors and clinical features

📝 WHO IS AT RISK, AND WHAT SHE FEELS

Risk Factors

Previous ectopic (recurrence 10–15%) or tubal surgery or sterilisation failure

Pelvic inflammatory disease, Chlamydia, or tuberculosis

Intrauterine device in place or progestogen-only pill (if pregnancy occurs, a higher share are ectopic)

Infertility, assisted reproduction, or ovulation induction

Smoking, age over 35, endometriosis, previous pelvic surgery

Clinical Features

Amenorrhoea of 6–8 weeks, then lower abdominal pain

Light, dark-brown vaginal bleeding (often not heavy)

Dizziness, shoulder-tip pain, or pain on defecation (blood in the pouch)

Tender adnexa or cervical motion tenderness; uterus often smaller than dates

Up to half have no risk factor; some are asymptomatic

Pregnancy of unknown location (PUL): positive test, no pregnancy seen on a good-quality TVS — about 7–20% turn out to be ectopic, so follow every PUL until the outcome is known.

STEP 2 · DIAGNOSE — ultrasound and β-hCG

🔬 ULTRASOUND AND β-hCG

Finding	Meaning	Next step
Intrauterine sac with yolk sac or embryo	Intrauterine pregnancy (heterotopic is rare, but think of it after assisted reproduction)	Routine care
Adnexal mass or 'tubal ring' with or without fetal heart	Ectopic pregnancy	Choose treatment by criteria
Empty uterus, hCG above the discriminatory level (about 3,500 mIU/mL by the conservative US standard; 1,500 is older practice)	Ectopic or failed pregnancy until proven otherwise	Repeat scan; consider repeat hCG; do not assume miscarriage
Empty uterus, hCG below the discriminatory level	PUL	Repeat hCG at 48 hours; scan again; safety-net advice
Free fluid with echoes (haemoperitoneum)	Likely rupture	Emergency surgery if unstable

hCG change over 48 hours	Interpretation
Rise of at least 49% (starting below 1,500), 40% (1,500–3,000), or 33% (above 3,000)	Consistent with a viable intrauterine pregnancy (but about 20% of ectopics can rise normally)
Fall of 21–35% or more (depends on starting level)	Likely a failing pregnancy; keep following until negative
Plateau, or abnormal rise or fall	Ectopic pregnancy or abnormal intrauterine; repeat scan and plan treatment

A single hCG value cannot diagnose or exclude an ectopic pregnancy; the level does not predict rupture.

INDIA · MoHFW STANDARD TREATMENT GUIDELINE — ectopic pregnancy

🏥 GOVERNMENT OF INDIA APPROACH

Topic	What the guideline says
Definition and risks	Implantation outside the uterine cavity, 1–3% of pregnancies; PID, endometriosis, IUCD, progestogen-only pill, tubal surgery or ligation, ovulation induction or assisted reproduction
Diagnosis	Pregnancy test; abdominal or vaginal ultrasound (empty uterus, pseudosac, adnexal mass, fluid in the pouch); culdocentesis if no ultrasound; blood group and cross-match; histopathology
Expectant management	Stable, ultrasound-diagnosed, hCG falling and below 1,000 IU/L; hCG twice weekly, weekly transvaginal scan, until hCG below 20 IU/L; if it plateaus or rises, switch to active treatment
Methotrexate eligibility	Stable, unruptured; absolute contraindications: breastfeeding, immunodeficiency, alcoholism, blood dyscrasia, active lung disease, peptic ulcer, liver, kidney or blood disease; relative: sac over 3.5 cm, fetal cardiac activity
Methotrexate dose	1 mg/kg or 50 mg/m² IM with leucovorin 0.1 mg/kg IM; hCG on days 4 and 7; another dose if hCG has not fallen by more than 15%; maximum 4 doses
Surgery	Ruptured ectopic: laparotomy to control bleeding and remove the tube; laparoscopic salpingostomy or salpingectomy where skilled; surgery if medical treatment fails
Anti-D	Give if the woman is Rh-negative and the partner Rh-positive
Referral	Secondary level: no serial hCG or medical care, no laparoscopy, heterotopic pregnancy to be continued, or transfusion needed. Super-specialty: major comorbidity, lack of skills, or assisted-reproduction heterotopic pregnancy

Note: this is a summary of the MoHFW Standard Treatment Guideline as reproduced on a secondary website; check the official publication. Its dosing differs slightly from international guidance (for example, leucovorin and the hCG fall of 15%).

STEP 3 · TREAT — choose by stability, hCG and mass

⚖️ CHOOSING THE TREATMENT

Option	Suitable when	Key points
Expectant	Stable, minimal symptoms; hCG under 1,000–1,500 and falling; no fetal heart; reliable follow-up	hCG every 48 hours, then weekly until negative; about 70% resolve; rupture risk remains
Medical (methotrexate)	Stable, unruptured; hCG under 5,000 (best results); mass under 3.5–4 cm; no fetal heart (or low hCG); no intrauterine pregnancy; normal blood count, liver and renal tests	Single dose 50 mg/m² IM on day 1; hCG on days 4 and 7; fall of 15% or more → weekly hCG to negative; less → second dose; success about 70–90%
Surgical	Unstable or rupture; significant pain; free fluid; hCG over 5,000–10,000; fetal heart; failed medical care; unable to follow up	Laparoscopic salpingectomy if the other tube is healthy; salpingostomy if the other tube is damaged and fertility is wanted (risk of persistent trophoblast, 5–15%: check hCG weekly)

Never give methotrexate when the diagnosis is uncertain — a viable intrauterine pregnancy may be exposed to a teratogen.

💉 METHOTREXATE — CHECKLIST AND COUNSELLING

Topic	Advice
Before the dose	Full blood count, liver and kidney tests, blood group; exclude intrauterine pregnancy; confirm reliable follow-up for 4–6 weeks
Do not give if	Breastfeeding, immunodeficiency, liver, kidney or marrow disease, peptic ulcer, active lung disease, or hypersensitivity
Regimens	Single-dose (50 mg/m²) is standard; two-dose (days 1 and 4) for higher hCG; multi-dose with leucovorin is older practice
During treatment	Avoid NSAIDs, alcohol, folic acid supplements, sun exposure, and intercourse; pain for 2–3 days is common ('separation pain')
Return at once if	Severe pain, dizziness, collapse, heavy bleeding, or shoulder-tip pain
Afterwards	Avoid pregnancy for 3 months; hCG until negative; folic acid is restarted

🔪 SURGERY AND SPECIAL SITES

Situation	Management
Unstable woman	Resuscitation and immediate laparoscopy or laparotomy; clamp the tube and control bleeding
Salpingectomy	Preferred when the contralateral tube looks normal; lower recurrence and no persistent trophoblast
Salpingostomy	For damaged contralateral tube and wish for fertility; follow hCG weekly; give methotrexate if it plateaus
Interstitial (cornual)	High rupture risk and heavy bleeding; methotrexate, cornual resection, or hysteroscopic or laparoscopic surgery by a specialist
Caesarean scar pregnancy	Dangerous; refer to a specialist; methotrexate, uterine artery embolisation, or local surgery; avoid curettage
Cervical, ovarian, abdominal	Specialist care with bleeding-control plan; abdominal pregnancy may need laparotomy
Heterotopic pregnancy	Intrauterine and ectopic together (rare, common after assisted reproduction); surgery if the intrauterine pregnancy is wanted — no methotrexate

STEP 4 · FOLLOW UP — after treatment

🔁 ANTI-D, FOLLOW-UP AND THE NEXT PREGNANCY

Rh-negative women: give anti-D immunoglobulin (about 250 IU / 50 micrograms within 72 hours); the national guideline gives it when the partner is Rh-positive

Follow-up hCG weekly until negative (the Indian guideline uses below 20 IU/L); rising hCG means persistent trophoblast

Recurrence risk is 10–15% after one ectopic and higher after two; offer early scan at 5–6 weeks in every later pregnancy

Contraception for 3 months after methotrexate; advise on smoking cessation and screening for Chlamydia

Emotional support: offer counselling and a follow-up visit; fertility advice if there is tubal damage

Women with an IUD: if the test is positive, exclude ectopic first

⚠️ COMMON PITFALLS

Assuming 'threatened miscarriage' without excluding ectopic, especially with no products of conception passed

Giving reassurance on a single hCG value or a 'normal' rise — about 1 in 5 ectopic pregnancies rise normally

Using methotrexate without a clear diagnosis or without checking the blood, liver and kidney tests

Omitting anti-D and safety-net advice, or losing patients with a PUL

Delaying surgery in an unstable woman because the hCG or ultrasound is not yet available

Memory Aid

ECTOPIC

Seven steps for ectopic pregnancy.

E

Early scan and hCG in any woman with pain or bleeding and a positive test

C

Check stability first — pulse, BP, pallor, and signs of shock; then look for rupture (peritonism, free fluid)

T

Transvaginal ultrasound and repeat hCG at 48 hours for a PUL

O

Options — expectant, methotrexate, or surgery, by criteria

P

Prevent Rh isoimmunisation — anti-D if Rh-negative

I

Inform and follow — hCG to negative; return advice

C

Counsel about recurrence, early scan, and contraception

Remember: shock means surgery; for everyone else, an exact diagnosis comes before methotrexate — and follow up until the hCG is negative.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary based on the Ministry of Health & Family Welfare, Govt of India (MoHFW) Standard Treatment Guideline, the American College of Obstetricians and Gynecologists (ACOG), the National Institute for Health and Care Excellence (NICE), and the Royal College of Obstetricians and Gynaecologists (RCOG) guidance; thresholds, intervals and regimens vary between guidelines — follow local protocol, obtain consent, and involve a senior obstetrician in any high-risk case.