Ectopic Pregnancy — Diagnosis & Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Hemodynamic assessment
   Reproductive-age woman, hCG-positive + abdominal pain/vaginal bleeding — hemodynamics? (Transvaginal ultrasound + serum β-hCG. Confirming an intrauterine pregnancy largely excludes ectopic (beware heterotopic pregnancy after assisted reproduction). β-hCG discriminatory zone ~1500–2000 (up to 3500) mIU/mL: above this an intrauterine sac should be seen; its absence with an adnexal mass suggests ectopic (rupture can occur at low β-hCG too). Check blood type/Rh, CBC.)
   • Unstable / ruptured / hemoperitoneum → Surgical treatment
   • Stable → Eligible for MTX?
2. [Decision] Eligible for MTX?
   Eligible for methotrexate (MTX) medical treatment? (MTX criteria: stable, unruptured, β-hCG usually <5000 mIU/mL (success rises as the value falls), no fetal cardiac activity, mass <3.5–4 cm, able to follow up, no MTX contraindication (hepatic/renal/hematologic disease, immunodeficiency, breastfeeding, active ulcer/lung disease, intrauterine pregnancy). Check CBC/liver and renal function before giving.)
   • Eligible for MTX → Methotrexate medical treatment
   • Not eligible / cannot follow up → Surgical treatment
3. [End] Methotrexate medical treatment
   Give methotrexate (MTX) to eligible patients, follow β-hCG on days 4 and 7 (expect ≥15% fall from day 4 to 7), then weekly to negative; repeat or convert to surgery if targets are not met. Give anti-D immunoglobulin (RhoGAM) if Rh-negative. A pregnancy of unknown location with very low/falling β-hCG may be managed expectantly under close follow-up.
4. [End] Surgical treatment
   Unstable/ruptured/hemoperitoneum → emergency surgery (laparoscopic salpingectomy or salpingostomy) + resuscitation, cross-match and transfuse; stable patients ineligible for MTX or unable to follow up reliably → elective laparoscopic surgery. Give anti-D immunoglobulin (RhoGAM) if Rh-negative, with immediate co-management by obstetrics & gynecology.

Source guidelines & references

• ACOG Practice Bulletin on tubal ectopic pregnancy; RCOG ectopic pregnancy guideline

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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