Ectopic Pregnancy · Expectant vs MTX vs Surgery

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] Rupture/stable + hCG/mass/cardiac activity + follow-up
   Hemodynamics? hCG/mass/cardiac activity? Able to follow up?
   • Rupture/hemodynamically unstable/acute abdomen/hemoperitoneum → Rupture/unstable → emergency surgery
   • Stable, low and falling hCG, asymptomatic (PUL/resolving) → Low and falling hCG → expectant
   • Stable, unruptured, hCG <5000, mass ≤3.5–4 cm, no cardiac activity, no MTX contraindication, can follow up → Meets criteria → methotrexate
   • Stable but high hCG/large mass/cardiac activity/MTX contraindicated or failed/patient chooses surgery → Surgery · salpingostomy vs salpingectomy
2. [End] Rupture/unstable → emergency surgery
   Rupture/hemodynamically unstable/acute abdomen/hemoperitoneum → emergency surgery (laparoscopic or open) + resuscitation and transfusion; usually ipsilateral salpingectomy.
3. [End] Low and falling hCG → expectant
   Stable, low hCG (e.g. <200) and steadily falling, asymptomatic → expectant management, close follow-up of hCG to negative; rising hCG/symptoms → switch to MTX or surgery.
4. [End] Meets criteria → methotrexate
   Meets criteria → single-dose MTX 50 mg/m² IM; check hCG on days 4 and 7 (expect ≥15% fall from day 4 to 7), inadequate → second dose or surgery; high hCG may use a multidose regimen; contraception during treatment, avoid folate/NSAID interactions, follow to negative.
5. [Decision] Surgery · salpingostomy vs salpingectomy
   Preserve the tube or remove it?
   • Contralateral tube normal/fertility preservation needed, bleeding controllable → salpingostomy → Salpingostomy
   • Ipsilateral severely damaged/uncontrolled bleeding/recurrence in same tube/no fertility wish → salpingectomy → Salpingectomy
6. [End] Salpingostomy
   Salpingostomy — preserves the tube; risk of persistent trophoblast, follow hCG to negative postoperatively.
7. [End] Salpingectomy
   Salpingectomy — ipsilateral destroyed/uncontrolled bleeding/recurrence in the same tube/no fertility wish; with a normal contralateral tube, future fertility is similar to salpingostomy.

Source guidelines & references

• Tubal ectopic pregnancy management (ACOG Practice Bulletin 193; MTX criterion hCG <5000)

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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