Management

Management of an ectopic pregnancy can be

• surgical - laparotomy, operative laparoscopy, by far the most commonly applied
• medical
• occasionally expectant – observation (1)

The strategy chosen must balance the risks to the mother with that of preserving future fertility. Women also should be informed regarding the possible advantages and disadvantages of each approach and should be involved fully in deciding the most appropriate treatment (1).

If a woman with a confirmed or suspected ectopic pregnancy is Rhesus negative, then she will require an anti-D immunoglobulin injection (1).

NICE have issued guidance regarding the decision making regarding choice between surgical and medical management

See expectant management of ectopic pregnancy in linked item.

Systemic methotrexate is first-line treatment to women who are able to return for follow-up and who have all of the following:

• no significant pain
• an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat
• a serum hCG level less than 1500 IU/litre
• no intrauterine pregnancy (as confirmed on an ultrasound scan)
• methotrexate should only be offered on a first visit when there is a definitive diagnosis of an ectopic pregnancy, and a viable intrauterine pregnancy has been excluded
• surgery should be offered where treatment with methotrexate is not acceptable to the woman

Surgery is first-line treatment to women who are unable to return for follow-up after methotrexate treatment or who have any of the following:

• an ectopic pregnancy and significant pain
• an ectopic pregnancy with an adnexal mass of 35 mm or larger
• an ectopic pregnancy with a fetal heartbeat visible on an ultrasound scan
• an ectopic pregnancy and a serum hCG level of 5000 IU/litre or more

Offer the choice of either methotrexate or surgical management to women with an ectopic pregnancy who have a serum hCG level of at least 1500 IU/litre and less than 5000 IU/litre, who are able to return for follow-up and who meet all of the following criteria:

• no significant pain
• an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat
• no intrauterine pregnancy (as confirmed on an ultrasound scan)

Advise women who choose methotrexate that their chance of needing further intervention is increased and they may need to be urgently admitted if their condition deteriorates

Notes:

• advise women who choose methotrexate that their chance of needing further intervention is increased and they may need to be urgently admitted if their condition deteriorates
• for women with ectopic pregnancy who have had methotrexate, take 2 serum hCG measurements in the first week (days 4 and 7) after treatment and then 1 serum hCG measurement per week until a negative result is obtained. If hCG levels plateau or rise, reassess the woman's condition for further treatment.

Reference:

• (1) Royal College of Obstetricians and Gynaecologists (2004). The management of tubal pregnancy
• (2) NICE (September 2023).Ectopic pregnancy and miscarriage: diagnosis and initial management