Treatment

• Begin acute stabilization.

• Obtain an immediate OB/GYN consult for emergency surgery.

Determine whether medical, surgical, or expectant management is appropriate.

• Consider clinical, laboratory, and radiological findings.

• Share decision-making with patients in consultation with OB/GYN.

Provide adequate supportive care.

Provide for all patients regardless of management approach.

• Pain management

• Prenatal and contraceptive counseling once treatment is complete

• Anti-D immunoglobulin for Rh-negative patients who present with bleeding

Do not forget anti-D immunoglobulin in all Rh-negative patients with bleeding!

Methotrexate (MTX) is the treatment of choice.

• Mechanism of action: inhibits folate-dependent steps in DNA synthesis to terminate the rapidly dividing ectopic pregnancy.

• Indications [15]

  • Uncomplicated ectopic pregnancies

  • Hemodynamically stable patients

  • Unruptured mass

  • β-hCG ≤ 2,000–5,000 mlU/mL

  • Mass size < 3.5 cm

  • No fetal heartbeat

• Absolute contraindications

  • Chronic conditions

    • Pulmonary (e.g., severe asthma)

    • Renal (e.g., creatinine clearance < 50 mL/min/1.73 m2)

    • Hepatic (e.g., alcohol use disorder or chronic liver disease)

    • Hematologic (e.g., leukopenia, thrombocytopenia, severe anemia)

  • Intrauterine pregnancy

  • Breastfeeding

  • Methotrexate sensitivity

  • Immunodeficiency

  • Peptic ulcer disease

  • Ruptured ectopic pregnancy

• Indications for nonurgent surgery

  • Contraindications for MTX

  • Unsuccessful medical treatment

  • A concurrent surgical procedure (e.g., bilateral tubal blockage) is necessary.

  • The patient has indicated a preference for surgical treatment.

• Approach Laparoscopy (preferred)

• Procedure: salpingostomy, i.e., removal of ectopic pregnancy without removing the affected fallopian tube (tube‑conserving operation)

  • Preferred in patients with unruptured tubal pregnancy who do not meet the criteria for conservative treatment

  • Complications

    • Risk of persistent ectopic pregnancy

    • Risk of repeat ectopic pregnancy

  • Additional considerations

    • Patients require serial hCG measurement.

    • Consider a prophylactic dose of MTX if there is concern for incomplete resection.

  • Salpingectomy may be required in select cases (e.g., large ectopic mass).

Asymptomatic patients with very low β-hCG levels may experience spontaneous resolution of ectopic pregnancy without medical or surgical treatment. Consider this approach in select patients after consultation with OB/GYN.

• Indications

  • Minimal symptoms

  • No evidence of ectopic mass on TVUS

  • Confirmed plateauing or decreasing serial β-hCG levels

• Considerations during expectant management

  • Provide extensive counseling on the risks of complications in addition to general counseling.

  • Arrange close surveillance and serial β-hCG measurement (e.g., every 2–7 days).

• Conversion to medical or surgical therapy

  • Increasing symptoms, e.g., pain, signs of ruptured ectopic pregnancy

  • Insufficient decrease, persistent plateau, or increase in β-hCG levels

Suspect ruptured ectopic pregnancy in patients in their first trimester with any of the following:

• Clinical features of shock: e.g., tachycardia, hypotension, pallor

• Severe abdominal or pelvic pain

• Peritoneal signs on examination

• Significant vaginal bleeding

• Clinical deterioration after receiving MTX therapy

• Start immediate IV fluid resuscitation.

• Rapidly deliver blood transfusion as soon as blood products are available.

• If hypotension persists, start vasopressors

• Indications for emergency surgery

  • Hemodynamic instability

  • Symptoms of impending rupture (e.g., severe pelvic pain)

  • Signs of intraperitoneal bleeding: e.g., peritonitis, POCUS positive for free fluid

  • Risk factors for rupture [26]

• Approach: Laparotomy is preferred for large intraperitoneal bleeding or critically unstable patients, otherwise a laparoscopic approach is typically performed.

• Procedure: salpingectomy, i.e., partial or complete removal of the affected fallopian tube (does not preserve tube function)

  • Preferred approach for:

    • Ruptured tube

    • Heavy bleeding

    • Large ectopic mass

    • Severe damage to the fallopian tube

  • Additional considerations

    • If the patient desires future pregnancies: Evaluate the status of the contralateral fallopian tube before salpingectomy.

    • If the patient does not desire future pregnancies: Bilateral salpingectomy may be performed.

• The condition is fatal for the fetus.

• Maternal mortality rate: ∼ 0.6/100,000 in the US [27]

• Future fertility: depends primarily on the fertility status prior to the ectopic pregnancy

• Recurrence [28]

  • Approx. 10%

• Risk factors

  • History of previous spontaneous miscarriage

  • Tubal damage

  • Age > 30 years