Ectopic pregnancy happens when the fertilized ovum implants outside the endometrial lining of the uterus.
Accurate early diagnosis is life-saving, reduces invasive diagnostic procedures & allows conservative treatment that can preserve fertility.
Ectopic pregnancy must be excluded in women of reproductive age w/ a positive pregnancy test, abdominal pain & vaginal bleeding.
Ruptured ectopic pregnancy remains to be the leading cause of maternal mortality in the first trimester.

Ectopic%20pregnancy Treatment

Principles of Therapy

  • Treatment decision should be made on an individual basis
  • For heterotopic pregnancy, the IUP must be considered when planning management 

Surgical Management

  • Surgical treatment remains the preferred approach for most ectopic pregnancies

Surgical management is indicated if:

  • The patient’s condition deteriorates
  • β-hCG levels are rising or plateaued and ectopic mass >3-4 cm
  • Unreliable patient who may not be available for close follow-up

Medical Management

  • Success is greatest if gestation <6 weeks and tubal mass <3.5 cm in diameter
  • Serial measurements of β-hCG are necessary in patients being managed medically

Medical management may be an option if:

  • Patient is hemodynamically stable with normal hemogram and normal liver and renal function
  • Ectopic pregnancy has been confirmed by US
  • Ectopic mass has not ruptured and is <3-4 cm in diameter by US
  • Absence of active bleeding or signs of hemoperitoneum
  • Patients with β-hCG levels <5000 IU/L (5000 mIU/mL) are more likely to respond to therapy
  • Patient is willing to comply with close follow-up

Medical management is contraindicated if:

  • Breastfeeding
  • Presence of fetal cardiac activity
  • Presence of fluid in the cul-de-sac
  • Immunodeficiency
  • β-hCG levels >5000 IU/L (5000 mIU/mL)
  • Presence of contraindications related to Methotrexate use
  • Ruptured ectopic pregnancy
  • Active pulmonary or peptic ulcer disease

Expectant Management

  • May be considered if the patient remains stable, is reliable and is willing to accept the potential risk of tubal rupture
  • Evidence of resolution eg declining β-hCG levels
  • 68-77% of ectopic pregnancies resolve without intervention but clinical markers to identify these patients have not been defined
  • Spontaneous resolution is more likely in patients with β-hCG levels <1000 IU/L (1000 mIU/mL)
  • Risk of rupture will remain until pregnancy is completely resolved
  • Serial measurements of β-hCG are necessary in patients being managed expectantly

Expectant management may be an option if:

  • β-hCG levels are <1000 IU/L (1000 mIU/mL) and are declining
  • Vaginal sonography shows no evidence of intra-abdominal rupture or bleeding
  • Patient is willing to comply with close follow-up



  • Action: Methotrexate is a folic acid antagonist that interferes with DNA synthesis in rapidly dividing cells like the trophoblastic tissue
  • Effects: Reported success rates are between 65-95%
    • Treatment success rates following Methotrexate therapy are comparable to surgery
    • Failure rates are higher with larger ectopic pregnancies, evidence of fetal cardiac activity and higher β-hCG levels
    • Studies have shown that a single-dose protocol may have similar efficacy to a multidose protocol
      • Failure rate is lower with multidose Methotrexate
  • Patients for Methotrexate therapy must be hemodynamically stable with serum β-hCG level of <5000 IU/L, has no demonstrated US evidence of fetal cardiac activity or IUP and no abdominal pain that is severe or persistent
  • Methotrexate treatment of tubal ectopic pregnancy has no effect on ovarian reserve  
  • Muscle relaxation training may be of help to patients on Methotrexate therapy 
  • Patients treated with Methotrexate may experience self-limiting abdominal pain which may mimic acute ectopic rupture, a transient rise in β-hCG levels, and vaginal spotting or bleeding
  • Side effects are infrequent with short regimen but can also be mitigated by co-administration of Leucovorin
  • Patient must be willing and available for close follow-up which may take as long as 7 weeks
    • β-hCG level should be followed up until it becomes undetectable or decreases to <15 IU/L
      • If hCG level increases or plateaus, patient may be given another dose of Methotrexate
    • Patient should also be made aware that medical therapy fails in approximately 5-10% of patients and will lead to surgery
  • Patients who underwent Methotrexate therapy must wait for at least 3 months before attempting to become pregnant again

Expectant Management

  • Expectant management with close observation may be undertaken in an attempt to increase possible future tubal patency in carefully selected patients
  • This option should be offered only when transvaginal US fails to locate the gestational sac and the serum levels of β-hCG and progesterone are low and declining
    • Candidates must be asymptomatic and clinically stable with declining β-hCG levels, initially <1500 IU/L
  • Serum β-hCG should be monitored on weekly basis while transvaginal US is done on weekly interval to confirm reduction in hCG level and decrease in the adnexal mass size in 7 days
    • Thereafter, serum β-hCG and transvaginal US monitoring are done on a weekly basis until serum hCG concentration is no longer detectable since there are reports of tubal rupture at low levels of β-hCG
  • This method of treatment tends to be discouraged due to persistence of the risk of rupture until the pregnancy has been completely resolved

Anti-D Immunoglobulin

  • Based on expert opinion, anti-D immunoglobulin is recommended in nonsensitized patients who are rhesus negative and who have ectopic pregnancy
  • Anti-D prophylaxis may be offered to women who had surgical removal of an ectopic pregnancy or if bleeding is heavy, repeated or with abdominal pain 
  • Suggested dose is 250 IU (50 mcg)
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS JPOG - Malaysia digital copy today!
Sign In To Download
Editor's Recommendations
Most Read Articles
Roshini Claire Anthony, 2 days ago

The addition of methylprednisolone to standard care* reduced mortality risk in patients with hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF), according to a study from China.

05 Feb 2021

Primary immunodeficiency disease (PIDD) and allergies are two groups of conditions related to the immune system. However, they are uniquely different in terms of symptoms and treatment.

Pearl Toh, 26 Nov 2020
Inhaled corticosteroid (ICS) should be the mainstay of long-term asthma management — such is the key message of the latest Singapore ACE* Clinical Guidance (ACG) for asthma, released in October 2020.
Stephen Padilla, 22 Feb 2021
Treatment with intravenous (IV) dexamethasone for 10 days significantly reduces duration of mechanical ventilation at 28 days and 60-day mortality in patients with established moderate-to-severe acute respiratory disease syndrome (ARDS) compared with no dexamethasone, results of the DEXA-ARDS trial have shown.