Ectopic Pregnancy
NICE Guideline [NG126] Ectopic pregnancy and miscarriage: diagnosis and initial management. Last updated: Aug 2023.
Guidelines
Referral Criteria
Rationale: These referral criteria apply to all suspected early pregnancy complications, including 1) ectopic pregnancy (the most dangerous one), 2) miscarriage, and 3) early viable intrauterine pregnancy.
Refer immediately to the Early Pregnancy Assessment Service if any of the following 2 scenarios:
- +ve Pregnancy test AND abdo-pelvic pain / tenderness OR cervical motion tenderness (high risk of ectopic pregnancy)
- Per vaginal bleeding AND pain OR >6 weeks gestation OR uncertain gestation (possible ectopic pregnancy or miscarriage)
NICE explicitly states to use expectant management if ALL the following apply (likely very early miscarriage or implantation bleeding in viable pregnancy):
- Pregnancy <6 weeks
- Bleeding but NO PAIN
- No risk factors (e.g. previous ectopic pregnancy)
Expectant management involves: 1) safety netting – return if bleeding continues or pain develops, 2) repeat urine pregnancy test after 7-10 days, and to return if +ve
Investigation and Diagnosis
Investigation of choice: TVUS to evaluate the uterus, adnexa and surrounding structures
Alternative: TAUS
- can be considered if TVUS is not appropriate
- Note TAUS has a lower sensitivity and specificity
- Can also be used to exclude differential diagnoses (e.g. acute appendicitis)
If ultrasound identifies moderate to large amount of free fluid in the peritoneal cavity or Pouch of Douglas, that is indicative of haemoperitoneum, likely due to a ruptured ectopic pregnancy.
NICE has made the following extensive recommendations regarding TVUS findings in diagnosing ectopic pregnancy.
TVUS Findings
| Interpretation | TVUS findings |
|---|---|
| Diagnosis of ectopic pregnancy |
|
| High probability of ectopic pregnancy |
|
| Possible ectopic pregnancy |
|
Management
There are 3 main approaches to managing ectopic pregnancies:
- Expectant management
- Medical management
- Surgical management
Decision Algorithm
First, check for any indications to offer surgery as 1st line management. ANY of the following:
- Significant pain
- Adnexal mass ≥35mm
- Fetal heartbeat is visible on US
- hCG ≥5,000 IU/L
- Ruptured ectopic pregnancy (not explicitly stated by NICE but presumed)
- Unable to return for follow-up (not explicitly stated by NICE but presumed, as this is a requirement for expectant / medical management)
Indications for expectant and medical management are similar:
| Approach | Indications (ALL must be met) |
|---|---|
| Expectant Management |
|
| Medical Management |
|
Main differences in indications for expectant and medical management are:
- Pain level: pain-free for expectant; no significant pain for medical
- No intrauterine pregnancy on ultrasound is a must for medical management
Offer choice of medical OR surgical management if all the following:
- Serum hCG 1,500-5,000 IU/L
- Able to attend follow-up
- No significant pain
- Unruptured ectopic pregnancy
- Adnexal mass <35mm
- No visible heartbeat
- No intrauterine pregnancy (confirmed on US)
Details on Various Management Approaches
| Approach | Description |
|---|---|
| Expectant management |
|
| Medical management |
|
| Surgical management | Laparoscopic approach is preferred
Emergency laparotomy is reserved for cases of massive haemorrhage
In addition to surgical management, offer anti-D immunoglobulin prophylaxis to all Rh-ve women |
NICE guidance recommends administering anti-D prophylaxis to Rhesus-negative individuals with ectopic pregnancy only if surgical management is undertaken. However, other bodies generally advise that anti-D prophylaxis should be given in all cases of ectopic pregnancy, regardless of the management approach.[Ref 1][Ref 2]