5.

4 Practice Guideline: Ectopic Pregnancy 

Rachel Twelmeyer 
 
Evaluation and management of Ectopic Pregnancy   
 
1. Definition or Key Clinical Information 
a. Ectopic pregnancy is any pregnancy implanted outside the endometrial cavity. 
b. According to the Centers for Disease Control and Prevention, ectopic pregnancy 
accounts for approximately 2% of all reported pregnancies 
c. Up to 18% of pregnant people presenting in the ER with first-trimester vaginal 
bleeding, or abdominal pain present with an ectopic pregnancy. 
d. The fallopian tube is the most common location of ectopic implantation, accounting 
for more than 90% of cases. However, implantation in the abdomen (1%), cervix 
(1%), ovary (1–3%), and cesarean scar (1–3%) can occur and often results in greater 
morbidity because of delayed diagnosis and treatment. 
e. A pregnancy of unknown location should not be considered a diagnosis, rather it 
should be treated as a transient state and efforts should be made to establish a 
definitive diagnosis when possible 
2. Assessment  
a. Risk Factors 
i. Previous ectopic Pregnancy 
ii. IUD 
iii. Tubule surgery 
iv. Chronic Salpingitis 
v. Smoking 
vi. Pelvic Inflammatory Disease 
vii. 50% of cases have no known risk factor 
b. Subjective Symptoms 
i. An absence of normal menses followed by intermittent, light bleeding 
ii. Cramp-like abdominal or pelvic pain, unilateral or diffuse. May be described 
as mild or severe. 
iii. Client may present with shoulder pain, indicating blood in the abdominal 
cavity. 
iv. Any combination of these symptoms must trigger an evaluation for an 
ectopic pregnancy when a woman has a risk of pregnancy. 
c. Objective Signs 
i. Fever, tachycardia, or low blood pressure 
ii. Adnexal enlargement or tenderness on pelvic examination 
d. Clinical Test Considerations  
i. Ultrasonography can definitively diagnose an ectopic pregnancy when a 
gestational sac with a yolk sac, or embryo, or both, is noted in the adnexa. 
 ii.
Measurement of hCG level aids in the diagnosis of women at risk of ectopic 
pregnancy. However, serum hCG values should be correlated with the 
patient’s history, symptoms, and ultrasound findings 
1. When clinical findings suggest an abnormal gestation, a second hCG 
value measurement is recommended 2 days after the initial 
measurement to assess for an increase or decrease.  
2. Subsequent assessments of hCG concentration should be obtained 
2–7 days apart, depending on the pattern and the level of change. 
3. Decreasing hCG values suggest a failing pregnancy and may be used 
to monitor spontaneous resolution, but this decrease should not be 
considered diagnostic. 
4. Decreasing hCG values and a possible ectopic pregnancy should be 
monitored until nonpregnant levels are reached because rupture of 
an ectopic pregnancy can occur while levels are decreasing or are 
very low. 
3. Management plan   
a. Therapeutic measures to consider 
i. Regardless of the therapeutic regimen chosen, ectopic pregnancy must be 
viewed as a life-threatening condition. 
ii. Methotrexate is a folate antagonist that inhibits DNA synthesis and repair 
and cell replication. Systemic methotrexate has been used to treat 
gestational trophoblastic disease since 1956. Methotrexate injection may 
also be used. Contraindications to methotrexate include: 
1. Intrauterine pregnancy, evidence of immunodeficiency, anemia, 
thrombocytopenia, leukopenia, pulmonary or peptic disease, 
hepatic or renal dysfunction, breastfeeding, ruptured ectopic 
pregnancy, hemodynamically unstable, inability to participate in 
follow-up. 
iii. If the ectopic pregnancy has ruptured a tube, emergency surgery is needed. 
Sometimes surgery is needed even if the fallopian tube has not ruptured. 
1. Salpingectomy is the surgical removal of the fallopian tube. 
2. A salpingostomy is a surgical incision into a fallopian tube to remove 
the ectopic tissue. 
iv. NOTE: Women with clinical signs and physical symptoms of a ruptured 
ectopic pregnancy, such as hemodynamic instability or an acute abdomen, 
should be evaluated and treated urgently.   
b. Complementary measures to consider 
i. Emotional support is vital after an ectopic pregnancy. Professional 
counseling and support groups can help clients care for mental and 
emotional help.  
ii. If the client took methotrexate, it’s important to restore folic acid levels 
with supplementation.  
c. Considerations for pregnancy, delivery and lactation 
 i. It is generally advised that clients should wait three months, or two 
menstrual cycles before attempting to conceive after the expulsion of an 
ectopic pregnancy. This has both physiologic and emotional benefits for the 
client. 
d. Client and family education 
i. The diagnosis of an ectopic pregnancy should be taken very seriously, as it 
is a life-threatening condition.  
ii. A client with an ectopic pregnancy may have not suspected a pregnancy at 
this time and might need to integrate a great deal of information at a very 
stressful moment. 
e. Follow-up  
i. After treatment, hCG levels should be checked often to track a drop in hCG 
levels to ensure complete resolution of an ectopic pregnancy. 
4. Indications for Consult, Collaboration or Referral 
a. Any suspicion of an ectopic pregnancy should prompt a swift referral to a physician 
for follow-up care. 
5. References 
a. ACOG. (Mar. 2018). ​Tubal Ectopic Pregnancy.​ Practice Bulletin Number 193. 
Retrieved from: 
https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Bulletins/Com
mittee-on-Practice-Bulletins-Gynecology/Tubal-Ectopic-Pregnancy?IsMobileSet=f
alse 
b. Jordan, R., Farley, C., & Grace, K.T. (2019). Prenatal and postnatal care: A 
woman-centered approach (2nd ed.). Hoboken, NJ: Wiley. 
c. King, T., Brucker, M., Osborne, K., & Jevitt, C. (2019). Varney’s midwifery (6th ed). 
Burlington, MA: Jones & Bartlett Learning.