Unruptured Ectopic Pregnancy

Unruptured ectopic pregnancy is an ectopic pregnancy diagnosed before rupture, in a stable patient, usually in the fallopian tube. Early detection allows medical treatment with methotrexate or expectant care, which preserves the tube and avoids surgery.

• Diagnosed at 5 to 8 weeks by ultrasound and hCG.
• Risk factors: previous ectopic, tubal disease, intrauterine contraceptive device, assisted reproduction, smoking.
• Chance of tubal rupture rises with size and rising hCG.

Patients may have mild lower abdominal pain, light vaginal bleeding and amenorrhoea, and be haemodynamically normal. A tender adnexal mass may be palpable.

• Some women are asymptomatic.
• No peritonism.
• Differential diagnosis: threatened miscarriage, corpus luteum cyst, appendicitis, pelvic inflammatory disease, urinary tract infection.
• Complications: rupture, haemorrhage, tubal loss, infertility, treatment failure.

The approach is transvaginal ultrasound with serial hCG.

• Ultrasound: empty uterus with adnexal mass, no or little free fluid.
• Serum hCG: record baseline; discriminatory level 1500 IU/L.
• Full blood count, creatinine, alanine aminotransferase, blood group and Rhesus status before methotrexate.
• Assess suitability: stable, reliable follow-up, hCG below 5000 IU/L, no fetal heart, mass below 35 mm.

The principle is medical or expectant treatment for suitable stable women, and surgery for the rest.

• Supportive: explain symptoms of rupture; ensure access to the hospital for 24 hours; avoid intercourse until hCG is negative.
• Pharmacological: methotrexate 50 mg/m2 IM single dose on day 1; hCG on days 4 and 7; repeat the dose if the fall is below 15 percent between days 4 and 7 (maximum 3 doses); then hCG weekly until below 5 IU/L; avoid NSAIDs, alcohol and sun exposure; avoid pregnancy for 3 months; for expectant care, hCG below 1000 IU/L and falling, repeat 48-hourly initially.
• Procedures: laparoscopic salpingectomy or salpingotomy if methotrexate is contraindicated, hCG above 5000 IU/L, fetal heart present, or treatment fails.
• Special groups: Rhesus negative women give anti-D immunoglobulin 250 IU IM within 72 hours; breastfeeding and hepatic or renal impairment contraindicate methotrexate.
• Red flags: worsening pain, dizziness, shoulder tip pain, pulse above 100 per minute.
• Follow-up: hCG weekly until negative (up to 6 weeks); early scan in the next pregnancy.