Patient handout

Ectopic pregnancy (tubal, interstitial, cornual, abdominal, cesarean-scar)

PRODUCTION

1. Your condition

This handout is for ectopic pregnancy (tubal, interstitial, cornual, abdominal, cesarean-scar). Your care team identified this based on: pelvic / lower-abdominal pain with positive β-hcg (acog pb 193, 2018).

Other reasons your team may use this plan: first-trimester vaginal bleeding (acog pb 193, 2018); abnormal β-hcg trend (rise <53% in 48 h or plateau — barnhart nejm 2009); no iup on tvus with β-hcg above discriminatory zone (~3500 — acog pb 193, 2018).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
methotrexate	50 mg/m² IM × 1	IM	single dose; recheck β-hCG day 4 and day 7	ACOG 193 — single-dose protocol; 80–90% success in selected patients; 2-dose or multi-dose for β-hCG 5000–10000 with caution

Plan: Ectopic pregnancy — MTX (medical) vs surgical (salpingostomy/salpingectomy) decision

3. When to call your provider

Contact your care team if any of the following happen:

New severe pain, peritoneal signs, syncope, heavy bleeding, shoulder-tip pain → ED for rupture evaluation (RCOG GTG 21 2016; ACOG PB 191/193 2018)
β-hCG decline < 15 % day 4 → day 7 OR rising β-hCG → 2nd MTX dose OR surgical management (ACOG PB 191/193 2018)
CBC drop or LFT elevation post-MTX → discontinue MTX; surgical management if persistent (ACOG PB 191/193 2018)
Persistent β-hCG > 5 mIU/mL after 12 wk of surveillance → laparoscopy for retained trophoblast (ESEP Mol Lancet 2014, PMID 24461715)
Pregnancy detected before β-hCG < 5 mIU/mL or before 3 months post-MTX → MFM consult for MTX-exposed pregnancy counseling (teratogenicity risk) (ACOG PB 191/193 2018)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Hypotension, tachycardia, syncope, peritoneal signs, or large free fluid on US (RCOG GTG 21, 2016)(life-threatening)
β-hCG drop <15% day 4 → day 7 OR rising β-hCG OR new pain after MTX (ACOG PB 193, 2018)
Breastfeeding, immunodeficiency, active hepatic/renal disease, peptic ulcer, blood dyscrasia, β-hCG >5000 with FCA, mass >3.5 cm, unreliable follow-up (ACOG PB 193, 2018)
Concurrent IUP and ectopic (especially in ART pregnancies — Barnhart NEJM 2009)
Non-tubal ectopic with high rupture/hemorrhage risk (RCOG GTG 21, 2016)

5. Follow-up

Contraception counselling (avoid pregnancy ≥3 mo after MTX due to teratogenicity — ACOG PB 193, 2018); preconception counselling on recurrence risk (~10% — Barnhart NEJM 2009); early ultrasound in any future pregnancy; mental-health screening (pregnancy loss); future-fertility plan (NICE 2024 ectopic)

6. Sources

Guideline: ACOG Practice Bulletin 193 (2018, reaff 2023) — Tubal Ectopic Pregnancy + ASRM 2024 + NICE NG126 (2023) + SOGC 2022 + ESEP trial (Mol Lancet 2014, salpingostomy vs salpingectomy)