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ob.ectopic-pregnancy.v1PRODUCTION
ob.ectopic-pregnancy.v1

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

obstetricsacuteadultpregnancy
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Suspect ectopic in any pregnant patient with pelvic pain, vaginal bleeding, or abnormal β-hCG trend; risk factors compound suspicion (ACOG PB 193, 2018; Barnhart NEJM 2009)

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Advance rule
Set
Advance when

pregnancy confirmed and ectopic on differential (ACOG PB 193, 2018)

Patient inputs (13)

Estimated gestational age frames discriminatory β-hCG zone and TVUS expectations (ACOG PB 193, 2018)

~10% recurrence; lower threshold for surgical management (Barnhart NEJM 2009)

Quantitative β-hCG drives MTX eligibility (<5000) and surveillance trend (15% drop day 4 → day 7 — ACOG PB 193, 2018)

Definitive imaging — IUP, adnexal mass, free fluid, fetal cardiac activity (ACOG PB 193, 2018; NICE 2024 ectopic)

Hemoglobin trend if rupture suspected; baseline for MTX (ACOG PB 193, 2018)

Hypotension = rupture until proven otherwise (RCOG GTG 21, 2016)

Tachycardia + hypotension = surgical OR now (RCOG GTG 21, 2016)

Rh-negative → RhoGAM 50–300 µg per gestational age and ACOG guidance (ACOG CO 818, 2021)

MTX contraindicated if Cr elevated; renal clearance dependent (ACOG PB 193, 2018)

MTX contraindicated if LFT elevated (ACOG PB 193, 2018)

Salpingostomy preserves tube but slightly higher persistence; salpingectomy if other tube healthy (ESEP Mol Lancet 2014)

MTX contraindicated in breastfeeding, immunodeficiency, active liver/renal disease, peptic ulcer, blood dyscrasia (ACOG PB 193, 2018)

Major risk factors — PID, prior tubal surgery/sterilization, IVF, IUD, smoking, age >35 (ACOG PB 193, 2018; Barnhart NEJM 2009)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningrupture_with_hemodynamic_instability — ACOG 2018
    Hypotension, tachycardia, syncope, peritoneal signs, or large free fluid on US (RCOG GTG 21, 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremtx_failure_or_persistence — ACOG 2018
    β-hCG drop <15% day 4 → day 7 OR rising β-hCG OR new pain after MTX (ACOG PB 193, 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremtx_contraindication — ACOG 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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereheterotopic_pregnancy — ACOG 2018
    Concurrent IUP and ectopic (especially in ART pregnancies — Barnhart NEJM 2009)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecesarean_scar_or_cornual_or_interstitial_or_cervical — ACOG 2018
    Non-tubal ectopic with high rupture/hemorrhage risk (RCOG GTG 21, 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterh_negative_unprotected — ACOG 2018
    Rh-negative patient with confirmed ectopic and no recent RhoGAM (ACOG CO 818, 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepul_with_rising_hcg_no_iup — ACOG 2018
    Pregnancy of unknown location, β-hCG rising suboptimally (<53% in 48 h — Barnhart NEJM 2009), no IUP at discriminatory zone
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Ectopic pregnancy — MTX (medical) vs surgical (salpingostomy/salpingectomy) decision
axis: ectopic_mtx_vs_surgicalstep 1 - Tier 1 — MTX eligibility gate (single-dose 50 mg/m² IM)
Selected step "Tier 1 — MTX eligibility gate (single-dose 50 mg/m² IM)" — β-hCG <5000 (preferred <3500) + no fetal cardiac activity + adnexal mass <3.5 cm + hemodynamically stable + normal CBC/Cr/LFTs + no MTX contraindications + reliable for follow-up (ACOG PB 193, 2018)
  • methotrexate
    first line
    antimetabolite_dihydrofolate_reductase_inhibitor
    50 mg/m² IM × 1 • IM • single dose; recheck β-hCG day 4 and day 7
    triggers: mtx_eligible
    ACOG 193 — single-dose protocol; 80–90% success in selected patients; 2-dose or multi-dose for β-hCG 5000–10000 with caution
    rxcui 6851

outpatient playbook — drug actions (5)

  1. 1. methotrexate (second dose)
    rxcui 6851
    50 mg/m² IM × 1 (2-dose protocol day 4) OR initiate multi-dose 1 mg/kg IM days 1/3/5/7 with leucovorin 0.1 mg/kg PO days 2/4/6/8 • IM • single dose OR 4-dose alternating
    trigger: β-hCG decline < 15 % day 4 → day 7 OR rising β-hCG OR new pain (MTX failure) — patient still otherwise MTX-eligible (ACOG PB 191/193 2018)
    ACOG PB 191/193 — 2-dose or multi-dose MTX for persistence after single-dose; consider surgical if 2nd dose fails
  2. 2. Rho(D) immune globulin (if not yet given)
    rxcui 35465
    50 µg IM if < 12 wk; 300 µg IM if ≥ 12 wk • IM • single dose within 72 h of diagnosis or surgery
    trigger: Rh-negative patient with confirmed ectopic, not yet documented to have received RhoGAM (ACOG CO 818, 2021)
    Alloimmunisation prevention (ACOG CO 818, 2021)
  3. 3. acetaminophen
    rxcui 161
    650-1000 mg PO q6h PRN (max 3 g/day) • PO • q6h PRN
    trigger: Persistent separation pain day 3-7 post-MTX or post-op pain (NICE NG126 2019)
    MTX-compatible analgesia (avoid NSAIDs with MTX — renal interaction)
  4. 4. oral combined contraceptive OR LARC initiation
    Per provider preference; LARC (copper IUD or LNG-IUS) acceptable once β-hCG < 5 mIU/mL; combined OC if no contraindications • PO / IUD • continuous
    trigger: Counseling for ≥ 3 months no-pregnancy post-MTX (ACOG PB 191/193 2018; ACOG CO 818, 2021)
    MTX teratogenicity / folate-receptor antagonism persists; effective contraception required (ACOG PB 191/193 2018)
  5. 5. oral iron OR IV iron
    Ferrous sulfate 325 mg PO daily if mild post-bleed anemia; IV iron sucrose 200 mg or ferric carboxymaltose 750 mg if Hgb < 10 g/dL or PO-intolerant • PO / IV • daily PO or weekly IV
    trigger: Post-rupture / post-op anemia (Hgb < 11 g/dL) (ACOG PB 191/193 2018)
    Iron repletion for post-bleed anemia recovery

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Pelvic / lower-abdominal pain with positive β-hCG (ACOG PB 193, 2018); First-trimester vaginal bleeding (ACOG PB 193, 2018); Abnormal β-hCG trend (rise <53% in 48 h or plateau — Barnhart NEJM 2009).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Ectopic pregnancy (tubal, interstitial, cornual, abdominal, cesarean-scar)** (ob.ectopic-pregnancy.v1).
Phenotype framing: Tubal (~95%) vs interstitial / cornual / cervical / cesarean-scar / ovarian / abdominal; rule out IUP missed, miscarriage, heterotopic, gestational trophoblastic disease, ovarian torsion, appendicitis (ACOG PB 193, 2018; Barnhart NEJM 2009)
Scope: Suspect ectopic in any pregnant patient with pelvic pain, vaginal bleeding, or abnormal β-hCG trend; risk factors compound suspicion (ACOG PB 193, 2018; Barnhart NEJM 2009)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Ectopic pregnancy — MTX (medical) vs surgical (salpingostomy/salpingectomy) decision** — step "Tier 1 — MTX eligibility gate (single-dose 50 mg/m² IM)".
1. methotrexate 50 mg/m² IM × 1 IM single dose; recheck β-hCG day 4 and day 7 (antimetabolite_dihydrofolate_reductase_inhibitor, first line) — ACOG 193 — single-dose protocol; 80–90% success in selected patients; 2-dose or multi-dose for β-hCG 5000–10000 with caution

Setting playbook (outpatient) — Methotrexate clinic follow-up + post-surgical gynecology follow-up: serial β-hCG to resolution, RhoGAM verification, contraception counseling (≥ 3-6 mo no pregnancy post-MTX), preconception counseling (recurrence ≈ 10-15 %), psychosocial screen, fertility evaluation if recurrent (ACOG PB 191/193 2018; NICE NG126 2019; SOGC 2022)
2. methotrexate (second dose) 50 mg/m² IM × 1 (2-dose protocol day 4) OR initiate multi-dose 1 mg/kg IM days 1/3/5/7 with leucovorin 0.1 mg/kg PO days 2/4/6/8 IM single dose OR 4-dose alternating — β-hCG decline < 15 % day 4 → day 7 OR rising β-hCG OR new pain (MTX failure) — patient still otherwise MTX-eligible (ACOG PB 191/193 2018) (ACOG PB 191/193 — 2-dose or multi-dose MTX for persistence after single-dose; consider surgical if 2nd dose fails)
3. Rho(D) immune globulin (if not yet given) 50 µg IM if < 12 wk; 300 µg IM if ≥ 12 wk IM single dose within 72 h of diagnosis or surgery — Rh-negative patient with confirmed ectopic, not yet documented to have received RhoGAM (ACOG CO 818, 2021) (Alloimmunisation prevention (ACOG CO 818, 2021))
4. acetaminophen 650-1000 mg PO q6h PRN (max 3 g/day) PO q6h PRN — Persistent separation pain day 3-7 post-MTX or post-op pain (NICE NG126 2019) (MTX-compatible analgesia (avoid NSAIDs with MTX — renal interaction))
5. oral combined contraceptive OR LARC initiation Per provider preference; LARC (copper IUD or LNG-IUS) acceptable once β-hCG < 5 mIU/mL; combined OC if no contraindications PO / IUD continuous — Counseling for ≥ 3 months no-pregnancy post-MTX (ACOG PB 191/193 2018; ACOG CO 818, 2021) (MTX teratogenicity / folate-receptor antagonism persists; effective contraception required (ACOG PB 191/193 2018))
6. oral iron OR IV iron Ferrous sulfate 325 mg PO daily if mild post-bleed anemia; IV iron sucrose 200 mg or ferric carboxymaltose 750 mg if Hgb < 10 g/dL or PO-intolerant PO / IV daily PO or weekly IV — Post-rupture / post-op anemia (Hgb < 11 g/dL) (ACOG PB 191/193 2018) (Iron repletion for post-bleed anemia recovery)

Non-pharmacologic actions:
- Strict return precautions in writing — severe pain, lightheadedness, syncope, heavy bleeding, fever, shoulder-tip pain → ED immediately (RCOG GTG 21 2016; NICE NG126 2019)
- Pelvic rest 1-2 weeks post-MTX or post-op — no intercourse / pelvic exam / strenuous activity until resolution (ACOG PB 191/193 2018; NICE NG126 2019)
- Avoid NSAIDs while on MTX (renal interaction) and folate supplements during MTX course (antagonism) (ACOG PB 191/193 2018)
- Avoid alcohol + sun exposure during MTX course (hepatotoxicity + photosensitivity) (ACOG PB 191/193 2018)
- Contraception counseling — ≥ 3 months no pregnancy post-MTX; effective method (barrier / LARC / combined OC); next-pregnancy early TVUS at 6-7 wk gestation (ACOG PB 191/193 2018)
- Preconception counseling — recurrence 10-15 % per prior ectopic; cumulative ≈ 25 % after 2 ectopics; early TVUS at 6-7 wk in next pregnancy is screening anchor (Barnhart NEJM 2009; ACOG PB 191/193 2018)
- Psychosocial support — pregnancy-loss resources, PTSD screen (especially after rupture / emergent surgery), infertility-distress counseling (NICE NG126 2019)
- Fertility evaluation if 2nd ectopic — HSG / laparoscopy + tubal patency assessment + ART counseling (SOGC 2022)
- Patient education — recognise rupture symptoms in next pregnancy; importance of early TVUS at 6-7 wk; importance of completing β-hCG surveillance to < 5 mIU/mL (ACOG PB 191/193 2018; NICE NG126 2019)

AVOID / contraindication checks:
- Mtx_contraindicated_breastfeeding (ACOG PB 193, 2018)
- Mtx_contraindicated_immunodeficiency (ACOG PB 193, 2018)
- Mtx_contraindicated_active_liver_or_renal_disease (ACOG PB 193, 2018)
- Mtx_contraindicated_peptic_ulcer_disease (ACOG PB 193, 2018)
- Mtx_contraindicated_blood_dyscrasia (ACOG PB 193, 2018)
- Avoid_NSAIDs_with_MTX_renal_clearance (ACOG PB 193, 2018)
- Avoid_folate_supplements_during_MTX_course (ACOG PB 193, 2018)
- Avoid_alcohol_and_sun_exposure_during_MTX (ACOG PB 193, 2018)
- Contraception_at_least_3_months_after_MTX_teratogenicity (ACOG PB 193, 2018)
- Avoid_intercourse_pelvic_exam_strenuous_activity_until_resolution (ACOG PB 193, 2018; NICE 2024 ectopic)

Monitoring

Regimen monitoring:
- beta hcg day 0 4 7 post MTX (ACOG PB 193, 2018)
- beta hcg weekly until under 5 mIU per mL (ACOG PB 193, 2018)
- pain check q24h after MTX until day 7 (NICE 2024 ectopic)
- CBC and LFT at one week post MTX (ACOG PB 193, 2018)
- return precautions for severe pain or lightheadedness (RCOG GTG 21, 2016)
- serial beta hcg after salpingostomy until under 5 (ESEP Mol Lancet 2014; ACOG PB 193, 2018)

Setting (outpatient) monitoring:
- β-hCG day 0, day 4, day 7 post-MTX (≥ 15 % decline d4→d7 expected) then weekly until < 5 mIU/mL (ACOG PB 191/193 2018; Stovall 1989 derivation)
- CBC + LFT at 1 week post-MTX (ACOG PB 191/193 2018)
- Hemoglobin at 1-2 weeks post-rupture / post-op (ACOG PB 191/193 2018)
- Pain assessment at each follow-up — escalating pain day 3-7 post-MTX is separation pain; new severe pain or peritoneal signs = surgical concern (NICE NG126 2019)
- Return-precautions adherence + symptom diary review at each visit (NICE NG126 2019)
- Contraception adherence at each visit until clearance for next pregnancy (ACOG PB 191/193 2018)
- Psychosocial screen at 2-week and 6-week follow-up (NICE NG126 2019)
- Future-pregnancy early TVUS at 6-7 wk gestation in any next pregnancy (Barnhart NEJM 2009; ACOG PB 191/193 2018)

Follow-up plan: 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)
- Close-out criterion: contraception + future-fertility plan documented

Monitoring phase: MTX: β-hCG day 4 and day 7 — expect ≥15% drop day 4→7; weekly until <5 mIU/mL (ACOG PB 193, 2018); surgical: weekly β-hCG until <5 if salpingostomy or any conservative procedure (ESEP Mol Lancet 2014); pain re-evaluation at 24, 48, 72 h post-MTX (separation pain expected — NICE 2024 ectopic)

Disposition

Current setting: outpatient — Methotrexate clinic follow-up + post-surgical gynecology follow-up: serial β-hCG to resolution, RhoGAM verification, contraception counseling (≥ 3-6 mo no pregnancy post-MTX), preconception counseling (recurrence ≈ 10-15 %), psychosocial screen, fertility evaluation if recurrent (ACOG PB 191/193 2018; NICE NG126 2019; SOGC 2022)

Disposition criteria:
- Continue outpatient surveillance until β-hCG < 5 mIU/mL × 1 measurement; transition to gynecology preconception clinic for next-pregnancy planning (ACOG PB 191/193 2018)
- 6-week postpartum-equivalent visit covers: β-hCG resolution, contraception adherence, psychosocial recovery, future-pregnancy plan, recurrence counseling, fertility evaluation if indicated (ACOG PB 191/193 2018; NICE NG126 2019; SOGC 2022)
- Discharge from gynecology to primary care once β-hCG resolved + contraception in place + future-pregnancy plan documented + psychosocial recovery confirmed (NICE NG126 2019)

Escalation triggers (move to higher acuity):
- 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)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Hypotension, tachycardia, syncope, peritoneal signs, or large free fluid on US (RCOG GTG 21, 2016)
- [SEVERE] β-hCG drop <15% day 4 → day 7 OR rising β-hCG OR new pain after MTX (ACOG PB 193, 2018)
- [SEVERE] 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)

Citations

- 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) [PMID:24461715](https://pubmed.ncbi.nlm.nih.gov/24461715/)
- Cited evidence (PMID 15466057) [PMID:15466057](https://pubmed.ncbi.nlm.nih.gov/15466057/)
- Cited evidence (PMID 29528616) [PMID:29528616](https://pubmed.ncbi.nlm.nih.gov/29528616/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 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) — PMID:24461715
  • Cited evidence (PMID 15466057) — PMID:15466057
  • Cited evidence (PMID 29528616) — PMID:29528616