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Ectopic pregnancy

Updated Oct 21, 2026Adults · ED management16 sources · 9 checked in PubMed2 figuresNICE NG126 (updated June 2026) · ACEP 2017

Bottom line

  • Think ectopic in anyone who could be pregnant. Atypical presentations are common, and about a third of patients with an ectopic pregnancy have no known risk factor.1
  • Scan at any hCG level. ACEP recommends a pelvic ultrasound for every symptomatic pregnant patient (Level B).2 In ED patients, an hCG under 1,500 mIU/mL raised the likelihood of ectopic (LR 2.24), and 25% of those patients had one.3
  • An intrauterine pregnancy on bedside ultrasound largely rules ectopic out. Emergency physician scanning had a pooled sensitivity of 99.3% and a negative predictive value of 99.96%.4 The exception is heterotopic pregnancy, about 1 in 100 after assisted reproduction.5
  • An indeterminate scan is not a negative scan. hCG cannot exclude ectopic here: a 3,000 mIU/mL cutoff had 35% sensitivity and 58% specificity.6 Every patient with an indeterminate scan needs specialty consultation or close follow-up.2
  • Unstable, or free fluid in Morison's pouch: get the patient to surgery. Free fluid there had a positive LR of 112 for needing an operation.7 A tubal ectopic in an unstable patient is a surgical emergency.8

First 10 minutes

  1. Check for shock. Warning signs include heart rate over 100, blood pressure under 100/60 mm Hg, orthostatic hypotension, syncope, peritoneal signs, and shoulder tip pain.1
  2. Unstable: call OB/GYN for immediate surgery.8 Do a bedside FAST that includes Morison's pouch. Trendelenburg positioning may make fluid easier to see.7,5
  3. Stable: send a quantitative hCG and blood type with Rh status, and get a pelvic ultrasound at any hCG level.2,5
  4. Look for a definite intrauterine pregnancy: a gestational sac in the uterus containing a yolk sac or an embryo.2 Also scan the adnexa for a heterotopic pregnancy.1
  5. No intrauterine pregnancy? Call it a pregnancy of unknown location and manage it as a possible ectopic until the location is known.1
  6. Confirmed or likely ectopic: call OB/GYN to choose expectant, medical or surgical management.1,5

Who has it

  • Common symptoms: abdominal or pelvic pain, a missed period, and vaginal bleeding. Other reported symptoms include dizziness or fainting, shoulder tip pain, GI or urinary symptoms, and rectal pressure.1
  • Signs: pelvic, adnexal or abdominal tenderness are the most common. Cervical motion tenderness, peritoneal signs, pallor and shock can also occur.1
  • It mimics other illness. Symptoms can resemble a GI problem or a urinary tract infection, so offer a pregnancy test even when complaints are vague.1
  • Risk factors include prior ectopic, prior genital tract infection, prior D&C or tubal ligation, an IUD in place, assisted reproduction, progestin-only contraception, age over 35, and smoking.5 Rule out ectopic even when there are none.1
  • How common: among symptomatic ED patients, prevalence has been as high as 13% in some series.2 US ED visits with an ectopic diagnosis rose from 11.0 to 13.7 per 1,000 live births between 2006 and 2013.9
  • How deadly: US mortality fell to 0.50 deaths per 100,000 live births in 2003–2007. It was 6.8 times higher in Black women than in white women. Hemorrhage, shock or renal failure accompanied 67.4% of deaths in hospitalized patients.10

Diagnosis: ultrasound and hCG

Ultrasound

  • Scan regardless of hCG. ACEP raised this to a Level B recommendation in 2017.2 Ectopics can present at almost any hCG level, and rupture has been documented at very low levels.2
  • Low hCG does not make the scan useless. In two older series, ultrasound at hCG under 1,000 mIU/mL detected or suggested 92% and 86% of ectopic pregnancies.2
  • Bedside scans miss some intrauterine pregnancies. Bedside sensitivity for an intrauterine pregnancy was 71%, with 99% specificity.6 A nondiagnostic bedside scan still needs a comprehensive scan, consultation or close follow-up.2
  • Expect indeterminate results. ED studies report an indeterminate rate of 20% to 30%.2
  • Know the criteria in use. ED studies usually require a yolk sac or fetal pole. Radiologists may accept a gestational sac with a double decidual sign.2
Transvaginal findingWhat it means (NICE)
Adnexal mass moving separately from the ovary, with a gestational sac containing a yolk sac or fetal pole (with or without a heartbeat)Tubal ectopic
Adnexal mass moving separately from the ovary with an empty sac ("tubal ring" or "bagel" sign), or a complex inhomogeneous adnexal massHigh probability. Weigh with the rest of the scan, the clinical picture and hCG
Empty uterus, or a fluid collection in the uterine cavity (pseudo-sac)Possible ectopic. Weigh with the rest of the scan, the clinical picture and hCG
Moderate to large free fluid in the peritoneal cavity or pouch of DouglasPossible hemoperitoneum

Adapted from the NICE ultrasound recommendations. NICE also advises scanning the uterus and both adnexa for a heterotopic pregnancy every time.1

Bedside ultrasound of the right upper quadrant showing an anechoic stripe of free fluid between the liver and the right kidney, marked with an arrow
FIG 1Free fluid in Morison's pouch. Right upper quadrant view in a patient with an ectopic pregnancy. The arrow marks fluid between the liver and the right kidney. In suspected ectopic, this finding predicted the need for an operation.7James Heilman, MD · Wikimedia Commons · CC BY-SA 3.0

In 242 ED patients with suspected ectopic, 10 had free fluid in Morison's pouch. Nine of them went to surgery (positive LR 112).7

hCG

  • There is no safe "discriminatory zone". The traditional cutoff of 1,000–2,000 mIU/mL comes from radiology transvaginal scans. ACEP does not endorse the concept or any cutoff.2
  • Low hCG means higher risk, not lower. In 730 ED patients, 40 of the 158 with hCG under 1,500 mIU/mL (25%) had an ectopic pregnancy, and only 16% had a normal intrauterine pregnancy.3
  • hCG does not sort indeterminate scans. With no intrauterine pregnancy on bedside scan, a 3,000 mIU/mL cutoff gave 35% sensitivity and 58% specificity for ectopic.6 ACEP says not to use hCG to exclude ectopic after an indeterminate scan (Level B).2
  • Use hCG for trend, not location. NICE says not to use serum hCG to locate the pregnancy. Take two levels as close as possible to 48 hours apart, and give symptoms more weight than the numbers.1
  • Skip progesterone. NICE advises against it for diagnosing either a viable intrauterine pregnancy or an ectopic.1
hCG change over 48 hLikely meaningNICE action
Rise > 63%Probably a developing intrauterine pregnancy. Ectopic is still possibleTransvaginal scan in 7–14 days, sooner if hCG ≥ 1,500 IU/L
Fall > 50%Pregnancy unlikely to continueUrine pregnancy test 14 days after the second hCG. If positive, review within 24 h
Rise < 63% or fall < 50%Uncertain. Includes ectopicReview in the early pregnancy service within 24 h

From the NICE recommendations for a pregnancy of unknown location.1 For hCG, 1 IU/L equals 1 mIU/mL.

Sources disagree

How slow a rise is still normal: NICE uses 63% over 48 hours.1 In 287 symptomatic patients who turned out to have a viable intrauterine pregnancy, the slowest rise was 53% at 2 days.11 A later cohort used an even more cautious minimum of 35% over 2 days.12 A slow rise does not prove an ectopic, so don't let a single ratio drive treatment in a pregnancy that may be wanted.

Treatment

An unstable patient needs prompt surgery.8 For stable patients, NICE matches the treatment to pain, mass size, fetal heartbeat and hCG. OB/GYN usually makes this decision.1

OptionWho (NICE)hCG follow-up
ExpectantStable and pain free. Tubal mass < 35 mm with no heartbeat. hCG ≤ 1,000 IU/L (offer) or 1,000–1,500 (consider). Able to returnDays 2, 4 and 7. If it falls ≥ 15% each time, weekly until < 20 IU/L
MethotrexateNo significant pain. Unruptured, mass < 35 mm, no heartbeat. hCG < 1,500 IU/L. No intrauterine pregnancy on scan. Able to returnDays 4 and 7, then weekly until negative
Methotrexate or surgerySame criteria, but hCG 1,500 to < 5,000 IU/L. Methotrexate carries a higher chance of needing more treatmentAs above
Surgery firstSignificant pain, mass ≥ 35 mm, visible heartbeat, hCG ≥ 5,000 IU/L, or unable to returnAfter salpingotomy: day 7, then weekly. After salpingectomy: urine test at 3 weeks
  • Methotrexate needs a definite diagnosis. NICE allows it on a first visit only when an ectopic is confirmed and a viable intrauterine pregnancy is excluded.1
  • Surgery: laparoscopic when possible. Salpingectomy is preferred unless there are other risk factors for infertility. Up to 1 in 5 patients need further treatment after salpingotomy.1
  • Contraindications to methotrexate listed by Core EM: renal insufficiency, immunodeficiency, active lung disease, peptic ulcer disease, hypersensitivity, breastfeeding, and a heterotopic pregnancy with a viable intrauterine pregnancy.5
AgentAdult doseNotes
MethotrexateNo dose given here. Use the OB/GYN protocolThe US label we checked has no ectopic pregnancy indication. NICE notes that this use was off label.13,1
Rho(D) immune globulin (US label)300 µg (1,500 IU) IM within 72 hThe label lists ectopic pregnancy as an indication for Rh-negative patients who are not sensitized.14
Anti-D immunoglobulin (NICE 2026)≥ 250 IU (50 µg), only at 12+0 to 12+6 weeksFor Rh-negative patients having medical or surgical management. NICE advises none up to 11+6 weeks.1

Unreviewed doses. Verify against the current label and your institution's protocol before giving anything.

Sources disagree

Anti-D in early ectopic pregnancy: the 2026 NICE update recommends no anti-D up to 11+6 weeks, citing a lack of evidence of benefit.1 The US RhoGAM label lists ectopic pregnancy as an indication, at 300 µg within 72 hours.14 ACEP's 2003 policy found too little evidence to recommend for or against it in ectopic pregnancy, and ACEP dropped the question in 2017.2 Follow your institution's policy.

FIG 2hCG follow-up in the first week. Drawn for this page from the NICE follow-up schedules. Each shaded mark is a blood draw. Every pathway continues weekly until hCG is negative.1 The Rh row shows the US label window, if Rh immune globulin is given.14

Disposition

  • Unstable, or free fluid in Morison's pouch: to the operating room with OB/GYN.8,7
  • Confirmed ectopic, stable: OB/GYN decides on expectant, medical or surgical care, using the criteria above.1
  • Indeterminate scan, stable: get specialty consultation or arrange close outpatient follow-up (ACEP Level C).2 Plan a repeat hCG at 48 hours.1
  • Before discharge: give written advice on new or worse symptoms and on how to reach emergency care 24 hours a day.1
  • After methotrexate: when these patients come back with worrying symptoms, strongly consider rupture. This was ACEP's 2012 advice, described again in 2017.2

Discharge before the location is known carries real risk. In one Canadian ED, 550 patients were sent home with a diagnosis of ectopic pregnancy, rule-out ectopic, or pregnancy of unknown location. Of these, 230 had an ectopic pregnancy, and 28 ruptured after the ED visit. Of the 221 discharged without a transvaginal scan, 73 were later diagnosed with an ectopic.15

ACEP found no study large enough to show that deferring the scan is safe. In one small series of 37 ectopic patients sent home for outpatient ultrasound, there were no adverse events despite a median delay of 14 hours.2

Pitfalls

  • Skipping the ultrasound because the hCG is "below the zone". Low hCG raises the risk of ectopic.2,3
  • Reading an indeterminate scan as reassuring. Make sure it has follow-up.2,6
  • Calling an intrauterine fluid collection a pregnancy. A pseudo-sac can occur with an ectopic.1
  • Stopping at an intrauterine pregnancy after IVF. Heterotopic pregnancy happens in about 1 in 100 pregnancies after assisted reproduction.5 ACEP's policy excludes these patients.2
  • Skipping the pregnancy test because the story sounds like a UTI or gastroenteritis.1
  • Applying the ACEP policy to unstable patients. It covers only patients with a normal pulse and blood pressure.2

How strong is the evidence?

ACEP's two ED recommendations are Level B (scan at any hCG; don't use hCG to exclude ectopic) and Level C (follow-up for indeterminate scans). Its 2017 searches found no new studies for either question.2 Most NICE recommendations on diagnosis and treatment date from evidence reviews in 2012 or 2019. The anti-D advice was updated in 2026.1 The bedside ultrasound data are a meta-analysis of 10 studies with 2,057 patients.4 The Morison's pouch finding comes from one prospective study.7 Emergency Medicine Cases covers this topic for further reading.16

On-shift teaching

Questions to ask a learner at the bedside. Tap a question to see the answer. Every answer uses facts cited above.

Q1A stable patient with pelvic pain has an hCG of 800 mIU/mL. Does the patient need an ultrasound today?
Yes. ACEP recommends a pelvic ultrasound at any hCG level (Level B).2 In ED patients, an hCG under 1,500 mIU/mL raised the likelihood of ectopic (LR 2.24), and 25% of those patients had one.3
Q2Your bedside scan shows a yolk sac in the uterus. How well does that rule out ectopic?
Very well. In a meta-analysis, emergency physician ultrasound had a pooled sensitivity of 99.3% and a negative predictive value of 99.96%.4 The exception is heterotopic pregnancy, about 1 in 100 after assisted reproduction.5
Q3The scan is indeterminate and the hCG is 4,000 mIU/mL. Does the hCG tell you it's ectopic?
No. With no intrauterine pregnancy on bedside scan, a 3,000 mIU/mL cutoff had 35% sensitivity and 58% specificity.6 ACEP advises against using hCG to exclude ectopic and calls for consultation or close follow-up.2
Q4What does free fluid in Morison's pouch mean in suspected ectopic?
It predicts surgery. Nine of 10 patients with this finding went to the operating room (positive LR 112).7
Q5Which patients does NICE offer methotrexate?
No significant pain, an unruptured mass under 35 mm with no heartbeat, hCG under 1,500 IU/L, no intrauterine pregnancy on scan, and able to return for follow-up. For hCG between 1,500 and 5,000, offer a choice of methotrexate or surgery.1
Q6Two hCGs 48 hours apart rise by 40%. What next?
Under 63% is outside the NICE range for a likely intrauterine pregnancy, so arrange review within 24 hours.1 Still, viable pregnancies have risen as slowly as 53% in 2 days, so a slow rise alone does not prove an ectopic.11

References

  1. 1
    National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management (NG126). Published April 2019; last updated June 17, 2026.Guidelinenice.org.ukPMID 31393678Full text read
  2. 2
    American College of Emergency Physicians Clinical Policies Subcommittee on Early Pregnancy; Hahn SA, Promes SB, Brown MD. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med. 2017;69(2):241–250.e20.GuidelinePMID 28126120acep.org (PDF)Full text read
  3. 3
    Kohn MA, Kerr K, Malkevich D, et al. Beta-human chorionic gonadotropin levels and the likelihood of ectopic pregnancy in emergency department patients with abdominal pain or vaginal bleeding. Acad Emerg Med. 2003;10(2):119–126.CohortPMID 12574008PubMed
  4. 4
    Stein JC, Wang R, Adler N, et al. Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis. Ann Emerg Med. 2010;56(6):674–683.Meta-analysisPMID 20828874PubMed
  5. 5
    McCarty M. Ectopic pregnancy. Core EM; June 7, 2017.FOAMcoreem.netPage read
  6. 6
    Wang R, Reynolds TA, West HH, et al. Use of a β-hCG discriminatory zone with bedside pelvic ultrasonography. Ann Emerg Med. 2011;58(1):12–20.Diagnostic studyPMID 21310509PubMed
  7. 7
    Moore C, Todd WM, O'Brien E, Lin H. Free fluid in Morison's pouch on bedside ultrasound predicts need for operative intervention in suspected ectopic pregnancy. Acad Emerg Med. 2007;14(8):755–758.Diagnostic studyPMID 17554008PubMed
  8. 8
    American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No. 193: Tubal ectopic pregnancy. Obstet Gynecol. 2018;131(3):e91–e103.GuidelinePMID 29470343DOIPubMed record; full text not openly accessible
  9. 9
    Mann LM, Kreisel K, Llata E, Hong J, Torrone EA. Trends in ectopic pregnancy diagnoses in United States emergency departments, 2006–2013. Matern Child Health J. 2020;24(2):213–221.CohortPMID 31848926PMCPubMed
  10. 10
    Creanga AA, Shapiro-Mendoza CK, Bish CL, et al. Trends in ectopic pregnancy mortality in the United States: 1980–2007. Obstet Gynecol. 2011;117(4):837–843.RegistryPMID 21422853PubMed
  11. 11
    Barnhart KT, Sammel MD, Rinaudo PF, et al. Symptomatic patients with an early viable intrauterine pregnancy: hCG curves redefined. Obstet Gynecol. 2004;104(1):50–55.CohortPMID 15229000PubMed
  12. 12
    Seeber BE, Sammel MD, Guo W, et al. Application of redefined human chorionic gonadotropin curves for the diagnosis of women at risk for ectopic pregnancy. Fertil Steril. 2006;86(2):454–459.CohortPMID 16753158PubMed
  13. 13
    Methotrexate injection (Accord Healthcare). FDA label, DailyMed.Drug labelDailyMedLabel text searched; no ectopic pregnancy indication found
  14. 14
    RhoGAM / MICRhoGAM Ultra-Filtered PLUS (human Rho(D) immune globulin), Kedrion Biopharma. FDA label, DailyMed.Drug labelDailyMedLabel text read
  15. 15
    Hawrylyshyn K, McLeod SL, Thomas J, Varner C. Ectopic pregnancy outcomes in patients discharged from the emergency department. CJEM. 2019;21(1):71–74.CohortPMID 29501067PubMed
  16. 16
    Emergency Medicine Cases. Ectopic pregnancy. Further reading; not used for any claim above.FOAMemergencymedicinecases.comLink checked
How this page was made
  • Written from scratch. No source text was copied; facts are restated and cited.
  • Anchored on NICE NG126 (last updated June 2026), read in full on nice.org.uk, and the 2017 ACEP clinical policy, read in full from the PDF on acep.org.
  • ACOG Practice Bulletin 193 was not openly accessible. Only the statement in its PubMed abstract (an unstable tubal ectopic needs prompt surgery) is used. No ACOG recommendation, strength or dose is quoted.
  • Each PubMed citation was resolved through NCBI E-utilities and checked against its abstract.
  • No methotrexate dose is given. The FDA methotrexate label checked has no ectopic pregnancy indication, and neither guideline read gives a dose. The Rho(D) immune globulin dose is from the FDA label.
  • The CanadiEM page on the discriminatory zone and LITFL pages could not be fetched (blocked), so they are not cited. Core EM was read for risk factors, heterotopic rates and methotrexate contraindications.
  • Adults. Adolescent care was not reviewed separately.
  • Figure 2 was drawn for this page from the NICE follow-up schedules. Figure 1 is an openly licensed image from Wikimedia Commons, credited under it, and it keeps its own license.
  • Not for clinical use until physician review.
Not for clinical use

AI-generated draft. Not reviewed by a physician. This page is for education only and may contain errors, including in doses. Do not use it to diagnose, treat or make decisions about any patient. Rely on your own clinical judgment, your institution's protocols and current drug labeling. Reading this page does not create a physician-patient relationship. Full terms