About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Incidence: ~11 per 1,000 pregnancies. 97% are tubal (ampulla most common site)
- Risk factors: previous ectopic, PID/STI history, IUD in situ, tubal surgery, assisted reproduction
- Classic triad: amenorrhoea + unilateral iliac fossa pain + vaginal bleeding (but presentation varies widely)
- Diagnosis: transvaginal USS showing adnexal mass ± empty uterus + positive serum beta-hCG
- Medical: IM methotrexate (single dose 50 mg/m²) for unruptured, haemodynamically stable, hCG <5,000
- Surgical: laparoscopic salpingectomy preferred. Salpingotomy if contralateral tube damaged
Overview
An ectopic pregnancy occurs when a fertilised ovum implants outside the endometrial cavity. The most common site is the fallopian tube (~97%), particularly the ampulla. Other sites include the ovary, cervix, interstitial portion, caesarean section scar, and abdomen. Ectopic pregnancy cannot progress to a viable pregnancy and is potentially life-threatening if rupture occurs, causing intraperitoneal haemorrhage. It remains a significant cause of maternal death in the first trimester in the UK.
Epidemiology
Ectopic pregnancy occurs in approximately 1 in 90 pregnancies in the UK. The maternal mortality rate is approximately 0.2 per 1,000 estimated ectopic pregnancies. Risk factors include previous ectopic pregnancy (10–20% recurrence), previous PID or chlamydia infection, previous tubal surgery, IUD or IUS in situ at conception, assisted reproduction, smoking, and endometriosis. However, over half of women with ectopic pregnancy have no identifiable risk factors.
Clinical Features
Symptoms
Amenorrhoea — typically 6–8 weeks, though may be minimal or absent
Unilateral lower abdominal or iliac fossa pain — may be constant or colicky
Vaginal bleeding — often scanty, dark brown ("prune juice") and intermittent
Shoulder tip pain (diaphragmatic irritation from free fluid)
Dizziness, syncope, or collapse (suggesting rupture and haemoperitoneum)
Diarrhoea or pain on defecation (pouch of Douglas irritation)
Sudden-onset severe abdominal pain with haemodynamic instability
Signs
Adnexal tenderness — localised to the affected side
Cervical excitation (cervical motion tenderness) on bimanual examination
Adnexal mass palpable in some cases
Guarding and rebound tenderness (if ruptured)
Tachycardia, hypotension (hypovolaemic shock — ruptured ectopic)
Uterus slightly enlarged but smaller than expected for dates
Investigations
First-line
Urinary pregnancy testPositive in virtually all ectopic pregnancies — first step
Serum beta-hCGQuantitative level guides management. Suboptimal rise (<63% in 48 h) or plateau suggests ectopic/non-viable pregnancy
Transvaginal ultrasound (TVUSS)First-line imaging — look for adnexal mass with gestational sac (±yolk sac/fetal pole). Empty uterus with positive hCG is suspicious. No IUP seen when hCG >1,500 IU/L = likely ectopic (discriminatory zone)
Second-line
Serial serum beta-hCG48-hourly if pregnancy of unknown location — rising suboptimally, falling, or plateauing informs diagnosis
FBCHaemoglobin — baseline and to assess blood loss
Group and save / crossmatchIn case of surgical intervention or significant haemorrhage
Specialist
Diagnostic laparoscopyWhen diagnosis uncertain and clinical condition warrants — both diagnostic and therapeutic
1
Emergency — ruptured ectopic
- A-E approach, IV access (2 large-bore cannulae), aggressive fluid resuscitation
- Crossmatch blood, activate massive haemorrhage protocol if needed
- Emergency laparotomy or laparoscopy — salpingectomy
- Do NOT delay surgery for imaging if clinically unstable
2
Medical management — unruptured
- IM methotrexate (50 mg/m² single dose) if: confirmed ectopic on USS, haemodynamically stable, no significant pain, unruptured, hCG <5,000, no intrauterine pregnancy
- Follow up with serial hCG: day 4 and day 7. Must see ≥15% fall between day 4 and 7
- If inadequate fall: offer second dose of methotrexate or surgery
- Contraindications: hepatic/renal impairment, immunodeficiency, breastfeeding, active infection
3
Surgical management — unruptured
- Laparoscopic salpingectomy is first-line surgical option
- Offer laparoscopic salpingotomy if contralateral tube is damaged or absent (to preserve fertility)
- If salpingotomy: follow up with serial hCG until undetectable (risk of persistent trophoblast)
- Anti-D if Rh-negative and surgical management chosen
4
Expectant management
- May be considered if: clinically stable, declining hCG, hCG <1,500, able to attend follow-up
- Serial hCG monitoring until undetectable
- Clear safety-netting: return immediately if pain worsens, bleeding increases, or symptoms of rupture
Complications
- Tubal rupture: Massive intraperitoneal haemorrhage — surgical emergency. Most common cause of death
- Persistent trophoblast: After salpingotomy — residual trophoblastic tissue continues to produce hCG. Requires serial monitoring ± methotrexate
- Reduced future fertility: Risk of recurrence ~10–20%. Salpingectomy does not significantly reduce fertility if contralateral tube is healthy
- Psychological impact: Grief, anxiety about future pregnancies — offer support and counselling
UKMLA Exam Tips
- 1Shoulder tip pain = ruptured ectopic until proven otherwise. Diaphragmatic irritation from free blood
- 2Empty uterus on TVUSS + positive hCG = pregnancy of unknown location. Think ectopic
- 3Methotrexate: hCG <5,000, unruptured, stable. Monitor hCG day 4 and 7 (≥15% fall needed)
- 4Salpingectomy preferred over salpingotomy unless contralateral tube is damaged
- 5Cervical excitation on examination is classic for ectopic (and PID) — highly tested sign
- 6hCG should double every 48 h in normal early pregnancy. Suboptimal rise = ectopic or miscarriage
- 7Risk factors: PID, previous ectopic, IUD/IUS, tubal surgery, smoking, IVF
practicetest your knowledge on ectopic pregnancyApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — obstetrics and beyond.
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