Executive summary
- Assume pregnancy until proven otherwise in reproductive-age patients with bleeding, pelvic pain, syncope, or shoulder-tip pain.
- Rule out ectopic urgently: haemodynamic instability, severe/unilateral pelvic pain, collapse/syncope, shoulder-tip pain, or significant risk factors require same-day emergency assessment.
- Early pregnancy assessment units (EPAU) are the usual route for stable patients; ED is appropriate if unstable or severe symptoms.
- Investigations are staged: urine pregnancy test, vitals, baseline bloods where indicated, and ultrasound + serial hCG via pathway.
- Do not over-reassure on “light bleeding” alone — early ectopic can present subtly; safety-net is essential.
- Support matters: acknowledge uncertainty, provide written advice, and ensure clear follow-up plan and return precautions.
Assessment (what to ask + examine)
- Symptoms: PV bleeding (amount, clots/tissue), pelvic/abdominal pain (unilateral?), dizziness/syncope, shoulder-tip pain, GI symptoms.
- Gestation estimate: LMP, cycle regularity, contraception, prior scans/hCG results.
- Ectopic risk factors: prior ectopic, tubal surgery, PID, fertility treatment, IUCD in situ, smoking, prior pelvic surgery.
- Red flags: haemodynamic compromise, peritonism, marked cervical motion tenderness (if examined), significant anaemia symptoms.
- Exam: vitals first; abdominal tenderness/guarding; speculum/bimanual only if safe and clinically indicated (often deferred to EPAU/ED).
Investigations (primary care realities)
- Urine pregnancy test: do early and repeat if suspicion persists (very early gestations can be false-negative).
- Bloods (where relevant): FBC, group and save, and baseline renal function if severe symptoms or expected admission; serum hCG is typically arranged/owned by the EPAU pathway.
- Ultrasound: definitive localisation is usually via transvaginal ultrasound in EPAU/secondary care.
- Rh status/anti-D: follow local + national guidance; indications vary by gestation, bleeding severity, and management route.
Management + safety-netting (what patients need in writing)
- Stable + mild symptoms: route to EPAU/early pregnancy pathway for scan +/- serial hCG; provide clear timeframes and how to access care if worse.
- Analgesia: paracetamol is generally safe; avoid NSAIDs if ectopic management is being considered (and in pregnancy generally unless advised by specialist).
- Return immediately if: fainting/collapse, shoulder-tip pain, severe or worsening abdominal pain, heavy bleeding (soaking pads), fever, or feeling very unwell.
- Emotional support: signpost to local early pregnancy support and explain that uncertainty (pregnancy of unknown location) is common early on.
Frequently asked questions
If the bleeding is light, can I reassure?
Not fully. Light bleeding can occur in normal pregnancy, miscarriage, and ectopic pregnancy. Use symptom severity + risk factors and ensure pathway follow-up and clear safety-net advice.
What symptoms are most concerning for ectopic rupture?
Collapse/syncope, severe abdominal pain, shoulder-tip pain, signs of shock, and peritonism. These require emergency assessment.
What is “pregnancy of unknown location”?
A situation where pregnancy is confirmed biochemically but not yet seen on ultrasound. It needs structured follow-up (serial hCG and repeat imaging) via EPAU/secondary care pathway.
Should I do a pelvic exam in primary care?
Only if it will change immediate management and it is safe. In many settings, stable patients are best assessed in EPAU where ultrasound and specialist review are available.
What do I tell the patient today?
Explain uncertainty, the plan (EPAU/ED), what to expect next (scan +/- blood tests), and exact “come back now” triggers. Provide written advice.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.