Give all women with an ectopic pregnancy oral and written information about:
the treatment options and what to expect during and after treatment
how they can contact a healthcare professional for advice after treatment if needed, and who this will be
where and when to get help in an emergency.
See also recommendation 1.2.1 for details of further information that should be provided. [2012, amended 2019]
Inform women who have had an ectopic pregnancy that they can self-refer to an early pregnancy assessment service in future pregnancies if they have any early concerns. [2012]
Offer expectant management as an option to women who:
are clinically stable and pain free and
have a tubal ectopic pregnancy measuring less than 35 mm with no visible heartbeat on transvaginal ultrasound scan and
have serum hCG levels of 1,000 IU/L or less and
are able to return for follow-up. [2019]
Consider expectant management as an option for women who:
are clinically stable and pain free and
have a tubal ectopic pregnancy measuring less than 35 mm with no visible heartbeat on transvaginal ultrasound scan and
have serum hCG levels above 1,000 IU/L and below 1,500 IU/L and
are able to return for follow-up. [2019]
For women with a tubal ectopic pregnancy being managed expectantly, repeat hCG levels on days 2, 4 and 7 after the original test and:
if hCG levels drop by 15% or more from the previous value on days 2, 4 and 7, then repeat weekly until a negative result (less than 20 IU/L) is obtained or
if hCG levels do not fall by 15%, stay the same or rise from the previous value, review the woman's clinical condition and seek senior advice to help decide further management. [2019]
Advise women that, based on limited evidence, there seems to be no difference following expectant or medical management in:
the rate of ectopic pregnancies ending naturally
the risk of tubal rupture
the need for additional treatment, but that they might need to be admitted urgently if their condition deteriorates
health status, depression or anxiety scores. [2019]
Advise women that the time taken for ectopic pregnancies to resolve and future fertility outcomes are likely to be the same with either expectant or medical management. [2019]
The evidence showed no significant differences in the number of ectopic pregnancies ending naturally, the need for additional treatment, the incidence of tubal rupture or the effect on health-related quality of life between expectant management and medical management, so the committee recommended that expectant management could be offered to clinically stable women with small ectopic pregnancies and low hCG levels, and should be considered for clinically stable women with small ectopic pregnancies and slightly higher hCG levels, as an alternative to medical management.
There was no evidence for the time taken for ectopic pregnancies to end naturally or the effects on future fertility but the committee agreed, based on their expertise and experience, that these outcomes were likely to be the same with expectant management compared with medical management.
Full details of the evidence and the committee's discussion are in evidence review B: expectant versus medical management of ectopic pregnancy.
These recommendations will standardise the management of ectopic pregnancy and make expectant management available for women when it is clinically appropriate. More women might have expectant management of ectopic pregnancy as a result. This could result in cost savings through a reduction in drug use and treatment of associated side effects. Local protocols will be needed for assessment, monitoring and follow-up of women choosing expectant management.
In April 2019, the use of methotrexate in recommendations 1.15.1 to 1.15.4 was off label. See NICE's information on prescribing medicines.
Offer systemic methotrexate to women who:
have no significant pain and
have an unruptured tubal ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat and
have a serum hCG level less than 1,500 IU/litre and
do not have an intrauterine pregnancy (as confirmed on an ultrasound scan) and
are able to return for follow-up.
Methotrexate should only be offered on a first visit when there is a definitive diagnosis of an ectopic pregnancy, and a viable intrauterine pregnancy has been excluded. Offer surgery where treatment with methotrexate is not acceptable to the woman. [2012, amended 2019]
Offer surgery as a first-line treatment to women who are unable to return for follow-up after methotrexate treatment or who have any of the following:
an ectopic pregnancy and significant pain
an ectopic pregnancy with an adnexal mass of 35 mm or larger
an ectopic pregnancy with a fetal heartbeat visible on an ultrasound scan
an ectopic pregnancy and a serum hCG level of 5,000 IU/litre or more. [2012]
Offer the choice of either methotrexate or surgical management to women with an ectopic pregnancy who have a serum hCG level of at least 1,500 IU/litre and less than 5,000 IU/litre, who are able to return for follow‑up and who meet all of the following criteria:
no significant pain
an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat
no intrauterine pregnancy (as confirmed on an ultrasound scan).
Advise women who choose methotrexate that their chance of needing further intervention is increased and they may need to be urgently admitted if their condition deteriorates. [2012]
For women with ectopic pregnancy who have had methotrexate, take 2 serum hCG measurements in the first week (days 4 and 7) after treatment and then 1 serum hCG measurement per week until a negative result is obtained. If hCG levels plateau or rise, reassess the woman's condition for further treatment. [2012]
When surgical treatment is indicated for women with an ectopic pregnancy, it should be performed laparoscopically whenever possible, taking into account the condition of the woman and the complexity of the surgical procedure. [2012]
Surgeons providing care to women with ectopic pregnancy should be competent to perform laparoscopic surgery. [2012]
Commissioners and managers should ensure that equipment for laparoscopic surgery is available. [2012]
Offer a salpingectomy to women undergoing surgery for an ectopic pregnancy unless they have other risk factors for infertility. [2012]
Consider salpingotomy as an alternative to salpingectomy for women with risk factors for infertility such as contralateral tube damage. [2012]
Inform women having a salpingotomy that up to 1 in 5 women may need further treatment. This treatment may include methotrexate and/or a salpingectomy. [2012]
For women who have had a salpingotomy, take 1 serum hCG measurement at 7 days after surgery, then 1 serum hCG measurement per week until a negative result is obtained. [2012]
Advise women who have had a salpingectomy that they should take a urine pregnancy test after 3 weeks. Advise women to return for further assessment if the test is positive. [2012]