Obstetrics and gynaecology · core
Unstable ectopic pregnancy
A haemodynamically unstable woman with a suspected ectopic pregnancy needs immediate resuscitation and urgent surgical management. Methotrexate, serial β-hCG, and outpatient ultrasound are for selected stable patients. They must not delay theatre.
Why this is high-yield for the PLAB 1
PLAB 1 regularly tests whether an IMG will treat shock before applying an early-pregnancy protocol written for well women. The trap is “get a scan first” or reaching for methotrexate because the stem mentions an ectopic. NICE NG126 is explicit: instability means admit, resuscitate, and operate.
The question
A 29-year-old woman is brought to the emergency department after collapsing at home. Her last menstrual period was 7 weeks ago. She has sudden left iliac fossa pain and shoulder-tip pain. A urinary pregnancy test is positive. Blood pressure is 78/44 mmHg, heart rate 128 beats per minute, and she is pale and clammy. Abdomen is peritonitic. There is no vaginal bleeding. Intravenous access has just been obtained.
What is the most appropriate immediate management?
- A. Intramuscular methotrexate and discharge with 48-hour β-hCG
- B. Discharge to the early pregnancy unit for transvaginal ultrasound tomorrow
- C. Immediate resuscitation and urgent surgical management
- D. Repeat serum β-hCG in 48 hours, treating this as a pregnancy of unknown location
- E. Oral analgesia and GP review if the pain continues
Reveal the worked answer
Correct answer: C. Immediate resuscitation and urgent surgical management
A — Methotrexate is only for selected haemodynamically stable ectopics that meet NICE size, pain, and β-hCG criteria, with guaranteed follow-up. This woman is in shock. Medical management here delays the operation that stops the bleeding.
B — Outpatient ultrasound is for stable women. A next-day slot does not treat intraperitoneal bleeding. She needs resuscitation and theatre now.
C (correct) — NICE NG126: women who are haemodynamically unstable with a suspected ectopic pregnancy should be admitted and offered surgical management. ABC, blood, senior obstetric review, and laparoscopy run together — do not wait for a formal EPAU scan first.
D — Serial β-hCG is a stable PUL pathway. Collapse, peritonitis, and a positive test make a ruptured ectopic the working diagnosis. Waiting 48 hours is unsafe.
E — This is a ruptured-ectopic picture, not musculoskeletal pain. Sending her home is a never-event in this stem.
Clinical pearl. Shock plus a positive pregnancy test is a theatre case until proven otherwise. Scan and methotrexate are for the woman who can sit in a chair.
MLA Content Map. Reproductive health · Ectopic pregnancy and miscarriage
Guideline. NICE guideline NG126 — Ectopic pregnancy and miscarriage (NG126)
Key facts to remember
- First-line management of a haemodynamically unstable suspected ectopic (NICE NG126)?
- Immediate resuscitation and urgent surgical management.
- When is methotrexate appropriate for ectopic pregnancy?
- Only in selected haemodynamically stable women who meet NICE criteria and can attend follow-up. Never in shock.
- What does shoulder-tip pain suggest in early pregnancy?
- Diaphragmatic irritation from intraperitoneal blood — a ruptured ectopic until proven otherwise.
- Why not wait for a formal EPAU ultrasound in this stem?
- Instability is the indication for theatre. Imaging must not delay resuscitation and surgery.
Frequently asked questions
What is the first-line treatment for an unstable ectopic pregnancy?
NICE NG126: resuscitate and offer urgent surgical management. Do not start methotrexate or send the woman to an outpatient scan.
Can I confirm the ectopic on ultrasound before calling theatre?
Do not delay surgery in a shocked woman for a formal EPAU slot. Resuscitation and senior review come first; imaging is arranged only if it does not delay theatre.
Is this the same as a pregnancy of unknown location protocol?
No. PUL pathways assume the woman is stable. Collapse and peritonitis take her out of that protocol.
Related reading
Related learning paths
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