ODOBGYNDECODED
Emergency Hub / Early pregnancy

⚡ Suspected Ruptured Ectopic

IN REVIEWPENDING CLINICAL VERIFICATIONTIME-CRITICAL PROTOCOLFull clinical topic →
1 RECOGNIZE
  • Possible pregnancy with abdominal/pelvic pain, bleeding, collapse, syncope or shoulder-tip pain; instability/peritonism suggests rupture.
  • A low/falling hCG or no previously visualised ectopic does not exclude rupture.
2 CALL FOR HELP
  • Call senior gynaecology, anaesthetist, emergency theatre and blood bank immediately; activate major-haemorrhage support for shock.
3 IMMEDIATE ACTION
  1. ABC, two large-bore IV cannulae, bloods/crossmatch and rapid access to blood. Give emergency uncrossmatched blood when required through the blood-bank policy; do not wait for hCG results to resuscitate.
  2. Perform bedside ultrasound only while the resuscitation/surgical team is being mobilised; unstable suspected rupture proceeds to operative assessment without a prolonged diagnostic work-up.
  3. Keep nil by mouth, monitor closely and prepare emergency laparoscopy/laparotomy according to stability, expertise and resources.
4 INVESTIGATIONS (never delaying treatment)
  • CBC, blood group/RhD, crossmatch and coagulation/renal tests with quantitative hCG when useful; none should delay surgery.
5 DEFINITIVE MANAGEMENT
  1. Obtain surgical haemostasis. Salpingectomy is commonly appropriate; salpingotomy is selected for specific fertility circumstances and requires postoperative hCG surveillance.
  2. Methotrexate and expectant care are NOT treatments for haemodynamic instability or suspected rupture.
  3. Assess contralateral tube/fertility implications and obtain histology as appropriate.
6 ESCALATION
  • Continuing shock or haemorrhage: major-transfusion pathway, senior operative control and ICU.
7 POST-EVENT CARE
  • Gestation-specific RhD prophylaxis follows the linked NICE NG126 2026 criteria and confirmed local policy; record eligibility/product/dose rather than a blanket injection for every early loss.
  • Arrange hCG follow-up when required by the operation/pathology, bereavement support and advice for early assessment in a future pregnancy.

Admission & discharge after the acute event

Care setting: Emergency admission if rupture/instability; selected stable cases can be managed as outpatients

Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.

When admission or continued hospital care is needed

  • Suspected rupture, instability, significant pain or major bleeding requires admission and urgent surgery. Inability to return for follow-up or surgical-treatment criteria changes the management choice.

When clinic, day care or home care may be suitable

  • Expectant or methotrexate treatment requires documented eligibility, no significant pain/instability and reliable access to serial hCG and emergency care.

Before going home

  • After surgery: observations, bleeding, pain, oral intake, mobilisation and voiding are satisfactory, with review of operative findings/complications.
  • After medical/expectant selection: treatment and follow-up eligibility are confirmed, hCG appointments are booked and emergency access is feasible. Discharge does not mean that rupture risk has ended.

Discharge medicines and treatment changes

  • If methotrexate was administered, give the checked regimen-specific interaction, breastfeeding and contraception advice. No automatic repeat dose is a discharge instruction.
  • After surgery provide the indicated oral analgesic and review any VTE/anti-D requirements.
Medicine doses — use only when indicated

Use the medicines selected for this patient. Listed alternatives are not instructions to prescribe all of them together. Confirm the actual remaining course, pregnancy/postnatal context and monitoring plan.

For uncomplicated postoperative pain when prescribed; increasing pain still needs assessment.

Paracetamol (acetaminophen) — oral pain reliefMédecins Sans Frontières · Current online monographchecked
Dose1 g (two 500 mg tablets) per dose
RouteOral
FrequencyEvery 6–8 hours when needed; maximum 4 doses in 24 hours
DurationAccording to clinical response: reduce/stop as pain improves. Record the prescribed supply and review date; persistent or increasing pain needs reassessment rather than an automatic repeat course.
PreparationCheck tablet strength: two 500 mg tablets = 1 g. Count paracetamol in every combination/OTC product towards the total; this is not an IV preparation.
Max dose4 g in 24 hours for the stated adult population. Lower weight, hepatic impairment or other risk factors require an individual reduced prescription; do not automatically use this maximum.
  • Indication: Short-term maternal postoperative/postpartum pain or other mild pain after assessment; adult ≥50 kg
  • MSF oral monograph: no pregnancy or breastfeeding contraindication. The dose does not replace assessment of the cause of pain.
Monitoring
  • Pain and functional recovery; investigate increasing pain, fever or other warning symptoms.
  • Check all prescribed/OTC paracetamol, weight and hepatic risk; suspected excess dosing requires urgent assessment.
Contraindications: Paracetamol allergy; avoid duplicate paracetamol-containing products. · Hepatic impairment needs caution and a clinician-adjusted regimen. This adult ≥50 kg card is not a weight-based prescription for smaller adults or children.

Tests, pending results and their reviewer

  • Methotrexate: hCG on days 4 and 7, then weekly until negative, with review of inadequate fall/plateau/rise.
  • Expectant management: hCG days 2, 4 and 7, then weekly if the expected fall occurs. After salpingotomy: hCG at day 7 then weekly; after salpingectomy: urine pregnancy test at 3 weeks, review if positive.

Home care and counselling

  • Give written rupture symptoms, avoid becoming pregnant until the methotrexate follow-up/contraception interval is completed, and arrange an early assessment in the next pregnancy.

Follow-up: when and what to review

WhenAction / responsible service
Before leaving
Book the exact hCG/urine-test schedule for the treatment received; identify the results reviewer.
At treatment completion
Review recovery, fertility implications, contraception and early scanning in a future pregnancy.

Return urgently

  • Increasing abdominal/shoulder-tip pain, faintness, collapse, heavy bleeding, breathlessness or fever requires immediate assessment.

Open the complete discharge checklist →

Sources for this plan:
NICE · NG126checkedNHS Greater Glasgow and Clyde · Version 4; last reviewed July 2021; scheduled review September 2026summary checkedRCOG · Current public recovery informationcheckedMédecins Sans Frontières · Current online monographchecked

Sources

NICE · NG126checkedNICE · NG126, June 2026checkedMSFcheckedNHS Greater Glasgow and Clyde · Version 4; last reviewed July 2021; scheduled review September 2026summary checkedRCOG · Current public recovery informationcheckedMédecins Sans Frontières · Current online monographcheckedNICE · NG194, recommendationscheckedIndia MoHFW / NHM · LaQshya district-hospital SOP, linked editioncheckedWHO · 2022 official recommendation summarycheckedNICE · CG50, recommendationschecked