1. Scope and purpose

Covers diagnosis and initial & definitive management of ectopic pregnancy up to early gestation (includes tubal, cervical, cesarean-scar, interstitial/cornual, ovarian, abdominal and heterotopic). Aims to provide a safe, fertility-preserving, context-adapted pathway for Bangladesh hospitals and community services.

2. Key principles (summary)

1. Early recognition and prompt intervention to prevent haemorrhage and death.
2. Use clinical assessment + transvaginal ultrasound (TVS) ± serial serum β-hCG to classify pregnancy location and stability.
3. Management choice guided by: haemodynamic stability, patient desire for fertility, size and location of ectopic, β-hCG trend, local expertise & resources (operating theatre, blood bank, interventional radiology).
4. For rare ectopics (CSP, cervical, interstitial), preferentially manage in centres with experienced gynaecologists, laparoscopy/hysteroscopy capability and access to interventional radiology where possible.

3. Presentation & triage

A. Immediate red flags — urgent laparotomy/laparoscopy or resuscitation

• Shock or haemodynamic instability (SBP <90 mmHg, HR >120, signs of poor perfusion).
• Peritonitis or severe abdominal pain with guarding/rebound.
• Ongoing heavy vaginal bleeding with haemodynamic compromise.
  Action: resuscitate (ABC), cross-match blood, urgent transfer to OT; do not delay definitive surgery.

B. Stable patients

• Evaluate with TVS and serum β-hCG. If TVS shows adnexal mass with cardiac activity or free fluid + rising β-hCG → consider surgical management.
• If inconclusive — treat as pregnancy of unknown location per NICE pathway (repeat β-hCG in 48 hours; early pregnancy unit follow-up).

4. Investigations (initial)

• Urgent TVS (transvaginal) performed by experienced operator. Document: location, size, sac/embryo, vascularity (Doppler), relation to bladder/cesarean scar if suspected.
• Serum quantitative β-hCG (baseline), full blood count, type & crossmatch, coagulation profile, renal & liver function (if methotrexate likely).
• Pregnancy test + clinical exam.
• If CSP suspected, transvaginal ultrasound by an experienced sonographer with Doppler (look for empty uterine cavity, empty cervical canal, triangular/oval gestational sac embedded in anterior lower uterine segment scar and rich vascularity).

5. Management options (general)

A. Expectant management

• Only when serial β-hCG falling appropriately and no ultrasound evidence of viable ectopic and patient reliable for follow up. Not recommended for viable ectopic or CSP with vascularity.

B. Medical management — Methotrexate (MTX)

• Single-dose or multi-dose MTX protocols for unruptured, stable, tubal ectopic in selected patients: small ectopic, low β-hCG (commonly <3,500–5,000 IU/L but local policy may vary), no fetal cardiac activity, normal LFT/RFT, able for follow-up. Follow NICE/RCOG criteria and local protocols for dosing/monitoring.
• Not routinely recommended for cervical or CSP as single therapy if high vascularity / implanted deeply — combined or surgical approaches often needed.

C. Surgical management

• Laparoscopy is preferred if immediate surgery is needed and expertise available (salpingostomy vs salpingectomy for tubal ectopic based on fertility desire & tube condition). Laparotomy if unstable or extensive haemorrhage.
• For CSP / cervical / interstitial sites, surgical options include hysteroscopic resection, laparoscopic wedge resection, laparotomy excision, hysterectomy (in severe bleeding or no fertility desire). Pre-operative planning essential.

6. Specific guidance: Caesarean-scar pregnancy (CSP)

Diagnosis

• TVS diagnostic features: empty uterine cavity and cervical canal; gestational sac implanted in the anterior lower uterine segment at the site of the scar; thin/absent myometrium between sac and bladder; high peritrophoblastic vascularity on Doppler. MRI can be adjunct if ultrasound equivocal.

Management principles (adapted)

• CSP is high risk for massive haemorrhage and placenta accreta spectrum if pregnancy continues; individualized plan required. Options include:

1. Surgical excision (hysteroscopic resection ± laparoscopy or combined approach) — best when feasible to remove sac and repair defect; allows histology and repair of scar.
2. Uterine artery embolization (UAE) followed by local or systemic MTX or surgical evacuation — useful where available for reducing blood loss.
3. Medical management (MTX ± local injection) may be attempted in selected stable patients with small sac and low vascularity, but carries risk of heavy bleeding and need for subsequent surgery — counsel carefully.
4. Hysterectomy for uncontrollable bleeding or completed childbearing with life-threatening haemorrhage.

• For Bangladesh: preference for combined hysteroscopy + laparoscopy where expertise exists; if not, plan transfer to tertiary centre before attempted curettage. If bleeding anticipated and IR/UAE not available, ensure blood product availability and experienced surgeon.

7. Specific guidance: Cervical ectopic pregnancy

Diagnosis

• TVS shows gestational sac within cervical canal, ‘hourglass’ or ballooning cervix; empty uterine cavity; color Doppler shows peritrophoblastic vascularity. Clinical sign may be profuse painless bleeding on attempted manipulation.

Management principles

• Conservative, fertility-sparing management is possible in many cases: systemic MTX (single or multi-dose), local MTX injection into sac under ultrasound guidance, and/or hysteroscopic resection combined with cervical tamponade (Foley balloon), cervical sutures (cerclage-type), or uterine artery embolization (when available).
• Surgical hysterectomy reserved for life-threatening haemorrhage or completed fertility.
• In Bangladesh, because MTX is relatively affordable, many stable cervical ectopics can be managed medically with close monitoring; however, counsel about bleeding risk and arrange theatre access and blood if there is any sign of bleeding.

8. Other rare ectopics

• Interstitial/cornual ectopic: high risk of massive haemorrhage; consider cornual resection (laparoscopic) or systemic MTX in selected cases; refer to tertiary unit for complex cases.
• Ovarian/abdominal ectopic: individualized; surgical management usually required.
• Heterotopic pregnancy: if concurrent intrauterine pregnancy exists, aim to preserve intrauterine pregnancy where possible (e.g., local injection of ectopic, surgical excision) — manage in tertiary care with specialist input.

9. Resource-stratified pathway for Bangladesh (practical)

Primary/community clinic

• Identify red flags and refer urgently. Do not attempt definitive management. Arrange transfer to nearest hospital with ultrasound/OT.

Secondary hospital (district)
Minimum expected capabilities:

• TVS by trained sonographer, basic labs, resuscitation, blood transfusion, general OR with gynaecologist able to perform laparotomy.
• Referral triggers to tertiary: suspected CSP, cervical pregnancy with vascularity, interstitial ectopic, heterotopic pregnancy, need for embolization, or anticipated high blood loss.

Tertiary hospital (specialist centre)

• Laparoscopy & hysteroscopy expertise, interventional radiology (UAE), 24/7 blood bank, ICU/HDU support, multi-disciplinary team (obstetrics, gynaecologic oncology/advanced laparoscopy, interventional radiologist, anaesthesia). Manage CSP, cervical ectopic, heterotopic or complicated cases here.

10. Perioperative planning & safety measures

• Crossmatch blood and have transfusion plan for surgical & CSP cases.
• Consent must include risk of hysterectomy, need for transfusion, and impact on future fertility.
• For cases with high vascularity (CSP, cervical), consider pre-op UAE if available, cell salvage, and experienced surgical team.

11. Follow up & contraception

• Serial β-hCG until negative after medical or surgical treatment (weekly until negative).
• Counsel regarding delay to next conception (often suggested 3 months after MTX), contraception options, and early ultrasound in next pregnancy.

12. Counselling & psychosocial support

• Offer clear counselling about diagnosis, prognosis, fertility implications, emergency signs, and emotional support. Consider referral to counselling/support services. Document discussion and informed consent.

13. Audit, training & quality indicators (suggested)

1. Time from presentation to ultrasound (target <24 hours for suspected ectopic).
2. Proportion of unstable ectopic requiring laparotomy vs laparoscopy.
3. Maternal mortality from ectopic pregnancy (target 0).
4. Proportion of CSP/cervical cases managed in tertiary centre or with pre-planned IR.
5. Rate of follow-up β-hCG completion.
6. Regular training in TVS for early pregnancy unit staff.

14. Practical checklists

A. Emergency triage (suspected ectopic)

• ABCs, vitals, IV access ×2, send bloods (FBC, group & crossmatch), urine pregnancy, bedside TVS/EPU referral, call on-call gynaecologist/anaesthetist, prepare OT & blood if suspect rupture.

B. Preoperative for CSP/cervical patient

• Informed consent (including hysterectomy risk), cross-match ≥2 units, consider pre-op UAE if available, assemble experienced team (laparoscopy/hysteroscopy), ensure bladder catheter & Foley for tamponade if needed.

C. Medical MTX candidate (selection)

• Haemodynamically stable, no rupture, β-hCG below local cut-off, sac size small, no fetal cardiac activity, normal LFT/RFT, patient reliable for follow-up, negative chest X-ray if multi-dose MTX planned.

15. Recommendations for Bangladesh policy makers & hospitals

• Strengthen Early Pregnancy Units (EPU) with trained sonographers and protocols (NICE pathways).
• Develop referral networks so CSP/cervical and complicated ectopics reach tertiary centres quickly.
• Increase training in minimally invasive surgery (laparoscopy/hysteroscopy) and support expansion of interventional radiology services where feasible.

16. Useful references (for download / hospital library)

• RCOG Green-top Guideline: Diagnosis and management of ectopic pregnancy (Green-top No. 21).
• NICE Guideline NG126: Ectopic pregnancy and miscarriage: diagnosis and initial management (2019; last reviewed 2025).
• Cesarean Scar Pregnancy — review & management options (systematic reviews / PMC articles).
• Recent network meta-analysis on CSP interventions (2024–2025).
• Cervical ectopic management reviews (systematic reviews and case series).

Compiled By:

Dr. Reshma Sharmin

Contributors

1. Prof Fawzia Hossain
2. Prof Ferdousi Begum
3. Prof Sheikh Zinat Nasreen
4. Prof KH Shahnewaz
5. Dr Tanjila Karim
6. Dr Taslima Akter
7. Dr Umme Rumman
8. Dr Ayesha Siddika
9. Dr Amena Fardous
10. Dr Mahadia Bashar
11. Dr Shain Fariya Shetu
12. Dr Arefin Arif
13. Dr Syeda Farhana Islam
14. Dr SM Shahida
15. Dr Fatema-Tuz-Zohora Kumkum