Ectopic pregnancy — MSF Essential obstetric and newborn care — Médecins Sans Frontières 2026

MSFClinical guideline (chapter)Current edition

From Essential obstetric and newborn care › Chapter 2: Bleeding during the first half of pregnancy · Médecins Sans Frontières, Current online edition, 2026

Clinical guideline on diagnosis and management of ectopic pregnancy for clinicians in resource-limited settings.

In one sentenceSuspect ectopic pregnancy with amenorrhoea, abdominal pain and vaginal bleeding; insert 16–18G IV, give Ringer lactate, prepare screened blood, and urgently refer for laparotomy.

Issuer: Médecins Sans Frontières
Edition: Current online edition, 2026
Audience: Clinicians providing emergency obstetric care
Evidence: Expert consensus based on MSF field experience
Reviewed: 23 Oct 2026 · GMJ

Read the original on MSF Whole guideline (PDF)

Summary by GMJ Guidelines Desk•Reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD•Record updated 23 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This MSF clinical guideline section addresses the diagnosis and management of ectopic pregnancy, defined as implantation of the fertilized egg outside the uterine cavity, usually in the Fallopian tube. The document outlines clinical presentation ranging from early symptoms (amenorrhoea, intermittent abdominal pain, vaginal bleeding) through complications including haematosalpinx, haematocele formation, and life-threatening tubal rupture with haemoperitoneum and hypovolaemic shock.

Diagnostic approaches include pregnancy testing (usually positive), ultrasound showing an empty uterus with or without adnexal mass or intraperitoneal fluid, and culdocentesis (Pouch of Douglas puncture) when ultrasound is unavailable and the diagnosis uncertain. The guideline emphasises that culdocentesis is pointless when laparotomy is clearly indicated.

Management centres on urgent preparation for laparotomy or referral to a comprehensive emergency obstetric and newborn care (CEmONC) facility. Essential initial steps include IV access with 16–18G catheter, Ringer lactate administration, close monitoring of vital signs and bleeding, and preparation for possible transfusion with screened blood (HIV-1, HIV-2, hepatitis B, hepatitis C, syphilis, malaria in endemic areas). Special considerations are provided for cervical and abdominal pregnancy.

Key points

For clinicians — doses and thresholds as stated in the guideline

Suspect ectopic pregnancy with amenorrhoea, intermittent abdominal pain, vaginal bleeding, unilateral abdominal tenderness, and cervical/posterior fornix tenderness on examination
Tubal rupture presents with hypovolaemic shock: rapid weak pulse, very low/unmeasurable blood pressure, tachypnoea, pallor, cold damp skin, distended tender abdomen, and scapular pain
Perform culdocentesis using 1% lidocaine local or ketamine general anaesthesia, swab with 10% povidone iodine, puncture posterior fornix with 20G spinal needle; non-clotting blood aspirate indicates haemoperitoneum
Insert IV line with 16–18G catheter and administer Ringer lactate when ectopic pregnancy highly likely
Screen all transfusion blood for HIV-1, HIV-2, hepatitis B, hepatitis C, syphilis, and malaria in endemic areas
Prepare for laparotomy or urgent referral to CEmONC facility as definitive management
For cervical pregnancy, attempt temporary haemostasis with intracervical Foley catheter compression or cerclage before considering total hysterectomy
In abdominal pregnancy at laparotomy, leave placenta in place if removal risks severe bleeding

From the guideline

Verbatim

“Insert an IV line (16-18G catheter) and administer Ringer lactate.”

— Médecins Sans Frontières, Ectopic pregnancy — MSF Essential obstetric and newborn care, Section 2.2.3 Management (2026)

Editor’s perspective

Why this matters for Georgia and the region

Prof. Giorgi Pkhakadze, MD, MPH, PhD

Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration

As we continue strengthening maternal health services across Georgia and the South Caucasus, this MSF guideline provides practical, field-tested approaches to ectopic pregnancy that are directly applicable to our district hospitals and rural health centres. The emphasis on early recognition, immediate stabilisation with IV access and fluids, and urgent surgical referral aligns well with Georgia's ongoing efforts to reduce maternal mortality through improved emergency obstetric care networks. I would stress to Georgian clinicians the critical importance of the clinical diagnosis—particularly recognising the progression from compensated haematocele to life-threatening rupture—as ultrasound may not always be immediately available in remote regions. The main implementation challenge will be ensuring that all facilities have reliable access to screened blood products and established protocols for emergency transfer to surgical centres, particularly in mountainous areas where transport times can be prolonged.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026

Applicability

Georgia and the South Caucasus

Ectopic pregnancy remains a leading cause of maternal mortality in the first trimester worldwide, and its timely recognition is critical in Georgia and the South Caucasus, where access to comprehensive emergency obstetric care may be limited in rural and mountainous regions. Georgian national programmes should ensure that primary and district-level facilities have the capacity to recognise ectopic pregnancy, stabilise patients with IV access and fluids, and arrange urgent referral or transfer to surgical centres. Availability of ultrasound at district level, protocols for emergency blood transfusion with appropriate screening (Georgia has made significant progress in blood safety and hepatitis screening programmes), and clear referral pathways are essential. Training in culdocentesis may be valuable where ultrasound is unavailable, though the guideline’s emphasis on urgent surgical referral as definitive management should guide resource allocation towards strengthening referral networks and surgical capacity rather than attempting conservative management at lower-level facilities.

Questions this guideline answers

Quick answers

When should culdocentesis be performed to diagnose ectopic pregnancy?

Culdocentesis (Pouch of Douglas puncture) may be useful when ultrasound is unavailable and there is still some doubt about the diagnosis. However, the procedure is pointless when laparotomy is clearly indicated. An aspirate containing non-clotting blood indicates haemoperitoneum.

What are the signs of tubal rupture requiring immediate intervention?

Tubal rupture presents with hypovolaemic shock due to haemoperitoneum: rapid, weak or unmeasurable pulse, very low or unmeasurable blood pressure, tachypnoea, pallor, cold sensation, damp skin, agitation and anxiety, distended tender abdomen with shifting dullness, exquisite pain in the Pouch of Douglas, and scapular pain.

Can pregnancy tests be negative in ectopic pregnancy?

Pregnancy tests are usually positive in ectopic pregnancy. However, in the case of haematocele formation, the pregnancy test may exceptionally be negative.

How should cervical pregnancy be managed differently?

Cervical pregnancy closely resembles incomplete abortion and is often discovered due to massive bleeding during vacuum aspiration or curettage. Management involves temporarily stopping bleeding, if possible, using intracervical Foley catheter compression or cerclage before considering total hysterectomy.

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Diagnosing pregnancy — MSF Essential obstetric and newborn careChapter 1: Diagnosing and monitoring pregnancy

Ectopic pregnancy — MSF Essential obstetric and newborn care

What this guideline says

Key points

From the guideline