What are the current guidelines for the medical management of ectopic

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Current guidelines for the medical management of ectopic pregnancy include:

Offering expectant management to women who are clinically stable, pain-free, with a tubal ectopic pregnancy measuring less than 35 mm, no visible heartbeat on transvaginal ultrasound, serum hCG levels of 1,000 IU/L or less, and who are able to return for follow-up .
Considering expectant management for women with serum hCG levels above 1,000 IU/L and below 1,500 IU/L under the same stability and ultrasound criteria .
Offering systemic methotrexate as first-line treatment to women with no significant pain, an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm, no visible heartbeat, serum hCG less than 1,500 IU/L, and no intrauterine pregnancy, provided they can return for follow-up .
Using surgery, such as salpingectomy or salpingotomy, as first-line treatment for women with significant pain, an adnexal mass of 35 mm or larger, fetal heartbeat visible, or serum hCG of 5,000 IU/L or more .
Offering a choice of either methotrexate or surgical management to women with serum hCG levels between 1,500 and 5,000 IU/L, who are able to follow-up, with no significant pain, no intrauterine pregnancy, and an unruptured ectopic with a small mass and no visible heartbeat .

Surgical intervention should be considered in the following circumstances:

If the woman has significant pain, an adnexal mass of 35 mm or larger, fetal heartbeat on ultrasound, or serum hCG of 5,000 IU/L or more, surgery is recommended as first-line treatment .
When medical management with methotrexate is not acceptable or if the woman cannot return for follow-up, surgery should be performed .

What are the current guidelines for the medical management of ectopic pregnancy, and when should surgical intervention be considered?