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Ectopic Pregnancy

What is an ectopic pregnancy?

An ectopic pregnancy, also known as an extrauterine pregnancy, is a fairly common pregnancy complication, in which a fertilized egg implants and develops outside of the uterus (womb). The word ectopic means ‘out of place’. In about 95 percent of cases, the fertilized egg (ovum) implants in one of the fallopian tubes. This is often due to scarring from previous infection or other abnormalities in the pelvic area, but it can also happen without a clear cause.

The symptoms of an ectopic pregnancy include vaginal bleeding, abdominal pain and absence of menstruation. However, some people experience symptoms that are similar to those found in gastroenteritis (stomach flu) and miscarriage.[1] Ectopic pregnancy may also be asymptomatic.

While most people make a good recovery from an ectopic pregnancy, the condition can be life -threatening if left untreated. An ectopic pregnancy cannot be moved to the uterus to grow normally and almost never survives. It may pass out of the cervix on its own, though medical or surgical intervention is normally required. [2]

Many people experience emotional distress after an ectopic pregnancy, particularly if it occurs during a planned pregnancy. A range of therapeutic treatment options are available.

Ectopic pregnancy symptoms

If symptoms of ectopic pregnancy occur, they typically appear early on in the pregnancy, sometimes before a person realizes they are pregnant.

When present, the most common early signs and symptoms of an ectopic pregnancy include:[2][3][4]

  • Lower abdominal (stomach) pain, often on one side
  • Vaginal bleeding, which may be dark, watery and heavier, lighter or more prolonged than a normal period
  • Pregnancy symptoms such as a missed menstrual period, breast tenderness, frequent urination or nausea

Less common symptoms include:

  • Bowel and bladder problems, such as diarrhea, and pain when defecating or urinating
  • A feeling of fullness when lying down that is not associated with eating, particularly in people who have already had a child
  • Back pain

It is possible to have an ectopic pregnancy without experiencing any symptoms until rupture of the fallopian tube or close organs. After rupture, signs and symptoms may include:[3]

  • Severe abdominal (tummy) pain
  • Vaginal bleeding
  • Lightheadedness, sometimes followed by fainting
  • Shoulder-tip pain, described as a strange pain that feels different to any pain that a person has otherwise experienced, caused by internal bleeding

Ectopic pregnancy causes

When a person becomes pregnant, the sperm and the egg (ovum) join in the fallopian tube, the tube that carries the ovum from the ovary to the uterus. Usually, the fertilized ovum passes along the fallopian tube and into the uterus and implants into the lining of the uterus (endometrium), where it will grow and develop.

Ectopic pregnancy occurs when a fertilized ovum implants and starts to grow outside the uterus, usually in a fallopian tube. As the ectopic pregnancy gets bigger, it can run out of space to grow and rupture the fallopian tube, causing severe pain and internal bleeding. Rarely, an ectopic pregnancy can also occur in other places, such as the ovary or inside the abdomen.

Ectopic pregnancy risk factors

The following factors may not be the sole cause of a person experiencing an ectopic pregnancy, but they are linked to a heightened risk of ectopic pregnancy:[3][5]

  • Previous ectopic pregnancy: If a person has experienced an ectopic pregnancy already, they have an increased risk of having another one.
  • Fertility treatment: Embryo transfer during in vitro fertilization (IVF) can occasionally result in ectopic pregnancy if, for example, an embryo travels into the fallopian tube.
  • Infertility: Women with infertility have a two or three times higher risk of ectopic pregnancy, possibly reflecting the increased number of people in this group who have tubal abnormalities, which may also be a cause of infertility.[6]
  • Age: The risk of ectopic pregnancy increases with age.
  • Pelvic inflammatory disease (PID): Previous infection of the pelvic region, commonly chlamydia and gonorrhea, can sometimes damage the fallopian tubes.
  • Tubal sterilization: People who become pregnant after tubal sterilization, either because it has failed or because they have had it reversed, are at higher risk.
  • Cesarean section: An embryo can implant in the scar tissue of the uterus lining, caused by cesarean section.
  • Copper contraceptive coil (IUD): IUDs ensure a very low risk of any pregnancy, either intrauterine or ectopic. However, if a person does conceive, the probability of the pregnancy being ectopic is higher than in women not using an IUD.[3] An IUD is still more protective against ectopic pregnancy than not using contraception.
  • Smoking tobacco: This can hinder the transfer of the ovum to the uterus by decreasing the ability of the muscles in the fallopian tube walls to contract.
  • In-utero diethylstilbestrol (DES) exposure: Exposure before birth to DES, a synthetic form of the female hormone estrogen that was prescribed to pregnant women from the 1940s to 1970s to prevent pregnancy complications, has been found to increase the risk of ectopic pregnancy by about four times.[6]

Types of ectopic pregnancy

The kind of ectopic pregnancy a person has depends on where the fertilized ovum implants.

Fallopian pregnancy

Also known as tubal pregnancy, a fallopian ectopic pregnancy can be further divided into three sub-types:

  • Ampullary (in the middle part of the fallopian tube), accounting for 80% of ectopic pregnancies
  • Isthmic (in the upper part of the fallopian tube close to the uterus), accounting for 12% of ectopic pregnancies
  • Fimbrial (at the end of the tube), accounting for 5% of ectopic pregnancies

The tube has a delicate structure made up of cilia (tiny hair-like projections) and mucus-producing cells, which work together to propel an ovum, fertilized in the fallopian tube, to the uterus to implant, over the space of about four days.

Sometimes, the transportation of the developing embryo is slow, perhaps for reasons of inflammation or infection of the fallopian tube or for no obvious reason. In such cases, it can implant in the fallopian tube.

About 95 percent of ectopic pregnancies occur in the fallopian tube.

Other types of ectopic pregnancy

There are other types of ectopic pregnancies, all of which are rare. These include:[7]

  • Interstitial pregnancy: This occurs in the part of the fallopian tube embedded in the uterus wall. It is typically hard to diagnose and can therefore be particularly dangerous, as it may progress further and rupture later, damaging both the fallopian tube and the uterus wall.
  • Cervical pregnancy: Pregnancy in the cervix (the passage between the womb and vagina) is one of the rarest forms of ectopic pregnancy and carries a risk of life-threatening vaginal hemorrhage. This is due to the possibility of heavy bleeding when the ectopic pregnancy tissue separates from the highly vascular (containing many blood vessels) cervix.
  • Ovarian ectopic pregnancy: This is typically difficult to diagnose, as it can appear very similar to a tubal ectopic pregnancy that is stuck to the ovary. It is usually not diagnosed until surgery, when partial or complete removal of the ovary will usually be necessary.
  • Cesarean scar ectopic pregnancies: This occurs when a fertilized ovum implants into the scar from a cesarean section. The pregnancy can grow out of the uterus or into the cervix, which can lead to massive internal or vaginal bleeding. In some cases, the fetus may be able to survive, but with the risk of significant maternal bleeding and hysterectomy (removal of the womb) at delivery.
  • Intramural pregnancy: This is a difficult-to-diagnose pregnancy that implants outside of the womb cavity, but within its muscular wall. It may occur if the uterus is scarred from surgery or if a condition called adenomyosis is present, in which the inner lining of the uterus breaks through the muscle wall of the uterus.
  • Abdominal pregnancy: Pregnancies in the abdomen are thought to start as tubal pregnancies, before separating from the wall of the fallopian tube and passing into the abdominal cavity, where they reattach. These can take many weeks before showing symptoms.
  • Heterotopic pregnancy: This term describes the co-existence of an intrauterine pregnancy and an ectopic pregnancy. The intrauterine twin is able to survive in about one third of cases, after surgical treatment of the ectopic pregnancy.

Ectopic pregnancy diagnosis

Diagnosis of ectopic pregnancy usually begins with a physical exam and taking the person’s medical history.

Ectopic pregnancies are most commonly diagnosed using a combination of tests, including:

  • Ultrasound
  • Human chorionic gonadotropin (hCG) test
  • Laparoscopy (keyhole surgery) if the previous exam results are still ambiguous

Good to know: Diagnosis of ectopic pregnancy can be delayed because the symptoms are often similar to other, more well-known conditions, such as gastroenteritis, appendicitis or miscarriage. See this resource for more information about the signs of miscarriage.

Ultrasound

Ultrasound is an imaging technique which uses soundwaves to create an image of the developing pregnancy. It is a painless and non-invasive procedure which can be performed in two different ways:[8]

  • Transvaginally: A scanning probe is inserted into the vagina.
  • Transabdominally: Gel is spread onto the skin of the lower abdomen, and the scanner is passed over the area.

In diagnosing an ectopic pregnancy, doctors will look for where the pregnancy is located in the ultrasound images. These can help them determine whether the person’s symptoms are being caused by an ectopic pregnancy, a healthy pregnancy or another condition. Ultrasound indicators for ectopic pregnancy include:[9]

  • No pregnancy in the uterus, or a gestation sac in the uterus missing an embryo: This is a pregnancy of unknown location (PUL). This is a label given until the pregnancy location can be found, and a diagnosis can be given. Many of these will not be ectopic and will not need treatment.
  • No pregnancy in the uterus and a possible mass in the area of a fallopian tube: This would likely lead to diagnosis of a possible ectopic pregnancy.

hCG test

Human chorionic gonadotropin (hCG) is a hormone produced by the placenta, an organ that develops in the womb during pregnancy. A beta hCG blood test can detect hCG in the blood approximately 11 days after conception and establish the precise amount of hCG present. This might be used if a person has been pregnant for six weeks, but an ultrasound scan does not show a developing pregnancy in the uterus. The test may be repeated at intervals to measure changes in hCG levels.[10]

Possible indicators for ectopic pregnancy from a beta hCG blood test include:[11]

  • Declining hCG levels: This can be an indicator that the ectopic pregnancy has ended and is self-resolving or will be miscarried in the coming days or weeks.
  • Slow rising hCG levels: If the levels rise more slowly than in a normal pregnancy, it is likely that the pregnancy is ectopic.

In a healthy pregnancy, hCG levels in the blood double about every two to four days throughout the first trimester, reaching their peak after 8-11 weeks and then decreasing before plateauing during the second trimester.

Laparoscopy

Rarely, laparoscopy, a type of keyhole surgery, is used to confirm the diagnosis, if hCG and ultrasound results are ambiguous. Under general anesthetic, a laparoscope (a narrow instrument with a camera and light on the end) is inserted through a small cut, usually into the umbilicus (belly button), to look at the pelvis. If an ectopic pregnancy is found, treatment to remove it may take place during the same operation.[3]

Ectopic pregnancy treatment

An ectopic pregnancy can be life threatening if left untreated and normally requires medical or surgical intervention to remove it. However, in some cases, when it is diagnosed early, ectopic pregnancy may be monitored to see if it will resolve on its own.

Treatment options depend on:[12]

  • hCG levels
  • How many weeks pregnant a person is
  • Size and impact of the ectopic pregnancy as shown on an ultrasound
  • Pain levels
  • General health
  • The options the hospital has available
  • Personal views and preferences, such as future pregnancy plans

Expectant management

Also known as conservative or wait-and-see management, expectant management involves waiting to see if the ectopic pregnancy tissue passes out of the cervix on its own, instead of undergoing immediate treatment.

Expectant management is only offered as an option in some cases of very early diagnosis. Candidates should:[13]

  • Have no symptoms
  • Show signs that the ectopic pregnancy is resolving, such as declining beta-human chorionic gonadotropin (β-HCG) levels
  • Not show signs of rupture
  • Not show signs of hemodynamic instability (abnormal blood pressure)
  • Be fully compliant
  • Be willing to accept the potential risks of tubal rupture

The approach involves close monitoring by medical professionals through repeated blood tests to check that hCG levels are dropping. It can take a few weeks or sometimes months for this to happen. About half of ectopic pregnancies may resolve on their own where there is a drop in hCG levels.

If a person develops new symptoms, another ultrasound scan may be done, and treatment options will be reassessed. Medical or surgical intervention may be required if it does not complete as planned.[14]

Medical management

Sometimes, an ectopic pregnancy may be treated with a medicine called methotrexate. This stops the growth of the embryo and typically allows surgery to be avoided. Medical management may be suitable if a diagnosis has been made very early.

Treatment with methotrexate is an especially attractive option if the pregnancy is located in the cervix or ovary or in the interstitial or the cornual portion of the tube. Surgical treatment in these cases is often associated with an increased risk of hemorrhage.

Methotrexate is administered as an injection, usually a single shot into the buttock muscle. After the injection, there may be an overnight stay in hospital, and regular follow-up visits will be needed for a few weeks to monitor hCG levels until they return to normal. Some people will need a second injection of methotrexate. Very occasionally, surgery will still be required.

Methotrexate is a chemotherapy drug used to treat a variety of other conditions and which can cause significant side-effects. However, the dose used to treat ectopic pregnancy is much lower and is unlikely to cause severe problems.[12] Some pain is likely in the first few days after the injection, but this can usually be controlled with paracetamol. Certain substances should be avoided during treatment, including:[3]

  • Nonsteroidal antiinflammatory drugs (NSAIDs), e.g. ibuprofen or naprosyn, as they can interact with methotrexate and reduce its effectiveness
  • Alcoholic beverages, as the liver will be working hard to metabolise methotrexate
  • Supplements containing folic acid, as this can interact with methotrexate, preventing it from achieving the desired effect

Surgical management

There are two possible aims for surgical management, which will be decided depending on damage to the affected fallopian tube and the condition of the other tube. These are:[12][13]

  • Total salpingectomy: This involves removal of the tube containing the ectopic pregnancy and is normally recommended for people who either do not want to have any children in future, who have had another ectopic pregnancy in the same fallopian tube, or who have severely damaged tubes. This reduces the risk of a persistent ectopic pregnancy, in which some ectopic cells are left behind and continue to grow, or further ectopic pregnancies. Total salpingectomy may also be chosen in cases of uncontrolled bleeding and hemodynamic instability (abnormal blood pressure).
  • Linear salpingostomy: This is a more conservative approach, involving a surgical incision into a fallopian tube, which aims to remove the ectopic pregnancy without removing the tube. This is normally recommended for people who have an unruptured ectopic pregnancy in the ampullary (middle) portion of the tube. This may also be chosen if the person only has one tube, or their other tube does not seem to be healthy. It carries a higher risk of future ectopic pregnancy and persistent ectopic pregnancy, but still leaves the possibility of a future uterine pregnancy. However, salpingostomy is not always possible.

The operation will be performed under general anesthetic in one of two ways:

  • Laparoscopy: This is keyhole surgery involving minimal incisions. Recovery is about two to four weeks, though this varies from person to person.
  • Laparotomy: This is open surgery, which is used if severe internal bleeding is suspected. It involves a larger incision in the lower abdomen. Recovery is about four to six weeks, though this varies from person to person.

Ectopic pregnancy and emotions

It is normal to feel distressed after an ectopic pregnancy. It can mean coming to terms with the loss of a baby, with a potential impact on future fertility or, for some, with the thought of having nearly lost their life. In some people, these emotions can develop into depression and anxiety if left untreated.

According to the Miscarriage Association, a person with ectopic pregnancy may be emotionally affected in a variety of ways, including:[15]

  • Shock: A person may experience shock about the diagnosis, especially in cases where there has been emergency surgery or about what might have happened without diagnosis.
  • Loss and grief: It is normal to feel grief for the baby that was expected.
  • Feeling ‘in limbo’ and unable to move on: It is common to feel frustrated at having to wait some time before being able to try again and having to have follow-up and repeated blood and urine tests.

Counseling is available for people affected by an ectopic pregnancy. Support groups are also available and may be able to put a person in touch with others in a similar situation.

A health professional will be able to provide advice on choosing the most appropriate kind of support for a person, couple or family who has experienced an ectopic pregnancy.

Ectopic pregnancy FAQs

Q: Can a person have an ectopic pregnancy with a copper coil (IUD)?
A: IUDs ensure a very low risk of any pregnancy, either intrauterine or ectopic. However, if a person does conceive, the probability of the pregnancy being ectopic is higher than in women not using an IUD.[3] An IUD is still more protective against ectopic pregnancy than not using contraception.[16]

Q: Can a person have an ectopic pregnancy with IVF?
A: Yes, in vitro fertilization puts a person at higher risk of ectopic pregnancy. It may increase the occurrence of unusual types of ectopic pregnancies, such as heterotopic (simultaneous intrauterine and tubal pregnancies) and interstitial pregnancy.[17]

Q: Is it possible to miscarry an ectopic pregnancy?
A: In the very early stages, the fetus may pass out of the cervix on its own, without the need for further treatment (expectant management). This may result in some symptoms of miscarriage being present. As the fetus develops, it becomes less likely that it will pass out of the womb on its own, and medical or surgical management will be needed to remove it. However, the techniques used to treat ectopic pregnancy may differ from those used to treat incomplete miscarriage. See this resource on miscarriage for more information.

Other names for ectopic pregnancy

  • Extrauterine pregnancy
  • Tubal pregnancy
  • Interstitial pregnancy
  • Cervical pregnancy
  • Ovarian ectopic pregnancy
  • Cesarean scar ectopic pregnancies
  • Intramural pregnancy
  • Abdominal pregnancy
  • Heterotopic pregnancy

  1. Patient. "Ectopic Pregnancy | Symptoms and Complications." 11 September 2017. Accessed 27 April 2018.

  2. Penn State Hershey Medical Center - ADAM. "Ectopic Pregnancy." 9 December 2012. Accessed 27 April 2018.

  3. UpToDate. "Patient education: Ectopic (tubal) pregnancy (Beyond the Basics)." 21 March 2018. Accessed 26 April 2018.

  4. The Ectopic Pregnancy Trust. "Symptoms of ectopic pregnancy." Accessed 26 April 2018.

  5. The Ectopic Pregnancy Trust. "Reasons for an ectopic pregnancy." Accessed 26 April 2018.

  6. UpToDate. "Ectopic pregnancy: Epidemiology, risk factors, and anatomic sites." 14 January 2018. Accessed 15 May 2018.

  7. The Ectopic Pregnancy Trust. "What is an ectopic pregnancy?" Accessed 26 April 2018.

  8. The Miscarriage Association. "Ultrasound scans." Accessed 26 April 2018.

  9. The Ectopic Pregnancy Trust. "Diagnosing an ectopic pregnancy." Accessed 27 April 2018.

  10. NHS Choices. "Ectopic pregnancy - Diagnosis." Accessed 27 April 2018.

  11. Medscape eMedicine. "Ectopic Pregnancy." 28 September 2017. Accessed 27 April 2018.

  12. RCOG. "Ectopic pregnancy." Accessed 26 April 2018.

  13. Medscape eMedicine. "Ectopic Pregnancy Treatment & Management." 28 September 2017. Accessed 15 May 2018.

  14. Manchester University. "Expectant management of ectopic pregnancy." Accessed 27 April 2018.

  15. The Miscarriage Association. "Ectopic pregnancy." Accessed 16 May 2018.

  16. NHS Choices. "Intrauterine device (IUD)." Accessed 27 April 2018.

  17. Oxford University Press. "A woman with three ectopic pregnancies after in-vitro fertilization and embryo transfer." Accessed 27 April 2018.