Ectopic Pregnancy (Symptoms, Signs, Treatment)

  • Medical Author:
    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

  • Medical Editor: Charles Patrick Davis, MD, PhD
    Charles Patrick Davis, MD, PhD

    Charles Patrick Davis, MD, PhD

    Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

An ectopic pregnancy also is known as a tubal pregnancy as it often occurs in the Fallopian tubes.

Ectopic pregnancy facts

  • An ectopic pregnancy is a pregnancy located outside the inner lining of the uterus.
  • The Fallopian tubes are the most common locations for an ectopic pregnancy.
  • The characteristic three symptoms of ectopic pregnancy are
  • However, only about 50% of women have all three of these symptoms.
  • Risk factors for ectopic pregnancy include previous ectopic pregnancies and conditions (surgery, infection) that disrupt the normal anatomy of the Fallopian tubes.
  • The major health risk of an ectopic pregnancy is rupture, leading to internal bleeding.
  • Ectopic pregnancy occurs in 1%-2% of all pregnancies.
  • Diagnosis of ectopic pregnancy is usually established by blood hormone tests and pelvic ultrasound.
  • Treatment options for ectopic pregnancy include both surgery and medication.

Quick GuideConception: The Amazing Journey from Egg to Embryo

Conception: The Amazing Journey from Egg to Embryo

Bleeding During the First Trimester of Pregnancy

Causes of bleeding during the first trimester of pregnancy

Examples of causes of bleeding during the first trimester of pregnancy are

  • ectopic pregnancy,
  • cervical polyps, or
  • pelvic or urinary tract infection (UTI).
All ectopic pregnancies can be dangerous, requiring prompt medical intervention.

What is the definition of an ectopic pregnancy?

An ectopic pregnancy is an early pregnancy that occurs outside of the normal location (uterine lining) for a developing pregnancy. Most ectopic pregnancies occur in the Fallopian tubes. An ectopic pregnancy cannot progress normally and typically results in the death of the embryo or fetus.

What is an ectopic pregnancy?

An ectopic pregnancy (EP) is a condition in which a fertilized egg settles and grows in any location other than the inner lining of the uterus. The vast majority of ectopic pregnancies are so-called tubal pregnancies and occur in the Fallopian tube. However, they can occur in other locations, such as the ovary, cervix, and abdominal cavity. An ectopic pregnancy occurs in about one in 1%-2% of all pregnancies. A molar pregnancy differs from an ectopic pregnancy in that it is usually a mass of tissue derived from an egg with incomplete genetic information that grows in the uterus in a grape-like mass that can cause symptoms to those of pregnancy.

The major health risk of ectopic pregnancy is rupture leading to internal bleeding. Before the 19th century, the mortality rate (death rate) from ectopic pregnancies exceeded 50%. By the end of the 19th century, the mortality rate dropped to five percent because of surgical intervention. Statistics suggest that with current advances in early detection, the mortality rate has improved to less than five in 10,000. The survival rate from ectopic pregnancies is improving even though the incidence of ectopic pregnancies is also increasing. The major reason for a poor outcome is failure to seek early medical attention. Ectopic pregnancy remains the leading cause of pregnancy-related death in the first trimester of pregnancy.

In rare cases, an ectopic pregnancy may occur at the same time as an intrauterine pregnancy. This is referred to as heterotopic pregnancy. The incidence of heterotopic pregnancy has risen in recent years due to the increasing use of IVF (in vitro fertilization) and other assisted reproductive technologies (ARTs).

What does an ectopic pregnancy look like?

For additional diagrams and photos, please see the last reference listed below.

Picture of an ectopic or tubal pregnancy
Picture of an ectopic or tubal pregnancy
Symptoms of ectopic pregnancies may mimic the early signs of a normal pregnancy.

Three classic signs and symptoms of an ectopic pregnancy

The three classic signs and symptoms of ectopic pregnancy include

However, about 50% of females with an ectopic pregnancy will not have all three signs.

What are other signs and symptoms of an ectopic pregnancy?

The woman may not be aware that she is pregnant. These characteristic symptoms occur in ruptured ectopic pregnancies (those accompanied by severe internal bleeding) and non-ruptured ectopic pregnancies. However, while these symptoms are typical for an ectopic pregnancy, they do not mean an ectopic pregnancy is necessarily present and could represent other conditions. In fact, these symptoms also occur with a threatened abortion (miscarriage) in nonectopic pregnancies.

The signs and symptoms of an ectopic pregnancy typically occur six to eight weeks after the last normal menstrual period, but they may occur later if the ectopic pregnancy is not located in the Fallopian tube. Other symptoms of pregnancy (for example, nausea and breast discomfort, etc.) may also be present in ectopic pregnancy. Weakness, dizziness, and a sense of passing out upon standing can (also termed near-syncope) be signs of serious internal bleeding and low blood pressure from a ruptured ectopic pregnancy and require immediate medical attention. Unfortunately, some women with a bleeding ectopic pregnancy do not recognize they have symptoms of ectopic pregnancy. Their diagnosis is delayed until the woman shows signs of shock (for example, low blood pressure, weak and rapid pulse, pale skin and confusion) and often is brought to an emergency department. This situation is a medical emergency.

The greatest risk factor for an ectopic pregnancy is a history of other ectopic pregnancies.

What are risk factors for ectopic pregnancy?

  1. Age: Ectopic pregnancy can occur in any woman, of any age, who is ovulating and is sexually active with a male partner. The highest likelihood ectopic pregnancy occurs in women aged 35-44 years.
  2. History: The greatest risk factor for an ectopic pregnancy is a prior history of an ectopic pregnancy.
  3. Fallopian tube abnormalities: Any disruption of the normal architecture of the Fallopian tubes can be a risk factor for a tubal pregnancy or ectopic pregnancy in other locations.
  4. Previous gynecological surgeries: Previous surgery on the Fallopian tubes such as tubal sterilization or reconstructive, procedures can lead to scarring and disruption of the normal anatomy of the tubes and increases the risk of an ectopic pregnancy.
  5. Infections: Infection in the pelvis (pelvic inflammatory disease) is another risk factor for ectopic pregnancy. Pelvic infections are usually caused by sexually-transmitted organism, such as Chlamydia or N. gonorrhoeae, the bacteria that cause gonorrhea. However, non-sexually transmitted bacteria can also cause pelvic infection and increase the risk of an ectopic pregnancy. Infection causes an ectopic pregnancy by damaging or obstructing the Fallopian tubes. Normally, the inner lining of the Fallopian tubes is coated with small hair-like projections called cilia. These cilia are important to transport the egg smoothly from the ovary through the Fallopian tube and into the uterus. If these cilia are damaged by infection, egg transport becomes disrupted. The fertilized egg can settle in the Fallopian tube without reaching the uterus, thus becoming an ectopic pregnancy. Likewise, infection-related scarring and partial blockage of the Fallopian tubes can also prevent the egg from reaching the uterus.
  6. Multiple sex partners: Because having multiple sexual partners increases a woman's risk of pelvic infections, multiple sexual partners also are associated with an increased risk of ectopic pregnancy.
  7. Gynecological conditions: Like pelvic infections, conditions such as endometriosis, fibroid tumors, or pelvic scar tissue (pelvic adhesions), can narrow the Fallopian tubes and disrupt egg transportation, thereby increasing the chances of an ectopic pregnancy.
  8. IUD use: Approximately half of pregnancies in women using intrauterine devices (IUDs) will be located outside of the uterus. However, the total number of women becoming pregnant while using IUDs is extremely low. Therefore, the overall number of ectopic pregnancies related to IUDs is very low.
  9. Cigarette smoking: Cigarette smoking around the time of conception has also been associated with an increased risk of ectopic pregnancy. This risk was observed to be dose-dependent, which means that the risk is dependent upon the individual woman's habits and increases with the number of cigarettes smoked.
  10. Infertility: A history of infertility for two or more years also is associated with an increased risk of ectopic pregnancy.
    Other causes: Infection, congenital abnormalities, or tumors of the Fallopian tubes can increase a woman's risk of having an ectopic pregnancy.
Diagnosing ectopic pregnancy includes a standard pregnancy test and physical exam.

Is there a test to diagnose ectopic pregnancy?

The first step in the diagnosis is an interview and examination by the doctor. The usual second step is to obtain a qualitative (positive or negative for pregnancy) or quantitative (measures hormone levels) pregnancy test. Occasionally, the doctor may feel a tender mass during the pelvic examination. If an ectopic pregnancy is suspected, the combination of blood hormone pregnancy tests and pelvic ultrasound can usually help to establish the diagnosis. Transvaginal ultrasound is the most useful test to visualize an ectopic pregnancy. In this test, an ultrasound probe is inserted into the vagina, and pelvic images are visible on a monitor. Transvaginal ultrasound can reveal the gestational sac in either a normal (intrauterine) pregnancy or an ectopic pregnancy, but often the findings are not conclusive. Rather than a gestational sac containing a visible embryo, the examination may simply reveal a mass in the area of the Fallopian tubes or elsewhere that is suggestive of, but not conclusive for, an ectopic pregnancy. The ultrasound can also demonstrate the absence of pregnancy within the uterus.

Pregnancy tests are designed to detect specific hormones; the beta subunit of human chorionic gonadotrophin (beta HCG) blood levels are also used in the diagnosis of ectopic pregnancy. Beta HCG levels normally rise during pregnancy. An abnormal pattern in the rise of this hormone can be a clue to the presence of an ectopic pregnancy. In rare cases, laparoscopy may be needed to confirm a diagnosis of ectopic pregnancy. During laparoscopy, viewing instruments are inserted through small incisions in the abdominal wall to visualize the structures in the abdomen and pelvis, thereby revealing the site of the ectopic pregnancy.

Surgical intervention is often required in cases of ectopic pregnancy when complications arise.

Is an ectopic pregnancy dangerous?

Some women spontaneously absorb the fetus from the ectopic pregnancy, and have no apparent side effects. In these instances, the woman can be observed without treatment. However, the true incidence of spontaneous resolution of ectopic pregnancies is unknown. It is not possible to predict which women will spontaneously resolve their ectopic pregnancies.

The most feared complication of an ectopic pregnancy is rupture, leading to internal bleeding, pelvic and abdominal pain, shock, and even death. Therefore, bleeding in an ectopic pregnancy may require immediate surgical attention. Bleeding results from the rupture of the Fallopian tube or from blood leaking from the end of the tube as the growing placenta erodes into the veins and arteries located inside the tubal wall. Blood coming from the tube can be very irritating to other tissues and organs in the pelvis and abdomen, and result in significant pain. The pelvic blood can lead to scar tissue formation that can result in problems with becoming pregnant in the future. The scar tissue can also increase the risk of future ectopic pregnancies.

Which specialties of doctors treat ectopic pregnancy?

Obstetrician-gynecologists (OB-GYNs) are the specialists who typically treat ectopic pregnancies. However, emergency medicine specialists and surgeons treat ruptured ectopic pregnancies. If you think you may have a ruptured ectopic pregnancy go to your nearest emergency room right away.

Early diagnosis and treatment has significantly decreased the mortality rate for ectopic pregnancy.

What treatment options are available for ectopic pregnancy?

Treatment options for ectopic pregnancy include observation, laparoscopy, laparotomy, and medication. Selection of these options is individualized. Some ectopic pregnancies will resolve on their own without the need for any intervention, while others will need urgent surgery due to life-threatening bleeding. However, because of the risk of rupture and potential dire consequences, most women with a diagnosed ectopic pregnancy are treated with medications or surgery.

For those who require intervention, the most common treatment is surgery. Two surgical options are available; laparotomy and laparoscopy. Laparotomy is an open procedure whereby a transverse (bikini line) incision is made across the lower abdomen. Laparoscopy involves inserting viewing instruments into the pelvis through tiny incisions in the skin. For many surgeons and patients, laparoscopy is preferred over laparotomy because of the tiny incisions used and the speedy recovery afterwards. Under optimal conditions, a small incision can be made in the Fallopian tube and the ectopic pregnancy removed, leaving the Fallopian tube intact. However, certain conditions make laparoscopy less effective or unavailable as an alternative. These include massive pelvic scar tissue and excessive blood in the abdomen or pelvis. In some instances, the location or extent of damage may require removal of a portion of the Fallopian tube, the entire tube, the ovary, and even the uterus.

What medications treat ectopic pregnancy?

Medical therapy can also be successful in treating certain groups of women who have an ectopic pregnancy. Medical treatment method involves the use of an anti-cancer drug called methotrexate (Rheumatrex, Trexall). This drug acts by killing the growing cells of the placenta, thereby inducing miscarriage of the ectopic pregnancy. Some patients may not respond to methotrexate, and will require surgical treatment. Methotrexate is gaining popularity because of its high success rate and low rate of side effects.

There are certain factors, including the size of the mass associated with the ectopic pregnancy and the blood beta HCG concentrations that help doctors decide which women are candidates for medical rather than surgical treatment. The optimal candidates for methotrexate treatment are women with a beta-subunit (HCG) concentration less than or equal to 5000 mIU/mL. In a properly selected patient population, methotrexate therapy is about 90% effective in treating ectopic pregnancy. There is no evidence that the use of this drug causes any adverse effects in subsequent pregnancies. Additional tests (HCG) are usually ordered to confirm that methotrexate treatment is effective.

Can an ectopic pregnancy go full term?

Although there have been a few reported cases of women giving birth by cesarean section to live infants that were located outside the uterus, this is extremely rare. The chance of carrying an ectopic pregnancy to full term is so remote, and the risk to the woman so great, that it can never be recommended. It would be ideal if an ectopic pregnancy in the Fallopian tube could be saved by surgery to relocate it into the uterus. This concept has yet to become accepted as a successful procedure.

Overall, there have been great advances in the early diagnosis and treatment of ectopic pregnancy, and the mortality from this condition has decreased dramatically.

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Reviewed on 9/27/2017
References
REFERENCE: Sepilian, V. MD. "Ectopic Pregnancy." Medscape. Jul 05, 2016.
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