Version August 2024
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ECTOPIC PREGNANCY OVERVIEW — Ectopic pregnancy occurs when a developing embryo implants at a site other than the inside wall of the uterus. A brief overview of early pregnancy may be helpful in understanding ectopic pregnancy.
Normal pregnancy — The female reproductive system includes the uterus, two ovaries, two fallopian tubes, and the vagina. The fallopian tubes are narrow tubes that link the ovaries and uterus (figure 1).
When an egg and sperm join, they rapidly begin to develop new cells. This group of cells, called the embryo, normally implants on the inner lining of the uterus, called the endometrium. Once implanted, the embryo continues to grow and also forms the placenta, which is the organ that provides the blood supply to the developing embryo.
Ectopic pregnancy — In an ectopic pregnancy, the developing embryo does not implant on the endometrial wall, but instead attaches to some other surface. For 98 percent of pregnancies outside the uterus, that surface is within the fallopian tube. This is also called a tubal pregnancy.
Very rarely, the developing embryo will attach to another site, such as the cervix or an ovary. It can also implant at the site where the fallopian tube and uterus join; this is called an interstitial pregnancy. The embryo can also attach to the abdominal wall or to a previous cesarean scar.
Rarely, in twin pregnancies, one embryo implants in the uterus and the other implants at an ectopic location. This rare event is called a heterotopic pregnancy and, if it occurs, is more common in people undergoing fertility treatments.
Why is ectopic pregnancy dangerous? — An embryo that does not implant in the uterine wall is generally unable to develop normally. In addition, an ectopic pregnancy can rupture the organ on which it is implanted, typically the fallopian tube.
Rupture can result in severe internal bleeding, shock, and death. Fortunately, the ability to diagnose, monitor, and treat ectopic pregnancy reduces the risk of these life-threatening complications.
ECTOPIC PREGNANCY RISK FACTORS — A number of factors increase the risk of having an ectopic pregnancy.
Strong risk factors
●Abnormalities of the fallopian tubes – If the fallopian tubes are damaged or abnormal as a result of previous infection or surgery, tumors, or, rarely, due to malformations present since birth, there is an increased risk of ectopic pregnancy. Surgery to reconstruct the fallopian tube (to improve the chances of becoming pregnant) can increase the risk of ectopic pregnancy.
●Previous ectopic pregnancy – Those who have had one ectopic pregnancy have an increased risk of having another. The underlying tubal disorder that led to the first ectopic increases the risk for another ectopic pregnancy.
Moderate risk factors
●Previous genital infections – Pelvic infection with gonorrhea or chlamydia is a major cause of tubal problems and increases the risk of ectopic pregnancy. Having more than one sexual partner is associated with an increased risk of pelvic infection and therefore an increased risk of ectopic pregnancy. (See "Patient education: Gonorrhea (Beyond the Basics)" and "Patient education: Chlamydia (Beyond the Basics)".)
●Infertility – The incidence of ectopic pregnancy is higher in people with infertility, mostly due to an increased incidence of tubal abnormalities. Fertility drugs may also increase the risk in this population. (See "Patient education: Evaluation of infertility in couples (Beyond the Basics)".)
Other risk factors
●In vitro fertilization (IVF) – IVF, a fertility treatment in which an egg is fertilized outside the body and then placed in the uterus, is associated with a slightly increased risk of both ectopic and heterotopic pregnancy. (See "Patient education: In vitro fertilization (IVF) (Beyond the Basics)".)
●Tubal ligation – Tubal ligation (having the "tubes tied" or "clipped") is a surgical procedure in which the fallopian tubes are cut, clamped, or sealed shut as a form of permanent birth control. Rarely, tubal ligation fails and pregnancy can result. People who become pregnant after tubal ligation have a higher risk for ectopic pregnancy. (See "Patient education: Permanent birth control for females (Beyond the Basics)".)
●Intrauterine contraceptive devices (IUD) – People who use an IUD are less likely to have an ectopic pregnancy, because the IUD is effective at preventing all types of pregnancy. However, if a pregnancy occurs while using an IUD, there is a high risk that it will be an ectopic pregnancy. (See "Patient education: Long-acting methods of birth control (Beyond the Basics)".)
ECTOPIC PREGNANCY SYMPTOMS — Symptoms of ectopic pregnancy, when they occur, typically appear early in pregnancy, sometimes before the person realizes they are pregnant. The most common symptoms include:
●Abdominal pain
●A missed menstrual period
●Vaginal bleeding, which may be minimal
●Symptoms of pregnancy (such as breast tenderness, frequent urination, or nausea)
However, some people have no symptoms until the fallopian tube ruptures. Following rupture of the tube, symptoms can include severe pain and vaginal bleeding. Lightheadedness or dizziness may occur first, followed by a drop in blood pressure, fainting, and shock.
Sometimes, the embryo is expelled by the fallopian tube before rupture occurs. This is called a "tubal abortion." Those who have tubal abortion can develop either severe bleeding, requiring surgery, or minimal bleeding that does not require treatment.
Ectopic pregnancies rarely resolve on their own. As it can be life threatening, it should be treated as soon as possible after it is diagnosed.
ECTOPIC PREGNANCY DIAGNOSIS — Tests used to diagnose an ectopic pregnancy include a transvaginal ultrasound and a blood test that measures the pregnancy hormone, human chorionic gonadotropin (hCG).
●Ultrasound uses sound waves to visualize structures within the body. In a transvaginal ultrasound, the ultrasound transducer is inserted into the vagina, allowing clearer visualization of the uterus and other pelvic organs. It can generally detect intrauterine pregnancies that are 5 to 6 weeks along.
Ultrasound is most useful for identifying pregnancy inside the uterus. A negative pelvic ultrasound (that is, not seeing anything) does not mean that there is no ectopic pregnancy, since approximately 15 to 26 percent of people with an ectopic pregnancy will have a negative ultrasound. On the other hand, it does not eliminate the possibility of a viable pregnancy inside the uterus either.
●hCG is a substance secreted by the developing embryo/placenta. The hCG blood level is measured to confirm a pregnancy and can be used to monitor the progress of the pregnancy.
How do I know if I have an ectopic pregnancy? — Ectopic pregnancy is diagnosed if the ultrasound detects fetal cardiac activity or an embryo that is outside of the uterus. Since ectopic pregnancies may not be detected by ultrasound, the hCG level is also measured. If the hCG is above a certain level (usually 3500 mIU/mL), but no pregnancy is seen with ultrasound, an ectopic pregnancy is usually suspected.
If the hCG is below 3500 mIU/mL and no pregnancy is seen with ultrasound, this may indicate either an ectopic pregnancy or an early intrauterine pregnancy. When this happens, the ultrasound and hCG are repeated every 2 days until an ectopic pregnancy can be either confirmed or ruled out.
People with moderate or strong risk factors for ectopic pregnancy, and those who conceived after in vitro fertilization, are often monitored with ultrasound and blood testing after their first missed period to detect and treat a potential ectopic pregnancy.
ECTOPIC PREGNANCY TREATMENT — Once an ectopic pregnancy is diagnosed, it must be treated to stop its growth; observation or "watch and wait" treatment is rarely recommended, because the life of the pregnant person is at risk if treatment is delayed. Treatment is started as soon as a diagnosis of ectopic pregnancy is confirmed and includes either medication or surgery.
Medical management — Most people with ectopic pregnancies can be treated with a medication called methotrexate, which stops the growth of the embryo. It is given in an intramuscular injection. After the injection, the pregnant person may experience abdominal pain or cramps, which can usually be controlled with acetaminophen (sample brand name: Tylenol). Nonsteroidal anti-inflammatory drugs, or "NSAIDS" (eg, ibuprofen [sample brand names: Advil, Motrin] or naproxen [sample brand names: Aleve, Naprosyn]), should be avoided due to the risk of an interaction between NSAIDs and methotrexate.
Human chorionic gonadotropin (hCG) levels are monitored after treatment until the level has fallen to undetectable. Some people may need additional methotrexate injections. Methotrexate is most successful in people with lower hCG levels and an embryo that is small in size. When used in appropriate situations, treatment with methotrexate is successful up to 99 percent of the time. If treatment with methotrexate is unsuccessful, tubal rupture can occur. This complication can be avoided with close monitoring and surgical management, if needed.
Surgical management — Surgery is sometimes recommended as treatment for ectopic pregnancy. Indications include:
●Ruptured ectopic pregnancy, surgery often needs to be done immediately, especially if the person's blood pressure has fallen and they are unstable.
●Those who are unable or unwilling to return for monitoring after methotrexate therapy.
●Those who would normally be a candidate for medical treatment, but who could not reach a hospital (due to lack of transportation or distance to an appropriate health care facility) in the event of tubal rupture during medical therapy.
How is surgery performed? — Surgery may be performed using a laparoscopic approach or through an abdominal incision. In laparoscopy, instruments are inserted into the abdomen through a few small incisions. These instruments are used to see and remove the ectopic pregnancy and control bleeding. Compared with abdominal surgery, laparoscopic surgery causes less pain and allows for a faster recovery.
In an abdominal procedure, a surgeon opens the abdomen using a single larger incision to directly see and remove the ectopic pregnancy.
Will my fallopian tube be removed? — During surgery, it is sometimes possible to remove the ectopic pregnancy and repair the tube (called salpingostomy).
In other cases, it is necessary to remove the fallopian tube (called salpingectomy). This may be required if there is uncontrolled bleeding, recurrent ectopic pregnancy in the same tube, a severely damaged tube, or a large tubal pregnancy. It may also be performed in people who have completed childbearing. If the remaining opposite tube is normal, the chance of a subsequent healthy pregnancy is good.
In a small number of people treated surgically, embryonic tissue may still be present after surgery and cause the hCG level to remain elevated. A dose of methotrexate may be given if this occurs.
WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Ectopic pregnancy (The Basics)
Patient education: Pregnancy in Rh-negative people (The Basics)
Patient education: Salpingectomy (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Gonorrhea (Beyond the Basics)
Patient education: Chlamydia (Beyond the Basics)
Patient education: Evaluation of infertility in couples (Beyond the Basics)
Patient education: In vitro fertilization (IVF) (Beyond the Basics)
Patient education: Permanent birth control for females (Beyond the Basics)
Patient education: Long-acting methods of birth control (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Ectopic pregnancy: Clinical manifestations and diagnosis
Ectopic pregnancy: Expectant management of tubal pregnancy
Ectopic pregnancy: Epidemiology, risk factors, and anatomic sites
Ectopic pregnancy: Methotrexate therapy
Tubal ectopic pregnancy: Surgical treatment
Cervical pregnancy: Diagnosis and management
Abdominal pregnancy
The following organizations also provide reliable health information.
●National Library of Medicine
(https://medlineplus.gov/healthtopics.html)
●The Nemours Foundation
●Planned Parenthood Federation of America
●Mayo Clinic
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