Ectopic pregnancy

Definition

An ectopic pregnancy is a pregnancy that occurs outside the womb (uterus).  It is a life-threatening condition to the mother. The baby (fetus) cannot survive.

Alternative Names

Tubal pregnancy; Cervical pregnancy; Abdominal pregnancy

Causes, incidence, and risk factors

An ectopic pregnancy is often caused by a condition that blocks or slows the movement of a fertilized egg through the fallopian tube to the uterus. Such causes include:

• Birth defect in the fallopian tubes
• Complications of a ruptured appendix
• Endometriosis
• Having an ectopic pregnancy before
• Scarring from past infections or surgery

The following also increase your risk for an ectopic pregnancy:

• Age over 35
• Getting pregnant while having an intrauterine device (IUD)
• Had surgery to untie tubes (tubal sterilization) to become pregnant
• Having had many sexual partners
• In vitro fertilization
• Having your tubes tied (tubal ligation) - more likely 2 or more years after the procedure

Sometimes the cause is unknown. Hormones may play a role.

Ectopic pregnancies occur in 1 in every 40 to 1 in every 100 pregnancies.

The most common site for an ectopic pregnancy is within one of the tubes through which the egg passes from the ovary to the uterus (fallopian tube). However, in rare cases, ectopic pregnancies can occur in the ovary, stomach area, or cervix.

Symptoms

• Abnormal vaginal bleeding
• Low back pain
• Mild cramping on one side of the pelvis
• No periods
• Pain in the lower belly or pelvic area

If the area around the abnormal pregnancy ruptures and bleeds, symptoms may get worse. They may include:

• Fainting or feel faint
• Intense pressure in the rectum
• Low blood pressure
• Pain in the shoulder area
• Severe, sharp, and sudden pain in the lower abdomen

Signs and tests

The health care provider will do a pelvic exam, which may show tenderness in the pelvic area.

A pregnancy test and vaginal ultrasound will be done.

HCG is a hormone normally produced during pregnancy. Checking blood levels of this hormone (quantitative HCG blood test) can diagnose pregnancy. A rise in quantitative HCG levels over 1 to 2 days may help tell a normal pregnancy from an ectopic pregnancy.

Treatment

Ectopic pregnancies is a life-threatening condition. The pregnancy cannot continue to birth (term). The developing cells must be removed to save the mother's life.

You will need emergency medical help if the area of the ectopic pregnancy breaks open (ruptures). Rupture can lead to shock, an emergency condition. Treatment for shock may include:

• Blood transfusion
• Fluids given through a vein
• Keeping warm
• Oxygen
• Raising the legs

If there is a rupture, surgery (laparotomy) is done to stop blood loss. This surgery is also done to:

• Confirm an ectopic pregnancy
• Remove the abnormal pregnancy
• Repair any tissue damage

In some cases, the doctor may have to remove the fallopian tube.

If the ectopic pregnancy has not ruptured, treatment may include:

• Mini-laparotomy and laparoscopy
• Medicine called methotrexate and close monitoring by your doctor

Support Groups

Expectations (prognosis)

One-third of women who have had one ectopic pregnancy are later able to have a baby. A repeated ectopic pregnancy may occur in one-third of women. Some women do not become pregnant again.

The likelihood of a successful pregnancy after an ectopic pregnancy depends on:

• The woman's age
• Whether she has already had children
• Why the first ectopic pregnancy occurred.

Complications

The most common complication is rupture with internal bleeding that leads to shock. Death from rupture is rare.

Calling your health care provider

Call your doctor or nurse if you have:

• Abnormal vaginal bleeding
• Lower abdominal or pelvic pain

An ectopic pregnancy can occur even if you use birth control.

Prevention

Most forms of ectopic pregnancy that occur outside the fallopian tubes are probably not preventable. However, a tubal pregnancy (the most common type of ectopic pregnancy) may be prevented in some cases by avoiding conditions that might scar the fallopian tubes.

The following may reduce your risk:

• Avoiding risk factors for pelvic inflammatory disease (PID) such as having many sexual partners, having sex without a condom, and getting sexually transmitted diseases (STDs)
• Early diagnosis and treatment of STDs
• Early diagnosis and treatment of salpingitis and PID
• Stopping smoking

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References

Houry DE, Salhi BA. Acute complications of pregnancy. In: Marx JA, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, Pa: Mosby Elsevier;2009:chap 176.

Lobo RA. Ectopic pregnancy: Etiology, pathology, diagnosis, management, fertility prognosis. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier;2007:chap 17.

Barnhart KT. Ectopic pregnancy. N Engl J Med. 2009;361:379-387.

ACOG Practice Bulletin Committee. ACOG Practice Bulletin No.94: Medical management of ectopic pregnancy. Obstet Gynecol. 2008;111:1479–1485.