Ectopic pregnancy (also known as tubal pregnancy) is any pregnancy implanted outside the uterus. It usually occurs in the fallopian tubes, but may occur in the ovary, cervix, abdomen or the site where the fallopian tube and the uterus join.

In a normal pregnancy, a woman’s egg passes through the fallopian tube and becomes fertilized. Now known as an embryo, it continues through the fallopian tube into the uterus. Once in the uterus, the embryo implants in the uterine wall and begins to develop. When the embryo implants in an organ outside of the uterus, such as the fallopian tube, it may cause the organ to rupture. This can lead to severe bleeding and possibly shock, a life-threatening condition caused by lack of blood flow. To prevent rupture of the internal organs, the embryo must be removed. Ectopic pregnancies are not allowed to continue to term due to the risk of death for the mother.

Ectopic pregnancies result from an embryo’s inability to make its way through the fallopian tube to the uterus. Conditions that may block or slow this passage include fallopian tube abnormalities, such as those caused by sexually transmitted diseases (STDs), endometriosis and pelvic inflammatory disease (PID).

Common signs and symptoms of ectopic pregnancy include pain in the pelvis or lower abdomen, as well as common signs of early pregnancy, such as amenorrhea (absence of menstruation) and breast tenderness. Signs and symptoms of a ruptured ectopic pregnancy are often more severe. They can include sharp and sudden pain in the lower abdominal area, fainting with low blood pressure and shock.

The condition is normally diagnosed in the first eight weeks of pregnancy, usually before the organ ruptures. Early diagnosis is achieved through the use of blood tests for hormone levels, ultrasound exams, laparoscopy or dilation and curettage. The condition is treated soon after it is diagnosed in order to prevent complications. Medical treatment for ectopic pregnancy can include the use of medication (e.g., methotrexate) or surgery to remove or destroy the pregnancy tissue. In many cases, the organs can be preserved. However, several types of surgical treatments can lead to infertility because of the possibility of post-operative adhesions. Following treatment, women are also at an increased risk for another ectopic pregnancy.

According to the American Society for Reproductive Medicine (ASRM), ectopic pregnancies account for 1 to 2 percent of all pregnancies in the United States. A woman is more likely to develop the condition as she ages. The risk is also higher for black and Hispanic women, and those who have had three or more pregnancies.

Although ectopic pregnancies occurring in the ovary, cervix and abdomen are not preventable, a woman may reduce her risk of tubal pregnancy by avoiding conditions that may lead to scarring in the fallopian tubes (e.g., having multiple sex partners, failing to use a condom), all of which carry an increased infection risk (e.g., chlamydia).

Ectopic pregnancy occurs when a fertilized egg implants in tissue outside the uterus. Left untreated, the condition can lead to serious complications, including hemorrhage and death.

Normally, after an egg is released by an ovary, it travels through the fallopian tube (narrow tubes that link the ovaries and the uterus) to the uterus (womb). If the egg joins with sperm in the fallopian tube, pregnancy begins. After being fertilized by the sperm, the fertilized egg, known as an embryo, travels further through the fallopian tube until it reaches the uterus three to four days later. Once in the uterus, the embryo implants in the lining of the uterus, where it begins to develop and grow.

In some women, however, the fallopian tube may be blocked or damaged. This can prevent the embryo from reaching the uterus. Instead, the fertilized egg may implant in the lining of the fallopian tube (tubal pregnancy). According to the American Society for Reproductive Medicine (ASRM), this is the most common form of ectopic pregnancy, accounting for approximately 95 percent of all cases. Although it occurs rarely, ectopic pregnancy may also develop in a woman’s ovary (ovarian pregnancy), cervix (cervical pregnancy), abdomen (abdominal pregnancy) or the narrow part where the fallopian tube and the uterus join (interstitial pregnancy).

In general, embryos that implant themselves outside the uterus are unable to survive. The uterus is the only organ that can safely and successfully support a pregnancy. As a result, the organs carrying ectopic pregnancies often rupture when the pregnancy outgrows the site of implantation. This serious condition can result in severe bleeding and lead to shock. For this reason, ectopic pregnancies can never continue to term. Currently, physicians are unable to remove the embryo and transplant it into the uterus to grow normally.

In some cases, the embryo is expelled by the fallopian tube at an early stage before rupture occurs. Known as a tubal abortion, this process may result in the pregnancy tissue deteriorating. In some women, the expelled tissue may reimplant in the ovary or abdomen. In other cases, the ectopic pregnancy may resolve on its own. However, the incidence of such “spontaneous resolution” is unknown.

In rare cases, an ectopic pregnancy can occur in a multiple pregnancy. In some twin pregnancies, one embryo may implant in the uterus while the other embryo implants in another location. Known as a heterotopic pregnancy, this condition occurs more often in women undergoing certain infertility treatments, such as in vitro fertilization or GIFT.

The incidence of ectopic pregnancy is rising. According to the National Institutes of Health (NIH), the rate increased four-fold between 1970 and 1992. The ASRM estimates that ectopic pregnancies account for 1 to 2 percent of all pregnancies.

Ectopic pregnancy is rarely fatal. According to the NIH, the maternal death rate from ectopic pregnancy in the United States is less than 0.1 percent but ectopic pregnancy can be a physically and emotionally traumatic experience. As a result, women may benefit from receiving psychological treatment from counseling and support groups.

Ectopic pregnancies are most often caused by conditions that block or slow the passage of a fertilized egg (embryo) through the fallopian tube to the uterus.

Although an ectopic pregnancy can occur in any woman who is fertile and sexually active, women with pre-existing fallopian tube damage are more likely to develop the condition. In fact, most cases of ectopic pregnancy are the result of scarring caused by tubal infection or surgery involving the fallopian tubes. In some cases, women are born with tubal abnormalities.

Common causes of fallopian tube abnormalities include:

• Sexually transmitted diseases (e.g., chlamydia, gonorrhea)
  
  
• Endometriosis
  
  
• Pelvic inflammatory disease (PID), especially salpingitis
  
  
• Previous pelvic surgery, especially procedures involving the fallopian tubes (e.g., tubal ligation, tubal reversal)
  
  
• Diethylstilbestrol (DES) exposure
  
  
• Appendicitis or ruptured appendix

Other risk factors for ectopic pregnancy include:

• Previous ectopic pregnancy. Women who have had one ectopic pregnancy are more likely to experience another one. This is due to the underlying cause of the initial ectopic pregnancy, combined with the scarring caused by the first episode’s treatment.
  
  
• Fertility drugs. Women who conceive as the result of fertility drugs have a slightly higher risk of developing an ectopic pregnancy.
  
  
• In vitro fertilization (IVF). Women who conceive as the result of IVF have a slightly higher risk of developing an ectopic pregnancy.
  
  
• Morning after pill. According to the National Institutes of Health (NIH), when the morning after pill fails to prevent a pregnancy, the pregnancy is 10 times more likely to be ectopic.
  
  
• Progestin-only birth control pills (“mini pill”). The NIH estimates that women who become pregnant while taking the mini pill are five times as likely to have an ectopic pregnancy.
  
  
• Intrauterine device (IUD). Women who become pregnant despite using an IUD as a form of contraception are more likely to develop an ectopic pregnancy. According to the NIH, the risk while using a copper-bearing IUD is 5 percent higher, whereas the risk while using a progestin-releasing IUD is 15 percent higher. This occurs because the mobility is affected by the contraception device and the transport is slower.
  
  
• Age. A woman’s risk of ectopic pregnancy increases with age.
  
  
• Numerous pregnancies. Women who have had three or more pregnancies are more likely to develop the condition.
  
  
• Race. Black and Hispanic women are more likely to have an ectopic pregnancy than white women. 
  
  
• Smoking. According to the Centers for Disease Control and Prevention (CDC), tobacco use may slightly increase a woman’s risk of ectopic pregnancy.

Symptoms of ectopic pregnancy occur early in the pregnancy, often before the woman realizes she is pregnant. In fact, the condition is often difficult to diagnose because its symptoms often mimic the normal symptoms of early pregnancy.

Common signs and symptoms of ectopic pregnancy include:

• Pain in the lower abdomen or pelvic region
  
  
• Mild cramping on one side of the pelvis
  
  
• Amenorrhea (absence of menstruation)
  
  
• Dysfunctional uterine bleeding 
  (typically menorrhagia)
  
  
• Breast pain or tenderness
  
  
• Nausea
  
  
• Frequent urination
  
  
• Lower back pain
  
  
• Tenderness in the uterine adnexal (fallopian tube or ovary region)
  
  
• Increased white blood cell count
  
  
• Decreased hematocrit (the proportion of the blood that consists of red blood cells)

Left untreated, ectopic pregnancy can lead to rupture and severe bleeding. As a result, signs and symptoms may become more severe, including:

• Severe, sharp and sudden pain in the lower abdominal area
• Feeling faint or fainting
• Low blood pressure
• Pain localized to the shoulder area
• Shock

Women who are pregnant, or think they may be pregnant, and experience any of these symptoms should contact their obstetrician-gynecologist (ObGyn). The earlier the condition is diagnosed, the earlier it can be treated and the lower the risk of serious complications.

In the past, ectopic pregnancies were often not diagnosed until symptoms (e.g., pelvic pain, dysfunctional uterine bleeding) developed several weeks into the pregnancy. Due to advances in medical technology, ectopic pregnancies are now discovered much earlier. In many cases, tests can discover an ectopic pregnancy in the first eight weeks of pregnancy, usually before the organ ruptures.

When common signs and symptoms of ectopic pregnancy are present, a woman may first be given a pregnancy test. When the test comes back positive, or the woman already knows she is pregnant, a number of additional tests may be ordered to diagnose ectopic pregnancy including:

• Human chorionic gonadotropin (hCG) measurement. In a normal pregnancy, levels of hCG (a hormone produced by the placenta) in the blood approximately double every 48 hours for the first 10 weeks of pregnancy. When this increase fails to occur at an appropriate rate it may indicate ectopic pregnancy or miscarriage.
  
  
• Progesterone measurements. During the early stages of pregnancy, the levels of the hormone progesterone in the blood rise. According to the National Institutes of Health (NIH) a serum progesterone level of 25 nanograms per milliliter (ng/mL) or more is associated with a normal pregnancy 98 percent of the time. Low levels of the hormone (less than 5 ng/mL) often indicate ectopic pregnancy or an impending miscarriage.
  
  
• Pelvic examination. During this exam, an obstetrician-gynecologist (ObGyn) examines the pelvic organs for any masses. The exam may also reveal a pregnancy in the uterus or tenderness in the uterine adnexal (fallopian tube or ovary region).
  
  
• Ultrasound examinations. During the early stages of pregnancy, ultrasound can be used to determine whether a pregnancy is located inside the uterus. Ultrasound scans can also reveal fluid or blood in the abdominal cavity, a possible sign of bleeding caused by an ectopic pregnancy. 

In some cases, results from an ultrasound, combined with hCG measurements and/or progesterone measurements, are all that is required for a diagnosis. In other cases, more invasive tests are needed, including:

• Laparoscopy. During this procedure, small incisions are made above the pubic area. Then, a thin lighted tube (laparoscope) is inserted into the abdominal cavity through the incisions. The instrument allows the physician to view internal organs and insert other instruments as needed.
  
  
• Dilation and curettage (D&C). During this procedure, the physician gently scrapes out the lining of the uterus. The tissue sample is then examined for the presence of pregnancy tissue. When pregnancy tissue is not detected in the sample, it may indicate an ectopic pregnancy.  

In addition, a less common test known as a culdocentesis may be used to determine if blood is present in the abdomen. During this procedure, a needle is inserted into the space at the top of the vagina, behind the uterus and in front of the rectum. The test is used to detect fluid or blood in the area that may have resulted from a ruptured ectopic pregnancy.

It may be difficult to detect an ectopic pregnancy that is less than six weeks along. When physicians are unable to diagnose or rule out the condition, they may require their patients to have their hCG levels tested every two days. When these levels do not rise as quickly as they should, the physicians will continue to carefully monitor the patients until the six week mark. At that time an ultrasound can be used to reveal more information.

Ectopic pregnancies cannot continue to term, so removal of the developing pregnancy cells is necessary to save the life of the mother. In some cases, drugs may be used to destroy the cells instead. Treatment usually begins soon after the condition is diagnosed.

Most unruptured ectopic pregnancies are treated with methotrexate. Originally designed to treat cancer, this drug destroys ectopic pregnancy tissue, allowing it to be reabsorbed by the body. It may be given as a single shot or as a multi-dose regimen of shots or pills for several days. The treatment has a high success rate and minimizes scarring of the pelvic organs. However, the procedure may be unsuccessful, particularly when the ectopic pregnancy is large. Ultrasounds and human chorionic gonadotropin (a hormone produced by the placenta) levels are monitored after treatment to determine the drug’s effectiveness. When the treatment fails, it may be repeated or surgery may be used to terminate the pregnancy.

Methotrexate is most effective when used in the first six weeks of pregnancy. There are general protocols and guidelines established that determine if the use of methotrexate will be effective. For pregnancies that are further along, or pregnancies that have ruptured, surgery is often performed. Common surgical treatment options for ectopic pregnancy include:

• Salpingostomy. During this procedure, the fallopian tube is opened and the pregnancy tissue is removed. The fallopian tube is preserved, and heals on its own. In some cases, however, some of the pregnancy tissue may remain in the fallopian tube and continue to grow. According to the American Society for Reproductive Medicine (ASRM), this occurs in 5 to 15 percent of cases. When the procedure is unsuccessful, the pregnancy may be treated with methotrexate therapy or surgical removal of the tube.
  
  
• Partial salpingectomy. This procedure may be performed when the section of fallopian tube containing the ectopic pregnancy cannot be saved. During this procedure, the section of fallopian tube containing the ectopic pregnancy is surgically removed. When only a small portion of the tube is removed, it may be possible to rejoin the tube later using microsurgery.
  
  
• Total salpingectomy. During this procedure, the fallopian tube is completely removed. It may be used when the fallopian tube is extremely damaged or the ectopic pregnancy is large and requires rapid removal. It also may be the choice of treatment when future fertility is not an issue.
  
  
• Salpingo-oophorectomy. During this procedure, the fallopian tube and ovary are removed. This procedure will result in infertility for the woman. 
  
  
• Hysterectomy. During this procedure, the uterus is surgically removed. This procedure may be used to treat certain rare types of ectopic pregnancy, such as cervical pregnancies. Future pregnancies are not possible following a hysterectomy.
   

Surgery for ectopic pregnancy is often performed using a laparoscopic approach or through an abdominal incision. A laparoscopy is a procedure in which small incisions are made above the pubic area. A thin lighted tube (laparoscope) is inserted into the abdominal cavity through the incisions. The instrument allows the physician to view internal organs and insert other instruments as needed to remove the ectopic pregnancy and control bleeding. During a laparotomy, the surgeon uses a larger incision to open the abdomen. This procedure allows the surgeon to directly explore the internal organs, remove the ectopic pregnancy and repair surrounding tissue damage.  

Although laparoscopy is less invasive and yields similar results to that of laparotomy, not all surgeries can be performed with the technique. For example, ruptured ectopic pregnancies that cause internal bleeding may require a laparotomy because it is faster. In addition, some types of surgical procedures are too risky to perform laparoscopically. The decision may also be based on the surgeon’s experience using the techniques. 

A woman’s ability to become pregnant following surgery depends on the type of surgery performed. According to the American Academy of Family Physicians, the odds of having a successful pregnancy in the future are 60 percent when the fallopian tube has been spared. A woman who had one fallopian tube removed can have more than a 40 percent chance of having a successful pregnancy with the other tube. Hysterectomies result in the inability to become pregnant.

Internal bleeding caused by ruptured ectopic pregnancy may lead to shock, a life-threatening condition that occurs when the body does not receive enough blood flow. Immediate treatment for shock may involve keeping the patient warm, elevating her legs and administering oxygen. Treatment with intravenous fluids (into a vein), and in some cases a blood transfusion, is also required as soon as possible. Laparotomy may be required to stop the immediate loss of blood.   

Following treatment, there is an increased risk of infertility and subsequent ectopic pregnancy. According to the National Institutes of Health (NIH), infertility occurs in 10 to 15 percent of women who have experienced an ectopic pregnancy and subsequent ectopic pregnancies occur in about 10 to 20 percent of cases. In addition, some women who achieve pregnancy after ectopic pregnancy experience a miscarriage during the first trimester. The NIH estimates that approximately 85 percent of women who have experienced an ectopic pregnancy are able to achieve a normal pregnancy in the future.

Since the risk of infertility and subsequent ectopic pregnancies is high, women who have experienced an ectopic pregnancy should discuss plans of pregnancy with their obstetrician-gynecologist (ObGyn) before becoming pregnant again. Patients may be encouraged to wait three to six months after treatment before attempting another pregnancy.

For women who have had multiple ectopic pregnancies, in vitro fertilization (IVF) may be recommended. During this procedure, a woman’s egg is combined with sperm outside the body. The resulting embryo is then implanted into the uterus. According to the ASRM, there is only about a 5 percent chance of a tubal pregnancy with IVF.

Ectopic pregnancies occurring in the ovary, cervix and abdomen are not preventable. Tubal pregnancies, however, may be prevented in some cases by avoiding conditions that may lead to scarring in the fallopian tubes. Methods to prevent these conditions include:

• Consistently and correctly using a condom during sexual intercourse
• Not having multiple sexual partners
• Obtaining early diagnosis and proper treatment of sexually transmitted diseases (STDs)
• Obtaining early diagnosis and proper treatment of pelvic inflammatory disease (PID)

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions about ectopic pregnancy:

1. Am I at risk for ectopic pregnancy?
   
   
2. What tests will be used to determine if I have an ectopic pregnancy?
   
   
3. How quickly does the condition need to be treated?
   
   
4. What signs will indicate that I have a medical emergency with ectopic pregnancy?
   
   
5. What are my treatment options?
   
   
6. If I need surgery what type of procedure will be performed?
   
   
7. What are the risks associated with these treatments?
   
   
8. Do I have a greater risk of developing another ectopic pregnancy?
   
   
9. What can be done to help prevent the condition in the future?
   
   
10. How long should I wait before trying to become pregnant again?
    
    
11. What tests can be done to determine if I have permanent problems with my fallopian tubes?
    
    
12. How can IVF reduce my chances of this condition in a future pregnancy?