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 (98%); however, they can occur in other locations, such as
the ovary, cervix, and abdominal cavity. An ectopic pregnancy occurs in about one in 50 pregnancies. A
molar differs from an ectopic 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 tointernal bleeding. Before the 19th century,
the mortality rate (the 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 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). For additional diagrams and photos, please see the last reference listed below.

What are the risk factors for ectopic pregnancy?

There are multiple factors that increase a women's likelihood of
having an ectopic pregnancy, but it is important to note that
ectopic pregnancies can occur in women without any of these risk
factors.
The greatest risk factor for an ectopic pregnancy is a prior history
of an ectopic pregnancy. The recurrence rate is 15% after the first
ectopic pregnancy, and 30% after the second.
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. 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. Likewise, infection, congenital abnormalities, or tumors of the
Fallopian tubes can increase a woman's risk of having an ectopic pregnancy.
Infection in the pelvis (pelvic inflammatory disease) is another risk factor for ectopic pregnancy. Pelvic
infections are usually caused by sexually-transmitted organisms, 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.
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.
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.
Approximately 50% 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.
 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.
What are signs and symptoms of an ectopic pregnancy?
The classic signs and symptoms of ectopic pregnancy include:
 abdominal pain, 
 the absence of menstrual periods (amenorrhea), and 
 vaginal bleeding or intermittent bleeding (spotting).
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 andlow blood pressure from a ruptured ectopic
pregnancy and require immediate medical attention. Unfortunately, as many as 15% to 20% of 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.
How is ectopic pregnancy diagnosed?
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 ultimately 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.
What is the health risk of an ectopic pregnancy?
Some women spontaneously absorb their ectopic pregnancy with no apparent ill effects, and 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.
 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.
Medical therapy can also be successful in treating certain groups of women who have an ectopic
pregnancy. About 35% of women with ectopic pregnancies are candidates for medical rather than surgical
treatment. 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.
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.
Ectopic Pregnancy At A Glance
 An ectopic pregnancy is a pregnancy located outside the inner lining of the uterus. 
 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 internal bleeding. 
 Diagnosis of ectopic pregnancy is usually established by blood hormone tests and pelvic
ultrasound. 
 Treatment options for ectopic pregnancy include both surgery and medication.