Ectopic pregnancy

• Alternative Names

  Tubal pregnancy; Cervical pregnancy; Abdominal pregnancy

• Causes, incidence, and risk factors

  An ectopic pregnancy occurs when the baby starts to develop outside the womb (uterus). 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.

  An ectopic pregnancy is usually caused by a condition that blocks or slows the movement of a fertilized egg through the fallopian tube to the uterus. This may be caused by a physical blockage in the tube.

  Most cases are a result of scarring caused by:

  • Past ectopic pregnancy
  • Past infection in the fallopian tubes
  • Surgery of the fallopian tubes

  Up to 50% of women who have ectopic pregnancies have had swelling (inflammation) of the fallopian tubes (salpingitis) or pelvic inflammatory disease (PID).

  Some ectopic pregnancies can be due to:

  • Birth defects of the fallopian tubes
  • Complications of a ruptured appendix
  • Endometriosis
  • Scarring caused by previous pelvic surgery

  In a few cases, the cause is unknown.

  Sometimes, a woman will become pregnant after having her tubes tied (tubal sterilization). Ectopic pregnancies are more likely to occur 2 or more years after the procedure, rather than right after it. In the first year after sterilization, only about 6% of pregnancies will be ectopic, but most pregnancies that occur 2 - 3 years after tubal sterilization will be ectopic.

  Women who have had surgery to reverse tubal sterilization in order to become pregnant also have an increased risk of ectopic pregnancy.

  Taking hormones, especially estrogen and progesterone (such as those in birth control pills), can slow the normal movement of the fertilized egg through the tubes and lead to ectopic pregnancy.

  Women who have in vitro fertilization or who have an intrauterine device (IUD) using progesterone also have an increased risk of ectopic pregnancy.

  The "morning after pill" (emergency contraception) has been linked to some cases of ectopic pregnancy.

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

• Symptoms
  • Abnormal vaginal bleeding
  • Amenorrhea
  • Breast tenderness
  • Low back pain
  • Mild cramping on one side of the pelvis
  • Nausea
  • Pain in the lower abdomen or pelvic area

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

  • Feeling faint or actually fainting
  • Pain that is felt in the shoulder area
  • Severe, sharp, and sudden pain in the lower abdomen

  Internal bleeding due to a rupture may lead to shock. Shock is the first symptom of almost 20% of ectopic pregnancies.

• Signs and tests

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

  Tests that may be done include:

  • Culdocentesis
  • Hematocrit
  • Pregnancy test
  • Quantitative HCG blood test
  • Transvaginal ultrasound or pregnancy ultrasound
  • White blood count

  A rise in quantitative HCG levels may help tell a normal (intrauterine) pregnancy from an ectopic pregnancy. Women with high levels should have a vaginal ultrasound to identify a normal pregnancy.

  Other tests may be used to confirm the diagnosis, such as:

  • D and C
  • Laparoscopy
  • Laparotomy

  An ectopic pregnancy may affect the results of a serum progesterone test.

• Treatment

  Ectopic pregnancies 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.

  A minilaparotomy and laparoscopy are the most common surgical treatments for an ectopic pregnancy that has not ruptured. If the doctor does not think a rupture will occur, you may be given a medicine called methotrexate and monitored. You may have blood tests and liver function tests.

• Expectations (prognosis)

  Most women who have had one ectopic pregnancy are later able to have a normal pregnancy. A repeated ectopic pregnancy may occur in 10 - 20% of women. Some women do not become pregnant again.

  The rate of death due to an ectopic pregnancy in the United States has dropped in the last 30 years to less than 0.1%.

• Complications

  The most common complication is rupture with internal bleeding that leads to shock. Death from rupture is rare. Infertility occurs in 10 - 15% of women who have had an ectopic pregnancy.

• Calling your health care provider

  If you have symptoms of ectopic pregnancy (especially lower abdominal pain or abnormal vaginal bleeding), call your health care provider. You can have an ectopic pregnancy if you are able to get pregnant (fertile) and are sexually active, 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
• References

  Jian Z, Linan C. Ectopic gestation following emergency contraception with levonorgestrel. Eur J Contracept Reprod Health Care. 2003;8(4):225-228.

  Sheffer-Mimouni G, Pauzner D, Maslovitch S, Lessing JB, Gamzu R. Contraception. 2003;6(4):267-269.

  Nielsen CL, Miller L. Ectopic gestation following emergency contraceptive pill administration. Contraception. 2000;62(5):275-276.

  Furlong LA. Ectopic pregnancy risk when contraception fails. A review. J Reprod Med. 2002;47(11):881-885.

  Katz VL, Lentz GM, Lobo RA, Gershenson DM. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby;2007.

Review Date: 2/5/2008

Reviewed By: Peter Chen, MD, Department of Obstetrics & Gynecology, University of Pennsylvania Medical Center, Philadelphia, PA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.