Ectopic Pregnancy

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In ectopic pregnancy, implantation occurs in a site other than the endometrial

lining of the uterine cavityin the fallopian tube, uterine interstitium, cervix,
ovary, or abdominal or pelvic cavity. Ectopic pregnancies cannot be carried to
term and eventually rupture or involute. Early symptoms and signs include pelvic
pain, vaginal bleeding, and cervical motion tenderness. Syncope or hemorrhagic
shock can occur with rupture. Diagnosis is by -human chorionic gonadotropin
measurement and ultrasonography. Treatment is with laparoscopic or open
surgical resection or with IM methotrexate.
Incidence of ectopic pregnancy (overall, 2/100 diagnosed pregnancies) increases
as maternal age increases. Other risk factors include prior pelvic inflammatory
disease (particularly due to Chlamydia trachomatis), prior tubal surgery, prior
ectopic pregnancy (10 to 25% recurrence risk), cigarette smoking, exposure to
diethylstilbestrol, and prior induced abortion. Pregnancy is less likely to occur

when an intrauterine device (IUD) is in place; however, about 5% of such

pregnancies are ectopic. Simultaneous ectopic and intrauterine pregnancies occur
in only 1/10,000 to 30,000 pregnancies but may be more common among women
who have undergone ovulation induction or assisted reproductive techniques
such as in vitro fertilization and gamete intrafallopian tube transfer (GIFT); in
such cases, the reported ectopic pregnancy rate is 1%.
The most common site of ectopic implantation is a fallopian tube, followed by
the uterine interstitium (cornua). Cervical, cesarean section scar, ovarian,
abdominal, and pelvic pregnancies are rare. Rupture of an ectopic pregnancy
results in bleeding that can be gradual, or rapid enough to produce hemorrhagic
shock. Intraperitoneal blood eventually causes peritonitis.
Symptoms and Signs
Symptoms vary. Most patients have pelvic pain, sometimes crampy, vaginal
bleeding, or both. Menses may or may not be delayed or missed. Rupture may be
heralded by sudden, severe pain, followed by syncope or by symptoms and signs
of hemorrhagic shock or peritonitis. Rapid hemorrhage is more likely in cornual
ectopic pregnancies.
Cervical motion tenderness, unilateral or bilateral adnexal tenderness, or an
adnexal mass may be present. The uterus may be slightly enlarged (but less than
anticipated based on date of last menstrual period).
Diagnosis
Ectopic pregnancy is suspected in any female of reproductive age with pelvic
pain, vaginal bleeding or unexplained syncope or hemorrhagic shock, regardless
of sexual, contraceptive, and menstrual history. Findings of physical (including
pelvic) examination are neither sensitive nor specific. Diagnosis requires
measurement of the urine subunit of human chorionic gonadotropin (-hCG),
which is about 99% sensitive for pregnancy (ectopic and otherwise). If urine hCG is negative and if clinical findings do not strongly suggest ectopic
pregnancy, further evaluation is unnecessary unless symptoms recur or worsen. If
urine -hCG is positive or if clinical findings strongly suggest ectopic pregnancy,
quantitative serum -hCG and pelvic ultrasonography are indicated. If
quantitative serum -hCG is < 5 mIU/mL, ectopic pregnancy is excluded. If
ultrasonography detects an intrauterine gestational sac, ectopic pregnancy is
extremely unlikely except in women who have used assisted reproductive
technologies; however, cornual and intraabdominal pregnancies may appear
similar to intrauterine pregnancies. Ultrasonographic findings suggesting ectopic
pregnancy (noted in 16 to 32%) include complex (mixed solid and cystic)
masses, particularly in the adnexa; free fluid in the cul-de-sac; and absence of a
uterine gestational sac on transvaginal views, particularly if the -hCG level is >

1000 to 2000 mIU/mL. Absence of an intrauterine sac with a -hCG level > 2000
mIU/mL strongly suggests an ectopic pregnancy. Use of transvaginal and color
Doppler ultrasonography may improve detection rates.
If ectopic pregnancy appears unlikely and patients are stable, serum levels of hCG can be measured serially on an outpatient basis. Normally, the level doubles
every 1.4 to 2.1 days up to 41 days; in ectopic pregnancy (and in abortions),
levels may be lower than expected by dates and usually do not double as rapidly.
If initial evaluation or serial -hCG levels suggest ectopic pregnancy, diagnostic
laparoscopy may be necessary for confirmation. Progesterone levels may be
measured when the diagnosis is unclear; if they are 5 ng/mL, a viable
intrauterine pregnancy is very unlikely.
Prognosis and Treatment
Untreated ectopic pregnancy is fatal to the fetus, but if treatment occurs before
rupture, maternal death is very rare. In the US, ectopic pregnancy probably
accounts for 9% of pregnancy-related maternal deaths.
Hemorrhagic shock is treated (see Shock and Fluid Resuscitation: Prognosis and
Treatment); such hemodynamically unstable patients require immediate
laparotomy. For stable patients, treatment is usually laparoscopic surgery;
sometimes laparotomy is required. If possible, salpingotomy, usually using
cautery or laser, is done to conserve the tube, and the products of conception are
evacuated. Salpingectomy is indicated when ectopic pregnancies recur or are > 5
cm, when the tubes are severely damaged, or when no future childbearing is
planned. Only the irreversibly damaged portion of the tube is removed,
maximizing the chance that tubal repair can restore fertility. The tube may or
may not be repaired simultaneously. After a cornual pregnancy, the tube and
ovary involved can usually be salvaged, but occasionally repair is impossible and
hysterectomy is necessary.
If unruptured tubal pregnancies are 3.0 cm in diameter, no fetal heart activity is
detected, and -hCG level is < 5,000 mIU/mL ideally but < 15,000 mIU/mL
certainly, women can be given a single dose of methotrexate Some Trade Names
RHEUMATREX
Click for Drug Monograph
50 mg/m2 IM. -hCG measurement and ultrasonography are repeated on about
days 4 and 7. If the -hCG level does not decrease 15%, a 2nd dose of
methotrexate Some Trade Names
RHEUMATREX
Click for Drug Monograph
or surgery is needed. About 10 to 30% of women treated with methotrexate
Some Trade Names
RHEUMATREX

Click for Drug Monograph

eventually require a 2nd dose. Success rates with methotrexate Some Trade
Names
RHEUMATREX
Click for Drug Monograph
are about 87%; 7% of women have serious complications (eg, rupture). Surgery
is indicated when methotrexate Some Trade Names
RHEUMATREX
Click for Drug Monograph
is inappropriate (eg, -hCG level > 15,000 mIU/mL) or ineffective.
Last full review/revision November 2005
Content last modified November 2005

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