Ectopic Pregnancy

Topic Overview

What is an ectopic pregnancy?

In a normal pregnancy, a fertilized egg travels through a fallopian tube to the uterus. The egg attaches in the uterus and starts to grow. But in an ectopic pregnancy, the fertilized egg attaches (or implants) someplace other than the uterus, most often in the fallopian tube. (This is why it is sometimes called a tubal pregnancy.) In rare cases, the egg implants in an ovary, the cervix, or the belly.

See a picture of an ectopic pregnancy .

There is no way to save an ectopic pregnancy. It cannot turn into a normal pregnancy. If the egg keeps growing in the fallopian tube, it can damage or burst the tube and cause heavy bleeding that could be deadly. If you have an ectopic pregnancy, you will need quick treatment to end it before it causes dangerous problems.

What causes an ectopic pregnancy?

An ectopic pregnancy is often caused by damage to the fallopian tubes. A fertilized egg may have trouble passing through a damaged tube, causing the egg to implant and grow in the tube.

Things that make you more likely to have fallopian tube damage and an ectopic pregnancy include:

• Smoking. The more you smoke, the higher your risk of an ectopic pregnancy.
• Pelvic inflammatory disease (PID). This is often the result of an infection such as chlamydia or gonorrhea.
• Endometriosis, which can cause scar tissue in or around the fallopian tubes.
• Being exposed to the chemical DES before you were born.

Some medical treatments can increase your risk of ectopic pregnancy. These include:

• Surgery on the fallopian tubes or in the pelvic area.
• Fertility treatments such as in vitro fertilization.

What are the symptoms?

In the first few weeks, an ectopic pregnancy usually causes the same symptoms as a normal pregnancy, such as a missed menstrual period, fatigue, nausea, and sore breasts.

The key signs of an ectopic pregnancy are:

• Pelvic or belly pain. It may be sharp on one side at first and then spread through your belly. It may be worse when you move or strain.
• Vaginal bleeding.

If you think you are pregnant and you have these symptoms, see your doctor right away.

How is an ectopic pregnancy diagnosed?

A urine test can show if you are pregnant. To find out if you have an ectopic pregnancy, your doctor will likely do:

• A pelvic exam to check the size of your uterus and feel for growths or tenderness in your belly.
• A blood test that checks the level of the pregnancy hormone (hCG). This test is repeated 2 days later. During early pregnancy, the level of this hormone doubles every 2 days. Low levels suggest a problem, such as ectopic pregnancy.
• An ultrasound. This test can show pictures of what is inside your belly. With ultrasound, a doctor can usually see a pregnancy in the uterus 6 weeks after your last menstrual period.

How is it treated?

The most common treatments are medicine and surgery. In most cases, a doctor will treat an ectopic pregnancy right away to prevent harm to the woman.

Medicine can be used if the pregnancy is found early, before the tube is damaged. In most cases, one or more shots of a medicine called methotrexate will end the pregnancy. Taking the shot lets you avoid surgery, but it can cause side effects. You will need to see your doctor for follow-up blood tests to make sure the shot worked.

For a pregnancy that has gone beyond the first few weeks, surgery is safer and more likely to work than medicine. If possible, the surgery will be laparoscopy (say "lap-uh-ROSS-kuh-pee"). This type of surgery is done through one or more small cuts (incisions) in your belly. If you need emergency surgery, you may have a larger incision.

What can you expect after an ectopic pregnancy?

Losing a pregnancy is always hard, no matter how early it happened. Take time to grieve your loss, and get the support you need to make it through this time.

You could be at risk for postpartum depression after an ectopic pregnancy. If you have symptoms of depression that last for more than 2 weeks, be sure to tell your doctor so you can get the help you need.

It is common to worry about your fertility after an ectopic pregnancy. Having an ectopic pregnancy does not mean that you can't have a normal pregnancy in the future. But it does mean that:

• You may have trouble getting pregnant.
• You are more likely to have another ectopic pregnancy.

If you get pregnant again, be sure your doctor knows that you had an ectopic pregnancy before. Regular testing in the first weeks of pregnancy can find a problem early or let you know that the pregnancy is normal.

Frequently Asked Questions

Cause

Fallopian tube damage is a common cause of ectopic pregnancy. A fertilized egg can become caught in the damaged area of a tube and begin to grow there. Some ectopic pregnancies develop without any known cause. See a picture of locations where an ectopic pregnancy can develop .

Common causes of fallopian tube damage that may lead to an ectopic pregnancy include:

• Smoking. Women who smoke or who used to smoke have higher rates of ectopic pregnancy. The more you smoke, the higher your risk.¹ Smoking is thought to damage the fallopian tubes' ability to move the fertilized egg toward the uterus.
• Pelvic inflammatory disease (PID), such as from a chlamydia or gonorrhea infection. PID can create scar tissue in the fallopian tubes.
• Fallopian tube surgery, often used to reverse a tubal ligation or to repair a scarred or blocked tube.
• A previous ectopic pregnancy in a fallopian tube.

Although pregnancy is rare after a tubal ligation or with an intrauterine device (IUD), those pregnancies that do develop have an increased chance of being ectopic.² Ectopic risk is also higher for women who get pregnant while using progestin-only birth control pills or implants.³

Symptoms

An early ectopic pregnancy often feels like a normal pregnancy. A woman with an ectopic pregnancy may experience common signs of early pregnancy, such as:

• A missed menstrual period.
• Tender breasts.
• Fatigue.
• Nausea.
• Increased urination.

As an ectopic pregnancy progresses, however, other symptoms develop, including:

• Abdominal or pelvic pain, usually 6 to 8 weeks after a missed period.⁴ Pain may get worse with movement or straining. It may occur sharply on one side at first and then spread throughout the pelvic region.
• Vaginal bleeding that may be light or heavy.
• Pain with intercourse or during a pelvic exam.
• Dizziness, lightheadedness, or fainting (syncope) caused by internal bleeding.
• Signs of shock.
• Shoulder pain caused by bleeding into the abdomen under the diaphragm. The bleeding irritates the diaphragm and is experienced as shoulder pain.

Symptoms of miscarriage often are similar to symptoms experienced in early ectopic pregnancy. For more information, see the topic Miscarriage.

What Happens

Normally, at the beginning of a pregnancy, the fertilized egg travels from the fallopian tube to the uterus, where it implants and grows. In about 2% of diagnosed pregnancies, however, the fertilized egg attaches to an area outside of the uterus, which results in an ectopic pregnancy (also known as a tubal pregnancy or an extrauterine pregnancy).⁵

An ectopic pregnancy cannot support the life of a fetus for very long. However, an ectopic pregnancy can grow large enough to rupture the area it occupies, cause heavy bleeding, and endanger the mother. A woman with signs or symptoms of an ectopic pregnancy requires immediate medical care.

In most ectopic pregnancies, the fertilized egg has implanted in a fallopian tube.

On rare occasions:

• The egg attaches and grows in an ovary, the cervix, or the abdominal cavity (outside of the reproductive system ).
• One or more eggs grow in the uterus, and one or more grow in a fallopian tube, the cervix, or the abdominal cavity. This is called a heterotopic pregnancy.

Although extremely rare, there are reports of women developing abdominal ectopic pregnancies after surgical removal of the uterus (hysterectomy).⁶

See a picture of locations where an ectopic pregnancy can develop .

Complications of ectopic pregnancy

Ectopic pregnancy can damage the fallopian tube, which can make it difficult to become pregnant in the future.

Ectopic pregnancies are usually detected early enough to prevent life-threatening complications such as severe bleeding. A ruptured ectopic pregnancy requires emergency surgery to prevent heavy bleeding into the abdomen. The affected tube is partially or fully removed. For more information, see the Surgery section of this topic.

What Increases Your Risk

Factors that can increase your risk of having an ectopic pregnancy include:¹

• A previous ectopic pregnancy.
• Past or present cigarette smoking, which increases your risk of having an ectopic pregnancy. The more you smoke, the higher the risk. Experts suspect that smoking affects fallopian tube function.^{1, 3}
• A history of pelvic inflammatory disease (PID), often caused by chlamydia or gonorrhea.
• Endometriosis, which can cause scar tissue in or around the fallopian tubes.
• Exposure to the chemical DES (diethylstilbestrol) before you were born.

Use of a copper intrauterine device (IUD) for birth control lowers your overall risk for ectopic pregnancy. This is because you are very unlikely to conceive with an IUD-only 1 to 6 per 1,000 progestin IUD users become pregnant per year. (However, these rare pregnancies are more likely than usual to be ectopic.)⁷

Medical treatments and procedures that can increase your risk of having an ectopic pregnancy include:

• Previous fallopian tube surgery to treat infertility or to reverse a tubal ligation.
• A tubal ligation failure. On the rare occasion that pregnancy happens after a sterilization surgery, there is a higher-than-usual risk that the pregnancy is ectopic.
• A progestin-only birth control failure (pills or implants).³
• Treatment with assisted reproductive technology (ART), such as in vitro fertilization (IVF).³ This may result from the flushing of the fertilized egg into a damaged fallopian tube after it is transferred to the uterus.
• Infection after any kind of surgery done on the uterus or fallopian tubes. This can lead to scar tissue.⁸

Ectopic pregnancy has been linked to the use of medicine used to make the ovary release multiple eggs (superovulation). Experts do not yet know whether this is because many women using it already have fallopian tube damage or because of the medicine itself.¹

If you become pregnant and are at high risk for ectopic pregnancy, you will be closely monitored. Health professionals do not always agree about which risk factors are serious enough to watch closely. However, research suggests that risk is serious enough if you have had a tubal surgery or an ectopic pregnancy before, had DES exposure before birth, have known fallopian tube problems, or have a pregnancy with an intrauterine device (IUD) in place.¹

When To Call a Doctor

If you are pregnant, be alert to the symptoms that may indicate an ectopic pregnancy, especially if you are at risk.

If you have vaginal bleeding or severe pain in your abdomen (with or without positive pregnancy test results or during treatment for ectopic pregnancy):

• Call your health professional immediately.
• Rest as much as possible.
• Avoid strenuous activity until your symptoms have been evaluated by a health professional.

If you have minor abdominal pain that does not seem to be going away, call your health professional. For any abdominal pain or vaginal bleeding, see the following topics to evaluate your symptoms:

• Abdominal Pain, Age 12 and Older
• Abnormal Vaginal Bleeding

Watchful Waiting

Watchful waiting means taking a wait-and-see approach.

Because an ectopic pregnancy can become life-threatening, watchful waiting at home is not safe. Call your health professional immediately if you have symptoms of an ectopic pregnancy.

Who To See

The following health professionals can evaluate you for an ectopic pregnancy:

• Certified nurse-midwife
• Obstetrician/gynecologist
• Family medicine physician
• Nurse practitioner
• Physician assistant
• Emergency medicine specialist

A diagnosed ectopic pregnancy is treated by a gynecologist.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Most ectopic pregnancies can be detected using a pelvic exam, ultrasound, and blood tests. If you have symptoms of a possible ectopic pregnancy, you will have:

• A pelvic exam, which can detect tenderness in the uterus or fallopian tubes, less enlargement of the uterus than expected for a pregnancy, or a mass in the pelvic area.
• A pelvic ultrasound (transvaginal or abdominal), which uses sound waves to produce a picture of the organs and structures in the lower abdomen. A transvaginal ultrasound is the most dependable way to show where a pregnancy is. A pregnancy in the uterus is visible 6 weeks after the last menstrual period. An ectopic pregnancy is likely if there are no signs of an embryo or fetus in the uterus but hCG levels are elevated or rising.
• Two or more blood tests of pregnancy hormone (human chorionic gonadotropin, or hCG) levels, taken 48 hours apart. During the early weeks of a normal pregnancy, hCG levels double every 2 days. Low or slowly increasing levels of hCG in the blood suggest an early abnormal pregnancy, such as an ectopic pregnancy or a miscarriage. If hCG levels are abnormally low, further testing is done to find the cause.

Sometimes a surgical procedure using laparoscopy is used to look for an ectopic pregnancy. An ectopic pregnancy after 5 weeks can usually be diagnosed and treated with a laparoscope. But laparoscopy is not often used to diagnose a very early ectopic pregnancy, because ultrasound and blood pregnancy tests are very accurate.

Follow-up testing after treatment

During the week after treatment for an ectopic pregnancy, your hCG (human chorionic gonadotropin) blood levels are tested several times. Your health professional will look for a drop in hCG levels, which is a sign that the pregnancy is ending (hCG levels sometimes rise during the first few days of treatment, then drop). In some cases, hCG testing continues for weeks to months until hCG levels drop to a low level.

What to think about

If you become pregnant and are at high risk for an ectopic pregnancy, you will be closely monitored. Health professionals do not always agree about which risk factors are serious enough to watch closely. But research suggests that risk is serious enough if you have had a tubal surgery or an ectopic pregnancy before, had DES exposure before birth, have known fallopian tube problems, or have a pregnancy with an intrauterine device (IUD) in place.¹

A urine pregnancy test-including a home pregnancy test-can accurately diagnose a pregnancy but cannot detect whether it is an ectopic pregnancy. If a urine pregnancy test confirms pregnancy and an ectopic pregnancy is suspected, further blood testing or ultrasound is needed to diagnose an ectopic pregnancy.

Treatment Overview

In most cases, an ectopic pregnancy is treated right away to avoid rupture and severe blood loss. The decision about which treatment to use depends on how early the pregnancy is detected and your overall condition. For an early ectopic pregnancy that is not causing bleeding, you may have a choice between using medicine or surgery to end the pregnancy.

Medication. Using methotrexate to end an ectopic pregnancy spares you from an incision and general anesthesia. But it does cause side effects and can take several weeks of hormone blood-level testing to make sure that treatment has been successful. Methotrexate is most likely to work:

• When your pregnancy hormone levels (human chorionic gonadotropin, or hCG) are low (less than 5,000).
• During the first 6 weeks of pregnancy.
• When the embryo has no heart activity.

Surgery. If you have an ectopic pregnancy that is causing severe symptoms, bleeding, or high hCG levels, surgery is needed. This is because medicine is not likely to work and a rupture becomes more likely as time passes. Whenever possible, laparoscopic surgery that uses a small incision is done. For a ruptured ectopic pregnancy, emergency surgery is needed.

Expectant management. For an early ectopic pregnancy that appears to be naturally miscarrying (aborting) on its own, you may not need treatment. Your health professional will regularly test your blood to make sure that your pregnancy hormone (hCG, or human chorionic gonadotropin) levels are dropping. This is called expectant management.

Ectopic pregnancies can be resistant to treatment.

• If hCG levels do not drop or bleeding does not stop after taking methotrexate, your next step may be surgery.
• If you have surgery, you may take methotrexate afterward.

If your blood type is Rh-negative, Rh immunoglobulin is used to protect any future pregnancies against Rh sensitization. For more information, see the topic Rh Sensitization During Pregnancy.

What To Think About

Surgery versus medication

• Methotrexate is usually the first treatment choice for ending an early ectopic pregnancy. Regular follow-up blood tests are needed for days to weeks after the medicine is injected.
• There are different types of surgery for a tubal ectopic pregnancy-when possible, only a slit is made in the fallopian tube (salpingostomy), rather than removing a section of the tube (salpingectomy).
• On average, salpingostomy is equal to methotrexate (for an early ectopic pregnancy) in terms of being effective and preserving a woman's ability to become pregnant in the future.⁹
• Although surgery is a faster treatment, it can cause scar tissue that could cause future pregnancy problems. Tubal surgery may damage the fallopian tube, depending on where and how big the embryo is and the type of surgery needed.

Surgery may be your only treatment option if an ectopic pregnancy has gone past 6 weeks or if you have internal bleeding.

Prevention

If you smoke, quitting will lower your risk of ectopic pregnancy. Women who smoke or who used to smoke have higher rates of ectopic pregnancy. The more you now smoke, the higher your risk is.¹

Using safe sex practices, such as using a condom every time you have sex, lowers your risk of ectopic pregnancy. This is because safe sex helps protect you from sexually transmitted diseases (STDs) that can lead to pelvic inflammatory disease (PID). PID is a common cause of scar tissue in the fallopian tubes, which can cause ectopic pregnancy.

You cannot prevent ectopic pregnancy, but you can prevent life-threatening complications with early diagnosis and treatment. If you have one or more risk factors for ectopic pregnancy, you and your health professional can closely monitor your first weeks of a pregnancy.

Home Treatment

If you are at risk for having an ectopic pregnancy and you think you may be pregnant, use a home pregnancy test. If it is positive, be sure to have a confirmation test done by a health professional, especially if you are concerned about developing an ectopic pregnancy.

If you are receiving methotrexate treatment to end an ectopic pregnancy, you may experience side effects from the medicine. See these tips for managing methotrexate treatment for helpful suggestions on minimizing these side effects.

If you experience an ectopic pregnancy loss, no matter how early in a pregnancy, expect that you and your partner will need time to grieve. It is also possible to develop postpartum depression from the hormonal changes after a pregnancy loss. If you experience symptoms of depression that last for more than 2 weeks, it is important that you call your health professional or a psychologist, clinical social worker, or licensed mental health counselor.

Contacting a support group, reading about the experiences of other women, and talking to friends, a counselor, or a member of the clergy may help you and your family deal with a pregnancy loss. For more information, see the Other Places to Get Help section of this topic.

Concerns about future pregnancy

If you have had an ectopic pregnancy, you may worry about your chances of having a healthy or ectopic pregnancy in the future. Your risk factors and any fallopian tube damage you may have will impact your future risk and your ability to become pregnant. Your health professional can answer your questions based on your risk factors.

Medications

Medicine can only be used for early ectopic pregnancies that have not ruptured. Depending on where the ectopic growth is and what type of surgery would otherwise be used, medicine may be less likely than surgical treatment to cause fallopian tube damage.

Medicine is most likely to work when an early ectopic pregnancy is not causing bleeding and:

• Your pregnancy hormone (hCG, or human chorionic gonadotropin) level is low (less than 5,000).
• It has been 6 weeks or less since your last menstrual period.
• The embryo has no heart activity.

For an ectopic pregnancy that is more developed, surgery is a safer and more dependable treatment.

Medication Choices

Methotrexate is used to stop the growth of an early ectopic pregnancy. It can also be used after surgical ectopic treatment to ensure that all ectopic cell growth has stopped.

If your blood type is Rh-negative, Rh immunoglobulin is used to protect any future pregnancies against Rh sensitization. For more information, see the topic Rh Sensitization During Pregnancy.

What To Think About

Methotrexate treatment is usually the first choice for ending an early ectopic pregnancy. If the pregnancy is further along, surgery is safer and more likely to be effective than medicine.

Regular follow-up blood tests are needed for days to weeks after the medicine is injected.

Methotrexate can cause unpleasant side effects, such as nausea, indigestion, and diarrhea. For information about how to minimize side effects, see these tips for managing methotrexate treatment.

Sudden abdominal pain affects about 1 in 4 women who have the higher, more effective dose of methotrexate. This may be related to the medicine itself or to the movement of the pregnancy out of the fallopian tube.¹⁰

Methotrexate versus surgery

If your ectopic pregnancy is not too far advanced and has not ruptured, methotrexate may be a treatment option for you. Successful methotrexate treatment of an early ectopic pregnancy avoids the risks of surgery, may be less likely to damage the fallopian tube than surgery, and is more likely to preserve your fertility after treatment.

If you are not concerned with preserving fertility, surgery for an ectopic pregnancy is faster than methotrexate treatment and will likely cause less bleeding.

Surgery

At any stage of development, surgical removal of an ectopic growth and/or the fallopian tube section where it has implanted is the fastest treatment for ectopic pregnancy. Surgery may be your only treatment option if an ectopic pregnancy has gone past 6 weeks or if you have internal bleeding. Whenever possible, surgery is done through a small incision using laparoscopy. This type of surgery usually has a short recovery period.

Surgery Choices

An ectopic pregnancy can be removed from a fallopian tube by using salpingostomy or salpingectomy.

• Salpingostomy. The ectopic growth is removed through a small, lengthwise cut in the fallopian tube (linear salpingostomy). The cut is left to close by itself or is stitched closed. This surgery can be done when an embryo is smaller than 2 cm and is growing near the far end of the fallopian tube.⁸
• Salpingectomy. A fallopian tube segment is removed. The remaining healthy fallopian tube may be reconnected. Salpingectomy is needed when the fallopian tube is being stretched by the pregnancy and may rupture or when it has already ruptured or is very damaged.

Both salpingostomy and salpingectomy can be done either through a small incision using laparoscopy or through a larger open abdominal incision (laparotomy). Laparoscopic surgery has few risks and heals more quickly than laparotomy.⁸ But for an abdominal ectopic pregnancy or an emergency tubal ectopic removal, a laparotomy is usually required.

What To Think About

When an ectopic pregnancy is located in an unruptured fallopian tube, every attempt is made to remove the pregnancy without removing or damaging the tube.

Emergency surgery is needed for a ruptured ectopic pregnancy.

Future fertility

Your future fertility and your risk of having another ectopic pregnancy will be affected by your own combination of risk factors. These can include smoking, use of assisted reproductive technology (ART) to get pregnant, and how much fallopian tube damage you have.

As long as you have one healthy fallopian tube, salpingostomy (small tubal slit) and salpingectomy (part of a tube removed) have about the same effect on your future fertility. But if your other tube is damaged, your doctor may try to do a salpingostomy. This may improve your chances of getting pregnant in the future.³

Other Treatment

Ectopic pregnancy is a potentially life-threatening condition that must be treated with surgery, medicine, or frequent testing. Alternative treatments are not appropriate for this condition.

Other Places To Get Help

Organizations

Related Information

• Abdominal Pain, Age 12 and Older
• Abnormal Vaginal Bleeding
• Endometriosis
• Exposure to Sexually Transmitted Diseases
• Fertility Problems
• Pregnancy
• Shock

References

Citations

1. Speroff L, Fritz MA (2005). Ectopic pregnancy. In Clinical Gynecologic Endocrinology and Infertility, 7th ed., pp. 1275-1302. Philadelphia: Lippincott Williams and Wilkins.

2. Tay JI, et al. (2000). Ectopic pregnancy. BMJ, 320(7239): 916-919.

3. Farquhar CM (2005). Ectopic pregnancy. Lancet, 366: 583-591.

4. DeCherney AH (2002). Ectopic pregnancy and spontaneous abortion. In DC Dale, DD Federman, eds., Scientific American Medicine, section 16, chap. 8. New York: WebMD.

5. American College of Obstetricians and Gynecologists (1998). Medical management of tubal pregnancy. ACOG Practice Bulletin No. 3. Obstetrics and Gynecology, 92(6): 1-7.

6. Brown WD, et al. (2002). Ectopic pregnancy after cesarean hysterectomy. Obstetrics and Gynecology, 5(2): 933-934.

7. Hatcher RA, et al. (2004). Choosing among available methods. In A Pocket Guide to Managing Contraception, pp. 36-39. Tiger, GA: Bridging the Gap Foundation.

8. Cunningham FG, et al. (2005). Ectopic pregnancy. In Williams Obstetrics, 22nd ed., pp. 253-272. New York: McGraw-Hill.

9. Hajenius PJ, et al. (2006). Interventions for tubal ectopic pregnancy. Cochrane Database of Systematic Reviews (1). Oxford: Update Software.

10. Barnhart KT, et al. (2003). The medical management of ectopic pregnancy: A meta-analysis comparing "single dose" and "multidose" regimens. Obstetrics and Gynecology, 101(4): 778-784.

Other Works Consulted

• American Society for Reproductive Medicine (March 2001). Early Diagnosis and Management of Ectopic Pregnancy: A Practice Committee Report. Birmingham, AL: American Society for Reproductive Medicine.

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