Ectopic means "out of place." In an ectopic pregnancy, a fertilized egg has implanted outside the uterus. The egg settles in the fallopian tubes more than 95% of the time. This is why ectopic pregnancies are commonly called "tubal pregnancies." The egg can also implant in the ovary, abdomen, or the cervix, so you may see these referred to as cervical or abdominal pregnancies. None of these areas has as much space or nurturing tissue as a uterus for a pregnancy to develop. As the fetus grows, it will eventually burst the organ that contains it. This can cause severe bleeding and endanger the mother's life. A classical ectopic pregnancy never develops into a live birth.
Ectopic pregnancy can be difficult to diagnose because symptoms often mirror those of a normal early pregnancy. These can include missed periods, breast tenderness, nausea, vomiting, or frequent urination.
Pain is usually the first red flag. You might feel pain in your pelvis, abdomen, or, in extreme cases, even your shoulder or neck (if blood from a ruptured ectopic pregnancy builds up and irritates certain nerves). Most women describe the pain as sharp and stabbing. It may concentrate on one side of the pelvis, and it may come and go or vary in intensity.
Any of the following additional symptoms can suggest an ectopic pregnancy:
An ectopic pregnancy results from a fertilized egg's inability to work its way quickly enough down the fallopian tube into the uterus. An infection or inflammation of the tube may have partially or entirely blocked it. Pelvic inflammatory disease (PID) is the most common of these infections.
Endometriosis (when cells from the lining of the uterus detach and grow elsewhere in the body) or scar tissue from previous abdominal or fallopian surgeries can also cause blockages. More rarely, birth defects or abnormal growths can alter the shape of the tube and disrupt the egg's progress.
An ectopic pregnancy has to be suspected in any woman with lower abdominal pain and/or unusual bleeding who is or might be sexually active and whose pregnancy test is positive. An abnormal rise in blood hCG levels may also indicate an ectopic pregnancy. The threshold of discrimination of intrauterine pregnancy today is around 3000 IU/ml of Human Chorionic Gonadotropin (HCG). A high resolution, vaginal ultrasound scan showing no intrauterine pregnancy is presumptive evidence that an ectopic pregnancy is present if the threshold of discrimination for HCG has been reached. An empty uterus with levels lower than 3000IU/ml may be evidence of an ectopic pregnancy, but may also be consistent with an intrauterine pregnancy which is simply too small to be seen on ultrasound. If there is uncertainty it might be necessary to wait a few days and repeat the bloodwork and ultrasound.
An ultrasound showing a gestational sac with fetal heart is clear evidence of ectopic pregnancy.
Free fluid which is non echogenic is a normal finding in the late menstrual cycle and early normal pregnacy. This is a transudate and is not presumptive evidence of bleeding. Echogenic free fluid suggests the presence of blood clot and is suggestive of free blood in the peritoneum.
A laparoscopy or laparotomy can also be performed to visually confirm an ectopic pregnancy. Often if a tubal abortion has occurred, or a tubal rupture has occurred, it is hard actually to find the pregnancy tissue. Laparoscopy in very early ectopic pregnancy may rarely show a normal looking Fallopian tube.
Early treatment of an ectopic pregnancy with the drug methotrexate has proven to be a viable alternative to surgical treatment since 1993. If administered early in the pregnancy, methotrexate can disrupt the growth of the developing embryo causing the cessation of pregnancy.
If hemorrhaging has already occurred, surgical intervention may be necessary if there is evidence of ongoing blood loss. However, as already stated, about half of ectopics result in tubal abortion and are self limiting. The option to go to surgery is thus often a difficult decision to make in an obviously stable patient with minimal evidence of blood clot on ultrasound.
Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy). This long, hollow tube with a lighted end allows the doctor to view internal organs and insert other instruments as needed. Sometimes, a second small abdominal incision is made for the instruments. The ectopic pregnancy is then surgically removed and any damaged organs are repaired or removed. General or regional anesthesia may be used. The first successful surgery for an ectopic pregnancy was performed by Robert Lawson Tait in 1883.
Whatever your treatment, the doctor will want to see you regularly afterward to make sure your hCG levels return to zero. This may take up to 12 weeks. An elevated hCG could mean that some ectopic tissue was missed. This tissue may have to be removed using methotrexate or additional surgery.
Approximately 30% of women who have had ectopic pregnancies will have difficulty becoming pregnant again. Your prognosis depends mainly on the extent of the damage and the surgery that was done.
If the fallopian tube has been spared, the chances of a future successful pregnancy are 60%. Even if one fallopian tube has been removed, the chances of having a successful pregnancy with the other tube can be greater than 40%.
The likelihood of a repeat ectopic pregnancy increases with each subsequent ectopic pregnancy. Once you have had one ectopic pregnancy, you face an approximate 15% chance of having another.
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.
The risk of ectopic pregnancy is highest for women who are between 35 and 44 years old and have had:
Some birth control methods can also increase your risk of ectopic pregnancy. If you get pregnant while using progesterone-only oral contraceptives, progesterone intrauterine devices (IUDs), or the morning-after pill, you're more likely to have an ectopic pregnancy.