Persistent Ectopic Pregnancy
   HOME

TheInfoList



OR:

Ectopic pregnancy is a
complication of pregnancy Complications of pregnancy are health problems that are related to or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are term ...
in which the embryo attaches outside the
uterus The uterus (from Latin ''uterus'', : uteri or uteruses) or womb () is the hollow organ, organ in the reproductive system of most female mammals, including humans, that accommodates the embryonic development, embryonic and prenatal development, f ...
. Signs and symptoms classically include
abdominal pain Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given th ...
and
vaginal bleeding Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductiv ...
, but fewer than 50 percent of affected women have both of these symptoms. The pain may be described as sharp, dull, or crampy. Pain may also spread to the shoulder if bleeding into the abdomen has occurred. Severe bleeding may result in a
fast heart rate Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal ...
,
fainting Syncope , commonly known as fainting or passing out, is a loss of consciousness and muscle strength characterized by a fast onset, short duration, and spontaneous recovery. It is caused by a decrease in blood flow to the brain, typically from ...
, or
shock Shock may refer to: Common uses Healthcare * Acute stress reaction, also known as psychological or mental shock ** Shell shock, soldiers' reaction to battle trauma * Circulatory shock, a medical emergency ** Cardiogenic shock, resulting from ...
. With very rare exceptions, the
fetus A fetus or foetus (; : fetuses, foetuses, rarely feti or foeti) is the unborn offspring of a viviparous animal that develops from an embryo. Following the embryonic development, embryonic stage, the fetal stage of development takes place. Pren ...
is unable to survive. Overall, ectopic pregnancies annually affect less than 2% of pregnancies worldwide. Risk factors for ectopic pregnancy include
pelvic inflammatory disease Pelvic inflammatory disease (PID), also known as pelvic inflammatory disorder, is an infection of the upper part of the female reproductive system, mainly the uterus, fallopian tubes, and ovaries, and inside of the pelvis. Often, there may be no ...
, often due to
chlamydia infection Chlamydia, or more specifically a chlamydia infection, is a sexually transmitted infection caused by the bacterium ''Chlamydia trachomatis''. Most people who are infected have no symptoms. When symptoms do appear, they may occur only several w ...
;
tobacco smoking Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or released from the mouth, as is generally done with pipes and cigars. The practice is believed to hav ...
;
endometriosis Endometriosis is a disease in which Tissue (biology), tissue similar to the endometrium, the lining of the uterus, grows in other places in the body, outside the uterus. It occurs in women and a limited number of other female mammals. Endomet ...
; prior tubal surgery; a history of
infertility In biology, infertility is the inability of a male and female organism to Sexual reproduction, reproduce. It is usually not the natural state of a healthy organism that has reached sexual maturity, so children who have not undergone puberty, whi ...
; and the use of
assisted reproductive technology Assisted reproductive technology (ART) includes medical procedures used primarily to address infertility. This subject involves procedures such as in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), and cryopreservation of ga ...
. Those who have previously had an ectopic pregnancy are at much higher risk of having another one. Most ectopic pregnancies (90%) occur in the
fallopian tube The fallopian tubes, also known as uterine tubes, oviducts or salpinges (: salpinx), are paired tubular sex organs in the human female body that stretch from the Ovary, ovaries to the uterus. The fallopian tubes are part of the female reproduct ...
, which are known as tubal pregnancies, but implantation can also occur on the
cervix The cervix (: cervices) or cervix uteri is a dynamic fibromuscular sexual organ of the female reproductive system that connects the vagina with the uterine cavity. The human female cervix has been documented anatomically since at least the time ...
,
ovaries The ovary () is a gonad in the female reproductive system that produces ova; when released, an ovum travels through the fallopian tube/oviduct into the uterus. There is an ovary on the left and the right side of the body. The ovaries are endocr ...
,
caesarean Caesarean section, also known as C-section, cesarean, or caesarean delivery, is the surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen. It is often performed because vaginal delivery would ...
scar, or within the
abdomen The abdomen (colloquially called the gut, belly, tummy, midriff, tucky, or stomach) is the front part of the torso between the thorax (chest) and pelvis in humans and in other vertebrates. The area occupied by the abdomen is called the abdominal ...
. Detection of ectopic pregnancy is typically by blood tests for
human chorionic gonadotropin Human chorionic gonadotropin (hCG) is a hormone for the maternal recognition of pregnancy produced by trophoblast cells that are surrounding a growing embryo (syncytiotrophoblast initially), which eventually forms the placenta after implantat ...
(hCG) and
ultrasound Ultrasound is sound with frequency, frequencies greater than 20 Hertz, kilohertz. This frequency is the approximate upper audible hearing range, limit of human hearing in healthy young adults. The physical principles of acoustic waves apply ...
. This may require testing on more than one occasion. Other causes of similar symptoms include:
miscarriage Miscarriage, also known in medical terms as a spontaneous abortion, is an end to pregnancy resulting in the loss and expulsion of an embryo or fetus from the womb before it can fetal viability, survive independently. Miscarriage before 6 weeks ...
,
ovarian torsion Ovarian torsion (OT) or adnexal torsion is an abnormal condition where an ovary twists on its attachment to other structures, such that blood flow is decreased. Symptoms typically include pelvic pain on one side. While classically the pain is su ...
, and
acute appendicitis Appendicitis is inflammation of the appendix. Symptoms commonly include right lower abdominal pain, nausea, vomiting, fever and decreased appetite. However, approximately 40% of people do not have these typical symptoms. Severe complications o ...
. Prevention is by decreasing risk factors such as chlamydia infections through screening and treatment. While some ectopic pregnancies will miscarry without treatment, the standard treatment for ectopic pregnancy is a procedure to either remove the embryo from the fallopian tube or to remove the fallopian tube altogether. The use of the medication
methotrexate Methotrexate, formerly known as amethopterin, is a chemotherapy agent and immunosuppressive drug, immune-system suppressant. It is used to treat cancer, autoimmune diseases, and ectopic pregnancy, ectopic pregnancies. Types of cancers it is u ...
works as well as surgery in some cases. Specifically, it works well when the
beta-HCG Human chorionic gonadotropin (hCG) is a hormone for the maternal recognition of pregnancy produced by trophoblast cells that are surrounding a growing embryo (syncytiotrophoblast initially), which eventually forms the placenta after implantatio ...
is low and the size of the ectopic is small. Surgery such as a
salpingectomy Salpingectomy refers to the surgical removal of a fallopian tube. This may be done to treat an ectopic pregnancy or cancer, to prevent cancer, or as a form of contraception. This procedure is now sometimes preferred over its ovarian tube-sparin ...
is still typically recommended if the tube has ruptured, there is a fetal heartbeat, or the woman's
vital sign Vital signs (also known as vitals) are a group of the four to six most crucial medical signs that indicate the status of the body's vital (life-sustaining) functions. These measurements are taken to help assess the general physical health of a ...
s are unstable. The surgery may be
laparoscopic Laparoscopy () is an operation performed in the abdomen or human pelvis, pelvis using small Surgical incision, incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few ...
or through a larger incision, known as a
laparotomy A laparotomy is a surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy. Origins and history The first successful laparotomy was performed without ...
. Maternal morbidity and mortality are reduced with treatment. The rate of ectopic
pregnancy Pregnancy is the time during which one or more offspring gestation, gestates inside a woman's uterus. A multiple birth, multiple pregnancy involves more than one offspring, such as with twins. Conception (biology), Conception usually occurs ...
is about 11 to 20 per 1,000 live births in developed countries, though it may be as high as 4% among those using
assisted reproductive technology Assisted reproductive technology (ART) includes medical procedures used primarily to address infertility. This subject involves procedures such as in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), and cryopreservation of ga ...
. It is the most common cause of death among women during the first trimester at approximately 6-13% of the total. In the
developed world A developed country, or advanced country, is a sovereign state that has a high quality of life, developed economy, and advanced technological infrastructure relative to other less industrialized nations. Most commonly, the criteria for eval ...
outcomes have improved while in the developing world they often remain poor. The risk of death among those in the developed world is between 0.1 and 0.3 percent while in the developing world it is between one and three percent. The first known description of an ectopic pregnancy is by
Al-Zahrawi Abū al-Qāsim Khalaf ibn al-'Abbās al-Zahrāwī al-Ansari (;‎ c. 936–1013), popularly known as al-Zahrawi (), Latinisation of names, Latinised as Albucasis or Abulcasis (from Arabic ''Abū al-Qāsim''), was an Arabs, Arab physician, su ...
in the 11th century. The word "ectopic" means "out of place".


Signs and symptoms

Up to 10% of those with ectopic pregnancy have no symptoms, and one-third have no
medical sign Signs and symptoms are diagnostic indications of an illness, injury, or condition. Signs are objective and externally observable; symptoms are a person's reported subjective experiences. A sign for example may be a higher or lower temperature ...
s. In many cases the symptoms have low specificity, and can be similar to those of other
genitourinary The genitourinary system, or urogenital system, are the sex organs of the reproductive system and the organs of the urinary system. These are grouped together because of their proximity to each other, their common embryological origin and the us ...
and
gastrointestinal disorder Gastrointestinal diseases (abbrev. GI diseases or GI illnesses) refer to diseases involving the Human gastrointestinal tract, gastrointestinal tract, namely the esophagus, stomach, small intestine, large intestine and rectum; and the accessory or ...
s, such as
appendicitis Appendicitis is inflammation of the Appendix (anatomy), appendix. Symptoms commonly include right lower abdominal pain, nausea, vomiting, fever and anorexia (symptom), decreased appetite. However, approximately 40% of people do not have these t ...
,
salpingitis Salpingitis is an infection causing inflammation in the fallopian tubes (also called ''salpinges''). It is often included in the umbrella term of pelvic inflammatory disease (PID), along with endometritis, oophoritis, myometritis, parametritis ...
, rupture of a corpus luteum cyst, miscarriage, ovarian torsion or
urinary tract infection A urinary tract infection (UTI) is an infection that affects a part of the urinary tract. Lower urinary tract infections may involve the bladder (cystitis) or urethra (urethritis) while upper urinary tract infections affect the kidney (pyel ...
. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of four to eight weeks. Later presentations are more common in communities deprived of modern diagnostic ability. Signs and symptoms of ectopic pregnancy include increased hCG, vaginal bleeding (in varying amounts), sudden lower abdominal pain, pelvic pain, a tender cervix, an adnexal mass, or adnexal tenderness. In the absence of ultrasound or hCG assessment, heavy vaginal bleeding may lead to a misdiagnosis of miscarriage.
Nausea Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. It can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the throat. Over 30 d ...
,
vomiting Vomiting (also known as emesis, puking and throwing up) is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose. Vomiting can be the result of ailments like food poisoning, gastroenteritis, pre ...
and
diarrhea Diarrhea (American English), also spelled diarrhoea or diarrhœa (British English), is the condition of having at least three loose, liquid, or watery bowel movements in a day. It often lasts for a few days and can result in dehydration d ...
are more rare symptoms of ectopic pregnancy. Rupture of an ectopic pregnancy can lead to symptoms such as
abdominal distension Abdominal distension occurs when substances, such as air (gas) or fluid, accumulate in the abdomen causing its expansion. It is typically a symptom of an underlying disease or dysfunction in the body, rather than an illness in its own right. Peo ...
, tenderness, peritonism and
hypovolemic shock Hypovolemic shock is a form of Shock (circulatory), shock caused by severe hypovolemia (insufficient blood volume or extracellular fluid in the body). It can be caused by severe dehydration or blood loss. Hypovolemic shock is a medical emergency ...
. Someone with a ruptured ectopic pregnancy may experience pain when lying flat and may prefer to maintain an upright posture as intrapelvic blood flow can lead to swelling of the abdominal cavity and cause additional pain.


Complications

The most common complication is rupture with internal bleeding, which may lead to hypovolemic shock. Damage to the fallopian tubes can lead to difficulty becoming pregnant in the future. The woman's other fallopian tube may function sufficiently for pregnancy. After the removal of one damaged fallopian tube, pregnancy remains possible in the future. If both are removed, in-vitro fertilization remains an option for women hoping to become pregnant.


Causes

There are several risk factors for ectopic pregnancies. However, in as many as one-third to one-half no risk factors can be identified. Risk factors include:
pelvic inflammatory disease Pelvic inflammatory disease (PID), also known as pelvic inflammatory disorder, is an infection of the upper part of the female reproductive system, mainly the uterus, fallopian tubes, and ovaries, and inside of the pelvis. Often, there may be no ...
, infertility, use of an
intrauterine device An intrauterine device (IUD), also known as an intrauterine contraceptive device (IUCD or ICD) or coil, is a small, often T-shaped birth control device that is inserted into the uterus to prevent pregnancy. IUDs are a form of long-acting rever ...
(IUD), previous exposure to
diethylstilbestrol Diethylstilbestrol (DES), also known as stilbestrol or stilboestrol, is a nonsteroidal estrogen medication, which is presently rarely used. In the past, it was widely used for a variety of indications, including pregnancy support for those with ...
(DES), tubal surgery, intrauterine surgery (e.g. D&C),
smoking Smoking is a practice in which a substance is combusted, and the resulting smoke is typically inhaled to be tasted and absorbed into the bloodstream of a person. Most commonly, the substance used is the dried leaves of the tobacco plant, whi ...
, previous ectopic pregnancy,
endometriosis Endometriosis is a disease in which Tissue (biology), tissue similar to the endometrium, the lining of the uterus, grows in other places in the body, outside the uterus. It occurs in women and a limited number of other female mammals. Endomet ...
, and
tubal ligation Tubal ligation (commonly known as having one's "tubes tied") is a surgical procedure for female sterilization in which the fallopian tubes are permanently blocked, clipped or removed. This prevents the fertilization of eggs by sperm and thus the ...
. A previous induced
abortion Abortion is the early termination of a pregnancy by removal or expulsion of an embryo or fetus. Abortions that occur without intervention are known as miscarriages or "spontaneous abortions", and occur in roughly 30–40% of all pregnan ...
does not appear to increase the risk. The IUD does not increase the risk of ectopic pregnancy, but with an IUD if pregnancy occurs it is more likely to be ectopic than intrauterine. The risk of ectopic pregnancy after chlamydia infection is low. The exact mechanism through which chlamydia increases the risk of ectopic pregnancy is uncertain, though some research suggests that the infection can affect the structure of fallopian tubes.


Tube damage

Tubal pregnancy is when the egg is implanted in the fallopian tubes. Hair-like
cilia The cilium (: cilia; ; in Medieval Latin and in anatomy, ''cilium'') is a short hair-like membrane protrusion from many types of eukaryotic cell. (Cilia are absent in bacteria and archaea.) The cilium has the shape of a slender threadlike proj ...
located on the internal surface of the fallopian tubes carry the fertilized egg to the uterus. Fallopian cilia are sometimes seen in reduced numbers after an ectopic pregnancy, leading to a hypothesis that cilia damage in the fallopian tubes is likely to lead to an ectopic pregnancy. Women who smoke have a higher chance of an ectopic pregnancy in the fallopian tubes. Smoking leads to risk factors of damaging and destroying cilia. As cilia degenerate, the amount of time it takes for the fertilized egg to reach the uterus will increase. The fertilized egg, if it does not reach the uterus in time, will hatch from the non-adhesive
zona pellucida The ''zona pellucida'' (Latin meaning "transparent zone") is the specialized area surrounding mammalian oocytes (eggs). It is also known as an egg coat. The ''zona pellucida'' is essential for oocyte growth and fertilization. The ''zona pelluc ...
and implant itself inside the fallopian tube, thus causing ectopic pregnancy. Women with pelvic inflammatory disease (PID) have a high occurrence of ectopic pregnancy. This results from the build-up of
scar tissue "Scar Tissue" is the first single from American rock band Red Hot Chili Peppers' seventh studio album, ''Californication'' (1999). Released on May 25, 1999, the song spent a then-record 16 consecutive weeks atop the US ''Billboard'' Hot Modern R ...
in the fallopian tubes, causing damage to the cilia. However, if both tubes were completely blocked, so that sperm and egg were physically unable to meet, then fertilization of the egg would naturally be impossible, and neither normal pregnancy nor ectopic pregnancy could occur. Intrauterine adhesions (IUA) present in
Asherman's syndrome Asherman's syndrome (AS) is an acquired uterine condition that occurs when scar tissue (adhesions) forms inside the uterus and/or the cervix. It is characterized by variable scarring inside the uterine cavity, where in many cases the front and bac ...
can cause ectopic cervical pregnancy or, if adhesions partially block access to the tubes via the ostia, ectopic tubal pregnancy. Asherman's syndrome usually occurs from intrauterine surgery, most commonly after D&C. Endometrial/pelvic/genital
tuberculosis Tuberculosis (TB), also known colloquially as the "white death", or historically as consumption, is a contagious disease usually caused by ''Mycobacterium tuberculosis'' (MTB) bacteria. Tuberculosis generally affects the lungs, but it can al ...
, another cause of Asherman's syndrome, can also lead to ectopic pregnancy as infection may lead to tubal adhesions in addition to intrauterine adhesions. Tubal ligation can predispose to ectopic pregnancy. Reversal of tubal sterilization (
tubal reversal Tubal reversal, also called tubal sterilization reversal, tubal ligation reversal, or microsurgical tubal reanastomosis, is a surgical procedure that can restore fertility to women after a tubal ligation. By rejoining the separated segments of th ...
) carries a risk for ectopic pregnancy. This is higher if more destructive methods of tubal ligation (tubal cautery, partial removal of the tubes) have been used than less destructive methods (tubal clipping). A history of a tubal pregnancy increases the risk of future occurrences to about 10%. This risk is not reduced by removing the affected tube, even if the other tube appears normal. The best method for diagnosing this is to do an early ultrasound.


Endometriosis

Endometriosis is a disease in which cells similar to those of the
endometrium The endometrium is the inner epithelium, epithelial layer, along with its mucous membrane, of the mammalian uterus. It has a basal layer and a functional layer: the basal layer contains stem cells which regenerate the functional layer. The funct ...
, the tissue covering the inside of the uterus, grow outside the uterus. An embryo attaching to such lesions leads to an ectopic pregnancy. The results of a 30-year study of reproductive and pregnancy outcomes, involving 14,000+ women of child-bearing age, were presented at the 2015
European Society of Human Reproduction and Embryology The European Society of Human Reproduction and Embryology (ESHRE) was founded in 1985 by Robert Edwards (University of Cambridge) and Jean Cohen (Paris), who felt that the study and research in the field of reproduction needed to be encouraged and ...
(ESHRE) annual congress. 39% of the study group had surgically confirmed endometriosis. Compared to their peers, the endometriosis subgroup had a 76% higher risk for miscarriage and a 270% higher risk for ectopic pregnancy. The higher endometriosis risks were attributed to increased pelvic inflammation and structural and functional changes in the uterine lining.


Other

Although some investigations have shown that patients may be at higher risk for ectopic pregnancy with advancing age, it is believed that age is a variable that could act as a surrogate for other risk factors. Vaginal douching is thought by some to increase ectopic pregnancies. Women exposed to DES in utero (also known as "DES daughters") also have an elevated risk of ectopic pregnancy. However, DES has not been used since 1971 in the United States. It has also been suggested that pathologic generation of
nitric oxide Nitric oxide (nitrogen oxide, nitrogen monooxide, or nitrogen monoxide) is a colorless gas with the formula . It is one of the principal oxides of nitrogen. Nitric oxide is a free radical: it has an unpaired electron, which is sometimes den ...
through increased
iNOS Nitric oxide synthases (NOSs) are a family of enzymes catalyzing the production of nitric oxide (NO) from L-arginine. NO is an important cellular signaling molecule. It helps modulate vascular tone, insulin secretion, airway tone, and perist ...
production may decrease tubal ciliary beats and smooth muscle contractions and thus affect embryo transport, which may consequently result in ectopic pregnancy. Low socioeconomic status may also be a risk factor for ectopic pregnancy.


Diagnosis

An ectopic pregnancy should be considered as the cause of abdominal pain or vaginal bleeding in everyone who has a positive
pregnancy test A pregnancy test is used to determine whether a person is Pregnancy, pregnant or not. The two primary methods are testing for the pregnancy hormone (human chorionic gonadotropin (hCG)) in blood or urine using a pregnancy test kit, and scanning ...
. The primary goal of diagnostic procedures in possible ectopic pregnancy is to
triage In medicine, triage (, ; ) is a process by which care providers such as Health professional, medical professionals and those with first aid knowledge determine the order of priority for providing treatment to injured individuals and/or inform th ...
according to risk rather than establishing pregnancy location.


Transvaginal ultrasonography

An
ultrasound Ultrasound is sound with frequency, frequencies greater than 20 Hertz, kilohertz. This frequency is the approximate upper audible hearing range, limit of human hearing in healthy young adults. The physical principles of acoustic waves apply ...
showing a
gestational sac The gestational sac is the large cavity of fluid surrounding the embryo. During early embryogenesis, it consists of the extraembryonic coelom, also called the chorionic cavity. The gestational sac is normally contained within the uterus. It is the ...
with the fetal heart in the fallopian tube has a very high specificity of ectopic pregnancy. It involves a long, thin transducer, covered with the conducting gel and a plastic/latex sheath and inserted into the vagina.
Transvaginal ultrasonography Vaginal ultrasonography is a medical ultrasonography that applies an ultrasound transducer (or "probe") in the vagina to visualize organs within the pelvic cavity. It is also called transvaginal ultrasonography because the ultrasound waves go ''a ...
has a sensitivity of at least 90% for ectopic pregnancy. The diagnostic ultrasonographic finding in ectopic pregnancy is an adnexal mass that moves separately from the ovary. In around 60% of cases, it is an inhomogeneous or a noncystic adnexal mass sometimes known as the "blob sign". It is generally spherical, but a more tubular appearance may be seen in the case of
hematosalpinx Hematosalpinx (sometimes also hemosalpinx) is a medical condition involving bleeding into the fallopian tubes. Symptoms A hematosalpinx from a tubal pregnancy may be associated with pelvic pain and uterine bleeding. A gynecologic ultrasound will ...
. This sign has been estimated to have a sensitivity of 84% and specificity of 99% in diagnosing ectopic pregnancy. In the study estimating these values, the blob sign had a
positive predictive value The positive and negative predictive values (PPV and NPV respectively) are the proportions of positive and negative results in statistics and diagnostic tests that are true positive and true negative results, respectively. The PPV and NPV desc ...
of 96% and a
negative predictive value The positive and negative predictive values (PPV and NPV respectively) are the proportions of positive and negative results in statistics and diagnostic tests that are true positive and true negative results, respectively. The PPV and NPV desc ...
of 95%. The visualization of an empty extrauterine gestational sac is sometimes known as the "bagel sign", and is present in around 20% of cases. In another 20% of cases, there is visualization of a gestational sac containing a yolk sac or an embryo. Ectopic pregnancies where there is visualization of cardiac activity are sometimes termed "viable ectopic". File:Schematic figure of vaginal ultrasonography in ectopic pregnancy.svg,
Transvaginal ultrasonography Vaginal ultrasonography is a medical ultrasonography that applies an ultrasound transducer (or "probe") in the vagina to visualize organs within the pelvic cavity. It is also called transvaginal ultrasonography because the ultrasound waves go ''a ...
of an ectopic pregnancy, showing the field of view in the following image File:Blob sign of ectopic pregnancy.png, A "blob sign", which consists of the ectopic pregnancy. The ovary is distinguished from it by having follicles, whereof one is visible in the field. This patient had an intrauterine device (IUD) with progestogen, whose cross-section is visible in the field, leaving an ultrasound shadow distally to it. File:Ectopicleftmass.PNG, Ultrasound image showing an ectopic pregnancy where a
gestational sac The gestational sac is the large cavity of fluid surrounding the embryo. During early embryogenesis, it consists of the extraembryonic coelom, also called the chorionic cavity. The gestational sac is normally contained within the uterus. It is the ...
and fetus have been formed
The combination of a positive pregnancy test and the presence of what appears to be a normal intrauterine pregnancy does not exclude ectopic pregnancy, since there may be either a
heterotopic pregnancy A heterotopic pregnancy is a complication of pregnancy in which both extrauterine ( ectopic) pregnancy and intrauterine pregnancy occur simultaneously. It may also be referred to as a combined ectopic pregnancy, multiple‑sited pregnancy, or co ...
or a "", which is a collection of within the endometrial cavity that may be seen in up to 20% of women. A small amount of anechogenic-free fluid in the
recto-uterine pouch The rectouterine pouch (rectovaginal pouch, pouch of Douglas or cul-de-sac) is the extension of the peritoneum into the space between the posterior wall of the uterus and the rectum in the human female. Structure In women, the rectouterine pouch ...
is commonly found in both intrauterine and ectopic pregnancies. The presence of
echogenic Echogenicity (sometimes as echogenecity) or echogeneity is the ability to bounce an echo, e.g. return the signal in medical ultrasound examinations. In other words, echogenicity is higher when the surface bouncing the sound echo reflects increase ...
fluid is estimated at between 28 and 56% of women with an ectopic pregnancy, and strongly indicates the presence of
hemoperitoneum Hemoperitoneum (also haemoperitoneum, sometimes also hematoperitoneum) is the presence of blood in the peritoneal cavity. The blood accumulates in the space between the inner lining of the abdominal wall and the internal abdominal organs. Hemope ...
. However, it does not necessarily result from tubal rupture but is commonly a result from leakage from the
distal tubal opening The fallopian tubes, also known as uterine tubes, oviducts or salpinges (: salpinx), are paired tubular sex organs in the human female body that stretch from the ovaries to the uterus. The fallopian tubes are part of the female reproductive sys ...
. As a rule of thumb, the finding of free fluid is significant if it reaches the fundus or is present in the
vesico-uterine pouch In human female anatomy, the vesicouterine pouch, also uterovesicle pouch, is a fold of peritoneum over the uterus and the bladder. Like the rectouterine pouch, it is a female pelvic recess, but shallower and closer to the anterior fornix of the ...
. A further marker of serious intra-abdominal bleeding is the presence of fluid in the hepatorenal recess of the subhepatic space. Currently,
Doppler ultrasonography Doppler ultrasonography is medical ultrasonography that employs the Doppler effect to perform imaging of the movement of tissues and body fluids (usually blood), and their relative velocity to the probe. By calculating the frequency shift of a ...
is not considered to significantly contribute to the diagnosis of ectopic pregnancy. A common misdiagnosis is of a normal intrauterine pregnancy is where the pregnancy is implanted laterally in an
arcuate uterus The arcuate uterus is a form of a uterine anomaly or variation where the uterine cavity displays a concave contour towards the fundus. Normally the uterine cavity is straight or convex towards the fundus on anterior-posterior imaging, but in the ...
, potentially being misdiagnosed as an
interstitial pregnancy An interstitial pregnancy is a uterine but ectopic pregnancy; the pregnancy is located outside the uterine cavity in that part of the fallopian tube that penetrates the muscular layer of the uterus. The term cornual pregnancy is sometimes used as ...
.


Ultrasonography and β-hCG

Where no intrauterine pregnancy (IUP) is seen on ultrasound, measuring β-human chorionic gonadotropin (β-hCG) levels may aid in the diagnosis. The rationale is that a low β-hCG level may indicate that the pregnancy is intrauterine but yet too small to be visible on ultrasonography. While some physicians consider that the threshold where an intrauterine pregnancy should be visible on transvaginal ultrasound is around 1500 mIU/mL of β-hCG, a review in the JAMA Rational Clinical Examination Series showed that there is no single threshold for the β-human chorionic gonadotropin that confirms an ectopic pregnancy. Instead, the best test in a pregnant woman is a high-resolution transvaginal ultrasound. The presence of an adnexal mass in the absence of an intrauterine pregnancy on transvaginal sonography increases the likelihood of an ectopic pregnancy 100-fold (LR+ 111). When there are no adnexal abnormalities on transvaginal sonography, the likelihood of an ectopic pregnancy decreases (LR- 0.12). An empty uterus with levels higher than 1500 mIU/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 the diagnosis is uncertain, it may be necessary to wait a few days and repeat the blood work. This can be done by measuring the β-hCG level approximately 48 hours later and repeating the ultrasound. The serum hCG ratios and
logistic regression In statistics, a logistic model (or logit model) is a statistical model that models the logit, log-odds of an event as a linear function (calculus), linear combination of one or more independent variables. In regression analysis, logistic regres ...
models appear to be better than absolute single serum hCG level. If the β-hCG falls on repeat examination, this strongly suggests a spontaneous abortion or rupture. The fall in serum hCG over 48 hours may be measured as the hCG ratio, which is calculated as: hCG~ratio = \frac An hCG ratio of 0.87, that is, a decrease in hCG of 13% over 48 hours, has a sensitivity of 93% and specificity of 97% for predicting a failing
pregnancy of unknown location Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these sympto ...
(PUL). The majority of cases of ectopic pregnancy will have serial serum hCG levels that increase more slowly than would be expected with an IUP (that is, a ''suboptimal rise''), or decrease more slowly than would be expected with a failing PUL. However, up to 20% of cases of ectopic pregnancy have serum hCG doubling times similar to that of an IUP, and around 10% of EP cases have hCG patterns similar to a failing PUL.


Other methods


Direct examination

A
laparoscopy Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medli ...
or laparotomy can also be performed to visually confirm an ectopic pregnancy. This is generally reserved for women presenting with signs of an
acute abdomen An acute abdomen refers to a sudden, severe abdominal pain. It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need immediate surgical treatment. Differential diagnosis Common causes of an acute a ...
and
hypovolemic shock Hypovolemic shock is a form of Shock (circulatory), shock caused by severe hypovolemia (insufficient blood volume or extracellular fluid in the body). It can be caused by severe dehydration or blood loss. Hypovolemic shock is a medical emergency ...
. Often, if a tubal abortion or tubal rupture has occurred, it is difficult to find the pregnancy tissue. A laparoscopy in very early ectopic pregnancy rarely shows a normal-looking fallopian tube.


Culdocentesis

Culdocentesis Culdocentesis is a medical procedure involving the extraction of fluid from the rectouterine pouch (pouch of Douglas) posterior to the vagina through a needle. It can be one diagnostic technique used in identifying pelvic inflammatory disease (in ...
, in which fluid is retrieved from the space separating the vagina and rectum, is a less commonly performed test that may be used to look for internal bleeding. In this test, a needle is inserted into the space at the very top of the vagina, behind the uterus, and in front of the rectum. Any blood or fluid found may have been derived from a ruptured ectopic pregnancy.


Progesterone levels

Progesterone Progesterone (; P4) is an endogenous steroid and progestogen sex hormone involved in the menstrual cycle, pregnancy, and embryogenesis of humans and other species. It belongs to a group of steroid hormones called the progestogens and is the ma ...
levels of less than 20 nmol/L have a high
predictive value Predictive value of tests is the probability of a target condition given by the result of a test, often in regard to medical tests. *In cases where binary classification can be applied to the test results, such yes versus no, test target (such as a ...
for failing pregnancies, whilst levels over 25 nmol/L are likely to predict viable pregnancies, and levels over 60 nmol/L are strongly so. This may help in identifying failing PUL that are at low risk and thereby needing less follow-up.
Inhibin A Activin and inhibin are two closely related protein complexes that have almost directly opposite biological effects. Identified in 1986, activin enhances FSH biosynthesis and secretion, and participates in the regulation of the menstrual c ...
may also be useful for predicting spontaneous resolution of PUL, but is not as good as progesterone for this purpose.


Mathematical models

There are various mathematical models, such as logistic regression models and Bayesian networks, for the prediction of PUL outcomes based on multiple parameters. Mathematical models also aim to identify PULs that are ''low risk'', that is, failing PULs and IUPs.


Dilation and curettage

Dilation and curettage Dilation (or dilatation) may refer to: Physiology or medicine * Cervical dilation, the widening of the cervix in childbirth, miscarriage etc. * Coronary dilation, or coronary reflex * Dilation and curettage, the opening of the cervix and s ...
(D&C) is sometimes used to diagnose pregnancy location to differentiate between an EP and a non-viable IUP in situations where a viable IUP can be ruled out. Specific indications for this procedure include either of the following: * No visible IUP on transvaginal ultrasonography with a serum hCG of more than 2000 mIU/mL. * An abnormal rise in hCG level. A rise of 35% over 48 hours is proposed as the minimal rise consistent with a viable intrauterine pregnancy. * An abnormal fall in hCG level, such as defined as one of less than 20% in two days.


Classification


Tubal pregnancy

The vast majority of ectopic pregnancies implant in the fallopian tube. Pregnancies can grow in the fimbrial end (5% of all ectopic pregnancies), the ampullary section (80%), the isthmus (12%), and the cornual and interstitial part of the tube (2%). Mortality of a tubal pregnancy at the isthmus or within the uterus (interstitial pregnancy) is higher as there is increased vascularity that may result more likely in sudden major internal bleeding. A review published in 2010 supports the hypothesis that tubal ectopic pregnancy is caused by a combination of retention of the embryo within the fallopian tube due to impaired embryo-tubal transport and alterations in the tubal environment allowing early implantation to occur.


Nontubal ectopic pregnancy

Two percent of ectopic pregnancies occur in the ovary, cervix, or are intra-abdominal. Transvaginal ultrasound examination is usually able to detect a
cervical pregnancy A cervical pregnancy is an ectopic pregnancy that has implanted in the uterine endocervix. Such a pregnancy typically aborts within the first trimester, however, if it is implanted closer to the uterine cavity – a so-called cervico-isthmic pre ...
. An
ovarian pregnancy Ovarian pregnancy refers to an ectopic pregnancy that is located in the ovary. Typically the egg cell is not released or picked up at ovulation, but fertilized within the ovary where the pregnancy implants. Such a pregnancy usually does not proce ...
is differentiated from a tubal pregnancy by the
Spiegelberg criteria The Spiegelberg criteria are four criteria used to identify ovarian ectopic pregnancies named after Otto Spiegelberg. Description Four criteria for differentiating ovarian from other ectopic pregnancies: # The gestational sac is located in ...
. While a fetus of ectopic pregnancy is typically not viable, very rarely, live babies have been delivered from
abdominal pregnancy An abdominal pregnancy is a rare type of ectopic pregnancy where the embryo or fetus is growing and developing outside the uterus, in the abdomen, and not in a fallopian tube (usual location), an ovary, or the broad ligament. Because tubal, ov ...
or C-section scar ectopic pregnancy. In the former situation, the
placenta The placenta (: placentas or placentae) is a temporary embryonic and later fetal organ that begins developing from the blastocyst shortly after implantation. It plays critical roles in facilitating nutrient, gas, and waste exchange between ...
sits on the intra-abdominal organs or the
peritoneum The peritoneum is the serous membrane forming the lining of the abdominal cavity or coelom in amniotes and some invertebrates, such as annelids. It covers most of the intra-abdominal (or coelomic) organs, and is composed of a layer of mesotheli ...
and has found sufficient blood supply. This is generally bowel or mesentery, but other sites, such as the renal (kidney), liver or hepatic (liver) artery, or even the aorta, have been described. Support to near viability has occasionally been described, but even in
Third World The term Third World arose during the Cold War to define countries that remained non-aligned with either NATO or the Warsaw Pact. The United States, Canada, Taiwan, Japan, South Korea, the Southern Cone, NATO, Western European countries and oth ...
countries, the diagnosis is most commonly made at 16 to 20 weeks' gestation. Such a fetus would have to be delivered by laparotomy. Maternal morbidity and mortality from extrauterine pregnancy are high, as attempts to remove the placenta from the organs to which it is attached usually lead to uncontrollable bleeding from the attachment site. If the organ to which the placenta is attached is removable, such as a section of the bowel, then the placenta should be removed together with that organ. This is such a rare occurrence that true data is unavailable and reliance must be made on anecdotal reports. However, the vast majority of abdominal pregnancies require intervention well before
fetal viability Fetal viability is the ability of a human fetus to survive outside the uterus. Viability depends upon factors such as birth weight, gestational age, and the availability of advanced medical care. In low-income countries, more than 90% of extr ...
because of the risk of bleeding. With the increase in Cesarean sections performed worldwide, Cesarean section ectopic pregnancies (CSP) are rare, but becoming more common. The incidence of CSP is not well known, however there have been estimates based on different populations of 1:1800–1:2216. CSP are characterized by abnormal implantation into the scar from a previous cesarean section, and allowed to continue can cause serious complications such as uterine rupture and hemorrhage. Patients with CSP generally present without symptoms, however symptoms can include vaginal bleeding that may or may not be associated with pain. The diagnosis of CSP is made by ultrasound and four characteristics are noted: (1) Empty uterine cavity with bright hyperechoic endometrial stripe (2) Empty cervical canal (3) Intrauterine mass in the anterior part of the uterine isthmus, and (4) Absence of the anterior uterine muscle layer, and/or absence or thinning between the bladder and gestational sac, measuring less than 5 mm. Given the rarity of the diagnosis, treatment options tend to be described in case reports and series, ranging from medical with methotrexate or KCl to surgical with dilation and curettage, uterine wedge resection, or hysterectomy. A double-balloon catheter technique has also been described, allowing for uterine preservation. The recurrence risk for CSP is unknown, and early ultrasound in the next pregnancy is recommended.


Heterotopic pregnancy

In rare cases of ectopic pregnancy, there may be two fertilized eggs, one outside the uterus and the other inside. This is called a
heterotopic pregnancy A heterotopic pregnancy is a complication of pregnancy in which both extrauterine ( ectopic) pregnancy and intrauterine pregnancy occur simultaneously. It may also be referred to as a combined ectopic pregnancy, multiple‑sited pregnancy, or co ...
. Often, the intrauterine pregnancy is discovered later than the ectopic, mainly because of the painful emergency nature of ectopic pregnancies. Since ectopic pregnancies are normally discovered and removed very early in the pregnancy, an ultrasound may not find the additional pregnancy inside the uterus. When hCG levels continue to rise after the removal of the ectopic pregnancy, there is a chance that a pregnancy inside the uterus is still viable. This is normally discovered through an ultrasound. Although rare, heterotopic pregnancies are becoming more common, likely due to increased use of IVF. The survival rate of the uterine fetus of a heterotopic pregnancy is around 70%.


Rudimentary horn pregnancy

A
pregnancy in a rudimentary horn Pregnancy in a rudimentary horn of the uterus is a very rare type of ectopic pregnancy. This type of pregnancy can be life-threatening, as the rudimentary horn is not meant to sustain a pregnancy and is at risk of rupturing. Unicornuate uterus wit ...
refers to a rare and life-threatening condition that occurs when a fertilized egg implants inside the small rudimentary horn of a
unicornuate uterus A unicornuate uterus represents a uterine malformation where the uterus is formed from only one of the paired Müllerian ducts while the other Müllerian duct does not develop or only in a rudimentary fashion. The sometimes called hemi-uterus ha ...
, which is a type of congenital uterine abnormality caused by the incomplete development of one of the
Müllerian ducts The paramesonephric ducts (or Müllerian ducts) are paired ducts of the embryo in the reproductive system of humans and other mammals that run down the lateral sides of the genital ridge and terminate at the sinus tubercle in the primitive urogen ...
. This type of ectopic pregnancy is often results in rupture of the rudimentary horn between 10 and 15 weeks of gestation, leading to a high risk of morbidity and mortality.


Persistent ectopic pregnancy

A persistent ectopic pregnancy refers to the continuation of trophoblastic growth after a surgical intervention to remove an ectopic pregnancy. After a conservative procedure that attempts to preserve the affected fallopian tube such as a
salpingotomy Salpingectomy refers to the surgical removal of a fallopian tube. This may be done to treat an ectopic pregnancy or cancer, to prevent cancer, or as a form of contraception. This procedure is now sometimes preferred over its ovarian tube-sparin ...
, in about 15–20%, the major portion of the ectopic growth may have been removed, but some trophoblastic tissue, perhaps deeply embedded, has escaped removal and continues to grow, generating a new rise in hCG levels. After weeks, this may lead to new clinical symptoms, including bleeding. For this reason, hCG levels may have to be monitored after the removal of an ectopic pregnancy to ensure their decline, also
methotrexate Methotrexate, formerly known as amethopterin, is a chemotherapy agent and immunosuppressive drug, immune-system suppressant. It is used to treat cancer, autoimmune diseases, and ectopic pregnancy, ectopic pregnancies. Types of cancers it is u ...
can be given at the time of surgery prophylactically.


Pregnancy of unknown location

Pregnancy of unknown location (PUL) is the term used for a pregnancy where there is a positive pregnancy test but no pregnancy has been visualized using transvaginal ultrasonography. Specialized early pregnancy departments have estimated that between 8% and 10% of women attending for an ultrasound assessment in early pregnancy will be classified as having a PUL. The true nature of the pregnancy can be an ongoing viable intrauterine pregnancy, a failed pregnancy, an ectopic pregnancy or rarely a persisting PUL. Because of frequent ambiguity on ultrasonography examinations, the following classification is proposed: In women with a pregnancy of unknown location, between 6% and 20% have an ectopic pregnancy. In cases of pregnancy of unknown location and a history of heavy bleeding, it has been estimated that approximately 6% have an underlying ectopic pregnancy. Between 30% and 47% of women with pregnancy of unknown location are ultimately diagnosed with an ongoing intrauterine pregnancy, whereof the majority (50–70%) will be found to have failing pregnancies where the location is never confirmed. is where the hCG level does not spontaneously decline and no intrauterine or ectopic pregnancy is identified on follow-up transvaginal ultrasonography. A persisting PUL is likely either a small ectopic pregnancy that has not been visualized, or a retained trophoblast in the endometrial cavity. Treatment should only be considered when a potentially viable intrauterine pregnancy has been definitively excluded. A ''treated persistent PUL'' is defined as one managed medically (generally with methotrexate) without confirmation of the location of the pregnancy, such as by ultrasound, laparoscopy, or uterine evacuation. A ''resolved persistent PUL'' is defined as serum hCG reaching a non-pregnant value (generally less than 5 IU/L) after expectant management, or after uterine evacuation without evidence of
chorionic villi Chorionic villi are Wiktionary:villus, villi that sprout from the chorion to provide maximal contact area with maternal blood. They are an essential element in pregnancy from a histology, histomorphologic perspective, and are, by definition, a pr ...
on histopathological examination. In contrast, a relatively low and unresolving level of serum hCG indicates the possibility of an hCG-secreting tumor.


Differential diagnosis

Other conditions that cause similar symptoms include: miscarriage, ovarian torsion, acute appendicitis, ruptured ovarian cyst,
kidney stone Kidney stone disease (known as nephrolithiasis, renal calculus disease, or urolithiasis) is a crystallopathy and occurs when there are too many minerals in the urine and not enough liquid or hydration. This imbalance causes tiny pieces of cr ...
, and pelvic inflammatory disease, among others.


Treatment


Expectant management

Most women with a PUL are followed up with serum hCG measurements and repeat TVS examinations until a final diagnosis is confirmed. Low-risk cases of PUL that appear to be failing pregnancies may be followed up with a urinary pregnancy test after two weeks and get subsequent telephone advice. Low-risk cases of PUL that are likely intrauterine pregnancies may have another TVS in two weeks to assess viability. High-risk cases of PUL require further assessment, either with a TVS within 48 h or additional hCG measurement.


Medical

Early treatment of ectopic pregnancy with methotrexate is a viable alternative to surgical treatment which was developed in the 1980s. If administered early in the pregnancy, methotrexate terminates the growth of the developing embryo; the developing embryo may then be either resorbed by the woman's body or pass with a
menstrual period The menstrual cycle is a series of natural changes in hormone production and the structures of the uterus and ovaries of the female reproductive system that makes pregnancy possible. The ovarian cycle controls the production and release of eg ...
. Contraindications include ectopic embryonic mass > 3.5 cm and evidence of ruptured fallopian tube, as well as renal or hepatic dysfunction. Also, it may lead to the inadvertent termination of an undetected intrauterine pregnancy or severe abnormality in any surviving pregnancy. Therefore, it is recommended that methotrexate should only be administered when hCG has been serially monitored with a rise of less than 35% over 48 hours, which practically excludes a viable intrauterine pregnancy. For nontubal ectopic pregnancy, evidence from randomized clinical trials in women with CSP is uncertain regarding treatment success, complications and side effects of methotrexate compared with surgery ( uterine arterial embolization or uterine arterial chemoembolization). The United States uses a multi-dose protocol of methotrexate (MTX), which involves four doses of intramuscular MTX along with an intramuscular injection of folinic acid to protect cells from the effects of the drug and to reduce side effects. In France, the single-dose protocol is followed, but a single dose has a greater chance of failure.


Surgery

If bleeding has already occurred, surgical intervention may be necessary. However, whether to pursue surgical intervention is an often difficult decision in a stable patient with minimal evidence of a blood clot on ultrasound. Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected fallopian tube and remove only the pregnancy (
salpingostomy Salpingectomy refers to the surgical removal of a fallopian tube. This may be done to treat an ectopic pregnancy or cancer, to prevent cancer, or as a form of contraception. This procedure is now sometimes preferred over its ovarian tube-sparin ...
) or remove the affected tube with the pregnancy (
salpingectomy Salpingectomy refers to the surgical removal of a fallopian tube. This may be done to treat an ectopic pregnancy or cancer, to prevent cancer, or as a form of contraception. This procedure is now sometimes preferred over its ovarian tube-sparin ...
). The first successful surgery for an ectopic pregnancy was performed by Robert Lawson Tait in 1883. It is estimated that an acceptable rate of PULs that eventually undergo surgery is between 0.5 and 11%. People that undergo salpingectomy and salpingostomy have a similar recurrent ectopic pregnancy rate of 5% and 8% respectively. Additionally, their intrauterine pregnancy rates are also similar, 56% and 61%.
Autotransfusion Autotransfusion is a process wherein a person receives their own blood for a Blood transfusion, transfusion, instead of blood bank, banked allogenic (separate-Blood donor, donor) blood. There are two main kinds of autotransfusion: Blood can be Aut ...
of a woman's own blood as drained during surgery may be useful in those who have a lot of bleeding into their abdomen. No technique exists to re-implant an ectopic
embryo An embryo ( ) is the initial stage of development for a multicellular organism. In organisms that reproduce sexually, embryonic development is the part of the life cycle that begins just after fertilization of the female egg cell by the male sp ...
in the uterus – all interventions, whether surgical or pharmaceutical, result in the termination of the ectopic pregnancy. Published reports that a re-implanted embryo survived to birth were debunked as false.


Prognosis

When ectopic pregnancies are treated, the prognosis for the mother is very good in Western countries; maternal death is rare, although treatment nearly always requires the removal of the nonviable fetus. For instance, in the UK, between 2003 and 2005, there were 32,100 ectopic pregnancies resulting in 10 maternal deaths (meaning that 1 in 3,210 women with an ectopic pregnancy died). In 2006–2008 the UK Confidential Enquiry into Maternal Deaths found that ectopic pregnancy was the cause of 6 maternal deaths out of 2.3 million pregnancies in that period (0.26/100,000 pregnancies). In the developing world, however, especially in Africa, the death rate is very high, and ectopic pregnancies are a major cause of death among women of childbearing age. In women who have had an ectopic pregnancy, the risk of another one in the next pregnancy is around 10%.


Future fertility

Fertility following ectopic pregnancy depends upon several factors, the most important of which is a prior history of infertility. The treatment choice does not play a major role; a randomized study in 2013 concluded that the rates of intrauterine pregnancy two years after treatment of ectopic pregnancy are approximately 64% with radical surgery, 67% with medication, and 70% with conservative surgery. In comparison, the cumulative pregnancy rate of women under 40 years of age in the general population over two years is over 90%.Fertility: assessment and treatment for people with fertility problems
. NICE clinical guideline CG156 – Issued: February 2013
Methotrexate does not affect future fertility treatments. The number of oocytes that were retrieved before and after treatment with methotrexate does not change. In case of ovarian ectopic pregnancy, the risk of subsequent ectopic pregnancy or infertility is low. There is no evidence that massage improves fertility after ectopic pregnancy.


Epidemiology

The rate of ectopic pregnancy is about 1% and 2% of live births in developed countries, though it is as high as 4% in pregnancies involving assisted reproductive technology. Between 93% and 97% of ectopic pregnancies are located in a fallopian tube. Of these, in turn, 13% are located in the
isthmus An isthmus (; : isthmuses or isthmi) is a narrow piece of land connecting two larger areas across an expanse of water by which they are otherwise separated. A tombolo is an isthmus that consists of a spit or bar, and a strait is the sea count ...
, 75% are located in the
ampulla An ampulla (; : ampullae) was, in Ancient Rome, a small round vessel, usually made of glass and with two handles, used for sacred purposes. The word is used of these in archaeology, and of later flasks, often handle-less and much flatter, for ho ...
, and 12% in the fimbriae. Ectopic pregnancy is responsible for 6% of maternal deaths during the first trimester of pregnancy making it the leading cause of maternal death during this stage of pregnancy. Between 5% and 42% of women seen for ultrasound assessment with a positive pregnancy test have a pregnancy of unknown location, that is a positive pregnancy test but no pregnancy visualized at transvaginal ultrasonography. Between 6% and 20% of pregnancy of unknown location are subsequently diagnosed with actual ectopic pregnancy.


Society and culture

Salpingectomy Salpingectomy refers to the surgical removal of a fallopian tube. This may be done to treat an ectopic pregnancy or cancer, to prevent cancer, or as a form of contraception. This procedure is now sometimes preferred over its ovarian tube-sparin ...
as a treatment for ectopic pregnancy is one of the common cases when the principle of double effect can be used to justify accelerating the death of the embryo by doctors and patients opposed to outright abortions. In the
Catholic Church The Catholic Church (), also known as the Roman Catholic Church, is the List of Christian denominations by number of members, largest Christian church, with 1.27 to 1.41 billion baptized Catholics Catholic Church by country, worldwid ...
, there are moral debates on certain treatments. A significant number of Catholic moralists consider the use of methotrexate and the salpingostomy procedure to be not "morally permissible" because they destroy the embryo; however, situations are considered differently in which the mother's health is endangered, and the whole fallopian tube with the developing embryo inside is removed. Organizations exist that provide information and support to help those who experience ectopic pregnancy. Studies show that people can experience post-traumatic stress, depression, and anxiety for which they would need specialist therapies. Partners can also experience post-traumatic stress.


Live birth

There have been cases where ectopic pregnancy lasted many months and ended in a live baby delivered by laparotomy. In July 1999, Lori Dalton gave birth by
caesarean section Caesarean section, also known as C-section, cesarean, or caesarean delivery, is the Surgery, surgical procedure by which one or more babies are Childbirth, delivered through an incision in the mother's abdomen. It is often performed because va ...
in
Ogden, Utah Ogden ( ) is a city in and the county seat of Weber County, Utah, Weber County, Utah, United States, approximately east of the Great Salt Lake and north of Salt Lake City. The population was 87,321 in 2020, according to the United States Census ...
, United States, to a healthy baby girl, Saige, who had developed outside of the uterus. Previous ultrasounds had not discovered the problem. "
alton Alton may refer to: People *Alton (given name) * Alton (surname) Places Australia * Alton National Park, Queensland * Alton, Queensland, a town in the Shire of Balonne Canada * Alton, Ontario * Alton, Nova Scotia New Zealand * Alton, New Zeala ...
s delivery was slated as a routine Caesarean birth at Ogden Regional Medical Center in Utah. When Dr. Naisbitt performed Lori's Caesarean, he was astonished to find Saige within the amniotic membrane outside the womb ... ." "But what makes this case so rare is that not only did mother and baby survive—they're both in perfect health. The father, John Dalton, took home video inside the delivery room. Saige came out doing extremely well because even though she had been implanted outside the womb, a rich blood supply from a
uterine fibroid Uterine fibroids, also known as uterine leiomyomas, fibromyoma or fibroids, are benign smooth muscle tumors of the uterus, part of the female reproductive system. Most people with fibroids have no symptoms while others may have painful or h ...
along the outer uterus wall had nourished her with a rich source of blood." In September 1999, an English woman, Jane Ingram (age 32) gave birth to triplets: Olivia, Mary, and Ronan, with an extrauterine fetus (Ronan) below the womb and
twins Twins are two offspring produced by the same pregnancy.MedicineNet > Definition of Twin Last Editorial Review: 19 June 2000 Twins can be either ''monozygotic'' ('identical'), meaning that they develop from one zygote, which splits and forms two e ...
in the womb. All three survived. The twins in the womb were taken out first. On May 29, 2008, an Australian woman, Meera Thangarajah (age 34), who had an ectopic pregnancy in the
ovary The ovary () is a gonad in the female reproductive system that produces ova; when released, an ovum travels through the fallopian tube/ oviduct into the uterus. There is an ovary on the left and the right side of the body. The ovaries are end ...
, gave birth to a healthy full-term 6-pound 3-ounce (2.8 kg) baby girl, Durga, via Caesarean section. She had no problems or complications during the 38‑week pregnancy.


Animals

Ectopic gestation exists in
mammal A mammal () is a vertebrate animal of the Class (biology), class Mammalia (). Mammals are characterised by the presence of milk-producing mammary glands for feeding their young, a broad neocortex region of the brain, fur or hair, and three ...
s other than humans. In
sheep Sheep (: sheep) or domestic sheep (''Ovis aries'') are a domesticated, ruminant mammal typically kept as livestock. Although the term ''sheep'' can apply to other species in the genus '' Ovis'', in everyday usage it almost always refers to d ...
, it can go to term, with
mammary A mammary gland is an exocrine gland that produces milk in humans and other mammals. Mammals get their name from the Latin word ''mamma'', "breast". The mammary glands are arranged in organs such as the breasts in primates (for example, humans ...
preparation to
parturition Birth is the act or process of bearing or bringing forth offspring, also referred to in technical contexts as parturition. In mammals, the process is initiated by hormones which cause the muscular walls of the uterus to contract, expelling the f ...
, and expulsion efforts. The fetus can be removed by caesarean section. Pictures of caesarian section of a euthanized ewe, five days after parturition signs. File:Poirtêye foû matrice pate.JPG, Leg of fetal lamb appearing out of the uterus during caesarean section File:Poirtêye foû matrice saetch1.JPG, External view of fetal sac, necrotic distal part File:Poirtêye foû matrice saetch2.JPG, Internal view of fetal sac, before resection of distal necrotic part File:Poirtêye foû matrice saetch3.JPG, Internal view of fetal sac. The necrotic distal part is to the left. File:Poirtêye foû matrice saetch&coine.JPG, External side of fetal sac, proximal end, with ovary and uterine horn File:Poirtêye foû matrice saetch ådfoû pwels.JPG, Resected distal part of fetal sac, with attached placenta


See also

*
Indirect abortion Indirect abortion is the name given by Catholic theologians to a medical procedure which has a beneficial medical effect and also results in an abortion as a secondary effect. Edwin F. Healy makes a distinction between "direct abortions" that is ...


References


External links


CT of the abdomen showing abdominal ectopic pregnancy
{{Authority control Wikipedia articles with sections published in WikiJournal of Medicine Medical emergencies Health issues in pregnancy Wikipedia medicine articles ready to translate Acute pain