eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Pregnancy, Ectopic

Author: Verena T Valley, MD, Associate Professor, Director of Ultrasound, Department of Emergency Medicine, University of Mississippi School of Medicine; Consulting Staff, Department of Emergency Medicine, Singing River Hospital System, Singing River Hospital, and Ocean Springs Hospital
Coauthor(s): Christopher A Fly, MD, Assistant Professor, Department of Emergency Medicine, Medical College of Georgia
Contributor Information and Disclosures

Updated: Jun 8, 2006

Introduction

Background

An ectopic pregnancy occurs when a fertilized ovum implants at a site other than the endometrial lining of the uterus. Ectopic pregnancies occur in the fallopian tube in 97% of cases, with 55% in the ampulla; 25% in the isthmus; 17% in the fimbria; and 3% of cases within the abdomen, ovary, and cervix.

Pathophysiology

Ectopic pregnancies are primarily due to prior tubal/genital infection or surgery, fallopian anatomic abnormalities, or endometrial abnormalities. Abnormal implantation sites include the fallopian tube, interstitium (formerly cornu), ovary, cervix, and peritoneum.

Frequency

United States

The incidence of ectopic pregnancy in 1992 based on aggregated inpatient and outpatient data was 108,800, or 19.7 per 1000 reported pregnancies. Females taking fertility drugs have a higher risk of ectopic pregnancy than that of females not taking such drugs.

Mortality/Morbidity

  • Ectopic pregnancy is the leading cause of pregnancy-related death in the first trimester, and it is a cause of significant morbidity. It is responsible for 10% of maternal deaths.
  • Surveillance data for pregnancy-related deaths in the United States for 1987-1990 revealed 1,459 deaths. Ectopic pregnancy accounted for 10.8% of these deaths.

Race

African American teenagers and teenagers of other minority races have a mortality rate that was almost 5 times higher than that of white teenagers.

Age

Most ectopic pregnancies occur in women aged 25-34 years.

  • Surveillance data of pregnancy-related deaths (from all causes) in 1987-1990 demonstrated that women aged 30 years or older had a higher risk for pregnancy related death than that of younger women.
  • Women aged 35-39 years had a 2.6-fold higher risk for death than that of women aged 25-29 years; the risk was 5.9-fold higher for women aged 40 years or older.

Clinical

History

The history of patients with an ectopic pregnancy may include the following features:

  • History of late or delayed menses
  • Abdominal and/or pelvic pain and cramping
  • Vaginal bleeding (may be absent)
  • Shoulder pain
  • Faintness
  • Marked or painful fetal movements

Physical

Physical examination is unreliable for clinicians who face this significant diagnostic challenge. Abbott et al and Stovall et al reported an alarming rate of missed and/or delayed diagnoses in the ED. Although findings at physical examination may be variable, they may include the following:

  • Vaginal bleeding may be mild or absent. Up to 30% of patients with ectopic pregnancies have no vaginal bleeding.
  • Abdominal pain may be minimal or severe.
  • Shoulder pain is suggestive of peritoneal free fluid (significant hemorrhage).
  • Ectopic pregnancies can be accompanied by sloughing material, which is suggestive of a miscarriage.
  • Adnexal masses may be palpable in only 60% of patients (under anesthesia).
  • Tenesmus or syncope may occur.
  • Decidual cast may be passed.
  • Clinical shock may occur after rupture.
  • No combination of physical findings may reliably exclude the diagnosis of ectopic pregnancy.

Causes

Causes of ectopic pregnancy may include the following:

  • Previous tubal pregnancy or surgery
  • Pelvic inflammatory disease (PID)
  • Endometriosis
  • Salpingitis isthmica nodosa
  • Pelvic adhesions
  • Pelvic tumors
  • Atrophic endometrium
  • Septate uterus
  • Presence of an intrauterine device (IUD)
  • Oral contraceptive use

More on Pregnancy, Ectopic

Overview: Pregnancy, Ectopic
Differential Diagnoses & Workup: Pregnancy, Ectopic
Treatment & Medication: Pregnancy, Ectopic
Follow-up: Pregnancy, Ectopic
Multimedia: Pregnancy, Ectopic
References
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References

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Further Reading

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Keywords

abnormal implantation, pregnancy-related death, ectopic pregnancy, pregnancy outside of the uterus, abnormal implantation, tubal infection, fallopian anatomic abnormalities, endometrial abnormalities, fertility drugs, abdominal pain, pelvic pain, adnexal masses, tenesmus, syncope, shock, pelvic inflammatory disease, PID, endometriosis, salpingitis isthmica nodosa, pelvic adhesions, pelvic tumors, atrophic endometrium, septate uterus, presence of an intrauterine device, IUD, oral contraceptive use

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Contributor Information and Disclosures

Author

Verena T Valley, MD, Associate Professor, Director of Ultrasound, Department of Emergency Medicine, University of Mississippi School of Medicine; Consulting Staff, Department of Emergency Medicine, Singing River Hospital System, Singing River Hospital, and Ocean Springs Hospital
Verena T Valley, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher A Fly, MD, Assistant Professor, Department of Emergency Medicine, Medical College of Georgia
Christopher A Fly, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Assaad J Sayah, MD, Chief, Department of Emergency Medicine, Cambridge Health Alliance
Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Associate Professor, Program Director, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles School of Medicine
Pamela L Dyne, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

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