eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Pregnancy, Ectopic

Author: Thomas J Chi, MD, Assistant Clinical Professor, Emergency Medicine, State University of New York Downstate Medical Center; Attending Physician, Emergency Medicine, Kings County Hospital Center, New York
Contributor Information and Disclosures

Updated: Nov 9, 2009

Introduction

Background

An ectopic pregnancy is any implantation of a fertilized ovum at a site other than the endometrial lining of the uterus. Virtually all ectopic pregnancies are considered nonviable and are at risk of eventual rupture. Rupture of an ectopic pregnancy and resulting hemorrhage is one of the leading causes of first-trimester maternal death in the developed world; therefore, early diagnosis and treatment (before rupture) is important to prevent morbidity and mortality.1

An endovaginal sonogram demonstrates an early ect...

An endovaginal sonogram demonstrates an early ectopic pregnancy. An echogenic ring (tubal ring) found outside of the uterus can be seen in this view.

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An endovaginal sonogram demonstrates an early ect...

An endovaginal sonogram demonstrates an early ectopic pregnancy. An echogenic ring (tubal ring) found outside of the uterus can be seen in this view.


Pregnancy, ectopic. An endovaginal sonogram revea...

Pregnancy, ectopic. An endovaginal sonogram reveals an intrauterine pregnancy at approximately 6 weeks. A yolk sac (ys), gestational sac (gs), and fetal pole (fp) are depicted.

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Pregnancy, ectopic. An endovaginal sonogram revea...

Pregnancy, ectopic. An endovaginal sonogram reveals an intrauterine pregnancy at approximately 6 weeks. A yolk sac (ys), gestational sac (gs), and fetal pole (fp) are depicted.


Pathophysiology

The faulty implantation that occurs in ectopic pregnancy occurs because of a defect in the anatomy or normal function of either the fallopian tube (as in surgical or infectious scarring), the ovary (as in women undergoing fertility treatments), or the uterus (as in cases of bicornuate uterus, cesarean delivery scar).
 
Reflecting this, about 95% of ectopic pregnancies occur in the fallopian tube — 70% in the ampulla; 12%, isthmus; 11.1%, fimbria; and 2.4%, interstitium (or cornual region of the uterus). Some ectopic pregnancies implant in the cervix (<1%), in prior cesarean delivery scars, or in a rudimentary uterine horn; although these may be technically in the uterus, they are not considered normal intrauterine pregnancies. About 3.2% of ectopic pregnancies occur in the ovary, and 1.3% occur in the abdomen.2 About 80% of ectopic pregnancies are found on the same side as the corpus luteum (the old ruptured follicle), when present.3 In the absence of modern prenatal care, abdominal pregnancies can present at an advanced stage (>28 wk) and have the potential for catastrophic rupture and bleeding.4

Frequency

United States

Using inpatient data derived from the National Hospital Discharge Survey, the Centers for Disease Control and Prevention (CDC) reported that the incidence of ectopic pregnancies rose dramatically in the United States from 1970 until 1989, from 4.5 to 16.0 per 1,000 reported pregnancies.5 Since then, changes in the management of ectopic pregnancy have made it difficult to reliably monitor incidence (and therefore mortality rates).6

A review of hospital discharges in California found a rate of 15 cases per 1,000 in 1991, declining to a rate of 9.3 cases per 1,000 in 2000,7 but a review of electronic medical records (inpatient and outpatient) from a large health maintenance organization in northern California found a stable rate of 20.7 cases per 1,000 reported pregnancies from 1997-2000.8 This suggests that the incidence of ectopic pregnancy in the United States remained steady at about 2% in the 1990s, despite the shift to outpatient treatment.

International

The increase in incidence of ectopic pregnancy in the 1970s in the United States was also mirrored in Africa, although data there tend to be hospital-based rather than nationwide surveys, with most recent estimates in the range of 1.1-4.6%.9

The United Kingdom estimates the incidence of ectopic pregnancy at about 11.1 per 1,000 reported pregnancies from 1997-2005 compared with 9.6 per 1,000 from 1991-1993.10

Mortality/Morbidity

From 1970-1989, the US mortality rate dropped from 35.5 to 3.8 per 10,000 ectopic pregnancies.5 If the overall incidence of ectopic pregnancy remained stable in the 1990s, then the mortality rate dropped to 3.19 per 10,000 ectopic pregnancies by 1999.11 The mortality rate reported in African hospital-based studies varies from 50-860 per 10,000 ectopic pregnancies; these are almost certainly underestimates due to underreporting of maternal deaths and misclassification of ectopic pregnancies as induced abortions.9

Surveillance data for pregnancy-related deaths in the United States from 1991-1999 showed that ectopic pregnancy was the cause of 5.6% of 4,200 maternal deaths. Of these deaths, 93% occurred via hemorrhage.12 Using data from 1997-2002, the World Health Organization (WHO) estimated that ectopic pregnancy was the cause of 4.9% of pregnancy-related deaths in the developed world.13 Ectopic pregnancy caused 26% of maternal deaths in early pregnancy in the United Kingdom from 2003-2005, second only to venous thromboembolism, despite a relatively low mortality rate of 0.035 per 10,000 estimated ectopic pregnancies.10

Race

In the United States from 1991-1999, ectopic pregnancy was the cause of 8% of all pregnancy-related deaths of African American women compared with 4% for white women.12

Sex

Any woman with functioning ovaries can potentially have an ectopic pregnancy.

Age

Any woman from the age of menarche until menopause can potentially have an ectopic pregnancy. Women older than 40 years were found to have an adjusted odds ratio of 2.9 (95% confidence interval [CI], 1.4-6.1) for ectopic pregnancy.14

Clinical

History

The classic triad of symptoms in ectopic pregnancy is abdominal pain, amenorrhea, and vaginal bleeding, but fewer than half of patients present with all 3 symptoms. In one case series of ectopic pregnancies, abdominal pain presented in 98.6%, amenorrhea in 74.1%, and irregular vaginal bleeding in 56.4%.15 These symptoms overlap with those of spontaneous abortion; a prospective consecutive case series found no statistically significant differences in the presenting symptoms of patients with unruptured ectopic pregnancies versus those with intrauterine pregnancies.16

In first-trimester symptomatic patients, pain as the presenting symptom is associated with an odds ratio of 1.42 (95% CI, 1.06-1.92), and moderate-to-severe vaginal bleeding at presentation is associated with an odds ratio of 1.42 (95% CI, 1.04-1.93) for ectopic pregnancy.17 In one study, 9% of patients with ectopic pregnancy presented with painless vaginal bleeding.18

Other presenting complaints may be nonspecific such as painful fetal movements (in the case of advanced abdominal pregnancy), dizziness or weakness, fever, flu-like symptoms, vomiting, syncope, or cardiac arrest. Shoulder pain may be reflective of peritoneal irritation.

In a review of deaths from ectopic pregnancy in Michigan, 44% were either found dead at home or were dead on arrival at the emergency department.19

Physical

The physical examination of patients with ectopic pregnancy is highly variable and often unhelpful. Patients frequently present with benign examination findings, and adnexal masses are rarely found. Patients in hemorrhagic shock from ruptured ectopic may not be tachycardic.20

Some physical findings that have been found to be predictive (although not diagnostic) for ectopic pregnancy were the presence of peritoneal signs, cervical motion tenderness, and unilateral or bilateral abdominal or pelvic tenderness. However, midline abdominal tenderness or a uterine size of greater than 8 weeks on pelvic examination decreases the risk of ectopic pregnancy.21

The presence of uterine contents in the vagina, which can be caused by shedding of endometrial lining stimulated by an ectopic pregnancy, may lead to a misdiagnosis of an incomplete or complete abortion and therefore a delayed or missed diagnosis of ectopic pregnancy.

Causes

An ectopic pregnancy requires the occurrence of 2 events: fertilization of the ovum and abnormal implantation. Many risk factors affect both events; for example, history of major tubal infection decreases fertility and increases abnormal implantation. Major risk factors include previous ectopic pregnancy, previous tubal surgery, documented tubal pathology, and maternal in utero DES exposure.

Previous treatment of pelvic infections (whether documented or not), 2 or more years of infertility (whether treated or not), and multiple sexual partners were associated with mildly elevated risk.22 A large case-control study in France found that about one third of cases could be attributed to smoking (presumably by impairing tubal motility), one-third to infectious history and prior tubal surgery (considered together), 18% to a history of infertility, and 14% to maternal age (although this is not an independent risk factor); 24% had no attributable risk factors.14 Women using assisted reproduction seem to have a doubled risk of ectopic pregnancy (to 4%), although this is mostly due to the underlying infertility.23

All contraceptive methods lead to an overall lower risk of pregnancy, and therefore also an overall lower risk of ectopic pregnancy. However, among cases of contraceptive failure, women at increased risk of ectopic pregnancy compared with pregnant controls include those using progestin-only oral contraceptives, progestin-only implants, or intrauterine devices (IUDs), and those with a history of tubal ligation.24 In one study, 33% of pregnancies occurring after tubal ligation were ectopic; those who underwent electrocautery and women younger than 35 years were at higher risk.25 Emergency contraception (levonorgestrel, or Plan B) does not appear to lead to a higher-than-expected rate of ectopic pregnancy.26 A recent literature review found 56 reported cases of ectopic pregnancy (by definition) after hysterectomy, dating back to 1937.27

Other causes of ectopic pregnancy include anatomic abnormalities of the uterus such as a bicornuate uterus, fibroids or other uterine tumors, or endometriosis; or abnormalities of the tubes such as salpingitis isthmica nodosa or tubal ligation reversal. Appendicitis has also been found to be a risk factor for ectopic pregnancy.14

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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Contributor Information and Disclosures

Author

Thomas J Chi, MD, Assistant Clinical Professor, Emergency Medicine, State University of New York Downstate Medical Center; Attending Physician, Emergency Medicine, Kings County Hospital Center, New York
Thomas J Chi, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Medical Society of the State of New York
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: eMedicine Salary Employment

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: Medicines Company Consulting fee Consulting; Pfizer Salary Employment

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, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

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