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Ectopic Pregnancy

Topic Overview

What is an ectopic pregnancy?

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

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

What causes an ectopic pregnancy?

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

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

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

What are the symptoms?

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

The key signs of an ectopic pregnancy are:

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

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

How is an ectopic pregnancy diagnosed?

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

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

How is it treated?

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

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

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

What can you expect after an ectopic pregnancy?

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

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

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

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

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

Frequently Asked Questions

Learning about ectopic pregnancy:

Being diagnosed:

Getting treatment:

Ongoing concerns:

Cause

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

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

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

Although pregnancy is rare after a tubal ligation or with an intrauterine device (IUD), those pregnancies that do develop may have an increased chance of being ectopic.

Symptoms

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

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

First signs of an ectopic pregnancy may include:

  • Vaginal bleeding, which may be light.
  • Abdominal (belly) pain or pelvic pain, usually 6 to 8 weeks after a missed period.

As an ectopic pregnancy progresses, though, other symptoms may develop, including:

  • Belly pain or pelvic pain that may get worse with movement or straining. It may occur sharply on one side at first and then spread throughout the pelvic region.
  • Heavy or severe vaginal bleeding.
  • Pain with intercourse or during a pelvic exam.
  • Dizziness, lightheadedness, or fainting (syncope) caused by internal bleeding.
  • Signs of shock.
  • Shoulder pain caused by bleeding into the abdomen under the diaphragm. The bleeding irritates the diaphragm and is experienced as shoulder pain.

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

What Happens

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

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

An ectopic pregnancy can develop in different locations. In most ectopic pregnancies, the fertilized egg has implanted in a fallopian tube.

In rare cases:

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

Complications of ectopic pregnancy

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

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

What Increases Your Risk

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

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

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

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

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

When To Call a Doctor

If you are pregnant, be alert to the symptoms that may mean you have an ectopic pregnancy, especially if you are at risk. If you have symptoms of an ectopic pregnancy or you are being treated for an ectopic pregnancy, avoid strenuous activity until your symptoms have been evaluated by a doctor.

Call 911 or other emergency services immediately if:

  • You passed out (lost consciousness).
  • You have severe vaginal bleeding.
  • You have sudden, severe pain in your belly or pelvis.

Call your doctor now or seek immediate medical care if:

  • You are dizzy or lightheaded, or you feel like you may faint.
  • You have vaginal bleeding.
  • You have new cramps or new pain in your belly or pelvis.

Who to see

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

A diagnosed ectopic pregnancy is treated by a gynecologist.

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

Exams and Tests

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

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

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

Follow-up testing after treatment

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

What to think about

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

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

Treatment Overview

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

Medicine

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

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

Surgery

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

Expectant management

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

Ectopic pregnancies can be resistant to treatment.

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

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

What to think about

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

Surgery may be your only treatment option if you have internal bleeding.

Prevention

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

If you smoke, quit to lower your risk of ectopic pregnancy. Women who smoke or who used to smoke have higher rates of ectopic pregnancy.

Using safer sex practices, such as using a male condom or a female condom every time you have sex helps protect you from sexually transmitted infections (STIs) that can lead to pelvic inflammatory disease (PID). PID is a common cause of scar tissue in the fallopian tubes, which can cause ectopic pregnancy.

Home Treatment

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

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

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

You can contact a support group, read about the experiences of other women, and talk to friends, a counselor, or a member of the clergy. These things may help you and your family deal with a pregnancy loss.

Concerns about future pregnancy

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

Medications

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

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

  • Your pregnancy hormone (hCG, or human chorionic gonadotropin) level is low (less than 5,000).
  • The embryo has no heart activity.

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

Medicine choices

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

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

What to think about

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

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

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

Methotrexate versus surgery

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

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

Surgery

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

Surgery choices

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

  • Salpingostomy. The ectopic growth is removed through a small, lengthwise cut in the fallopian tube (linear salpingostomy). The cut is left to close by itself or is stitched closed.
  • Salpingectomy. A fallopian tube segment is removed. The remaining healthy fallopian tube may be reconnected. Salpingectomy is needed when the fallopian tube is being stretched by the pregnancy and may rupture or when it has already ruptured or is very damaged.

Both salpingostomy and salpingectomy can be done either through a small incision using laparoscopy or through a larger open abdominal incision (laparotomy). Laparoscopy takes less time than laparotomy. And the hospital stay is shorter. But for an abdominal ectopic pregnancy or an emergency tubal ectopic removal, a laparotomy is usually required.

What to think about

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

Emergency surgery is needed for a ruptured ectopic pregnancy.

Future fertility

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

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

Other Places To Get Help

Organizations

American Congress of Obstetricians and Gynecologists (ACOG)
409 12th Street SW
P.O. Box 70620
Washington, DC  20024-9998
Phone: 1-800-673-8444
Phone: (202) 638-5577
Email: resources@acog.org
Web Address: www.acog.org
 

American Congress of Obstetricians and Gynecologists (ACOG) is a nonprofit organization of professionals who provide health care for women, including teens. The ACOG Resource Center publishes manuals and patient education materials. The Web publications section of the site has patient education pamphlets on many women's health topics, including reproductive health, breast-feeding, violence, and quitting smoking.


American Pregnancy Association
1425 Greenway Drive
Suite 440
Irving, TX  75038
Phone: 1-800-672-2296
Fax: (972) 550-0800
Email: questions@americanpregnancy.org
Web Address: www.americanpregnancy.org
 

The American Pregnancy Association is a national health organization committed to promoting reproductive and pregnancy wellness through education, research, advocacy, and community awareness. You can call a toll-free helpline or use the Web site to request patient education materials.


Planned Parenthood Federation of America
434 West 33rd Street
New York, NY  10001
Phone: 1-800-230-PLAN (1-800-230-7526)
(212) 541-7800
Fax: (212) 245-1845
Web Address: www.plannedparenthood.org
 

The Planned Parenthood Federation of American provides comprehensive reproductive health care and consumer information about family planning, sexual health, and sexually transmitted diseases (STDs).

The Teen Talk Web site (www.plannedparenthood.org/teen-talk) has information for teens about dating, teen pregnancy, sexual orientation, gender identity, how teens can protect themselves against STDs, and more.


References

Other Works Consulted

  • American College of Obstetricians and Gynecologists (2008, reaffirmed 2012). Medical management of ectopic pregnancy. ACOG Practice Bulletin No. 94. Obstetrics and Gynecology, 111(6): 1479–1485.
  • Cunningham FG, et al. (2010). Ectopic pregnancy. In Williams Obstetrics, 23rd ed., pp. 238–256. New York: McGraw-Hill.
  • Fritz MA, Speroff L (2011). Ectopic pregnancy. In Clinical Gynecologic Endocrinology and Infertility, 8th ed., pp. 1383–1412. Philadelphia: Lippincott Williams and Wilkins.
  • Leven ED, et al. (2010). Ectopic pregnancy and spontaneous abortion. In RG Nabel. ed., ACP Medicine, section 16, chap. 6. Hamilton, ON: BC Decker.
  • Surette AM, Dunham SM (2013). Early pregnancy risks. In AH DeCherney et al., eds., Current Diagnosis and Treatment Obstetrics & Gynecology, 11th ed., pp. 234–249. New York: McGraw-Hill.
  • Varma R, Gupta J (2012). Tubal ectopic pregnancy, search date July 2011. BMJ Clinical Evidence. Available online: http://www.clinicalevidence.com.

Credits

By Healthwise Staff
Primary Medical Reviewer Sarah Marshall, MD - Family Medicine
Specialist Medical Reviewer Kirtly Jones, MD - Obstetrics and Gynecology
Last Revised April 26, 2013

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