Ectopic Pregnancy

last authored: June 2009, Reuben Kiggundu
last reviewed: May 2015, Neerja Sharma




Ectopic pregnancy (Greek ektopos, or out of place) refers to the implantation of a fertilized egg outside of the uterine cavity. Ectopic pregnancies frequently rupture, leading to hemorrhage - the leading cause of first-trimester dealth due to pregnancy. Approximately 2% of all first trimester pregnancies are ectopic (ACOG, 2008).

laparoscopic image provided by Dr Charles Hamm


Most ectopic pregnancies - 95-96% - occur in the fallopian tubes, with the majority of the rest being ovarian or cervical.


The abnormally implanted blastocyst grows and draws its blood supply from the site of abnormal implantation. As the gestation enlarges, it creates the potential for rupture and hemorrhage - one of its most dangerous complications.









Causes and Risk Factors

All women of reproductive age are at risk, though rates increase in women over 35.

Black women have the highest rates, followed by non-white and then white women.

Multigravid women have higher rates than nulliparous women.

Anything that hampers the migration of the embryo to the endometrial cavity can predispose to ectopic pregnancy.


Heterotopic pregnancy, where one embryo is ectopic and the other intrauterine, is on the rise due to increased rates of assisted reproductive technology.


However, over half of all cases of ectopic pregnancy occur in women with none of these risk factors.

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Signs and Symptoms

  • history
  • physical exam


The classic clinical triad of ectopic pregnancy includes:

  • lower abdominal pain
  • amenorrhea
  • vaginal bleeding

However, only 50% of patients present typically.


Other symptoms include:

  • dizziness, fainting
  • passage of tissue
  • those common to early pregnancy (nausea, breast fullness, fatigue, heavy cramping etc.)

Inquire into:

  • menstrual history (LMP)
  • sexual history
  • constraceptive use
  • gynecologic history (surgery, infections)

Physical exam may reveal:

  • unstable vitals: tachycardia, hypotension
  • cervical motion tenderness (most frequent sign)
  • adnexal tenderness or mass
  • abdominal tenderness, rebounding, or guarding
  • Cullen sign: blue discoloration around umbilicus suggesting retroperitoneal hemorrhage
  • uterine enlargement
  • fever
  • orthostatic hypotension

Vaginal bleeding is usually minimal, compared to that seen with spontaneous miscarriage.

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  • lab investigations
  • diagnostic imaging

Lab Investigations

When considering ectopic pregnancy, the following may be helpful:

  • beta-HCG: quantitative testing can be done at 48h intervals; it normally doubles in this time with intrauterine pregnancy, and will rise more slowly with ectopic pregnancy
  • serum progesterone may distinguish between viable and nonviable pregnancy

In order to assess stability, and prepare for treatment, consider:

  • CBC
  • Rh type
  • crossmatch

Diagnostic Imaging

Transvaginal ultrasound (TVUS) is the preferred modality to identify extrauterine pregnancy. A gestational sac is typically visible, regardless of location, if beta-HCG is more than 1500 IU. However, a negative ultrasound does not exclude ectopic pregnancy.


Ectopic findings include:

  • complex adnexal mass
  • fluid-filled adnexal mass
  • free fluid in the peritoneal cavity
  • gestational sac in the cornual area
  • intracervical location

CT, MRI, or Doppler flow may also be done, though are not as helpful.

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Differential Diagnosis

Other possible conditions include:

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Damage to the cilia in Fallopian tubes is frequently responsible for ectopic pregnancy, caused by factors such as pelvic inflammatory disease (PID) or surgery.

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laparoscopic image provided by Dr Charles Hamm

Initial focus should be on the ABC's to stabilize the patient:

Rhogam should be given as appropriate.




Methotrexate is the primary nonsurgical treatment. It can be used in situations of:

Indications include:

Contraindications include:



If surgery is warranted, laparascopy followed by salpingectomy or salpingostomy is the preferred approach. Open laparotomy is mandated if the patient is unstable..

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Consequences and Course

Ectopic pregnancy can lead to massive hemorrhage, infertility, and death.


Between 25-30% of women will have another ectopic pregnancy if they conceive.


Prevention of STIs, especially Chlamydia, may reduce incidence of ectopic pregnancy.

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Resources and References

Murray H et al. 2005. Diagnosis and treatment of ectopic pregnancy. CMAJ. 173(8).

ACOG Practice Bulletin. 2008. Number 94: Medical management of ectopic pregnancy.