In an ectopic pregnancy, the fertilized egg fails to implant in a normal position in the uterus where it can develop and thrive. Instead, the pregnancy attaches elsewhere in the reproductive system or body — usually in the fallopian tube. With an ectopic pregnancy there is no hope of a live, healthy birth.
An ectopic pregnancy puts the pregnant woman at risk. Eventually, if the pregnancy grows too large, it can cause the fallopian tube to burst open. This rupture represents a life-threatening emergency for the mother, who could potentially bleed to death.
Here are the facts on ectopic pregnancy: symptoms and risk factors, how it can be caught early and treatment options to protect the mother’s life and health.
How an Ectopic Pregnancy Occurs
“While the most common type of ectopic pregnancy is in the fallopian tube, it’s not limited to that,” says Dr. Julia Cormano, an OB-GYN and assistant professor of obstetrics, gynecology and reproductive sciences with UC San Diego Health System. For example, she says, “You can get a pregnancy that implants near the ovary or even in a prior C-section scar inside the uterus.”
During conception, “if you think about the normal journey, the egg leaves or ovulates from the ovary, travels down the tube and can be fertilized in a number of locations,” says Dr. Scott Sullivan a professor of maternal-fetal medicine and vice-chair of the OB/GYN department at Medical University of South Carolina. “Typically, it would happen in the tube. Sperm would go from the vagina to the cervix, into the uterus, into the tube and reach the egg. Typically, that fertilized egg would continue its trip through the tube into the uterus.”
In medical terminology, ectopic refers to something that occurs abnormally. With ectopic pregnancy, “Our current theory is that the normal mechanism of implantation, which is supposed to happen in the uterus, is triggered or a mistake is made and it implants right where it’s fertilized,” Sullivan says. “We think that’s why 90% of ectopic pregnancies are in the tube — because that’s where fertilization usually occurs.”
Pregnancy That Can’t Proceed
Any ectopic pregnancy — whether it’s in the tube or other abnormal location, such as an ovary or the cervix — cannot progress normally. The fetus itself cannot survive but the growing tissue can cause severe bleeding if untreated, jeopardizing the mother’s life.
“Ectopic pregnancy is rare — it happens in about two of every 100 pregnancies,” says June Gupta, a women’s health nurse practitioner and senior director of medical services at Planned Parenthood Federation of America. But when they happen, they are dangerous if not treated, she adds.
An ectopic pregnancy must be ended. “Even though they’re rare, ectopic pregnancies are not viable and cannot develop in the same way that a pregnancy inside the uterus can,” Gupta says. “A pregnancy won’t survive if it’s ectopic. If not treated, an ectopic pregnancy can place a pregnant person for infection and even death.”
Cormano says that as the health care provider, it’s important to frame the situation clearly for patients. “There is no choice,” she says. “You’re not ending your pregnancy voluntarily. You’re doing something to save your life — otherwise both of you would die. This is not the same as a termination.”
It’s impossible to give birth to a healthy baby when an ectopic pregnancy happens, for several reasons, Sullivan says:
— “In the majority of cases, there’s actually no baby there,” he says. “It’s just placental tissue. If you think about it: When an egg is earlier fertilized, part of that egg turns into placenta and part of that egg turns into a fetus and the eventual baby. But a lot of times, since it’s implanting in the tube or in a strange area, it doesn’t develop properly. With most ectopic pregnancies I deal with you really can’t even identify a fetus. You just have a growing, invasive placenta.”
— In the next-most common scenario, “there may be a fetus there, but it’s often abnormal,” Sullivan says. “It’s not (developing) the way you would think about it. Because you don’t have a normal blood flow, you don’t have endometrium.” The endometrium is the inner lining of the uterus that’s supplied with blood and nutrients to support the pregnancy.
— Finally, in some cases, “you see a normal-appearing fetus in the tube or even the abdomen,” he says. “We don’t have any technology, any way to remove the placenta with the fetus and put it back in the uterus. We don’t have any mechanism for doing that. So it’s disruptive when you remove it from wherever it’s attached, say it’s the tube. Then it sort of ends that pregnancy. But if you don’t do it, it’s very likely to kill the mother. So you don’t have any choice in the matter. In the vast, vast majority of cases, it’s not a healthy or normal pregnancy, anyway.”
Ectopic Pregnancy Symptoms
Severe pelvic-area pain and vaginal bleeding are hallmark ectopic pregnancy symptoms. However, some people may have few or no early signs.
Symptoms of an ectopic pregnancy include:
— Severe lower pelvic or abdominal pain, especially on one side.
— Vaginal bleeding or spotting.
— Shoulder pain.
— Feeling very weak, dizzy, lightheaded or fainting.
— Low back pain.
— Mild or moderate one-sided cramping.
“But,” adds Gupta, “everyone’s body is different, so getting checked out by a doctor or nurse is the only way to know for sure if you have an ectopic pregnancy. Your doctor or nurse may do a pelvic exam, blood test or ultrasound to find out.”
Seek Care Immediately
“The most common presentation is somebody who is having persistent vaginal spotting during their first trimester,” Cormano says. “Especially if they’re having any pain associated with that, they should seek emergency care. It’s been estimated that as high as 15% to 20% of women with that set of symptoms — persistent spotting in the first trimester and pelvic pain — may actually have an ectopic when they go to the ED.”
It’s essential to treat an ectopic pregnancy immediately if it ruptures. “The really concerning thing is if an ectopic grows and grows to a size that can’t be supported by whatever it’s attached to,” Cormano explains. “So, in the fallopian tube, for example, if it grows to the size where the fallopian tube bursts open, that is a very acute emergency. Somebody can literally bleed to death within a few hours if they don’t get appropriate care.”
Gupta also emphasizes the urgency of seeking care: “If you’re pregnant and have symptoms of ectopic pregnancy, call your nurse or doctor or go to the emergency room right away,” Gupta says. “Ectopic pregnancy is a medical emergency. So the earlier an ectopic pregnancy is found, the better.”
Ultrasound exam results in conjunction with blood tests can indicate a possible ectopic pregnancy. Tests provide these key details:
— A blood test for a beta-hCG level — human chorionic gonadotropin, a hormone made by the placenta — which elevates in pregnancy. “It has a predictable rise for a healthy pregnancy that’s implanted in the correct position,” Cormano explains. “For a pregnancy that’s not in the correct place — the uterus — that rise might not be as appropriate.” Progesterone is another key hormone in pregnancy.
— An ultrasound scan to visualize the pregnancy. “Once the (b-hCG) reaches a certain level, we know that we ought to see a pregnancy in the uterus if it’s a normal pregnancy,” she says.
“So, the two pieces of information we get are: the pregnancy level, so how far along should this pregnancy be, and then what do we see on ultrasound?” Cormano says. “Do we see anything in the uterus where we think it ought to be? Or do we see anything in the fallopian tubes or in the ovary? And if the pregnancy hormone is high — indicating that we ought to see something but we see nothing — then it’s very concerning that we have an ectopic somewhere that we just can’t see on ultrasound.”
Identifying a fetal heartbeat outside the uterine cavity can confirm the ectopic pregnancy. However, a fetal heartbeat may never develop in some ectopic pregnancies.
Ultrasound exams are being done sooner in pregnancy than in the past, starting with ultrasound to confirm the pregnancy in the first trimester. Earlier ultrasounds often can identify ectopic pregnancies sooner, Sullivan notes, which may allow more treatment options.
Ectopic pregnancy can be treated with medication or surgery.
Ultrasound results, pregnancy hormone levels, symptoms, health status and how far the pregnancy has progressed are major factors in the ectopic treatment decision.
Methotrexate, given by injection, is the medication used to end an ectopic pregnancy. One or two doses may be used, depending on the patient’s hCG levels.
“It is a chemotherapy drug but we give it in a much lower dose,” to manage ectopic pregnancy, Cormano explains. “And we’re only giving it, typically, one to two times as opposed to repeat dosing the way you would with cancer.”
Once given, the medication requires close monitoring. “When somebody gets methotrexate they have to come back four days after, and then again seven days after they got it to measure those pregnancy hormones,” she says. “We look to see that the pregnancy hormone is coming down appropriately. And then we continue to follow them out, usually weekly, until the pregnancy hormones have completely gone to negative. It does require a lot more follow-up, but it is a nice way to avoid surgery when an ectopic is caught early.” Patients can then avoid any surgical or anesthesia risks.
Side effects for methotrexate may include cramping, light sensitivity, injection site pain, redness or swelling, rare hair loss, mouth sores, nausea and GI upset, Cormano says. Patients receive a list of medications to avoid during the treatment regimen. After the treatment and post-treatment period are completed, women can eventually go on to have a healthy pregnancy.
“If they got medical management, it’s very important that they wait to get pregnant for at least three months, because that medical management could be harmful to a future pregnancy initially,” Cormano notes. “But then it’s cleared from the body and there’s no further consequence. In the future, as long as they’re not having an ectopic recurrence, which is usually about 10%, they can have a totally normal pregnancy.”
Surgery is used to remove an ectopic pregnancy from the fallopian tube or other abnormal location where it’s implanted. Laparoscopic surgery, or minimally invasive surgery, is usually done. The procedure uses a laparoscope, a thin camera inserted into the abdomen through small incisions, while the patient is under general anesthesia.
If an ectopic pregnancy has ruptured, surgery is required. If the pregnancy is well-established in the abnormal location, with a large pregnancy and possibly a fetal heartbeat present, those are also signs that medical management is unlikely to be sufficient, Cormano says. If there’s any concern that there’s active bleeding in the abdomen, surgery is the far better option, she adds.
Minimally invasive surgery is used most often, Sullivan says. “That’s where you can go in and remove the pregnancy,” he says. “Most of the time, you would take the tube out or wherever the site is.” It’s sometimes possible to save the tube, he notes. “On the other hand, that tube can be so damaged by the ectopic that it could set them up for another ectopic, which is even worse,” he adds. “So the surgeon, more often than not, has no choice but to take out the tube.”
Side effects from surgery for ectopic pregnancy can include bleeding, pain, infection or fatigue. However, Sullivan says, “Typically, patients recover very quickly from laparoscopy, from minimally invasive surgery, and do quite well from it.”
In special cases, such as an ectopic pregnancy that is implanted in the abdomen, it’s more complicated, Sullivan says. Open surgery through a larger cut, called laparotomy, may need to be done.
Risk Factors and Causes
“We don’t always know the cause of the ectopic pregnancy,” Gupta says. “But you may be more likely to have an ectopic pregnancy if you have a sexually transmitted disease that has gone untreated, pelvic inflammatory disease or endometriosis. People who have already had an ectopic pregnancy, or have had pelvic or abdominal surgery may be more likely to have an ectopic pregnancy.”
Uncommon scenarios can also occur. “Sterilization, for example getting your ‘tubes tied,’ and intrauterine devices are some of the most effective forms of birth control, but there is still a very small chance that pregnancy can happen,” Gupta notes. “If you get pregnant after sterilization or while you have an IUD, the chances of an ectopic pregnancy are higher.”
Ectopic Pregnancy Risk Factors
Certain factors related to a woman’s reproductive history and health can increase the chances of having an ectopic pregnancy:
— Previous ectopic pregnancy.
— Sexually transmitted disease.
— Pelvic inflammatory disease.
— Previous fallopian tube surgery.
— Age older than 35.
However, about half of women who have an ectopic pregnancy do not have any known risk factors, according to the American College of Obstetricians and Gynecologists.
Although ectopic pregnancies can’t be prevented, limiting sexual partners and using barrier birth control methods like condoms to reduce STDs are ways to lower ectopic pregnancy risk. Not smoking or quitting is another way an individual can lower their risk.
Emotional Effects and Support
Going through an ectopic pregnancy can be an emotional challenge. “Some people may have the same feelings as those who experience other kinds of pregnancy loss, like miscarriage, especially if they wanted to be pregnant,” Gupta says. “But everyone is different.”
Disappointment, shock, fear, grief or relief may all be among the mix of feelings you have. “Whatever emotions you feel are all normal and will usually feel less intense over time,” Gupta says. “If it feels safe, consider speaking to a friend you can trust, family member or a partner about how you’re feeling and what you need. Your nurse, doctor or local Planned Parenthood health center can also suggest resources and support groups to help you with your emotions.”
You can find resources and learn more about ectopic pregnancy online:
— ACOG offers reader-friendly FAQs on ectopic pregnancy.
— Planned Parenthood provides reproductive health care in locations throughout the country.
An important first step is making sure to follow up if you’re told that you may have an ectopic pregnancy, Sullivan emphasizes. Completing the work-up and receiving treatment recommendations is imperative to avoid severe complications and safeguard your health.
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