Ectopic pregnancy Information | Mount Sinai

Tubal pregnancy; Cervical pregnancy; Tubal ligation – ectopic pregnancy

An ectopic pregnancy is a pregnancy that occurs outside the womb (uterus).

Laparoscopy is performed when less-invasive surgery is desired. It is also called Band-Aid surgery because only small incisions need to be made to accommodate the small surgical instruments that are used to view the abdominal contents and perform the surgery.

The ultrasound has become a standard procedure used during pregnancy. It can demonstrate fetal growth and can detect increasing numbers of conditions in the fetus including meningomyelocele, congenital heart disease, kidney abnormalities, hydrocephalus, anencephaly, club feet, and other deformities. Ultrasound does not produce ionizing radiation and is considered a very safe procedure for both the mother and the fetus.

External structures of the female reproductive anatomy include the labium minora and majora, the vagina and the clitoris. Internal structures include the uterus, ovaries, and cervix.

The uterus is a hollow muscular organ located in the female pelvis between the bladder and rectum. The ovaries produce the eggs that travel through the fallopian tubes. Once the egg has left the ovary it can be fertilized and implant itself in the lining of the uterus. The main function of the uterus is to nourish the developing fetus prior to birth.

An ectopic pregnancy is one in which the fertilized egg implants in tissue outside of the uterus and the placenta and fetus begin to develop there. The most common site is within a Fallopian tube, however, ectopic pregnancies can occur in the ovary, the abdomen, and in the lower portion of the uterus (the cervix).

Causes

In most pregnancies, the fertilized egg travels through the fallopian tube to the womb (uterus). If the movement of the egg is blocked or slowed through the tubes, it can lead to an ectopic pregnancy. Things that may cause this problem include:

• Birth defect in the fallopian tubes
• Scarring after a ruptured appendix
• Endometriosis
• Having had an ectopic pregnancy in the past
• Scarring from past infections or surgery of the female organs

The following also increase risk for an ectopic pregnancy:

• Age over 35
• Getting pregnant while having an intrauterine device (IUD)
• Having your tubes tied
• Having had surgery to untie tubes to become pregnant
• Having had many sexual partners
• Sexually transmitted infections (STI)
• Some infertility treatments

Sometimes, the cause is not known. Hormones may play a role.

The most common site for an ectopic pregnancy is the fallopian tube. In rare cases, this can occur in the ovary, abdomen, or cervix.

An ectopic pregnancy can occur even if you use birth control.

Symptoms

Symptoms of ectopic pregnancy may include:

• Abnormal vaginal bleeding
• Mild cramping on one side of the pelvis
• No periods
• Pain in the lower belly or pelvic area

If the area around the abnormal pregnancy ruptures and bleeds, symptoms may get worse. They may include:

• Fainting or feeling faint
• Intense pressure in the rectum
• Low blood pressure
• Pain in the shoulder area
• Severe, sharp, and sudden pain in the lower abdomen

Exams and Tests

The health care provider will do a pelvic exam. The exam may show tenderness in the pelvic area.

A pregnancy test and vaginal ultrasound will be done.

Human chorionic gonadotropin (hCG) is a hormone that is produced during pregnancy. Checking the blood level of this hormone can detect pregnancy.

• When hCG levels are above a certain value, a pregnancy sac in the uterus should be seen with ultrasound.
• If the sac is not seen, this may indicate that an ectopic pregnancy is present.

You may need more than one exam, ultrasound, and blood test. Your provider will instruct you about signs to watch for until your next visit.

Treatment

Ectopic pregnancy may be life threatening. The pregnancy cannot continue to birth (term).  Effective treatment requires either medical treatment to end the pregnancy or surgical removal of the pregnancy.

If the ectopic pregnancy has not ruptured, treatment may include:

• Surgery
• Medicine that ends the pregnancy, along with close monitoring by your doctor

You will need emergency medical help if the area of the ectopic pregnancy breaks open (ruptures). Rupture can lead to bleeding and shock. Treatment for shock may include:

• Blood transfusion
• Fluids given through a vein
• Keeping warm
• Oxygen
• Raising the legs

If there is a rupture, surgery is done to stop blood loss and remove the pregnancy. In some cases, the doctor may have to remove the fallopian tube.

Outlook (Prognosis)

If diagnosed early, treatment is very effective. It’s important to seek early care whenever you believe you may be pregnant so your provider may determine the location of the pregnancy.

One out of three women who have had one ectopic pregnancy can have a baby in the future. Another ectopic pregnancy is more likely to occur. Some women do not become pregnant again.

The likelihood of a successful pregnancy after an ectopic pregnancy depends on:

• The woman’s age
• Whether she has already had children
• Why the first ectopic pregnancy occurred
• The health of her fallopian tubes

When to Contact a Medical Professional

Contact your provider if you have:

• Abnormal vaginal bleeding
• Lower abdominal or pelvic pain or
• Suspect you might be pregnant

Prevention

Most forms of ectopic pregnancy that occur outside the fallopian tubes are probably not preventable. You may be able to reduce your risk by avoiding conditions that may scar the fallopian tubes. These steps include:

• Practicing safer sex by taking steps before and during sex, which can prevent you from getting an infection
• Getting early diagnosis and treatment of all STIs
• Stopping smoking

Alur-Gupta S, Cooney LG, Senapati S, Sammel MD, Barnhart KT. Two-dose versus single-dose methotrexate for treatment of ectopic pregnancy: a meta-analysis. Am J Obstet Gynecol. 2019;221(2):95-108.e2. PMID: 30629908 pubmed.ncbi.nlm.nih.gov/30629908/.

Henn MC, Lall MD. Complications of pregnancy. In: Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier; 2023:chap 173.

Hur HC, Lobo RA.. Ectopic pregnancy: etiology, pathology, diagnosis, management, fertility prognosis. In: Gershenson DM, Lentz GM, Valea FA, Lobo RA, eds. Comprehensive Gynecology. 8th ed. Philadelphia, PA: Elsevier; 2022:chap 17.

Nelson AL, Gambone JC. Ectopic pregnancy. In: Hacker NF, Gambone JC, Hobel CJ, eds. Hacker & Moore’s Essentials of Obstetrics and Gynecology. 6th ed. Philadelphia, PA: Elsevier; 2016:chap 24.

Last reviewed on: 1/10/2022

Reviewed by: John D. Jacobson, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Ovarian ectopic pregnancy: A rare case

1. Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and infertility. 8th Ed. Philadelphia: 2011. p. 1409. [Google Scholar]

2. Shrestha A, Chawla CD, Shrestha RM. Ruptured primary ovarian pregnancy: a rare case report. Kathmandu Univ Med J. 2012;10:76–77. [PubMed] [Google Scholar]

3. Scutiero G, Di Gioia P, Spada A, Greco P. Primary ovarian pregnancy and its management. JSLS. 2012;16:492–494. [PMC free article] [PubMed] [Google Scholar]

4. Odejinmi F, Rizzuto MI, MacRae R, Olowu O, Hussain M. Diagnosis and laparoscopic management of 12 consecutive cases of ovarian pregnancy and review of literature. J Minim Invasive Gynecol. 2009;16:354–359. [PubMed] [Google Scholar]

5. Hallet JG. Primary ovarian pregnancy. A case report of twenty five cases. Am J Obstet Gynecol. 1982;143(1):55–60. [PubMed] [Google Scholar]

6. Grimes H, Nosal RA, Gallagher JC. Ovarian pregnancy. A series of 24 cases. Obstet Gyncol. 1983;61:174–180. [PubMed] [Google Scholar]

7. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Williams Obstetrics. 23rd Ed. Mc Graw Hill; 2010. Ectopic pregnancy; p. 251. [Google Scholar]

8. Bouyer J, Coste J, Fernandez H, Pouly JL, Job-Spira N. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod. 2002;17:3224–3230. [PubMed] [Google Scholar]

9. Gerin-Lajoie L. Discussion of Gerin-Lojoie L. Ovarian pregnancy. Am J Obstet Gynecol. 1951;62:920. [PubMed] [Google Scholar]

10. Sergent F, Mauger-Tinlot F, Gravier A, Verspyck E, Marpeau L. Grossesses ovariennes: réévaluation des critères diagnostiques. J Gynecol Obstet Biol Reprod (Paris) 2002;31:741–746. [PubMed] [Google Scholar]

11. Mehmood SA, Thomas JA. Primary ectopic ovarian pregnancy, report of three cases. J Postgrad Med. 1985;31:219–222. [PubMed] [Google Scholar]

12. Ercal T, Cinar O, Mumcu A, Lacin S, Ozer E. Ovarian pregnancy; relationship to an intrauterine device. Aust N Z J Obstet Gynaecol. 1997;37:362–364. [PubMed] [Google Scholar]

13. Bouyer J, Rachou E, Germain E, Fernandez H, Coste J, Pouly JL, et al. Risk factors for extrauterine pregnancy in women using an intrauterine device. Fertil Steril. 2000;74:899–908. [PubMed] [Google Scholar]

14. Comstock C, Huston K, Lee W. The ultrasonographic appearance of ovarian ectopic pregnancies. Obstet Gynecol. 2005;105:42–45. [PubMed] [Google Scholar]

15. Ghi T, Banfi A, Marconi R, Iaco PD, Pilu G, Aloysio DD, et al. Three dimensional sonographic diagnosis of ovarian pregnancy. Ultrasound Obstet Gynecol. 2005;26:102–104. [PubMed] [Google Scholar]

16. Raziel A, Golan A, Pansky M, Ron-El R, Bukovsky I, Caspi E. Ovarian pregnancy: a report of twenty cases in one institution. Am J Obstet Gynecol. 1990;163:1182–1185. [PubMed] [Google Scholar]

17. Herbertsson G, Magnusson SS, Benediktsdottir K. Ovarian pregnancy and IUCD use in a defined complete population. Acta Obstet Gynecol Scand. 1987;66:607–610. [PubMed] [Google Scholar]

18. Cabero A, Laso E, Lain JM, Manas C, Escribano I, Calaf J. Increasing incidence of ovarian pregnancy. Eur J Obstet Gynecol Reprod Biol. 1989;31:227–232. [PubMed] [Google Scholar]

19. Ciortea R, Costin N, Chiroiu B, Malutan A, Mocan R, Hudacsko A, et al. Ovarian pregnancy associated with pelvicadhesions. Clujul Med. 2013;86:77–79. [PMC free article] [PubMed] [Google Scholar]

20. Sandvier Sandstad E, Steir JA. Ovarian pregnancy associated with intrauterine contracepyive device. Acta Obstet Gynecol Scand. 1987;66:137–41. [PubMed] [Google Scholar]

21. Joseph RJ, Irvine LM. Ovarian ectopic pregnancy: aetiology, diagnosis, and challenges in surgical management. J Obstet Gynaecol. 2012;32:472–474. [PubMed] [Google Scholar]

22. Mehra S, Negi H, Hotchandi M. Rare case of Ovarian pregnancy managed by laparascopy: A case report. JK Sci. 2003;5:29. [Google Scholar]

23. Hassan S, Arora R, Bhatia K. Primary ovarian pregnancy: case report and review of literature. BMJCase Rep. 2012;2012:bcr2012007112. [PMC free article] [PubMed] [Google Scholar]

24. Patel Y, Wanyonyi SZ, Rana SF. Laparascopic management of an ovarian ectopic pregnancy: case report. East Afr Med J. 2008;85:201–204. [PubMed] [Google Scholar]

25. Comstock C, Huston K, Lee W. The ultrasonographic appearance of ovarian ectopic pregnancies. Obstet Gynecol. 2005;105:42–45. [PubMed] [Google Scholar]

26. Di Luigi G, Patacchiola F, La Posta V, Bonitatibus A, Ruggeri G, Carta G. Early ovarian pregnancy diagnosed by ultrasound and successfully treated with multidose methotrexate. A case report. Clin Exp Obstet Gynecol. 2012;39:390–393. [PubMed] [Google Scholar]

27. Nadarajah S, Sim LN, Loh SF. Laparscopic management of an ovarian pregnancy A case report. Singapore Med J. 2002;43:95–96. [Google Scholar]

28. Koo YJ, Choi HJ, Im KS, Jung HJ, Kwon YS. Pregnancy outcomes after surgical treatment of ovarian pregnancy. Int J Gynecol Obstet. 2011;11:97–100. [PubMed] [Google Scholar]

29. Resta S, Fuggetta E, D’Itri F, Evangelista S, Ticino A, Porpora MG. Rupture of Ovarian Pregnancy in a Woman with Low Beta-hCG Levels. Case Rep Obstet Gynecol . 2012:213169. [PMC free article] [PubMed] [Google Scholar]

Ectopic pregnancy – causes and treatment

If the fixation and subsequent development of the ovum occurs outside the uterus, then the pregnancy is called ectopic (ectopic). It occurs in 2% of all pregnancies. The embryo can be fixed on the ovary, in the abdominal cavity, in the cervix, in the fallopian tubes. An ectopic pregnancy in the early stages is no different from a normal one.

An egg is released from the ovary during ovulation and enters the fallopian tube. Fertilization occurs when a sperm and an egg meet in the ampulla of the fallopian tube. Normally, at the end of the first week after fertilization, the embryo enters the uterine cavity and implantation occurs. A fertilized egg can develop normally only in the uterus.

Types

• tubal – the embryo develops in the fallopian tubes;
• abdominal – the embryo is attached to the walls of the peritoneum;
• ovarian – the embryo is attached to the walls of the cervix;
• cervical – the embryo is attached to the cavity of the ovary.

Very rare bilateral ectopic pregnancy, as well as heterotopic pregnancy (combination of uterine and ectopic). An ectopic pregnancy of any type is considered a medical emergency.

Let’s take a look at tubal pregnancy next, because it is the most common and accounts for 98-99% of all pregnancies outside the uterus.

Signs of ectopic pregnancy

Until the fetal egg overstretches the wall of the fallopian tube, pregnancy is no different from normal and is characterized by standard signs:

• delayed menstruation;
• positive test;
• early toxicosis;
• drowsiness;
• breast enlargement and soreness;
• change in taste preferences.

During menstruation, scanty dark-colored blood discharge is possible. It is impossible for a woman to determine an ectopic pregnancy at home, and diagnostics and specialist advice are required.

Until a certain point, the fertilized egg develops normally. But the embryo grows and it ceases to have enough nutrients. At some point, he ruptures the fallopian tube and bleeding occurs. At the same time, the blood practically does not flow out, only small spotting discharges may appear, the main bleeding occurs in the abdominal cavity.

An ectopic pregnancy may show symptoms after 2 weeks of delayed menstruation. A woman may feel:

• weakness, dizziness;
• pain in rectum radiating to back;
• loss of appetite;
• pain in the lower abdomen, sometimes with nausea and vomiting;
• scanty spotting.

Particular attention should be paid to pain in the lower abdomen. This symptom is also characteristic of a normal uterine pregnancy. But in a normal pregnancy, the pain is temporary. With tubal, as a rule, the pain increases, intensifies and does not stop.

If you experience any of the symptoms listed, seek medical attention immediately. The condition can worsen sharply at any time, which threatens the health and life of a woman.

Causes of ectopic pregnancy

Causes are all conditions that disrupt the movement of a fertilized egg into the uterine cavity:

• chronic inflammatory processes of the pelvic organs;
• violation of patency – the appearance of adhesions and scarring of tissues;
• violation of the peristalsis of the fallopian tube
• the exit from the pipe is closed;
• endometrial pathology;
• transferred infectious diseases;
• congenital factor – pipes are twisted and very long;
• single fallopian tube.

Risk factors:

• history of ectopic pregnancy;
• adhesive process in the small pelvis;
• interventions on the fallopian tubes;
• intrauterine contraception;
• surgery;
• pregnancy after prolonged infertility, after IVF procedure;
• anatomical features;
• bad habits;
• age from 35 years;
• hormonal and endocrine disorders.

Diagnosis

It is very difficult to detect a tubal pregnancy during a routine gynecological examination. Methods for diagnosing ectopic pregnancy:

• beta-hCG test is the only biochemical indicator for diagnosing ectopic pregnancy. In a normal course, the increase in hCG should double every 2-3 days. Suspicion will be a sluggish increase in hCG, no more than 1.5 times every 2-3 days. A low rise in beta-hCG may be with an undeveloped uterine or ectopic pregnancy;
• An early ultrasound of an ectopic pregnancy should be transvaginal to determine where the embryo has attached. It is desirable to carry out for 5-7 days after the delay of menstruation.

Blood progesterone testing is not indicated for the diagnosis of tubal pregnancy. Only according to beta-hCG data, it is impossible to make a diagnosis, it is necessary to do a transvaginal ultrasound.

Complications

Termination of an ectopic pregnancy usually occurs for 4-6 weeks and develops as a rupture of the tube or as a tubal abortion.

Signs of interruption by type of tube rupture:

• delayed menstruation;
• intra-abdominal bleeding, characterized by a sharp decrease in blood pressure, pallor, cold sweat, dizziness, fainting, nausea, vomiting;
• sharp and very severe pain in the abdomen.

May occur after 6 weeks of pregnancy. An extremely dangerous situation for a woman’s life and require immediate surgical intervention.

Signs of interruption by type of tubal abortion:

• delayed menstruation;
• bleeding from labia;
• constant aching, dull pain in the lower abdomen, may radiate to the lower back, groin, rectum.

Tubal abortion proceeds for a long time, without acute manifestations. With detachment of the fetal from the fallopian tube, blood enters the abdominal cavity in small portions and therefore there are no sharp symptoms. On gynecological examination, an increase in the size of the uterus and appendages, pain on palpation of the posterior fornix of the vagina is determined.

What complications can be:

• severe bleeding;
• repeated ectopic pregnancy;
• infertility.

Ectopic pregnancy and consequences

• probability of normal pregnancy and childbirth – about 50%;
• repeated ectopic pregnancy – about 20%;
• 15-20% miscarriages;
• 25% infertility.

Ectopic pregnancy, what treatment is used

If an ectopic pregnancy is suspected, a woman should be urgently hospitalized in a hospital, even if there are no complaints of well-being. The main threat is that the pregnancy can be terminated at any time.

The effectiveness of treatment is determined by timely diagnosis at an early stage and the choice of using laparoscopic access.

In the hospital, after 48-72 hours, repeat ultrasound, determine the level of beta-hCG and conduct a gynecological examination. If the increase in beta-hCG is less than 50% in 48-72 hours and the fetal egg is not detected, then the patient will be shown a diagnostic laparoscopy. Such diagnostics will help not to wait for the rupture of the tube, blood loss and shock.

Currently in Russia, ectopic pregnancy is treated only surgically:

• radical (tubectomy) – removal of the tube along with ectopic pregnancy. It is used for rupture or overstretching of the pipe;
• organ-preserving (tubotomy) – the tube is cut and the fetal egg is removed. The method is used with timely detection and slight stretching of the pipe.

Only surgery can remove a fertilized egg that has attached itself outside the uterine cavity. The most common is laparoscopy. The surgeon removes the fetal egg and partially or completely the fallopian tube through small punctures. After 3 days, the woman is allowed to go home.

Opening of the abdominal cavity is usually used when laparoscopic access is difficult (pronounced adhesive process, a large amount of blood in the abdominal cavity, obesity).

The nature of the operation depends on the condition of the woman, the volume of blood loss, location and size of the ovum. With laparoscopic access, the incidence of recurrent ectopic pregnancy is lower than with laparotomy.

Recovering from an ectopic pregnancy

It is important to have a complete examination to understand the cause of an ectopic pregnancy and eliminate it. Observe physical and sexual rest for at least a month after surgery. Measures should be aimed at restoring reproductive function after surgery:

• prevention of adhesions – physiotherapy, reflexology, injections of longidase, lidase;
• oral contraceptives are recommended for the duration of rehabilitation therapy. As a rule, 6 months after an ectopic pregnancy, you can become pregnant again.

If a tubal pregnancy was diagnosed in time, then the chances of conceiving and carrying a healthy child are quite high. When planning a pregnancy, be sure to consult a doctor.

How to avoid ectopic pregnancy

Prevention involves reducing the likelihood of occurrence of causes that lead to the development of ectopic pregnancy:

• timely treatment of inflammatory diseases of the genital organs;
• reliable contraception as abortion prevention;
• use of contraceptives strictly under medical supervision;
• pregnancy planning, complete examination;
• treatment of hormonal disorders.

Regular visits to the gynecologist and examination for various infections are also important. If pregnancy is suspected, contact the MEDICA Fetal Medicine Center, experienced specialists will consult, diagnose and determine the type of pregnancy.

If you suspect pregnancy or you are concerned about a delay, then contact the Medica Fetal Medicine Center, experienced specialists will consult, diagnose and determine the type of pregnancy.

Ministry of Health

cysts
during pregnancy complicate its course and can lead to surgical
childbirth by caesarean section. Doctors to save pregnancy
gynecological department of UOKTSVMP carry out special treatment with the help of
high precision equipment.

Cyst
– This is a formation in the form of a cavity filled with liquid. This pathology occurs
one in a thousand pregnant women. If the cyst reaches a large size, then
its rupture may occur, torsion of the legs of the ovarian cyst, which leads to intra-abdominal
bleeding, is accompanied by unbearable pain and can cause miscarriage and premature
childbirth. Large (over 6-8 cm in diameter) cysts are usually removed surgically.
by, mostly laparoscopically, through small incisions. During pregnancy
the most suitable period for the operation is 14-16 weeks. Few take up treatment
such patients surgically.

home
the task of the Department of Gynecology of the UOKTSVMP is to provide surgical medical
help with gynecological diseases in a short time, as much as possible
effective, painless and with minimal side effects. Job
is built in accordance with the standards of evidence-based medicine practiced
among foreign colleagues. In conditions
gynecological department for more than five years, active surgical
treatment of ovarian tumors
time of pregnancy. Gynecologists-surgeons have extensive experience, modern equipment,
used by gynecologists of the most popular clinics around the world.

IN
their practice during operations, doctors – gynecological department
actively use special equipment that helps to stop
bleeding during surgery, prevents the formation of adhesions, reduces the time
operations. With the use of endoscopic technologies and small accesses,
surgical treatment of women at gestational age from 10 to 18 weeks, with
the size of the cysts is from 6 to 12 cm. The volume of the operation is to remove the cyst.
The time of surgical intervention varies from 30 to 45 minutes. Already on the 3-4th day of the patient
are discharged home in good condition.

“In our practice, there was a 25-year-old patient with her first pregnancy, from an early date she was registered with the women’s
consultations. She was diagnosed with a cyst for the first time at 8 weeks.
right ovary measuring 10×10 centimeters. To the gynecological department
was admitted at 15 weeks of pregnancy with complaints of bleeding, nagging pain
lower abdomen. First, we treated the threat of preterm birth,
pregnancy-preserving therapy was prescribed. All this time the woman was
under the constant supervision of qualified medical personnel. After
removal of all symptoms of a threatened abortion, the patient was successfully operated on
by laparoscopy using modern equipment. We removed her
cyst of the right ovary, the operation lasted 35 minutes, blood loss was minimal.