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An ectopic pregnancy is one that occurs anywhere outside of the uterus. The most common location for ectopic pregnancy to occur is in one of the fallopian tubes. In the UK, there are approximately 11,000 ectopic pregnancies annually.1

Classification

Ectopic pregnancies are classified by the anatomical site of the implantation of the pregnancy (listed here from most to least common):

  • Ampullary ectopic: 64%
  • Fallopian isthmus ectopic: 25%
  • Fallopian infundibular ectopic: 9%
  • Interstitial ectopic (implantation in the interstitium where the fallopian tube meets the uterus): 1-2%
  • Ovarian ectopic: 0.5%
  • Cervical ectopic: 0.4%
  • Other: <1% 

Ectopics can occur in the myometrium where a fertilised ovum implants in a Caesarean section scar. There have been isolated cases of ectopic pregnancies as far afield as the liver.


Risk factors

There is often no identifiable cause for ectopic pregnancy, however, the following risk factors are associated with an increased likelihood of developing the condition:

  • Assisted reproduction techniques (e.g. in-vitro fertilisation)
  • History of pelvic inflammatory disease (resulting in tubal occlusion due to adhesions)
  • Endometriosis

Clinical features

History

Typical symptoms of ectopic pregnancy include:

  • Abdominal pain
  • Pelvic pain
  • Amenorrhoea or a missed period
  • Vaginal bleeding (with or without clots)
  • Dizziness, fainting or syncope
  • Shoulder tip pain

Other important areas to cover in the history include:

  • Menstrual history (e.g. date of last menstrual period)
  • Sexual history (e.g. when did the patient last have unprotected sexual intercourse)
  • Medication history (e.g. contraceptives, anticoagulants)

Clinical examination

In the context of a suspected ectopic pregnancy, a thorough pelvic examination is necessary. See our pelvic examination guide for further information.

Typical clinical findings in ectopic pregnancy include:

  • Pelvic or abdominal tenderness
  • Adnexal tenderness

Investigations

Bedside investigations

Relevant bedside investigations in the context of ectopic pregnancy include:

  • Urine pregnancy test (hCG urine dipstick): would be positive in the context of ectopic pregnancy.
  • Urinalysis: to rule out a urinary tract infection. If findings suggest a urinary tract infection, ectopic pregnancy would still need ruling out (as the patient may have both).

Laboratory investigations

Relevant laboratory investigations in the context of ectopic pregnancy include:

  • Baseline blood tests (FBC, U&E, Coagulation, CRP): white cells may be raised and there may be anaemia.
  • Serum hCG: the level will depend on the gestation and viability of the pregnancy. This is often used to monitor response to treatment (see below)
  • Group and save: important to perform as the patient may require a blood transfusion.

Imaging

Relevant imaging investigations in the context of ectopic pregnancy include:

  • Transvaginal ultrasound scan: the most accurate method of confirming the presence of tubal ectopic pregnancy.

Management

Initial assessment

An ABCDE approach should be adopted during the initial assessment and management of patients with suspected ectopic pregnancy. Ectopic pregnancy may present with significant haemodynamic instability which requiring large bore IV access to be established and fluid resuscitation to be commenced. 

Medical management

NICE recommends systemic methotrexate as the first-line option for women who meet the following criteria:2

  • Able to return for follow-up
  • No significant pain
  • Unruptured ectopic pregnancy with an adnexal mass <35 mm and no visible heartbeat
  • No intrauterine pregnancy is seen on the ultrasound scan
  • Serum hCG <1500 IU/L

The serum hCG level is monitored to ensure it is declining and not continuing to rise. If serum hCG levels continue to rise, a further dose of systemic methotrexate may need to be administered.

Surgical management

Surgical management involves the surgical removal of the ectopic pregnancy.

Surgery should be offered to those women who meet any of the following criteria:

  • Unable to return for follow-up
  • Significant pain
  • Adnexal mass ≥35 mm
  • Fetal heartbeat visible on the scan
  • Serum hCG level ≥5000 IU/L

In cases of tubal ectopics, a laparoscopic salpingectomy is usually performed, removing both the ectopic pregnancy and the tube that it is implanted within.

Surgical management options

Salpingectomy is the removal of the ectopic pregnancy along with the Fallopian tube. It is the preferred option in women who have no other risks to their fertility, as it reduces the likelihood of a repeat ectopic pregnancy. It can affect future fertility, so women should be carefully counselled about the pros and cons of the procedure.

Salpingotomy is an alternative that seeks to remove the ectopic pregnancy whilst preserving the Fallopian tube. It is usually offered to women who have other fertility issues, such as damage to the other Fallopian tube. It does carry a greater risk of a future ectopic pregnancy than salpingectomy.


Complications

If an ectopic pregnancy is not diagnosed and treated promptly, complications can include:

  • Fallopian tube or uterine rupture
  • Secondary massive haemorrhage and disseminated intravascular coagulation
  • Death

Complications of surgical management can include:

  • Bleeding
  • Infection
  • Damage to local structures (bladder, bowel, vasculature)

A word on psychological support

Whilst an ectopic pregnancy is a potentially life-threatening situation for a woman, it is important to also acknowledge that the removal of an ectopic pregnancy also represents the loss of what may be a much-longed-for pregnancy. Women should be offered the same emotional support as anyone who has experienced early pregnancy loss.

For women who have undergone a salpingectomy, there may be further emotional support needed to allow them to come to terms with the potential impact on their future fertility.

The Ectopic Pregnancy Trust website has some useful resources for patients and professionals.


Key points

  • An ectopic pregnancy is one that occurs anywhere outside of the uterus.
  • The most common location for ectopic pregnancy to occur is in one of the fallopian tubes.
  • The most common symptoms include abdominal pain, pelvic pain, amenorrhoea and vaginal bleeding (with or without clots).
  • The most common clinical findings include pelvic or abdominal tenderness and adnexal tenderness.
  • Urine hCG, serum hCG and abdominal ultrasound are the primary investigations required to confirm the diagnosis.
  • Medical management involves the administration of systemic methotrexate, with ongoing monitoring of serum hCG levels.
  • Surgical management involves the surgical removal of the ectopic pregnancy (most commonly a laparoscopic salpingectomy).
  • Complications can include fallopian tube rupture, haemorrhage and death.

References

  1. Panagiotis et al. (2011). Differential Diagnosis of Ectopic Pregnancy – Morbidity and Mortality. 10.5772/22704.
  2. Collins S, Arulkumaran S, Hayes K, Jackson S, Impey L. (2008) The Oxford Handbook of Obstetrics and Gynaecology, 3rd Edition pp. 534-537
  3. NICE Clinical Guideline. Ectopic pregnancy and miscarriage: diagnosis and initial management. Published December 2012. Available from: [LINK].

 

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