Ectopic means "out of place." In a normal pregnancy, the fertilized egg implants and develops in the uterus.

In most ectopic pregnancies, the egg settles in the fallopian tubes. This is why ectopic pregnancies are commonly called "tubal pregnancies." The egg can also implant in the ovary, abdomen, or the cervix, so you also might see these referred to as cervical or abdominal pregnancies. None of these areas has as much space or nurturing tissue as a uterus for a pregnancy to develop. As the fetus grows, it will eventually burst the organ that contains it. This can cause severe bleeding and endanger the mother's life. A classical ectopic pregnancy does not develop into a live birth. Signs and Symptoms Ectopic pregnancy can be difficult to diagnose because symptoms often mirror those of a normal early pregnancy. These can include missed periods, breast tenderness, nausea, vomiting, fatigue, or frequent urination. The first warning signs of an ectopic pregnancy are often pain or vaginal bleeding. There might be pain in the pelvis, abdomen, or, even the shoulder or neck (if blood from a ruptured ectopic pregnancy builds up and irritates certain nerves). The pain can be mild or crampy early on, and can become sharp and stabbing. It may concentrate on one side of the pelvis. Any of these additional symptoms can be seen with an ectopic pregnancy: vaginal spotting dizziness or fainting (caused by blood loss) low blood pressure (also caused by blood loss) lower back pain

What Causes an Ectopic Pregnancy? An ectopic pregnancy results from a fertilized egg's inability to work its way quickly enough down the fallopian tube into the uterus. An infection or inflammation of the tube might have partially or entirely blocked it. Pelvic inflammatory disease (PID), which can be caused by gonorrhea or chlamydia, is a common cause of blockage of the fallopian tube. Endometriosis (when cells from the lining of the uterus implant and grow elsewhere in the body) or scar tissue from previous abdominal or fallopian surgeries can also cause blockages. More rarely, birth defects or abnormal growths can alter the shape of the tube and disrupt the egg's progress.

Diagnosis If you arrive in the emergency department complaining of abdominal pain, you'll likely be given a urine pregnancy test. Although these tests aren't sophisticated, they are fast and speed can be crucial in treating ectopic pregnancy. If you already know you're pregnant, or if the urine test comes back positive, you may have a quantitative hCG test. This blood test measures levels of the hormone human chorionic gonadotropin (hCG), which is produced by the placenta. You may also have an ultrasound to look for a developing fetus in the uterus or elsewhere. Early in pregnancy, the ultrasound may be done using a wand-like device in your vagina. The doctor might give you a pelvic exam to locate the areas causing pain; to check for an enlarged, pregnant uterus; or to find any masses outside of the uterus. Even with the best equipment, it's hard to see a pregnancy less than 5 weeks after the last menstrual period. If your doctor can't diagnose ectopic pregnancy but can't rule it out, he or she may ask you to return every few days for blood work and an ultrasound until it is clear whether or not there is an ectopic pregnancy. Options for Treatment Treatment of an ectopic pregnancy varies, depending on how medically stable the woman is and the size and location of the pregnancy. An early ectopic pregnancy can sometimes be treated with an injection of methotrexate, which stops the growth of the embryo. If the pregnancy is farther along, you'll likely need surgery to remove the abnormal pregnancy. In the past, this was a major operation, requiring a large incision across the pelvic area, and this can still be necessary in cases of emergency or extensive internal injury. But sometimes ectopic tissue can be removed using laparoscopy, a less invasive surgical procedure. The surgeon makes small incisions in the lower abdomen and then inserts a tiny video camera and instruments through these incisions. The image from the camera is shown on a screen in the operating room, allowing the surgeon to see what's going on inside of your body without making large incisions. The ectopic tissue is then surgically removed and any damaged organs are repaired or removed. Whatever your treatment, the doctor will want to see you regularly afterward to make sure your hCG levels return to zero. This may take several weeks. An elevated hCG could mean that some ectopic tissue was missed. This tissue may have to be removed using methotrexate or additional surgery.

What About Future Pregnancies? Many women who have had an ectopic pregnancy will go on to have normal pregnancies in the future, but some will have difficulty becoming pregnant again. This difficulty is more common in women who also had fertility problems before the ectopic pregnancy. Your prognosis depends on your fertility before the ectopic pregnancy, as well as the extent of any damage incurred. The likelihood of a repeat ectopic pregnancy increases with each subsequent ectopic pregnancy. Once you have had one ectopic pregnancy, you face an approximate 15% chance of having another. Who's at Risk for an Ectopic Pregnancy? While any woman can have an ectopic pregnancy, the risk is higher for women who are over 35 and those who have had: PID a previous ectopic pregnancy surgery on a fallopian tube infertility problems or medication to stimulate ovulation

Some birth control methods also can affect a woman's risk of ectopic pregnancy. Those who become pregnant while using an intrauterine device (IUD) might be more likely to have an ectopic pregnancy. Smoking and having multiple sexual partners also increase the risk of an ectopic pregnancy. When to Call Your Doctor If you believe you're at risk for an ectopic pregnancy, meet with your doctor to discuss your options before you become pregnant. You can help protect yourself against a future ectopic pregnancy by not smoking and by always using condoms when you're having sex but not trying to get pregnant. Condoms can protect against sexually transmitted infections (STDs) that can cause PID. If you are pregnant and have any concerns about the pregnancy being ectopic, talk to your doctor it's important to make sure it's detected early. You and your doctor might want to plan on checking your hormone levels or scheduling an early ultrasound to ensure that your pregnancy is developing normally.

Call your doctor immediately if you're pregnant and experiencing any pain, bleeding, or other symptoms of ectopic pregnancy. When it comes to detecting an ectopic pregnancy, the sooner it is found, the better. An ectopic pregnancy, or eccysis, is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the mother, since internal haemorrhage is a life threatening complication. Most ectopic pregnancies occur in the Fallopian tube (so-calledtubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen. An ectopic pregnancy is a potential medical emergency, and, if not treated properly, can lead to death. In a normal pregnancy, the fertilized egg enters the uterus and settles into the uterine lining where it has plenty of room to divide and grow. About 1% of pregnancies are in an ectopic location with implantation not occurring inside of the womb, and of these 98% occur in the Fallopian tubes. Detection of ectopic pregnancy in early gestation has been achieved mainly due to enhanced diagnostic capability. Despite all these notable successes in diagnostics and detection techniques ectopic pregnancy remains a source of serious maternal morbidity and mortality worldwide, especially in countries with poor prenatal care.
[2] [1]

In a typical ectopic pregnancy, the embryo adheres to the lining of the fallopian tube and burrows into the tubal lining. Most commonly this invades vessels and will cause bleeding. This intratubal bleeding hematosalpinx expels the implantation out of the tubal end as a tubal abortion. Tubal abortion is a common type of miscarriage. There is no inflammation of the tube in ectopic pregnancy. The pain is caused by prostaglandins released at the implantation site, and by free blood in the peritoneal cavity, which is a local irritant. Sometimes the bleeding might be heavy enough to threaten the health or life of the woman. Usually this degree of bleeding is due to delay in diagnosis, but sometimes, especially if the implantation is in the proximal tube (just before it enters the uterus), it may invade into the nearby Sampson artery, causing heavy bleeding earlier than usual. If left untreated, about half of ectopic pregnancies will resolve without treatment. These are the tubal abortions. The advent ofmethotrexate treatment for ectopic pregnancy has reduced the need for surgery; however, surgical intervention is still required in cases where the Fallopian tube has ruptured or is in danger of doing so. This intervention may be laparoscopic or through a larger incision, known as a laparotomy.

Classification Tubal pregnancy The vast majority of ectopic pregnancies implant in the Fallopian tube. Pregnancies can grow in the fimbrial end (5% of all ectopics
[clarification needed] [3]

), the ampullary section (80%), the isthmus (12%), and the cornual and

interstitial part of the tube (2%). Mortality of a tubal pregnancy at the isthmus or within the uterus (interstitial pregnancy) is higher as there is increased vascularity that may result more likely in sudden major internal hemorrhage. A review published in 2010 supports the hypothesis that tubal ectopic pregnancy is caused by a combination of retention of the embryo within the fallopian tube due to impaired embryo-tubal transport and alterations in the tubal environment allowing early implantation to occur. Nontubal ectopic pregnancy Two percent of ectopic pregnancies occur in the ovary, cervix, or are intraabdominal.
[4]

Transvaginal ultrasound examination is usually able to detect a cervical pregnancy. An ovarian pregnancy is differentiated from a tubal pregnancy by the Spiegelberg criteria. While a fetus of ectopic pregnancy is typically not viable, very rarely, a live baby has been delivered from an abdominal pregnancy. In such a situation the placenta sits on the intraabdominal organs or the peritoneum and has found sufficient blood supply. This is generally bowel or mesentery, but other sites, such as the renal (kidney), liver or hepatic (liver) artery or even aorta have been described. Support to near viability has occasionally been described, but even in third world countries, the diagnosis is most commonly made at 16 to 20 weeks gestation. Such a fetus would have to be delivered by laparotomy. Maternal morbidity and mortality from extrauterine pregnancy are high as attempts to remove the placenta from the organs to which it is attached usually lead to uncontrollable bleeding from the attachment site. If the organ to which the placenta is attached is removable, such as a section of bowel, then the placenta should be removed together with that organ. This is such a rare occurrence that true data are unavailable and reliance must be made on anecdotal reports. However, the vast majority of abdominal pregnancies require intervention well beforefetal viability because of the risk of hemorrhage. Heterotopic pregnancy In rare cases of ectopic pregnancy, there may be two fertilized eggs, one outside the uterus and the other inside. This is called a heterotopic pregnancy. Often the intrauterine pregnancy is discovered later than the ectopic, mainly because of the painful emergency nature of ectopic pregnancies. Since ectopic pregnancies

are normally discovered and removed very early in the pregnancy, an ultrasound may not find the additional pregnancy inside the uterus. When hCG levels continue to rise after the removal of the ectopic pregnancy, there is the chance that a pregnancy inside the uterus is still viable. This is normally discovered through an ultrasound. Although rare, heterotopic pregnancies are becoming more common, likely due to increased use of IVF. The survival rate of the uterine fetus of an ectopic pregnancy is around 70%. Successful pregnancies have been reported from ruptured tubal pregnancy continuing by the placenta implanting on abdominal organs or on the outside of the uterus. Persistent ectopic pregnancy A persistent ectopic pregnancy refers to the continuation of trophoplastic growth after a surgical intervention to remove an ectopic pregnancy. After a conservative procedure that attempts to preserve the affected fallopian tube such as a salpingotomy, in about 15-20% the major portion of the ectopic growth may have been removed, but some trophoblastic tissue, perhaps deeply embedded, has escaped removal and continues to grow, generating a new rise in hCG levels. After weeks this may lead to new clinical symptoms including bleeding. For this reason hCG levels may have to be monitored after removal of an ectopic to assure their decline, also methotrexate can be given at the time of surgery prophylactically. Signs and symptoms Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8 weeks. Later presentations are more common in communities deprived of modern diagnostic ability. Early signs include:

Pain in the lower abdomen, and inflammation (pain may be confused with a strong stomach pain, it may also feel like a strong cramp).

Pain while urinating. Pain and discomfort, usually mild. A corpus luteum on the ovary in a normal pregnancy may give very similar symptoms.

Vaginal bleeding, usually mild. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding. This can be indistinguishable from an early miscarriage or the 'implantation bleed' of a normal early pregnancy.

Pain while having a bowel movement.

Patients with a late ectopic pregnancy typically experience pain and bleeding. This bleeding will be both vaginal and internal and has two discrete pathophysiologic mechanisms:

External bleeding is due to the falling progesterone levels. Internal bleeding (hematoperitoneum) is due to hemorrhage from the affected tube.

The differential diagnosis at this point is between miscarriage, ectopic pregnancy, and early normal pregnancy. The presence of a positive pregnancy test virtually rules out pelvic infection as it is rare indeed to find pregnancy with an active pelvic inflammatory disease(PID). The most common misdiagnosis assigned to early ectopic pregnancy is PID. More severe internal bleeding may cause:

Lower back, abdominal, or pelvic pain. Shoulder pain. This is caused by free blood tracking up the abdominal cavity and irritating the diaphragm, and is an ominous sign.

There may be cramping or even tenderness on one side of the pelvis. The pain is of recent onset, meaning it must be differentiated from cyclical pelvic pain, and is often getting worse.

Ectopic pregnancy can mimic symptoms of other diseases such as appendicitis, other gastrointestinal disorder, problems of the urinary system, as well as pelvic inflammatory disease and other gynaecologic problems. Causes There are a number of risk factors for ectopic pregnancies. However, in as many as one third half
[12] [11]

to one

of ectopic pregnancies, no risk factors can be identified. Risk factors include: pelvic inflammatory

disease, infertility, use of an intrauterine device (IUD), previous exposure to DES, tubal surgery, intrauterine surgery (e.g. D&C), smoking, previous ectopic pregnancy, and tubal ligation.
[13]

Although older texts suggest an association between endometriosis and ectopic pregnancy this is not evidence based and current research suggests no association between endometriosis and ectopic pregnancy.
[14]

Cilial damage and tube occlusion Hair-like cilia located on the internal surface of the Fallopian tubes carry the fertilized egg to the uterus. Fallopian cilia are sometimes seen in reduced numbers subsequent to an ectopic pregnancy, leading to a hypothesis that cilia damage in the Fallopian tubes is likely to lead to an ectopic pregnancy. with pelvic inflammatory disease (PID) have a high occurrence of ectopic pregnancy. build-up of scar tissue in the Fallopian tubes, causing damage to cilia.
[3] [16] [15]

Women

This results from the

If however both tubes were completely

blocked, so that sperm and egg were physically unable to meet, then fertilization of the egg would naturally be impossible, and neither normal pregnancy nor ectopic pregnancy could occur. Tubal surgery for damaged tubes might remove this protection and increase the risk of ectopic pregnancy
[citation needed]

. Intrauterine

adhesions (IUA) present in Asherman's syndrome can cause ectopic cervical pregnancy or, if adhesions partially block access to the tubes via the ostia, ectopic tubal pregnancy. occurs from intrauterine surgery, most commonly after D&C.
[17] [17][18][19]

Asherman's syndrome usually

Endometrial/pelvic/genital tuberculosis, another

cause of Asherman's syndrome, can also lead to ectopic pregnancy as infection may lead to tubal adhesions in addition to intrauterine adhesions.
[20]

Tubal ligation can predispose to ectopic pregnancy. Seventy percent of pregnancies after tubal cautery are ectopic, while 70% of pregnancies after tubal clips are intrauterine
[citation needed]

. Reversal of tubal sterilization

(Tubal reversal) carries a risk for ectopic pregnancy. This is higher if more destructive methods of tubal ligation (tubal cautery, partial removal of the tubes) have been used than less destructive methods (tubal clipping). A history of a tubal pregnancy increases the risk of future occurrences to about 10%.
[3]

This risk is not reduced

by removing the affected tube, even if the other tube appears normal. The best method for diagnosing this is to do an early ultrasound. Other Although some investigations have shown that patients may be at higher risk for ectopic pregnancy with advancing age, it is believed that age is a variable which could act as a surrogate for other risk factors. Also, it has been noted that smoking is associated with ectopic risk. Vaginal douching is thought by some to increase ectopic pregnancies. Women exposed to diethylstilbestrol (DES) in utero (also known as "DES daughters") also have an elevated risk of ectopic pregnancy, up to 3 times the risk of unexposed women
[citation needed] [3]

. It has

also been suggested that pathologic generation of nitric oxide through increased iNOS production may decrease tubal ciliary beats and smooth muscle contractions and thus affect embryo transport, which may consequently result in ectopic pregnancy. Diagnosis An opened oviduct with an ectopic pregnancy at about 7 weeks gestational age. An ectopic pregnancy should be considered in any woman with abdominal pain or vaginal bleeding who has a positive pregnancy test. An ultrasound showing a gestational sac with fetal heart in the fallopian tube is clear evidence of ectopic pregnancy. An abnormal rise in blood -human chorionic gonadotropin (-hCG) levels may indicate an ectopic pregnancy. The threshold of discrimination of intrauterine pregnancy is around 1500 IU/ml of -hCG. A high resolution, transvaginal ultrasound showing no intrauterine pregnancy is presumptive evidence that an ectopic pregnancy is present if the threshold of discrimination for -hCG has been reached. An empty uterus with levels higher than 1500 IU/ml may be evidence of an ectopic pregnancy, but may also be consistent with an intrauterine pregnancy which is simply too small to be seen on ultrasound. If the diagnosis is uncertain, it may be necessary to wait a few days and repeat the blood work. This can be done by measuring the -hCG level approximately 48 hours later and repeating the ultrasound. If the -hCG falls on repeat examination, this strongly suggests a spontaneous abortion or rupture. A laparoscopy or laparotomy can also be performed to visually confirm an ectopic pregnancy. Often if a tubal abortion or tubal rupture has occurred, it is difficult to find the pregnancy tissue. A laparoscopy in very early ectopic pregnancy rarely shows a normal looking fallopian tube. Culdocentesis, in which fluid is retrieved from the space separating the vagina and rectum, is a less commonly performed test that may be used to look for internal bleeding. In this test, a needle is inserted into the space at the very top of the vagina, behind the uterus and in front of the rectum. Any blood or fluid found may have been derived from a ruptured ectopic pregnancy. Cullen's sign can indicate a ruptured ectopic pregnancy. Treatment Medical
[21]

Early treatment of an ectopic pregnancy with methotrexate is a viable alternative to surgical treatment at least 1993.
[23]

[22]

since

If administered early in the pregnancy, methotrexate terminates the growth of the developing

embryo; this may cause an abortion, or the tissue may then be either resorbed by the woman's body or pass with a menstrual period. Contraindications include liver, kidney, or blood disease, as well as an ectopic mass > 3.5 cm. Surgical If hemorrhage has already occurred, surgical intervention may be necessary. However, whether to pursue surgical intervention is an often difficult decision in a stable patient with minimal evidence of blood clot on ultrasound. Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy). The first successful surgery for an ectopic pregnancy was performed by Robert Lawson Tait in 1883.
[24]

[edit]Complications The most common complication is rupture with internal haemorrhage which may lead to hypovolaemic shock. Death from rupture is rare in women who have access to modern medical facilities. Prognosis The prognosis in Western countries is very good; maternal death is rare. For instance, in the UK, between 2003 and 2005 there were 32,100 ectopic pregnancies resulting in 10 maternal deaths (meaning that 1 in 3,210 women with an ectopic pregnancy died). In the developing world, however, especially in Africa, the death rate is very high, and ectopic pregnancies are a major cause of death among women of childbearing age. Future fertility Fertility following ectopic pregnancy depends upon several factors, the most important of which is a prior history of infertility.
[26]

The treatment choice, whether surgical or nonsurgical, also plays a role. For example,

the rate of intrauterine pregnancy may be higher following methotrexate compared to surgical treatment.
[27]

Rate of fertility may be better following salpingostomy than salpingectomy.

[27]

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Cases with live birth There have been cases where ectopic pregnancy lasted many months and ended in a live baby delivered by laparotomy. In July 1999, Lori Dalton gave birth by Caesarean section in Ogden, Utah, USA, to a healthy baby girl who had developed outside of theuterus. Previous ultrasounds had not discovered the problem. "[Sage Dalton]'s delivery was slated as a routine Cesarean birth at Ogden Regional Medical Center in Utah. When Dr. Naisbitt performed Loris Cesarean, he was astonished to find Sage within the amniotic membrane outside the womb []."
[28]

"But what makes this case so rare is that not only did mother and baby survive they're both in

perfect health. John Dalton [(the father)] took home video inside the delivery room. Saige came out doing extremely well because even though she had been implanted outside the womb, a rich blood supply from a benign fibrous tumor along the outer uterus wall had nourished her with a rich source of blood."
[29]

On 19 April 2008 an English woman, Jayne Jones (age 37) who had an ectopic pregnancy attached to the omentum, the fatty covering of her large bowel, gave birth to her son Billy by a laparotomy at 28 weeks gestation. The surgery, the first of its kind to be performed in the UK, was successful, and both mother and baby survived. On May 29, 2008 an Australian woman, Meera Thangarajah (age 34), who had an ectopic pregnancy in the ovary, gave birth to a healthy full term 6 pound 3 ounce (2.8 kg) baby girl, Durga, via Caesarean section. She had no problems or complications during the 38-week pregnancy.
[31][32]

In September 1999 an English woman, Jane Ingram (age 32) gave birth to triplets: Olivia, Mary and Ronan, with an extrauterine fetus (Ronan) and intrauterine twins. All three survived. The intrauterine twins were taken out first. In other animals than humans Ectopic gestation exists in other mammals than humans. In sheep, it can go to term, with mammary preparation to parturition, and expulsion efforts. The fetus can be removed by caesarian section.

11