{{Short description|Female reproductive system health issue}} {{cs1 config|name-list-style=vanc|display-authors=6}} {{Infobox medical condition | name = Ectopic pregnancy | synonyms = EP, eccyesis, extrauterine pregnancy, EUP, tubal pregnancy (when in fallopian tube) | image = Ectopic pregnancy on laparoscopy.png | caption = Laparoscopic view, looking down at the uterus (marked by blue arrows). In the left fallopian tube, there is an ectopic pregnancy and bleeding (marked by red arrows). The right tube is normal. | field = Obstetrics and Gynaecology, Emergency Medicine | symptoms = Abdominal pain, vaginal bleeding<ref name="Crochet2013" /> | complications = | onset = | duration = | types = | causes = | risks = Pelvic inflammatory disease, tobacco smoking, prior tubal surgery, history of infertility, use of assisted reproductive technology<ref name="Cec2014" /> | diagnosis = Blood tests for human chorionic gonadotropin (hCG), ultrasound<ref name="Crochet2013" /> | differential = Miscarriage, ovarian torsion, acute appendicitis,<ref name="Crochet2013" /> corpus luteum cyst rupture<ref>{{Cite journal | vauthors = Bauman R, Horvat G | title = Management of Ruptured Corpus Luteum With Hemoperitoneum in Early Pregnancy – A Case Report | journal = Acta Clinica Croatica | volume = 57 | issue = 4 | pages = 785–788 | date = December 2018 | pmid = 31168219 | pmc = 6544092 | doi = 10.20471/acc.2018.57.04.24 }}</ref> | prevention = | treatment = methotrexate, surgery<ref name="Cec2014" /> | medication = | prognosis = Mortality 0.2% (developed world), 2% (developing world)<ref name="Mignini_2007" /> | frequency = ~1.5% of pregnancies (developed world)<ref name="Kirk_2014" /> | deaths = }} <!-- Definition and symptoms -->
'''Ectopic pregnancy''' is a complication of pregnancy in which the embryo attaches outside the uterus.<ref name="Kirk_2014" /> This complication has also been referred to as an '''extrauterine pregnancy''' ({{aka}} EUP).<ref>{{Cite book |title=Logan's Medical and Scientific Abbreviations |vauthors=Logan CM, Rice MK |publisher=J. B. Lippincott |year=1987 |isbn=0-397-54589-4 |page=183 |type=Hardbound book}}</ref> Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms.<ref name="Crochet2013" /> The pain may be described as sharp, dull, or crampy.<ref name="Crochet2013" /> Pain may also spread to the shoulder if bleeding into the abdomen has occurred.<ref name="Crochet2013" /> Severe bleeding may result in a fast heart rate, fainting, or shock.<ref name="Kirk_2014" /><ref name="Crochet2013" /> With very rare exceptions, the fetus is unable to survive.<ref>{{Cite journal | vauthors = Zhang J, Li F, Sheng Q | title = Full-term abdominal pregnancy: a case report and review of the literature | journal = Gynecologic and Obstetric Investigation | volume = 65 | issue = 2 | pages = 139–141 | date = 2008 | pmid = 17957101 | doi = 10.1159/000110015 | s2cid = 35923100 }}</ref>
<!-- Cause and diagnosis --> Overall, ectopic pregnancies annually affect less than 2% of pregnancies worldwide.<ref name="Kirk_2014" /> Risk factors for ectopic pregnancy include pelvic inflammatory disease, often due to chlamydia infection; tobacco smoking; endometriosis; prior tubal surgery; a history of infertility; and the use of assisted reproductive technology.<ref name="Cec2014" /> Those who have previously had an ectopic pregnancy are at much higher risk of having another one.<ref name="Cec2014" /> Most ectopic pregnancies (90%) occur in the fallopian tube, which are known as tubal pregnancies,<ref name="Cec2014" /> but implantation can also occur on the cervix, ovaries, caesarean scar, or within the abdomen.<ref name="Crochet2013">{{Cite journal | vauthors = Crochet JR, Bastian LA, Chireau MV | title = Does this woman have an ectopic pregnancy?: the rational clinical examination systematic review | journal = JAMA | volume = 309 | issue = 16 | pages = 1722–1729 | date = April 2013 | pmid = 23613077 | doi = 10.1001/jama.2013.3914 | s2cid = 205049738 }}</ref> Detection of ectopic pregnancy is typically by blood tests for human chorionic gonadotropin (hCG) and ultrasound.<ref name="Crochet2013" /> This may require testing on more than one occasion.<ref name="Crochet2013" /> Other causes of similar symptoms include: miscarriage, ovarian torsion, and acute appendicitis.<ref name="Crochet2013" />
<!-- Treatment --> Prevention is by decreasing risk factors, such as chlamydia infections, through screening and treatment.<ref name="Nama2009" /> While some ectopic pregnancies will miscarry without treatment,<ref name="Cec2014" /> the standard treatment for ectopic pregnancy is a procedure to either remove the embryo from the fallopian tube or to remove the fallopian tube altogether. The use of the medication methotrexate works as well as surgery in some cases.<ref name="Cec2014" /> Specifically, it works well when the beta-HCG is low, and the size of the ectopic is small.<ref name="Cec2014" /> Surgery such as a salpingectomy is still typically recommended if the tube has ruptured, there is a fetal heartbeat, or the woman's vital signs are unstable.<ref name="Cec2014" /> The surgery may be laparoscopic or through a larger incision, known as a laparotomy.<ref name="Kirk_2014" /> Maternal morbidity and mortality are reduced with treatment.<ref name="Cec2014">{{Cite journal | vauthors = Cecchino GN, Araujo Júnior E, Elito Júnior J | title = Methotrexate for ectopic pregnancy: when and how | journal = Archives of Gynecology and Obstetrics | volume = 290 | issue = 3 | pages = 417–423 | date = September 2014 | pmid = 24791968 | doi = 10.1007/s00404-014-3266-9 | s2cid = 26727563 }}</ref>
<!-- Epidemiology and history --> The rate of ectopic pregnancy is about 11 to 20 per 1,000 live births in developed countries, though it may be as high as 4% among those using assisted reproductive technology.<ref name="Kirk_2014">{{Cite journal | vauthors = Kirk E, Bottomley C, Bourne T | title = Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location | journal = Human Reproduction Update | volume = 20 | issue = 2 | pages = 250–261 | year = 2014 | pmid = 24101604 | doi = 10.1093/humupd/dmt047 | doi-access = free }}</ref> It is the most common cause of death among women during the first trimester at approximately 6–13% of the total.<ref name="Cec2014" /> In the developed world outcomes have improved while in the developing world they often remain poor.<ref name="Nama2009">{{Cite journal | vauthors = Nama V, Manyonda I | title = Tubal ectopic pregnancy: diagnosis and management | journal = Archives of Gynecology and Obstetrics | volume = 279 | issue = 4 | pages = 443–453 | date = April 2009 | pmid = 18665380 | doi = 10.1007/s00404-008-0731-3 | s2cid = 22538462 }}</ref> The risk of death among those in the developed world is between 0.1 and 0.3 percent while in the developing world it is between one and three percent.<ref name="Mignini_2007">{{Cite web | vauthors = Mignini L | title = Interventions for tubal ectopic pregnancy | date = 26 September 2007 | url = http://apps.who.int/rhl/gynaecology/lmcom2/en/ | archive-url = https://web.archive.org/web/20150402121902/http://apps.who.int/rhl/gynaecology/lmcom2/en/ | archive-date = 2 April 2015 | access-date = 12 March 2015 | website = who.int | publisher = The WHO Reproductive Health Library }}</ref> The first known description of an ectopic pregnancy is by Al-Zahrawi in the 11th century.<ref name="Nama2009" /> The word ''ectopic'' means 'out of place'.<ref>{{Cite book | vauthors = Cornog MW | title = Merriam-Webster's vocabulary uilder | location = Springfield, Mass. | page = 313 | date = 1998 | url = https://books.google.com/books?id=cyD059eY2RYC&pg=PA313 | publisher = Merriam-Webster | isbn = 978-0-87779-910-8 | archive-url = https://web.archive.org/web/20170910181336/https://books.google.com/books?id=cyD059eY2RYC&pg=PA313 | archive-date = 2017-09-10 | url-status = live }}</ref>{{TOC limit|3}}
== Signs and symptoms == thumb|upright=1.4|Ectopic pregnancy Up to 10% of those with ectopic pregnancy have no symptoms, and one-third have no medical signs.<ref name="Kirk_2014" /> In many cases the symptoms have low specificity, and can be similar to those of other genitourinary and gastrointestinal disorders, such as appendicitis, salpingitis, rupture of a corpus luteum cyst, miscarriage, ovarian torsion or urinary tract infection.<ref name="Kirk_2014" /> Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of four to eight weeks. Later presentations are more common in communities deprived of modern diagnostic abilities.<ref>{{Cite journal | vauthors = Hayashi T, Sano K, Konishi I | title = Histopathological Findings of Ectopic Pregnancy in Contraceptive-Wearing Woman | journal = Journal of Clinical Medicine Research | volume = 15 | issue = 7 | pages = 384–389 | date = July 2023 | pmid = 37575351 | pmc = 10416193 | doi = 10.14740/jocmr4924 | issn = 1918-3003 }}</ref>
Signs and symptoms of ectopic pregnancy include increased hCG, vaginal bleeding (in varying amounts), sudden lower abdominal pain,<ref name="Kirk_2014" /> pelvic pain, a tender cervix, an adnexal mass, or adnexal tenderness.<ref name="Crochet2013" /> In the absence of ultrasound or hCG assessment, heavy vaginal bleeding may lead to a misdiagnosis of miscarriage.<ref name="Kirk_2014" /> Nausea, vomiting and diarrhea are more rare symptoms of ectopic pregnancy.<ref name="Kirk_2014" />
Rupture of an ectopic pregnancy can lead to symptoms such as abdominal distension, tenderness, peritonism, and hypovolemic shock.<ref name="Kirk_2014" /> Someone with a ruptured ectopic pregnancy may experience pain when lying flat and may prefer to maintain an upright posture, as intrapelvic blood flow can lead to swelling of the abdominal cavity and cause additional pain.<ref>{{Cite journal | vauthors = Skipworth RJ | title = A new clinical sign in ruptured ectopic pregnancy | journal = Lancet | location = London, England | volume = 378 | issue = 9809 | pages = e27 | date = December 2011 | pmid = 22177516 | doi = 10.1016/s0140-6736(11)61901-6 | s2cid = 333306 | doi-access = free }}</ref>
=== Complications ===
[[File:FluidMorisonsPouchEctop.PNG|thumb|Blood in Morrison's pouch between the liver and kidney due to a ruptured ectopic pregnancy]]
The most common complication is rupture with internal bleeding, which may lead to hypovolemic shock. Damage to the fallopian tubes can lead to difficulty becoming pregnant in the future. The woman's other fallopian tube may function sufficiently for pregnancy. After the removal of one damaged fallopian tube, pregnancy remains possible in the future. If both are removed, in-vitro fertilization remains an option for women hoping to become pregnant.<ref>{{Cite web | title = Ectopic pregnancy | url = http://nhp.gov.in/disease/gynaecology-and-obstetrics/ectopic-pregnancy | archive-url = https://web.archive.org/web/20210828072425/https://www.nhp.gov.in/disease/gynaecology-and-obstetrics/ectopic-pregnancy | archive-date = 28 August 2021 | access-date = 4 December 2018 }}</ref><ref>{{Cite book | title = Pediatric clinical advisor: instant diagnosis and treatment | pages = 180–181 | date = 2007 | publisher = Mosby Elsevier | isbn = 978-0-323-03506-4 | edition = 2 }}</ref><ref>{{Cite journal | vauthors = Tenore JL | title = Ectopic pregnancy | journal = American Family Physician | volume = 61 | issue = 4 | pages = 1080–1088 | date = February 2000 | pmid = 10706160 }}</ref>
== Causes ==
There are several risk factors for ectopic pregnancies. However, in as many as one-third<ref name="Farquhar_2005">{{Cite journal | vauthors = Farquhar CM | title = Ectopic pregnancy | journal = Lancet | location = London, England | volume = 366 | issue = 9485 | pages = 583–591 | year = 2005 | pmid = 16099295 | doi = 10.1016/S0140-6736(05)67103-6 | s2cid = 26445888 }}</ref> to one-half<ref name="Majhi_2007">{{Cite journal | vauthors = Majhi AK, Roy N, Karmakar KS, Banerjee PK | title = Ectopic pregnancy--an analysis of 180 cases | journal = Journal of the Indian Medical Association | volume = 105 | issue = 6 | pages = 308, 310, 312 passim | date = June 2007 | pmid = 18232175 }}</ref> no risk factors can be identified. Risk factors include: pelvic inflammatory disease, infertility, use of an intrauterine device (IUD), previous exposure to diethylstilbestrol (DES), tubal surgery, intrauterine surgery (e.g. D&C), smoking, previous ectopic pregnancy, endometriosis, and tubal ligation.<ref>{{Cite web | title = BestBets: Risk Factors for Ectopic Pregnancy | url = http://www.bestbets.org/bets/bet.php?id=921 | url-status = live | archive-url = https://web.archive.org/web/20081219012137/http://www.bestbets.org/bets/bet.php?id=921 | archive-date = 2008-12-19 }}</ref><ref>{{Cite journal | vauthors = Rana P, Kazmi I, Singh R, Afzal M, Al-Abbasi FA, Aseeri A, Singh R, Khan R, Anwar F | title = Ectopic pregnancy: a review | journal = Archives of Gynecology and Obstetrics | volume = 288 | issue = 4 | pages = 747–757 | date = October 2013 | pmid = 23793551 | doi = 10.1007/s00404-013-2929-2 | s2cid = 42807796 }}</ref> A previous induced abortion does not appear to increase the risk.<ref>{{Cite book | chapter = 16 Answering questions about long term outcomes | title = Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care | date = 2011 | publisher = John Wiley & Sons | isbn = 978-1-4443-5847-6 | chapter-url = https://books.google.com/books?id=iK7xrRr2p9sC&pg=RA1-PT376 | archive-url = https://web.archive.org/web/20170910181336/https://books.google.com/books?id=iK7xrRr2p9sC&pg=RA1-PT376 | archive-date = 2017-09-10 | url-status = live }}</ref> The IUD does not increase the risk of ectopic pregnancy, but with an IUD if pregnancy occurs it is more likely to be ectopic than intrauterine.<ref name="Tubal ectopic pregnancy">{{Cite journal | vauthors = Kumar V, Gupta J | title = Tubal ectopic pregnancy | journal = BMJ Clinical Evidence | volume = 2015 | date = November 2015 | pmid = 26571203 | pmc = 4646159 }}</ref> The risk of ectopic pregnancy after chlamydia infection is low.<ref>{{Cite journal | vauthors = Bakken IJ | title = Chlamydia trachomatis and ectopic pregnancy: recent epidemiological findings | journal = Current Opinion in Infectious Diseases | volume = 21 | issue = 1 | pages = 77–82 | date = February 2008 | pmid = 18192790 | doi = 10.1097/QCO.0b013e3282f3d972 | s2cid = 30584041 }}</ref> The exact mechanism through which chlamydia increases the risk of ectopic pregnancy is uncertain, though some research suggests that the infection can affect the structure of fallopian tubes.<ref>{{Cite journal |author5-link=Andrew W. Horne | vauthors = Sivalingam VN, Duncan WC, Kirk E, Shephard LA, Horne AW | title = Diagnosis and management of ectopic pregnancy | journal = The Journal of Family Planning and Reproductive Health Care | volume = 37 | issue = 4 | pages = 231–240 | date = October 2011 | pmid = 21727242 | pmc = 3213855 | doi = 10.1136/jfprhc-2011-0073 }}</ref>
{| class="wikitable" |+Risk factors <ref>{{Cite journal | vauthors = Marion LL, Meeks GR | title = Ectopic pregnancy: History, incidence, epidemiology, and risk factors | journal = Clinical Obstetrics and Gynecology | volume = 55 | issue = 2 | pages = 376–386 | date = June 2012 | pmid = 22510618 | doi = 10.1097/GRF.0b013e3182516d7b }}</ref><ref name="Saraswat_2015" /> ! colspan="2" |Relative risk factors |- |High |Tubal sterilization, IUD, prior ectopic, PID (pelvic inflammatory disease), endometriosis, SIN (salpingitis isthmica nodosa) |- |Moderate |Smoking, having more than 1 recent sexual (male) partner, infertility, and chlamydia |- |Low |Douching, age greater than 35, age less than 25, GIFT (gamete intrafallopian transfer) |}
=== Tube damage === [[File:EUG 2.png|thumb|Left fallopian tube with an ectopic pregnancy in a 25-year-old woman after a salpingectomy]] Tubal pregnancy is when the egg is implanted in the fallopian tubes. 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 after an ectopic pregnancy, leading to a hypothesis that cilia damage in the fallopian tubes is likely to lead to an ectopic pregnancy.<ref name="Lyons_2006">{{Cite journal | vauthors = Lyons RA, Saridogan E, Djahanbakhch O | title = The reproductive significance of human Fallopian tube cilia | journal = Human Reproduction Update | volume = 12 | issue = 4 | pages = 363–372 | year = 2006 | pmid = 16565155 | doi = 10.1093/humupd/dml012 | doi-access = free }}</ref> Women who smoke have a higher chance of an ectopic pregnancy in the fallopian tubes. Smoking leads to risk factors of damaging and destroying cilia.<ref name="Lyons_2006" /> As cilia degenerate, the amount of time it takes for the fertilized egg to reach the uterus will increase. The fertilized egg, if it does not reach the uterus in time, will hatch from the non-adhesive zona pellucida and implant itself inside the fallopian tube, thus causing ectopic pregnancy.<ref>{{Citation | vauthors = Vadakekut ES, Gnugnoli DM|title=Ectopic Pregnancy |date=2025 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK539860/ |access-date=2025-06-07 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=30969682 }}</ref>
Women with pelvic inflammatory disease (PID) have a high occurrence of ectopic pregnancy.<ref name="Tay_2000">{{Cite journal | vauthors = Tay JI, Moore J, Walker JJ | title = Ectopic pregnancy | journal = The Western Journal of Medicine | volume = 173 | issue = 2 | pages = 131–134 | date = August 2000 | pmid = 10924442 | pmc = 1071024 | doi = 10.1136/ewjm.173.2.131 }}</ref> This results from the build-up of scar tissue in the fallopian tubes, causing damage to the cilia.<ref name="speroff" /> However, if 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. 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.<ref name="Schenker">{{Cite journal | vauthors = Schenker JG, Margalioth EJ | title = Intrauterine adhesions: an updated appraisal | journal = Fertility and Sterility | volume = 37 | issue = 5 | pages = 593–610 | date = May 1982 | pmid = 6281085 | doi = 10.1016/S0015-0282(16)46268-0 | doi-access = free }}</ref><ref name="Kyszejko_1987">{{Cite journal | vauthors = Kłyszejko C, Bogucki J, Kłyszejko D, Ilnicki W, Donotek S, Koźma J | title = [Cervical pregnancy in Asherman's syndrome] | journal = Ginekologia Polska | volume = 58 | issue = 1 | pages = 46–48 | date = January 1987 | pmid = 3583040 }}</ref><ref name="Dicker_1985">{{Cite journal | vauthors = Dicker D, Feldberg D, Samuel N, Goldman JA | title = Etiology of cervical pregnancy. Association with abortion, pelvic pathology, IUDs and Asherman's syndrome | journal = The Journal of Reproductive Medicine | volume = 30 | issue = 1 | pages = 25–27 | date = January 1985 | pmid = 4038744 }}</ref> Asherman's syndrome usually occurs from intrauterine surgery, most commonly after D&C.<ref name="Schenker" /> 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.<ref name="Bukulmez_1999">{{Cite journal | vauthors = Bukulmez O, Yarali H, Gurgan T | title = Total corporal synechiae due to tuberculosis carry a very poor prognosis following hysteroscopic synechialysis | journal = Human Reproduction | location = Oxford, England | volume = 14 | issue = 8 | pages = 1960–1961 | date = August 1999 | pmid = 10438408 | doi = 10.1093/humrep/14.8.1960 | doi-access = free }}</ref>
Tubal ligation can predispose to ectopic pregnancy. 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%.<ref name="speroff" /> 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 perform an early ultrasound.<ref>{{EMedicine|article|2041923|Ectopic Pregnancy}}</ref>
=== Endometriosis === {{Main|Endometriosis}}
Endometriosis is a disease in which cells similar to those of the endometrium, the tissue covering the inside of the uterus, grow outside the uterus. An embryo attaching to such lesions leads to an ectopic pregnancy. The results of a 30-year study of reproductive and pregnancy outcomes, involving 14,000+ women of childbearing age, were presented at the 2015 European Society of Human Reproduction and Embryology (ESHRE) annual congress.<ref name="Saraswat_2015">{{Cite web | vauthors = Saraswat L | title = ESHRE2015: Endometriosis associated with a greater risk of complications in pregnancy | date = 2015 | url = https://endometriosis.org/news/congress-highlights/eshre2015-endometriosis-associated-with-a-greater-risk-of-complications-in-pregnancy/#:~:text=After%20adjustments%20for%20age%20and%20previous%20pregnancy%2C%20results,three%20times%20higher%20for%20ectopic%20pregnancy%20%28OR%202.7%29 | access-date = 14 February 2024 | website = endometriosis.org | publisher = European Society of Human Reproduction and Embryology }}</ref> 39% of the study group had surgically confirmed endometriosis. Compared to their peers, the endometriosis subgroup had a 76% higher risk for miscarriage and a 270% higher risk for ectopic pregnancy. The higher risk of endometriosis was attributed to increased pelvic inflammation and structural and functional changes in the uterine lining.<ref>{{Citation | vauthors = Tsamantioti ES, Mahdy H |title=Endometriosis |date=2025 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK567777/ |access-date=2025-06-07 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=33620854 }}</ref>
=== 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 that could act as a surrogate for other risk factors. Vaginal douching is thought by some to increase ectopic pregnancies.<ref name="speroff" /> Women exposed to DES in utero (also known as "DES daughters") also have an elevated risk of ectopic pregnancy.<ref name="Schrager2004">{{Cite journal | vauthors = Schrager S, Potter BE | title = Diethylstilbestrol exposure | journal = American Family Physician | volume = 69 | issue = 10 | pages = 2395–2400 | date = May 2004 | pmid = 15168959 | url = http://www.aafp.org/afp/2004/0515/p2395.html | url-status = live | archive-url = https://web.archive.org/web/20150402101957/http://www.aafp.org/afp/2004/0515/p2395.html | archive-date = 2015-04-02 }}</ref> However, DES has not been used since 1971 in the United States.<ref name="Schrager2004" /> 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.<ref>{{Cite journal | vauthors = Al-Azemi M, Refaat B, Amer S, Ola B, Chapman N, Ledger W | title = The expression of inducible nitric oxide synthase in the human fallopian tube during the menstrual cycle and in ectopic pregnancy | journal = Fertility and Sterility | volume = 94 | issue = 3 | pages = 833–840 | date = August 2010 | pmid = 19482272 | doi = 10.1016/j.fertnstert.2009.04.020 }}</ref> Low socioeconomic status may also be a risk factor for ectopic pregnancy.<ref name="Yuk_2013">{{Cite journal | vauthors = Yuk JS, Kim YJ, Hur JY, Shin JH | title = Association between socioeconomic status and ectopic pregnancy rate in the Republic of Korea | journal = International Journal of Gynaecology and Obstetrics| volume = 122 | issue = 2 | pages = 104–107 | date = August 2013 | pmid = 23726169 | doi = 10.1016/j.ijgo.2013.03.015 | s2cid = 25547683 }}</ref>
== Diagnosis ==
An ectopic pregnancy should be considered as the cause of abdominal pain or vaginal bleeding in everyone who has a positive pregnancy test.<ref name="Crochet2013" /> The primary goal of diagnostic procedures in possible ectopic pregnancy is to triage according to risk rather than establishing pregnancy location.<ref name="Kirk_2014" />
=== Transvaginal ultrasonography ===
An ultrasound showing a gestational sac with the fetal heart in the fallopian tube has a very high specificity for ectopic pregnancy. It involves a long, thin transducer, covered with the conducting gel and a plastic/latex sheath, and inserted into the vagina.<ref>{{Cite web | title = Pelvic Ultrasound | date = 8 August 2021 | url = https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/pelvic-ultrasound | access-date = 2022-04-26 | website = www.hopkinsmedicine.org | language = en }}</ref> Transvaginal ultrasonography has a sensitivity of at least 90% for ectopic pregnancy.<ref name="Kirk_2014" /> The diagnostic ultrasonographic finding in ectopic pregnancy is an adnexal mass that moves separately from the ovary. In around 60% of cases, it is an inhomogeneous or a noncystic adnexal mass, sometimes known as the "blob sign". It is generally spherical, but a more tubular appearance may be seen in the case of hematosalpinx. This sign has been estimated to have a sensitivity of 84% and a specificity of 99% in diagnosing ectopic pregnancy.<ref name="Kirk_2014" /> In the study estimating these values, the blob sign had a positive predictive value of 96% and a negative predictive value of 95%.<ref name="Kirk_2014" /> The visualization of an empty extrauterine gestational sac is sometimes known as the "bagel sign", and is present in around 20% of cases.<ref name="Kirk_2014" /> In another 20% of cases, there is visualization of a gestational sac containing a yolk sac or an embryo.<ref name="Kirk_2014" /> Ectopic pregnancies where there is visualization of cardiac activity are sometimes termed "viable ectopic".<ref name="Kirk_2014" /> <gallery mode="packed"> File:Schematic figure of vaginal ultrasonography in ectopic pregnancy.svg|Transvaginal ultrasonography of an ectopic pregnancy, showing the field of view in the following image File:Blob sign of ectopic pregnancy.png|A "blob sign", which consists of the ectopic pregnancy. The ovary is distinguished from it by having follicles, whereof one is visible in the field. This patient had an intrauterine device (IUD) with progestogen, whose cross-section is visible in the field, leaving an ultrasound shadow distally to it. File:Ectopicleftmass.PNG|Ultrasound image showing an ectopic pregnancy where a gestational sac and fetus have been formed </gallery> thumb|A pregnancy not in the uterus<ref>{{Cite web | title = UOTW#61 - Ultrasound of the Week | date = 14 October 2015 | url = https://www.ultrasoundoftheweek.com/uotw-61/ | url-status = live | archive-url = https://web.archive.org/web/20170509152013/https://www.ultrasoundoftheweek.com/uotw-61/ | archive-date = 9 May 2017 | website = Ultrasound of the Week }}</ref> The combination of a positive pregnancy test and the presence of what appears to be a normal intrauterine pregnancy does not exclude ectopic pregnancy, since there may be either a heterotopic pregnancy or a "{{visible anchor|pseudosac}}", which is a collection of within the endometrial cavity that may be seen in up to 20% of women.<ref name="Kirk_2014" />
A small amount of anechogenic-free fluid in the recto-uterine pouch is commonly found in both intrauterine and ectopic pregnancies.<ref name="Kirk_2014" /> The presence of echogenic fluid is estimated at between 28 and 56% of women with an ectopic pregnancy, and strongly indicates the presence of hemoperitoneum.<ref name="Kirk_2014" /> However, it does not necessarily result from tubal rupture but is commonly a result from leakage from the distal tubal opening.<ref name="Kirk_2014" /> As a rule of thumb, the finding of free fluid is significant if it reaches the fundus or is present in the vesico-uterine pouch.<ref name="Kirk_2014" /> A further marker of serious intra-abdominal bleeding is the presence of fluid in the hepatorenal recess of the subhepatic space.<ref name="Kirk_2014" />
{{As of|2014}}, Doppler ultrasonography is not considered to significantly contribute to the diagnosis of ectopic pregnancy.<ref name="Kirk_2014" />
A common misdiagnosis of a normal intrauterine pregnancy is when the pregnancy is implanted laterally in an arcuate uterus, potentially being misdiagnosed as an interstitial pregnancy.<ref name="Kirk_2014" />
=== Ultrasonography and β-hCG === [[File:Algorithm in pregnancy of unknown location.svg|thumb|upright=1.4|Algorithm of the management of a pregnancy of unknown location, that is, a positive pregnancy test but no pregnancy is found on transvaginal ultrasonography.<ref name="Kirk_2014" /> If serum hCG at 0 hours is more than 1000 IU/L and there is no history suggestive of complete miscarriage, the ultrasonography should be repeated as soon as possible.<ref name="Kirk_2014" />]]
Where no intrauterine pregnancy (IUP) is seen on ultrasound, measuring β-human chorionic gonadotropin (β-hCG) levels may aid in the diagnosis. The rationale is that a low β-hCG level may indicate that the pregnancy is intrauterine but too small to be visible on ultrasonography. While some physicians consider that the threshold where an intrauterine pregnancy should be visible on transvaginal ultrasound is around 1500 mIU/mL of β-hCG, a review in the JAMA Rational Clinical Examination Series showed that there is no single threshold for the β-human chorionic gonadotropin that confirms an ectopic pregnancy. Instead, the best test for a pregnant woman is a high-resolution transvaginal ultrasound.<ref name="Crochet2013" /> The presence of an adnexal mass in the absence of an intrauterine pregnancy on transvaginal sonography increases the likelihood of an ectopic pregnancy 100-fold (LR+ 111). When there are no adnexal abnormalities on transvaginal sonography, the likelihood of an ectopic pregnancy decreases (LR- 0.12). An empty uterus with levels higher than 1500 mIU/mL may be evidence of an ectopic pregnancy, but it may also be consistent with an intrauterine pregnancy, which is 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 β-hCG level approximately 48 hours later and repeating the ultrasound. The serum hCG ratios and logistic regression models appear to be better than absolute single serum hCG level.<ref>{{Cite journal | vauthors = van Mello NM, Mol F, Opmeer BC, Ankum WM, Barnhart K, Coomarasamy A, Mol BW, van der Veen F, Hajenius PJ | title = Diagnostic value of serum hCG on the outcome of pregnancy of unknown location: a systematic review and meta-analysis | journal = Human Reproduction Update | volume = 18 | issue = 6 | pages = 603–617 | year = 2012 | pmid = 22956411 | doi = 10.1093/humupd/dms035 | doi-access = free }}</ref> If the β-hCG falls on repeat examination, this strongly suggests a spontaneous abortion or rupture. The fall in serum hCG over 48 hours may be measured as the hCG ratio, which is calculated as:<ref name="Kirk_2014" /> <math>hCG~ratio = \frac{hCG~at~48h}{hCG~at~0h}</math>
An hCG ratio of 0.87 – a decrease in hCG of 13% over 48 hours – has a sensitivity of 93% and specificity of 97% for predicting a failing pregnancy of unknown location (PUL).<ref name="Kirk_2014" /> The majority of cases of ectopic pregnancy will have serial serum hCG levels that increase more slowly than would be expected with an IUP (known as a suboptimal rise), or decrease more slowly than would be expected with a failing PUL. However, up to 20% of cases of ectopic pregnancy have serum hCG doubling times similar to that of an IUP, and around 10% of EP cases have hCG patterns similar to a failing PUL.<ref name="Kirk_2014" />
=== Other methods ===
==== Direct examination ==== A laparoscopy or laparotomy can also be performed to confirm an ectopic pregnancy visually. This is generally reserved for women presenting with signs of an acute abdomen and hypovolemic shock.<ref name="Kirk_2014" /> Often, if a tubal abortion or tubal rupture has occurred, it is difficult to find the pregnancy tissue. A laparoscopy in a very early ectopic pregnancy rarely shows a normal-looking fallopian tube.<ref>{{cite journal | vauthors = Soriano D, Yefet Y, Oelsner G, Goldenberg M, Mashiach S, Seidman DS | title = Operative laparoscopy for management of ectopic pregnancy in patients with hypovolemic shock | journal = The Journal of the American Association of Gynecologic Laparoscopists | volume = 4 | issue = 3 | pages = 363–367 | date = May 1997 | pmid = 9154787 | doi = 10.1016/s1074-3804(05)80229-4 }}</ref>
==== Culdocentesis ==== 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.<ref>{{Citation | vauthors = Lafans K, Kok SJ |title=Culdocentesis |date=2025 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK564360/ |access-date=2025-06-07 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=33232030 }}</ref>
==== Progesterone levels ==== Progesterone levels of less than 20 nmol/L have a high predictive value for failing pregnancies, whilst levels over 25 nmol/L are likely to predict viable pregnancies, and levels over 60 nmol/L are strongly so. This may help identify failing PUL that are at low risk and thereby require less follow-up.<ref name="Kirk_2014" /> Inhibin A may also be useful for predicting spontaneous resolution of PUL, but is not as effective as progesterone for this purpose.<ref name="Kirk_2014" />
==== Mathematical models ==== There are various mathematical models, such as logistic regression models and Bayesian networks, for the prediction of PUL outcomes based on multiple parameters.<ref name="Kirk_2014" /> Mathematical models also aim to identify PULs that are ''low risk'', that is, failing PULs and IUPs.<ref name="Kirk_2014" />
==== Dilation and curettage ==== Dilation and curettage (D&C) is sometimes used to diagnose pregnancy location to differentiate between an EP and a non-viable IUP in situations where a viable IUP can be ruled out. Specific indications for this procedure include either of the following:<ref name="Kirk_2014" /> * No visible IUP on transvaginal ultrasonography with a serum hCG of more than 2000 mIU/mL. * An abnormal rise in hCG level. A rise of 35% over 48 hours is proposed as the minimal rise consistent with a viable intrauterine pregnancy. * An abnormal fall in hCG level, defined as one of less than 20% in two days.
=== Classification ===
==== Tubal pregnancy ====
The vast majority of ectopic pregnancies implant in the fallopian tube. Pregnancies can grow in the fimbrial end (5% of all ectopic pregnancies), the ampullary section (80%), the isthmus (12%), and the cornual and interstitial part of the tube (2%).<ref name="speroff">{{Cite book | vauthors = Speroff L, Glass RH, Kase NG | title = Clinical Gynecological Endocrinology and Infertility, 6th Ed. | pages = 1149ff | year = 1999 | publisher = Lippincott Williams & Wilkins (1999) | isbn = 978-0-683-30379-7 }}</ref> 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 bleeding. 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.<ref>{{Cite journal | vauthors = Shaw JL, Dey SK, Critchley HO, Horne AW | title = Current knowledge of the aetiology of human tubal ectopic pregnancy | journal = Human Reproduction Update | volume = 16 | issue = 4 | pages = 432–444 | date = January 2010 | pmid = 20071358 | pmc = 2880914 | doi = 10.1093/humupd/dmp057 }}</ref>
==== Nontubal ectopic pregnancy ====
Two percent of ectopic pregnancies occur in the ovary, cervix, or are intra-abdominal. Transvaginal ultrasound examination is usually able to detect a cervical pregnancy. An ovarian pregnancy is differentiated from a tubal pregnancy by the Spiegelberg criteria.<ref>{{WhoNamedIt|synd|2274|Spiegelberg's criteria}}</ref>
While a fetus of ectopic pregnancy is typically not viable, very rarely, live babies have been delivered from abdominal pregnancy or C-section scar ectopic pregnancy. In the former situation, the placenta sits on the intra-abdominal 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 the 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 the bowel, then the placenta should be removed together with that organ. This is such a rare occurrence that true data is unavailable, and reliance must be made on anecdotal reports.<ref>{{Cite news | title = 'Special' baby grew outside womb | date = 2005-08-30 | url = https://news.bbc.co.uk/2/hi/uk_news/england/beds/bucks/herts/4197194.stm | url-status = live | archive-url = https://web.archive.org/web/20070212010650/http://news.bbc.co.uk/1/hi/england/beds/bucks/herts/4197194.stm | archive-date = 2007-02-12 | access-date = 2006-07-14 | work = BBC News }}</ref><ref>{{Cite news | title = Bowel baby born safely | date = 2005-03-09 | url = https://news.bbc.co.uk/2/hi/health/671390.stm | url-status = live | archive-url = https://web.archive.org/web/20070211233539/http://news.bbc.co.uk/2/hi/health/671390.stm | archive-date = 2007-02-11 | access-date = 2006-11-10 | work = BBC News }}</ref><ref name="Zhang_2008a">{{Cite journal | vauthors = Zhang J, Li F, Sheng Q | title = Full-term abdominal pregnancy: a case report and review of the literature | journal = Gynecologic and Obstetric Investigation | volume = 65 | issue = 2 | pages = 139–141 | year = 2008 | pmid = 17957101 | doi = 10.1159/000110015 | s2cid = 35923100 }}</ref> However, the vast majority of abdominal pregnancies require intervention well before fetal viability because of the risk of bleeding.
With the increase in Cesarean sections performed worldwide,<ref>{{cite journal | title = Rates of cesarean delivery--United States, 1993 | journal = MMWR. Morbidity and Mortality Weekly Report | volume = 44 | issue = 15 | pages = 303–307 | date = 21 April 1995 | pmid = 7708041 | url = http://www.cdc.gov/mmwr/preview/mmwrhtml/00036845.htm }}</ref><ref>{{Cite journal | vauthors = Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR | title = The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014 | journal = PLOS ONE | volume = 11 | issue = 2 | article-number = e0148343 | date = 2016-02-05 | pmid = 26849801 | pmc = 4743929 | doi = 10.1371/journal.pone.0148343 | bibcode = 2016PLoSO..1148343B | doi-access = free }}</ref> Cesarean section ectopic pregnancies (CSP) are rare, but becoming more common. The incidence of CSP is not well known; however, there have been estimates based on different populations of 1:1800–1:2216.<ref>{{Cite journal | vauthors = Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ | title = First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar | journal = Ultrasound in Obstetrics & Gynecology| volume = 21 | issue = 3 | pages = 220–227 | date = March 2003 | pmid = 12666214 | doi = 10.1002/uog.56 | s2cid = 27272542 | doi-access = free }}</ref><ref name="Cesarean scar pregnancy: issues in">{{Cite journal | vauthors = Seow KM, Huang LW, Lin YH, Lin MY, Tsai YL, Hwang JL | title = Cesarean scar pregnancy: issues in management | journal = Ultrasound in Obstetrics & Gynecology| volume = 23 | issue = 3 | pages = 247–253 | date = March 2004 | pmid = 15027012 | doi = 10.1002/uog.974 | s2cid = 36067188 | doi-access = free }}</ref> CSP are characterized by abnormal implantation into the scar from a previous cesarean section,<ref name="Luis_Izquierdo_2019">{{Cite journal | vauthors = Luis Izquierdo MD, Mariam Savabi MD | title = How to diagnose and treat cesarean scar pregnancy | journal = Contemporary Ob/Gyn Journal | volume = 64 | issue = 8 | date = 16 August 2019 | url = https://www.contemporaryobgyn.net/view/how-diagnose-and-treat-cesarean-scar-pregnancy | series = Vol 64 No 08 | access-date = 2020-08-11 }}</ref> and allowed to continue can cause serious complications such as uterine rupture and hemorrhage.<ref name="Cesarean scar pregnancy: issues in" /> Patients with CSP generally present without symptoms; symptoms can include vaginal bleeding that may or may not be associated with pain.<ref>{{Cite journal | vauthors = Rotas MA, Haberman S, Levgur M | title = Cesarean scar ectopic pregnancies: etiology, diagnosis, and management | journal = Obstetrics and Gynecology | volume = 107 | issue = 6 | pages = 1373–1381 | date = June 2006 | pmid = 16738166 | doi = 10.1097/01.AOG.0000218690.24494.ce | s2cid = 39198754 }}</ref><ref name="Ash_2007">{{Cite journal | vauthors = Ash A, Smith A, Maxwell D | title = Caesarean scar pregnancy | journal = BJOG: An International Journal of Obstetrics and Gynaecology | volume = 114 | issue = 3 | pages = 253–263 | date = March 2007 | pmid = 17313383 | doi = 10.1111/j.1471-0528.2006.01237.x | s2cid = 34003037 | doi-access = free }}</ref> The diagnosis of CSP is made by ultrasound and four characteristics are noted: (1) Empty uterine cavity with bright hyperechoic endometrial stripe (2) Empty cervical canal (3) Intrauterine mass in the anterior part of the uterine isthmus, and (4) Absence of the anterior uterine muscle layer, and/or absence or thinning between the bladder and gestational sac, measuring less than 5 mm.<ref name="Luis_Izquierdo_2019" /><ref>{{Cite book | title = Williams obstetrics | location = New York | publisher = McGraw-Hill Education | date = 12 April 2018 | isbn = 978-1-259-64432-0 | veditors = Hoffman BL, Casey BM, Spong CY, Cunningham FG, Dashe JS, Leveno KJ, Bloom SL | edition = 25th | oclc = 986236927 }}</ref><ref>{{Cite journal | vauthors = Weimin W, Wenqing L | title = Effect of early pregnancy on a previous lower segment cesarean section scar | journal = International Journal of Gynaecology and Obstetrics| volume = 77 | issue = 3 | pages = 201–207 | date = June 2002 | pmid = 12065130 | doi = 10.1016/S0020-7292(02)00018-8 | s2cid = 28083933 }}</ref> Given the rarity of the diagnosis, treatment options tend to be described in case reports and series, ranging from medical with methotrexate or KCl<ref>{{Cite journal | vauthors = Godin PA, Bassil S, Donnez J | title = An ectopic pregnancy developing in a previous caesarian section scar | journal = Fertility and Sterility | volume = 67 | issue = 2 | pages = 398–400 | date = February 1997 | pmid = 9022622 | doi = 10.1016/S0015-0282(97)81930-9 | doi-access = free }}</ref> to surgical with dilation and curettage,<ref>{{Cite journal | vauthors = Shu SR, Luo X, Wang ZX, Yao YH | title = Cesarean scar pregnancy treated by curettage and aspiration guided by laparoscopy | journal = Therapeutics and Clinical Risk Management | volume = 11 | pages = 1139–1141 | date = 2015-08-01 | pmid = 26345396 | pmc = 4529265 | doi = 10.2147/TCRM.S86083 | doi-access = free }}</ref> uterine wedge resection,<ref>{{cite journal | vauthors = Liao CY, Tse J, Sung SY, Chen SH, Tsui WH | title = Cornual wedge resection for interstitial pregnancy and postoperative outcome | journal = The Australian & New Zealand Journal of Obstetrics & Gynaecology | volume = 57 | issue = 3 | pages = 342–345 | date = June 2017 | pmid = 27456318 | doi = 10.1111/ajo.12497 }}</ref> or hysterectomy.<ref name="Ash_2007" /> A double-balloon catheter technique has also been described,<ref>{{Cite journal | vauthors = Monteagudo A, Calì G, Rebarber A, Cordoba M, Fox NS, Bornstein E, Dar P, Johnson A, Rebolos M, Timor-Tritsch IE | title = Minimally Invasive Treatment of Cesarean Scar and Cervical Pregnancies Using a Cervical Ripening Double Balloon Catheter: Expanding the Clinical Series | journal = Journal of Ultrasound in Medicine| volume = 38 | issue = 3 | pages = 785–793 | date = March 2019 | pmid = 30099757 | doi = 10.1002/jum.14736 | s2cid = 51966025 }}</ref> allowing for uterine preservation. The recurrence risk for CSP is unknown, and early ultrasound in the next pregnancy is recommended.<ref name="Luis_Izquierdo_2019" />
==== Heterotopic pregnancy ==== {{main|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.<ref name="Crochet2013" /> 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 a chance that a pregnancy inside the uterus is still viable. This is normally discovered through an ultrasound.<ref>{{Cite journal | vauthors = Hassani KI, Bouazzaoui AE, Khatouf M, Mazaz K | title = Heterotopic pregnancy: A diagnosis we should suspect more often | journal = Journal of Emergencies, Trauma, and Shock | volume = 3 | issue = 3 | page = 304 | date = July 2010 | pmid = 20930992 | pmc = 2938513 | doi = 10.4103/0974-2700.66563 | doi-access = free | issn = 0974-519X }}</ref>
Although rare, heterotopic pregnancies are becoming more common, likely due to increased use of IVF. The survival rate of the uterine fetus of a heterotopic pregnancy is around 70%.<ref>{{Cite journal | vauthors = Lau S, Tulandi T | title = Conservative medical and surgical management of interstitial ectopic pregnancy | journal = Fertility and Sterility | volume = 72 | issue = 2 | pages = 207–215 | date = August 1999 | pmid = 10438980 | doi = 10.1016/s0015-0282(99)00242-3 | doi-access = free }}</ref>
==== Rudimentary horn pregnancy ==== {{main|Rudimentary horn pregnancy}}
A pregnancy in a rudimentary horn refers to a rare and life-threatening condition that occurs when a fertilized egg implants inside the small rudimentary horn of a unicornuate uterus, which is a type of congenital uterine abnormality caused by the incomplete development of one of the Müllerian ducts. This type of ectopic pregnancy is often results in rupture of the rudimentary horn between 10 and 15 weeks of gestation, leading to a high risk of morbidity and mortality.<ref>{{Cite journal | vauthors = Chopra S, Keepanasseril A, Rohilla M, Bagga R, Kalra J, Jain V | title = Obstetric morbidity and the diagnostic dilemma in pregnancy in rudimentary horn: retrospective analysis | journal = Archives of Gynecology and Obstetrics | volume = 280 | issue = 6 | pages = 907–910 | date = 2009-03-13 | pmid = 19283398 | doi = 10.1007/s00404-009-1013-4 | publisher = Springer Science and Business Media LLC | issn = 0932-0067 | s2cid = 5616550 }}</ref>
==== Persistent ectopic pregnancy ====
A persistent ectopic pregnancy refers to the continuation of trophoblastic 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.<ref>{{Cite journal | vauthors = Kemmann E, Trout S, Garcia A | title = Can We predict patients at risk for persistent ectopic pregnancy after laparoscopic salpingotomy? | journal = The Journal of the American Association of Gynecologic Laparoscopists | volume = 1 | issue = 2 | pages = 122–126 | date = February 1994 | pmid = 9050473 | doi = 10.1016/S1074-3804(05)80774-1 }}</ref> After weeks, this may lead to new clinical symptoms, including bleeding. For this reason, hCG levels may have to be monitored after the removal of an ectopic pregnancy to ensure their decline, also methotrexate can be given at the time of surgery prophylactically.<ref>{{Cite journal | vauthors = Compadre AJ, Ukoha EP, Zhang W | title = Combined surgical and medical management of a broad ligament ectopic pregnancy: A case report | journal = Case Reports in Women's Health | volume = 31 | article-number = e00316 | date = July 2021 | pmid = 34036051 | pmc = 8134953 | doi = 10.1016/j.crwh.2021.e00316 | issn = 2214-9112 }}</ref>
==== Pregnancy of unknown location ====
Pregnancy of unknown location (PUL) is the term used for a pregnancy where there is a positive pregnancy test but no pregnancy has been visualized using transvaginal ultrasonography.<ref name="Kirk_2014" /> Specialized early pregnancy departments have estimated that between 8% and 10% of women attending for an ultrasound assessment in early pregnancy will be classified as having a PUL.<ref name="Kirk_2014" /> The true nature of the pregnancy can be an ongoing viable intrauterine pregnancy, a failed pregnancy, an ectopic pregnancy or rarely a persisting PUL.<ref name="Kirk_2014" />
Because of frequent ambiguity on ultrasonography examinations, the following classification is proposed:<ref name="Kirk_2014" />
{| class="wikitable" ! Condition !! Criteria |- | Definite ectopic pregnancy || Extrauterine gestational sac with yolk sac or embryo (with or without cardiac activity). |- | Pregnancy of unknown location – probable ectopic pregnancy || Inhomogeneous adnexal mass or extrauterine sac-like structure. |- | "True" pregnancy of unknown location || No signs of intrauterine or extrauterine pregnancy on transvaginal ultrasonography. |- | Pregnancy of unknown location – probable intrauterine pregnancy || Intrauterine gestational sac-like structure. |- | Definite intrauterine pregnancy || Intrauterine gestational sac with yolk sac or embryo (with or without cardiac activity). |}
In women with a pregnancy of unknown location, between 6% and 20% have an ectopic pregnancy.<ref name="Kirk_2014" /> In cases of pregnancy of unknown location and a history of heavy bleeding, it has been estimated that approximately 6% have an underlying ectopic pregnancy.<ref name="Kirk_2014" /> Between 30% and 47% of women with pregnancy of unknown location are ultimately diagnosed with an ongoing intrauterine pregnancy, of which the majority (50–70%) will be found to have failed pregnancies where the location is never confirmed.<ref name="Kirk_2014" />
[[File:Histopathology of tubal pregnancy.jpg|thumb|Chorionic villus on histopathological examination of a tubal pregnancy]] {{visible anchor|Persisting PUL}} is where the hCG level does not spontaneously decline, and no intrauterine or ectopic pregnancy is identified on follow-up transvaginal ultrasonography.<ref name="Kirk_2014" /> A persisting PUL is likely either a small ectopic pregnancy that has not been visualized or a retained trophoblast in the endometrial cavity.<ref name="Kirk_2014" /> Treatment should only be considered when a potentially viable intrauterine pregnancy has been definitively excluded.<ref name="Kirk_2014" /> A ''treated persistent PUL'' is defined as one managed medically (generally with methotrexate) without confirmation of the location of the pregnancy, such as by ultrasound, laparoscopy, or uterine evacuation.<ref name="Kirk_2014" /> A ''resolved persistent PUL'' is defined as serum hCG reaching a non-pregnant value (generally less than 5 IU/L) after expectant management, or after uterine evacuation without evidence of chorionic villi on histopathological examination.<ref name="Kirk_2014" /> In contrast, a relatively low and unresolving level of serum hCG indicates the possibility of an hCG-secreting tumor.<ref name="Kirk_2014" />
=== Differential diagnosis ===
Other conditions that cause similar symptoms include: miscarriage, ovarian torsion, acute appendicitis, ruptured ovarian cyst, kidney stone, and pelvic inflammatory disease, among others.<ref name="Crochet2013" />
== Treatment ==
=== Expectant management ===
Most women with a PUL are followed up with serum hCG measurements and repeat TVS examinations until a final diagnosis is confirmed.<ref name="Kirk_2014" /> Low-risk cases of PUL that appear to be failing pregnancies may be followed up with a urinary pregnancy test after two weeks and get subsequent telephone advice.<ref name="Kirk_2014" /> Low-risk cases of PUL that are likely intrauterine pregnancies may have another TVS in two weeks to assess viability.<ref name="Kirk_2014" /> High-risk cases of PUL require further assessment, either with a TVS within 48 h or additional hCG measurement.<ref name="Kirk_2014" />
=== Medical ===
Early treatment of ectopic pregnancy with methotrexate is a viable alternative to surgical treatment<ref name="pmid17591007">{{Cite journal | vauthors = Mahboob U, Mazhar SB | title = Management of ectopic pregnancy: a two-year study | journal = Journal of Ayub Medical College, Abbottabad | volume = 18 | issue = 4 | pages = 34–37 | year = 2006 | pmid = 17591007 }}</ref> which was developed in the 1980s.<ref>[http://www.ectopicpregnancy.co.uk/for-professionals/perspectives/history-and-diagnosis/ "History, Diagnosis and Management of Ectopic Pregnancy"] {{webarchive|url=https://web.archive.org/web/20151005225652/http://www.ectopicpregnancy.co.uk/for-professionals/perspectives/history-and-diagnosis/ |date=2015-10-05 }}</ref> If administered early in the pregnancy, methotrexate terminates the growth of the developing embryo; the developing embryo may then be either resorbed by the woman's body or pass with a menstrual period. Contraindications include ectopic embryonic mass > 3.5 cm and evidence of ruptured fallopian tube, as well as renal or hepatic dysfunction.<ref>{{cite journal | vauthors = Kim PY, de La Vallee C | title = Isthmic ectopic gestation: A contraindication to methotrexate therapy? | journal = American Journal of Obstetrics and Gynecology | volume = 176 | issue = 3 | pages = 711–712 | date = March 1997 | pmid = 9077635 | doi = 10.1016/s0002-9378(97)70576-3 }}</ref>
Also, it may lead to the inadvertent termination of an undetected intrauterine pregnancy or severe abnormality in any surviving pregnancy.<ref name="Kirk_2014" /> Therefore, it is recommended that methotrexate should only be administered when hCG has been serially monitored with a rise of less than 35% over 48 hours, which practically excludes a viable intrauterine pregnancy.<ref name="Kirk_2014" />
For nontubal ectopic pregnancy, evidence from randomized clinical trials in women with CSP is uncertain regarding treatment success, complications and side effects of methotrexate compared with surgery (uterine arterial embolization or uterine arterial chemoembolization).<ref>{{Cite journal | vauthors = Long Y, Zhu H, Hu Y, Shen L, Fu J, Huang W | title = Interventions for non-tubal ectopic pregnancy. | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | issue = 7 | article-number = CD011174 | date = 1 July 2020 | pmid = 32609376 | pmc = 7389314 | doi = 10.1002/14651858.CD011174.pub2 }}</ref>
The United States uses a multi-dose protocol of methotrexate (MTX), which involves four doses of intramuscular MTX along with an intramuscular injection of folinic acid to protect cells from the effects of the drug and to reduce side effects. In France, the single-dose protocol is followed, but a single dose has a greater chance of failure.<ref>{{Cite journal | vauthors = Marret H, Fauconnier A, Dubernard G, Misme H, Lagarce L, Lesavre M, Fernandez H, Mimoun C, Tourette C, Curinier S, Rabishong B, Agostini A | title = Overview and guidelines of off-label use of methotrexate in ectopic pregnancy: report by CNGOF | journal = European Journal of Obstetrics, Gynecology, and Reproductive Biology | volume = 205 | pages = 105–109 | date = October 2016 | pmid = 27572300 | doi = 10.1016/j.ejogrb.2016.07.489 }}</ref>
===Surgery=== thumb|Surgical treatment: Laparoscopic view of an ectopic pregnancy located in the left fallopian tube, hematosalpinx is present on the left, the right tube is of normal appearance
thumb|The left fallopian tube containing the ectopic pregnancy has been removed (salpingectomy).
If bleeding 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 a blood clot on ultrasound.<ref name="EMedicine 267384 Surgical Management of Ectopic Pregnancy">{{EMedicine|article|267384|Surgical Management of Ectopic Pregnancy}}</ref>
Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected fallopian tube 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.<ref name="EMedicine 267384 Surgical Management of Ectopic Pregnancy"/> It is estimated that an acceptable rate of PULs that eventually undergo surgery is between 0.5 and 11%.<ref name="Kirk_2014" /> Women who undergo salpingectomy and salpingostomy have a similar recurrent ectopic pregnancy rate of 5% and 8%, respectively. Additionally, their intrauterine pregnancy rates are also similar, 56% and 61%.<ref>{{Cite journal | vauthors = Brady PC | title = New Evidence to Guide Ectopic Pregnancy Diagnosis and Management | journal = Obstetrical & Gynecological Survey | volume = 72 | issue = 10 | pages = 618–625 | date = October 2017 | pmid = 29059454 | doi = 10.1097/OGX.0000000000000492 }}</ref>
Autotransfusion of a woman's own blood as drained during surgery may be useful in those who have a lot of bleeding into their abdomen.<ref>{{Cite journal | vauthors = Selo-Ojeme DO, Onwude JL, Onwudiegwu U | title = Autotransfusion for ruptured ectopic pregnancy | journal = International Journal of Gynaecology and Obstetrics| volume = 80 | issue = 2 | pages = 103–110 | date = February 2003 | pmid = 12566181 | doi = 10.1016/s0020-7292(02)00379-x | s2cid = 24721754 | doi-access = free }}</ref>
No technique exists to re-implant an ectopic embryo in the uterus – all interventions, whether surgical or pharmaceutical, result in the termination of the ectopic pregnancy. Published reports that a reimplanted embryo survived to birth were debunked as false.<ref>{{Cite journal | vauthors = Smith R | title = Research misconduct: the poisoning of the well | journal = Journal of the Royal Society of Medicine | volume = 99 | issue = 5 | pages = 232–237 | date = May 2006 | pmid = 16672756 | pmc = 1457763 | doi = 10.1177/014107680609900514 }}</ref>
== Prognosis ==
When ectopic pregnancies are treated, the prognosis for the mother is very good in Western countries; maternal death is rare, although treatment nearly always requires the removal of the nonviable fetus. 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).<ref>{{Cite web | title = Ectopic Pregnancy | url = http://patient.info/doctor/ectopic-pregnancy-pro | url-status = live | archive-url = https://web.archive.org/web/20151014214331/http://patient.info/doctor/ectopic-pregnancy-pro | archive-date = 2015-10-14 | access-date = 2015-10-22 }}</ref> In 2006–2008 the UK Confidential Enquiry into Maternal Deaths found that ectopic pregnancy was the cause of 6 maternal deaths out of 2.3 million pregnancies in that period (0.26/100,000 pregnancies).<ref name="Tubal ectopic pregnancy" />
In the developing world, however, the death rate is substantially higher at around 1–3% case fatality rate.<ref name="African countries">{{cite journal | vauthors = Goyaux N, Leke R, Keita N, Thonneau P | title = Ectopic pregnancy in African developing countries | journal = Acta Obstetricia et Gynecologica Scandinavica | volume = 82 | issue = 4 | pages = 305–312 | date = April 2003 | pmid = 12716313 | doi = 10.1034/j.1600-0412.2003.00175.x }}</ref> The burden of ectopic pregnancy is much higher in developing countries, causing the deaths of 3478 (95% confidence interval: 2849 to 4187) people in low income countries in 2019, or 0.68 (95% CI: 0.56 to 0.82) per 100,000 population, and was responsible for the loss of 37.69 (95% CI: 30.83 to 45.33) disability adjusted life years per 100,000, indicating that it is a significant cause of death and disease burden among women of child-bearing age in these countries.<ref name="Chen_2025">{{cite journal | vauthors = Chen W, Zhou Y, Zhang X, Xu X, Yin Y, He S | title = Global burden of ectopic pregnancy from 1990 to 2019: A tendency, forecasted trend and inequality analyses based on the Global Burden of Disease Study 2019 | journal = European Journal of Obstetrics, Gynecology, and Reproductive Biology | volume = 310 | article-number = 113957 | date = June 2025 | pmid = 40252331 | doi = 10.1016/j.ejogrb.2025.113957 }}</ref>
In women who have had an ectopic pregnancy, the risk of another one in the next pregnancy is around 10%.<ref>{{cite book | vauthors = Ryley DA | chapter = Modern management of ectopic pregnancy | title = Boston IVF Handbook of Infertility | pages = 135–148 | date = 2007 | doi = 10.3109/9781439804353-17 | chapter-url = {{GBurl | Hz8ICT95HHgC | p = 135}}| veditors = Bayer SR, Alper MM | isbn=978-1-4398-0435-3}}</ref>
=== Future fertility ===
Fertility following ectopic pregnancy depends upon several factors, the most important of which is a prior history of infertility.<ref name="Tulandi_2002">{{Cite book | vauthors = Tulandi T, Tan SL, Tan SL, Tulandi T | title = Advances in Reproductive Endocrinology and Infertility: Current Trends and Developments | page = 240 | year = 2002 | publisher = Informa Healthcare | isbn = 978-0-8247-0844-3 }}<!--|access-date=2009-12-21--></ref> The treatment choice does not play a major role; a randomized study in 2013 concluded that the rates of intrauterine pregnancy two years after treatment of ectopic pregnancy are approximately 64% with radical surgery, 67% with medication, and 70% with conservative surgery.<ref>{{Cite journal | vauthors = Fernandez H, Capmas P, Lucot JP, Resch B, Panel P, Bouyer J | title = Fertility after ectopic pregnancy: the DEMETER randomized trial | journal = Human Reproduction | location = Oxford, England | volume = 28 | issue = 5 | pages = 1247–1253 | date = May 2013 | pmid = 23482340 | doi = 10.1093/humrep/det037 | doi-access = free }}</ref> In comparison, the cumulative pregnancy rate of women under 40 years of age in the general population over two years is over 90%.<ref name="nice2013">[http://guidance.nice.org.uk/CG156 Fertility: assessment and treatment for people with fertility problems] {{webarchive|url=https://web.archive.org/web/20130223023043/http://guidance.nice.org.uk/CG156 |date=2013-02-23}}. NICE clinical guideline CG156 – Issued: February 2013</ref>
Methotrexate does not affect future fertility treatments. The number of oocytes that were retrieved before and after treatment with methotrexate does not change.<ref>{{Cite journal | vauthors = Ohannessian A, Loundou A, Courbière B, Cravello L, Agostini A | title = Ovarian responsiveness in women receiving fertility treatment after methotrexate for ectopic pregnancy: a systematic review and meta-analysis | journal = Human Reproduction | location = Oxford, England | volume = 29 | issue = 9 | pages = 1949–1956 | date = September 2014 | pmid = 25056087 | doi = 10.1093/humrep/deu174 | doi-access = free }}</ref>
In case of ovarian ectopic pregnancy, the risk of subsequent ectopic pregnancy or infertility is low.<ref name="Goyal_2014">{{Cite journal | vauthors = Goyal LD, Tondon R, Goel P, Sehgal A | title = Ovarian ectopic pregnancy: A 10 years' experience and review of literature | journal = Iranian Journal of Reproductive Medicine | volume = 12 | issue = 12 | pages = 825–830 | date = December 2014 | pmid = 25709640 | pmc = 4330663 }}</ref>
There is no evidence that massage improves fertility after an ectopic pregnancy.<ref name="Fogarty_2018">{{Cite journal | vauthors = Fogarty S | title = Fertility Massage: an Unethical Practice? | journal = International Journal of Therapeutic Massage & Bodywork | volume = 11 | issue = 1 | pages = 17–20 | date = March 2018 | pmid = 29593844 | pmc = 5868897 }}</ref>
== Epidemiology ==
thumb|An opened oviduct with an ectopic pregnancy at about seven weeks' gestational age<ref>{{Cite journal | vauthors = Uthman E | title = Tubal pregnancy with embryo | journal = WikiJournal of Medicine | volume = 1 | issue = 2 | date = 2014 | doi = 10.15347/wjm/2014.007 | doi-access = free }}</ref>
The rate of ectopic pregnancy is between about 1% and 2% of live births in developed countries, though it is as high as 4% in pregnancies involving assisted reproductive technology.<ref name="Kirk_2014" /> Between 93% and 97% of ectopic pregnancies are located in a fallopian tube.<ref name="Crochet2013" /> Of these, in turn, 13% are located in the isthmus, 75% are located in the ampulla, and 12% in the fimbriae.<ref name="Kirk_2014" /> Ectopic pregnancy is responsible for 6% of maternal deaths during the first trimester of pregnancy making it the leading cause of maternal death during this stage of pregnancy.<ref name="Crochet2013" />
Between 5% and 42% of women seen for ultrasound assessment with a positive pregnancy test have a pregnancy of unknown location, that is, a positive pregnancy test but no pregnancy visualized at transvaginal ultrasonography.<ref name="Kirk_2014" /> Between 6% and 20% of pregnancies of unknown location are subsequently diagnosed with actual ectopic pregnancy.<ref name="Kirk_2014" />
== Society and culture ==
Salpingectomy as a treatment for ectopic pregnancy is one of the common cases when the principle of double effect can be used to justify accelerating the death of the embryo by doctors and patients opposed to outright abortions.<ref name="How does the principle of double-effect relate to ectopic pregnancies?">{{Cite web | vauthors = Delgado G | title = Pro-Life Open Forum, Apr 10, 2013 (49min40s) | url = http://www.catholic.com/audio-player/8236 | archive-url = https://web.archive.org/web/20150402110050/http://www.catholic.com/audio-player/8236 | archive-date = 2 April 2015 | access-date = 2 September 2014 | website = Catholic answers }}</ref>
In the Catholic Church, there are moral debates on certain treatments. A significant number of Catholic moralists consider the use of methotrexate and the salpingostomy procedure to be not "morally permissible" because they destroy the embryo; however, situations are considered differently in which the mother's health is endangered, and the whole fallopian tube with the developing embryo inside is removed.<ref>{{Cite web | vauthors = Pacholczyk T | title = When Pregnancy Goes Awry | url = http://www.ncbcenter.org/Page.aspx?pid=940 | archive-url = https://web.archive.org/web/20111123115757/http://www.ncbcenter.org/Page.aspx?pid=940 | archive-date = 2011-11-23 | website = Making Sense Out of Bioethics (blog) | publisher = National Catholic Bioethics Center }}</ref><ref>Anderson, MA et al. [http://johnpaulbioethics.org/finalproofs.pdf Ectopic Pregnancy and Catholic Morality] {{webarchive|url=https://web.archive.org/web/20160418071158/http://johnpaulbioethics.org/FinalProofs.pdf |date=2016-04-18 }}. National Catholic Bioethics Quarterly, Spring 2011</ref>
Organizations exist that provide information and support to help those who experience ectopic pregnancy. Studies show that people can experience post-traumatic stress, depression, and anxiety for which they would need specialist therapies.<ref name="pmid31953115">{{cite journal | vauthors = Farren J, Jalmbrant M, Falconieri N, Mitchell-Jones N, Bobdiwala S, Al-Memar M, Tapp S, Van Calster B, Wynants L, Timmerman D, Bourne T | title = Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multicenter, prospective, cohort study | journal = American Journal of Obstetrics and Gynecology | volume = 222 | issue = 4 | pages = 367.e1–367.e22 | date = April 2020 | pmid = 31953115 | doi = 10.1016/j.ajog.2019.10.102 }}</ref> Partners can also experience post-traumatic stress.<ref>{{Cite web | title = Post-traumatic stress experienced by partners following miscarriage | date = 9 October 2020 | url = https://www.imperial.ac.uk/news/206373/post-traumatic-stress-experienced-partners-following-miscarriage/#:~:text=One%20in%2012%20partners%20experience,ectopic%20pregnancy%20before%2012%20weeks }}</ref>
== History == Until 1888, surgical treatment of ruptured ectopic pregnancies was either not considered at all, or did not save the woman's life due to blood loss.<ref name=":2">{{Cite book |last=Rosin |first=Danny |title=Schein's Common Sense Emergency Abdominal Surgery |date=2020 |publisher=TFM Publishing Limited |others=Paul N. Rogers, Mark Cheetham |isbn=978-1-910079-88-1 |edition=5th |location=Shrewsbury |language=en |chapter=Chapter 2 |via=Perlego <!-- WP:TWL -->}}</ref> Surgeon Robert Lawson Tait, who performed the first successful surgery, initially refused to consider surgery; however, after participating in the autopsy of a young woman who died of a ruptured ectopic pregnancy, he determined how it could be surgically repaired. His first patient died, but most of the subsequent ones survived.<ref name=":2" />
== 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, United States, to a healthy baby girl, Sage, who had developed outside of the uterus. Previous ultrasounds had not discovered the problem, and the doctor performing the caesarean was surprised to find the baby "within the amniotic membrane outside the womb".<ref>{{Cite news | title = Registry Reports | location = Ogden, Utah | date = October 1999 | url = http://www.ardms.org/downloads/RegistryReports/Sep99.pdf | archive-url = https://web.archive.org/web/20101223214452/http://www.ardms.org/downloads/RegistryReports/Sep99.pdf | archive-date = 2010-12-23 | access-date = 2011-06-22 | work = Volume XVI, Number 5 | publisher = ARDMS The Ultrasound Choice }}</ref> The baby had a solid blood supply outside the womb due to the presence of a uterine fibroid on the outer wall of the uterus, and suffered no ill effects as a result.<ref>{{Cite news | title = Miracle baby | location = Ogden, Utah | date = 1999-08-05 | url = http://web.ksl.com/dump/news/cc/special/science/ectopic.htm | archive-url = https://web.archive.org/web/20110930051227/http://web.ksl.com/dump/news/cc/special/science/ectopic.htm | archive-date = 2011-09-30 | access-date = 2011-06-22 | publisher = Utah News from KSL-TV }}</ref>
In September 1999, an English woman, Jane Ingram (age 32), gave birth to triplets: Olivia, Mary, and Ronan, with an extrauterine fetus (Ronan) below the womb and twins in the womb. All three survived. The twins in the womb were taken out first.<ref>{{Cite news | title = Doctors hail 'miracle' baby | date = 2009-09-10 | url = https://news.bbc.co.uk/2/hi/health/443373.stm | url-status = live | archive-url = https://web.archive.org/web/20080919160301/http://news.bbc.co.uk/1/hi/health/443373.stm | archive-date = 2008-09-19 | work = BBC News }}</ref>
In May 2003, a South African woman, Cwayita Ncise (age 20), gave birth, via surgery, to healthy baby girl, Nhlahla, where the placenta had attached to the liver. The placenta and amniotic sac were left inside her, as it was expected they would be reabsorded, and since an operation to remove them would have placed her life at risk.<ref>{{Cite news |date=2003-05-23 |title=Miracle baby 'grew in liver' |url=http://news.bbc.co.uk/2/hi/health/2932608.stm |access-date=2026-05-06 |work=BBC News |language=en-GB}}</ref><ref>{{Cite web |last=Johannesburg |first=From Michael Dynes in |date=2003-05-24 |title=Miracle birth of the elusive baby found growing on mother’s liver |url=https://www.thetimes.com/travel/destinations/africa-travel/south-africa/cape-town/miracle-birth-of-the-elusive-baby-found-growing-on-mothers-liver-58lcmwhp73h |access-date=2026-05-06 |website=www.thetimes.com |language=en-GB}}</ref>
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 {{convert|6|lb|3|oz|adj=on}} baby girl, Durga, via caesarean section. She had no problems or complications during the 38‑week pregnancy.<ref>{{Cite news | title = Baby Born After Rare Ovarian Pregnancy | date = 2008-05-30 | url = http://ap.google.com/article/ALeqM5h7An_4HQLG6rSVO-h1eBIntgYOyAD90VRLKO1 | archive-url = https://web.archive.org/web/20080603100609/http://ap.google.com/article/ALeqM5h7An_4HQLG6rSVO-h1eBIntgYOyAD90VRLKO1 | archive-date = June 3, 2008 | access-date = 2008-05-30 | agency = Associated Press }}</ref><ref>{{Cite news | vauthors = Cavanagh R | title = Miracle baby may be a world first | date = 2008-05-30 | url = http://www.news.com.au/story/0,23599,23782145-2,00.html | archive-url = https://web.archive.org/web/20080530105132/http://www.news.com.au/story/0,23599,23782145-2,00.html | archive-date = 2008-05-30 | access-date = 2008-05-30 }}</ref>
== Animals ==
Ectopic gestation exists in mammals other than humans. In sheep, it can go to term, with mammary preparation to parturition, and expulsion efforts. The fetus can be removed by caesarean section. Pictures of the Caesarean section of a euthanized ewe, five days after parturition signs. <gallery> File:Poirtêye foû matrice pate.JPG|Leg of fetal lamb appearing out of the uterus during caesarean section File:Poirtêye foû matrice saetch1.JPG|External view of fetal sac, necrotic distal part File:Poirtêye foû matrice saetch2.JPG|Internal view of fetal sac, before resection of distal necrotic part File:Poirtêye foû matrice saetch3.JPG|Internal view of fetal sac. The necrotic distal part is to the left. File:Poirtêye foû matrice saetch&coine.JPG|External side of fetal sac, proximal end, with ovary and uterine horn File:Poirtêye foû matrice saetch ådfoû pwels.JPG|Resected distal part of fetal sac, with attached placenta </gallery>
== See also == * Indirect abortion
== References == {{Reflist}}
== External links == {{commons category|Ectopic pregnancy}} * [http://www.claripacs.com/case/CL0019 CT of the abdomen showing abdominal ectopic pregnancy]
*[https://www.safeabortionrx.com/blog/early-signs-of-ectopic-pregnancy/ Complete Guide on Signs of Ectopic Pregnancy]
*[https://www.9mfertility.com/blog/what-is-ectopic-pregnancy-essential-information-and-warning-signs/ Symptoms of Ectopic Pregnancy] {{Medical resources | DiseasesDB = 4089 | ICD10 = {{ICD10|O|00||o|00}} | ICD9 = {{ICD9|633}} | ICDO = | OMIM = | MedlinePlus = 000895 | eMedicineSubj = med | eMedicineTopic = 3212 | eMedicine_mult = {{eMedicine2|emerg|478}} {{eMedicine2|radio|231}} | MeshID = D011271 }}
{{Women's health|state=collapsed}} {{Pathology of pregnancy, childbirth and the puerperium}} {{Pregnancy}} {{Authority control}}
Category:Ectopic pregnancy Category:Wikipedia articles with sections published in WikiJournal of Medicine Category:Medical emergencies Category:Health issues in pregnancy Category:Wikipedia medicine articles ready to translate Category:Acute pain