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A Case Study of Ectopic Pregnancy

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Ectopic Pregnancy

Pregnancy is an occasion worth celebrating. The formation of a new life inside of a woman is a miracle to behold and should be experienced by women who want to seek the fulfillment they have always wanted. However, no matter how you handle pregnancy with care, there are still instances that it is compromised. Ectopic pregnancy is a complex and potentially life-threatening condition that occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tubes. As nursing professionals, understanding the unique challenges of ectopic pregnancy and providing early recognition and expert care is essential to ensure the well-being of women facing this critical obstetric emergency.

This article aims to serve as a comprehensive nursing guide to ectopic pregnancy, delving into its risk factors, clinical manifestations, diagnostic approaches, and evidence-based interventions.

Table of Contents

What is ectopic pregnancy, pathophysiology, risk factors, signs and symptoms, diagnostic tests, medical interventions, surgical interventions, nursing assessment, nursing diagnosis, nursing interventions.

• Ectopic pregnancy happens when the implantation of the fertilized egg occurs outside the uterine cavity.
• The implantation can either occur on the surface of the ovary, in the cervix, in the abdomen, and most commonly in the fallopian tube.
• Fertilization occurs at the usual distal third of the fallopian tube.
• After the union, zygote begins to divide and grow.
• However, due to an obstruction by several factors (see Risk Factors), the zygote cannot travel through the length of the tube.
• It lodges on that constricted part and implantation takes place at that area instead of the uterus.

Several factors could contribute to the occurrence of an ectopic pregnancy, such as:

• Previous infection such as salpingitis or pelvic inflammatory disease. Women who experience infection of the reproductive system increase the incidences of having ectopic pregnancy because the scar from these infections could cause adhesion in the fallopian tube.
• Scars from a tubal surgery . These scars cause an adhesion that would not let the fertilized egg travel towards the uterus.
• Congenital malformations. Physical defects of the reproductive system such as strictures in the fallopian tube could cause ectopic pregnancy.
• Uterine tumors. A tumor might be pressing at the proximal end of the tubes, which would not allow access of the fertilized egg into the uterus.
• Use of intrauterine device . IUDs are contraceptive devices shaped like an inverted T and inserted into the uterus of a woman. It may impede the traveling fertilized egg to reach the ideal place of implantation if it is inserted after conception.
• Smoking. Women who frequently smoke have a higher incidence of ectopic pregnancy than non-smoking women.
• A recent in vitro fertilization . Following an in vitro fertilization, a zygote may have slower transportation and lead to an increased incidence of tubal or ovarian implantation.
• Previous ectopic pregnancy. Women who underwent ectopic pregnancy are advised to avoid getting pregnant for a year after the incident because there is a 10% to 20% chance of a subsequent ectopic pregnancy.

It is important for both the pregnant woman and the health care provider to identify any signs and symptoms of an ectopic pregnancy before rupture occurs. However, most ectopic pregnancy does not show any unusual signs and symptoms at the time of implantation, so it would be difficult to identify them at first.

• Sharp abdominal pain . A pregnant woman with possible ectopic pregnancy might move suddenly, and as a result, the anterior uterine support might be pulled and cause pain in the abdomen.
• Vaginal spotting. This would rarely occur in conjunction with the pain , but this may be a sign that the ectopic pregnancy is nearing its rupture.
• Sharp, stabbing pain at the lower quadrant. This is one of the symptoms which tell that the ectopic pregnancy has already ruptured.
• Vaginal bleeding . Bleeding occurs after the ectopic pregnancy has ruptured. Tearing of the blood vessels and its destruction is the cause of the bleeding , and the amount would not be determined fully because some products of conception and blood might be expelled into the pelvic cavity.

Tests to determine the possibility of ectopic pregnancy must be performed first before the diagnosis.

• Pelvic Ultrasound. An early pregnancy ultrasound is the most common determinant of an ectopic pregnancy.
• Magnetic Resonance Imaging. This is also another way to detect the presence of ectopic pregnancy and it is safer than undergoing a CT scan for pregnant women.

The medical management of a woman with an ectopic pregnancy should be initiated the moment she is brought to the emergency room. Just a few moments of interval for action would cause a big difference in the safety of the patient.

• Administration of methotrexate . Methotrexate is a chemotherapeutic agent that is a folic acid antagonist. It destroys rapidly growing cells such as the trophoblast and the zygote. This would be administered until a negative hCg titer results have been produced.
• Administration of mifepristone . An abortifacient that causes sloughing off of the tubal implantation site. Both of these therapies would leave the tube intact and no surgical scarring.
• Intravenous therapy . This would be performed when the ectopic pregnancy has already ruptured to restore intravascular volume due to bleeding.
• Withdrawing of blood sample . A large amount of blood would be lost, so blood typing and crossmatching must be done in anticipation of a blood transfusion . The blood sample would also be used to determine the hemoglobin levels of the pregnant woman.

Surgical interventions would be performed after the rupture of the ectopic pregnancy to ensure that the reproductive system would still be functional and no complications would arise.

• Laparoscopy. This will be performed to ligate the bleeding blood vessels and repair or remove the damaged fallopian tube.
• Salpingectomy . This intervention would be performed if the fallopian tube is completely damaged. The affected tube would be removed and what would be left would be sutured appropriately.

Nursing Management

Nurses must also have their own function when it comes to ectopic pregnancy, even without a direct order from the physician.

• No unusual symptoms are usually present at the time of implantation of an ectopic pregnancy.
• The usual signs of pregnancy would occur, such as a positive pregnancy test, nausea and vomiting , and amenorrhea.
• At 6-12 weeks of pregnancy, the trophoblast would be large enough to rupture the fallopian tube.
• Bleeding would follow, and it would depend on the number and size of the affected blood vessels the amount of bleeding that would occur.
• Sharp, stabbing pain in the lower quadrant is likely to be felt by the woman once a rupture has occurred, followed by scant vaginal bleeding.
• Upon arrival at the hospital, a woman who has a ruptured ectopic pregnancy might present signs of shock such as rapid, thread pulse, rapid respirations, and decreased blood pressure .
• There would be a decreased hCg levels or progesterone levels that would indicate that the pregnancy has ended.
• Risk for Deficient Fluid Volume related to bleeding from a ruptured ectopic pregnancy.
• Powerlessness related to early loss of pregnancy secondary to ectopic pregnancy.
• Upon arrival at the emergency room, place the woman flat in bed.
• Assess the vital signs to establish baseline data and determine if the patient is under shock.
• Maintain accurate intake and output to establish the patient’s renal function.
• The goal of the evaluation is to ensure that maternal blood loss is replaced and the bleeding would stop.
• The patient must maintain adequate fluid volume at a functional level as evidenced by normal urine output at 30-60mL/hr and a normal specific gravity between the ranges of 1.010 to 1.021.
• Vital signs, especially the blood pressure and pulse rate , should be stable and within the normal range.
• Patient must exhibit moist mucous membranes, good skin turgor , and adequate capillary refill.

Ectopic pregnancy is a menace for both the mother and the zygote. However much we want to save the zygote, it would be impossible because it has grown outside the usual site of implantation. The only thing that we could provide to the woman and their families is proper education about ectopic pregnancy and ways on how to prevent it from recurring.

16 thoughts on “Ectopic Pregnancy”

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This article has a correction. Please see:

• Errata - September 03, 2010
• Sheikha Al-Jabri , fellow of minimally invasive gynaecology ,
• Michael Malus , associate professor, department of family medicine ,
• Togas Tulandi , professor of obstetrics and gynaecology and Milton Leong chair in reproductive medicine
• 1 McGill University, Montreal, QC, Canada H3A 1A1
• Correspondence to: S Al-Jabri s_umreem{at}hotmail.com
• Accepted 20 May 2010

Case scenario

A 33 year-old woman presented to the emergency department with a five day history of low abdominal pain. Her last menstrual period was five weeks before; she said she was using progesterone-only pills for contraception and had a history of Chlamydia infection, so a pregnancy test was not done. She was diagnosed with pelvic inflammatory disease and prescribed antibiotics. She returned to the emergency department two days later with worsening abdominal pain, hypotension, and tachycardia. An urgent pregnancy test and ultrasonography led to the diagnosis of a tubal ectopic pregnancy.

In women of reproductive age, ruling out ectopic pregnancy is mandatory as it is still the leading cause of death in the first trimester of pregnancy. This needs a high index of suspicion and an early pregnancy test. A negative test result excludes ectopic pregnancy, and a positive result demands further clinical, biochemical, and ultrasound examination to exclude or confirm ectopic pregnancy. The possibility of medical treatment for ectopic pregnancy makes early diagnosis even more important.

How common is it?

The estimated incidence of ectopic pregnancy in the United Kingdom is 11.1 per 1000 reported pregnancies. 1 However, some of these cases could be misdiagnosed. A retrospective study estimated that 12% of ectopic pregnancies were missed at initial presentation. 2 In a prospective consecutive case series among women with ectopic pregnancy who …

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Ectopic Pregnancy

A Clinical Casebook

• © 2015
• Togas Tulandi 0

Department of Obstetrics and Gynecology, McGill University, Montreal, Canada

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• A cased-based, practical guide to the management of ectopic pregnancy
• Discusses criteria and diagnosis of ectopic pregnancy as well as its many types
• An excellent resource for practicing clinicians, residents and students alike
• Includes supplementary material: sn.pub/extras

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About this book

Comprised exclusively of clinical cases covering ectopic pregnancy, this concise, practical casebook will provide clinicians in reproductive medicine and obstetrics/gynecology with the best real-world strategies to properly diagnose and treat the various forms of the condition they may encounter. Each chapter is a case that opens with a unique clinical presentation, followed by a description of the diagnosis, assessment and  management techniques used to treat it, as well as the case outcome and clinical pearls and pitfalls. Cases included illustrate different management strategies – from treatment with methotrexate to surgical interventions – as well as types of ectopic pregnancy, such as ovarian, interstitial, heterotopic and abdominal forms, among others. Pragmatic and reader-friendly, Ectopic Pregnancy: A Clinical Casebook will be an excellent resource for reproductive medicine specialists, obstetricians and gynecologists, and family and emergency medicine physicians alike.

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Rare Types of Ectopic Pregnancies

The many faces of ectopic pregnancies: demystifying the common and less common entities

Non-tubal Ectopic Pregnancies: Diagnosis and Management

• Cervical pregnancy
• Ectopic pregnancy
• Heterotopic pregnancy
• Interstitial pregnancy
• Intramural pregnancy
• Methotrexate treatment
• Ovarian pregnancy
• Retroperitoneal pregnancy
• Rudimentary uterine horn pregnancy
• Tubal pregnancy

Table of contents (21 chapters)

Front matter, identification of risk factors of ectopic pregnancy.

• Ali Ardehali, Ishwari Casikar, George Condous

Discriminatory Serum hCG Level for Ectopic Pregnancy

• Ishai Levin, Shiri Shinar

Pregnancy of Unknown Location

• Shabnam Bobdiwala, Tom Bourne

Ectopic Pregnancy After In Vitro Fertilization

• Lisa Caronia, Rebecca Flyckt, Tommaso Falcone

Surgical Treatment of Ectopic Pregnancy

• Jillian Main, Camran Nezhat

Bleeding Ectopic Pregnancy

• M. Jean Uy-Kroh

Medical Treatment of Ectopic Pregnancy

Togas Tulandi

Compliance with Methotrexate Treatment for Ectopic Pregnancy

• Ishai Levin, Benny Almog

Inadvertent Methotrexate Administration

• Togas Tulandi, Senem Ates

Effect of Methotrexate Treatment for Ectopic Pregnancy on Current and Subsequent Pregnancy

• Shirin Namouz-Haddad, Gideon Koren

Interstitial Pregnancy

• Margaret Dziadosz, Ana Monteagudo, Ilan Timor-Tritsch

Cervical Pregnancy

• Abdulrahman Alserri, Togas Tulandi

Ovarian Ectopic Pregnancy

• Warren J. Huber III, Gary N. Frishman

Cesarean Scar Pregnancy

• Marcos Cordoba, Ana Monteagudo, Ilan E. Timor-Tritsch

Abdominal Pregnancy

• Amanda Ecker, Richard Guido

Intramural Pregnancy

• Maria Memtsa, Davor Jurkovic

Heterotopic Pregnancy

• Mallory Stuparich, Kimberly A. Kho

Retroperitoneal Ectopic Pregnancy

• Ana Monzo-Miralles, Alicia Martinez-Varea, Antonio Pellicer

Ectopic Molar Pregnancy

• Atif Zeadna, Togas Tulandi

“This is a very well-written case-based, practical guide to the management of ectopic pregnancy. … It is an excellent resource for practicing clinicians, residents, and the students alike. Composed exclusively of clinical cases covering ectopic pregnancy, this concise, practical casebook will provide clinicians in reproductive medicine and obstetrics/gynecology with the best real-world strategies to properly diagnose and treat the various forms of the condition they may encounter.” (Moujahed Hammami, The Journal of Obstetrics and Gynecology of India, Vol. 65, 2015)

Editors and Affiliations

About the editor, bibliographic information.

Book Title : Ectopic Pregnancy

Book Subtitle : A Clinical Casebook

Editors : Togas Tulandi

DOI : https://doi.org/10.1007/978-3-319-11140-7

Publisher : Springer Cham

eBook Packages : Medicine , Medicine (R0)

Copyright Information : Springer International Publishing Switzerland 2015

Softcover ISBN : 978-3-319-11139-1 Published: 24 March 2015

eBook ISBN : 978-3-319-11140-7 Published: 26 February 2015

Edition Number : 1

Number of Pages : XIV, 165

Number of Illustrations : 4 b/w illustrations, 29 illustrations in colour

Topics : Reproductive Medicine , Gynecology

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Ectopic pregnancy.

Tyler Mummert ; David M. Gnugnoli .

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Last Update: August 8, 2023 .

• Continuing Education Activity

An ectopic pregnancy occurs when fetal tissue implants outside of the uterus or attaches to an abnormal or scarred portion of the uterus. Ectopic pregnancies carry high rates of morbidity and mortality if not recognized and treated promptly. Ectopic pregnancies may present with pain, vaginal bleeding, or more vague complaints such as nausea and vomiting. This activity will review the etiology of ectopic pregnancy and examine treatment approaches. This activity will outline the role of the interprofessional team in recognizing and treating patients with ectopic pregnancies.

• Provide a definition for ectopic pregnancy.
• Identify symptoms of ectopic pregnancy.
• Describe the proper evaluation for ectopic pregnancy.
• Plan a discussion amongst interprofessional, interprofessional team members regarding the detection, evaluation, and management of ectopic pregnancies so that they can be detected quickly and appropriate management can be implemented immediately, enhancing patient outcomes.
• Introduction

Ectopic pregnancy is a known complication of pregnancy that can carry a high rate of morbidity and mortality when not recognized and treated promptly.  It is essential that providers maintain a high index of suspicion for an ectopic in their pregnant patients as they may present with pain, vaginal bleeding, or more vague complaints such as nausea and vomiting. Fertilization and embryo implantation involve an interplay of chemical, hormonal, and anatomical interactions and conditions to allow for a viable intrauterine pregnancy.  Much of this system is outside the scope of this article but the most relevant anatomical components to our discussion on the ovaries, fallopian tubes, uterus, egg, and sperm.  Ovaries are the female reproductive organs located to both lateral aspects of the uterus in the lower pelvic region. Ovaries serve multiple functions, one of which is to release an egg each month for potential fertilization. The fallopian tubes are tubular structures that serve as a conduit to allow transport of the female egg from the ovaries to the uterus. When sperm is introduced, it will fertilize the egg forming an embryo. The embryo will then implant into endometrial tissue within the uterus. An ectopic pregnancy occurs when this fetal tissue implants somewhere outside of the uterus or attaching to an abnormal or scarred portion of the uterus.

Ectopic pregnancy, in essence, is the implantation of an embryo outside of the uterine cavity most commonly in the fallopian tube. Smooth muscle contraction and ciliary beat within the fallopian tubes to assist the transport of an oocyte and embryo. Damage to the fallopian tubes, usually secondary to inflammation, induces tubal dysfunction which can result in retention of an oocyte or embryo. There are several local factors, such as toxic, infectious, immunologic, and hormonal, that can induce inflammation. [1] There is upregulation of pro-inflammatory cytokines following tubal damage; this subsequently promotes embryo implantation, invasion, and angiogenesis within the fallopian tube. [1] Chlamydia trachomatis infection results in the production of interleukin 1 by tubal epithelial cells; this happens to be a vital indicator for embryo implantation within the endometrium [1] Interleukin 1 also has a role in downstream neutrophil recruitment which would further contribute to fallopian tubal damage. [1] Cilia beat frequency is negatively affected by smoking and infection. Hormonal variations throughout the menstrual cycle additionally have demonstrated effects on cilia beat frequency. [1] .

Ectopic implantation can occur in the cervix, uterine cornea, myometrium, ovaries, abdominal cavity, etc. [2] Women with tubal ligation or other post-surgical alterations to their fallopian tubes are at risk for ectopic pregnancies as the native function of the fallopian tube would be altered. The patient additionally can have an ectopic pregnancy with a concurrent intrauterine pregnancy, as known as a heterotopic pregnancy. [1]

• Epidemiology

The estimated rate of ectopic pregnancy in the general population is 1 to 2% and 2 to 5% among patients who utilized assisted reproductive technology [1] . Ectopic pregnancies with implantation occurring outside of the fallopian tube account for less than 10% of all ectopic pregnancies. [1] Cesarean scar ectopic pregnancies occur in 4% of all ectopic pregnancies, as well as 1 in 500 pregnancies in women who underwent at least one prior c-section. [3] Interstitial ectopic pregnancies are reported in up to 4% of all ectopic implantation sites and have morbidity with mortality rates up to 7 times higher than other ectopic implantation sites.  This increased morbidity and mortality are due to a high rate of hemorrhage in interstitial ectopic pregnancies. [1] Intramural ectopic pregnancies, those implanted in the myometrium, were reported in 1% of ectopic pregnancies. [1] Ectopic pregnancies implanting in the abdominal cavity account for 1.3% of ectopic implantation sites, of which adhere most commonly in the pouches anterior and posterior to the uterus as well as on the serosa of the adnexa and uterus. [1] Reports also exist of implantation sites in omental, retroperitoneal, splenic, and hepatic locations. [1]

Risk factors associated with ectopic pregnancies include advanced maternal age, smoking, history of ectopic pregnancy, tubal damage or tubal surgery, prior pelvic infections, DES exposure, IUD use, and assisted reproductive technologies. [1] Older age does bear risk with ectopic pregnancy; aged fallopian tubes likely have relatively decreased function predisposing to delay of oocyte transport. Women with prior ectopic pregnancies have up to ten times risk compared to the general population. Women pursuing in vitro fertilization have increased risk with developing an ectopic pregnancy with a concurrent intrauterine pregnancy, as known as heterotypic pregnancy. The risk is estimated as high as 1:100 women pursuing in vitro fertilization. The risk of developing a  heterotopic pregnancy has been estimated as high as 1:100 in women seeking in vitro fertilization. [1]

• Histopathology

The most common site for ectopic pregnancy adherence is in the ampullary region of the fallopian tube. [1] Reportedly 95% of ectopic pregnancies develop in the ampulla, infundibular, and isthmic portions of the fallopian tubes. [4] With cesarean scar pregnancies, there is a migration of blastocyst into the myometrium due to residual scarring defect from prior c-section. [3] The depth of implantation determines the type of cesarean scar pregnancy with type 1 having proximity to the uterine wall and type 2 implanting closer to the urinary bladder. [3]

• History and Physical

Women presenting with an ectopic pregnancy will often complain of pelvic pain; however, not all ectopic pregnancies manifest with pain. Women of childbearing age who complain of pelvic pain/discomfort, abdominal pain/discomfort, nausea/vomiting, syncope, lightheadedness, vaginal bleeding, etc. should merit consideration for the possibility of pregnancy. Providers need to identify when the patient's last menstrual period occurred and whether they have monthly routine menstrual periods. If patients have missed their last period or have abnormal uterine bleeding, and are sexually active, then they may be pregnant and thus need further testing with a pregnancy test. Providers should identify any known risk factors for ectopic pregnancy in their patient's history, such as if a patient has had a prior confirmed ectopic pregnancy, known fallopian tube damage (history of pelvic inflammatory disease, tubal surgery, known obstruction), or achieved pregnancy through infertility treatment. [2]

After obtaining a thorough history, an attentive physical exam is the next step. Evaluation of vital signs to assess for tachycardia and hypotension is pivotal in determining the patient’s hemodynamic stability. When examining the abdomen and suprapubic regions, attention should focus on the location of tenderness as well as any exacerbating factors. If voluntary/involuntary guarding of the abdominal musculature is elicited on palpation, this should raise concern for possible free fluid or other cause of peritoneal signs. Palpating a gravid uterus may suggest pregnancy, however, does not exclude other pathologies such as progressed ectopic pregnancy or heterotopic pregnancy. Patient’s presenting with vaginal bleeding would likely benefit from a pelvic exam to assess for infections as well as assess the cervical os. Bimanual pelvic exams additionally allow for palpation of bilateral adnexa to assess for any abnormal masses/structures or to elicit adnexal tenderness. A thorough history and physical exam will lend better certainty with testing obtained when evaluating for possible ectopic pregnancy.

Transvaginal ultrasound imaging is pivotal in diagnosing suspected ectopic pregnancy. Serial exams with transvaginal imaging, serum hCG level measurements, or both are necessary to confirm the diagnosis. The first marker of an intrauterine pregnancy on ultrasound is a small sac eccentrically located within the decidua. [2] Two rings of tissue will form around the sac thus terming it the “double decidual” sign. [2] The double decidual sign usually becomes visible during the 5th week of pregnancy seen on abdominal ultrasound imaging. [2] The yolk sac will become apparent at this time but will require transvaginal ultrasound imaging for identification. [2] An embryonic pole will become visible on transvaginal imaging at around six weeks of pregnancy. [2] Uterine fibroids or highly elevated body mass index can limit the accuracy of ultrasound imaging to identify an early intrauterine pregnancy. MRI imaging can be helpful in extreme circumstances, such as those with large obstructing uterine fibroids; however, its sensitivity and specificity require further research and the potential risks with gadolinium contrast exposure merit consideration. [2]

The best diagnostic confirmation of an ectopic pregnancy comes through identifying a fetal heartbeat outside of the uterine cavity on ultrasound imaging.  The absence of a discernable fetal heartbeat can be misleading; however, as a fetal heartbeat does not develop throughout all ectopic pregnancies. [2] Additional signs of ectopic pregnancy include identification of a gestational sac with or without a yolk sac within an ectopic location or having identified a complex adnexal mass that strays from the typical presentations of hemorrhagic corpus luteum. [2] When radiologic imaging fails to confirm the presence of an ectopic pregnancy adequately, direct visualization of the suspicious mass can occur via diagnostic laparoscopy. [2] Direct laparoscopy may not identify very small ectopic gestations, cervical pregnancies, or those located in cesarean scars. [2]

• Treatment / Management

Administration of intramuscular methotrexate or performance of laparoscopic surgery is safe and effective treatment modalities in hemodynamically stable women with a non-ruptured ectopic pregnancy. The decision of which modality to pursue is guided by the patient’s clinical picture, their laboratory findings, and radiologic imaging as well as the patient’s well-informed choice after having reviewed the risks and benefits with each procedure. Patients with relatively low hCG levels would benefit from the single-dose methotrexate protocol. Patients with higher hCG levels may necessitate two-dose regimens. There is literature suggestive that methotrexate treatment does not have adverse effects on ovarian reserve or fertility. [5] hCG levels should be trended until a non-pregnancy level exists post-methotrexate administration. [6]   Surgical management is necessary when the patients demonstrate any of the following: an indication of intraperitoneal bleeding, symptoms suggestive of ongoing ruptured ectopic mass, or hemodynamically instability. [6]

Surgical management including salpingostomy or salpingectomy should be guided by clinical status, the extent of fallopian tube compromise, and desire for future fertility. In simplest form salpingectomy involves removing the fallopian tube partially or in full. [1] Salpingostomy, or salpingotomy, involves removal of the ectopic pregnancy via tubal incision while leaving the fallopian tube in situ. [1]

• Differential Diagnosis

One should begin to formulate a differential diagnosis when taking into account the patient’s history and physical exam findings.  Important differential diagnoses to consider with ectopic pregnancies are ovarian torsion, tuba-ovarian abscess, appendicitis, hemorrhagic corpus luteum, ovarian cyst rupture, threatened miscarriage, incomplete miscarriage, pelvic inflammatory disease, and ureteral calculi. The patient's history and hemodynamic status on clinical presentation will influence the order of these differentials, as well as the testing necessary to rule out said differentials. 

Patients with a relatively low beta hCG level will likely have a better prognosis regarding treatment success with single-dose methotrexate. [6] The further the ectopic pregnancy has advanced, the less likely single-dose methotrexate therapy will suffice. The patients that present in extremis or with hemodynamically instability have more risk of deterioration such as from hemorrhagic shock or other perioperative complications. Prognosis will thus hinge on early recognition and timely intervention. Fertility outcomes with tubal conservation surgeries remain debatable as some data suggests no significant difference in intrauterine pregnancy rates when comparing salpingectomy versus conservative tubal management. [7]

• Complications

Women who present early in pregnancy and have testing suggestive of an ectopic pregnancy would jeopardize the viability of an intrauterine pregnancy if given Methotrexate. [4] Women who receive the single-dose Methotrexate regimen are at high risk of treatment failure if the hCG level does not decrease by 15% from day 4 to day 7 thus prompting second-dose regimen. [6] Women presenting with vaginal bleeding and pelvic pain may be misdiagnosed as an abortion in progress if the ectopic pregnancy is at the cervical os. The patient may have a cervical ectopic pregnancy and would thus run the risk of hemorrhage and potential hemodynamic instability if a dilation and curettage are performed. [4] Complications from management extend to treatment failure, in that women may present with/or develop hemodynamic instability which can result in death despite early operative interventions.  

• Deterrence and Patient Education

Patients who seek medical treatment for ectopic pregnancy may need to discuss with their obstetrician which foods, supplements, and drugs to avoid when taking methotrexate as there may be decreased efficacy due to adverse interactions with the drug. Methotrexate may increase immunosuppression when paired with other medications, among other potential adverse side effects. Patient’s that undergo surgical interventions will need to adhere to the recommendations by their surgeon as to limit the risk of infection as well as other post-operative complications.

• Enhancing Healthcare Team Outcomes

When faced with the possibility of an ectopic pregnancy, the health care team needs to work collectively and efficiently to diagnose accurately and treat the susceptible patient. Women typically will present to the ER with this ailment, accurate and timely identification starts from the initial encounter when triaged by the nursing or provider in triage staff. It is the provider's responsibility to include/consider ectopic pregnancy as a potential differential diagnosis in all sexually active women of childbearing age. A systematic review and meta-analysis were performed to compare and test the performance of current protocols used when managing women with a pregnancy of unknown location [8] . This study found that a logistic regression model, termed the M4 model, outperformed the comparison management protocols thus providing guidance for clinicians when treating patients with the pregnancy of unknown location [8] . This model may increase efficiency when considering unnecessary testing or treatment. Communication remains vital when the discussion takes place with consultants such as between obstetricians, emergency department physician, nurses, and pharmacists. Patient safety and patient-centered care must be implemented when discussing the patient's treatment plan with the obstetrician and when utilizing treatment/management protocols.

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Ectopic pregnancy Image courtesy S Bhimji MD

Locations of ectopic pregnancies Image courtesy S Bhimji MD

Ectopic Pregnancy. Transabdominal probe showing a gestational sac and fetal pole, not within the uterus. Contributed by A Kurzweil, MD

Ectopic Pregnancy, Ultrasound. This image demonstrates an ectopic pregnancy via ultrasound. Contributed by K Ghaffarian, DO

Disclosure: Tyler Mummert declares no relevant financial relationships with ineligible companies.

Disclosure: David Gnugnoli declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Mummert T, Gnugnoli DM. Ectopic Pregnancy. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• In vitro fertilization and multiple pregnancies: an evidence-based analysis. [Ont Health Technol Assess Ser....] In vitro fertilization and multiple pregnancies: an evidence-based analysis. Medical Advisory Secretariat. Ont Health Technol Assess Ser. 2006; 6(18):1-63. Epub 2006 Oct 1.
• Review The etiology of ectopic pregnancy. [Clin Obstet Gynecol. 1987] Review The etiology of ectopic pregnancy. Russell JB. Clin Obstet Gynecol. 1987 Mar; 30(1):181-90.
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