Skip to main content

Tubal ectopic pregnancy: diagnosis and management

Archives of Gynecology and Obstetrics volume 279, pages 443–453 (2009)Cite this article

Abstract

Ectopic pregnancy is the gynaecological emergency par excellence and remains the leading cause of pregnancy-related first trimester deaths in the UK. Its prevalence continues to rise because of increases in the incidence of the risk factors predisposing to ectopic pregnancy. Classically, the diagnosis is based on a history of pelvic pain associated with amenorrhoea, a positive pregnancy test with or without slight vaginal bleeding. While the immediate differential diagnosis includes threatened or inevitable miscarriage, the likelihood of ectopic pregnancy is increased if transvaginal sonography (TVS) reveals an empty uterine cavity, and is confirmed if an adnexal mass with or without an embryo is seen. However, the diagnosis is often not that simple, especially when the patient presents early, has minimal pain, is haemodynamically stable, and TVS shows an empty uterus but no obvious adnexal mass. This could then be an early intrauterine pregnancy, or could indeed be an ectopic—a diagnosis of pregnancy of unknown location is made while additional investigations are made. The latter usually include serial measurements of serum beta human chorionic gonadotrophin (beta-hCG) and repeat TVS. Changes in beta-hCG levels in normal, failing and ectopic pregnancy are now reasonably well characterised, and at early stages of presentation where the risk of rupture of an ectopic are minimal, the patient can often be managed as an outpatient while the diagnosis is pursued. In the patient who presents with pain and haemodynamic instability, the diagnosis is often obvious, and the management is immediate laparotomy. However, in modern gynaecological practice in the developed world the vast majority of ectopic pregnancies present early, and the general consensus is that laparoscopic management offers both economic and aesthetic advantages, and should be used whenever possible. Salpingectomy (excision of the fallopian tube containing the ectopic) is performed if the contra-lateral tube is healthy, while salpingotomy (linear incision made in the fallopian tube with removal of ectopic pregnancy and conservation of tube) is performed if the contra-lateral tube is unhealthy. Medical therapy using methotrexate given systemically or injected directly into the ectopic pregnancy is an option occasionally used with good results. There appear to be no major differences in subsequent fertility outcomes, or risk of recurrence of ectopic pregnancy, between the surgical or medical treatments. Although the rates of ectopic pregnancy are not falling in the developed world, mortality and morbidity are falling mainly due to early and improving diagnostic and treatment modalities. Mass screening and treatment of Chlamydia in the young, sexually active populations, and education regarding risk factors, may in future result in a reduction in the rates. Lack of resource mean that the picture may remain dismal for some time to come in the developing world, but the development of basic protocols, improved training and the infusion of basic resources may go a long way to improving the situation.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

References

  1. Lurie S, Rabinerson D, Shoham Z (1998) The veracious etiology of ectopic pregnancy. Acta Obstet Gynecol Scand 77:120–121

    Article  PubMed  CAS  Google Scholar 

  2. Kriebs JM, Fahey JO (2006) Ectopic pregnancy. J Midwifery Womens Health 51:431–439. doi:10.1016/j.jmwh.2006.07.008

    Article  PubMed  Google Scholar 

  3. Goldner TE, Lawson HW, Xia Z, Atrash HK (1993) Surveillance for ectopic pregnancy—United States, 1970–1989. MMWR CDC Surveill Summ 42:73–85

    PubMed  CAS  Google Scholar 

  4. Lewis Ge. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer—2003–2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom London: CEMACH 2007

  5. Baffoe S, Nkyekyer K (1999) Ectopic pregnancy in Korle Bu Teaching Hospital, Ghana: a three-year review. Trop Doct 29:18–22

    PubMed  CAS  Google Scholar 

  6. Goyaux N, Leke R, Keita N, Thonneau P (2003) Ectopic pregnancy in African developing countries. Acta Obstet Gynecol Scand 82:305–312. doi:10.1034/j.1600-0412.2003.00175.x

    Article  PubMed  Google Scholar 

  7. Hajenius PJ, Mol F, Mol BW, Bossuyt PM, Ankum WM, van der Veen F Interventions for tubal ectopic pregnancy. Cochrane database of systematic reviews (Online) 2007(1):CD000324

  8. Stovall TG, Kellerman AL, Ling FW, Buster JE (1990) Emergency department diagnosis of ectopic pregnancy. Ann Emerg Med 19:1098–1103. doi:10.1016/S0196-0644(05)81511-2

    Article  PubMed  CAS  Google Scholar 

  9. Majhi AK, Roy N, Karmakar KS, Banerjee PK (2007) Ectopic pregnancy—an analysis of 180 cases. J Indian Med Assoc 105:308

    PubMed  Google Scholar 

  10. Pradhan P, Thapamagar SB, Maskey S (2006) A profile of ectopic pregnancy at nepal medical college teaching hospital. Nepal Med Coll J 8:238–242

    PubMed  Google Scholar 

  11. Karaer A, Avsar FA, Batioglu S (2006) Risk factors for ectopic pregnancy: a case-control study. Aust N Z J Obstet Gynaecol 46:521–527. doi:10.1111/j.1479-828X.2006.00653.x

    Article  PubMed  Google Scholar 

  12. Borgatta L, Murthy A, Chuang C, Beardsley L, Burnhill MS (2002) Pregnancies diagnosed during Depo-Provera use. Contraception 66:169–172. doi:10.1016/S0010-7824(02)00340-2

    Article  PubMed  Google Scholar 

  13. Furlong LA (2002) Ectopic pregnancy risk when contraception fails. A review. J Reprod Med 47:881–885

    CAS  Google Scholar 

  14. Xiong X, Buekens P, Wollast E (1995) IUD use and the risk of ectopic pregnancy: a meta-analysis of case-control studies. Contraception 52:23–34. doi:10.1016/0010-7824(95)00120-Y

    Article  PubMed  CAS  Google Scholar 

  15. Brown DL, Doubilet PM (1994) Transvaginal sonography for diagnosing ectopic pregnancy: positivity criteria and performance characteristics. J Ultrasound Med 13:259–266

    PubMed  CAS  Google Scholar 

  16. Gracia CR, Barnhart KT (2001) Diagnosing ectopic pregnancy: decision analysis comparing six strategies. Obstet Gynecol 97:464–470. doi:10.1016/S0029-7844(00)01159-5

    Article  PubMed  CAS  Google Scholar 

  17. Barnhart KT, Sammel MD, Rinaudo PF, Zhou L, Hummel AC, Guo W (2004) Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined. Obstet Gynecol 104:50–55

    PubMed  Google Scholar 

  18. Mol BW, Hajenius PJ, Engelsbel S, Ankum WM, Van der Veen F, Hemrika DJ et al (1998) Serum human chorionic gonadotropin measurement in the diagnosis of ectopic pregnancy when transvaginal sonography is inconclusive. Fertil Steril 70:972–981. doi:10.1016/S0015-0282(98)00278-7

    Article  PubMed  CAS  Google Scholar 

  19. Dart RG, Mitterando J, Dart LM (1999) Rate of change of serial beta-human chorionic gonadotropin values as a predictor of ectopic pregnancy in patients with indeterminate transvaginal ultrasound findings. Ann Emerg Med 34:703–710. doi:10.1016/S0196-0644(99)70094-6

    Article  PubMed  CAS  Google Scholar 

  20. Katsikis I, Rousso D, Farmakiotis D, Kourtis A, Diamanti-Kandarakis E, Panidis D (2006) Receiver operator characteristics and diagnostic value of progesterone and CA-125 in the prediction of ectopic and abortive intrauterine gestations. Eur J Obstet Gynecol Reprod Biol 125:226–232. doi:10.1016/j.ejogrb.2005.10.014

    Article  PubMed  CAS  Google Scholar 

  21. Mol BW, Lijmer JG, Ankum WM, van der Veen F, Bossuyt PM (1998) The accuracy of single serum progesterone measurement in the diagnosis of ectopic pregnancy: a meta-analysis. Hum Reprod 13:3220–3227. doi:10.1093/humrep/13.11.3220

    Article  PubMed  CAS  Google Scholar 

  22. Condous G, Lu C, Van Huffel SV, Timmerman D, Bourne T (2004) Human chorionic gonadotrophin and progesterone levels in pregnancies of unknown location. Int J Gynaecol Obstet 86:351–357. doi:10.1016/j.ijgo.2004.04.004

    Article  PubMed  CAS  Google Scholar 

  23. Condous G, Kirk E, Lu C, Van Calster B, Van Huffel S, Timmerman D et al (2006) There is no role for uterine curettage in the contemporary diagnostic workup of women with a pregnancy of unknown location. Hum Reprod 21:2706–2710. doi:10.1093/humrep/del223

    Article  PubMed  CAS  Google Scholar 

  24. Lundorff P, Thorburn J, Hahlin M, Kallfelt B, Lindblom B Laparoscopic surgery in ectopic pregnancy. A randomized trial versus laparotomy. Acta Obstet Gynecol Scand 70:343–348 doi:10.3109/00016349109007885

  25. Vermesh M, Silva PD, Rosen GF, Stein AL, Fossum GT, Sauer MV (1989) Management of unruptured ectopic gestation by linear salpingostomy: a prospective, randomized clinical trial of laparoscopy versus laparotomy. Obstet Gynecol 73:400–404

    PubMed  CAS  Google Scholar 

  26. Lundorff P, Hahlin M, Kallfelt B, Thorburn J, Lindblom B (1991) Adhesion formation after laparoscopic surgery in tubal pregnancy: a randomized trial versus laparotomy. Fertil Steril 55:911–915

    PubMed  CAS  Google Scholar 

  27. Vermesh M, Presser SC (1992) Reproductive outcome after linear salpingostomy for ectopic gestation: a prospective 3-year follow-up. Fertil Steril 57:682–684

    PubMed  CAS  Google Scholar 

  28. Graczykowski JW, Mishell DR Jr (1997) Methotrexate prophylaxis for persistent ectopic pregnancy after conservative treatment by salpingostomy. Obstet Gynecol 89:118–122. doi:10.1016/S0029-7844(96)00370-5

    Article  PubMed  CAS  Google Scholar 

  29. Sharma JB, Gupta S, Malhotra M, Arora R (2003) A randomized controlled comparison of minialpartomy and lapartomy in ectopic pregnancy cases. Indian J Med Sci 57:493–500

    PubMed  CAS  Google Scholar 

  30. Atri M, Chow CM, Kintzen G, Gillett P, Aldis AA, Thibodeau M et al (2001) Expectant treatment of ectopic pregnancies: clinical and sonographic predictors. Ajr 176:123–127

    PubMed  CAS  Google Scholar 

  31. Korhonen J, Stenman UH, Ylostalo P (1994) Serum human chorionic gonadotropin dynamics during spontaneous resolution of ectopic pregnancy. Fertil Steril 61:632–636

    PubMed  CAS  Google Scholar 

  32. Makinen JI, Kivijarvi AK, Irjala KM (1990) Success of non-surgical management of ectopic pregnancy. Lancet 335:1099. doi:10.1016/0140-6736(90)92674-7

    Article  PubMed  CAS  Google Scholar 

  33. Shalev E, Peleg D, Tsabari A, Romano S, Bustan M (1995) Spontaneous resolution of ectopic tubal pregnancy: natural history. Fertil Steril 63:15–19

    PubMed  CAS  Google Scholar 

  34. Trio D, Strobelt N, Picciolo C, Lapinski RH, Ghidini A (1995) Prognostic factors for successful expectant management of ectopic pregnancy. Fertil Steril 63:469–472

    PubMed  CAS  Google Scholar 

  35. Ylostalo P, Cacciatore B, Korhonen J, Kaariainen M, Makela P, Sjoberg J et al (1993) Expectant management of ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 49:83–84. doi:10.1016/0028-2243(93)90126-W

    Article  PubMed  CAS  Google Scholar 

  36. Korhonen J, Stenman UH, Ylostalo P (1996) Low-dose oral methotrexate with expectant management of ectopic pregnancy. Obstet Gynecol 88:775–778. doi:10.1016/0029-7844(96)00293-1

    Article  PubMed  CAS  Google Scholar 

  37. Helmy S, Sawyer E, Ofili-Yebovi D, Yazbek J, Ben Nagi J, Jurkovic D (2007) Fertility outcomes following expectant management of tubal ectopic pregnancy. Ultrasound Obstet Gynecol 30:988–993. doi:10.1002/uog.5186

    Article  PubMed  CAS  Google Scholar 

  38. Lipscomb GH, Bran D, McCord ML, Portera JC, Ling FW (1998) Analysis of three hundred fifteen ectopic pregnancies treated with single-dose methotrexate. Am J Obstet Gynecol 178:1354–1358. doi:10.1016/S0002-9378(98)70343-6

    Article  PubMed  CAS  Google Scholar 

  39. Brown DL, Felker RE, Stovall TG, Emerson DS, Ling FW (1991) Serial endovaginal sonography of ectopic pregnancies treated with methotrexate. Obstet Gynecol 77:406–409

    PubMed  CAS  Google Scholar 

  40. Tawfiq A, Agameya AF, Claman P (2000) Predictors of treatment failure for ectopic pregnancy treated with single-dose methotrexate. Fertil Steril 74:877–880. doi:10.1016/S0015-0282(00)01547-8

    Article  PubMed  CAS  Google Scholar 

  41. Dudley PS, Heard MJ, Sangi-Haghpeykar H, Carson SA, Buster JE (2004) Characterizing ectopic pregnancies that rupture despite treatment with methotrexate. Fertil Steril 82:1374–1378. doi:10.1016/j.fertnstert.2004.03.066

    Article  PubMed  Google Scholar 

  42. Lipscomb GH, McCord ML, Stovall TG, Huff G, Portera SG, Ling FW (1999) Predictors of success of methotrexate treatment in women with tubal ectopic pregnancies. N Engl J Med 341:1974–1978. doi:10.1056/NEJM199912233412604

    Article  PubMed  CAS  Google Scholar 

  43. Mol BW, Hajenius PJ, Engelsbel S, Ankum WM, Hemrika DJ, Van der Veen F et al (1999) Treatment of tubal pregnancy in the netherlands: an economic comparison of systemic methotrexate administration and laparoscopic salpingostomy. Am J Obstet Gynecol 181:945–951. doi:10.1016/S0002-9378(99)70330-3

    Article  PubMed  CAS  Google Scholar 

  44. Yao M, Tulandi T (1997) Current status of surgical and nonsurgical management of ectopic pregnancy. Fertil Steril 67:421–433. doi:10.1016/S0015-0282(97)80064-7

    Article  PubMed  CAS  Google Scholar 

  45. Fernandez H, Yves Vincent SC, Pauthier S, Audibert F, Frydman R (1998) Randomized trial of conservative laparoscopic treatment and methotrexate administration in ectopic pregnancy and subsequent fertility. Hum Reprod 13:3239–3243. doi:10.1093/humrep/13.11.3239

    Article  PubMed  CAS  Google Scholar 

  46. Saraj AJ, Wilcox JG, Najmabadi S, Stein SM, Johnson MB, Paulson RJ (1998) Resolution of hormonal markers of ectopic gestation: a randomized trial comparing single-dose intramuscular methotrexate with salpingostomy. Obstet Gynecol 92:989–994. doi:10.1016/S0029-7844(98)00324-X

    Article  PubMed  CAS  Google Scholar 

  47. Sowter MC, Farquhar CM, Petrie KJ, Gudex G (2001) A randomised trial comparing single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured tubal pregnancy. BJOG 108:192–203

    Article  PubMed  CAS  Google Scholar 

  48. Hajenius PJ, Engelsbel S, Mol BW, Van der Veen F, Ankum WM, Bossuyt PM et al (1997) Randomised trial of systemic methotrexate versus laparoscopic salpingostomy in tubal pregnancy. Lancet 350:774–779. doi:10.1016/S0140-6736(97)05487-1

    Article  PubMed  CAS  Google Scholar 

  49. Dias Pereira G, Hajenius PJ, Mol BW, Ankum WM, Hemrika DJ, Bossuyt PM et al (1999) Fertility outcome after systemic methotrexate and laparoscopic salpingostomy for tubal pregnancy. Lancet 27(353):724–725

    Article  Google Scholar 

  50. Tzafettas J, Anapliotis S, Zournatzi V, Boucklis A, Oxouzoglou N, Bondis J (1994) Transvaginal intra-amniotic injection of methotrexate in early ectopic pregnancy. Advantages over the laparoscopic approach. Early Hum Dev 39:101–107. doi:10.1016/0378-3782(94)90159-7

    Article  PubMed  CAS  Google Scholar 

  51. Fernandez H, Bourget P, Ville Y, Lelaidier C, Frydman R (1994) Treatment of unruptured tubal pregnancy with methotrexate: pharmacokinetic analysis of local versus intramuscular administration. Fertil Steril 62:943–947

    PubMed  CAS  Google Scholar 

  52. Cohen DR, Falcone T, Khalife S (1996) Methotrexate: local versus intramuscular. Fertil Steril 65:206–207

    PubMed  CAS  Google Scholar 

  53. Katz DL, Barrett JP, Sanfilippo JS, Badway DM (2003) Combined hysteroscopy and laparoscopy in the treatment of interstitial pregnancy. Am J Obstet Gynecol 188:1113–1114. doi:10.1067/mob.2003.258

    Article  PubMed  Google Scholar 

  54. Fylstra DL (1998) Tubal pregnancy: a review of current diagnosis and treatment. Obstet Gynecol Surv 53:320–328. doi:10.1097/00006254-199805000-00024

    Article  PubMed  CAS  Google Scholar 

  55. Gervaise A, Masson L, de Tayrac R, Frydman R, Fernandez H (2004) Reproductive outcome after methotrexate treatment of tubal pregnancies. Fertil Steril 82:304–308. doi:10.1016/j.fertnstert.2004.04.023

    Article  PubMed  Google Scholar 

  56. Stovall TG, Ling FW, Buster JE (1990) Reproductive performance after methotrexate treatment of ectopic pregnancy. Am J Obstet Gynecol 162:1620–1623

    PubMed  CAS  Google Scholar 

  57. Buster JE, Krotz S (2007) Reproductive performance after ectopic pregnancy. Semin Reprod Med 25:131–133. doi:10.1055/s-2007-970052

    Article  PubMed  Google Scholar 

  58. Bouyer J, Job-Spira N, Pouly JL, Germain E, Coste J, Aublet-Cuvelier B et al (1996) Fertility after ectopic pregnancy. Results of the first three years of the Auvergne Registry. Contracept Fertil Sex 24:475–481

    CAS  Google Scholar 

  59. Mol BW, Matthijsse HC, Tinga DJ, Huynh T, Hajenius PJ, Ankum WM et al (1998) Fertility after conservative and radical surgery for tubal pregnancy. Hum Reprod 13:1804–1809. doi:10.1093/humrep/13.7.1804

    Article  PubMed  CAS  Google Scholar 

  60. Rulin MC (1995) Is salpingostomy the surgical treatment of choice for unruptured tubal pregnancy? Obstet Gynecol 86:1010–1013. doi:10.1016/0029-7844(95)00330-T

    Article  PubMed  CAS  Google Scholar 

  61. Silva PD, Schaper AM, Rooney B (1993) Reproductive outcome after 143 laparoscopic procedures for ectopic pregnancy. Obstet Gynecol 81:710–715

    PubMed  CAS  Google Scholar 

  62. Machado AC, Guimaraes EM, Sakurai E, Fioravante FC, Amaral WN, Alves MF (2007) High titers of Chlamydia trachomatis antibodies in Brazilian women with tubal occlusion or previous ectopic pregnancy. Infectious diseases in obstetrics and gynecology 2007:24816

    PubMed  CAS  Google Scholar 

  63. Odland JO, Anestad G, Rasmussen S, Lundgren R, Dalaker K (1993) Ectopic pregnancy and chlamydial serology. Int J Gynaecol Obstet 43:271–275. doi:10.1016/0020-7292(93)90515-X

    Article  PubMed  CAS  Google Scholar 

  64. Bjartling C, Osser S, Persson K (2000) The frequency of salpingitis and ectopic pregnancy as epidemiologic markers of Chlamydia trachomatis. Acta Obstet Gynecol Scand 79:123–128. doi:10.1034/j.1600-0412.2000.079002123.x

    Article  PubMed  CAS  Google Scholar 

  65. Roberts TE, Robinson S, Barton PM, Bryan S, McCarthy A, Macleod J et al (2007) Cost effectiveness of home based population screening for Chlamydia trachomatis in the UK: economic evaluation of chlamydia screening studies (ClaSS) project. BMJ 335:291

    Article  PubMed  Google Scholar 

  66. Menon S, Sammel MD, Vichnin M, Barnhart KT (2007) Risk factors for ectopic pregnancy: a comparison between adults and adolescent women. J Pediatr Adolesc Gynecol 20:181–185. doi:10.1016/j.jpag.2007.01.007

    Article  PubMed  Google Scholar 

  67. Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J (1997) The risk of ectopic pregnancy after tubal sterilization. US Collaborative Review of Sterilization Working Group. N Engl J Med 336:762–767. doi:10.1056/NEJM199703133361104

    CAS  Google Scholar 

  68. Peterson HB, Xia Z, Wilcox LS, Tylor LR, Trussell J (1999) Pregnancy after tubal sterilization with bipolar electrocoagulation. US Collaborative Review of Sterilization Working Group. Obstet Gynecol 94:163–167. doi:10.1016/S0029-7844(99)00316-6

    CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Obstetrics and Gynaecology, St George’s University of London, Cranmer Terrace, Tooting, London, SW17 0RE, UK

    Vivek Nama & Isaac Manyonda

Authors
  1. Vivek Nama
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Isaac Manyonda
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Vivek Nama.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Nama, V., Manyonda, I. Tubal ectopic pregnancy: diagnosis and management. Arch Gynecol Obstet 279, 443–453 (2009). https://doi.org/10.1007/s00404-008-0731-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00404-008-0731-3

Keywords

  • Ectopic
  • Pregnancy
  • TVS
  • Salpingectomy
  • Salpingotomy
  • Beta-hCG
  • Methotrexate
  • Tubal pregnancy