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Ectopic Pregnancy

Ectopic Pregnancy is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

Ectopic: pregnancy implanted outside the uterine cavity. Subtypes include:

  • Tubal: pregnancy implanted in any portion of the fallopian tube
  • Abdominal: pregnancy implanted intra-abdominally, most commonly after tubal abortion or rupture of tubal ectopic pregnancy
  • Heterotopic: pregnancy implanted intrauterine and a separate pregnancy implanted outside uterine cavity
  • Ovarian: implantation of pregnancy in ovarian tissue
  • Cervical: implantation of pregnancy in cervix
  • Intraligamentary: implantation of pregnancy within the broad ligament

Epidemiology

Incidence
  • 108,800 cases in 1992 in the United States, according to CDC census (most recent data available), meaning that 1.5–2.0% of all pregnancies were ectopic. The true incidence is difficult to estimate.
  • In the United States, ectopic pregnancy is the leading cause of 1st trimester maternal deaths and accounts for 6% of all pregnancy-related deaths.
  • Heterotopic pregnancy, although rare (1:30,000), occurs with greater frequency in women undergoing in vitro fertilization (IVF) (1/1,000).
  • Increasing incidence of nontubal, and particularly cesarean scar ectopic pregnancies, due in part to more cesarean sections and more IVF

Prevalence
~33% recurrence rate if prior ectopic pregnancy

Etiology and Pathophysiology

  • 95–97% of ectopic pregnancies occur in the fallopian tube, of which, 55–80% in the ampulla, 12–25% in the isthmus, and 5–17% in the fimbria.
  • One risk factor for a tubal pregnancy is impaired movement of the fertilized ovum to the uterine cavity due to dysfunction of the tubal cilia, scarring, or narrowing of the tubal lumen.
  • Other locations are rare but may occur from reimplantation of an aborted tubal pregnancy or from uterine structural abnormalities (mainly cervical pregnancy).

Risk Factors

  • History of pelvic inflammatory disease (PID), endometritis, or current gonorrhea/chlamydia infection
  • Previous ectopic pregnancy
  • History of tubal surgery (~33% of pregnancies after tubal ligation will be ectopic.)
  • Pelvic adhesive disease (infection or prior surgery)
  • Use of an intrauterine device (IUD): Overall chance of any pregnancy with an IUD is low; however, there is an increased likelihood of ectopic location if pregnancy occurs. IUDs reduce absolute risk of ectopic pregnancy.
  • Use of assisted reproductive technologies
  • Maternal diethylstilbestrol (DES) exposure in utero (DES was last used in 1972.)
  • Tobacco use
  • Patients with disorders that affect ciliary motility may be at increased risk (e.g., endometriosis, Kartagener).

General Prevention

  • Reliable contraception or abstinence
  • Screening for and treatment of STIs (i.e., gonorrhea, chlamydia) that can cause PID and tubal scarring

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Citation

Stephens, Mark B., et al., editors. "Ectopic Pregnancy." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116201/all/Ectopic_Pregnancy.
Ectopic Pregnancy. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116201/all/Ectopic_Pregnancy. Accessed March 19, 2019.
Ectopic Pregnancy. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116201/all/Ectopic_Pregnancy
Ectopic Pregnancy [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 March 19]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116201/all/Ectopic_Pregnancy.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Ectopic Pregnancy ID - 116201 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116201/all/Ectopic_Pregnancy PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -