Ectopic pregnancy typically presents 6 to 8 weeks after the last normal menstrual period, but can present earlier or later.
Risk of ectopic pregnancy increases with prior ectopic pregnancy, tubal surgery, history of sexually transmitted infections, smoking, in vitro fertilisation, or if the woman pregnant despite IUD usage.
Classical symptoms and signs of ectopic pregnancy are pain, vaginal bleeding, and amenorrhoea. Haemodynamic instability and cervical motion tenderness may indicate rupture or imminent rupture of an ectopic pregnancy.
If the woman is haemodynamically stable, transvaginal ultrasound is the initial test of choice.
Treatment approaches for ectopic pregnancy include expectant, medical (methotrexate), or surgical (salpingectomy, salpingostomy).
If an ectopic pregnancy ruptures, the woman may present in shock from blood loss and with unusual patterns of referred pain from intraperitoneal blood.
An ectopic pregnancy occurs when a fertilised ovum implants and matures outside the uterine endometrial cavity, with the most common site being the fallopian tube (97%), followed by the ovary (3.2%) and the abdomen (1.3%). If undiagnosed or untreated, it may lead to maternal death due to rupture of the implantation site and intraperitoneal haemorrhage.
History and exam
Key diagnostic factors
- abdominal pain
- vaginal bleeding
- abdominal tenderness
- adnexal tenderness or mass
- blood in vaginal vault
- haemodynamic instability, orthostatic hypotension
- cervical motion tenderness
Other diagnostic factors
- urge to defecate
- referred shoulder pain
- previous ectopic pregnancy
- previous tubal sterilisation surgery
- in utero diethylstilbestrol exposure of the mother
- intrauterine device (IUD) use
- previous genital infections
- chronic salpingitis
- salpingitis isthmica nodosa
- multiple sexual partners
- assisted reproductive technology (ART)
- first sexual encounter <18 years
- maternal age >35 years
- tubal reconstruction surgery
1st investigations to order
- urine or serum pregnancy test
- high resolution transvaginal ultrasound (TVUS)
- transabdominal ultrasound
Investigations to consider
- serial serum human chorionic gonadotrophin (hCG)
- uterine aspiration
tubal ectopic pregnancy: ruptured ectopic pregnancy or failed medical management
tubal ectopic pregnancy: moderate risk or failed expectant management
tubal ectopic pregnancy: low risk
Kurt T. Barnhart, MD, MSCE
William Shippen Jr. Professor of Obstetrics and Gynecology and Epidemiology
Vice Chair for Clinical Research
Director, Women's Health Clinic Research Center
The Perelman School of Medicine
University of Pennsylvania
Associate Chief, Penn Fertility Care
KTB is a co-author on several papers cited in this topic.
Dr Kurt T. Barnhart would like to gratefully acknowledge Dr Ingrid Granne, Dr Veronica Gomez-Lobo, Dr Sina Haeri, and Dr Mohammad Ezzati, previous contributors to this topic.
IG, VGL, SH, and ME declare that they have no competing interests.
Alan Decherney, MD
Reproductive Biology Medicine and Biology
AD declares that he has no competing interests.
Joanna C. Girling, MA, MRCP, FRCOG
Consultant in Obstetrics and Gynaecology
West Middlesex University Hospital
JCG declares that she has no competing interests.
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