An ectopic pregnancy, widely known as a tubal or extrauterine pregnancy, occurs when the fertilised egg implants outside the uterus. About 95% of ectopic pregnancies involve implantation of the fertilised egg in the fallopian tubes. Rarely, the fertilised egg may implant on the surface of the ovary, in the cervix, or in neighbouring organs. However, in all these ectopic locations, the embryo cannot develop, and the pregnancy cannot progress. Most ectopic pregnancies require surgical management or, if diagnosed early, may be treated with medication. Early treatment is crucial so that a woman may later achieve a normal pregnancy, if she wishes.
What are the symptoms of an ectopic pregnancy?
Common symptoms and clinical signs include missed periods, a positive pregnancy test, vaginal bleeding, abdominal pain, and fainting. In the early stages, the symptoms are similar to those of a normal pregnancy, such as frequent urination, nausea, and breast tenderness.
Common symptoms of ectopic pregnancy include:
- Missed or delayed period
- Feeling nauseous
- Vomiting
- Fatigue
- Breast pain, tenderness, or swelling
- Frequent urination or constipation
- Vaginal discharge
- Heightened sense of smell
- Changes in appetite and taste
Symptoms that do not align with a normal pregnancy may include:
- Vaginal bleeding
- Abdominal or lower pelvic pain
- Diarrhea and stomach discomfort
- Pain during bowel movements
- Back pain
- Generalised weakness
- Dizziness
How is the diagnosis made?
Today, ectopic pregnancy is usually diagnosed early through physical examination, measurement of beta-human chorionic gonadotropin (β-hCG) in blood or urine, and ultrasound imaging. A key goal is early detection so that appropriate treatment can be given promptly. Rupture of an ectopic pregnancy may cause internal bleeding, requiring emergency surgery.
What are the risk factors for ectopic pregnancy?
Risk factors that increase the likelihood of ectopic pregnancy include:
- Previous inflammation or infection of the fallopian tubes (pelvic inflammatory disease)
- Previous surgery on the fallopian tubes (such as tubal sterilisation reversal or other tubal procedures)
- Previous ectopic pregnancy
- Unplanned conception despite using an intrauterine device (IUD) or birth control pills that contain only progesterone
Treatment of ectopic pregnancy
Treatment options include medical management with methotrexate or surgical intervention. Ectopic pregnancies are often diagnosed and treated laparoscopically (a minimally invasive method). If there is severe or uncontrolled bleeding, an open surgery (laparotomy) may be necessary, using an incision just above the pubic hairline.
Beta-hCG and ultrasound in diagnosis
In a normal intrauterine pregnancy, beta-hCG roughly doubles every 48 hours in the first weeks. When it rises slowly, plateaus or falls, the pregnancy is not developing normally. When the level exceeds about 1,500 to 2,000 mIU/ml and the transvaginal ultrasound shows no sac inside the uterus, an ectopic pregnancy is strongly suspected. Two or three measurements and a repeat ultrasound are often needed before a definite diagnosis is made. This wait is difficult, but it prevents mistakes.
When it is an emergency
Call your doctor immediately or go to a maternity hospital emergency department if you have a positive pregnancy test and:
- sudden, severe pain in the lower abdomen,
- pain at the tip of the shoulder,
- dizziness, paleness, fainting,
- heavy vaginal bleeding.
These signs may indicate a ruptured fallopian tube with internal bleeding.
Treatment options in detail
- Follow-up: for selected women without pain, with a low beta-hCG that is falling on its own. It requires regular measurements until it reaches zero.
- Methotrexate: a single intramuscular injection that stops the pregnancy tissue from growing. It is indicated when the woman is hemodynamically stable, beta-hCG is relatively low and there is no fetal heartbeat. Beta-hCG measurements follow for several weeks, and contraception is recommended for at least three months.
- Laparoscopy: removal of the fallopian tube (salpingectomy) or, when the other tube is damaged, opening the tube and removing only the pregnancy (salpingotomy).
Rh-negative women are given anti-D immunoglobulin.
Pregnancy after an ectopic pregnancy
Most women later have a normal pregnancy, even with one fallopian tube. The risk of another ectopic pregnancy is about 10%, so in the next pregnancy an early ultrasound is done, around week 6, to confirm the location of the sac. If the tubes are severely damaged, in vitro fertilization bypasses them. Their patency is checked with hysterosalpingography (HSG).
Losing a pregnancy, no matter how early, is a loss. Give yourself time and ask for support if you need it.
Pregnancy of unknown location: when the ultrasound does not yet show where it is
Very often the first visit does not lead to a diagnosis. The test is positive, but the transvaginal ultrasound shows no sac either inside or outside the uterus. This is called a pregnancy of unknown location and does not necessarily mean an ectopic pregnancy.
There are three possible explanations:
- A very early normal pregnancy, which is simply still too small to be seen. This often happens when ovulation occurred later than you calculated.
- A pregnancy that is not developing and will miscarry on its own.
- Ectopic pregnancy that is not yet visible.
The answer comes with a repeat beta-hCG measurement in 48 hours and a new ultrasound. In the meantime you will be given clear instructions: if you develop severe pain, shoulder pain, dizziness or heavier bleeding, go immediately to a maternity hospital emergency department and do not wait for your scheduled appointment.
Ectopic pregnancy in unusual locations
Most ectopic pregnancies are located in the fallopian tube. A small percentage, however, implant elsewhere, and these forms need different management, often at a specialized center.
- Interstitial pregnancy: at the point where the fallopian tube enters the wall of the uterus. It can grow larger before causing symptoms, and its rupture causes severe bleeding.
- Cesarean scar pregnancy: the sac implants in the old incision. It is becoming more common due to the rise in cesarean sections and is diagnosed with a careful transvaginal ultrasound in the first weeks.
- Cervical pregnancy: in the cervix, with a risk of heavy bleeding.
- Ovarian or abdominal pregnancy: very rare forms.
- Heterotopic pregnancy: an intrauterine and an ectopic pregnancy at the same time. It is extremely rare with natural conception, but more common after in vitro fertilization, especially when more than one embryo is transferred.
That is why women with a previous cesarean section, or a pregnancy after assisted reproduction, need an early ultrasound by an experienced doctor.
Methotrexate: what to expect in the following weeks
Medical treatment avoids surgery, but it requires cooperation and patience.
- Pain in the first days: mild pain in the lower abdomen is common 2 to 3 days after the injection. Severe or worsening pain, however, needs immediate assessment, because it may mean a rupture.
- Beta-hCG may rise at first. That is why the values on day 4 and day 7 are compared. If they do not fall enough, a second dose or surgical treatment may be needed.
- What to avoid until beta-hCG reaches zero: alcohol, folic acid supplements, anti-inflammatory painkillers, strenuous exercise, sexual intercourse and prolonged sun exposure.
- Side effects: nausea, fatigue, mouth ulcers. They are usually mild and temporary.
Follow-up lasts until beta-hCG returns to negative levels, which can take several weeks.
Recovery after surgical treatment
Laparoscopy is done through three or four small incisions, and most women go home the same day or the next. What to expect in the following days:
- Shoulder pain: caused by the gas used during the procedure, it subsides within one to two days.
- Light vaginal bleeding for a few days.
- Fatigue, which may last a little longer than the physical pain.
- Return to work usually within one to two weeks, depending on the type of job.
If a salpingotomy was performed, meaning the tube was preserved, beta-hCG measurements are needed until it reaches zero, because pregnancy tissue remains in a small percentage of cases. After a salpingectomy, a pregnancy test about three weeks later is usually enough.
Contact us right away if you develop fever, redness or discharge from the incisions, pain that gets worse instead of better, or bleeding heavier than a period.
Can an ectopic pregnancy be prevented?
It cannot be fully prevented, because an ectopic pregnancy can also occur in women with no risk factors at all. You can, however, lower the likelihood and, above all, ensure an early diagnosis.
- Protection from sexually transmitted infections: chlamydia infections often cause no symptoms, but they can damage the fallopian tubes. Testing and early treatment protect future fertility.
- Quitting smoking: smoking affects the motility of the fallopian tubes and is linked to an increased risk.
- Early ultrasound around week 6 for women with a history of ectopic pregnancy, tubal surgery, endometriosis or a pregnancy after assisted reproduction.
- An immediate pregnancy test if your period is late while you have an IUD or after tubal ligation. These methods are very effective, but in the rare event of conception, the likelihood of it being ectopic is increased.
Coping emotionally with the loss
An ectopic pregnancy brings a double shock: the loss of a pregnancy and, often, emergency surgery. Many women describe anger, fear for the future or guilt, even when nothing could have been done differently. Studies have shown that a significant percentage experience symptoms of anxiety or post-traumatic stress in the following months.
You do not have to go through this alone. Talk with your partner, ask your doctor to explain in detail what happened and what it means for the future, and seek support from a mental health professional if the sadness does not ease.
Conditions that mimic an ectopic pregnancy
Lower abdominal pain with a positive test is not always due to an ectopic pregnancy. Your doctor will consider other causes as well, which is why the diagnosis is never based on symptoms alone.
- Miscarriage in progress: bleeding and cramps in the middle of the abdomen.
- Corpus luteum cyst: a normal ovarian cyst in early pregnancy, which can rarely rupture or cause torsion.
- Urinary tract infection or kidney stone: pain in the side, burning on urination.
- Appendicitis: pain that starts around the navel and moves to the lower right, often with fever.
What happens when you arrive at the maternity hospital
Knowing the process reduces the anxiety of waiting. Usually:
- Your blood pressure and pulse are measured to assess whether there is internal bleeding.
- Blood is drawn for beta-hCG, hemoglobin and blood type with Rh factor.
- A transvaginal ultrasound follows, which looks for the sac, checks the ovaries and detects any fluid or blood in the abdomen.
- If you are stable and the diagnosis is uncertain, you will be asked to return for a recheck in 48 hours. If there are signs of rupture, surgery is performed immediately.
Do not eat or drink anything until a doctor has assessed you, in case anesthesia is needed, and bring the results of any previous beta-hCG measurements with you.
For a personalized assessment of your case, book an appointment with Dr. Panagiotis Polyzos at his office in Athens or Volos.
Frequently Asked Questions
Can an ectopic pregnancy progress normally?
No. Outside the uterus the embryo cannot develop, and the pregnancy cannot be moved into the uterus.
Is the pregnancy test positive with an ectopic pregnancy?
Yes. The test detects beta-hCG, which is also produced in an ectopic pregnancy, usually at lower levels.
In which week does an ectopic pregnancy show up?
It is usually diagnosed between the 5th and 8th week after the last period, using a combination of beta-hCG and transvaginal ultrasound.
When can I try again?
After surgery, usually after two cycles. After methotrexate, at least three months later, while taking folic acid.
Can I get pregnant with one fallopian tube?
Yes. If the other tube is healthy, the chances of natural conception are only slightly reduced.
Does methotrexate affect future fertility?
Available data do not show that methotrexate for ectopic pregnancy reduces ovarian reserve or the chances of a future pregnancy. However, you need to wait at least three months before trying again.
Can an ectopic pregnancy happen after IVF?
Yes. Although the embryo transfer takes place inside the uterus, the embryo can migrate toward the fallopian tube. That is why, after a positive test following IVF, beta-hCG measurements and an early ultrasound are done.
How does ectopic pregnancy pain differ from the cramps of a normal pregnancy?
Mild cramps in the middle of the abdomen are common in the first weeks. Ectopic pregnancy pain is usually on one side, persists or gets stronger, and may come with spotting, shoulder pain or dizziness. If in any doubt, you need an examination.
Do I need anti-D after an ectopic pregnancy?
Rh-negative women who undergo surgical treatment are given anti-D immunoglobulin to protect future pregnancies. For medical treatment, the recommendation is individualized.
Can an ectopic pregnancy resolve on its own?
Yes, some early ectopic pregnancies stop developing and are reabsorbed without treatment. This applies mainly when beta-hCG is low and falling steadily, and the woman has no pain. Even then, regular measurements are required until it reaches zero, because the risk of rupture does not disappear.
What other factors increase the risk of ectopic pregnancy?
Besides a previous ectopic pregnancy, infections and tubal surgery, the risk increases with smoking, age over 35, endometriosis and pregnancies after assisted reproduction. About half of women, however, have no known risk factor.
