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My Ectopic Summer

Me, my novel, and the orb in my right fallopian tube..

The first time something happened to me that I couldn’t find any way to laugh about was a week before I finished graduate school, when a doctor told me that I’d had a miscarriage. After that, I spent the days leading up to graduation binge drinking to such an extent that one night I tried to make a grilled cheese sandwich by putting bread and cheese in a vertical toaster and nearly burned my house down. When I stumbled up to the stage to receive my MFA diploma, hungover and toasterless, I couldn’t have been less proud of what I had achieved in my 31 years. I had worked plenty, but I’d never had a “real” job with insurance. I still wore clothes from Forever 21 that didn’t fit all that well anymore. I had never learned to cook, obviously. I was failing to find an agent for the third novel I had written. And when I’d tried to do something supposedly easy like having a baby, I managed to botch that too.

The friends I told unveiled an entire sorority of other friends, sisters, aunts, and hairdressers who’d also had miscarriages. Their stories always ended with “but it all worked out, because she went on to have two beautiful children!”—as if that would erase the bloody mess I’d found in the toilet one morning. But when my husband and I followed up with the doctor a week after graduation, I learned that the doctor had got it wrong the first time around and had misdiagnosed me: I was not part of the cool 1-in-5 miscarrying-as-a-rite-of-passage club, but the 1-in-10-to-100 club of women cursed with an ectopic pregnancy.

The young doctor, who was kind but made it clear she had seen much worse, told us that a fertilized egg had got stuck in my fallopian tube on the way to the uterus. The first step would be to inject me with a low dose of a chemotherapy drug. After that, I’d need to come in every few days so they could make sure the egg was shrinking instead of growing and threatening to rupture my tube—which could potentially kill me. If the drugs didn’t work, I’d need surgery, which would give me a 50 percent chance of losing that tube, essentially rendering half of the eggs in my body useless. I scared the doctor and an observing medical student by bursting into tears that rivaled the sounds of the baby crying in the next room. Then a woman in a hazmat suit came in to inject both my butt cheeks with a giant needle full of the drug. I was sent away with a vial of extremely potent uppers, which would help me deal with the fact that a woman who had an ectopic pregnancy was 10 times more likely to have a second one, and also that my husband and I would have to wait three months after the baby-orb was extinguished, the whole long summer at best, to try to get pregnant again.

Ectopic is Greek for “out of place,” which seemed fitting that summer. I’d planned to kick off the season by visiting my parents in Jersey and giving a speech at my friends’ commitment ceremony in Brooklyn. Instead my husband and I were stuck in Iowa, where we blasted through a season of Billions while I took my “happy pills” and returned to the hospital every few days to track the progress of the orb, which I still felt throbbing in my right tube. I spent most of my days on forums where women shared their sagas of multiple ectopic pregnancies, lost tubes, years of infertility, failed IVF, stillbirths, and other woes far worse than mine, and repeatedly checked my email to see if any agents were interested in my fairly autobiographical novel, which happened to end with the protagonist’s pregnancy. No one was getting back to me.

I had two unpublished novels under my belt at that point. Eight years earlier, well before anyone cared about Chernobyl, I wrote a novel about a preteen who evacuates Kyiv after the disaster and starts an inappropriate relationship with her best friend’s fascist grandfather—admittedly, a hard sell. I managed to find an agent, who strung me along for two years before giving up on the book. A few years later, I finished my second project, a 700-page comic novel about a Ukrainian immigrant whose life is upended when her agent gives up on her historical novel. My favorite scene in the book was when the girl’s father sends his oversize mobsters to Manhattan to convince the agent to give her a second chance. “I wish there was more I could do,” the agent cried as the mobsters hung her head out her 20 th -story window, “but your daughter simply isn’t ready.” The book was not a hit with literary agents.

As I went around Iowa City dodging people with agents and pregnant women like they were the radioactive firefighters from my Chernobyl novel, I told myself that what I saw as the lowest point in my life would be funny, one day. Dear agent , I could write, I want to find the right place for this novel, since I can’t seem to correctly place a fertilized egg in my messed-up body . Or perhaps I would write a tongue-in-cheek story about a Soviet immigrant egg stuck in a tube: “I was told America would be more spacious,” the egg would complain, while slowly suffocating.

A month after my diagnosis, the baby-orb did die. My husband and I didn’t do anything special when I got the news. It was a relief to vanquish the rogue invader of my body—or at least thinking of it as such made it easier to deal with it. Plus, this meant I could drink again.

After that, I began visiting a not particularly joyful therapist named Joy who did not offer me much solace. “Write down your biggest fears on a card and put it in your wallet,” she told me. “Then, if you’re worried about something, you can say, that’s OK, I already wrote it down on the card!” I burst into laughter—I knew well enough that writing something down did not strip it of its power. I also made a pregnancy shrine consisting of a small shelf of Russian literature topped by healing crystals given to me by a friend, and a Japanese statue that protects lost children, and atheist-prayed to it every morning, wondering if I was losing my mind. I taught creative writing to high school students, by far the most soul-rejuvenating thing I had done. Those kids saved me by reminding me how much I loved writing, even if I might have scared them when I wept while reading aloud from the ending of “The Dead.” At last, the summer mercifully ended, and the pulse that had lingered where the baby orb had been was finally quiet.

Things happened quickly after Labor Day. I got pregnant again, and I finally heard back from an agent—he wanted to sell my book, and he did, on the day that I heard my daughter’s heartbeat for the first time. Two years later, my novel was published and I have a healthy 1-year-old, but that doesn’t mean I never look back, or that I’ve found a way to laugh about it. Sometimes, around my period, I still feel pain in the injured tube, and it’s a comfort, in a way. After my rejected Chernobyl narrator evacuated her home, she asked herself, rather melodramatically, “What if the Chernobyl dust was something that got embedded in your pores, clutched onto your skin and hair, and resided under your fingernails—something that marked you for the rest of your life?” The book she was in wasn’t very good, but she was onto something. I won’t forget that endless summer by looking in my daughter’s eyes, and I’m OK with that. It’s just another thing that happened to me. More things will.

ERIN HENDRIKS, MD, RACHEL ROSENBERG, MD, AND LINDA PRINE, MD

Am Fam Physician. 2020;101(10):599-606

Author disclosure: No relevant financial affiliations.

Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. In the United States, the estimated prevalence of ectopic pregnancy is 1% to 2%, and ruptured ectopic pregnancy accounts for 2.7% of pregnancy-related deaths. Risk factors include a history of pelvic inflammatory disease, cigarette smoking, fallopian tube surgery, previous ectopic pregnancy, and infertility. Ectopic pregnancy should be considered in any patient presenting early in pregnancy with vaginal bleeding or lower abdominal pain in whom intrauterine pregnancy has not yet been established. The definitive diagnosis of ectopic pregnancy can be made with ultrasound visualization of a yolk sac and/or embryo in the adnexa. However, most ectopic pregnancies do not reach this stage. More often, patient symptoms combined with serial ultrasonography and trends in beta human chorionic gonadotropin levels are used to make the diagnosis. Pregnancy of unknown location refers to a transient state in which a pregnancy test is positive but ultrasonography shows neither intrauterine nor ectopic pregnancy. Serial beta human chorionic gonadotropin levels, serial ultrasonography, and, at times, uterine aspiration can be used to arrive at a definitive diagnosis. Treatment of diagnosed ectopic pregnancy includes medical management with intramuscular methotrexate, surgical management via salpingostomy or salpingectomy, and, in rare cases, expectant management. A patient with diagnosed ectopic pregnancy should be immediately transferred for surgery if she has peritoneal signs or hemodynamic instability, if the initial beta human chorionic gonadotropin level is high, if fetal cardiac activity is detected outside of the uterus on ultrasonography, or if there is a contraindication to medical management.

Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. The prevalence of ectopic pregnancy in the United States is estimated to be 1% to 2%, but this may be an underestimate because this condition is often treated in the office setting where it is not tracked. 1 , 2 The mortality rate for ruptured ectopic pregnancy has steadily declined over the past three decades, and from 2011 to 2013 accounted for 2.7% of pregnancy-related deaths. 1 , 3 Risk factors for ectopic pregnancy are listed in Table 1 4 , 5 ; however, one-half of women with diagnosed ectopic pregnancy have no identified risk factors. 4 – 6 The overall rate of pregnancy (including ectopic) is less than 1% when a patient has an intrauterine device (IUD). However, in the rare case that a woman does become pregnant while she has an IUD, the prevalence of ectopic pregnancy is as high as 53%. 7 , 8 There is no difference in ectopic pregnancy rates between copper or progestin-releasing IUDs. 9

Making the Diagnosis

Signs and symptoms.

Ectopic pregnancy should be considered in any pregnant patient with vaginal bleeding or lower abdominal pain when intrauterine pregnancy has not yet been established ( Table 2 ) . 10 Vaginal bleeding in women with ectopic pregnancy is due to the sloughing of decidual endometrium and can range from spotting to menstruation-equivalent levels. 10 This endometrial decidual reaction occurs even with ectopic implantation, and the passage of a decidual cast may mimic the passage of pregnancy tissue. Thus, a history of bleeding and passage of tissue cannot be relied on to differentiate ectopic pregnancy from early intrauterine pregnancy failure.

The nature, location, and severity of pain in ectopic pregnancy vary. It often begins as a colicky abdominal or pelvic pain that is localized to one side as the pregnancy distends the fallopian tube. The pain may become more generalized once the tube ruptures and hemoperitoneum develops. Other potential symptoms include presyncope, syncope, vomiting, diarrhea, shoulder pain, lower urinary tract symptoms, rectal pressure, or pain with defecation. 11

The physical examination can reveal signs of hemodynamic instability (e.g., hypotension, tachycardia) in women with ruptured ectopic pregnancy and hemoperitoneum. 12 Patients with unruptured ectopic pregnancy often have cervical motion or adnexal tenderness. 13 Sometimes the ectopic pregnancy itself can be palpated as a painful mass lateral to the uterus. There is no evidence that palpation during the pelvic examination leads to an increased risk of rupture. 10

BETA HUMAN CHORIONIC GONADOTROPIN

Beta human chorionic gonadotropin (β-hCG) can be detected in pregnancy as early as eight days after ovulation. 14 The rate of increase in β-hCG levels, typically measured every 48 hours, can aid in distinguishing normal from abnormal early pregnancy. In a viable intrauterine pregnancy with an initial β-hCG level less than 1,500 mIU per mL (1,500 IU per L), there is a 99% chance that the β-hCG level will increase by at least 49% over 48 hours. 15 As the initial β-hCG level increases, the rate of increase over 48 hours slows, with an increase of at least 40% expected for an initial β-hCG level of 1,500 to 3,000 mIU per mL (1,500 to 3,000 IU per L) and 33% for an initial β-hCG level greater than 3,000 mIU per mL. 15 A slower-than-expected rate of increase or a decrease in β-hCG levels suggests early pregnancy loss or ectopic pregnancy. The rate of increase slows as pregnancy progresses and typically plateaus around 100,000 mIU per mL (100,000 IU per L) at 10 weeks' gestation. 16 A decrease in β-hCG of at least 21% over 48 hours suggests a likely failed intrauterine pregnancy, whereas a smaller decrease should raise concern for ectopic pregnancy. 17

The discriminatory level is the β-hCG level above which an intrauterine pregnancy is expected to be seen on transvaginal ultrasonography; it varies with the type of ultrasound machine used, the sonographer, and the number of gestations. A combination of β-hCG level greater than the discriminatory level and ultrasonography that does not show an intrauterine pregnancy should raise concern for early pregnancy loss or an ectopic pregnancy. 5 The discriminatory zone was previously defined as a β-hCG level of 1,000 to 2,000 mIU per mL (1,000 to 2,000 IU per L); however, this cutoff can miss some intrauterine pregnancies that do not become apparent until a slightly higher β-hCG level is achieved. Therefore, in a desired pregnancy, it is recommended that a discriminatory level as high as 3,500 mIU per mL (3,500 IU per L) be used to avoid misdiagnosis and interruption of a viable pregnancy, although most pregnancies will be visualized by the time the β-hCG level reaches 1,500 mIU per mL. 18 , 19

TRANSVAGINAL ULTRASONOGRAPHY

Intrauterine pregnancy visualized on transvaginal ultrasonography essentially rules out ectopic pregnancy except in the exceedingly rare case of heterotopic pregnancy. 5 The definitive diagnosis of ectopic pregnancy can be made with ultrasonography when a yolk sac and/or embryo is seen in the adnexa; however, ultrasonography alone is rarely used to diagnose ectopic pregnancy because most do not progress to this stage. 5 More often, the patient history is combined with serial quantitative β-hCG levels, sequential ultrasonography, and, at times, uterine aspiration to arrive at a final diagnosis of ectopic pregnancy.

PREGNANCY OF UNKNOWN LOCATION

Ultrasonography showing neither intrauterine nor ectopic pregnancy in a patient with a positive pregnancy test is referred to as a pregnancy of unknown location. In a desired pregnancy, β-hCG levels and serial ultrasonography combined with patient reports of pain or bleeding guide management. 20 In an undesired pregnancy or when the possibility of a viable intrauterine pregnancy has been excluded, manual vacuum aspiration of the uterus can evaluate for chorionic villi that differentiate intrauterine pregnancy loss from ectopic pregnancy. If chorionic villi are seen, further workup is unnecessary, and exposure to methotrexate can be avoided  ( Figure 1 ) . 5 , 15 – 17 , 21 If chorionic villi are not seen after uterine aspiration, it is imperative to initiate treatment for ectopic pregnancy or repeat β-hCG measurement in 24 hours to ensure at least a 50% decrease. Ectopic precautions and serial β-hCG levels should be continued until the level is undetectable.

Management of Ectopic Pregnancy

It is appropriate for family physicians to treat hemodynamically stable patients in conjunction with their primary obstetrician. Patients with suspected or confirmed ectopic pregnancy who exhibit signs and symptoms of ruptured ectopic pregnancy should be emergently transferred for surgical intervention. If ectopic pregnancy has been diagnosed, the patient is deemed clinically stable, and the affected fallopian tube has not ruptured, treatment options include medical management with intramuscular methotrexate or surgical management with salpingostomy (removal of the ectopic pregnancy while leaving the fallopian tube in place) or salpingectomy (removal of part or all of the affected fallopian tube). The decision to manage the ectopic pregnancy medically or surgically should be informed by individual patient factors and preferences, clinical findings, ultrasound findings, and β-hCG levels. 12 Expectant management is rare but can be considered with close follow-up for patients with suspected ectopic pregnancy who are asymptomatic and have β-hCG levels that are very low and continue to decrease. 5

MEDICAL MANAGEMENT

Intramuscular methotrexate is the only medication appropriate for the management of ectopic pregnancy. A folate antagonist, it interrupts the rapidly dividing cells of the ectopic pregnancy, which are then resorbed by the body. 22 Its success rate decreases with higher initial β-hCG levels ( Table 3 ) . 23 Contraindications to methotrexate include renal insufficiency; moderate to severe anemia, leukopenia, or thrombocytopenia; liver disease or alcoholism; active peptic ulcer disease; and breastfeeding. 5 Therefore, a complete blood count and comprehensive metabolic panel should be obtained before it is administered.

Several methotrexate regimens have been studied, including a single-dose protocol, a two-dose protocol, and a multi-dose protocol ( Table 4 ) . 5 The single-dose protocol carries the lowest risk of adverse effects, whereas the two-dose protocol is more effective than the single-dose protocol in patients with higher initial β-hCG levels. 24 There is no consistent evidence or consensus regarding the cutoff above which a two-dose protocol should be used, so clinicians should choose a regimen based on the initial β-hCG level and ultrasound findings, as well as patient preference regarding effectiveness vs. the risk of adverse effects. In general, the single-dose protocol should be used in patients with β-hCG levels less than 3,600 mIU per mL (3,600 IU per L), and the two-dose protocol should be considered for patients with higher initial β-hCG levels, especially those with levels greater than 5,000 mIU per mL. Multidose protocols carry a higher risk of adverse effects and are not preferred. 25

Before administering methotrexate, β-hCG levels should be measured on days 1, 4, and 7 of treatment. The first measurement helps the clinician decide between the one- and two-dose protocols. Levels commonly increase between days 1 and 4, but should decrease by at least 15% between days 4 and 7. If this decrease does not occur, the clinician should discuss with the patient whether she prefers to repeat the course of methotrexate or pursue surgical treatment. If the β-hCG level does decrease by at least 15% between days 4 and 7, the patient should return for weekly β-hCG measurements until levels become undetectable, which can take up to eight weeks. 26

Close follow-up is critical for the safe use of methotrexate in women with ectopic pregnancies. Patients should be counseled that the risk of rupture persists until β-hCG levels are undetectable, and that they should seek emergency care if signs of ectopic pregnancy occur. It is common for patients to experience some abdominal pain two to three days after administration of methotrexate. This pain can be managed expectantly as long as there are no signs of rupture. 5 Gastrointestinal adverse effects (e.g., abdominal pain, vomiting, nausea) and vaginal spotting are common. Patients should be counseled to avoid taking folic acid supplements and nonsteroidal anti-inflammatory drugs, which can decrease the effectiveness of methotrexate, and to avoid anything that may mask the symptoms of ruptured ectopic pregnancy (e.g., narcotic analgesics, alcohol) and activities that increase the risk of rupture (e.g., vaginal intercourse, vigorous exercise). Sunlight exposure during treatment can cause methotrexate dermatitis and should be avoided. 5 Other adverse effects of methotrexate include alopecia and elevation of liver enzymes. Patients should be counseled to avoid repeat pregnancy until at least one ovulatory cycle after the serum β-hCG level becomes undetectable, although some experts recommend waiting three months so that the methotrexate can be cleared completely. 27 There is no evidence that methotrexate therapy affects future fertility. 28

SURGICAL MANAGEMENT

Overall, surgical management has a higher success rate for ectopic pregnancy than methotrexate. 5 The initial β-hCG level at which to transfer a patient for possible surgical treatment depends on local standards, although a level of 5,000 mIU per mL (5,000 IU per L) is commonly used. 5 , 11 Ultrasound visualization of an embryo with fetal cardiac activity outside of the uterus is an indication for urgent transfer for surgical management. 5 , 25 Additionally, social factors that preclude frequent laboratory testing (e.g., poor telephone access, work and family obligations, lack of transportation) can make surgical management the safer option 5 ( Table 5 5 , 11 ) . In cases where methotrexate is contraindicated or not preferred by the patient, surgical management can usually be performed laparoscopically if the patient is hemodynamically stable. Surgical options include salpingostomy or salpingectomy. Randomized trials have shown no difference in sequelae between methotrexate administration and fallopian tube–sparing laparoscopic surgery, including rates of future intrauterine pregnancy and risk of future ectopic pregnancy. 29 The decision whether to remove the fallopian tube or leave it in place depends on the extent of damage to the tube (evaluated intraoperatively) and the patient's desire for future fertility.

EXPECTANT MANAGEMENT

Expectant management can be considered for patients whose peak β-hCG level is below the discriminatory zone and is decreasing, but has plateaued or is decreasing more slowly than expected for a failed intrauterine pregnancy. 30 In cases where the initial β-hCG level is 200 mIU per mL (200 IU per L) or less, 88% of patients will have successful spontaneous resolution of the pregnancy; however, rates of spontaneous resolution decrease with higher β-hCG levels. 31 Patient counseling must include the risks of spontaneous rupture, hemorrhage, and need for emergency surgery. Patients who choose expectant management should have β-hCG levels monitored every 48 hours, and medical or surgical management should be recommended if β-hCG levels do not decrease sufficiently. 5

This article updates a previous article on this topic by Barash, et al. 12

Data Sources: An evidence summary from Essential Evidence Plus was reviewed and relevant studies referenced. Additionally, a PubMed search was completed in Clinical Queries using the key terms ectopic pregnancy, first trimester bleeding, and pregnancy of unknown location. The search included meta-analyses, guidelines, and reviews. Also searched were the Cochrane database, DynaMed, and the National Guideline Clearinghouse. Search dates: October 26, 2018, through January 14, 2020.

Creanga AA, Shapiro-Mendoza CK, Bish CL, et al. Trends in ectopic pregnancy mortality in the United States: 1980–2007. Obstet Gynecol. 2011;117(4):837-843.

Marion LL, Meeks GR. Ectopic pregnancy: history, incidence, epidemiology, and risk factors. Clin Obstet Gynecol. 2012;55(2):376-386.

Creanga AA, Syverson C, Seed K, et al. Pregnancy-related mortality in the United States, 2011–2013. Obstet Gynecol. 2017;130(2):366-373.

Ankum WM, Mol BW, Van der Veen F, et al. Risk factors for ectopic pregnancy: a meta-analysis. Fertil Steril. 1996;65(6):1093-1099.

ACOG practice bulletin no. 193: tubal ectopic pregnancy [published correction appears in Obstet Gynecol . 2019;133(5):1059]. Obstet Gynecol. 2018;131(3):e91-e103.

Barnhart KT, Sammel MD, Gracia CR, et al. Risk factors for ectopic pregnancy in women with symptomatic first-trimester pregnancies. Fertil Steril. 2006;86(1):36-43.

Backman T, Rauramo I, Huhtala S, et al. Pregnancy during the use of levonorgestrel intrauterine system. Am J Obstet Gynecol. 2004;190(1):50-54.

Hardeman J, Weiss BD. HardemanJWeissBDIntrauterine devices: an update. Am Fam Physician2014;89(6):445–450. Accessed November 9, 2019. https://www.ncbi.nlm.nih.gov/pubmed/24695563?dopt=Abstract

Bosco-Lévy P, Gouverneur A, Langlade C, et al. Safety of levonorgestrel 52 mg intrauterine system compared to copper intrauterine device: a population-based cohort study. Contraception. 2019;99(6):345-349.

Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy?: the rational clinical examination systematic review. JAMA. 2013;309(16):1722-1729.

Newbatt E, Beckles Z, Ullman R, et al.; Guideline Development Group. Ectopic pregnancy and miscarriage: summary of NICE guidance. BMJ. 2012;345:e8136.

Barash JH, Buchanan EM, Hillson C. BarashJHBuchananEMHillsonCDiagnosis and management of ectopic pregnancy. Am Fam Physician2014;90(1):34–40. Accessed November 9, 2019. https://www.aafp.org/afp/2014/0701/p34.html

Ramakrishnan K, Scheid DC. Ectopic pregnancy: forget the “classic presentation” if you want to catch it sooner. J Fam Pract. 2006;55(5):388-395.

Stewart BK, Nazar-Stewart V, Toivola B. Biochemical discrimination of pathologic pregnancy from early, normal intrauterine gestation in symptomatic patients. Am J Clin Pathol. 1995;103(4):386-390.

Barnhart KT, Guo W, Cary MS, et al. Differences in serum human chorionic gonadotropin rise in early pregnancy by race and value at presentation. Obstet Gynecol. 2016;128(3):504-511.

Barnhart KT, Sammel MD, Rinaudo PF, et al. Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined. Obstet Gynecol. 2004;104(1):50-55.

Barnhart K, Sammel MD, Chung K, et al. Decline of serum human chorionic gonadotropin and spontaneous complete abortion: defining the normal curve. Obstet Gynecol. 2004;104(5 pt 1):975-981.

Doubilet PM, Benson CB, Bourne T, et al.; Society of Radiologists in Ultrasound Multispecialty Panel on Early First Trimester Diagnosis of Miscarriage and Exclusion of a Viable Intrauterine Pregnancy. Diagnostic criteria for nonviable pregnancy early in the first trimester. N Engl J Med. 2013;369(15):1443-1451.

Connolly A, Ryan DH, Stuebe AM, et al. Reevaluation of discriminatory and threshold levels for serum β-hCG in early pregnancy. Obstet Gynecol. 2013;121(1):65-70.

Rodgers SK, Chang C, DeBardeleben JT, et al. Normal and abnormal US findings in early first-trimester pregnancy: review of the Society of Radiologists in Ultrasound 2012 consensus panel recommendations. Radiographics. 2015;35(7):2135-2148.

Reproductive Health Access Project. Diagnosis and treatment of ectopic pregnancy algorithm. June 2019. Accessed June 29, 2019. https://www.reproductiveaccess.org/resource/ectopic-algorithm

Stika CS. Methotrexate: the pharmacology behind medical treatment for ectopic pregnancy. Clin Obstet Gynecol. 2012;55(2):433-439.

Menon S, Colins J, Barnhart KT. Establishing a human chorionic gonadotropin cutoff to guide methotrexate treatment of ectopic pregnancy: a systematic review. Fertil Steril. 2007;87(3):481-484.

Yang C, Cai J, Geng Y, et al. Multiple-dose and double-dose versus single-dose administration of methotrexate for the treatment of ectopic pregnancy: a systematic review and meta-analysis. Reprod Biomed Online. 2017;34(4):383-391.

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Barnhart KT, Gosman G, Ashby R, et al. The medical management of ectopic pregnancy: a meta-analysis comparing “single dose” and “multidose” regimens. Obstet Gynecol. 2003;101(4):778-784.

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Revisiting ectopic pregnancy: a pictorial essay

Affiliations.

• 1 Department of Radiology, Winthrop University Hospital, New York, USA.
• 2 Department Obstetrics and Gynecology, Winthrop University Hospital, New York, USA.
• 3 Department of Radiology, Winthrop University Hospital, New York, USA ; Department of Radiology, SUNY Stony Brook School of Medicine, New York, USA.
• PMID: 25161806
• PMCID: PMC4142466
• DOI: 10.4103/2156-7514.137817

Ectopic pregnancies occur in approximately 1.4% of all pregnancies and account for 15% of pregnancy-related deaths. Considering the high degree of mortality, recognizing an ectopic pregnancy is important. Signs and symptoms of an ectopic pregnancy are nonspecific and include pain, vaginal bleeding, and an adnexal mass. Therefore, imaging can play a critical role in diagnosis. There are different types of ectopic pregnancies, which are tubal, cornual, cesarean scar, cervical, heterotopic, abdominal, and ovarian. Initial imaging evaluation of pregnant patients with pelvic symptoms is by ultrasonography, transabdominal, transvaginal or both. We review the sonographic appearance of different types of ectopic pregnancies that will aid in accurate and prompt diagnosis.

Keywords: Cervical; cesarean scar; cornual; heterotopic; ultrasonography of ectopic pregnancy.

Ectopic Pregnancy

An ectopic pregnancy occurs when a fertilized egg (embryo) implants in another location other than the uterine cavity (Houry & Salhi, 2009). It’s life-threatening complication and at most times not viable. It poses a great risk of internal hemorrhage secondary to rupture and is considered a medical emergency.

Most ectopic pregnancies implant in the fallopian tubes. The other likely areas of ectopic implantation are the ovaries, cervix and abdomen. According to Schenker and Margalioth (2012), implantation in these areas occurs if there’s a blockage that hinders movement of the fertilized egg through the fallopian tubes.

• Congenital abnormalities involving the fallopian tubes
• Scarring from sexually transmitted diseases, for instance Chlamydia or surgical procedure such as unsuccessful tubal ligation
• Ectopic pregnancy in the past
• Some fertility treatments for instance, in-vitro fertilization
• Pelvic inflammatory disease

According to Houry and Salhi (2009), one may experience early pregnancy symptoms such as amenorrhea, nausea/vomiting and breast tenderness. Other symptoms are as follows:

• Lower abdominal pain
• Abnormal vaginal bleeding
• Sharp abdominal cramps
• Weakness or dizziness
• One sided pain of the lower abdomen
• Severe bleeding and pain in case fallopian tubes rupture
• Low blood pressure

The woman may present with pelvic tenderness. A pelvic examination should be done and pregnancy (PDT) confirmed. In ectopic pregnancy, human chorionic gonadotrophin in the blood is lower than in normal pregnancy (Schenke & Margalioth,2012). A vaginal ultrasound and sonogram should be done to confirm the location of the embryo.

Ectopic pregnancy cannot grow to term and should be terminated to save the life of the mother (Houry & Salhi, 2009). In un-ruptured pregnancy, use of medication like methotrexate and surgery are employed to remove the growing cells. Ruptured ectopic pregnancy is an emergency which may lead to death through hemorrhage. Early treatment of STIs is necessary to avoid such pregnancies.

Houry, D. E., & Salhi, B. A. (2009). Acute complications of pregnancy (7th ed.). In J. Marx (Ed.), Rosen’s Emergency Medicine: Concepts and Clinical Practice (chap  176) . Philadelphia: Elsevier Mosby.

Schenker, J. G., Margalioth, E. J. (2012). “Intra-uterine adhesions: an updated appraisal”. Fertility and Sterility , 37(5) : 593–610. Web.

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• Ectopic pregnancy

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Coping and support, preparing for your appointment.

A pelvic exam can help your doctor identify areas of pain, tenderness, or a mass in the fallopian tube or ovary. However, your doctor can't diagnose an ectopic pregnancy by examining you. You'll need blood tests and an ultrasound.

Pregnancy test

Your doctor will order the human chorionic gonadotropin (HCG) blood test to confirm that you're pregnant. Levels of this hormone increase during pregnancy. This blood test may be repeated every few days until ultrasound testing can confirm or rule out an ectopic pregnancy — usually about five to six weeks after conception.

A transvaginal ultrasound allows your doctor to see the exact location of your pregnancy. For this test, a wandlike device is placed into your vagina. It uses sound waves to create images of your uterus, ovaries and fallopian tubes, and sends the pictures to a nearby monitor.

Abdominal ultrasound, in which an ultrasound wand is moved over your belly, may be used to confirm your pregnancy or evaluate for internal bleeding.

Transvaginal ultrasound

During a transvaginal ultrasound, you lie on an exam table while a health care provider or a medical technician puts a wandlike device, known as a transducer, into the vagina. Sound waves from the transducer create images of the uterus, ovaries and fallopian tubes.

Other blood tests

A complete blood count will be done to check for anemia or other signs of blood loss. If you're diagnosed with an ectopic pregnancy, your doctor may also order tests to check your blood type in case you need a transfusion.

More Information

A fertilized egg can't develop normally outside the uterus. To prevent life-threatening complications, the ectopic tissue needs to be removed. Depending on your symptoms and when the ectopic pregnancy is discovered, this may be done using medication, laparoscopic surgery or abdominal surgery.

An early ectopic pregnancy without unstable bleeding is most often treated with a medication called methotrexate, which stops cell growth and dissolves existing cells. The medication is given by injection. It's very important that the diagnosis of ectopic pregnancy is certain before receiving this treatment.

After the injection, your doctor will order another human chorionic gonadotropin (HCG) test to determine how well treatment is working, and if you need more medication.

Laparoscopic procedures

Salpingostomy and salpingectomy are two laparoscopic surgeries used to treat some ectopic pregnancies. In these procedure, a small incision is made in the abdomen, near or in the navel. Next, your doctor uses a thin tube equipped with a camera lens and light (laparoscope) to view the tubal area.

In a salpingostomy, the ectopic pregnancy is removed and the tube left to heal on its own. In a salpingectomy, the ectopic pregnancy and the tube are both removed.

Which procedure you have depends on the amount of bleeding and damage and whether the tube has ruptured. Also a factor is whether your other fallopian tube is normal or shows signs of prior damage.

Emergency surgery

If the ectopic pregnancy is causing heavy bleeding, you might need emergency surgery. This can be done laparoscopically or through an abdominal incision (laparotomy). In some cases, the fallopian tube can be saved. Typically, however, a ruptured tube must be removed.

From Mayo Clinic to your inbox

Losing a pregnancy is devastating, even if you've only known about it for a short time. Recognize the loss, and give yourself time to grieve. Talk about your feelings and allow yourself to experience them fully.

Rely on your partner, loved ones and friends for support. You might also seek the help of a support group, grief counselor or other mental health provider.

Many women who have an ectopic pregnancy go on to have a future, healthy pregnancy. The female body normally has two fallopian tubes. If one is damaged or removed, an egg may join with a sperm in the other tube and then travel to the uterus.

If both fallopian tubes have been injured or removed, in vitro fertilization (IVF) might still be an option. With this procedure, mature eggs are fertilized in a lab and then implanted into the uterus.

If you've had an ectopic pregnancy, your risk of having another one is increased. If you wish to try to get pregnant again, it's very important to see your doctor regularly. Early blood tests are recommended for all women who've had an ectopic pregnancy. Blood tests and ultrasound testing can alert your doctor if another ectopic pregnancy is developing.

Call your doctor's office if you have light vaginal bleeding or slight abdominal pain. The doctor might recommend an office visit or immediate medical care.

However, emergency medical help is needed if you develop these warning signs or symptoms of an ectopic pregnancy:

• Severe abdominal or pelvic pain accompanied by vaginal bleeding
• Extreme lightheadedness

Call 911 (or your local emergency number) or go to the hospital if you have the above symptoms.

What you can do

It can be helpful to jot down your questions for the doctor before your visit. Here are some questions you might want to ask your doctor:

• What kinds of tests do I need?
• What are the treatment options?
• What are my chances of having a healthy pregnancy in the future?
• How long should I wait before trying to become pregnant again?
• Will I need to follow any special precautions if I become pregnant again?

In addition to your prepared questions, don't hesitate to ask questions anytime you don't understand something. Ask a loved one or friend to come with you, if possible. Sometimes it can be difficult to remember all of the information provided, especially in an emergency situation.

What to expect from your doctor

If you don't require emergency treatment and haven't yet been diagnosed with an ectopic pregnancy, your doctor will talk to you about medical history and symptoms. You'll be asked many questions about your menstrual cycle, fertility and overall health.

Menstruation

• When was your last period?
• Did you notice anything unusual about it?
• Could you be pregnant?
• Have you taken a pregnancy test? If so, was the test positive?
• Have you been pregnant before? If so, what was the outcome of each pregnancy?
• Have you ever had fertility treatments?
• Do you plan to become pregnant in the future?
• Are you in pain? If so, where does it hurt?
• Do you have vaginal bleeding? If so, is it more or less than your typical period?
• Are you lightheaded or dizzy?

Health history

• Have you ever had reproductive surgery, including getting your tubes tied (or a reversal)?
• Have you had a sexually transmitted infection?
• Are you being treated for any other medical conditions?
• What medications do you take?

Mar 12, 2022

• Cunningham FG, et al., eds. Implantation and placental development. In: Williams Obstetrics. 25th ed. McGraw-Hill Education; 2018. https://accessmedicine.mhmedical.com. Accessed Dec. 4, 2019.
• Tulandi T. Ectopic pregnancy: Epidemiology, risk factors, and anatomic sites. https://www.uptodate.com/contents/search. Accessed Dec. 4, 2019.
• Cunningham FG, et al., eds. Ectopic pregnancy. In: Williams Obstetrics. 25th ed. McGraw-Hill Education; 2018. https://accessmedicine.mhmedical.com. Accessed Dec. 4, 2019.
• Frequently asked questions. Pregnancy FAQ 155. Ectopic pregnancy. American College of Obstetricians and Gynecologists. https://www.acog.org/Patients/FAQs/Ectopic-Pregnancy. Accessed Dec. 4, 2019.
• Tulandi T. Ectopic pregnancy: Clinical manifestations and diagnosis. https://www.uptodate.com/contents/search. Accessed Dec. 29, 2017.
• Burnett TL (expert opinion). Mayo Clinic. Dec. 4, 2019.
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Guest Essay

In a Post-Roe World, We Can Avoid Pitting Mothers Against Babies

By Leah Libresco Sargeant

Mrs. Sargeant has written books about religion and community building and runs an online community that focuses on the dignity of dependence.

Now that the Supreme Court has overturned Roe v. Wade, states face a new reality about where to draw the line in pregnancy for when abortion is permitted. In these debates, ectopic pregnancy is a key issue.

In an ectopic pregnancy , the baby implants somewhere other than the uterus — usually in a fallopian tube. The situation is fatal for the baby. It’s also dangerous for the mother. The fallopian tube can rupture, and the bleeding can be so fast and so sudden that it puts the mother’s life at risk.

Pro-life doctors and pro-life ethicists agree it is morally licit to save a mother’s life, even at her baby’s expense — but they draw a distinction between the treatment for ectopic pregnancy and an abortion.

From a pro-life perspective, delivering a baby who is ectopic is closer to delivering a baby very prematurely because the mother has life-threatening eclampsia. A baby delivered at 22 weeks may or may not survive. A baby delivered in the first trimester because of an ectopic pregnancy definitely won’t survive. But in both cases, a pro-life doctor sees herself as delivering a child, who is as much a patient as the mother.

A pro-life approach to ectopic pregnancy may countenance similar procedures but still sees it as different from an approach that equates it to abortion. When a mother’s life is threatened by the course of her pregnancy, there is a wide gulf between a culture that assumes she and her baby are pitted against each other and one in which both are valued.

Having gone through ectopic pregnancy, I have firsthand experience of this. And what I have learned is that a pro-life response to ectopic pregnancy isn’t just a matter of what is forbidden and what is permitted, but of what can be offered to parents to make room for their grief and to treat their child with love and dignity.

My goal for a post-Roe world is that we can offer more love and material support to mothers and children, especially in the hardest cases. The logic of abortion has been that you have to pick a side between the baby or the mother. But even in the case of ectopic pregnancy, you can side with both — treating mother and child with dignity. Both can benefit from the attention paid to the other.

My own experience illustrates the difficulties and promise of this approach. My husband and I had lost four children to first-trimester miscarriages when, in 2018, I was pregnant again. We went to the doctor’s office, braced for a familiar grief. The technician in the office was silent, and I could feel her pushing the ultrasound wand so far sideways that her knuckles were pressed into my leg.

“Can you see the baby?” I asked. “ Where are you looking for the baby?”

A previous surgeon had told me to stop crying during a miscarriage, so this time my husband and I took a train ride to reach the hospital of a Catholic surgeon in New Jersey. We wanted a surgeon who took the loss of our child as seriously as the danger to my life.

The first person to see us was another ultrasound technician. Her voice got sharp when I asked if our baby had a heartbeat. “It’s not a baby, don’t talk like that,” she told me, as I lay on the table. Her voice softened a little, “You don’t have to think of it that way.” For her, part of providing care was denying there was any room for grief.

But when the surgeon came in, he began by expressing his condolences. He talked about our options, he talked about our baby as a baby. He answered our questions about recovery times from surgery as naturally as he did our questions about how to specify that we wanted our child’s body for burial. He took our request seriously and told us that we should know that as far as he could tell, our baby had already died and it was the placenta that was still growing and putting me in danger. But if he could, he would make sure that our baby wasn’t treated as just a tissue sample but as a child lost.

We worked through the hospital checklists and questions as people cycled through our room asking about my blood type, my experience with anesthesia, my plans for getting home. No one asked about our plans for the baby. No one asked the baby’s name. No one, before or after the surgery, mentioned support groups for loss.

But I had a checklist of my own, and as I lay on the gurney, I prayed that I would open my eyes again. I prayed that if I didn’t, I could offer my life for the people I loved. And I hoped that this would be the first baby I could hold, even if I couldn’t see the baby take a breath. Every other child I lost had been miscarried at home, too early to retrieve a body.

I knew that the Trappist monks of New Melleray Abbey would send us a tiny coffin, free of charge, as part of their ministry to bereaved parents . My husband knew that, if anything went wrong, I wanted him to order an adult-size one for me.

We didn’t get to bury our baby. My husband didn’t have to bury me. Our surgeon had been right — our baby had died some time ago, and all he could find was the placenta. But while I recovered at home, we had something to know our baby by. We named this child Camillian, after St. Camillus de Lellis. He was a 16th-century gambler, who was treated so poorly by his doctors that he founded a nursing order and ultimately became a priest and a saint.

The specifications for surgery remain the same, whether the surgeon is pro-life or not, whether the mother kept repeating “baby” to her nurses or stuck to saying “pregnancy.” But I wonder if an observer in the operating room could have seen a difference; if my surgeon was visibly more tender as he worked, knowing he could be the first person to see our child, a child who would not ever see us.

Doctors can’t value women more by dismissing our babies as worth less . Even women who support abortion access may find it jarring to have their child’s life dismissed when they hoped they would hold this baby. It’s better to be honest about tragedy and loss than to pretend that only one person is on the table.

Leah Libresco Sargeant ( @LeahLibresco ) is the author of “ Arriving at Amen ” and “ Building the Benedict Option .” She writes about the dignity of dependence at Other Feminisms .

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• v.85(3); 2018 Aug

Treatment of an Ectopic Pregnancy

Maureen l. condic.

1 Department of Neurobiology and Anatomy, University of Utah, School of Medicine, Salt Lake City, UT, USA

Donna Harrison

2 American Association of Pro-Life Obstetricians and Gynecologists, Eau Claire, MI, USA

There is considerable lack of clarity on the medical facts surrounding management of ectopic pregnancy. In particular, it is not widely appreciated that by the time an ectopic pregnancy is diagnosed, in most cases, there is no viable fetus (i.e., the fetus has already died). Moreover, there is very little ethical guidance from the medical profession regarding the emotionally difficult decision to terminate a wanted pregnancy when the life of the mother is at risk. The best articulated positions on this topic come from religious groups, based on the principle of double effect. Yet the application of this reasoning to termination of an ectopic pregnancy is inconsistent with the medical facts in many cases. To resolve these inconsistencies, while still providing a robust ethical context for resolving such difficult situations, we propose clear guidelines for determining when a viable fetus is present in ectopic pregnancy and clarify the moral object in ectopic pregnancy management.

Summary: This paper explores the ethical framework for clinical decision making in the case of ectopic pregnancies. Focusing on the disordered union of mother and unborn child clarifies the object and purpose of the actions used to separate the mother and fetus in order to save the life of both, or at least one. Since over 90% of tubal ectopic pregnancies present as embryos who have already died, these cases present no ethical dilemma. This paper proposes a modification of currently used criteria for determining the viability of ectopic pregnancies and calls for further research.

Introduction

There is broad consensus that killing an innocent human being is never a good thing. Indeed, this understanding is the basis of a large body of American and Western jurisprudence that holds intentional killing of another person to be permissible only under highly specific circumstances: (1) in cases of self-defense or defense of others, where no other means of deterring the assailant are effective, (2) in cases of just war, and (3) in cases where the legitimate authorities of the state enact legally permissible capital punishment. This strong prohibition against killing, particularly killing of the innocent, spans a wide range of ethical frameworks, both religious and secular. Legal abortion, physician-assisted suicide, and euthanasia are the notable exceptions to this general view.

There is nonetheless considerable confusion regarding the application of this general prohibition against killing to the specific case of separating the mother and the fetus in cases where the life of the mother is at risk, irrespective of the views an individual holds on the contentious topic of abortion ( Markens, Browner, and Mabel Preloran 2010 ). Adding to this confusion are two confounding factors: (1) the considerable political connotations of terms such as “termination of pregnancy” and “abortion,” which to the nonmedical reader, are both equivalent to elective destruction of an embryo or fetus, and (2) equivocation over definitions and terminology, which use the same term abortion to denote both spontaneous and induced fetal loss. This article suggests a new terminology to describe the moral object of procedures intended to address a fatal condition of a pregnant woman: “separation of the mother and the fetus.” The use of this terminology, which is clearly defined and unequivocal both inside and outside of the medical profession, provides the precision of language needed to attempt a discussion of the ethical issues surrounding the management of ectopic pregnancy. This article also provides a moral analysis of ectopic pregnancy management based on this new vocabulary.

Ectopic Pregnancy: Current Framework for Moral Analysis

Losing a desired pregnancy for any reason can create considerable emotional distress, regardless of the parents’ views on abortion or religion ( Cowchock et al. 2010 ; Davies et al. 2005 ; Mann et al. 2008 ). Parents who desire a child are very reluctant to harm or destroy a fetus, even when the mother’s health or life is at risk. For those who face these difficult choices, and especially for those who view fetuses as human beings (as opposed to mere human tissue) or as human persons with intrinsic moral value, it is important to consider whether the separation of an unborn child from his or her mother before that unborn child is able to survive outside of his or her mother’s womb can be justified to save the life of the mother and, if so, under what circumstances.

Surprisingly, despite the medical challenges presented by ectopic pregnancy and the emotional distress this condition entails, many professional medical associations have no explicit policy on cases where the life of the mother is in jeopardy, other than to assert the general right to legal abortion. Thus, many professional medical associations offer no guidance on this difficult topic, leaving the decision in the hands of individual parents and their physicians. And, as noted by Foran (1999) , lack of clarity on the morality of existing procedures for management of ectopic pregnancy creates “serious problems of conscience for physicians, patients and hospital personnel” (p. 27).

In contrast, some religious groups, most notably the Catholic Church, have well-articulated ethical positions on the topic of intentional termination of a pregnancy to safeguard a mother’s health. While maintaining that direct killing of an innocent child is always wrong, the US Conference of Catholic Bishops ( USCCB 2009 ) asserts that, “Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child” (dir. 47).

This position invokes the ethical principle of double effect, that originated with Aristotle, and was refined by Thomas Aquinas in the Summa theologiae (II-II, q. 64, a. 7). There is a large and well-articulated body of literature concerning the principle of double effect ( Woodward 2001 ; Cavanaugh 2006 ; Boyle 1981 , 1980 ). In general, this principle asserts that an action directed toward a good end (e.g., a medical intervention designed to save the life of the mother) can be licitly conducted, even when this action has an unavoidable secondary effect that is not good (e.g., the death of the fetus), if the following three criteria are met. First, the act itself must not be unethical. Second, the intention must be to achieve the good effect and not the bad effect. And finally, the good effect must outweigh or at least equal the bad effect in ethical gravity.

In the view of the National Catholic Bioethics Center ( NCBC 2013 ), application of the principle of double effect to medical treatments that result in separation of the mother and her fetus before the fetus is capable of surviving outside the womb requires the following:

• Treatment is directly therapeutic in response to a serious pathology of the mother or child.
• The good effect of curing the disease is intended and the bad effect foreseen but unintended.
• The death of the child is not the means by which the good effect is achieved.
• The good of curing the disease is proportionate to the risk of the bad effect.

We would note that a central requirement of the principle of double effect is point number three above, that is, that the bad effect (in this case, the death of the child), cannot be the means by which the good effect is achieved, which would place the bad effect under the agent’s overall intention.

Ectopic Pregnancy: A Comparison to Uterine Cancer

Terminating a pregnancy in the case of uterine cancer is often contrasted to the case of an ectopic pregnancy, and the contrast between these two situations illustrates a number of disturbing inconsistencies in the current ethical framework.

Under the rule of double effect, removing a cancerous uterus of a pregnant woman is considered warranted because the intention is to cure the cancer, and not kill the baby, despite this consequence being foreseen. In this case, “The woman’s health benefits directly from the surgery , because of the removal of the cancerous organ,” and “there is nothing intrinsically wrong with surgery to remove a malfunctioning organ. It is morally justified when the continued presence of the organ causes problems for the rest of the body” ( USCCB 2010 ).

However, it is important to note that in this situation, the uterus is not removed because it is “malfunctioning.” Indeed, given that the primary function of the uterus is to gestate a fetus, a malfunctioning uterus would result in spontaneous miscarriage. Rather, the uterus is removed because it harbors cancerous cells. Cancer ultimately proves fatal only when the physical growth or biochemical products of the cancerous tumor compromise a vital organ or vital physiologic process. Removal of a cancerous uterus prevents the spread of these potentially fatal cells to new locations in the body. Thus, based on the position of the USCCB, removal of an otherwise functional uterus that harbors both a living fetus and cancerous cells is warranted to protect the life of the mother. However, in the face of chemotherapy agents and radiation therapy that have proven successful in the treatment of gynecological cancers in pregnant women without harming the fetus, this reasoning is further weakened ( Amant et al. 2015 ).

In contrast to the case of uterine cancer, the USCCB (2009) clearly states, “In the case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion,” with a direct abortion being, “Every procedure whose sole immediate effect is the termination of pregnancy before viability” (dirs. 48, 45). The USCCB seems to be condemning any act made upon a previable fetus directly in which fetal death is the expected outcome, even if, miraculously, death does not follow.

The difficulty with this definition of “direct abortion” is that it is not a medical definition, and operationally does not distinguish between the separation of the mother and the fetus in order to kill the fetus, and the separation of the mother and the fetus in order to save the mother’s life. Importantly, as defined by the USCCB, if direct abortion requires the “sole immediate effect” to be the termination of pregnancy, then inherent in the term “direct” is the assumption that any separation is by definition designed with the primary intent of killing the fetus. Thus, the definition itself implicitly assumes the malice that it condemns.

Thus, addressing even a life-threatening ectopic pregnancy by surgically opening the fallopian tube and separating the fetus from the mother (salpingostomy) is illicit because such a surgery would constitute a direct attack on the fetus ( Anderson et al. 2011 ). In contrast, if the entire fallopian tube is removed (salpingectomy), this is seen as morally licit under the principle of double effect because, “the intention of the surgeon is directed towards the good effect (removing the damaged tissue to save the mother’s life) while only tolerating the bad effect (death of the ectopic child). Importantly, the surgeon is choosing to act on the tube (a part of the mother’s body) rather than directly on the child ” ( Pacholczyk 2009 , emphasis added).

This argument asserts that because the presence of a fetus in the fallopian tube results in a pathological state of that tissue, removal of the pathological tissue is licit, despite the inevitable death of the fetus. However, it would be nonsensical to consider treating this condition by removal of the pathological segment of the fallopian without removal of the fetus (e.g., by carefully dissecting away the regions of the tube that have begun to malfunction and covering the fetus with “fresh” fallopian tissue). This would be absurd precisely because it would allow the underlying cause of the pathology to persist, which is the fact that the union of the mother and fetus should not take place in the tube. It is the union (the presence of the fetus implanted in an organ that cannot sustain fetal life) that is pathological. In fact, in many cases, the presence of the fetus in the fallopian tube is a result of the use of progestin contraceptives affecting the function of the normal tube. Women on continuous progestin-only contraceptives (except depo-provera users; Borgatta et al. 2002 ) are at increased risk of ectopic pregnancy ( Fylstra 2012 ). With levonorgestrel implants (Norplant), the risk is five times as high for ectopic pregnancy ( Furlong 2002 ). In these cases, there is no persistent underlying pathology in the fallopian tube but rather the response of a normal fallopian tube to a state induced by progestin. With the current argument, then, a fallopian tube that is functioning normally would be removed, and thus, the woman’s fertility would be permanently damaged.

The current reasoning requires that in administering an operation, treatment, or medication, it must have the direct purpose of alleviating a serious pathological condition in the mother. However, in the case of ectopic pregnancy, that pathological condition is the disordered physical union between the mother and her fetus. It is the continuation of the disordered union that gravely threatens the life of the mother. The separation of the mother from her embryo or fetus is indeed “the means by which” the pathology is actually addressed. The death of the fetus is an indirect result of the separation.

This disordered union remains disordered regardless of whether or not the fetus is alive. So, the death of the fetus does not undo the disorder. The dead fetal corpse must also be removed from the mother’s fallopian tube in most cases for the same reason a live fetus must be removed, that is, to eliminate the disordered union that is the cause of the pathology in the mother.

It is also not necessarily true that permanent pathology in the fallopian tube itself induced the disordered union. While known risk factors for ectopic pregnancy include previous tubal damage from infection or scarring, there are other temporary and transient risk factors that cause ectopic pregnancy, including the use of Intra Uterine Devices (IUDs) and progestins in hormonal contraceptives ( Li et al. 2015 ).

The fact that a normal fallopian tube can be altered by progestins to allow for ectopic implantation presents a problem for the ethical analysis which states that a diseased state must exist in the organ, necessitating surgical removal of the organ, despite the fetus dying as the unintentional “double effect.” In the case of progesterone contraceptive use, the tube is not abnormal, and to remove the tube or portion of the tube in order to treat the ectopic pregnancy results in the added effect of permanently decreasing or eliminating the woman’s future fertility. In cases of abdominal pregnancies, or ovarian pregnancies, control of hemorrhage may or may not require removal of the organ on which the fetus implanted, and most frequently, the fetus is removed and the placenta left to resorb on its own ( Ayinde et al. 2005 ; Huang et al. 2014 ). The idea of removing normally functioning organs because they harbor an implantation site of an ectopic pregnancy does not make those organs “diseased,” calling into question the basis of the current ethical framework.

Thus, in effecting the separation of the mother and the fetus, the least damaging means of performing the separation is the best option, out of respect for the fetal corpse and out of a desire to preserve the future fertility of the mother by protecting the function of her fallopian tube.

Ectopic Pregnancy: A New Framework for Moral Analysis

The difficulty in applying the principle of double effect in the case of ectopic pregnancy, or any other condition in which the continued physical union of a mother and her fetus immediately threatens the mother’s physical life, comes from two sources: from the definition of the moral object of treatment as “a direct attack on the fetus” and from significant confusion regarding the medical facts pertaining to ectopic pregnancy.

This article posits that defining the separation of the ectopic fetus from the mother as a direct attack on the fetus is inaccurate and precludes any serious moral analysis by assuming a priori that the intent of the separation of the mother and her ectopic fetus is to produce a dead fetus, an assumption that axiomatically makes the action immoral. If, however, the object of the action is the separation of the mother and the fetus, then using the framework presented below, a moral analysis based on the principle of double effect can be coherently applied to situations in which the separation of the mother and the fetus is necessary to save the life of the mother.

All pregnancies eventually end. In almost all circumstances, the ending of a pregnancy involves the separation of the mother and the fetus. The only exception to this is the case where both a mother and her fetus die prior to separation. The vocation of the obstetrician is to affect a separation of the mother and the fetus that offers the optimum conditions for life for both the mother and her fetus or newborn.

The morality of separating the mother and her fetus can be evaluated based on three components of moral action: (a) the action itself (i.e., the “moral object”), (b) the intention of the actor, and (c) the circumstances under which the action occurs. These three components are well articulated in a number of traditions, most clearly in the work of Aristotle (e.g., the Nicomachean Ethics ), Aquinas ( Summa theologiae I-II, q. 18), and in Catholic ( Catechism 1993 ) and Buddhist ( Bretfeld and Zander 2016 ) teaching. They also form the basis for legal determination of guilt in the Western legal tradition, with the legitimacy of the act itself ( actus reus ) being determined by statute, while both the intention of the actor ( mens rea ) and the extenuating circumstances surrounding the event being important considerations in both determination of guilt and in severity of sentencing.

The Moral Object

We propose that the proper moral object in question (i.e., the immediate objective or action taken for medical management of ectopic pregnancy) is the act of separating the mother and the embryo or fetus.

This act is neither intrinsically morally good nor intrinsically morally evil, and interpreting its moral character depends critically on the context in which it occurs. For example, the act of separation of the mother and the fetus is obviously good in the situation of childbirth, where separation occurs at the natural end of the intrauterine development of the fetus, who is now fully prepared for extrauterine life. Separation at childbirth is a good act, even in cases where the health of the mother and fetus requires that separation to occur through the act of a surgeon performing a Cesarean section (C-section). In contrast, the act of separation of the mother and the fetus as part of a violent assault on the mother is obviously immoral. In both of these cases, it is not the “ act of separation ,” but rather the intention with which that act is carried out and the circumstances under which it occurs, that determines the goodness or evil of the moral object of separation of the mother and the fetus.

A medical practitioner has a number of possible intentions when performing the act of separation of the mother and the fetus:

• To separate in order to bring about life for the mother and the fetus. This intention is always morally licit.
• To separate in order to ensure a dead fetus or to address the medical condition of the mother by means of actively killing the fetus. This appears to be at least one of the meanings of the phrase direct abortion, as used by the USCCB (although procedures taken against the fetus where fetal death is the likely outcome would also be condemned, even if the fetus survives). The difference between direct abortion and medically necessary separation of the mother and fetus is one of the most misunderstood and abused principles in the entire discussion surrounding pregnancy and its outcome. The goal of separation of mother and fetus can be many things, while the goal of direct abortion is to produce a dead embryo or fetus. For example, Giubilini and Minerva (2013) have argued that infanticide should be legally permitted in all circumstances that abortion is permitted, since both have the same effect, that is, death of the fetus. For those who view the fetus as a human person, this intention is always morally illicit.
• To separate in order to promote the health, mental well-being, or economic prosperity of the mother. The morality of this intention depends on the circumstances under which the separation takes place, most importantly on the extent to which the health and life of the fetus are affected by the separation (see below).

Circumstances

There are a number of important questions of fact pertinent to the moral evaluation of the circumstances surrounding the act of separation:

• Is the fetus alive? If the fetus is dead, then it is a morally good act to separate the mother and the fetus because the continuation of the state of physical union of a mother and a dead fetus poses an immediate threat to the physical life of the mother, through infection and the development of a situation called “disseminated intravascular coagulation”, which causes a mother to bleed to death internally. Separating the mother and fetus in this situation involves no moral controversy.

This situation also pertains to emergency situations such as placental abruption, cord prolapse, and fetal distress. Effecting separation of the fetus and the mother by emergency C-section is the fastest means of separation, in order to save the life of the fetus.

Ethical controversy exists in cases where the life of the fetus is immediately threatened and the mother refuses C-section. In cases where the risks to the mother are disproportionately low compared to the risks to the fetus and the mother refuses surgery, the moral issue becomes whether or not it is acceptable to legally compel a mother to undergo C-section surgery against her will.

Evaluating the morality of separation of the mother and the fetus under these grave circumstances requires consideration of whether or not the fetus is in a state of maturity which would, by best medical judgment, allow for the fetus to survive after physical separation from the mother’s body.

3.c.1: If, by best medical judgment, the fetus is able to survive after separation from the mother’s body, then the act of separation is morally good because separation involves the intent to save the life of both the mother and the fetus.

Continuing the state of physical union between the mother and the fetus, when the mother’s life is truly at risk of death and the fetus is able to survive is an evil act, because the death of the mother will put the fetus in grave risk of death as well, unless separation is carried out near the moment of death of the mother. Thus, the result of this inaction on the part of the practitioner will be one death (the mother), and very likely two deaths (both the mother and the fetus). This situation involves professional (prudential) judgment on the part of the medical practitioner regarding the risks to the fetus and the mother, but no fundamental moral controversy.

3.c.2: If the fetus alive and, by best medical judgment, will not survive after separation from the mother’s body, this situation is addressed by the principle of double effect outlined above.

A full analysis of the issue of separating the mother and fetus in cases where the fetus cannot survive separation and the mother will die unless the separation occurs is beyond the scope of this article. However, it is the opinion of the authors that in all such cases, the intention of the physician is to address the pathological state of the mother, not to kill the fetus. Thus, the death of the child is never the means by which the good effect is achieved, and the third condition of the moral framework proposed by the USCCB is always met. This is clearly illustrated in considering the case of life-threatening pre-eclampsia that is diagnosed either prior to or after the point of fetal viability. In both cases, the pathology of the mother is addressed by separation of the mother and the fetus. Yet prior to viability, the unintended effect is the death of the child and following viability, the child survives. Manifestly, therefore, death of the fetus cannot be “the means by which the good effect is achieved.”

Ectopic Pregnancy: Medical Considerations

Ectopic pregnancy is the state where an embryo has implanted in a place other than the endometrial (uterine) cavity. Locations of implantation can vary. In rare cases, full-term, healthy infants have been delivered after implanting in their mother’s ovary ( Huang et al. 2011 ; Sehgal et al. 2005 ), abdomen ( Badria et al. 2003 ; Dahab et al. 2011 ; Isah et al. 2008 ; Xiao et al. 2005 ; Zhang, Li, and Sheng 2008 ), or liver ( Shukla et al. 1985 ). However, by far the most common site of implantation is the fallopian tube. In a review of 1,679 ectopic pregnancies ( Bouyer et al. 2002 ), the fallopian tube was the site of implantation in 95.5 percent of the cases of ectopic pregnancy, with the next most common sites being the ovary (3.2 percent) and various locations within the abdomen (1.3 percent). Within the fallopian tube itself, the most common location was ampullary (70.0 percent), isthmic (12.0 percent), fimbria (11.1 percent), and interstitial (corneal; 2.4 percent). The next most common sites for ectopic pregnancies are the uterine cornua, C-section incision sites, and the cervix ( Chukus et al. 2015 ).

While ruptured ectopic pregnancy accounts for 3–4 percent of all mothers who die while pregnant, it is the leading cause of maternal death in the first twelve weeks of pregnancy in the United States ( Centers for Disease Control 2012 ). Delay in treatment of a diagnosed ectopic pregnancy is thus fraught with the very real danger of death to the mother. Balancing the timing of surgical intervention with the likelihood of tubal rupture is a matter of clinical judgment.

Tubal Rupture

In a recent review of 231 ectopic pregnancy cases ( Frates et al. 2014 ), neither sonographic findings nor human Chorionic Gonadotropin (hCG) levels were useful predictors of tubal rupture. In other words, there is currently no reliable marker that will predict when the ectopic pregnancy tissue will result in rupturing the mother’s tubes, with resultant life-threatening hemorrhage. In this study, 25 percent of the women who underwent surgery within twenty-four hours of the ultrasound scan had tubal rupture discovered at the time of surgery and were therefore in an immediately life-threatening situation. In order to avoid subjecting women to catastrophic hemorrhage, the treatment of choice when encountering an ectopic pregnancy in a clinical setting has been surgery to remove the fetus and placenta plus or minus the part or whole of the organ to which the placenta is attached.

Determination and Management of Ectopic Pregnancies with No Viable Fetus

As noted above, choices regarding the management of ectopic pregnancy depend on the status of the fetus. A recent study considered the status of the fetus in tubal (ectopic) pregnancy at the time of diagnosis ( Frates et al. 2014 ). Based on the analysis of 231 ectopic pregnancies, the study found that an embryo with cardiac activity was found only 7.4 percent of the time. In 92.4 percent of the cases of ectopic pregnancy, there was no clear living embryo present at the time of diagnostic ultrasound. Similarly, Pivarunas (2003) argues most ectopic pregnancies to not involve a living embryo/fetus, and therefore, “If embryonic death is present, then any treatment modality can be used. Kaczor (2009) also notes that “in the vast majority of actual cases in which MXT is medically indicated, the death of the embryo has indeed already occurred.”

In many cases of ectopic pregnancy, expectant management or administration of systemic methotrexate are sufficient treatments ( Demirdag et al. 2017 ). The concept of allowing some time to pass between the diagnosis of ectopic pregnancy and surgical intervention is an acceptable management technique for those pregnancies that clearly do not involve a living fetus ( Elson et al. 2004 ), the benefit being avoidance of unnecessary surgery. Moreover, these ectopic pregnancies involve no moral dilemma. If no living embryo or fetus is present at the site of ectopic implantation, then removal of the ectopic pregnancy with or without removing the organ to which the placenta has attached constitutes the moral equivalent of the removal of the deceased remains of the fetal corpse. In these cases, there is good moral reason to perform the surgery most capable of salvaging the mother’s future fertility. However, there is currently no accepted procedure for management of cases in which it is not clear whether a living fetus is present. The major limitation in such cases is that there are currently no accepted criteria for diagnosis of fetal demise in ectopic pregnancy.

Proposal for Diagnosis of Fetal Demise in Ectopic Pregnancies

While it is unlikely that medical criteria could be defined that would provide absolute certitude of fetal demise, it is possible to establish prudential (or moral) certitude. 1 In the case of intrauterine pregnancies, there are clear criteria that establish prudential certitude for diagnosis of fetal death ( Doubilet et al. 2013 ):

• crown-rump length of greater than seven millimeter and no heartbeat
• mean sac diameter of greater than or equal to twenty-five millimeter and no embryo
• absence of embryo with a heartbeat greater than or equal to two weeks after a scan that showed a gestational sac without a yolk sac
• absence of an embryo with a heartbeat greater than or equal to eleven days after a scan that showed a gestational sac with a yolk sac.

Applying these criteria to evaluation of ectopic pregnancies would help to make decision-making easier for both the parents and the clinician. We propose that the above four criteria with the addition of one more (below) could be used to diagnose ectopic embryonic demise with prudential certitude:

• (For ectopic pregnancy) Presence of a complex adnexal mass without a gestational sac.

We also call for further research using these criteria (e.g., correlation of diagnosis with a postsurgery pathology report) to determine whether they accurately diagnose fetal demise in cases of ectopic pregnancy. Importantly, a clear diagnosis of fetal demise eliminates the moral dilemma inherent in situations in which the continued presence of the living fetus threatens to kill the mother and fetus. And it is likely that clear fetal demise would be diagnosed in the majority of cases of ectopic pregnancy, perhaps in 90 percent or more, based on the sonographic findings at the time of diagnosis.

Management of the Minority of Ectopic Pregnancies with a Living Fetus

The above criteria were designed for evaluation of intrauterine pregnancy with the goal of prudential or moral certainty of no living embryo or fetus before intervening with curettage for miscarriage. The purpose of these criteria is to enable the clinician to avoid ending the life of an early human being with the mistaken diagnosis of miscarriage. However, the natural history of living intrauterine pregnancies is to proceed to live birth. The natural history of ectopic pregnancies is not so good. Tubal pregnancies are not thought to be capable of proceeding to live birth. Ovarian pregnancies and abdominal pregnancies can rarely survive to fetal viability, but their more common presentation is as an acute abdomen with intraabdominal hemorrhage. A ten-year review of ovarian pregnancies ( Goyal et al. 2014 ) revealed thirteen (93 percent) presenting in the first trimester as an acute abdomen, and one (7 percent) presenting at term as a breech presentation. Abdominal pregnancies are rare but worldwide, a few have been reported progressing to fetal viability with the outcome of live birth ( Huang et al. 2014 ).

This then is the moral dilemma in the less than 10 percent of ectopic pregnancies associated with a living fetus: both treatment and nonintervention of ectopic pregnancy result in unintended but unavoidable consequences for both the mother and the fetus. Inaction when action is called for to save the mother’s life also carries moral culpability. Whether the clinician removes the fetus and placenta, removes the attached organ with the fetus and placenta, watches and waits until hemorrhage and tubal rupture occurs, or waits until both the mother and the fetus die, all of these treatment options have real consequences for life or death of the mother and for her future ability to bear children. Any treatment option that involves delay in removal of the ectopic pregnancy in the case of a living embryo should have a reason proportionate to the risk to the mother’s life. If, as in the case of a tubal location of an ectopic pregnancy, there is no hope of fetal survival, and a very real and immediate risk of maternal death (see Circumstances 3.c.2), consistent with the existing ethical framework discussed above, the principle of double effect should apply to the separation of the mother and her fetus.

However, an important modification of the existing ethical framework afforded by the current analysis is that the means of curing the mother is always the separation of the mother and fetus, and never the direct killing of the fetus. Thus, so long as separation does not involve direct killing of the fetus (see below), separation should be performed in the manner that best preserves the health and fertility of the mother.

“Direct Killing” versus Allowing to Die

An important distinction in the medical management of ectopic pregnancy is the difference between actions that directly cause the death of the fetus (dismemberment, decapitation, methotrexate injection, etc.) and actions that allow the fetus to die (induction of premature labor or other means of removing the fetus from the body of the mother at a developmental stage when it is not able to survive independently). This distinction is based on the commonly accepted view that good cannot be accomplished by evil means, and therefore, if an action is objectively wrong (e.g., direct killing of the fetus), it cannot be permitted under any circumstances.

Although circumstances of a life-threatening medical complication of pregnancy may require a “fatal outcome” for the fetus, the distinction between actions that directly terminate the life of the fetus and those that indirectly result in the death of the fetus is both significant and nuanced. A simple example may help clarify this difficult distinction: Is there a moral difference between strangulation (direct killing by depriving the victim of oxygen) and salpingectomy (which results in the killing of the fetus by depriving it of oxygen)? Prior ethical analysis of this situation ( Anderson et al. 2011 ) would suggest that strangulation is a direct killing whereas, salpingectomy is allowing a fetus to die, after taking a direct action against a malfunctioning portion of the mother’s body.

Yet, based on this distinction, would “indirectly” depriving an adult of oxygen in a manner similar to salpingectomy, for example, by sealing off a room to prevent air circulation, be seen as simply allowing him or her to die, rather than a direct act of killing? Under the principle of double effect, the interpretation of this example turns entirely on the intentions behind the action. If sealing off the room met the criteria of double effect outlined above (e.g., if the room was sealed to prevent the escape of a toxic gas that would kill everyone in the building), it would not be a direct act of killing. In contrast, if the intention were to kill the adult by sealing the room, it would be a direct action against that person. In contrast, strangulation is always a direct killing because there can be no purpose intended other than the death of the victim.

Thus, while the distinction between direct killing and allowing to die can be subtle, it is an important distinction to avoid viewing killing simply as a convenient means of achieving a positive outcome for the mother.

In summary, determining the morality of separating a mother and her fetus involves a detailed evaluation of the three components of moral action: (a) object, (b) intention, and (c) circumstance. In this analysis, we propose:

• The moral object is the act of separation of the mother and her fetus, an act that is neither intrinsically good nor intrinsically evil.
• The intention of separating the mother and fetus is to produce the death of the fetus (i.e., direct abortion), to produce life for the mother and her fetus, or to improve the health, well-being, or prosperity of the mother. The morality of these intentions depends both on the circumstances under which the separation occurs and the view of the moral value or personhood of the fetus.
• The medical circumstances under which the separation of mother and fetus takes place, including whether or not the fetus is alive, the outcome for both fetus and mother if the physical union of the two persists, and the outcome for both the mother and the fetus following separation, are a critical component of the moral consideration.

In the vast majority of cases of ectopic pregnancy, there is no living fetus or embryo at the time of diagnosis. Therefore, after determination of fetal death by the rigorous medical criteria proposed here, removal of the fetal corpse is entirely warranted and morally uncompromised.

In cases where the status of the fetus is ambiguous, we propose further research using clear criteria for arriving at a sound medical judgment and call for more detailed medical evidence on the poorly researched subject of embryo viability in ectopic implantation sites.

In a minority of cases where the embryo is clearly alive (detection of a heartbeat), or the ambiguity regarding the status of the embryo cannot be resolved, the current reasoning under the rule of double effect applies with an important modification. The current guidelines that recommend the removal of the mother’s fallopian tube in order to avoid a “direct attack on the fetus” are fundamentally flawed. The flaws in the current reasoning result from (1) a failure to understand that the true pathology is a disordered union between the mother and the fetus, (2) a misidentification of the moral object as death of the fetus (i.e., direct abortion) rather than the separation of the mother and the fetus, and (3) a mischaracterization of the intent of separating the mother and the fetus as a direct attack on the fetus rather than an attempt to address the pathological condition of the mother.

This article respectfully calls for a reappraisal of the current moral analysis of ectopic pregnancy treatment and a clarification of the true moral object in cases involving the separation of the mother and her living fetus. So long as this separation does not involve direct killing of the fetus, separation should be performed in the manner that best preserves the health and fertility of the mother.

Biographical Notes

Maureen L. Condic , PhD, is an associate professor of neurobiology and anatomy at the University of Utah, School of Medicine, with an adjunct appointment in the Department of Pediatrics. Her current research involves the control of human stem-cell potency and differentiation. In addition to her scientific research, she teaches both graduate and medical students. Her teaching focuses primarily on embryonic development, and she is the director for human embryology in the University of Utah, School of Medicine’s curriculum.

Donna Harrison , MD, is a board-certified obstetrician and gynecologist and executive director of the American Association of Prolife Obstetricians and Gynecologists. She has lectured extensively as a continuing medical education speaker in the United States and internationally on topics of medical abortion with Mifepristone and Misoprostol, adverse events associated with Mifepristone and Misoprostol, emergency contraception with Ulipristal, maternal mortality and the association with abortion, and postabortion short- and long-term complications. She is an adjunct professor at Trinity International University in Deerfield, IL, USA.

1. For a discussion of the concept of prudential certitude, see Aquinas, Summa theologiae , I–II, q. 96, a. 1, ad 3; II-II, q. 47, a. 9, ad 2.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Home Essay Examples Health Pregnancy

Case Study: Ectopic Pregnancy

• Category Health
• Subcategory Reproductive Health
• Topic Pregnancy

Introduction

Ectopic pregnancy (EP) is defined as the implantation of a conceptus outside of the uterine endometrium (1). Major risk factors include history of pelvic inflammatory disease, tubal ligation and smoking as well as other factors age and intrauterine device usage (2). In New South Wales (NSW) the incidence of EP was found to be relatively common, at 16.2 per 1000 live births in a 1998 analysis of the NSW Department Inpatient Statistics Collection (3). Consequences of delayed diagnosis and rupture of EP includes haemorrhage, shock and death. Hence, timely diagnosis and management of EP is necessary for good outcomes. Although maternal mortality is uncommon as a consequence of EPs in high-income countries, there remains significant morbidity relating to pain, transfusion and operative complications (1). The following case discusses a 24-year-old’s presentation, diagnosis and progression of treatment of EP in comparison to clinical practice guidelines and literature.

Mrs. VL, a pregnant 24-year-old at 3 weeks and 6 days gestation presented to Blacktown Hospital Emergency Department (ED) with per vaginal (PV) bleeding and lower abdominal pain. Earlier that day, she had been discharged from Mount Druitt Hospital (MDH) ED with a diagnosis of miscarriage. She received an outpatient transvaginal ultrasound scan (TVUS) prior to coming to Blacktown Hospital ED. Her imaging results showed a right adnexal solid mass.

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The patient complained of a 2-week history of scant PV spotting and a 3-day history of a constant and crampy right iliac fossa (RIF) pain which had worsened that day. The pain radiated down the anterior aspect of her legs. She denied having abdominal symptoms of nausea, vomiting, diarrhoea as well as urinary symptoms of frequency, urgency and dysuria. She was otherwise well with no recent fevers.

This was her first pregnancy (gravida 1 parity 0) and has had outpatient serum -hCG blood tests (1+6 weeks: 205IU/L, 2 weeks: 305IU/L, 3 weeks: 985IU/L). Mrs. VL menstrual history revealed a last menstrual period starting 3 weeks 6 days ago which lasted 7 days. Prior to this, she had regular 28 days menstrual cycles with regular flow (4-5 pads per day) and menses lasting 5 days. She denied intermenstrual bleeding or heavy menstrual bleeding. The patient had no previous sexual activity before marriage with her partner 2 months ago. No forms of contraception had been used and there was no history of sexually transmitted infections. She denied PV discharge or post-coital bleeding. She has not had previous cervical screening tests and her human papillomavirus immunisation status was unknown.

Mrs. VL had no relevant past medical or surgical history and does not take any regular medication. She has a known drug allergy to amoxicillin which results in urticaria. Her family history was unremarkable. She denied smoking and illicit substance use however there was occasional consumption of alcohol.

On general inspection, Mrs. VL appeared alert and comfortable. Her vitals were in the normal ranges and remained stable throughout her admission. On examination, her abdomen was soft with tenderness and guarding in the right lower quadrant. However, there was no rebound tenderness or rigidity. A complete pelvic examination was performed. Speculum examination showed scant dried blood on the pad, a long, closed cervix and scant dark blood in the posterior fornix. No cervical excitation, adnexal tenderness, masses or enlargements were found on bimanual examination.

Mrs. VL was investigated with a urinalysis, full blood count (FBC), group and hold (G+H), C reactive protein, electrolytes, blood sugar level and serum -hCG. Her investigations were unremarkable apart from slight elevations of leukocytes, neutrophils and monocytes. Her blood group was A positive. Her -hCG level was 816IU/L at 3+6weeks, a decrease from 6 days prior. Her outpatient TVUS revealed endometrial thickening at 15mm, intrauterine fluid, right adnexal solid mass separate from the ovary (measuring at 2.7×2.4×3.6cm) and a normal left ovary.

Mrs. VL was admitted with a suspected right-sided EP which was clinically subacute and had not ruptured. This impression was formed based on history, clinical features and investigation results. She was kept nil by mouth (NBM) and intravenous (IV) fluids were administered. Her pain was well controlled by analgesia (regular paracetamol and oxycodone as needed). Conservative, medical and surgical management options were discussed with the patient and family. Prior to discharge, serum -hCG levels were repeated and follow-up in the outpatient Early Pregnancy Assessment Clinic (EPAC) was organised. She was to return for repeat bloods (FBC and -hCG) and further discussion of treatment. The patient was advised to return to ED immediately if there was further PV bleeding or the severity of her pain increased. Upon presenting for EPAC follow-up, the patient chose conservative expectant management and continued to return to EPAC for serial -hCG levels. These levels were found to be decreasing (3 days after discharge: 629IU/L, 6 days after discharge: 287IU/L). This was consistent with a resolving EP.

One and a half weeks after her discharge from Blacktown Hospital, Mrs. VL represented to ED with an acute worsening of the RIF pain. This pain had a pain score of 7/10, radiated to the back and down her legs, and was associated nausea. She had noticed fresh PV bleeding and blood clots of 5cm in diameter on her pad. The patient denied chest pain, dyspnoea, palpitation, pre-syncopal symptoms, visual changes or vomiting. Examination findings were consistent with the previous admission. On a TVUS, no intrauterine gestational sac was visible, and a complex mass was found in the right adnexa. Mrs. VL was consented for diagnostic laparoscopy with or without salpingectomy or dilatation and curettage. Before the operation, blood tests were repeated (-hCG: 174IU/L, G+H, FBC), she was kept NBM, given IV fluids, prophylactic antibiotics and TED stockings. Laparoscopically, an unruptured right tubal EP was visualised and a right salpingectomy was performed. A specimen of the right tube was analysed, and the diagnosis was later confirmed histologically. Post-operatively, the patient recovered well and was discharged 2 days after surgery. Follow-up at the gynaecology clinic 4 weeks later was arranged. During her follow-up consultation, Mrs. VL was advised of the risk of recurrence of EP. Early dating scans as well as preconceptual folic acid were recommended for future pregnancies.

The management of Mrs. VL can be evaluated with a focus on her initial presentation, diagnostic work-up and treatment options. EP commonly presents with abdominal pain and vaginal bleeding between 6 to 10 weeks’ gestation. However, abdominal pain and vaginal bleeding are common symptoms in early pregnancy and atypical presentations are also relatively common (4, 5). Other signs and symptoms include shoulder tip pain, syncope and shock which occur in up to 20% of women and are usually indicative of rupture of EP (4). Delayed or incorrect diagnosis and treatment may result in rupture and ultimately haemorrhage and early pregnancy maternal death (6). Hence clinicians should be suspicious of EP in women of reproductive age who present with abdominal or pelvic symptoms. In the context of a positive -hCG, it is recommended to refer to an early pregnancy assessment service (EPAS), as per National Institute for Health and Clinical Excellence guidelines (7). Due to incomplete documentation prior to discharge from MDH ED, it was unclear how a miscarriage was diagnosed, whether EP was considered and if a referral to an EPAS was made.

The recommended initial investigation on suspicion of miscarriage or EP is TVUS (8). The use of TVUS has been supported by previous studies reporting up to a 73.9% rate of visualising EPs in a single scan. However, this is complicated by EPs which may be too small to visualise if scanned early during pregnancy (9, 10). If imaging results are found to be indeterminant, serial quantitative serum -hCG is advised (8). The combined use of TVUS and serial quantitative serum -hCG for the diagnosis of EP have been found to be approximately 96 percent sensitive and 97 percent specific (11). A TVUS referral was appropriately arranged to be performed at an outpatient imaging clinic to identify location of implantation, products of conception and pelvic organ structure. However, serum -hCG levels were below the discriminatory zone of 1000-1500IU/L and hence the diagnosis of pregnancy of unknown location was made (1). Upon presentation to Blacktown Hospital ED, Mrs. VL was appropriately worked up with a suspicion of right tubal EP based on her symptoms and ultrasonographic findings.

Serial quantitative serum -hCG is frequently used to monitor the progression of foetal development and viability. An increase of 66% over 48 hours is commonly used as a threshold for normal development (12). In EP, -hCG may demonstrate atypical trends of falling, rising or plateauing. Due to this variability, -hCG is useful for confirming foetal viability but does not rule out EP (13, 14). Hence it should be interpreted in the context of clinical and sonographic findings (13). Mrs. VL’s decreasing -hCG and haemodynamic stability is commonly associated with a resolving EP (15). Other investigations including serum progesterone levels and diagnostic laparoscopy may be performed. Previous reports have suggested that serum progesterone value may be a useful predictive biomarker in ectopic pregnancies however this is not concordant with the NICE 2012 guidelines and was hence appropriately not performed (1, 12, 16). Diagnostic laparoscopy is ‘gold standard’ and may be indicated when ultrasound is inconclusive (12). Additionally, diagnostic laparoscopy is frequently done in conjunction with laparoscopic surgical management. However, Mrs. VL’s clinical impression of ectopic pregnancy was quite definitive and did not require further invasive diagnostic investigation or management.

EP has 3 main forms of treatment – expectant, medical and surgical. Expectant management involves the spontaneous resolution of EP through regression or tubal abortion. It is offered only when TVUS fails to show the location of the gestational sac and serum levels of -hCG are low and declining (12). Expectant management is an option for clinically stable asymptomatic women with an ultrasound diagnosis of EP and a decreasing serum hCG initially less than 1000IU/L (7). Fertility outcomes following expectant management are comparable to those following surgical intervention (17). Medical therapy involves systemic methotrexate offered to patients with no significant pain, hemodynamically stable, adnexal mass of less than 35mm, no intrauterine pregnancy or serum -hCG less than 5000IU/L (8, 12). When administered to appropriate patients, there is a success rate of 94% (18). Surgical management in the form of salpingectomy or salpingotomy is also offered to these patients who are suitable for medical management if serum -hCG is greater than 1500IU/L. Surgical management can be offered as first-line treatment when there is significant pain, haemodynamically unstable, adnexal mass greater than 35mm, fetal heartbeat visible on ultrasound scan or -hCG greater than 5000IU/L (NICE guidelines). On initial presentation to Blacktown Hospital ED, Mrs. VL was mildly symptomatic. However, she was clinically stable, and the pain was well controlled. Additionally, her serum -hCG was less than 1000IU/L and decreasing. Hence it was appropriate for both expectant and medical management to be offered. Falling -hCG levels is usually an indication for less invasive therapy but rupture of EP may still occur (19, 20). Therefore, as the patient had requested for expectant management, regular outpatient follow-up with continued serial -hCG every 2 days was appropriate to monitor her progress.

Upon representing to Blacktown Hospital ED with significant pain, Mrs. VL was consented and prepared for surgery. This was concordant with the NICE guidelines’ indications for surgical intervention (7). A laparoscopy salpingectomy, which involves the removal of the ipsilateral fallopian tube, was performed. This procedure is often compared to the more conservative procedure, salpingostomy, which allows for the preservation of the fallopian tube. Despite Mrs. VL’s loss of a fallopian tube, compared to a salpingostomy, there is no significant difference in impact on future fertility as she has a healthy unaffected contralateral tube (21, 22). Additionally, salpingostomies are associated with a small increase in risk of persistent trophoblasts and reoccurrence of EP (23). Hence, Mrs. VL’s salpingectomy is appropriate given she has a healthy contralateral fallopian tube with no known risk factors of EP. The laparoscopic approach that was performed was appropriate given the shorter operation times, improved haemorrhage control and increased safety compared to a laparotomy (24, 25). There is also no associated difference in reproductive outcome after treatment of EP by laparoscopy or laparotomy (18).

Ectopic pregnancy is a common cause of early pregnancy bleeding. It has good outcomes when managed appropriately however late diagnosis or inadequate treatment can result in a rupture of ectopic pregnancy. This is a medical emergency which can result in maternal morbidity and mortality. Hence, immediate investigation with transvaginal ultrasound and serial quantitative -hCG as well as appropriate selection of management options, including expectant, medical or surgical, is recommended.

• Kumar V, Gupta J. Tubal ectopic pregnancy. BMJ Clin Evid. 2015;2015.
• Bouyer J. [Epidemiology of ectopic pregnancy: incidence, risk factors and outcomes]. J Gynecol Obstet Biol Reprod (Paris). 2003;32(7 Suppl):S8-17.
• Boufous S, Quartararo M, Mohsin M, Parker J. Trends in the incidence of ectopic pregnancy in New South Wales between 1990-1998. Aust N Z J Obstet Gynaecol. 2001;41(4):436-8.
• Sivalingam VN, Duncan WC, Kirk E, Shephard LA, Horne AW. Diagnosis and management of ectopic pregnancy. J Fam Plann Reprod Health Care. 2011;37(4):231-40.
• Weckstein LN, Boucher AR, Tucker H, Gibson D, Rettenmaier MA. Accurate diagnosis of early ectopic pregnancy. Obstet Gynecol. 1985;65(3):393-7.
• Ankum WM, Mol BW, Van der Veen F, Bossuyt PM. Risk factors for ectopic pregnancy: a meta-analysis. Fertil Steril. 1996;65(6):1093-9.
• National Institute for Health and Care Excellence. Diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage [Internet]. [London]: NICE; 2012 [cited 2019 July 20]. (Clinical guideline [CG154]). Available from: https://www.nice.org.uk/guidance/cg154
• Kaplan BC, Dart RG, Moskos M, Kuligowska E, Chun B, Adel Hamid M, et al. Ectopic pregnancy: prospective study with improved diagnostic accuracy. Ann Emerg Med. 1996;28(1):10-7.
• Kirk E, Papageorghiou AT, Condous G, Tan L, Bora S, Bourne T. The diagnostic effectiveness of an initial transvaginal scan in detecting ectopic pregnancy. Hum Reprod. 2007;22(11):2824-8.
• Kirk E, Daemen A, Papageorghiou AT, Bottomley C, Condous G, De Moor B, et al. Why are some ectopic pregnancies characterized as pregnancies of unknown location at the initial transvaginal ultrasound examination? Acta Obstet Gynecol Scand. 2008;87(11):1150-4.
• Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2005;72(9):1707-14.
• Murray H, Baakdah H, Bardell T, Tulandi T. Diagnosis and treatment of ectopic pregnancy. CMAJ. 2005;173(8):905-12.
• Surampudi K, Gundabattula SR. The Role of Serum Beta hCG in Early Diagnosis and Management Strategy of Ectopic Pregnancy. J Clin Diagn Res. 2016;10(7):QC08-10.
• Silva C, Sammel MD, Zhou L, Gracia C, Hummel AC, Barnhart K. Human chorionic gonadotropin profile for women with ectopic pregnancy. Obstet Gynecol. 2006;107(3):605-10.
• Ankum WM, Van der Veen F, Hamerlynck JV, Lammes FB. Suspected ectopic pregnancy. What to do when human chorionic gonadotropin levels are below the discriminatory zone. J Reprod Med. 1995;40(7):525-8.
• Matthews CP, Coulson PB, Wild RA. Serum progesterone levels as an aid in the diagnosis of ectopic pregnancy. Obstet Gynecol. 1986;68(3):390-4.
• Helmy S, Sawyer E, Ofili-Yebovi D, Yazbek J, Ben Nagi J, Jurkovic D. Fertility outcomes following expectant management of tubal ectopic pregnancy. Ultrasound Obstet Gynecol. 2007;30(7):988-93.
• Yao M, Tulandi T. Current status of surgical and nonsurgical management of ectopic pregnancy. Fertil Steril. 1997;67(3):421-33.
• Irvine LM. Ruptured ectopic pregnancy after a decline in chorionic gonadotropin. J R Soc Med. 2006;99(2):90.
• Tulandi T, Hemmings R, Khalifa F. Rupture of ectopic pregnancy in women with low and declining serum beta-human chorionic gonadotropin concentrations. Fertil Steril. 1991;56(4):786-7.
• Jamard A, Turck M, Pham AD, Dreyfus M, Benoist G. [Fertility and risk of recurrence after surgical treatment of an ectopic pregnancy (EP): Salpingostomy versus salpingectomy]. J Gynecol Obstet Biol Reprod (Paris). 2016;45(2):129-38.
• Mol F, van Mello NM, Strandell A, Strandell K, Jurkovic D, Ross J, et al. Salpingotomy versus salpingectomy in women with tubal pregnancy (ESEP study): an open-label, multicentre, randomised controlled trial. Lancet. 2014;383(9927):1483-9.
• Mol F, Strandell A, Jurkovic D, Yalcinkaya T, Verhoeve HR, Koks CA, et al. The ESEP study: salpingostomy versus salpingectomy for tubal ectopic pregnancy; the impact on future fertility: a randomised controlled trial. BMC Womens Health. 2008;8:11.
• Shrestha J, Saha R. Comparison of laparoscopy and laparotomy in the surgical management of ectopic pregnancy. J Coll Physicians Surg Pak. 2012;22(12):760-4.
• Cohen A, Almog B, Satel A, Lessing JB, Tsafrir Z, Levin I. Laparoscopy versus laparotomy in the management of ectopic pregnancy with massive hemoperitoneum. Int J Gynaecol Obstet. 2013;123(2):139-41.

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• Reproductive Health

An ectopic pregnancy

Updated 08 June 2023

Subject Reproductive Health ,  Experience

Downloads 51

Category Health ,  Life

Topic Pregnancy ,  Problems ,  Abortion

Ectopic Pregnancy

An ectopic pregnancy happens when a fertilized egg remains in a fallopian tube. Because the fallopian tube might become blocked or damaged and hence fail to transport the egg into the womb. As a result, the egg implants and develops in the fallopian tube. However, ectopic pregnancies in the cervix or ovary can occur. It usually occurs during the first few weeks of pregnancy. Doctors typically identify the problem during the eighth week of pregnancy (Tulandi, 2015). The implanted egg has a difficult time surviving an ectopic pregnancy. As a result, it could rupture, resulting in a miscarriage. Moreover, the ectopic pregnancy may continue developing, which pushes away vital organs. Consequently, it causes low back pain, severe pelvic or abdominal pain, abnormal vaginal bleeding, and/or extreme fainting (Tulandi, 2015). It is critical to note that ectopic pregnancy can also cause death (Kumar et al., 2016; Tulandi, 2015).

Misdiagnosis of Ectopic Pregnancy

The frequent misdiagnosis of ectopic pregnancy happens because its symptoms can be nonspecific. For instance, the most common symptom is having abdominal pain. However, there are various possible causes of the abdominal pain. Additionally, women can develop vaginal bleeding that may not be associated with ectopic pregnancy (Tulandi, 2015). There are severe consequences of an ectopic misdiagnosis when receiving treatment. The treatment may involve surgery or administering methotrexate. When a healthy woman receives an ectopic misdiagnosis, it may lead to miscarriage or severe congenital disabilities if the treatment involved administering methotrexate. An ectopic misdiagnosis may also lead to surgery, which enhances complications such as infertility, ongoing pain, bleeding, infection, and scar tissues that impair normal functioning. Therefore, a family nurse practitioner has the responsibility of ensuring that the patients receive the right diagnosis for an ectopic pregnancy before treatment (Tulandi, 2015).

Kumar, S.P., Pratiksha, G., Poonam, G., Alka, S., Anju, H., Kataria, S., & Tandon, R. (2016). Ectopic pregnancy: A diagnostic dilemma. International Journal of Reproduction, Contraception, Obstetrics and Gynecology, 5(2), 367-370.

Tulandi, T. (Ed.). (2015). Ectopic pregnancy: A clinical casebook. Berlin: Springer.

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