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For further information, see CMDT Part 19-10: Ectopic Pregnancy

Key Features

Essentials of Diagnosis

  • Amenorrhea or irregular bleeding and spotting

    • Pelvic pain, usually adnexal

    • Adnexal mass by clinical examination or ultrasound

    • Failure of serum beta-human chorionic gonadotropin (β-hCG) to double every 48 hours

  • No intrauterine pregnancy on transvaginal ultrasound with serum β-hCG > 2000 mU/mL

General Considerations

  • Occurs in approximately 2% of first-trimester pregnancies; about 98% of cases being tubal pregnancies

  • Implantation may also occur in the peritoneum or abdominal viscera, the ovary, and the cervix

  • Undiagnosed or undetected ectopic pregnancy is one of the most common causes of first-trimester maternal death in the United States


  • Conditions that prevent or inhibit migration of the fertilized ovum to the uterus can predispose to ectopic implantation

  • Specific risk factors

    • History of infertility

    • Pelvic inflammatory disease

    • Ruptured appendix

    • Prior tubal surgery

Clinical Findings

Symptoms and Signs

  • Lower quadrant pain that is sudden, stabbing, intermittent, and does not radiate

  • Backache may be present during attacks

  • Shock in about 10%, often after pelvic examination

  • At least two-thirds of patients give a history of abnormal menstruation; many have been infertile

  • Blood may leak from the tubal ampulla over days

  • Persistent vaginal spotting is usually reported

  • A pelvic mass may be palpable

  • Abdominal distention and mild paralytic ileus are often present

Differential Diagnosis

  • Acute appendicitis

  • Intrauterine pregnancy (threatened abortion)

  • Pelvic inflammatory disease

  • Ruptured corpus luteum cyst or ovarian follicle

  • Urinary calculi

  • Tubo-ovarian abscess

  • Gestational trophoblastic neoplasia, eg, hydatidiform mole

  • Shock or sepsis due to other causes


Laboratory Tests

  • Complete blood count may show anemia and slight leukocytosis

  • Serum β-hCG levels are lower than expected for a normal pregnancy of the same gestational age

  • Serum β-hCG levels may rise slowly or plateau rather than double every 48 hours as in viable early pregnancy or fall as in spontaneous pregnancy loss

Imaging Studies

  • Transvaginal ultrasound

    • May occasionally identify the ectopic pregnancy

    • A β-hCG level of ≥ 2000 mU/mL can indicate an ectopic pregnancy if no products of conception are detected within the uterine cavity

  • Transabdominal ultrasound

    • A β-hCG level of 6500 mU/mL with an empty uterine cavity is highly suspicious

Diagnostic Procedures

  • Diagnosis should be suspected when postabortal tissue examination fails to reveal chorionic villi

  • Steps must be taken for immediate diagnosis, including prompt microscopic tissue examination, ultrasonography, and serial β-hCG titers every 48 hours



  • Intramuscular methotrexate (50 mg/m2)

    • Acceptable for early ectopic pregnancies < 3.5 cm and unruptured, ...

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