Ectopic Pregnancy: Symptoms, Causes, Diagnosis & Treatment Options

In short: An ectopic pregnancy is the implantation of the fertilised egg outside the cavity of the uterus, in the fallopian tube in 95% of cases. The main symptoms are pain on one side of the abdomen, a missed period and slight bleeding. Risk factors include a previous ectopic pregnancy and pelvic infection. It is managed by observation, by the drug methotrexate in suitable cases, or by laparoscopic surgery.

What Is an Ectopic Pregnancy?

An ectopic pregnancy happens when a fertilized egg implants outside the uterus, in a place where it cannot develop safely into a healthy pregnancy.

The most common site is the fallopian tube — known as a tubal pregnancy — which accounts for about 95% of cases.

Less commonly, an ectopic pregnancy can occur in the ovary, in the abdomen (“abdominal pregnancy”), or in the cervix, the lower part of the uterus (“cervical pregnancy”). Ectopic pregnancy affects roughly 1-2% of all pregnancies.

It’s important to know that ectopic pregnancy is a significant cause of maternal health complications in the first trimester, which is why early recognition and prompt care matter so much.

Symptoms of Ectopic Pregnancy

Early on, the symptoms of an ectopic pregnancy can feel just like a normal early pregnancy — headache, nausea, vomiting, and breast tenderness.

However, other signs may also appear, such as:

• Lower abdominal pain, sometimes felt more on one side. Pain is present in about 95% of cases
• Delayed or irregular periods, seen in around 75% of cases
• Light vaginal bleeding or spotting, often brownish in color, caused by shedding of the uterine lining when the pregnancy does not continue normally

If you notice these symptoms, it’s best not to wait — reaching out to your doctor promptly can help ensure timely diagnosis and care.

Causes of Ectopic Pregnancy

• About 50% of women with an ectopic pregnancy have a history of salpingitis or pelvic inflammatory disease (PID). This makes PID — often caused by infections such as gonorrhea, tuberculosis (TB), Chlamydia, or even appendicitis — one of the key contributing factors.

The tiny hair-like cells (cilia) lining the fallopian tube normally help guide the fertilized egg toward the uterus. When these are damaged by inflammation, the risk of ectopic pregnancy increases.

• Previous tubal surgery, such as tubal sterilization, raises the risk of ectopic pregnancy; if a pregnancy happens after sterilization, up to about one in three is ectopic.

Congenital tubal abnormalities, endometriosis, and tubal scarring from a ruptured appendix or previous pelvic surgery can also contribute to ectopic pregnancy.

• Contraceptive methods: including progesterone-only pills and intrauterine devices (copper or hormonal IUDs). While these methods are effective at preventing pregnancy overall, if pregnancy does occur, the relative risk of it being ectopic is higher. Progesterone can slow the natural movement of the tube, making it more likely for the fertilized egg to implant there instead of the uterus.

Risk Factors for Ectopic Pregnancy

Maternal age between 35-40

• A previous ectopic pregnancy: the chance of another ectopic pregnancy is about 10-15%
• Smoking
• Previous salpingitis resulting in tubal damage
• History of infertility
• Previous pelvic surgery, including sterilization
• Races other than white
• IUD (intra-uterine contraceptive device) users
• Exposure to diethylstilboestrol in utero

Complications of Ectopic Pregnancy

• Rupture of the ectopic pregnancy, leading to internal bleeding and shock — this is the most serious and common complication
• Infertility: reported in about 10-15% of women with a history of ectopic pregnancy

Can Ectopic Pregnancy Be Prevented?

Ectopic pregnancy cannot always be prevented, but there are meaningful steps that can help lower the risk of PID, which is closely linked to ectopic pregnancy:

• Avoiding multiple sexual partners
• Using condoms during intercourse when either partner has a sexually transmitted infection (STI)
• Seeking early diagnosis and proper treatment for STIs
• Seeking early diagnosis and treatment for PID

How Is Ectopic Pregnancy Diagnosed?

• Vaginal examination: may reveal tenderness in the uterus or adjacent area.
• Blood test: measures the pregnancy hormone (hCG). If hormone levels don’t rise as expected for that stage of pregnancy, an ectopic pregnancy may be suspected, and testing is usually repeated every few days.
• Ultrasound: transvaginal ultrasound is the main test and can detect most tubal pregnancies as a small mass next to the ovary, sometimes with an embryo inside. In many cases, however, the pregnancy stops developing early and is too small to be seen. Ultrasound can still reveal related signs, such as blood clots or remaining tissue. These tools have greatly reduced the need for laparoscopy, though this surgical procedure may still be used as a final diagnostic step when results remain unclear.

If hCG levels are above 1,500 IU/L and no pregnancy sac is seen inside the uterus on a vaginal scan, an ectopic pregnancy becomes more likely; the diagnosis is usually made by combining the scan with hCG tests repeated 48 hours apart.

• Culdocentesis (largely historical): a less commonly used test to check for internal bleeding; it is not reliable for detecting an early ectopic pregnancy.

Intact tubal pregnancy

Treatment of Ectopic Pregnancy

Conservative Management

When an ectopic pregnancy is very small — too small to detect on ultrasound — and hCG levels are very low, your doctor may recommend close monitoring.

In some cases, the pregnancy resolves on its own through a natural miscarriage via the fallopian tube, without needing medical or surgical treatment.

Medical Treatment

Medical treatment can be effective for many patients when started early.

For women without a prior history of infertility, later conception is possible for the majority of patients, and only a small proportion may experience another ectopic pregnancy.

This approach is generally gentler than surgery. It’s used when the embryo is still small and hCG levels are not too high, involving an injection of the medication methotrexate, with the dose calculated from body surface area (based on height and weight). The medication works by stopping the growth of the embryo and placental cells through the bloodstream. Over time, the body naturally reabsorbs the tissue.

Follow-up blood tests to track hCG levels are needed to confirm the pregnancy has fully resolved.

Methotrexate may cause some side effects, including:

• Abdominal pain or cramps
• Nausea and vomiting
• Diarrhea

Note:

During treatment, it’s important to avoid alcohol and multivitamins containing folic acid, as certain substances can interfere with how methotrexate works.

• Paracetamol may be used for pain relief if needed.
• It’s generally advised to use contraception for 3-6 months after methotrexate treatment.

Surgical Treatment of Ectopic Pregnancy

Laparoscopic Removal of Ectopic Pregnancy

• This is the most common surgical approach for stable patients in non-emergency situations.
• It is minimally invasive and typically requires only a short hospital stay, with about one week needed for recovery afterward.
• Laparoscopic treatment offers several benefits: shorter surgery time, lower hospital costs, quicker return to daily activities, and better cosmetic results.

Surgical Laparotomy to Remove Ectopic Pregnancy

• This is used when the embryo has grown larger or when rupture has already occurred with significant internal bleeding, requiring urgent surgical care. Recovery after this operation typically takes about six weeks.
• The surgery removes the pregnancy tissue; the fallopian tube may sometimes be preserved or may need to be removed, depending on the extent of damage. If the other tube looks healthy, removing the affected tube (salpingectomy) is usually preferred. Women with a Rh-negative blood group who have surgery are given an anti-D injection.

If you have concerns about ectopic pregnancy symptoms or risk factors, the team at Dr. Najeeb Layyous’s clinic is here to offer guidance, evaluation, and supportive, individualized care.

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist