presentation on ectopic pregnancy

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Ectopic pregnancy

• Overview  
• Theory  
• Diagnosis  
• Management  
• Follow up  
• Resources  

Ectopic pregnancy typically presents 6 to 8 weeks after the last normal menstrual period, but can present earlier or later.

Risk of ectopic pregnancy increases with prior ectopic pregnancy, tubal surgery, history of sexually transmitted infections, smoking, in vitro fertilisation, or if the woman is pregnant despite IUD usage.

Classical symptoms and signs of ectopic pregnancy are pain, vaginal bleeding, and amenorrhoea. Haemodynamic instability and cervical motion tenderness may indicate rupture or imminent rupture of an ectopic pregnancy.

If the woman is haemodynamically stable, transvaginal ultrasound is the initial test of choice.

Treatment approaches for ectopic pregnancy include expectant, medical (methotrexate), or surgical (salpingectomy, salpingostomy).

If an ectopic pregnancy ruptures, the woman may present in shock from blood loss and with unusual patterns of referred pain from intraperitoneal blood.

An ectopic pregnancy occurs when a fertilised ovum implants and matures outside the uterine endometrial cavity, with the most common site being the fallopian tube (97%), followed by the ovary (3.2%) and the abdomen (1.3%). [1] Bouyer J, Coste J, Fernandez H, et al. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod. 2002 Dec;17(12):3224-30. https://academic.oup.com/humrep/article/17/12/3224/569616 http://www.ncbi.nlm.nih.gov/pubmed/12456628?tool=bestpractice.com If undiagnosed or untreated, it may lead to maternal death due to rupture of the implantation site and intraperitoneal haemorrhage. [2] Ankum WM, Mol BW, Van Der Veen F, et al. Risk factors for ectopic pregnancy: a meta-analysis. Fertil Steril. 1996 Jun;65(6):1093-9. http://www.ncbi.nlm.nih.gov/pubmed/8641479?tool=bestpractice.com

History and exam

Key diagnostic factors.

• abdominal pain
• amenorrhoea
• vaginal bleeding
• abdominal tenderness
• adnexal tenderness or mass
• blood in vaginal vault
• haemodynamic instability, orthostatic hypotension
• cervical motion tenderness

Other diagnostic factors

• urge to defecate
• referred shoulder pain

Risk factors

• previous ectopic pregnancy
• previous tubal sterilisation surgery
• in utero diethylstilbestrol exposure of the mother
• intrauterine device (IUD) use
• previous genital infections
• chronic salpingitis
• salpingitis isthmica nodosa
• infertility
• multiple sexual partners
• race/ethnicity
• assisted reproductive technology (ART)
• first sexual encounter <18 years
• maternal age >35 years
• tubal reconstruction surgery

Diagnostic investigations

1st investigations to order.

• urine or serum pregnancy test
• high resolution transvaginal ultrasound (TVUS)
• transabdominal ultrasound

Investigations to consider

• serial serum human chorionic gonadotrophin (hCG)
• uterine aspiration

Treatment algorithm

Tubal ectopic pregnancy: ruptured ectopic pregnancy or failed medical management, tubal ectopic pregnancy: moderate risk or failed expectant management, tubal ectopic pregnancy: low risk, contributors, kurt t. barnhart, md, msce.

William Shippen Jr. Professor of Obstetrics and Gynecology and Epidemiology

Vice Chair for Clinical Research

Director, Women's Health Clinic Research Center

The Perelman School of Medicine

University of Pennsylvania

Associate Chief, Penn Fertility Care

Philadelphia

Disclosures

KTB is a co-author on several papers cited in this topic.

Acknowledgements

Dr Kurt T. Barnhart would like to gratefully acknowledge Dr Ingrid Granne, Dr Veronica Gomez-Lobo, Dr Sina Haeri, and Dr Mohammad Ezzati, previous contributors to this topic.

IG, VGL, SH, and ME declare that they have no competing interests.

Peer reviewers

Alan decherney, md.

Reproductive Biology Medicine and Biology

AD declares that he has no competing interests.

Joanna C. Girling, MA, MRCP, FRCOG

Consultant in Obstetrics and Gynaecology

West Middlesex University Hospital

JCG declares that she has no competing interests.

Differentials

• Miscarriage
• Acute appendicitis
• Ovarian torsion
• Ectopic pregnancy and miscarriage: diagnosis and initial management
• ACR appropriateness criteria: acute pelvic pain in the reproductive age group

Patient information

Ectopic pregnancy: what is it?

Ectopic pregnancy: what treatments work?

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Ectopic Pregnancy

• Author: Vicken P Sepilian, MD, MSc; Chief Editor: Michel E Rivlin, MD  more...
• Sections Ectopic Pregnancy
• Practice Essentials
• Epidemiology
• Patient Education
• Physical Examination
• Approach Considerations
• Beta–Human Chorionic Gonadotropin Levels
• Progesterone Levels
• Other Markers
• Ultrasonography
• Dilatation and Curettage
• Culdocentesis
• Laparoscopy
• Expectant Management
• Methotrexate Therapy
• Methotrexate Treatment Protocols
• Investigational Medical Treatments
• Salpingostomy and Salpingectomy
• Medication Summary
• Antineoplastics, Antimetabolite
• Vasopressors
• Media Gallery

Ectopic pregnancy is the result of a flaw in human reproductive physiology that allows the conceptus to implant and mature outside the endometrial cavity (see the image below), which ultimately ends in the death of the fetus. Without timely diagnosis and treatment, ectopic pregnancy can become a life-threatening situation. [ 1 ]

Signs and symptoms

The classic clinical triad of ectopic pregnancy is as follows:

Abdominal pain

Vaginal bleeding

Unfortunately, only about 50% of patients present with all 3 symptoms.

Patients may present with other symptoms common to early pregnancy (eg, nausea, breast fullness). The following symptoms have also been reported:

Painful fetal movements (in the case of advanced abdominal pregnancy)

Dizziness or weakness

Flulike symptoms

Cardiac arrest

The presence of the following signs suggests a surgical emergency:

Abdominal rigidity

Involuntary guarding

Severe tenderness

Evidence of hypovolemic shock (eg, orthostatic blood pressure changes, tachycardia)

Findings on pelvic examination may include the following:

The uterus may be slightly enlarged and soft

Uterine or cervical motion tenderness may suggest peritoneal inflammation

An adnexal mass may be palpated but is usually difficult to differentiate from the ipsilateral ovary

Uterine contents may be present in the vagina, due to shedding of endometrial lining stimulated by an ectopic pregnancy

See Clinical Presentation for more detail.

Serum β-HCG levels

In a normal pregnancy, the β-HCG level doubles every 48-72 hours until it reaches 10,000-20,000mIU/mL. In ectopic pregnancies, β-HCG levels usually increase less. Mean serum β-HCG levels are lower in ectopic pregnancies than in healthy pregnancies.

No single serum β-HCG level is diagnostic of an ectopic pregnancy. Serial serum β-HCG levels are necessary to differentiate between normal and abnormal pregnancies and to monitor resolution of ectopic pregnancy once therapy has been initiated.

The discriminatory zone of β-HCG (ie, the level above which an imaging scan should reliably visualize a gestational sac within the uterus in a normal intrauterine pregnancy) is as follows:

1500-1800 mIU/mL with transvaginal ultrasonography, but up to 2300 mIU/mL with multiple gestates [ 2 ]

6000-6500 mIU/mL with abdominal ultrasonography

Absence of an intrauterine pregnancy on a scan when the β-HCG level is above the discriminatory zone represents an ectopic pregnancy or a recent abortion.

Ultrasonography is probably the most important tool for diagnosing an extrauterine pregnancy.

Visualization of an intrauterine sac, with or without fetal cardiac activity, is often adequate to exclude ectopic pregnancy. [ 3 ]

Transvaginal ultrasonography, or endovaginal ultrasonography, can be used to visualize an intrauterine pregnancy by 24 days post ovulation or 38 days after the last menstrual period (about 1 week earlier than transabdominal ultrasonography). An empty uterus on endovaginal ultrasonographic images in patients with a serum β-HCG level greater than the discriminatory cut-off value is an ectopic pregnancy until proved otherwise.

Color-flow Doppler ultrasonography improves the diagnostic sensitivity and specificity of transvaginal ultrasonography, especially in cases in which a gestational sac is questionable or absent.

Laparoscopy remains the criterion standard for diagnosis; however, its routine use on all patients suspected of ectopic pregnancy may lead to unnecessary risks, morbidity, and costs. Moreover, laparoscopy can miss up to 4% of early ectopic pregnancies.

Laparoscopy is indicated for patients who are in pain or hemodynamically unstable.

See Workup for more detail.

Therapeutic options in ectopic pregnancy are as follows:

Expectant management

Methotrexate

Candidates for successful expectant management should be asymptomatic and have no evidence of rupture or hemodynamic instability. Candidates should demonstrate objective evidence of resolution (eg, declining β-HCG levels).

Close follow-up and patient compliance are of paramount importance, as tubal rupture may occur despite low and declining serum levels of β-HCG.

Methotrexate is the standard medical treatment for unruptured ectopic pregnancy. A single-dose IM injection is the more popular regimen. The ideal candidate should have the following:

Hemodynamic stability

No severe or persisting abdominal pain

The ability to follow up multiple times

Normal baseline liver and renal function test results

Absolute contraindications to methotrexate therapy include the following:

Existence of an intrauterine pregnancy

Immunodeficiency

Moderate to severe anemia, leukopenia, or thrombocytopenia

Sensitivity to methotrexate

Active pulmonary or peptic ulcer disease

Clinically important hepatic or renal dysfunction

Breastfeeding

Evidence of tubal rupture

Surgical treatment

Laparoscopy has become the recommended surgical approach in most cases. Laparotomy is usually reserved for patients who are hemodynamically unstable or for patients with cornual ectopic pregnancies; it also is a preferred method for surgeons inexperienced in laparoscopy and in patients in whom a laparoscopic approach is difficult.

See Treatment and Medication for more detail.

Ectopic pregnancy refers to the implantation of a fertilized egg in a location outside of the uterine cavity, including the fallopian tubes (approximately 97.7%), cervix, ovary, cornual region of the uterus, and abdominal cavity. Of tubal pregnancies, the ampulla is the most common site of implantation (80%), followed by the isthmus (12%), fimbria (5%), cornua (2%), and interstitia (2-3%). (See the image below.)

In ectopic pregnancy (the term ectopic is derived from the Greek word ektopos , meaning out of place), the gestation grows and draws its blood supply from the site of abnormal implantation. As the gestation enlarges, it creates the potential for organ rupture, because only the uterine cavity is designed to expand and accommodate fetal development. Ectopic pregnancy can lead to massive hemorrhage, infertility, or death (see the images below). (See Etiology and Prognosis.)

In 1970, the Centers for Disease Control and Prevention (CDC) began to record statistics regarding ectopic pregnancy, reporting 17,800 cases. By 1992, the number of ectopic pregnancies had increased to 108,800. Concurrently, however, the case-fatality rate decreased from 35.5 deaths per 10,000 cases in 1970 to 2.6 per 10,000 cases in 1992. (See Epidemiology.)

The increased incidence of ectopic pregnancy has been partially attributed to improved ability in making an earlier diagnosis. Ectopic pregnancies that previously would have resulted in tubal abortion or complete, spontaneous reabsorption and remained clinically undiagnosed are now detected. (See Presentation, DDx, and Workup.)

In the 1980s and 1990s, medical therapy for ectopic pregnancy was implemented; it has now replaced surgical therapy in many cases. [ 4 , 5 , 6 ] As the ability to diagnose ectopic pregnancy improves, physicians will be able to intervene sooner, preventing life-threatening sequelae and extensive tubal damage, as well as, it is hoped, preserving future fertility. (See Treatment and Medication.)

Implantation sites

The faulty implantation that occurs in ectopic pregnancy occurs because of a defect in the anatomy or normal function of either the fallopian tube (as can result from surgical or infectious scarring), the ovary (as can occur in women undergoing fertility treatments), or the uterus (as in cases of bicornuate uterus or cesarean delivery scar). Reflecting this, most ectopic pregnancies are located in the fallopian tube; the most common site is the ampullary portion of the tube, where over 80% of ectopic pregnancies occur. (See Etiology.)

Nontubal ectopic pregnancies are a rare occurrence, with abdominal pregnancies accounting for 1.4% of ectopic pregnancies and ovarian and cervical sites accounting for 0.2% each. Some ectopic pregnancies implant in the cervix (< 1%), in previous cesarean delivery scars, [ 7 , 8 ] or in a rudimentary uterine horn; although these may be technically in the uterus, they are not considered normal intrauterine pregnancies. [ 9 ]

About 80% of ectopic pregnancies are found on the same side as the corpus luteum (the old, ruptured follicle), when present. [ 10 ] In the absence of modern prenatal care, abdominal pregnancies can present at an advanced stage (>28 wk) and have the potential for catastrophic rupture and bleeding. [ 11 ]

An ectopic pregnancy requires the occurrence of 2 events: fertilization of the ovum and abnormal implantation. Many risk factors affect both events; for example, a history of major tubal infection decreases fertility and increases abnormal implantation.

Multiple factors contribute to the relative risk of ectopic pregnancy. In theory, anything that hampers or delays the migration of the fertilized ovum (blastocyst) to the endometrial cavity can predispose a woman to ectopic gestation. The following risk factors have been linked to ectopic pregnancy:

Tubal damage - Which can be the result of infections such as pelvic inflammatory disease (PID) or salpingitis (whether documented or not) or can result from abdominal surgery or tubal ligation or from maternal in utero diethylstilbestrol (DES) exposure [ 12 ]

History of previous ectopic pregnancy [ 12 ]

Smoking - A risk factor in about one third of ectopic pregnancies; smoking may contribute to decreased tubal motility by damage to the ciliated cells in the fallopian tubes [ 12 ]

Altered tubal motility - As mentioned, this can result from smoking, but it can also occur as the result of hormonal contraception; progesterone-only contraception and progesterone intrauterine devices (IUDs) have been associated with an increased risk of ectopic pregnancy

History of 2 or more years of infertility (whether treated or not) [ 13 ] - Women using assisted reproduction seem to have a doubled risk of ectopic pregnancy (to 4%), although this is mostly due to the underlying infertility [ 14 ]

History of multiple sexual partners [ 13 ]

Maternal age - Although this is not an independent risk factor [ 13 ]

The most logical explanation for the increasing frequency of ectopic pregnancy is previous pelvic infection; however, most patients presenting with an ectopic pregnancy have no identifiable risk factor. [ 15 ]

A literature review found 56 reported cases of ectopic pregnancy (by definition), dating back to 1937, after hysterectomy. [ 16 ]

Pelvic inflammatory disease

The most common cause of PID is an antecedent infection caused by Chlamydia trachomatis. Patients with chlamydial infection have a range of clinical presentations, from asymptomatic cervicitis to salpingitis and florid PID. More than 50% of women who have been infected are unaware of the exposure.

Other organisms that cause PID, such as Neisseria gonorrhoeae , also increase the risk of ectopic pregnancy, and a history of salpingitis increases the risk of ectopic pregnancy 4-fold. The incidence of tubal damage increases after successive episodes of PID (ie, 13% after 1 episode, 35% after 2 episodes, 75% after 3 episodes).

Effective vaccination against Chlamydia trachomatis is under investigation. Once clinically available, it should have a dramatic impact on the frequency of ectopic pregnancy, as well as on the overall health of the female reproductive system.

History of previous ectopic pregnancy

After 1 ectopic pregnancy, a patient incurs a 7- to 13-fold increase in the likelihood of another ectopic pregnancy. Overall, a patient with a previous ectopic pregnancy has a 50-80% chance of having a subsequent intrauterine gestation and a 10-25% chance of a future tubal pregnancy.

History of tubal surgery and conception after tubal ligation

Previous tubal surgery has been demonstrated to increase the risk of developing ectopic pregnancy. The increase depends on the degree of damage and the extent of anatomic alteration. Surgeries carrying higher risk of subsequent ectopic pregnancy include salpingostomy , neosalpingostomy, fimbrioplasty, tubal reanastomosis, and lysis of peritubal or periovarian adhesions.

Conception after previous tubal ligation also increases a women's risk of having an ectopic pregnancy; 35-50% of patients who conceive after a tubal ligation are reported to experience an ectopic pregnancy. Failure after bipolar tubal cautery is more likely to result in ectopic pregnancy than is occlusion using suture, rings, or clips. This failure is attributed to fistula formation that allows sperm passage. In one study, 33% of pregnancies occurring after tubal ligation were ectopic; those who underwent electrocautery and women younger than 35 years were at higher risk. [ 17 ]

Ectopic pregnancies following tubal sterilizations usually occur 2 or more years after sterilization rather than immediately after. In the first year, only about 6% of sterilization failures result in ectopic pregnancy.

Cigarette smoking has been shown to be a risk factor for ectopic pregnancy development. Studies have demonstrated an elevated risk ranging from 1.6 to 3.5 times that of nonsmokers. A dose-response effect has also been suggested.

Based on laboratory studies in humans and animals, researchers have postulated several mechanisms by which cigarette smoking might play a role in ectopic pregnancies. These mechanisms include one or more of the following: delayed ovulation, altered tubal and uterine motility, and altered immunity. To date, however, no study has supported a specific mechanism by which cigarette smoking affects the occurrence of ectopic pregnancy.

Use of oral contraceptives or an intrauterine device

All contraceptive methods lead to an overall lower risk of pregnancy and therefore to an overall lower risk of ectopic pregnancy. However, among cases of contraceptive failure, women at increased risk of ectopic pregnancy compared with pregnant controls included those using progestin-only oral contraceptives, progestin-only implants, or IUDs and those with a history of tubal ligation. [ 18 ]

The presence of an inert, copper-containing or progesterone IUD traditionally has been thought to be a risk factor for ectopic pregnancy. Data from the Contraceptive CHOICE Project demonstrated a relative risk of 3.16 for ectopic pregnancy in women not using any form of contraception as compared with women using the progesterone IUD. [ 19 ] Nevertheless, if a woman ultimately conceives with an IUD in place, it is more likely to be an ectopic pregnancy. [ 20 ] The incidence of ectopic pregnancy in IUD users is 1 in 1000 over a 5-year period. [ 19 ]

Emergency contraception (levonorgestrel, or Plan B) does not appear to lead to a higher-than-expected rate of ectopic pregnancy. [ 21 ]

Use of fertility drugs or assisted reproductive technology

Ovulation induction with clomiphene citrate or injectable gonadotropin therapy has been linked to a 4-fold increase in the risk of ectopic pregnancy in a case-control study. This finding suggests that multiple eggs and high hormone levels may be significant factors.

One study demonstrated that infertility patients with luteal phase defects have a statistically higher ectopic pregnancy rate than do patients whose infertility is caused by anovulation. In addition, the risk of ectopic pregnancy and heterotopic pregnancy (ie, pregnancies occurring simultaneously in different body sites) dramatically increases when a patient has used assisted reproductive techniques—such as  in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT)—to conceive. [ 22 ]

In a study of 3000 clinical pregnancies achieved through in vitro fertilization, the ectopic pregnancy rate was 4.5%, which is more than double the background incidence. Furthermore, studies have demonstrated that up to 1% of pregnancies achieved through IVF or GIFT can result in a heterotopic gestation, compared with an incidence of 1 in 30,000 pregnancies for spontaneous conceptions. [ 23 ]

In a retrospective (2006-2014) cohort study of 8120 assisted reproduction technology cycles, Rombauts et al found that endometrial combined thickness (ECT) measured prior to embryo transfer was associated with ectopic pregnancy. [ 24 ] The investigators reported that, following IVF, there was a 4-fold increased risk of ectopic pregnancy in women with an ECT of up to 9 mm compared with women with an ECT of  at least 12 mm. They noted that increased ECT is a marker for increased fundus-to-cervix uterine peristalsis, which may be a reason for the increased risk for placenta praevia but a decreased risk for ectopic pregnancy. [ 24 ]

Increasing age

The highest rate of ectopic pregnancy occurs in women aged 35-44 years. A 3- to 4-fold increase in the risk of developing an ectopic pregnancy exists compared with women aged 15-24 years. One proposed explanation suggests that aging may result in a progressive loss of myoelectrical activity in the fallopian tube; myoelectrical activity is responsible for tubal motility.

Salpingitis isthmica nodosum

Salpingitis isthmica nodosum is defined as the microscopic presence of tubal epithelium in the myosalpinx or beneath the tubal serosa. These pockets of epithelium protrude through the tube, similar to small diverticula. Studies of serial histopathologic sections of the fallopian tube have revealed that approximately 50% of patients treated with salpingectomy for ectopic pregnancy have evidence of salpingitis isthmica nodosum. The etiology of salpingitis isthmica nodosum is unclear, but proposed mechanisms include postinflammatory and congenital changes, as well as acquired tubal changes, such as those observed with endometriosis. [ 25 ]

DES exposure

Before 1971, several million women were exposed in utero to DES, which was given to their mothers to prevent pregnancy complications. In utero exposure of women to DES is associated with a high lifetime risk of a broad spectrum of adverse health outcomes, including infertility, spontaneous abortion, and ectopic pregnancy. [ 26 ]

Other risk factors associated with increased incidence of ectopic pregnancy include anatomic abnormalities of the uterus such as a T-shaped or bicornuate uterus, fibroids or other uterine tumors, previous abdominal surgery, failure with progestin-only contraception, and ruptured appendix. [ 15 ]

United States statistics

The incidence of ectopic pregnancy is reported most commonly as the number of ectopic pregnancies per 1000 conceptions. Since 1970, when the reported rate in the United States was 4.5 cases per 1000 pregnancies, the frequency of ectopic pregnancy has increased 6-fold, with ectopic pregnancies now accounting for approximately 1-2% of all pregnancies. Consequently, the prevalence is estimated at 1 in 40 pregnancies, or approximately 25 cases per 1000 pregnancies. These statistics are based on data from the US Centers for Disease Control and Prevention (CDC), which used hospitalizations for ectopic pregnancy to determine the total number of ectopic pregnancies.

Looking at raw data, 17,800 hospitalizations for ectopic pregnancies were reported in 1970. This number rose to 88,000 in 1989 [ 27 ] but fell to 30,000 in 1998. An estimated 108,800 ectopic pregnancies in 1992 resulted in 58,200 hospitalizations, with an estimated cost of $1.1 billion.

Changes in the management of ectopic pregnancy, however, have made it difficult to reliably monitor incidence (and therefore mortality rates). [ 28 ] A review of hospital discharges in California found a rate of 15 cases per 1000 in 1991, declining to a rate of 9.3 cases per 1,000 in 2000, [ 29 ] but a review of electronic medical records (inpatient and outpatient) from a large health maintenance organization (HMO) in northern California found a stable rate of 20.7 cases per 1,000 reported pregnancies from 1997-2000. [ 30 ] This suggests that the incidence of ectopic pregnancy in the United States remained steady at about 2% in the 1990s, despite the shift to outpatient treatment.

The above data raise the question of whether the number of ectopic pregnancies is declining or whether many ectopic pregnancies are now being treated in ambulatory surgical centers or are even being addressed with medical therapy, without admission. Some authors believe the latter is true, but truly accurate statistics are lacking.

Diagnoses of ectopic pregnancy in US emergency departments (ED) may be on the rise. From 2006 to 2013, the overall ratio of ED visits with an ectopic pregnancy diagnosis increased from 11.0 per 1000 live births to 13.7 per 1000 live births. [ 31 ]

Approximately 85-90% of ectopic pregnancies occur in multigravid women. In the United States, rates are nearly twice as high for women of other races compared with White women.

International statistics

The increase in incidence of ectopic pregnancy in the 1970s in the United States was also mirrored in Africa, although data there tend to be hospital based rather than derived from nationwide surveys, with estimates in the range of 1.1-4.6%. [ 32 ]

The United Kingdom estimated the incidence of ectopic pregnancy at about 11.1 per 1,000 reported pregnancies from 1997 to 2005, compared with 9.6 per 1,000 from 1991 to 1993. [ 33 ]

Racial- and age-related demographics

In the United States from 1991 to 1999, ectopic pregnancy was the cause of 8% of all pregnancy-related deaths among Black women, compared with 4% among White women. [ 34 ]

Any woman with functioning ovaries can potentially have an ectopic pregnancy, which includes women from the age of menarche until menopause. Women older than 40 years were found to have an adjusted odds ratio of 2.9 for ectopic pregnancy. [ 15 ]

Ectopic pregnancy presents a major health problem for women of childbearing age. It is the result of a flaw in human reproductive physiology that allows the conceptus to implant and mature outside the endometrial cavity, which ultimately ends in the death of the fetus. Without timely diagnosis and treatment, ectopic pregnancy can become a life-threatening situation. [ 1 ]

The evidence in the literature reporting on the treatment of ectopic pregnancy with subsequent reproductive outcome is limited mostly to observational data and a few randomized trials comparing treatment options.

Assessment of successful treatment and future reproductive outcome with various treatment options is often skewed by selection bias. For example, comparing a patient who was managed expectantly with a patient who received methotrexate or with a patient who had a laparoscopic salpingectomy is difficult.

A patient with spotting, no abdominal pain, and a low initial beta–human chorionic gonadotropin (β-HCG) level that is falling may be managed expectantly, whereas a patient who presents with hemodynamic instability, an acute abdomen, and high initial β-HCG levels must be managed surgically. These 2 patients probably represent different degrees of tubal damage; thus, comparing the future reproductive outcomes of the 2 cases would be flawed.

Salpingostomy, salpingectomy, and tubal surgery

Data in the literature have failed to demonstrate substantial and consistent benefit from either salpingostomy or salpingectomy with regard to improving future reproductive outcome. However, despite the risk of persistent ectopic pregnancy, some studies have shown salpingostomy to improve reproductive outcome in patients with contralateral tubal damage. Yao and Tulandi concluded from a literature review that laparoscopic salpingostomy had a reproductive performance that was equal to or slightly better than salpingectomy; however, slightly higher recurrent ectopic pregnancy rates were noted in the salpingostomy group. [ 35 ]

In reporting on 10 years of surgical experience in Paris, Dubuisson et al concluded that, for selected patients who desire future fertility, using salpingectomy, which is simpler and avoids the risk of persistent ectopic pregnancy, is possible and can result in a comparable fertility rate to tubal conservation surgery. [ 36 ] Future fertility rates were no different with either surgical approach when the contralateral tube was either normal or scarred but patent.

Clausen reviewed literature from the previous 40 years and concluded that only a small number of investigators have suggested, indirectly, that conservative tubal surgery increases the rate of subsequent intrauterine pregnancy. He also concluded that the more recent studies may reflect an improvement in surgical technique. [ 37 ]

In an earlier study, Maymon et al, after reviewing 20 years of ectopic pregnancy treatment, concluded that conservative tubal surgery provided no greater risk of recurrent ectopic pregnancy than the more radical salpingectomy. [ 38 ]

The modern pelvic surgeon has been led to believe that the treatment of choice for unruptured ectopic pregnancy is salpingostomy, sparing the affected fallopian tube and thereby improving future reproductive outcome.

However, if the treating surgeon has neither the laparoscopic skill nor the instrumentation necessary to atraumatically remove the trophoblastic tissue via linear salpingostomy, then salpingectomy by laparoscopy or laparotomy is not the wrong surgical choice. Leaving a scarred, charred fallopian tube behind after removing the ectopic pregnancy but requiring extensive cautery to control bleeding does not preserve reproductive outcome.

Fertility following surgery

Previous history of infertility has been found to be the most significant factor affecting postsurgical fertility.

Parker and Bistis concluded that when the contralateral fallopian tube is normal, the subsequent fertility rate is independent of the type of surgery. [ 39 ] Similarly, a prospective study of 88 patients by Ory et al indicated that the surgical method had no effect on subsequent fertility in women with an intact contralateral tube. [ 40 ]

Several other studies reported that the status of the contralateral tube, the presence of adhesions, and the presence of other risk factors, such as endometriosis, have a more significant impact on future fertility than does the choice of surgical procedure.

According to Rulin, salpingectomy should be the treatment of choice in women with intact contralateral tubes, because conservative treatment provides no additional benefit and incurs the additional costs and morbidity associated with persistent ectopic pregnancy and recurrent ectopic pregnancy in the already damaged tube. [ 41 ]

Future fertility rates have been found to be similar in patients who are treated surgically by laparoscopy or laparotomy. Salpingectomy by laparotomy carries a subsequent intrauterine pregnancy rate of 25-70%, compared with laparoscopic salpingectomy rates of 50-60%. Very similar rates exist for laparoscopic salpingostomy versus laparotomy. The rate of persistent ectopic pregnancy between the 2 groups is also similar, ranging from 5-20%.

A slightly higher recurrent ectopic pregnancy rate exists in patients treated by laparotomy (7-28%), regardless of conservative or radical approach, when compared with laparoscopy (6-16%). This surprising finding is believed to be secondary to increased adhesion formation in the group treated by laparotomy.

Comparison of medical and surgical treatment of small, intact extrauterine pregnancies also revealed similar success and subsequent spontaneous pregnancy rates in a prospective, randomized trial. [ 42 ]

A study by Xu et al found that in women undergoing 51,268 fresh in vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI) cycles, previous ectopic pregnancy has no effect on IVF-ICSI outcomes. The study also found that women with a prior history of ectopic pregnancy have a higher recurrence risk of ectopic pregnancy after IVF in comparison with women with no history of ectopic pregnancy. [ 43 ]

Methotrexate versus surgery

The success rates after methotrexate are comparable with laparoscopic salpingostomy, assuming that the previously mentioned selection criteria are observed. The average success rates using the multiple-dosage regimen are in the range of 91-95%, as demonstrated by multiple investigators. One study of 77 patients desiring subsequent pregnancy showed intrauterine pregnancies in 64% of these patients and recurrent ectopic pregnancy in 11% of them. Other studies have demonstrated similar results, with intrauterine pregnancy rates ranging from 20-80%.

The average success rates for the single-dosage methotrexate regimen are reported to be from 88-94%. In a study by Stovall and Ling, 113 patients (94%) were treated successfully, 4 (3.3%) of whom needed a second dose. [ 42 ] No adverse effects were encountered. Furthermore, 87.2% of these patients achieved a subsequent intrauterine pregnancy, whereas 12.8% experienced a subsequent ectopic pregnancy. [ 42 ] Other studies have reported similar results, with some mild adverse effects and lower reproductive outcomes.

A meta-analysis that included data from 26 trials demonstrated a success rate of 88.1% with the single-dose methotrexate regimen and a success rate of 92.7% with the multiple-dose regimen. [ 44 ] A small, randomized clinical trial also demonstrated the single-dose regimen to have a slightly higher failure rate. [ 45 ] A hybrid protocol, involving 2 equal doses of methotrexate (50 mg/m 2 ) given on days 1 and 4 without the use of leucovorin, has been shown to be an effective and convenient alternative to the existing regimens. [ 46 ]

Complications

Complications of ectopic pregnancy can be secondary to misdiagnosis, late diagnosis, or treatment approach. Failure to make the prompt and correct diagnosis of ectopic pregnancy can result in tubal or uterine rupture (depending on the location of the pregnancy), which in turn can lead to massive hemorrhage, shock, disseminated intravascular coagulopathy (DIC), and death. Ectopic pregnancy is the leading cause of maternal death in the first trimester, accounting for 9-13% of all pregnancy-related deaths. In the United States, an estimated 30-40 women die each year from ectopic pregnancy.

Any time a surgical approach is chosen as the treatment of choice, consider the complications attributable to the surgery, whether it is laparotomy or laparoscopy. These include bleeding, infection, and damage to surrounding organs, such as the bowel, bladder, and ureters, and to the major vessels nearby. Infertility may also result secondary to loss of reproductive organs after surgery. Also consider the risks and complications secondary to anesthesia. Make the patient aware of these complications, and obtain the appropriate written consents.

In the United States, ectopic pregnancy is estimated to occur in 1-2% of all pregnancies and accounts for 3-4% of all pregnancy-related deaths. [ 47 ] It is the leading cause of pregnancy-related mortality during the first trimester in the United States. In a review of deaths from ectopic pregnancy in Michigan, 44% of the women who died were either found dead at home or were dead on arrival at the emergency department. [ 48 ]

Virtually all ectopic pregnancies are considered nonviable and are at risk of eventual rupture and resulting hemorrhage. In addition to the immediate morbidity caused by ectopic pregnancy, the woman's future ability to reproduce may be adversely affected as well. However, patients who are diagnosed with ectopic pregnancy before rupture have a low mortality rate and also have a chance at preserved fertility.

From 1970 to 1989, the US mortality rate for ectopic pregnancies dropped from 35.5 deaths to 3.8 deaths per 10,000 ectopic pregnancies. [ 27 ] If the overall incidence of ectopic pregnancy remained stable in the 1990s, then the mortality rate dropped to 3.19 deaths per 10,000 ectopic pregnancies by 1999. [ 49 ]

Surveillance data for pregnancy-related deaths in the United States from 1991-1999 showed that ectopic pregnancy was the cause of 5.6% of 4200 maternal deaths. Of these deaths, 93% occurred via hemorrhage. [ 34 ]

Surveillance data from 2012-2019 indicated that ruptured ectopic pregnancy was the most common cause of hemorrhage-related maternal mortality (22.9%) in the United States. It accounted for 32.6% of hemorrhage-related deaths among non-Hispanic Black women. [ 50 ]

During 1999–2008, the ectopic pregnancy mortality rate in the United States was 0.6 deaths per 100,000 live births. The CDC reported a higher rate in Florida, 2.5 deaths per 100,000 live births during 2009-2010. The 11 ectopic pregnancy deaths in Florida during 2009-2010 contrasted with the total number of deaths (14) identified in national statistics for 2007. There was a high prevalence of illicit drug use among the women who died in Florida. [ 47 ]

The mortality rate reported in African hospital-based studies varied from 50-860 deaths per 10,000 ectopic pregnancies; these were almost certainly underestimates resulting from underreporting of maternal deaths and misclassification of ectopic pregnancies as induced abortions. [ 32 ]

Using data from 1997 to 2002, the World Health Organization (WHO) estimated that ectopic pregnancy was the cause of 4.9% of pregnancy-related deaths in the industrialized world. [ 51 ] Ectopic pregnancy caused 26% of maternal deaths in early pregnancy in the United Kingdom from 2003-2005, second only to venous thromboembolism, despite a relatively low mortality rate of 0.035 per 10,000 estimated ectopic pregnancies. [ 33 ]

Advise patients receiving methotrexate therapy to avoid alcoholic beverages, vitamins containing folic acid, nonsteroidal anti-inflammatory drugs (NSAIDs), and sexual intercourse, until advised otherwise. A signed written consent demonstrating the patient's comprehension of the course of treatment must be obtained.

Provide an information pamphlet to all patients receiving methotrexate; the pamphlet should include a list of adverse effects, a schedule of follow-up visits, and a method of contacting the physician or the hospital in case of emergency, as well as the need to return to the emergency department for concerning symptoms.

Patients with risk factors for ectopic pregnancy should be educated regarding their risk of having an ectopic pregnancy. Women who are being discharged with a pregnancy of unknown location should be educated regarding the possibility of ectopic pregnancy and their need for urgent follow-up.

Patients undergoing assisted reproduction technology should be educated regarding their risk of heterotopic pregnancy.

For patient education information, see the Pregnancy Center and the Women's Health Center , as well as Ectopic Pregnancy , Bleeding During Pregnancy , Vaginal Bleeding , Birth Control Overview , and Birth Control Methods .

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• Sites and frequencies of ectopic pregnancy. By Donna M. Peretin, RN. (A) Ampullary, 80%; (B) Isthmic, 12%; (C) Fimbrial, 5%; (D) Cornual/Interstitial, 2%; (E) Abdominal, 1.4%; (F) Ovarian, 0.2%; and (G) Cervical, 0.2%.
• Laparoscopic picture of an unruptured right ampullary tubal pregnancy; bleeding out of the fimbriated end has resulted in hemoperitoneum.
• A 12-week interstitial gestation, which eventually resulted in a hysterectomy. Courtesy of Deidra Gundy, MD, Department of Obstetrics and Gynecology at Medical College of Pennsylvania and Hahnemann University (MCPHU).
• An endovaginal sonogram reveals an intrauterine pregnancy at approximately 6 weeks. A yolk sac (ys), gestational sac (gs), and fetal pole (fp) are depicted.
• Linear incision being made at the antimesenteric side of the ampullary portion of the fallopian tube.
• Laparoscopic picture of an ampullary ectopic pregnancy protruding out after a linear salpingostomy was performed.
• Schematic of a tubal gestation being teased out after linear salpingostomy.

Contributor Information and Disclosures

Vicken P Sepilian, MD, MSc Medical Director, Reproductive Endocrinology and Infertility, CHA Fertility Center Vicken P Sepilian, MD, MSc is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Society for Reproductive Medicine Disclosure: Nothing to disclose.

Ellen Wood, DO, FACOG Voluntary Assistant Professor, University of Miami, Leonard M Miller School of Medicine Ellen Wood, DO, FACOG is a member of the following medical societies: American Society for Reproductive Medicine Disclosure: Nothing to disclose.

Frances E Casey, MD, MPH Associate Professor, Director of Family Planning Services, Department of Obstetrics and Gynecology, VCU Medical Center Frances E Casey, MD, MPH is a member of the following medical societies: American College of Obstetricians and Gynecologists , Association of Reproductive Health Professionals , National Abortion Federation , Physicians for Reproductive Health , Society of Family Planning Disclosure: Nothing to disclose.

Michel E Rivlin, MD Former Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Medical Association , Mississippi State Medical Association , Royal College of Surgeons of Edinburgh , Royal College of Obstetricians and Gynaecologists Disclosure: Nothing to disclose.

A David Barnes, MD, PhD, MPH, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners , American College of Obstetricians and Gynecologists , American Medical Association , Association of Military Surgeons of the US , and Utah Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert K Zurawin, MD Associate Professor, Director of Baylor College of Medicine Program for Minimally Invasive Gynecology, Director of Fellowship Program, Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine

Robert K Zurawin, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists , American College of Obstetricians and Gynecologists , American Society for Reproductive Medicine , Association of Professors of Gynecology and Obstetrics , Central Association of Obstetricians and Gynecologists , Harris County Medical Society , North American Society for Pediatric and Adolescent Gynecology , and Texas Medical Association

Disclosure: Johnson and Johnson Honoraria Speaking and teaching; Conceptus Honoraria Speaking and teaching; ConMed Consulting fee Consulting

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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

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• 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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21-10:  Ectopic Pregnancy

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Amenorrhea or irregular bleeding and spotting.

Pelvic pain, usually adnexal.

Adnexal mass by clinical examination or ultrasound.

Failure of serum beta-hCG to double every 48 hours.

No intrauterine pregnancy on transvaginal ultrasound with serum beta-hCG > 2000 mIU/mL.

Ectopic implantation occurs in approximately 2% of first trimester pregnancies. About 98% of ectopic pregnancies are tubal. Other sites of ectopic implantation are the peritoneum or abdominal viscera, the ovary, and the cervix ( eFigure 21–2 ). Any condition that prevents or inhibits migration of the fertilized ovum to the uterus can predispose to an ectopic pregnancy, including a history of infertility, pelvic inflammatory disease, ruptured appendix, and prior tubal surgery. Combined intrauterine and extrauterine pregnancy of two embryos (heterotopic) may occur rarely. In the United States, undiagnosed or undetected ectopic pregnancy is one of the most common causes of maternal death during the first trimester.

eFigure 21–2.

Various sites and frequency of ectopic pregnancies. (Reproduced, with permission, from Ectopic Pregnancy. In: Hoffman BL, Schorge JO, Halvorson LM, Hamid CA, Corton MM, Schaffer JI (editors). Williams Gynecology , 4th ed. McGraw Hill; 2020.)

A. Symptoms and Signs

Severe lower quadrant pain occurs in many cases. It is sudden in onset, stabbing, intermittent, and does not radiate. Backache may be present during attacks. Shock occurs 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 a period of days, and considerable blood may accumulate in the peritoneum. Slight but persistent vaginal spotting is usually reported, and a pelvic mass may be palpated. Abdominal distention and mild paralytic ileus are often present.

B. Laboratory Findings

The CBC may show anemia and slight leukocytosis. Quantitative serum pregnancy tests will show levels generally lower than expected for normal pregnancies of the same duration. If beta-hCG levels are followed over a few days, there may be a slow rise or a plateau rather than the near doubling every 2 days associated with normal early intrauterine pregnancy or the falling levels that occur with spontaneous abortion.

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Ectopic Pregnancy

Sep 14, 2014

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Ectopic Pregnancy. Dr. Yasir Katib MBBS, FRCSC, Perinatologist. Introduction. Ectopic pregnancy occurs when the developing blastocyst becomes implanted at a site other than the endometrium of the uterine cavity

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Presentation Transcript

Ectopic Pregnancy Dr. Yasir Katib MBBS, FRCSC, Perinatologist

Introduction • Ectopic pregnancy occurs when the developing blastocyst becomes implanted at a site other than the endometrium of the uterine cavity • The most common extra-uterine location is the fallopian tube, which accounts for 98%

Types of EP

Sites of EP Heterotopic Pregnancies: 1 in 30 000

Epidemiology • 2nd leading cause of overall maternal mortality in US • Leading cause of pregnancy-related deaths during T-1 • 1-2% of all diagnosed pregnancies

Epidemiology • Incidence is  •  incidence of salpingitis d/t chlamydia or other STI • Improved diagnostic techniques •  age • Blacks >non-whites>whites • Most occur in multigravid women • > 50% in women with  3 pregnancies • 10-15% in nulligravid women

Mortality • Causes 15% of maternal deaths • Overall risk of death 10X > the risk of childbirth; 50X > risk of legal abortion • Cause of death due • blood loss (80%)I • infection (3%) • anesthesia (2%) • Interstitial & abdominal 5X > risk of death than other sites

Of Historical Note……. • 1693 • 1st documentation of unruptured ectopic • 1752 • Infertility linked to EP • mid 19th century • Path reports stressed pelvic inflammation as cause of EP • 1800s • 30 abd operations in (5 women survived) • If not treated, 1 out of 3 survived (better!)

Risk Factors for EP • Definite (high risk) • Previous EP • Any tubal surgery or sterilization procedure • In-utero DES exposure 

Risk Factors for EP • Probable (modrate risk) • PID • Infertility • “Superovulating agents” • Pergonal, Clomiphene citrate • Multiple sexual partners  • Smoking

Risk Factors for EP • Uncertain Association (low risk) • IUCD • Vaginal douching  • Maternal age (extremes) • Use of reproductive techniques • In vitro fertilization • Gamete intrafallopian transfer • Embryo transfer

Classic TRIAD of EP • Delayed menses • Irregular vaginal bleeding • Abdominal pain Most commonly NOT encountered

Symptoms of Ectopic Pregnancy

Signs of EP * 20% of masses occur on the side opposite the EP.

Differential Diagnosis • Complication of IUP • Abortion • Early pregnancy plus uterine fibroid or ovarian tumour • Conditions causing acute abd pain • Torsion of ovarian tumour, FT, or subserous pedunculated fibroid • Salpino-oophoritis • Pelvic pain with an IUCD in situ • Appendicitis

Differential Dx – cont’d • Conditions causing hemoperitoneum • Ruptured corpus luteum • Ruptured follicular cyst • Ruptured endometriotic cyst • Conditions simulating a pelvic hematocele • Retroverted gravid uterus • Pelvic or tubo-ovarian abcess

Management of EP • Pre-operative diagnostic accuracy of EP based on clinical features alone is notoriously poor: ~50% • 20% of EP occur as surgical emergencies • Delay is justified only to correct shock

Acute Management of EP • Remember your ABCs • Oxygen • Large bore IV(s)  crystalloids • Blood • Labs • CBC, coagulation studies, T & C • -hCG

Usefulness of Quantitaive -hCG • Assessment of pregnancy viability • Serial rise usually indicates a normal pregnancy • Correlation with ultrasonography • With titers > 1500 IU/L, TVUS should ID an IUP • With multiple gestation, a gestational sac will not be apparent until titer rises a little higher • Assessment of treatment results • Declining levels are c/w effective medical or surgical Tx; if levels persist think GTD

The Importance of TVUS • Documentation of an intrauterine sac • A viable IUP should be identified when -hCG > 1500 IU/ml • Adnexal mass • An EP > 2 cm should be identified • Adnexal cardiac activity • Detectable when -hCG is ~ 15 000 – 20 000

U/S – Is it EP or miscarriage?

Surgical Management of EP • Radical • Salpingectomy with/out oophorectomy • Conservative • Salpingotomy • Salpingostomy or segmental resection  does not  repeat EP rate • fimbrial evacuation (traumatizes the endosalphinx & is assoc with  rate of recurrent EP (24%) compared withsalpingectomy

Medical Management of EPMethotrexate (MTX) • 1st used in Japan in 1982 • Antimetabolite that interferes with dihydrofolate reductase • Considered for low -hCG • Success rate 67%-94% • Indications • Hemodynamically stable pt • good F/U • Recurrent EP following Sx intervention

Methotrexate – cont’d • Contraindications • Evidence of rupture • Serum -hCG > 5 000 IU/L (varies) • FH detected on U/S • Adnexal mass> 3.5 cm on U/S • Unreliable pt • F/U unavailable • Laparoscopy required to make dx • Solid adnexal masses (germ cell tumour) • Free fluid > 30ml

Methotrexate Protocol • Exclude contraindications as well as • No evidence of renal, liver, or hematopoietic disease (Bilirubin, AST,ALT, urea, Cr, CBC) • Informed consent • 5% risk of hematoperitoneum 2° to rupture of EP following MTX • MTX 50mg/m² body surface area (~1mg/kg) given IV or IM

Methotrexate Protocol – cont’d • Pt F/U • repeat serum quantitative -hCG in 3-4 days, 7days, then weekly until < 10 IU/L • If > day-4 level at day-7  repeat MTX • If -hCG fails to fall by at least 25%/week at any time repeat dose • U/S not required routinely • Pt should avoid • Alcohol use, sexual I/C, oral folic acid (until HCG levels are neg)

Methotrexate Protocol – cont’d • What to expect • Majority experience some degree of abd pain (occurs in ~ 50% at day-6) • Shedding of a decidual cast • Moderate vaginal bleeding • Side effects (usually at higher doses) • Impaired liver function, bone marrow suppression, neutropenia, stomatitis, hematosalpinx

Expectant Mx of EP • Anticipates spontaneous regression of EP • Occurs in ~ 57% • Symptoms, HCG titers, & U/S findings followed • Risk of tubal rupture is 10% if HCG levels < 1000 • Criteria include • Sonographic diameter < 3cm • Initial -hCG < 1 000 IU/ml, no  in 2-day period, subsequent levels  • asymptomatic

Future Fertility following EP • Subsequent conception rate is ~ 60% • Incidence of recurrent EP is 15% • Other factors influencing include: • Age, parity, history of infertility, evidence of contralateral tubal disease, ruptured EP, IUCD use, salpingitis • No difference b/t laparoscopy vs laparotomy

Prevention of EP • Treat salpingitis early & correctly • MTX management lowers rate of subsequent EP • Risk of EP is  with all methods of contraception, except progesterone containing IUCDs • Remember Rh Sensitization • Rhogam for the Rh-neg woman

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• Treatment cost guides
• Ectopic Pregnancy

What is the cost of treating an ectopic pregnancy?

Severity levels of ectopic pregnancy, getting a diagnosis, imaging and laboratory tests, prescription medications, over-the-counter treatments, optimizing for cost, optimizing for efficiency, balancing cost and efficiency.

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Get a thorough self-assessment before your visit to the doctor.

Ectopic pregnancy can present with varying degrees of severity, which influence the approach to diagnosis and treatment. Understanding these severity levels is crucial for both patients and healthcare providers to ensure timely and appropriate care.

• Mild pelvic pain or discomfort
• Light vaginal bleeding
• No signs of shock
• Risk factors may include previous ectopic pregnancy, pelvic inflammatory disease, or use of an IUD
• Diagnosis method: In-person doctor visit (primary care physician or OB/GYN)
• Transvaginal ultrasound
• Serum hCG levels
• Expectant management (close monitoring)
• Medical management with methotrexate
• Moderate pelvic pain
• Heavier vaginal bleeding
• Possible shoulder pain
• Mild dizziness or lightheadedness
• Risk factors similar to mild cases, plus history of tubal surgery
• Diagnosis method: In-person doctor visit or ER visit, depending on symptom severity
• Complete blood count
• Laparoscopic surgery (salpingostomy or salpingectomy)
• Severe abdominal pain
• Heavy vaginal bleeding
• Signs of shock (rapid pulse, low blood pressure, pallor)
• Fainting or severe dizziness
• Risk factors similar to moderate cases, plus delayed diagnosis
• Diagnosis method: Emergency room visit
• Urgent transvaginal ultrasound
• Blood type and crossmatch
• Emergency surgery (laparoscopic or open abdominal)
• Blood transfusion if necessary

Summary Table: Severity Levels

Understanding the severity of an ectopic pregnancy is crucial for determining the appropriate course of action and minimizing potential complications. Patients experiencing any symptoms of ectopic pregnancy should seek medical attention promptly, as early diagnosis and treatment can significantly improve outcomes and reduce costs.

Getting an accurate and timely diagnosis for ectopic pregnancy is crucial. The method of diagnosis can vary depending on the severity of the condition and the patient's symptoms. Here are the primary options for obtaining a diagnosis:

In-person doctor visit

1. primary care physician (pcp).

• Severity level : Mild to Moderate
• Cash price: $75 - $300 for a basic exam, with an average of $171
• With insurance: Typically a copay of $25, but can vary depending on your plan
• With discount card: Prices may be reduced, but vary by provider and card
• Free with OptimalMD membership
• Time estimate : 30 minutes to 1 hour for the appointment, plus potential waiting time

2. OB/GYN Specialist

• Severity level : Mild to Severe
• Cash price: Average of $386 for a new patient visit, including pap smear and pelvic exam
• With insurance: Typically a specialist copay of $30-$50, but can vary depending on your plan
• Heavily discounted with OptimalMD membership
• Time estimate : 45 minutes to 1.5 hours for the appointment, plus potential waiting time

Virtual doctor visit

1. telemedicine consultation.

• Severity level : Mild
• Cash price: $40 - $90 per session on average
• With insurance: Costs vary, but generally less than in-person visits (e.g., $79 for acute respiratory infections)
• Time estimate : 15-30 minutes for the virtual consultation, with minimal waiting time

Emergency room visit

1. hospital emergency room.

• Severity level : Moderate to Severe
• Cash price: Average of $1,220 for uninsured patients, ranging from $623 to $3,087 depending on location and severity
• With insurance: Average of $1,082, but out-of-pocket costs depend on your plan's deductible and copay
• Note: Emergency care is typically not covered by OptimalMD membership
• Time estimate : 3-6 hours on average, but can be longer depending on the severity of the condition and hospital capacity

2. Urgent Care Center

• Cash price: $100 - $150 for a basic visit, with additional costs for specific tests or treatments
• With insurance: Typically a copay of $50-$100, but can vary depending on your plan
• Time estimate : 30 minutes to 2 hours, depending on wait times and required services

Summary Table: Assessment Options

Note: Prices and efficiency can vary based on location, specific provider, and individual circumstances. The OptimalMD option provides free virtual urgent care and heavily discounted services for a monthly membership fee.

Imaging and laboratory tests play a crucial role in diagnosing and monitoring ectopic pregnancy. The type and frequency of tests required may vary depending on the severity of the condition and the chosen treatment approach. Let's explore the common tests, their costs, and efficiency.

Ultrasound is the primary imaging tool for diagnosing ectopic pregnancy. There are two main types:

• Hospital Radiology Department: $161 - $781 (cash price)
• Insurance copay: Typically $20 - $50
• Discount with OptimalMD membership
• Time estimate: 15-30 minutes for the procedure, results usually available immediately
• Imaging Center: $568 (cash price)
• Time estimate: 20-30 minutes for the procedure, results usually available immediately

Blood Tests

Blood tests are essential for confirming pregnancy and monitoring its progression. The most crucial tests include:

• LabCorp: $49 (cash price)
• Quest Diagnostics: $55 (cash price)
• Insurance copay: Typically $10 - $30
• Time estimate: 5-10 minutes for blood draw, results available in 1-2 days
• Quest Diagnostics: $29 (cash price)
• LabCorp: $31 (cash price)

Other Imaging

In some cases, additional imaging may be necessary:

• Hospital Radiology Department: $791 - $3,024 (cash price, varies by location)
• Insurance copay: Typically $100 - $500
• Time estimate: 15-30 minutes for the procedure, results available in 1-2 days
• Imaging Center: $672 (cash price)
• Hospital Radiology Department: $1,000 - $5,000 (cash price, varies by location)
• Insurance copay: Typically $200 - $1,000
• Time estimate: 30-60 minutes for the procedure, results available in 1-3 days

It's important to note that while OptimalMD offers significant cost savings, the choice of diagnostic tests should always be based on medical necessity and your healthcare provider's recommendations. The severity of your condition will determine which tests are required, and in emergency situations, immediate care should be sought regardless of cost considerations.

Summary Table: Diagnostics

Note: All listed services are either free or heavily discounted with OptimalMD membership ($47/month for the entire family).

In the treatment of ectopic pregnancy, several prescription medications may be used depending on the severity of the condition and the chosen treatment approach. Let's explore the options, their costs, and availability.

Methotrexate

Methotrexate is the primary medication used for medical management of ectopic pregnancy. It's typically administered as an injection and works by stopping the growth of rapidly dividing cells, including those of the ectopic pregnancy.

Based on the information from our cost lookup, we can see that the cost of methotrexate varies depending on the form and quantity:

• Oral tablets: Range from about $35 for 20 tablets to $140 for 100 tablets.
• Injectable powder: Around $55-$75 per unit.
• Injectable solution: Approximately $44-$47 for 10 units.

With insurance, these costs may be significantly reduced, often to a copay of $10-$50 depending on your plan. Discount cards like GoodRx can also bring the price down, in some cases to as low as $11.70 for the most common version.

OptimalMD members can receive methotrexate for free as part of their $47 per month family membership, which could represent significant savings.

Pain Medications

Pain management is crucial in treating ectopic pregnancy. Prescription pain medications may include:

• Prescription NSAIDs (e.g., Ketorolac)

Based on our cost lookup:

• Oral tablets: $16-$68 for 10-20 tablets
• Injectable solution: $19-$67 depending on concentration and volume
• Nasal spray: Significantly more expensive at around $1,892

With insurance, these costs may be reduced to a copay of $5-$25. Discount cards can also help, bringing the price down to as low as $9-$16 for oral tablets.

• Opioids (e.g., Oxycodone)
• Oral tablets: $13-$27 for 20-100 tablets
• Oral solution: $11-$55 depending on volume
• Extended-release tablets: Significantly more expensive, ranging from $266 to $2,390 for 100 tablets

Insurance typically reduces these costs to a copay of $10-$40, depending on the plan. Discount cards can also provide savings.

For OptimalMD members, pain medications are either free or heavily discounted as part of the $47 per month family membership.

Anti-nausea Medications

Nausea is a common symptom in ectopic pregnancy. Anti-nausea medications that may be prescribed include:

• Ondansetron (Zofran)
• Oral tablets: $19-$134 for 12-30 tablets
• Oral solution: $81-$297 depending on volume
• Injectable solution: $14-$85 depending on volume

Insurance typically reduces these costs to a copay of $10-$30. Discount cards can bring the price down significantly, to as low as $11-$12 for a common prescription.

• Promethazine (Phenergan)
• Oral tablets: $10-$23 for 1-100 tablets, depending on strength
• Injectable solution: $45-$57 for 25 mL
• Oral syrup: About $13 for 120 mL

Insurance typically reduces these costs to a copay of $5-$20. Discount cards can bring the price down to around $9 for common prescriptions.

For OptimalMD members, anti-nausea medications are either free or heavily discounted as part of the $47 per month family membership.

Summary Table: Prescription Medications

Note: All medications listed are free or heavily discounted with OptimalMD membership ($47/month for the entire family).

Over-the-counter (OTC) treatments play a crucial role in managing pain and discomfort associated with ectopic pregnancy, particularly for mild cases or as supportive care alongside prescribed treatments. The two main OTC options recommended for ectopic pregnancy-related pain are acetaminophen (Tylenol) and ibuprofen (Advil, Motrin).

Acetaminophen (Tylenol)

Acetaminophen is often the first-line OTC pain reliever recommended for mild to moderate pain associated with ectopic pregnancy. It's generally considered safe and doesn't interfere with blood clotting.

• National Average Price : The cost of acetaminophen varies widely depending on the brand, formulation, and quantity purchased.
• Walmart: Extra Strength Acetaminophen 500mg, 100 tablets for $4.00 ($0.04 per tablet)
• CVS Health: Extra Strength Acetaminophen 500mg, 100 tablets for $6.79 ($0.07 per tablet)
• Walgreens: Tylenol Extra Strength 500mg, 100 tablets for $11.99 ($0.12 per tablet)
• Target: Tylenol Extra Strength 500mg, 100 caplets for $11.99 ($0.12 per caplet)

Ibuprofen ( Advil , Motrin )

Ibuprofen is another common OTC pain reliever that can be used for ectopic pregnancy-related pain, especially if acetaminophen isn't providing sufficient relief. However, it's important to consult with a healthcare provider before using ibuprofen, as it may not be suitable in all cases.

• National Average Price : Ibuprofen prices can vary based on brand, strength, and quantity.
• Walmart: Equate Ibuprofen 200mg, 100 tablets for $2.98 ($0.03 per tablet)
• CVS Health: Ibuprofen 200mg, 100 tablets for $5.49 ($0.05 per tablet)
• Walgreens: Advil 200mg, 100 tablets for $11.99 ($0.12 per tablet)
• Target: Advil 200mg, 100 tablets for $11.99 ($0.12 per tablet)

Cost Considerations

• Insurance : Most insurance plans do not cover OTC medications unless prescribed by a doctor. However, some flexible spending accounts (FSAs) or health savings accounts (HSAs) may allow you to use pre-tax dollars for these purchases.
• Discount Cards : Programs like GoodRx can offer significant savings. For example, acetaminophen extra strength can be obtained for as low as $3.15 with a GoodRx coupon, compared to the regular price of $18.84.
• Bulk Purchasing : Buying in larger quantities often reduces the per-unit cost. For instance, a 600-count bottle of extra strength acetaminophen caplets can cost as low as $14.65, or just $0.02 per caplet.
• Generic vs. Brand Name : Generic versions are typically much less expensive than brand-name products while offering the same active ingredients and effectiveness.

Efficiency Considerations

• Onset of Action : Both acetaminophen and ibuprofen typically start working within 20-30 minutes of ingestion.
• Duration of Effect : Acetaminophen usually lasts 4-6 hours, while ibuprofen can last 4-8 hours.
• Frequency of Use : Most OTC pain relievers can be taken every 4-6 hours as needed, but always follow the package instructions or your doctor's advice.

Summary Table: OTCs

Remember, while these OTC treatments can help manage pain, they are not a substitute for proper medical care in cases of ectopic pregnancy. Always consult with a healthcare provider for appropriate diagnosis and treatment.

Surgical procedures are often necessary for treating ectopic pregnancies, especially in moderate to severe cases or when medication management is not successful. The two main surgical approaches are laparoscopic surgery and open abdominal surgery.

Laparoscopic Surgery

Laparoscopic surgery is the preferred method for treating ectopic pregnancy due to its minimally invasive nature. There are two main types of laparoscopic procedures:

• Salpingostomy: The ectopic pregnancy is removed while preserving the fallopian tube.
• Salpingectomy: The entire fallopian tube containing the ectopic pregnancy is removed.

Cost Information:

• National average cost: $19,459
• Mayo Clinic Rochester: Requires contacting Patient Estimating Service for a quote
• UCLA Health: Requires using their Patient Estimates tool for a quote
• Mount Sinai Hospital New York: Requires using their Online Patient Cost Estimator Tool for a quote

Important Notes on Costs:

• Actual out-of-pocket costs vary significantly depending on insurance coverage.
• Many insurance plans cover a large portion of the cost, leaving patients responsible for copayments, deductibles, and coinsurance.
• Patients without insurance may be eligible for discounts or financial assistance programs offered by hospitals.

Time Estimate:

• Procedure: 1-2 hours
• Hospital stay: Same day or overnight
• Full recovery: 1-2 weeks

Open Abdominal Surgery

Open abdominal surgery is less common for treating ectopic pregnancies but may be necessary in certain situations, such as when there is significant internal bleeding or in cases where laparoscopic surgery is not feasible.

• Specific national average not available
• Likely more expensive than laparoscopic surgery
• For comparison, laparoscopic treatment ranges from $7,306 to $12,258 on MDsave
• Costs can vary significantly based on location, healthcare provider, and individual circumstances.
• Patients should consult with their healthcare provider and insurance company for accurate estimates.
• Procedure: 1-3 hours
• Hospital stay: 2-4 days
• Full recovery: 4-6 weeks

Summary Table: Procedures

It's crucial to note that these prices are estimates and can vary significantly based on individual circumstances, location, and specific medical needs. Patients should always consult with their healthcare provider and insurance company for more accurate cost estimates and to understand their coverage.

When seeking cost-effective treatment for ectopic pregnancy, consider the following strategies for each severity level:

Mild Ectopic Pregnancy

• Opt for an in-person visit with a primary care physician or OB/GYN instead of an ER visit
• Utilize telemedicine services for initial consultation if available
• Choose transvaginal ultrasound over more expensive imaging options
• Limit blood tests to essential hCG levels and complete blood count
• Use generic methotrexate instead of brand-name versions
• Opt for over-the-counter pain relievers when possible

Moderate Ectopic Pregnancy

• Visit an urgent care center instead of an ER if symptoms are not severe
• Consult with an OB/GYN for specialized care to potentially avoid unnecessary tests
• Combine ultrasound and blood tests in a single visit to reduce overall costs
• Avoid unnecessary follow-up tests by clearly communicating with healthcare providers
• Request generic versions of all prescribed medications
• Discuss the possibility of outpatient methotrexate treatment to avoid hospitalization costs

Severe Ectopic Pregnancy

• While an ER visit is necessary, choose in-network hospitals when possible
• Provide a clear medical history to avoid redundant tests
• Accept only essential emergency imaging and lab work
• Request copies of all test results to avoid duplicate testing if transferred to another facility
• If surgery is necessary, inquire about laparoscopic options, which generally have lower costs and faster recovery times
• Discuss the possibility of salpingostomy over salpingectomy if appropriate, as it may be less expensive and preserve fertility
• Follow post-operative instructions carefully to minimize the risk of complications and additional costs
• Utilize outpatient follow-up care instead of inpatient monitoring when medically appropriate

By implementing these cost-optimization strategies, patients can potentially reduce their overall expenses while still receiving appropriate care for ectopic pregnancy. However, it's crucial to prioritize medical necessity and consult with healthcare providers to ensure that cost-saving measures don't compromise the quality of care or patient safety.

When time is of the essence in treating ectopic pregnancy, efficiency becomes paramount. This section outlines the most time-efficient strategies for each severity level, balancing rapid diagnosis and treatment with medical effectiveness.

• Schedule an immediate virtual consultation with an OB/GYN
• Follow up with an in-person visit within 24 hours if recommended
• Prioritize transvaginal ultrasound for faster and more accurate results
• Conduct rapid hCG blood test with same-day results
• If eligible, opt for single-dose methotrexate treatment
• Begin prescribed pain management immediately
• Go directly to an emergency room or urgent care center with obstetric capabilities
• Inform staff of suspected ectopic pregnancy for expedited triage
• Immediate transvaginal ultrasound
• Stat blood tests including hCG levels and complete blood count
• If appropriate, receive methotrexate treatment on-site
• Prepare for potential laparoscopic surgery if medication is not suitable
• Immediate emergency room visit via ambulance if necessary
• Communicate suspected ectopic pregnancy for highest priority triage
• Stat transvaginal ultrasound and blood tests
• Rapid preparation for emergency surgery if rupture is suspected
• Emergency laparoscopic or open surgery as soon as diagnosis is confirmed
• Immediate post-operative care and monitoring

General Efficiency Tips

• Choose healthcare providers and facilities known for rapid ectopic pregnancy treatment
• Have all relevant medical history and insurance information readily available
• Follow up promptly for all recommended post-treatment monitoring and tests

By prioritizing speed without compromising medical care, patients can receive the most efficient treatment for ectopic pregnancy, potentially improving outcomes and reducing complications. However, it's crucial to remember that the fastest option may not always be the most cost-effective or medically appropriate for every situation.

When treating ectopic pregnancy, balancing cost and efficiency is crucial for optimal patient care and financial management. This section will explore strategies that combine cost-effectiveness and timely treatment for each severity level.

• Opt for an in-person visit with an OB/GYN for accurate diagnosis
• Schedule appointment during off-peak hours for potentially lower costs
• Choose transvaginal ultrasound for its accuracy and relatively lower cost
• Combine blood tests to minimize the number of blood draws and associated fees
• Consider methotrexate injection if appropriate, as it's less invasive and often more cost-effective than surgery
• Use generic medications when possible to reduce prescription costs
• Seek care at an urgent care center if symptoms worsen outside regular office hours
• This offers a balance between the cost of an ER visit and the immediacy of care needed
• Opt for a combination of transvaginal ultrasound and blood tests for a comprehensive yet efficient diagnosis
• Request expedited lab results if available, weighing additional costs against time saved
• Discuss both medical and surgical options with your healthcare provider
• If surgery is necessary, inquire about laparoscopic procedures, which often have shorter recovery times and lower overall costs
• Proceed directly to the ER for immediate care
• While more expensive, this is the most efficient option for severe cases and can be life-saving
• Undergo all necessary emergency imaging and lab tests as recommended by ER staff
• The focus here is on efficiency rather than cost, as timely treatment is critical
• Emergency surgery is likely necessary
• Discuss post-operative care options with your healthcare team to balance ongoing treatment costs with recovery efficiency

General Cost-Efficiency Strategies

• Understand your insurance coverage and in-network providers to minimize out-of-pocket expenses
• Consider negotiating cash prices if uninsured, as these can sometimes be lower than insurance rates
• Opt for telemedicine follow-up appointments when appropriate to save time and reduce costs
• Adhere strictly to medication schedules and post-treatment instructions to avoid complications and additional costs
• Discuss future pregnancy planning and preventive measures with your healthcare provider
• Addressing risk factors can help prevent recurrence and associated costs in the long term

By carefully considering these balanced approaches, patients can receive timely and effective treatment for ectopic pregnancy while managing costs. Always consult with healthcare providers to determine the most appropriate course of action for individual circumstances.

Ectopic pregnancy is a serious condition that requires prompt diagnosis and treatment. The cost of treating ectopic pregnancy can vary significantly depending on the severity of the condition, the chosen diagnostic methods, and the required treatments.

Key takeaways from this article include:

• Early detection is crucial for both health outcomes and cost management.
• Treatment costs can range from a few hundred dollars for medication-based treatments to several thousand for surgical interventions.
• Factors influencing costs include insurance coverage, choice of healthcare provider, and geographic location.
• There are often ways to balance cost and efficiency in treatment plans, such as opting for generic medications or considering outpatient procedures when appropriate.
• While cost is an important consideration, the primary focus should always be on ensuring the health and safety of the patient.

Remember, every case of ectopic pregnancy is unique, and treatment plans should be tailored to individual needs and circumstances. Always consult with a healthcare professional for personalized medical advice and to discuss the most appropriate and cost-effective treatment options for your situation.

By understanding the potential costs involved and the available options, patients can make more informed decisions about their care while working closely with their healthcare providers to ensure the best possible outcomes.

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Original research

Reasons, experiences and expectations of women with delayed medical care for ectopic pregnancies in chinese urban edges: a qualitative study.

1 School of Nursing, Southern Medical University, Guangzhou, Guangdong, China

2 Department of Obstetrics and Gynecology, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China

Yulian Liang

3 Department of Obstetrics and Gynecology, Guangzhou University of Traditional Chinese Medicine Dongguan Hospital, Dongguan, Guangdong, China

Hamza Saidi Lilenga

Jinguo zhai, associated data.

Data are available on reasonable request.

To explore the experiences of patients with ectopic pregnancies with delayed medical care, with the goals to promote timely access to care, reduce subsequent physical and psychological impacts, and provide recommendations for improved management of ectopic pregnancies.

A qualitative study.

A 1000-bed urban edge hospital located in the suburban area of Guangzhou, China, between December 2022 and February 2023.

Participants

21 patients with delays in seeking medical care for ectopic pregnancy.

Primary and secondary outcome measures

Semistructured, in-depth, face-to-face interviews were conducted to understand the experience and expectations of these women.

Three main themes emerged, including delaying medical care, physical and psychological experiences, and expectations of their healthcare providers. Each of these main themes had several subthemes. The central theme of reasons for delaying medical care had five subthemes, including lack of knowledge on early symptoms of ectopic pregnancy, family dynamics and circumstances, traditional fertility ideology and intentions, avoidance of medical treatment behaviour, and medical delays. The main theme of physical and psychological experiences had two subthemes, including learnings from the experiences and negative impacts of the experiences. The main theme of expectations of their healthcare providers included three subthemes that were reducing the length of outpatient examinations and waiting times, increasing public understanding of early symptoms of ectopic pregnancy and increasing male awareness of safe contraceptive methods.

Conclusions

A lack of knowledge about the early symptoms of ectopic pregnancy was the main reason for delays in seeking medical care and had a dual impact on patients’ physical and mental health, affecting their recovery and future healthcare. A collective effort from patients, families, healthcare providers and medical institutions is required for better medical education, family support, specialised professional training and local fertility policy to decrease the incidence of delayed medical care and achieve satisfactory pregnancy outcomes.

STRENGTHS AND LIMITATIONS OF THIS STUDY

• We performed the first qualitative study on women with ectopic pregnancy who lived on the urban edge of China and had delays in seeking medical care.
• This study can let us understand the reasons, experiences and expectations of women with ectopic pregnancy and delays in seeking medical care.
• The study limitations included a small number of patients in a single hospital.
• The reasons, experiences and expectations of women with ectopic pregnancy might also vary significantly among different countries with different socioeconomic statuses, cultural backgrounds and local fertility policies.

An ectopic pregnancy is when a fertilised egg implants and develops outside the body cavity of the uterus. About 95% of ectopic pregnancies occur in the fallopian tubes and are rare in the abdomen, ovaries and cervix. 1 The incidences of ectopic pregnancy vary in different regions of the world. For example, the incidences of ectopic pregnancy were reported from 7.0‰ to 8.3‰ during 2006–2010 in the USA, 2 whereas, in China, the incidence of ectopic pregnancy decreased from 7.6% in 2011 to 4.3% in 2020, probably due to improved contraceptive knowledge and a decreased prevalence of sexually transmitted diseases. 3

Ectopic pregnancy is a medical emergency and the leading cause of death in early pregnancy. 4 An embryo in the fallopian tube can cause it to rupture with subsequent intra-abdominal haemorrhage. 5 Without prompt treatments, it not only endangers the patient’s life but may also lead to infertility. 6 7 Hendriks et al reported improved survival rates and fertility preservations when ectopic pregnancies were diagnosed and managed promptly. 8 In addition, early detection and treatment increased the likelihood of conservative treatment options. 6 Therefore, timely access to medical care can effectively reduce poor physical and psychological outcomes in patients with ectopic pregnancy. However, it was reported that delays in seeking medical care could happen in pregnant women with ectopic pregnancy. 9–12 Delays in seeking medical care were associated with increases in maternal morbidity and mortality. 13 Understanding the reasons for delays in seeking medical care, maternal physical and psychological experiences, and the needs of patients with ectopic pregnancy might help them develop a sense of proper access to care and reduce the negative emotions, stress, and physical and psychological consequences associated with untimely access to care. Existing studies on ectopic pregnancy were mainly on the high-risk factors, diagnosis and treatments, with little in-depth investigation on the delays in seeking medical care in patients with ectopic pregnancy.

Qualitative research is an in-depth holistic exploration of the study phenomenon using data collection methods such as interviews, observations and physical analysis. It was used to study patients’ experiences with delays in seeking medical care for certain diseases, such as diabetic complications and cancer. 14 15 However, we did not find any previous qualitative study to explore women’s experience with delays in seeking medical care for ectopic pregnancy.

Therefore, we performed the present qualitative research on patients with delays in seeking medical care for ectopic pregnancy. We aimed to explore the reasons for delays in seeking medical care, understand the physical and psychological impacts, and provide evidence for policy-making on early prevention, intervention and the development of holistic optimisation measures for women with ectopic pregnancy.

A phenomenological qualitative research design was used, with data collected through in-depth interviews and observations, using a comprehensive 32-item checklist developed by Tong et al as a guide to ensure accurate findings and complete reports of the qualitative research. 16

A purposive sampling method was used to select patients who presented for ectopic pregnancy and underwent laparoscopic surgery for in-depth interviews. The participants were recruited from a 1000-bed urban edge hospital located in the suburban area of Guangzhou, the capital city of Guangdong province in southern China, between December 2022 and February 2023. Inclusion criteria were women with (1) diagnosis of ectopic pregnancy confirmed by the postoperative pathology 1 ; (2) age ≥18 years; (3) stable mental state, able to understand the research questions and communicate with the researcher; (4) informed consent for voluntary participation in this study; (5) no other serious physical or mental illnesses ; (6) delay in seeking medical treatment, which was defined as the behaviour of individuals who failed to seek medical treatment on time after the presence of abnormal physical symptoms, including missed or late menses, abdominal pain, or vaginal bleeding. 17 Those patients who disagreed with the treatment or were involved in medical disputes were excluded from the study. To make the interviewees more representative, the selection of interviewees took into account as much diversity as possible, including whether the ectopic pregnancy was ruptured, whether the embryo of the tubal pregnancy was alive, whether there was any previous history of ectopic pregnancy and whether the pregnancy was conceived spontaneously.

Data collection

Consistent with the aims of this study, the relevant literature was reviewed, and the opinions of gynaecologists and senior nurses were sought to develop a preliminary interview outline. Three patients were selected for preinterviews, and the outline was revised, resulting in a formal interview outline ( box 1 ). Between December 2022 and February 2023, we conducted semistructured, in-depth, face-to-face interviews with eligible patients on the third or fourth postoperative day. We did not select the first and second postoperative days because we wanted to avoid disruption in their recovery if interviews happened too early after the surgery. We also did not want to delay the interview beyond the fourth postoperative day because we wanted to avoid recall bias. In addition, we performed the interviews in the afternoon to avoid interruption by any treatments. We kept the length of the interview to 30–60 min. The interviews were conducted in a conversation room or single-person ward to avoid interference from others. Notes were taken on the content of the interview (including non-verbal information about the interviewee), and all of the conversations were audiorecorded for later analysis. During the interview, the interviewers followed the outline and guided the patients through the process, listening carefully and observing body language, avoiding leading questions and interruptions to better explore the patients’ actual thoughts and inner experiences. The sample size was considered saturated when information was repeated during the interview. 18

Outlines of the interview

• Since when have you been feeling unwell? What did you do then?
• What was the reason why you did not see a doctor right away? Was there any other reason?
• What new symptoms did you have before coming to the hospital? Were any symptoms getting worse? What did you do? What help did you get? What difficulty did you have when you tried to get help?
• What psychological changes did you have since the doctor informed you of your condition?
• Was there any psychological change after the surgery? What impact did this surgery have on your future life?
• How much did you know about ectopic pregnancy? How did you learn about it? In what ways do you think medical personnel can help you understand this disease?
• Do you have anything else to say about your illness and your delay in seeing a doctor?

Data analysis

The data analysis followed the Colaizzi’s seven-step method. 19 Briefly, two researchers converted the contents of the recordings into textual material by listening to the tapes individually and repeatedly within 48 hours after the interviews. They also paid attention to the non-verbal information of the interviewees, reviewed the electronic medical records and read the interview transcripts to find and refine the contents of the interviewees’ expressions relevant to this study. They marked and coded the content into categories and unified the information into analysable language that could be reviewed and recalled. Finally, the translations were transformed into themes, and the themes were refined. When there was any disagreement about the distilled themes, the research team discussed and finalised the themes, which were returned to the interviewees for confirmation if necessary.

Patient and public involvement

There was no patient or public involvement in setting the research agenda.

We reached theme saturation after interviewing 18 patients. We interviewed three additional patients to ensure no new theme emerged ( figure 1 ). Finally, 21 patients with ectopic pregnancy were included in the study and analysed. They all had a fallopian tubal pregnancy. Their information is shown in table 1 .

Participant selection and study flow chart.

General information of interviewees (N=21)

Obstetric history included G, gravidity; P, parity; A, abortion; E, ectopic pregnancy.

IUD, intrauterine device.

The three themes identified in the interview were the reasons for delaying medical care, physical and psychological experiences, and expectations of their healthcare providers.

Reasons for delaying medical care

This theme had five subthemes, including lack of knowledge about early symptoms of ectopic pregnancy, family dynamics and circumstances, traditional fertility ideology and intentions, avoidance of medical treatment behaviour, and medical delays.

Lack of knowledge on early symptoms of ectopic pregnancy

Most women of childbearing age used menstruation as a common method of ruling out pregnancy. Many women had irregular periods and did not accurately record their menstrual cycles. At the early stages of ectopic pregnancy, they could consider vaginal bleeding to be menstruation and abdominal pain to be dysmenorrhoea, which led to misjudgements. The lack of knowledge about ectopic pregnancy symptoms and the poor ability to assess the risk of the disease, as well as the atypical symptoms of early pregnancy, were the main reasons for their delay in seeking medical attention in this study. N3: ‘I frequently had irregular menstrual cycles. Whenever my period was irregular, I visited a Chinese medicine clinic and received medication to regulate my cycle. This time, I missed my period again, so I went to that clinic for the same medication. I did not realize that I was pregnant at that time. All of these resulted in my delayed seeking care for an ectopic pregnancy.’N7: ‘The doctor diagnosed me as having polycystic ovary syndrome before. Sometimes, I got my period once every 2–3 months or once every 6 months. The doctor said it was difficult for me to get pregnant, and I did not think about getting pregnant.’ N14: ‘I had an ectopic pregnancy last year and had one fallopian tube removed. At that time, the doctor said to prevent habitual ectopic pregnancy. I thought that I would not have another ectopic pregnancy if I had one fallopian tube removed. I always thought this pregnancy was a miscarriage (puzzled expression). How could it be possible to have an ectopic pregnancy?’ N6: ‘I also suspected that I had an ectopic pregnancy, but ectopic pregnancy can have bleeding and abdominal pain. I thought that my abdominal pain was caused by the inflammation from the pelvic inflammatory disease. I do not have vaginal bleeding. I do not think it is an ectopic pregnancy.’ N10: ‘I had some abdominal pain a few days ago. I was very busy at work and under stress. I also had an iced drink that day. I thought it was acute gastroenteritis and I would get better with some hot water. The pain was not so bad in the following days. So I did not take it seriously or was too careless.’

Family dynamics and circumstances

Patient health was greatly affected by the family status. Family members were the most important supporters of patients. Smooth communication, emotional support and problem-solving skills of family members had a crucial impact on patients’ timely medical care. Family economic status was also the main reason why patients decided whether to seek medical attention immediately when they had physical discomforts. Those with low income tended to choose to self-manage their symptoms at home. The distance between the family and the nearest medical institution also often affected the patient’s medical decision. N2: ‘My husband works in another city far away from home field, and I live in the countryside with my parents-in-law and children. I have difficulty communicating with my parents-in-law, and there is relatively little communication. My husband said that he heard miscarriage could happen very often during early pregnancy. If I have a miscarriage, the whole family will find it very hard to accept it and get disappointed. So, do not tell others yet.’ N17: ‘My husband is usually afraid of trouble. He said that it would be better if I took the pain reliever. He did not care about this so much. Sometimes he also ignores me (with a sad expression).’ N9: ‘I have systemic lupus erythematosus. The medicine costs me 1000 yuan (1 dollar converts approximately to 6.927 yuan) every month. Usually, I can only do easy work and cannot stay up late. The main source of family income is from my husband.’ N8: ‘My family lives in a town, relatively far away from a large hospital. If there is a small problem, I usually go to the town’s health centre to get some medicine prescribed and take it. It is not convenient to go to the county hospital to see a doctor. The public buses to the county are available only in the morning. However, I also have to cook breakfast for the child in the morning.’

Traditional fertility ideology and intentions

Young patients believed it was difficult to speak up during premarital pregnancy. They were worried that others treated them differently. In addition, a patient’s willingness to get pregnant determined her responses to abnormal symptoms during the pregnancy. N3: ‘I am not married yet. I did not have my menstrual period the other day. I was so scared. After the test, I found out that I was pregnant, but I did not know what to do. I was struggling until the pain was severe that day. The B-scan ultrasonography said it was ectopic pregnancy.’ N20: ‘I broke up with my boyfriend and did not dare to tell my parents when I found out I was pregnant. I was on duty that day and suddenly had severe pain. My coworker sent me to the hospital.’ N11: ‘My pregnancy was an accident. I took emergency birth control pills, but I do not know why I was pregnant. I have two children now. I did not feel any discomfort anyway. I was thinking of going to the hospital for an abortion a few days later.’

Avoidance of medical treatment behaviour

In this study, seven patients reported avoiding medical treatment, mainly due to long waiting times, cumbersome medical procedures, inability to complete the treatment process independently and concerns about the high costs. N5: ‘There were too many people in the hospital. I had to wait in line to see a doctor, check, and pay fees. It took a whole day to go there.’ N16: ‘I have a low education background. It is difficult for me to go to a large hospital. I cannot find a direction and follow the instructions. It also costs a considerable amount of money. I am not sure that they can tell any problem to me.’

Medical delays

Limited availability of medical facilities, unequal distribution of medical resources and difficult differential diagnosis of early pregnancy were the leading reasons for medical-related delays. N16: ‘At that time, I had a pain around my umbilicus and was rolling in bed. We did not have a B-scan. The doctor said it was a stone.’ N11: ‘I came to see the doctor that time. I received the blood test and a B-scan. The doctor said that my pregnancy was too early to see clearly. I was asked to go back there in one week.’

Physical and psychological experiences

In this study, we found substantial physical and mental experiences of patients after delays in seeking medical care. This topic was summarised into two subthemes, including learnings from the experiences and negative impacts of the experiences.

Learnings from the experiences

During the treatment process, patients had a specific understanding of the relevant knowledge of ectopic pregnancy, became aware of the dangers of delays in seeking medical care, understood that women need to pay attention to their menstrual cycle, took safe contraceptive measures during sex life and received more family and social supports. 10 patients mentioned that, through this experience of delays in seeking medical care, they realised the importance and necessity of timely medical treatment and would pay more attention to their physical condition. N1: ‘After this time, I will not be so careless. When I find abnormalities, I need to seek medical attention on time. I will not take it for granted that it will end in a few days.’ N10: ‘This time, I had one side of my fallopian tubes removed, which will have an impact on future pregnancies. I'm not married yet, so I need to pay more attention to my body in the future.’ N3: ‘In the future, I will record my menstrual period on the calendar. If my period does not come, I will do a pregnancy test right away. If my period is irregular, I need to see a doctor as soon as possible.’ N19: ‘The doctor told me that neither external ejaculation nor the safe day calculation can guarantee contraception. The emergency contraceptive pill is also unsafe. I will pay attention to these in the future.’ N6:’ Now I know that ectopic pregnancy can cause abdominal pain and bleeding. Even if the symptoms are not severe, I must see a doctor. I also have to see a doctor once I know that I am pregnant. I should monitor the symptoms in pregnancy.’ N14: ‘The doctor said that every pregnancy has a risk of ectopic pregnancy. The number of pregnancies, history of pelvic and abdominal surgery, choice of contraceptives, and previous history of ectopic pregnancy are all risk factors for ectopic pregnancy.’ N8: ‘My husband did not care about it before. After our local hospital did a B-scan that suspected an ovarian tumour, he became nervous and asked us to go to a large hospital immediately. Now he is very kind to me and starts caring about me.’ N13: ‘Several neighbors helped me call 120 for an emergency. In recent days, many neighbors have asked me how I am recovering. Indeed, distant relatives are not as good as close neighbors.’

Negative impacts of the experiences

After surgery, patients showed concerns about their physical condition. They found that delays in seeking medical care affected their health, interrupting treatment effects and postoperative recovery. They increased the financial burden and negative emotions among family members. N10: ‘The doctor said that my fallopian tube was broken, and there was no way to repair it. He cut off the fallopian tube. I lost much blood and had a blood transfusion, and now I still have anemia, which will take a long time for recovery.’ N7: ‘My current boyfriend is very kind and considerate to me. I want to marry him. However, I lost one fallopian tube. I also had abortions before. I do not know if I can get pregnant again (sobbing) in the future.’ N9: ‘Previously, a rheumatic doctor told me not to get pregnant, but now I am not only pregnant but also having an ectopic pregnancy. I do not know if the hormone level changes will have an impact on my condition or whether they will worsen (with a worried expression and hands clenched).’ N2: ‘My family’s income was very tight. Now I have to spend money every day in the hospital, which will increase the pressure on my husband.’ N4: ‘My parents and my parents-in-law are urging us to have a child. Now, I had an ectopic pregnancy. They all regret that they should not rush me.’ N12: ‘My husband is the only child in the family. His parents are relatively conservative. If we cannot have another child, we do not know how to deal with it.’ N13: ‘I got my life back this time, but my husband and I were terrified.’ N18: ‘I have had two miscarriages before. Now, I have an in vitro fertilization, but I found out it was an ectopic pregnancy. Why is it so hard for me to have a baby (with a thoughtful, helpless expression)?’

Expectations of their healthcare providers

This theme included three subthemes: reducing the length of outpatient examinations and waiting times, increasing public understanding of early symptoms of ectopic pregnancy and increasing male awareness of safe contraceptive methods.

Respondents hoped that medical service institutions would reduce outpatient examinations and waiting times, strengthen public understanding of early symptoms of ectopic pregnancy, enable women of childbearing age to have a certain ability to identify the reasons and early symptoms of ectopic pregnancy and encourage men to choose safe contraceptive methods to reduce the physical harm caused to women by unplanned pregnancies or unsafe contraceptive methods. N1: ‘I came to the emergency room at night and received the blood tests. I was also given a saline infusion. Because I had abdominal hematocele and could not see clearly by B-scan ultrasonography. I had to undergo CT and wait for a long time. This could easily delay my illness.’ N6: ‘There were many patients in the hospital. I had to wait in a line to see the doctor and then wait in another line for the B-scan ultrasonography. I waited all morning to finish all of these.’ N1: ‘The hospital can make and put some short educational videos on their website and update them regularly.’ N15: ‘Local community can also arrange health lectures for people of different ages.’ N20: ‘My boyfriend does not like wearing condoms. He gets angry if I remind him about it. Sometimes, he did external ejaculation. Sometimes, he even asked me to take emergency contraceptive pills. If he could listen to what the doctor said, I would not get pregnant.’ N6: ‘After I had an intrauterine device, I started to have irregular menstruation and severe back pain. I had to remove it. Sometimes, I was too busy and forgot to take the short-acting contraceptive pills. My husband did not like to use condoms. I am also agitated. Why don’t men care about us (a bit angry)?’

We performed a qualitative study with women who had experienced ectopic pregnancy and delays in seeking medical care. Three main themes emerged from the analysis, including reasons for delaying medical care, physical and psychological experiences, and expectations of their healthcare providers. Each main theme also included several subthemes to let us better understand the physical and mental health, as well as requirements, of these women. In the following paragraphs, we discuss our findings and recommendations to improve healthcare for women at risk of ectopic pregnancy.

Women’s healthcare education

This study found that interviewees were not aware of the symptoms of ectopic pregnancy. Some patients only knew specific symptoms or attributed abnormal symptoms to other diseases. This might be because the early signs of ectopic pregnancy are neither sensitive nor specific. It also indicated that patients lacked adequate knowledge about disease symptoms, particularly identifying early symptoms, diagnosing worsening conditions and understanding the medical emergency of ectopic pregnancy. All of these could lead to delays in seeking medical care. This was consistent with the study from Kulp and Barnhart. 20 The subjective physical feelings, the severity of their self-evaluations of the disease, the symptoms and the duration of the disease were the most critical factors that led to individuals’ decisions about whether to seek medical services. 21 According to the theory of protective motivation, patients who were fully aware that their conditions could cause severe damage to their bodies would be more willing to pay attention to their abnormal symptoms and change their lousy living habits. 22 23 Therefore, medical personnel and community medical workers should educate women of reproductive age, improve their healthcare knowledge, draw their attention to abnormal symptoms related to their reproductive system and make them respond to abnormal symptoms and signs appropriately. The prevention and treatment of risk factors for ectopic pregnancy should be fully explained to these women. At the same time, it is necessary to pay attention to the health education needs of patients, recommend appropriate education opportunities for different patients and emphasise the outcomes of delays in seeking medical care and bad habits. In addition, health education content should be personalised and innovative for future healthcare, not limited to the current patient requirement.

Emotional and family support

This study found that tight family economic budgets, lack of companionship at the onset of symptoms or lack of support from family members were significant factors that led to delays in seeking medical care. Low-income family conditions could exacerbate the fears of medical treatment and medical expenses. These patients would want to wait and delay medical care due to the stress from the discomforts caused by illness and lack of adequate psychological preparation. 24 25 When these patients had abnormal symptoms, they could suffer from varying degrees of tension and anxiety, making it difficult to make rational judgments. If family members accompany them, they might provide assistance and help the patient promptly seek medical treatment. 24 Therefore, it is critical to explain the importance of family support to patients and their families. The family members should give more support to women and seek medical care immediately if necessary. They should be educated that the medical cost could be much lower if they seek medical care immediately. The entire family should fully establish a correct attitude toward immediate medical care.

Fertility needs

In recent years, the adoption of ‘two-child policy’ and ‘three-child policy’, as well as the widespread development of assisted reproductive technology in China, have led to a rising trend in the proportion of pregnant women over 35 years of age. This could lead to an increasing increased incidence of ectopic pregnancy. Other factors, such as history of caesarean section, induced abortion, intrauterine device placement, pelvic inflammatory disease, pelvic surgery and a previous ectopic pregnancy, could also increase the risk for ectopic pregnancy. In addition, unintended pregnancy, choosing safe contraceptives and conceiving safely are challenging for women of childbearing age. 26 In many developing countries, men are the breadwinners who bring the most household income. Men often determine the medical expenses and opportunities to access medical treatments for women. Therefore, partner involvement should be encouraged to improve maternal health outcomes. 27 Therefore, medical personnel and community workers should proactively promote and guide family planning to reduce women’s physical and psychological stress caused by unplanned pregnancies or unsafe contraceptive methods. This study found that education, age and marital status were sociodemographic factors contributing to patients’ delay in seeking medical treatment. Patients with a low education level lacked adequate knowledge of the disease and did not understand the importance of timely medical attention. 28 Married women and women with children were likely to report symptoms earlier, consistent with the study by Sefogah et al . 29 Young and unmarried women tended to avoid medical attention due to traditional reproductive thinking, fearing that others would look at them differently. Research by Asah-Opoku et al showed that single women with multiple sexual partners were at high risk for sexually transmitted diseases, including pelvic inflammatory disease, associated with ectopic pregnancy. 30 Therefore, medical and community health institutions should develop personalised reproductive health guidance for women with different cultural levels, ages and reproductive needs, especially their spouses, parents and sexual partners.

Learnings from medical delays

This study found that, due to patients’ different family environments and reproductive needs, the physiological, mental, and social roles caused by surgery were different, resulting in different postoperative physical and mental experiences. This was similar to the study by Farren et al . 31 Women with ectopic pregnancy often experience high levels of post-traumatic stress, anxiety and depression. Although distress might decrease over time, it could remain at a clinically important level at 9 months post partum. 31 All of these could seriously impact the quality of life and physical and mental health of women. 32 Adequate nursing care could alleviate the psychological pressure and negative emotions and establish appropriate coping strategies in women with ectopic pregnancy. 31 Therefore, in the postoperative care of patients with ectopic pregnancy, medical personnel should take the initiative to care for the patients. We can assess their medical experience and reproductive needs, understand their physical and mental experiences, 33 guide them to attach importance to and use positive influences, encourage them to actively participate in medical activities, answer questions, and provide more assistance and support. At the same time, the trust, understanding, and recognition of patients and their families can be obtained through professional nursing services, good communication and targeted psychological interventions. 34 Patients’ negative experiences and emotions can be managed to improve their post-traumatic stress, anxiety and depression, reshape their medical experience, and promote their physical and mental recovery.

Medical resources and social supports

The research results showed that the convenience of therapy significantly impacted how patients seek medical care. 35 The distance between the residence and the medical institution could affect patients’ medical decision-making. 36 Limited medical resources in rural areas could easily lead to misdiagnosis and delays in seeking medical care. 37 Therefore, more attention should be paid to areas with little or lacking high-quality medical resources. The quality and level of medical services in the local community should be improved. At the same time, we should also improve access to healthcare, especially in the urban edge area. During the interviews, nearly half of the patients reported their experience of avoiding medical treatment due to high medical expenses, cumbersome procedures, long waiting times and the inability to complete the medical treatment process independently. Therefore, the local government should make policies to optimise the resident medical health insurance system, 38 reduce the prenatal cost for women and decrease their economic burden. 39 In addition, we can also use the mobile medical facility 40 and simplify the clinical steps to shorten patient waiting time. At the same time, medical personnel should continuously strengthen their service quality, enhance their professional skills and avoid excessive medical tests and treatments to improve patients’ experience and allow them to obtain medical care services more timely and efficiently.

Strengths and limitations

To our knowledge, we performed the first qualitative study on women with ectopic pregnancy and delays in seeking medical care in China. However, our study was limited by its small number of patients in a single hospital. In addition, patients’ experiences might change depending on different socioeconomic status, cultural backgrounds and local fertility policies. The results of our study might not be fully generalised to other regions in China and other countries. More studies are required to validate our results here.

The main reason for delaying medical care was the lack of knowledge about the early symptoms of ectopic pregnancy. Delays in seeking medical care negatively impacted patients’ physical and mental health, recovery and future healthcare. It could also lead to secondary infertility, pelvic inflammatory disease, post-traumatic stress, anxiety, depression and prolonged distress. Better medical education, family support, healthcare provider training and local fertility policies should be optimised to facilitate access to healthcare, reduce delayed medical treatments, improve pregnancy outcomes and decrease the incidences of maternal morbidity and mortality in these women.

Supplementary Material

Contributors: JL and JZ were involved in the study design and data analysis; JL, YL and YS performed the patient recruitment, data collection and manuscript drafting. JZ is responsible for the overall content as the guarantor. All authors (JL, YL, JZ, YS and HSL) participated in the manuscript writing and performed critical revisions of the manuscript.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement

Ethics statements, patient consent for publication.

Not applicable.

Ethics approval

The study was approved by the hospital ethics committee (ethics approval number: GYWY-L2022-98). Before the beginning of each interview, the investigator introduced the purpose, significance, time required and confidentiality principle of this study to the interviewees to obtain the patients’ informed consent, trust and cooperation. All patients were informed that they could withdraw from the study at any time without affecting the follow-up treatment, and all information would be used for the analysis only.

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Introduction, case report, acknowledgements, conflict of interest statement, consent for publication.

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Challenges in diagnosis and management of invasive ductal carcinoma in axillary ectopic breast tissue: a case study

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Alsadig Suliman, MagdAlden Osman, Siddig Ali, Sara Hussein, Reem Mohamed Osman, Enas Tageldin, Lobna E Ali, Challenges in diagnosis and management of invasive ductal carcinoma in axillary ectopic breast tissue: a case study, Journal of Surgical Case Reports , Volume 2024, Issue 8, August 2024, rjae531, https://doi.org/10.1093/jscr/rjae531

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Ectopic breast tissue (EBT) is breast tissue located outside the normal anatomic boundaries of the breasts, developing due to incomplete embryological regression of the mammary ridges. EBT can develop anywhere along the milk line, with the axilla being the most common site. While generally benign, EBT can undergo malignant transformation. This case report discusses a 24-year-old female with locally advanced invasive ductal carcinoma in the axillary EBT, highlighting its clinical presentation, diagnostic process, and management in a resource-limited setting. The patient underwent wide local excision and axillary lymph node dissection followed by adjuvant chemotherapy and radiotherapy, achieving a favorable short-term outcome. This case underscores the importance of considering EBT in differential diagnosis of axillary masses and the need for tailored treatment strategies in such settings.

Ectopic breast tissue (EBT), also known as accessory breast tissue, refers to the presence of breast tissue located outside the normal anatomical boundaries of the breasts [ 1 ]. EBT develops due to incomplete embryological regression of the mammary ridges, which extend from the axilla to the vulva [ 2 , 3 ]. It is present in 2%–6% of the population and, like normal breast tissue, has the potential to develop malignancy [ 4 , 5 ]. Although malignancies in EBT are rare, they tend to have a progressive clinical course. The incidence of EBT carcinoma is 0.3%–0.6% of all breast cancers, with the axilla being the most common site [ 6 ]. We present a unique case of invasive ductal carcinoma (IDC) in the EBT of the axilla, highlighting the diagnostic and therapeutic challenges associated with this condition.

A 24-year-old female, unmarried and a nonsmoker, presented with a painless mass in her left axilla that had been developing for approximately six months. She also reported significant weight loss and fatigue but had no family history of breast cancer. On physical examination, both breasts and the right axilla were normal. However, the left axilla revealed a hard, mobile lump measuring 12.6 × 8.4 × 4.5 cm with hyperpigmented and ulcerated skin. In addition, palpable, painless left axillary lymph nodes (ALNs) were observed ( Fig. 1 ).

Beginning of surgery (WLE) at left axilla with ulcerated prominent ectopic breast tissue (indicated by an arrow).

An ultrasound of the left axilla revealed a mass measuring 12.6 × 8.4 × 4.5 cm, located near the anterior border of the latissimus dorsi muscle and inferior to the axillary vein. The mass exhibited heterogeneous echotexture and irregular margins, suggestive of malignancy. Additionally, three enlarged ALNs with irregular borders were identified. A core needle biopsy of the mass, guided by ultrasound, confirmed the presence of IDC ( Fig. 2 ). Furthermore, an ultrasound-guided biopsy of the suspicious ALNs confirmed malignancy.

H&E stain slide shows histopathological features of IDC.

Immunohistochemical analysis of the axillary mass biopsy revealed estrogen receptor and progesterone receptor positivity, while human epidermal growth factor receptor 2 was negative. Thoracoabdominal CT showed no secondary localizations, and whole-body bone scintigraphy detected no bone metastases. The overall stage was determined to be T4bN1M0 (Stage IIIB).

A multidisciplinary team determined the patient to be a candidate for neoadjuvant chemotherapy (NAC) followed by surgical management and adjuvant chemotherapy (AC). However, due to the unavailability of chemotherapy at the time of diagnosis, surgical management proceeded after careful patient counseling. A wide local excision (WLE) of the mass with levels I and II axillary lymph node clearance (ALNC) was performed ( Fig. 3 ). Histopathology reported a Nottingham grade III IDC with infiltrative borders and dense marginal lymphatic infiltration. The tumor was totally excised with 10 out of 15 soft white lymph nodes showing extensive metastatic deposits. The patient did not suffer any complications postoperatively. Upon follow-up after three weeks, the patient was in good health. Postoperatively, she received four of the six planned cycles of adjuvant chemotherapy; the fourth cycle was canceled due to neutropenia. She also received hormonal therapy and radiotherapy as per the treatment plan.

Gross finding appearance of the EBT specimen showed a solid mass with clear margins. S : superficial margin; D : deep margin; M : medial margin; L : lateral margin.

EBT results from the failure of complete regression of the mammary ridges during embryological development. Axilla is the most common location for EBT, accounting for 58% of reported cases [ 6 ]. Other locations include the parasternal line, sub clavicular area, sub-mammary region, and vulvar region [ 7 ]. EBT may contain only glandular tissue or be associated with a nipple-areola complex [ 8 ]. Hormonal regulation influences its development, and it may become apparent during puberty and pregnancy, similar to normal breast tissue [ 9 ]. EBT is subject to the same pathologies, including pain, inflammation, fibroadenoma, and cancers [ 6 ]. However, the exact incidence of primary EBT carcinoma and the rate of malignant transformation remain unknown [ 2 ]. Accurate diagnosis of axillary EBT carcinoma is crucial as it provides precise staging information for patients with concurrent ipsilateral breast cancer [ 10 ]. IDC is the most frequently reported pathological type of EBT cancer, although other types such as medullary, lobular, and phyllodes have also been reported [ 6 ].

Managing EBT cancer is consistent with the guidelines for pectoral breast cancer, involving a multidisciplinary approach and standard triple therapy: surgery, systemic therapy, and radiation, depending on the staging and tumor biology [ 7 ]. Imaging studies like breast MRI, US, and mammography are vital for assessing EBT cancer [ 6 ]. Fine-needle aspiration cytology can aid in diagnosing malignancy, but distinguishing between EBT cancer and lymph node metastasis from occult primary lesions can be challenging. Histologically, the presence of adjacent normal breast tissue (ducts and lobules) and lack of lymphoid tissue confirm the diagnosis of EBT cancer and exclude metastatic lymph nodes [ 11 ]. According to lymph node guidelines, using ultrasound-guided biopsy of suspicious ALNs is essential in confirming malignancy before undertaking ALNC [ 12 ].

This case involves a young patient with locally advanced IDC of axillary EBT. Despite resource limitations, WLE with ALNC followed by AC and radiotherapy contributed to a favorable short-term outcome. The choice of treatment modalities was guided by the aggressive nature of the tumor, ALNs involvement, and the need to achieve optimal disease control.

In modern breast surgery, NAC would have been the gold standard prior to surgery for a premenopausal patient with metastatic ALNs. NAC is significant in reducing tumor volume to increase the breast-conserving rate. It is crucial for downgrading locally advanced inoperable patients to provide surgical opportunities [ 13 ]. On the other hand, AC was initiated to target potential micrometastases and systemic spread, aligning with recommendations for cases with adverse prognostic features. The patient's response highlights the critical role of surgical intervention in such cases [ 14 ]. Adjuvant radiotherapy was administered to enhance local control and reduce the risk of recurrence, in accordance with recommendations despite existing controversies regarding its use in ipsilateral disease-free pectoral breast [ 7 ].

Ectopic breast tissue pathologies are rarely reported, leading to a lack of awareness among clinicians regarding their presentation, diagnosis, and management. The absence of specific clinical guidelines for EBT cancer can result in misdiagnosis and inappropriate treatment, leading to poor prognosis. Clinicians should include EBT in breast examinations and consider its inclusion in screening procedures.

Our appreciation extends to the medical, surgical, and healthcare teams for their expertise and dedication in managing this case.

All authors declare no conflicts of interest.

This case report did not receive any specific funding.

An informed consent was signed by the patient.

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