Last reviewed: October 11, 2022
Recommendation:
- Diagnosis of an ectopic pregnancy should be excluded in individuals who have a concerning history or examination.
Strength of recommendation: Strong
Quality of evidence: Low
Epidemiology
In both high and low resource settings, ectopic pregnancy rates range from less than 1% to 2% of pregnancies (Al Naimi et al., 2021; Anyanwu & Titilope, 2021; Berhe et al., 2021; Ghimire, 2020; Stulberg et al., 2013; Tao, Patel, & Hoover, 2016; Trabert et al., 2011; Webster et al., 2019), and are even lower in pregnant people seeking abortion (Aiken et al., 2021; Cleland et al., 2013; Duncan, Reynolds-Wright, & Cameron, 2022). Ectopic pregnancy accounts for 2.7% of pregnancy-related deaths in the United States (Creanga et al., 2017). Ectopic pregnancy accounts for approximately 1% of pregnancy-related deaths in low resource settings where other causes of maternal death are more prevalent (Khan et al., 2006).
​Risk factors
Factors with the highest associated risk of ectopic pregnancy in a pregnant person are:
| ​Risk factor | Risk of ectopic in the current pregnancy​ |
| ​Previous ectopic pregnancy | ​10-25% |
| History of tubal surgery, including sterilization | ​25-50% |
| Intrauterine device (IUD) in place​ | ​25-50% |
(American College of Obstetricians and Gynecologists [ACOG], 2018; Ankum et al., 1996; Barnhart, 2009; Gaskins et al., 2018; Jacob, Kalder, & Kostev, 2017)
Other risk factors include a history of infertility and assisted reproductive technology use, a history of pelvic infections, multiple partners, early age at first intercourse, early age at first oral contraceptive use and smoking (ACOG, 2018; Ankum et al., 1996; Barnhart, 2009, Gaskins et al., 2018; Olamijulo et al., 2020).
Screening
Half of all ectopic pregnancies occur in people with no risk factors and with a benign clinical presentation in high-income countries (Stovall et al., 1990), whereas in low- and middle-income countries, people are more likely to present with acute clinical features, including hemodynamic instability (Olamijulo et al., 2020). Providers should screen for ectopic pregnancy risk factors during the history and physical examination including relevant history, such as previous ectopic pregnancy, tubal ligation, tubal surgery or an IUD in place. Screening should also include symptoms and signs of ectopic pregnancy found during history taking and physical examination, such as an adnexal mass, pain on examination or vaginal bleeding.
Some people present for abortion care very early in pregnancy, before there is definitive ultrasound evidence of an intrauterine gestation. A 2020 systematic review, including three retrospective comparative cohort studies of 5,315 people seeking early medical or aspiration abortion, found that there was no increase in incidence of missed diagnosis of ectopic pregnancy or incomplete abortion when abortion was initiated prior to ultrasound evidence of intrauterine pregnancy in women who did not have signs or symptoms of an ectopic pregnancy (Schmidt-Hansen et al., 2020). Two subsequent small, retrospective cohort studies have confirmed that among people with very early pregnancies and no major ectopic pregnancy risk factors, there is no increase in the diagnosis of a missed ectopic pregnancy when medical abortion was initiated before ultrasound evidence of pregnancy (Goldberg, et al., 2022; Jar-Allah et al., 2022).
Treatment for high-risk people
Ultrasound and serial hCG testing are often used to help assess pregnancy location (Fields & Hathaway, 2017). In some cases, the most expeditious way to confirm an intrauterine pregnancy is to perform vacuum aspiration; presence of products of conception in the uterine aspirate confirms that the pregnancy was intrauterine. Individuals with suspicious signs and symptoms or a concerning physical exam should be diagnosed and treated as soon as possible or transferred immediately to a facility that can manage ectopic pregnancy. Early diagnosis and treatment of ectopic pregnancy can help preserve fertility and save lives.
Post-procedure screening
For those undergoing vacuum aspiration, the aspirate should be strained and examined to confirm the presence of products of conception (see 3.4.4 Examining products of conception). If products of conception are not seen, a diagnosis of ectopic pregnancy should be considered.Â
References
Aiken, A., Lohr, P.A., Lord, J., Ghosh, N., & Starling, J. (2021). BJOG: An International Journal of Obstetrics & Gynaecology, 128(9), 1464-1474.
Al Naimi, A., Moore, P., Bruggmann, D., Krysa, L., Louwen, F., & Bahlmann, F. (2021). Ectopic pregnancy: A single-center experience over ten years. Reproductive Biology and Endocrinology, 19(1), 79
American College of Obstetricians and Gynecologists. (2018). Practice bulletin No 193: Tubal ectopic pregnancy. Obstetrics & Gynecology 131, e91-e103.
Ankum, W. M., Mol, B. W. J., Van der Veen, F., & Bossuyt, P. M. M. (1996). Risk factors for ectopic pregnancy: A meta-analysis. Fertility and Sterility, 60(6), 1093-9.
Anyanwu, M., & Titilope, G. (2021). Ectopic pregnancy at the Gambian tertiary hospital. African Health Sciences, 21(1), 295-303.Barnhart, K. T. (2009). Clinical practice. Ectopic pregnancy. New England Journal of Medicine, 361(4), 379-387.
Berhe, E.T., Kiros, K., Hagos, M.G., Gesesew, H.A., Ward, P.R., & Gebremeskel, T.G. (2021). Ectopic pregnancy in Tigray, Ethiopia: A cross-sectional survey of prevalence, management, outcomes, and associated factors. Journal of Pregnancy, 4443117. Doi: 10.1155/2021/4443117.
Creanga, A. A., Syverson, C., Seed, K., & Callaghan, W. M. (2017). Pregnancy-related mortality in the United States, 2011-2013. Obstetrics & Gynecology, 130(2), 366-373.
Duncan, C.I., Reynolds-Wright, J.J., & Cameron, S.T. (2022). Utility of a routine ultrasound for detection of ectopic pregnancies among women requesting abortion: A retrospective review. BMJ Sexual and Reproductive Health, 48(1), 22-27.
Fields, L., & Hathaway, A. (2017). Key concepts in pregnancy of unknown location: Identifying ectopic pregnancy and providing patient-centered care. Journal of Midwifery and Womens Health, 62(2), 172-179.
Gaskins, A. J., Missmer, S. A., Rich-Edwards, J. W., Williams, P. L., Souter, I., & Chavarro, J. E. (2018). Demographic, lifestyle, and reproductive risk factors for ectopic pregnancy. Fertility and Sterility, 110(7), 1328-1337.
Ghimire, S.P. (2021). Study of ectopic pregnancy at tertiary care hospital in Province 1 of Nepal. Journal of Nepal Health Research Council, 18(4), 698-701.
Goldberg, A.B., Fulcher, I.R., Fortin, J., Hofer, R.K., Cottrill, A., Dethier, D., Gilbert, A., Janiak, E., & Roncari, D. (2022). Mifepristone and misoprostol for undesired pregnancy of unknown location. Obstetrics & Gynecology, 139(5), 771-780.
Jacob, L., Kalder, M., & Kostev, K. (2017). Risk factors for ectopic pregnancy in Germany: a retrospective study of 100,197 patients. German Medical Science, 15, Doc19.
Jar-Allah, T., Hognert, H., Kocher, L., Berggren, L., Fiala, C., Milsom, I., & Gemzell-Danielsson, K. (2022). Detection of ectopic pregnancy and serum beta hCG level in women undergoing very early medical abortion: A retrospective study. European Journal of Contraception and Reproductive Health Care, 27(3), 240-246.
Khan, K. S., Wojdyla, D., Say, L., Gulmezoglu, A. M., & Van Look, P. F. (2006). WHO analysis of causes of maternal death: A systematic review. The Lancet, 367(9516), 1066-1074.
Olamijulo, J.A., Okusanya, B.O., Adenekan, M.A., Ugwu, A.O., Olorunfemi, G., & Okojie, O. (2020). Ectopic pregnancy at the Lagos University Teaching Hospital, Lagos, South-Western Nigeria: Temporal trends, clinical presentation and management outcomes from 2005 to 2014. Nigerian Postgraduate Medical Journal, 27, 177-83.
Schmidt-Hansen, M., Cameron, S., Lord, J., & Hasler, E. (2020). Initiation of abortion before there is definitive ultrasound evidence of intrauterine pregnancy: A systematic review with meta-analyses. Acta Obstetricia et Gynecologica Scandinavica 99, 451-458.
Stovall, T. G., Kellerman, A. L., Ling, F. W., & Buster, J. E. (1990). Emergency department diagnosis of ectopic pregnancy. Annals of Emergency Medicine, 19(10), 1098-1103.
Stulberg, D., Cain, L. R., Dahlquist, I., & Lauderdale, D. S. (2013). Ectopic pregnancy rates in the Medicaid population. American Journal of Obstetrics & Gynecology, 208(4), 274.e1-7.
Tao, G., Patel, C., & Hoover, K. W. (2016). Updated estimates of ectopic pregnancy among commercially and Medicaid-insured women in the United States, 2002-2013. Southern Medical Journal, 110(1), 18-24.
Trabert, B., Holt, V. L., Yu, O., Ven Den Eeden, S. K., & Scholes, D. (2011). Population-based ectopic trends, 1993-2007. American Journal of Preventative Medicine, 40(5), 556-560.
Webster, K., Eadon, H., Fishburn, S, & Kumar, G. (2019). Ectopic pregnancy and miscarriage: diagnosis and initial management: summary of updated NICE guidance. British Medical Journal, 367, 16283.