During a normal pregnancy, a fertilized egg travels from the fallopian tube to the uterus, where it implants. Rarely, in approximately 2% of pregnancies, the fertilized egg implants elsewhere, usually within the fallopian tube, a condition called ectopic or tubal pregnancy (1). Because the uterus is the only organ that can sustain a healthy, full-term pregnancy, implantation in the fallopian tube or elsewhere must be diagnosed early and treated. Improved diagnostics now allow 85% or more of ectopic pregnancies to be diagnosed at early stages in North America (2). Some women present with early symptoms, such as nausea, vomiting, localized one-sided abdominal pain, cramping, and bleeding or spotting. In the event of these symptoms, a woman should immediately consult her physician to allow an ectopic pregnancy to be diagnosed by transvaginal ultrasound and human chorionic gonadotropin evaluation (3). However, some women do not have symptoms, increasing the chances that an ectopic pregnancy will go undiagnosed. If an ectopic pregnancy is not diagnosed in time, the growing embryo can cause the fallopian tube or other non-uterine site of implantation to rupture. Although the incidence of ruptured ectopic pregnancy has become less common in developed countries, it remains a major medical emergency, causing 4-10% of pregnancy-related deaths.
What are the signs of a ruptured ectopic pregnancy?
- Sudden, severe abdominal or pelvic pain that is generally located on one side. Sometimes the pain is so severe, a woman cannot stand (4).
- Bleeding. A woman may or may not be aware of bleeding, because this may be restricted to internal bleeding. The internal bleeding can be heavy, leading to substantial blood loss and shock.
- Lightheadedness or dizziness, which may be severe enough to cause loss of consciousness due to blood loss. There may be additional external symptoms, such as a pale appearance or clammy, sweaty skin (5, 6).
- Hypotension (low blood pressure) and a rapid heartbeat due to blood loss and shock (5, 6)
- Other localized pain. Pain may also occur in the lower back or even in the shoulders due to internal abdominal bleeding causing irritation of nerves that travel from the abdominal to shoulder region (5, 6, 7).
A prior history of ectopic pregnancy places a woman at risk for future ectopic pregnancies. Additional risk factors include sexually transmitted infections, pelvic inflammatory disease, endometriosis, tubal ligation, infertility treatments, and use of an intrauterine device (8). Although early ectopic pregnancies may be managed with the drug methotrexate, ruptured ectopic pregnancy requires surgery to remove the pregnancy and damaged tube. Substantial blood loss may also necessitate a blood transfusion. In rare cases, about one of 2,600 pregnancies, an ectopic pregnancy coincides with an intrauterine pregnancy, a condition called heterotopic pregnancy (1). The incidence of heterotopic pregnancy has increased with the use of fertility treatments. In such cases, to attempt to save the intrauterine pregnancy, the ectopic pregnancy must be surgically removed.
Ruptured ectopic pregnancy is a medical emergency and must be treated immediately. Women should contact their physician if they experience vaginal bleeding, lightheadedness, fainting, or shoulder pain, particularly when accompanied by severe abdominal pain. Even after tubal rupture and subsequent surgical treatment, most women are able to go on to have future, successful pregnancies.
- Tenore JL. Ectopic Pregnancy. American Family Physician 2000;61(4):1080-1088.
- Marion LL and Meeks GR. Ectopic pregnancy: history, incidence, epidemiology, and risk factors. Clin Obstet Gynecol 2012;55(2):376-86.
- Clinical Management Guidelines for Tubal Ectopic Pregnancy. March 2018.
- Metz S and Disney J. Ectopic Pregnancy. eMedicine Health. 02/15/2019.
- Danielsson K. Signs of a ruptured ectopic pregnancy. VeryWellFamily. 03/15/2019.
- Ectopic Pregnancy. 11/27/2018.
- Corvese A. Shoulder pain as an indication of ruptured ectopic pregnancy. 12/11/1924.
- What to know about ectopic pregnancy. 02/06/2019.