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Nutrition facts label
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A sample nutrition facts label, with instructions from the U.S. Food and Drug Administration.[1]
The nutrition facts label (also known as the nutrition information panel, and other slight variations) is a label required on most packaged food in many countries. Most countries also release overall nutrition guides for general educational purposes. In some cases, the guides are based on different dietary targets for various nutrients than the labels on specific foods.
Nutrition facts labels are only one of many types of food label required by regulation or applied by manufacturers.
Contents
1 Australia and New Zealand
2 Canada
3 China
4 European Union
5 Hong Kong
6 India
7 Mexico
8 United States
8.1 Description
8.2 2016 revision
8.3 Alcohol
8.4 Caffeine
9 See also
10 References
11 External links
Australia and New Zealand[edit]
Australia and New Zealand use a nutritional information panel of the following format:
NUTRITION INFORMATION
Servings per package:
Serving size: g
Quantity per Serving
Quantity per 100 g
Energy 0 kJ (Cal)
Protein 0 g
Fat, total 0 g
- saturated 0 g
Carbohydrate g g
- sugars g g
Sodium mg mg
Other items are included as appropriate, and the units may be varied as appropriate (e.g. substituting ml for g, or mmol for mg in the 'Sodium' row).[2] In April 2013 the New Zealand government introduced rules around common claims made on food packaging, such as 'low in fat'.[3]
Canada[edit]
See also: Canadian health claims for food
A Canadian Nutrition Label displaying information in both English and French.
In Canada, a standardized "Nutrition Facts" label was introduced as part of regulations passed in 2003, and became mandatory for most prepackaged food products on December 12, 2005. (Smaller businesses were given until December 12, 2007 to make the information available.).[4] In accordance with food packaging laws in the country, all information, including the nutrition label, must be written in both English and French, the country's two official languages.[5]
Canadian regulation tightly controls the manner in which the nutrition fact table (NFT) data are laid out. There is a wide variety of possible formats for use on a given food package. A selection hierarchy is used to select among the many formats (28 main formats, and 2-7 sub formats for each). This results in standard (vertical) formats being considered for use before horizontal and linear formats. The selection hierarchy also allows the NFT to occupy no more than 15% of the physical package's available display area (ADS), but never to be smaller than a format that would be <=15% of ADS. In practice, determining the ADS of a package, and selecting the appropriate NFT format, can be a detailed calculation.
China[edit]
In 2011 the Chinese Ministry of Health released the National Food Safety Standard for Nutrition Labeling of Prepackaged Foods (GB 28050-2011). The core nutrients that must be on a label are: protein, fat, carbohydrate and sodium. Energy is noted in kJ. And all values must be per 100g/100ml.,[6][7]
European Union[edit]
A UK nutrition information label, for low-fat yoghurt. A key difference from US labelling is that it always gives values for a set quantity (100 ml or - like here - 100 g), allowing easy comparison between products. Also, fibre is not considered a type of carbohydrate
A rare example of optional nutrition facts on a label for oranges (in the EU not mandatory for unprocessed fruits)
It was regulated by the Commission Directive 2008/100/EC of 28 October 2008 amending Council Directive 90/496/EEC on nutrition labelling for foodstuffs as regards recommended daily allowances, energy conversion factors and definitions.[8] A new regulation is now in force (Regulation 1169/2011).[9] Nutritional labelling becomes mandatory for most pre-packaged foods as from December 2016.
In the European Union, along the "old" rules (Directive 90/496, amended), the information (usually in panel format) is most often labelled "Nutrition Information" (or equivalent in other EU languages). An example is shown on the right. The panel is optional, but if provided, the prescribed content and format must be followed. It will always give values for a set quantity — 100 g (3.5 oz) or 100 ml (3.5 imp fl oz; 3.4 US fl oz) of the product — and often also for a defined "serving", as an option. First will come the energy values, in both kilocalories and kilojoules.
Then will come a breakdown of constituent elements: usually most or all of protein, carbohydrate, starch, sugar, fat, fibre and sodium. The "fat" figure is likely to be further broken down into saturated and unsaturated fat, while the "carbohydrate" figure is likely to give a subtotal for sugars. With the "new" rules, the mandatory information is: energy, fat, saturates, carbohydrates, sugars, protein and salt, in that particular order, with options to extend this list to: mono-unsaturates, polyunsaturates, polyols, starch, fibre, and vitamins and minerals.[9]
With regards to health claims and nutrition (composition) claims, these are harmonised in the EU through Regulation 1924/2006, amended.[10] In November 2012, the European Commission published two new regulations: Regulation (EC) No. 1047/2012 and Regulation (EC) No.1048/2012. Certain nutrition claim groups as of Regulation (EC) No 1924/2006 had to be changed. Moreover, the health claims associated to barley beta-gluten were amended (e.g. lowering blood cholesterol).[11][12]
Within Regulation 1924, there are legal definitions of terms such as "low fat", "high fibre", "reduced calories".[10]
All health claims have been harmonised in the European Union. They can be used if they have been approved by EFSA. The list of approved and rejected claims is available on a web site.[13]
Provided the full nutrition information is shown on the packet, additional nutritional information and formats (e.g. a traffic light rating system) may be included and this falls outside the scope of regulation.
The United Kingdom regulations are given in Schedules 6 and 7 of the Food Labelling Regulations 1996.[14]
Further information: Guideline Daily Amount and Dietary Reference Values
Hong Kong[edit]
In Hong Kong nutrition facts labels are regulated by the subsidiary legislation Food and Drugs (Composition and Labelling) (Amendment: Requirements for Nutrition Labelling and Nutrition Claim) Regulation 2008.[15]
India[edit]
The Ministry of Health and Family Welfare had, on September 19, 2008, notified the Prevention of Food Adulteration (5th Amendment) Rules, 2008, mandating packaged food manufacturers to declare on their product labels nutritional information and a mark from the F.P.O or Agmark (Companies that are responsible for checking food products) to enable consumers make informed choices while purchasing.[16] Prior to this amendment, disclosure of nutritional information was largely voluntary though many large manufacturers tend to adopt the international practice.[17]
Mexico[edit]
Food products sold in Mexico use the NOM-051-SCFI-1994 "Información nutrimental" product labelling standard, very similar to "Nutrition Facts" in the US. The Official Mexican Standard, or NOM (Norma Oficial Mexicana), was developed by the Mexican Secretary of Commerce and Industrial Promotion (Secretaría de Comercio y Fomento Industrial), now a part of the Secretary of the Economy (SECOFI). It entered into effect on January 24, 1996[18] and defines "General specifications for labelling foods and pre-bottled non-alcoholic beverages."[19]
United States[edit]
Description[edit]
In the United States, the Nutritional Facts label lists the percentage supplied that is recommended to be met, or to be limited, in one day of human nutrients based on a daily diet of 2,000 calories.
With certain exceptions, such as foods meant for babies, the following Daily Values are used.[20] These are called Reference Daily Intake (RDI) values and were originally based on the highest 1968 Recommended Dietary Allowances (RDA) for each nutrient in order to assure that the needs of all age and sex combinations were met.[21] These are older than the current Recommended Dietary Allowances of the Dietary Reference Intake. For vitamin C, vitamin D, vitamin E, vitamin K, calcium, phosphorus, magnesium, and manganese, the current highest RDAs are up to 50% higher than the older Daily Values used in labeling, whereas for other nutrients the recommended needs have gone down. A side-by-side table of the old and new adult Daily Values is provided at Reference Daily Intake. As of October 2010, the only micronutrients that are required to be included on all labels are vitamin A, vitamin C, calcium, and iron.[22] To determine the nutrient levels in the foods, companies may develop or use databases, and these may be submitted voluntarily to the U.S. Food and Drug Administration for review.[23]
Nutrient
Daily Value for label
(before 2016 update)
highest RDA
of DRI
unit
Vitamin A 5,000 3,000 IU
Vitamin C 60 90 mg
Calcium 1,000 1,300 mg
Iron 18 18 mg
Vitamin D 400 600 IU
Vitamin E 30 IU 15 mg (33
IU synthetic)
Vitamin K 80 120 μg
Thiamin 1.5 1.2 mg
Riboflavin 1.7 1.3 mg
Niacin 20 16 mg
Vitamin B6 2 1.7 mg
Folate 400 400 μg
Vitamin B12 6 2.4 μg
Biotin 300 30 μg
Pantothenic acid 10 5 mg
Phosphorus 1,000 1,250 mg
Iodine 150 150 μg
Magnesium 400 420 mg
Zinc 15 11 mg
Selenium 70 55 μg
Copper 2 0.9 mg
Manganese 2 2.3 mg
Chromium 120 35 μg
Molybdenum 75 45 μg
Chloride 3,400 2,300 mg
Additionally, there is a requirement for ingredients to be listed in order from highest to lowest quantity, according to their weight.[citation needed]
The original FDA Nutrition Facts label, as of 2006
The new Nutrition Facts label
The label was mandated for most food products under the provisions of the 1990 Nutrition Labeling and Education Act (NLEA), per the recommendations of the U.S. Food and Drug Administration.[24] It was one of several controversial actions taken during the tenure of FDA Commissioner Dr. David Kessler. The law required food companies to begin using the new food label on packaged foods beginning May 8, 1994. (Meat and poultry products were not covered by NLEA, though the U.S. Department of Agriculture proposed similar regulations for voluntary labeling of raw meat and poultry.[25]) Foods labeled before that day could use the old label. This appeared on all products in 1995. The old label was titled "Nutrition Information Per Serving" or simply, "Nutrition Information".
The label begins with a standard serving measurement, calories are listed second, and then following is a breakdown of the constituent elements. Always listed are total fat, sodium, carbohydrates and protein; the other nutrients usually shown may be suppressed, if they are zero. Usually all 15 nutrients are shown: calories, calories from fat, fat, saturated fat, trans fat, cholesterol, sodium, carbohydrates, dietary fiber, sugars, protein, vitamin A, vitamin C, calcium, and iron.
Products containing less than 5 g of fat show amounts rounded to the nearest 0.5 g. Amounts less than 0.5 g are rounded to 0 g. For example, if a product contains 0.45 g of trans fat per serving, and the package contains 18 servings, the label would show 0 g of trans fat, even though the product actually contains a total of 8.1 g of trans fat.
In addition to the nutrition label, products may display certain nutrition information or health claims on packaging. These health claims are only allowed by the FDA for "eight diet and health relationships based on proven scientific evidence", including: calcium and osteoporosis, fiber-containing grain products, fruits and vegetables and cancer, fruits, vegetables, and grain products that contain fiber—particularly soluble fiber—and the risk of coronary heart disease, fat and cancer, saturated fat and cholesterol and coronary heart disease, sodium and hypertension, and folate and neural tube defects.[26] The Institute of Medicine recommended these labels contain the most useful nutritional information for consumers: saturated fats, trans fats, sodium, calories, and serving size.[27] In January 2011, food manufacturers and grocery stores announced plans to display some of this nutrition information on processed food.[28]
The nutrition facts label currently appears on more than 6.5 billion food packages. President Bill Clinton issued an award of design excellence for the nutrition facts label in 1997 to Burkey Belser in Washington, DC.[29]
The FDA does not require any specific typeface be used in the Nutrition Facts label, mandating only that the label "utilize a single easy-to-read type style",[30] though its example label uses Helvetica.[31] However, as regulated by the FDA and the USDA, it is mandatory for certain information listed in the label to be written in English, including: name of the product, net quantity, serving size and number of servings per package, nutrition facts, ingredient list, and name of manufacturer or distributor.[32] The smallest lettering should be at least 1/16th of an inch tall (1.5875 millimeters), based on the height of a lowercase "o".[33]
In January 2006, Trans fat was required to be listed under saturated fat. This was the first significant change to the Nutrition Facts panel since it was introduced in 1993.[34]
2016 revision[edit]
In 2014, the U.S. Food and Drug Administration proposed several simultaneous improvements to nutrition labeling for the first time in over 20 years.[35][36] The proposed changes were based on trends of consumption of nutrients of public health importance.[37] However, studies had shown that the majority of the U.S. population could not understand the information in the then current Nutrition Facts Label.[38] Nutrition label numeracy is particularly low in older individuals, of black and Hispanic race/ethnicity, who are unemployed, born outside of the US, have lower English proficiency, lower education achievement, lower income, or live in the South.[39]
Proposed changes included a new design requiring serving sizes to more accurately reflect how many servings the average individual is actually consuming. The new recommendation also proposed removing “calories from fat”, and instead focusing on total calories and type of fats being consumed in a product. The proposed labels were to also list how much sugar is added (rather than inherent) to a product, as well as declaring the amount of Vitamin D and potassium in a product.[35][40] Some of these changes sparked a major debate between the food industry and public health agencies. The proposal to indicate sugar added during food production, in particular, was brought forward by the FDA as a measure to counter the increase in per capita sugar consumption in the US, which over the last decades exceeded the limits recommended by scientific institutions and governmental agencies.[41][42] Major American food associations opposed the label change, indicating "lack of merit" and "no preponderance of evidence" to justify the inclusion of sugar added in the new label.[43][44]
The rules for the new design were finalized on May 20, 2016. Manufacturers were initially given until July 26, 2018 to comply (or July 26, 2019 if they have less than $10 million in annual food sales).[45] A proposed rule by the FDA would extend the compliance deadline to January 1, 2020 (or January 1, 2021 for qualified small business).[46] For food and dietary supplement labeling purposes the amounts of vitamins and nutritionally essential minerals in a serving are expressed as a percent of Daily Value (%DV). Many of the definitions of 100% Daily Value were changed as part of the revision.[47] A table of the old and new adult Daily Values is provided at Reference Daily Intake.
Alcohol[edit]
In the United States, alcoholic beverages are regulated by the Alcohol and Tobacco Tax and Trade Bureau (TTB). As of 2012, the TTB does not require alcoholic beverage packaging to have a nutrition facts label. Since at least 2003, consumer groups have lobbied the TTB to require labelling disclosing Nutrition Facts information.[48] Some marketing terms, such as "light" and "table wine", must follow TTB guidelines. Packaging must disclose alcohol content in some circumstances.[48][which?]
Mandatory information on the label varies by type of beverage, and includes:[49][50][51][52]
Brand name
Name and address of manufacturer (either bottling plant or main headquarters)
Country of origin if imported (required by U.S. Customs and Border Protection regulations)
Class, the definitions of which are regulated (e.g. beer, ale, lager, gin, vodka, rum, tequilla, cordial, liqueurs)
Health warning for beverages 0.5% or more alcohol by volume
Net contents
For malt beverages, must be in United States customary units (e.g. pints or fluid ounces)
For distilled spirits, must be in metric units. Bottles must be 50 mL, 100 mL, 200 mL, 375mL, 750 mL, 1 L, or 1.75 L. Bottles must be 50 mL, 100 mL, 200 mL, or 355 mL.
For wine, must be in metric units, and bottles must be 50 mL, 100 mL, 187 mL, 375 mL, 500 mL, 750 mL, 1L, 1.5 L, 3 L, or a larger size with an even number of liters.
Alcohol content (percent by volume):
For malt beverages, mandatory only if some alcohol is due to added flavors, or if required by state law
For distilled spirits, mandatory
For wine, optional
Declaration of sulfites required for wine sold in interstate (not intrastate) commerce if 10 ppm or more of sulfur dioxide
Optional but regulated terms:
For malt beverages: "draft", "light", "low-carbohydrate"
For wine: grape variety and appellation of origin, wine designation (e.g. "white", "red", "rose", "table"), viticultural area, "estate bottled, "vinted", vintage date
"Organic" (regulated by USDA)
Declarations for major allergens
Caffeine[edit]
Health researchers have called for the mandatory labelling of food products with added caffeine, which is a psychoactive nervous system stimulant.[who?][when?] If over-consumed, caffine can cause seizures, kidney problems, liver problems, heart arrhythmia, and death.[53] The Coca-Cola Company and PepsiCo began labelling caffeine content in 2007.[54]
See also[edit]
Diet (nutrition)
Food energy
List of food labeling regulations
Table of food nutrients
Nutritional scale
Serving size
Atwater system (for calculating available food energy)
The Non-GMO Project
Quack Miranda warning
References[edit]
Wikimedia Commons has media related to Nutrition information.
Jump up ^ "Nutrition Facts Label Images for Download". Fda.gov. 2011-09-23. Retrieved 2013-01-26.
Jump up ^ Food Standards Australia and New Zealand Standard 1.2.8 "Archived copy" (PDF). Archived from the original (PDF) on 2009-05-14. Retrieved 2009-01-03.
Jump up ^ "Greens welcome food labelling move". 3 News NZ. April 8, 2013.
Jump up ^ "Nutrition Labelling - Food and Nutrition - Health Canada". Hc-sc.gc.ca. Retrieved 2013-01-26.
Jump up ^ Directorate, Government of Canada, Canadian Food Inspection Agency, Food Labelling and Claims. "Bilingual Labelling". www.inspection.gc.ca.
Jump up ^ "General Rules for Nutrition labeling of prepackaged foods" (PDF). USDA Foreign Agriculture Service. Retrieved 2018-03-16.
Jump up ^ "GB 28050-2011 (chinese)". www.gsciq.gov.cn. Retrieved 2018-03-16.
Jump up ^ "COMMISSION DIRECTIVE 2008/100/EC of 28 October 2008". EUR-Lex.europa.eu. Retrieved 2013-01-26.
^ Jump up to: a b "REGULATION (EU) No 1169/2011 on the provision of food information to consumers".
^ Jump up to: a b "REGULATION (EC) No 1924/2006 on nutrition and health claims made on foods".
Jump up ^ Commission Regulation (EU) No 1047/2012, European Commission, 8 November 2012, Retrieved 7 April 2015
Jump up ^ Commission Regulation (EU) No 1048/2012, European Commission, 8 November 2012, Retrieved 7 April 2015
Jump up ^ SANTE, DG. "Nutrition and Health Claims - European Commission". ec.europa.eu.
Jump up ^ Food Labelling Regulations 1996, Schedule 7 - Nutrition Labelling, The Stationery Office, 1996, retrieved 2009-04-04
Jump up ^ "Hong Kong government". Nutritionlabel.gov.hk. Retrieved 2014-08-01.
Jump up ^ "PFA Rule Relating to Nutritional Labeling of Packaged Food Implemented" (PDF). USDA Foreign Agricultural Service. Retrieved 24 November 2014.
Jump up ^ "India: Packaged foods must list nutritional facts". Freshplaza.com. Retrieved 2013-01-26.
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Jump up ^ "mexicolaws.com". mexicolaws.com. Retrieved 2013-01-26.
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Jump up ^ See 21 CFR 101.9(c)(8) Archived 2009-08-13 at the Wayback Machine..
Jump up ^ VII. Nutrition Labeling; Questions G1 through P8. Guidance for Industry: A Food Labeling Guide. Accessed 2010-10-08. See also Guidance for Industry: Nutrition Labeling Manual - A Guide for Developing and Using Data Bases from the FDA.
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Jump up ^ Saltos E, Davis C, et al. (December 1994). "Using Food Labels To Follow the Dietary Guidelines for Americans: A Reference". Agriculture Information Bulletin Number 704. United States Department of Agriculture, Center for Nutrition Policy and Promotion. Retrieved November 25, 2008.
Jump up ^ Wheeler, Madelyn; Marion Franz; Joan Heins; Rebecca Schafer; Harold Holler; et al. (May 1994). "Food Labeling" (PDF). Diabetes Care. 17 (5): 482. doi:10.2337/diacare.17.5.480. Retrieved 28 January 2014.
Jump up ^ "Examination of Front-of-Package Nutrition Rating Systems and Symbols: Phase 1 Report". Institute of Medicine. 2010-10-13. Archived from the original on 2011-01-11. Retrieved 2011-01-26.
Jump up ^ "Food Makers Devise Own Label Plan". New York Times. 2010-01-25. Retrieved 2011-01-26.
Jump up ^ "Briefs - The NIH Record". National Institutes of Health. 2006-04-27. Archived from the original on 2009-06-09. Retrieved 2009-06-16.
Jump up ^ "21 CFR 101.9(d)(1)(ii)(A)" (PDF).
Jump up ^ "Examples of Revised Nutrition Facts Panel Listing Trans Fat". U.S. Food and Drug Administration, Center for Food Safety and Applied Nutrition. 2003-07-09. Archived from the original on October 13, 2007. Retrieved 2007-11-08.
Jump up ^ Davidson, Tish (2008). "Food Labeling". The Gale Encyclopedia of Diets: A Guide to Health and Nutrition. 1: 407–412. Retrieved 23 January 2014.
Jump up ^ "21 CFR 101.2 - Information panel of package form food". www.gpo.gov.
Jump up ^ "Trans Fats Added To Nutrition Labels". MedicineNet. Retrieved 2016-04-15.
^ Jump up to: a b "Proposed Changes to the Nutrition Facts Label". U.S. Food and Drug Administration. 1 August 2014. Retrieved 15 February 2015.
Jump up ^ "Nutrition Facts Label: Proposed Changes Aim to Better Inform Food Choices" (PDF). Consumer Health Information. US Food and Drug Administration. February 2014. Retrieved 15 February 2015.
Jump up ^ "Proposed Nutrition Facts Label Changes Are Based on Science and Research".
Jump up ^ Rothman, Russell L.; Housam, Ryan; Weiss, Hilary; Davis, Dianne; Gregory, Rebecca; Gebretsadik, Tebeb; Shintani, Ayumi; Elasy, Tom A. (2006-11-01). "Patient Understanding of Food Labels: The Role of Literacy and Numeracy". American Journal of Preventive Medicine. 31 (5): 391–398. doi:10.1016/j.amepre.2006.07.025.
Jump up ^ Nogueira, Leticia M.; Thai, Chan L.; Nelson, Wendy; Oh, April (2016-07-01). "Nutrition Label Numeracy: Disparities and Association with Health Behaviors". American Journal of Health Behavior. 40 (4): 427–436. doi:10.5993/AJHB.40.4.4.
Jump up ^ "FDA finalizes menu and vending machine calorie labeling rules". www.fda.gov. Food and Drug Administration. Retrieved 25 November 2014.
Jump up ^ Ferdman, Roberto A. (25 June 2014). "How the sugar lobby helps perpetuate that sweet tooth of yours". The Washington Post. Retrieved 15 February 2015.
Jump up ^ Weingus, Leigh (3 February 2015). "Here's Why Nutrition Labels Should List Added Sugar". The Huffington Post. Retrieved 15 February 2015.
Jump up ^ Ferdman, Roberto A. (2 July 2014). "The crucial FDA nutrition label battle you probably don't know about, but should". The Washington Post. Retrieved 15 February 2015.
Jump up ^ Prentice, Chris (4 August 2014). "Food fight builds as U.S. regulators weigh 'added sugar' label". Reuters. Retrieved 15 February 2015.
Jump up ^ Nutrition, Center for Food Safety and Applied. "Labeling & Nutrition - Changes to the Nutrition Facts Label". www.fda.gov.
Jump up ^ Abram, Anna K. (October 2, 2017). "Food Labeling: Revision of the Nutrition and Supplement Facts Labels and Serving Sizes of Foods That Can Reasonably Be Consumed at One Eating Occasion; Dual-Column Labeling; Updating, Modifying, and Establishing Certain Reference Amounts Customarily Consumed; Serving Size for Breath Mints; and Technical Amendments; Proposed Extension of Compliance Dates". Regulations.gov. Retrieved October 3, 2017.
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^ Jump up to: a b Michelle Locke (2011-01-23). "Alcohol industry grapples with nutrition labeling". USA Today. Retrieved 2013-01-20.
Jump up ^ Alcohol Beverage Labeling and Advertising
Jump up ^ What You Should Know About Malt Beverage Labels
Jump up ^ What You Should Know About Distilled Spirit Labels
Jump up ^ What You Should Know About Grape Wine Labels
Jump up ^ Jon Kole1; Anne Barnhill (2013). "Caffeine Content Labeling: A Missed Opportunity for Promoting Personal and Public Health". Journal of Caffeine Research. 3 (3): 108–113. doi:10.1089/jcr.2013.0017. PMC 3777296  . PMID 24761278.
Jump up ^ Elena Conis (December 28, 2009). "Labeling standards for caffeine". Los Angeles Times.
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Ectopic pregnancy
From Wikipedia, the free encyclopedia
Jump to navigation Jump to search
Ectopic pregnancy
Synonyms
EP, eccyesis, extrauterine pregnancy, EUP, tubal pregnancy (when in fallopian tube)
Laparoscopic view, looking down at the uterus (marked by blue arrows). In the left Fallopian tube there is an ectopic pregnancy and bleeding (marked by red arrows). The right tube is normal.
Specialty
Obstetrics and gynecology
Symptoms
Abdominal pain, vaginal bleeding[1]
Risk factors
Pelvic inflammatory disease, tobacco smoking, prior tubal surgery, history of infertility, use of assisted reproductive technology[2]
Diagnostic method
Blood tests for human chorionic gonadotropin (hCG), ultrasound[1]
Differential diagnosis
Miscarriage, ovarian torsion, acute appendicitis[1]
Treatment
Methotrexate, surgery[2]
Prognosis
Mortality 0.2% (developed world), 2% (developing world)[3]
Frequency
~1.5% of pregnancies (developed world)[4]
Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus.[4] Signs and symptoms classically include abdominal pain and vaginal bleeding.[1] Fewer than 50 percent of affected women have both of these symptoms.[1] The pain may be described as sharp, dull, or crampy.[1] Pain may also spread to the shoulder if bleeding into the abdomen has occurred.[1] Severe bleeding may result in a fast heart rate, fainting, or shock.[4][1] With very rare exceptions the fetus is unable to survive.[5]
Risk factors for ectopic pregnancy include: pelvic inflammatory disease, often due to chlamydia infection, tobacco smoking, prior tubal surgery, a history of infertility, and the use of assisted reproductive technology.[2] Those who have previously had an ectopic pregnancy are at much higher risk of having another one.[2] Most ectopic pregnancies (90%) occur in the Fallopian tube which are known as tubal pregnancies.[2] Implantation can also occur on the cervix, ovaries, or within the abdomen.[1] Detection of ectopic pregnancy is typically by blood tests for human chorionic gonadotropin (hCG) and ultrasound.[1] This may require testing on more than one occasion.[1] Ultrasound works best when performed from within the vagina.[1] Other causes of similar symptoms include: miscarriage, ovarian torsion, and acute appendicitis.[1]
Prevention is by decreasing risk factors such as chlamydia infections through screening and treatment.[6] While some ectopic pregnancies will resolve without treatment, this approach has not been well studied as of 2014.[2] The use of the medication methotrexate works as well as surgery in some cases.[2] Specifically it works well when the beta-HCG is low and the size of the ectopic is small.[2] Surgery is still typically recommended if the tube has ruptured, there is a fetal heartbeat, or the person's vital signs are unstable.[2] The surgery may be laparoscopic or through a larger incision, known as a laparotomy.[4] Outcomes are generally good with treatment.[2]
The rate of ectopic pregnancy is about 1 and 2% that of live births in developed countries, though it may be as high as 4% among those using assisted reproductive technology.[4] It is the most common cause of death among women during the first trimester at approximately 10% of the total.[2] In the developed world outcomes have improved while in the developing world they often remain poor.[6] The risk of death among those in the developed world is between 0.1 and 0.3 percent while in the developing world it is between one and three percent.[3] The first known description of an ectopic pregnancy is by Al-Zahrawi in the 11th century.[6] The word "ectopic" means "out of place".[7]
Contents
1 Signs and symptoms
1.1 Complications
2 Causes
2.1 Tube damage
2.2 Other
3 Diagnosis
3.1 Transvaginal ultrasonography
3.2 Ultrasonography and β-hCG
3.3 Other diagnostic methods
3.4 Classification
3.4.1 Tubal pregnancy
3.4.2 Nontubal ectopic pregnancy
3.4.3 Heterotopic pregnancy
3.4.4 Persistent ectopic pregnancy
3.4.5 Pregnancy of unknown location
3.5 Differential diagnosis
4 Treatment
4.1 Expectant management
4.2 Medical
4.3 Surgical
5 Prognosis
5.1 Future fertility
6 Epidemiology
7 Society and culture
8 Live birth
9 Other animals
10 References
11 External links
Signs and symptoms[edit]
Ectopic pregnancy.
Up to 10% of women with ectopic pregnancy have no symptoms, and one third have no medical signs.[4] In many cases the symptoms have low specificity, and can be similar to those of other genitourinary and gastrointestinal disorders, such as appendicitis, salpingitis, rupture of a corpus luteum cyst, miscarriage, ovarian torsion or urinary tract infection.[4] Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 4 to 8 weeks. Later presentations are more common in communities deprived of modern diagnostic ability.
Signs and symptoms of ectopic pregnancy include increased hCG, vaginal bleeding (in varying amounts), sudden lower abdominal pain,[4] pelvic pain, a tender cervix, an adnexal mass, or adnexal tenderness.[1] In the absence of ultrasound or hCG assessment, heavy vaginal bleeding may lead to a misdiagnosis of miscarriage.[4] Nausea, vomiting and diarrhea are more rare symptoms of ectopic pregnancy.[4]
Rupture of an ectopic pregnancy can lead to symptoms such as abdominal distension, tenderness, peritonism and hypovolemic shock.[4] A woman with ectopic pregnancy may be excessively mobile with upright posturing, in order to decrease intrapelvic blood flow, which can lead to swelling of the abdominal cavity and cause additional pain.[8]
Complications[edit]
Blood in Morrison's pouch between the liver and kidney due to a ruptured ectopic pregnancy
The most common complication is rupture with internal bleeding which may lead to hypovolemic shock. Death from rupture is still the leading cause of death in the first trimester of the pregnancy.[citation needed]
Causes[edit]
There are a number of risk factors for ectopic pregnancies. However, in as many as one third[9] to one half[10] no risk factors can be identified. Risk factors include: pelvic inflammatory disease, infertility, use of an intrauterine device (IUD), previous exposure to DES, tubal surgery, intrauterine surgery (e.g. D&C), smoking, previous ectopic pregnancy, endometriosis, and tubal ligation.[11][12] A previous induced abortion does not appear to increase the risk.[13]
Tube damage[edit]
Left fallopian tube with an ectopic pregnancy in a 25-year-old woman after a salpingectomy.
Tubal pregnancy is when the egg is implanted in the Fallopian tubes. Hair-like cilia located on the internal surface of the Fallopian tubes carry the fertilized egg to the uterus. Fallopian cilia are sometimes seen in reduced numbers subsequent to an ectopic pregnancy, leading to a hypothesis that cilia damage in the Fallopian tubes is likely to lead to an ectopic pregnancy.[14] Women who smoke have a higher chance of an ectopic pregnancy in the fallopian tubes. Smoking leads to risk factors of damaging and/or killing cilia.[14] As cilia degenerate, the amount of time it takes for the fertilized egg to reach the uterus will increase. The fertilized egg, if it doesn't reach the uterus in time, will hatch from the non-adhesive zona pellucida and implant itself inside the fallopian tube, thus causing the pregnancy.
Women with pelvic inflammatory disease (PID) have a high occurrence of ectopic pregnancy.[15] This results from the build-up of scar tissue in the Fallopian tubes, causing damage to cilia.[16] If however both tubes were completely blocked, so that sperm and egg were physically unable to meet, then fertilization of the egg would naturally be impossible, and neither normal pregnancy nor ectopic pregnancy could occur. Intrauterine adhesions (IUA) present in Asherman's syndrome can cause ectopic cervical pregnancy or, if adhesions partially block access to the tubes via the ostia, ectopic tubal pregnancy.[17][18][19] Asherman's syndrome usually occurs from intrauterine surgery, most commonly after D&C.[17] Endometrial/pelvic/genital tuberculosis, another cause of Asherman's syndrome, can also lead to ectopic pregnancy as infection may lead to tubal adhesions in addition to intrauterine adhesions.[20]
Tubal ligation can predispose to ectopic pregnancy. Reversal of tubal sterilization (Tubal reversal) carries a risk for ectopic pregnancy. This is higher if more destructive methods of tubal ligation (tubal cautery, partial removal of the tubes) have been used than less destructive methods (tubal clipping). A history of a tubal pregnancy increases the risk of future occurrences to about 10%.[16] This risk is not reduced by removing the affected tube, even if the other tube appears normal. The best method for diagnosing this is to do an early ultrasound.
Other[edit]
Although some investigations have shown that patients may be at higher risk for ectopic pregnancy with advancing age, it is believed that age is a variable which could act as a surrogate for other risk factors. Vaginal douching is thought by some to increase ectopic pregnancies.[16] Women exposed to diethylstilbestrol (DES) in utero (also known as "DES daughters") also have an elevated risk of ectopic pregnancy.[21] It has also been suggested that pathologic generation of nitric oxide through increased iNOS production may decrease tubal ciliary beats and smooth muscle contractions and thus affect embryo transport, which may consequently result in ectopic pregnancy.[22] The low socioeconomic status may be risk factors for ectopic pregnancy.[23]
Diagnosis[edit]
An ectopic pregnancy should be considered as the cause of abdominal pain or vaginal bleeding in every woman who has a positive pregnancy test.[1] The primary goal of diagnostic procedures in possible ectopic pregnancy is to triage according to risk rather than establishing pregnancy location.[4]
Transvaginal ultrasonography[edit]
An ultrasound showing a gestational sac with fetal heart in the fallopian tube has a very high specificity of ectopic pregnancy. Transvaginal ultrasonography has a sensitivity of at least 90% for ectopic pregnancy.[4] The diagnostic ultrasonographic finding in ectopic pregnancy is an adnexal mass that moves separately from the ovary. In around 60% of cases, it is an inhomogeneous or a noncystic adnexal mass sometimes known as the "blob sign". It is generally spherical, but a more tubular appearance may be seen in case of hematosalpinx. This sign has been estimated to have a sensitivity of 84% and specificity of 99% in diagnosing ectopic pregnancy.[4] In the study estimating these values, the blob sign had a positive predictive value of 96% and a negative predictive value of 95%.[4] The visualization of an empty extrauterine gestational sac is sometimes known as the "bagel sign", and is present in around 20% of cases.[4] In another 20% of cases, there is visualization of a gestational sac containing a yolk sac and/or an embryo.[4] Ectopic pregnancies where there is visualization of cardiac activity are sometimes termed "viable ectopic".[4]
Transvaginal ultrasonography of an ectopic pregnancy, showing the field of view in the following image.
A "blob sign", which consists of the ectopic pregnancy. The ovary is distinguished from it by having follicles, whereof one is visible in the field. This patient had an intrauterine device (IUD) with progestogen, whose cross-section is visible in the field, leaving an ultrasound shadow distally to it.
Ultrasound image showing an ectopic pregnancy where a gestational sac and fetus has been formed.
The combination of a positive pregnancy test and the presence of what appears to be a normal intrauterine pregnancy does not exclude an ectopic pregnancy, since there may be either a heterotopic pregnancy or a "pseudosac", which is a collection of within the endometrial cavity that may be seen in up to 20% of women.[4]
A small amount of anechogenic-free fluid in the recto-uterine pouch is commonly found in both intrauterine and ectopic pregnancies.[4] The presence of echogenic fluid is estimated at between 28 and 56% of women with an ectopic pregnancy, and strongly indicates the presence of hemoperitoneum.[4] However, it does not necessarily result from tubal rupture, but is commonly a result from leakage from the distal tubal opening.[4] As a rule of thumb, the finding of free fluid is significant if it reaches the fundus or is present in the vesico-uterine pouch.[4] A further marker of serious intra-abdominal bleeding is the presence of fluid in the hepatorenal recess of the subhepatic space.[4]
Currently, Doppler ultrasonography is not considered to significantly contribute to the diagnosis of ectopic pregnancy.[4]
A common misdiagnosis is of a normal intrauterine pregnancy is where the pregnancy is implanted laterally in an arcuate uterus, potentially being misdiagnosed as an interstitial pregnancy.[4]
Ultrasonography and β-hCG[edit]
A pregnancy not in the uterus[24]
Algorithm of the management of a pregnancy of unknown location, that is, a positive pregnancy test but no pregnancy is found on transvaginal ultrasonography.[4] If serum hCG at 0 hours is more than 1000 IU/L and there is no history suggestive of complete miscarriage, the ultrasonography should be repeated as soon as possible.[4]
Where no intrauterine pregnancy is seen on ultrasound, measuring β-human chorionic gonadotropin (β-hCG) levels may aid in the diagnosis. The rationale is that a low β-hCG level may indicate that the pregnancy is intrauterine but yet too small to be visible on ultrasonography. While some physicians consider that the threshold where an intrauterine pregnancy should be visible on transvaginal ultrasound is around 1500 IU/ml of β-hCG, a review in the JAMA Rational Clinical Examination Series showed that there is no single threshold for the β-human chorionic gonadotropin that confirms an ectopic pregnancy. Instead, the best test in a pregnant woman is a high resolution transvaginal ultrasound.[1] The presence of an adnexal mass in the absence of an intrauterine pregnancy on transvaginal sonography increases the likelihood of an ectopic pregnancy 100-fold (LR+ 111). When there are no adnexal abnormalities on transvaginal sonography, the likelihood of an ectopic pregnancy decreases (LR- 0.12). An empty uterus with levels higher than 1500 IU/ml may be evidence of an ectopic pregnancy, but may also be consistent with an intrauterine pregnancy which is simply too small to be seen on ultrasound. If the diagnosis is uncertain, it may be necessary to wait a few days and repeat the blood work. This can be done by measuring the β-hCG level approximately 48 hours later and repeating the ultrasound. The serum hCG ratios and logistic regression models appear to be better than absolute single serum hCG level.[25] If the β-hCG falls on repeat examination, this strongly suggests a spontaneous abortion or rupture. The fall in serum hCG over 48 hours may be measured as the hCG ratio, which is calculated as:[4] h C G r a t i o = h C G a t 48 h h C G a t 0 h {\displaystyle hCG~ratio={\frac {hCG~at~48h}{hCG~at~0h}}}
An hCG ratio of 0.87, that is, a decrease in hCG of 13% over 48 hours, has a sensitivity of 93% and specificity of 97% for predicting a failing PUL.[4] The majority of cases of ectopic pregnancy will have serial serum hCG levels that increase more slowly than would be expected with an IUP (that is, a suboptimal rise), or decrease more slowly than would be expected with a failing PUL. However, up to 20% of cases of ectopic pregnancy have serum hCG doubling times similar to that of an IUP, and around 10% of EP cases have hCG patterns similar to a failing PUL.[4]
Other diagnostic methods[edit]
A laparoscopy or laparotomy can also be performed to visually confirm an ectopic pregnancy. This is generally reserved for women presenting with signs of an acute abdomen and/or hypovolemic shock.[4] Often if a tubal abortion or tubal rupture has occurred, it is difficult to find the pregnancy tissue. A laparoscopy in very early ectopic pregnancy rarely shows a normal looking fallopian tube.
Culdocentesis, in which fluid is retrieved from the space separating the vagina and rectum, is a less commonly performed test that may be used to look for internal bleeding. In this test, a needle is inserted into the space at the very top of the vagina, behind the uterus and in front of the rectum. Any blood or fluid found may have been derived from a ruptured ectopic pregnancy.
Progesterone levels of less than 20 nmol/l have a high predictive value for failing pregnancies, whilst levels over 25 nmol/l are likely to predict viable pregnancies, and levels over 60 nmol/l are strongly so. This may help in identifying failing PULs that are at low risk and thereby needing less follow-up.[4] Inhibin A may also be useful for predicting spontaneous resolution of PUL, but is not as good as progesterone for this purpose.[4]
In addition, there are various mathematical models, such as logistic regression models and Bayesian networks, for the prediction of PUL outcome based on multiple parameters.[4] Mathematical models also aim to identify PULs that are low risk, that is, failing PULs and IUPs.[4]
Dilation and curettage (D&C) is sometimes used to diagnose pregnancy location with the aim of differentiating between an EP and a non-viable IUP in situations where a viable IUP can be ruled out. Specific indications for this procedure include either of the following:[4]
no visible IUP on transvaginal ultrasonography with a serum hCG of more than 2000 IU/ml
an abnormal rise in hCG level. A rise of 35% over 48 hours is proposed as the minimal rise consistent with a viable intrauterine pregnancy.
an abnormal fall in hCG level, such as defined as one of less than 20% in 2 days
Classification[edit]
Tubal pregnancy[edit]
The vast majority of ectopic pregnancies implant in the Fallopian tube. Pregnancies can grow in the fimbrial end (5% of all ectopic pregnancies), the ampullary section (80%), the isthmus (12%), and the cornual and interstitial part of the tube (2%).[16] Mortality of a tubal pregnancy at the isthmus or within the uterus (interstitial pregnancy) is higher as there is increased vascularity that may result more likely in sudden major internal bleeding. A review published in 2010 supports the hypothesis that tubal ectopic pregnancy is caused by a combination of retention of the embryo within the fallopian tube due to impaired embryo-tubal transport and alterations in the tubal environment allowing early implantation to occur.[26]
Nontubal ectopic pregnancy[edit]
Two percent of ectopic pregnancies occur in the ovary, cervix, or are intra-abdominal. Transvaginal ultrasound examination is usually able to detect a cervical pregnancy. An ovarian pregnancy is differentiated from a tubal pregnancy by the Spiegelberg criteria.[27]
While a fetus of ectopic pregnancy is typically not viable, very rarely, a live baby has been delivered from an abdominal pregnancy. In such a situation the placenta sits on the intra-abdominal organs or the peritoneum and has found sufficient blood supply. This is generally bowel or mesentery, but other sites, such as the renal (kidney), liver or hepatic (liver) artery or even aorta have been described. Support to near viability has occasionally been described, but even in Third World countries, the diagnosis is most commonly made at 16 to 20 weeks' gestation. Such a fetus would have to be delivered by laparotomy. Maternal morbidity and mortality from extrauterine pregnancy are high as attempts to remove the placenta from the organs to which it is attached usually lead to uncontrollable bleeding from the attachment site. If the organ to which the placenta is attached is removable, such as a section of bowel, then the placenta should be removed together with that organ. This is such a rare occurrence that true data is unavailable and reliance must be made on anecdotal reports.[28][29][30] However, the vast majority of abdominal pregnancies require intervention well before fetal viability because of the risk of bleeding.
Heterotopic pregnancy[edit]
In rare cases of ectopic pregnancy, there may be two fertilized eggs, one outside the uterus and the other inside. This is called a heterotopic pregnancy.[1] Often the intrauterine pregnancy is discovered later than the ectopic, mainly because of the painful emergency nature of ectopic pregnancies. Since ectopic pregnancies are normally discovered and removed very early in the pregnancy, an ultrasound may not find the additional pregnancy inside the uterus. When hCG levels continue to rise after the removal of the ectopic pregnancy, there is the chance that a pregnancy inside the uterus is still viable. This is normally discovered through an ultrasound.
Although rare, heterotopic pregnancies are becoming more common, likely due to increased use of IVF. The survival rate of the uterine fetus of a heterotopic pregnancy is around 70%.[31]
Persistent ectopic pregnancy[edit]
A persistent ectopic pregnancy refers to the continuation of trophoblastic growth after a surgical intervention to remove an ectopic pregnancy. After a conservative procedure that attempts to preserve the affected fallopian tube such as a salpingotomy, in about 15–20% the major portion of the ectopic growth may have been removed, but some trophoblastic tissue, perhaps deeply embedded, has escaped removal and continues to grow, generating a new rise in hCG levels.[32] After weeks this may lead to new clinical symptoms including bleeding. For this reason hCG levels may have to be monitored after removal of an ectopic pregnancy to assure their decline, also methotrexate can be given at the time of surgery prophylactically.
Pregnancy of unknown location[edit]
Pregnancy of unknown location (PUL) is the term used for a pregnancy where there is a positive pregnancy test but no pregnancy has been visualized using transvaginal ultrasonography.[4] Specialized early pregnancy departments have estimated that between 8 and 10% of women attending for an ultrasound assessment in early pregnancy will be classified as having a PUL.[4] The true nature of the pregnancy can be an ongoing viable intrauterine pregnancy, a failed pregnancy, an ectopic pregnancy or rarely a persisting PUL.[4]
Because of frequent ambiguity on ultrasonography examinations, the following classification is proposed:[4]
Condition
Criteria
Definite ectopic pregnancy Extrauterine gestational sac with yolk sac and/or
embryo (with or without cardiac activity).
Pregnancy of unknown location - probable ectopic pregnancy Inhomogeneous adnexal mass or extrauterine sac-like structure.
"True" pregnancy of unknown location No signs of intrauterine nor extrauterine pregnancy on transvaginal ultrasonography.
Pregnancy of unknown location - probable intrauterine pregnancy Intrauterine gestational sac-like structure.
Definite intrauterine pregnancy Intrauterine gestational sac with yolk sac and/or embryo (with or without cardiac activity).
In women with a pregnancy of unknown location, between 6% and 20% have an ectopic pregnancy.[4] In cases of pregnancy of unknown location and a history of heavy bleeding, it has been estimated that approximately 6% have an underlying ectopic pregnancy.[4] Between 30 and 47% of women with pregnancy of unknown location are ultimately diagnosed with an ongoing intrauterine pregnancy, whereof the majority (50 –70%) will be found to have failing pregnancies where the location is never confirmed.[4]
Persisting PUL is where the hCG level does not spontaneously decline and no intrauterine or ectopic pregnancy is identified on follow-up transvaginal ultrasonography.[4] A persisting PUL is likely either a small ectopic pregnancy that has not been visualized, or a retained trophoblast in the endometrial cavity.[4] Treatment should only be considered when a potentially viable intrauterine pregnancy has been definitively excluded.[4] A treated persistent PUL is defined as one managed medically (generally with methotrexate) without confirmation of the location of the pregnancy such as by ultrasound, laparoscopy or uterine evacuation.[4] A resolved persistent PUL is defined as serum hCG reaching a non-pregnant value (generally less than 5 IU/l) after expectant management, or after uterine evacuation without evidence of chorionic villi on histopathological examination.[4] In contrast, a relatively low and unresolving level of serum hCG indicates the possibility of an hCG-secreting tumour.[4]
Differential diagnosis[edit]
Other conditions that cause similar symptoms include: miscarriage, ovarian torsion, and acute appendicitis, ruptured ovarian cyst, kidney stone, and pelvic inflammatory disease, among others.[1]
Treatment[edit]
Expectant management[edit]
Most women with a PUL are followed up with serum hCG measurements and repeat TVS examinations until a final diagnosis is confirmed.[4] Low-risk cases of PUL that appear to be failing pregnancies may be followed up with a urinary pregnancy test after two weeks and get subsequent telephone advice.[4] Low-risk cases of PUL that are likely intrauterine pregnancies may have another TVS in two weeks to access viability.[4] High-risk cases of PUL require further assessment, either with a TVS within 48 h or additional hCG measurement.[4]
Medical[edit]
Early treatment of an ectopic pregnancy with methotrexate is a viable alternative to surgical treatment[33] which was developed in the 1980s.[34] If administered early in the pregnancy, methotrexate terminates the growth of the developing embryo; this may cause an abortion, or the developing embryo may then be either resorbed by the woman's body or pass with a menstrual period. Contraindications include liver, kidney, or blood disease, as well as an ectopic embryonic mass > 3.5 cm.
Also, it may lead to the inadvertent termination of an undetected intrauterine pregnancy, or severe abnormality in any surviving pregnancy.[4] Therefore, it is recommended that methotrexate should only be administered when hCG has been serially monitored with a rise less than 35% over 48 hours, which practically excludes a viable intrauterine pregnancy.[4]
Surgical[edit]
Surgical treatment: Laparoscopic view of an ectopics pregnancy located in the left Fallopian tube, hematosalpinx is present on the left, the right tube is of normal appearance
The left Fallopian tube containing the ectopic pregnancy has been removed (salpingectomy).
If bleeding has already occurred, surgical intervention may be necessary. However, whether to pursue surgical intervention is an often difficult decision in a stable patient with minimal evidence of blood clot on ultrasound.[citation needed]
Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy). The first successful surgery for an ectopic pregnancy was performed by Robert Lawson Tait in 1883.[35] It is estimated that an acceptable rate of PULs that eventually undergo surgery is between 0.5 and 11%.[4]
Autotransfusion of a woman's own blood as drained during surgery may be useful in those who have a lot of bleeding into their abdomen.[36]
Published reports that a re-implanted embryo survived to birth were debunked as false.[37]
Prognosis[edit]
When ectopic pregnancies are treated, the prognosis for the mother is very good in Western countries; maternal death is rare, but most fetuses die or are aborted. For instance, in the UK, between 2003 and 2005 there were 32,100 ectopic pregnancies resulting in 10 maternal deaths (meaning that 1 in 3,210 women with an ectopic pregnancy died).[38]
In the developing world, however, especially in Africa, the death rate is very high, and ectopic pregnancies are a major cause of death among women of childbearing age.
In women having had an ectopic pregnancy, the risk of another one in the next pregnancy is around 10%.[39]
Future fertility[edit]
Fertility following ectopic pregnancy depends upon several factors, the most important of which is a prior history of infertility.[40] The treatment choice does not play a major role; A randomized study in 2013 concluded that the rates of intrauterine pregnancy two years after treatment of ectopic pregnancy are approximately 64% with radical surgery, 67% with medication, and 70% with conservative surgery.[41] In comparison, the cumulative pregnancy rate of women under 40 years of age in the general population over 2 years is over 90%.[42]
In case of ovarian ectopic pregnancy, the risk of subsequent ectopic pregnancy or infertility is low.[43]
Epidemiology[edit]
An opened oviduct with an ectopic pregnancy at about 7 weeks' gestational age.[44]
The rate of ectopic pregnancy is about 1 and 2% of that of live births in developed countries, though it is as high as 4% in pregnancies involving assisted reproductive technology.[4] Between 93 and 97% of ectopic pregnancies are located in a Fallopian tube.[1] Of these, in turn, 13% are located in the isthmus, 75% are located in the ampulla, and 12% in the fimbriae.[4] Ectopic pregnancy is responsible for 6% of maternal deaths during the first trimester of pregnancy making it the leading cause of maternal death during this stage of pregnancy.[1]
Between 5% and 42% of women seen for ultrasound assessment with a positive pregnancy test have a pregnancy of unknown location (PUL), that is a positive pregnancy test but no pregnancy visualized at transvaginal ultrasonography.[4] Between 6 and 20% of PUL are subsequently diagnosed with actual ectopic pregnancy.[4]
Society and culture[edit]
Salpingectomy as a treatment for ectopic pregnancy is one of the common cases when the principle of double effect can be used to justify accelerating the death of the embryo by doctors and patients opposed to outright abortions.[45]
In the Catholic Church, there are moral debates on certain treatments. A significant number of Catholic moralists consider use of methotrexate and the salpingostomy procedure to be not "morally permissible" because they destroy the embryo; however, situations are considered differently in which the mother's health is endangered, and the whole fallopian tube with the developing embryo inside is removed.[46][47]
Live birth[edit]
There have been cases where ectopic pregnancy lasted many months and ended in a live baby delivered by laparotomy.
In July 1999, Lori Dalton gave birth by caesarean section in Ogden, Utah, United States, to a healthy baby girl who had developed outside of the uterus. Previous ultrasounds had not discovered the problem. "[Sage Dalton]'s delivery was slated as a routine Caesarean birth at Ogden Regional Medical Center in Utah. When Dr. Naisbitt performed Lori's Caesarean, he was astonished to find Sage within the amniotic membrane outside the womb ... ."[48] "But what makes this case so rare is that not only did mother and baby survive—they're both in perfect health. John Dalton [(the father)] took home video inside the delivery room. Sage came out doing extremely well because even though she had been implanted outside the womb, a rich blood supply from a uterine fibroid along the outer uterus wall had nourished her with a rich source of blood."[49]
In September 1999 an English woman, Jane Ingram (age 32) gave birth to triplets: Olivia, Mary and Ronan, with an extrauterine fetus (Ronan) below the womb and twins in the womb. All three survived. The twins in the womb were taken out first.[50]
On May 29, 2008 an Australian woman, Meera Thangarajah (age 34), who had an ectopic pregnancy in the ovary, gave birth to a healthy full term 6 pound 3 ounce (2.8 kg) baby girl, Durga, via caesarean section. She had no problems or complications during the 38‑week pregnancy.[51][52]
Other animals[edit]
Ectopic gestation exists in mammals other than humans. In sheep, it can go to term, with mammary preparation to parturition, and expulsion efforts. The fetus can be removed by caesarean section. Pictures of caesarian section of a euthanized ewe, 5 days after parturition signs.
Leg of fetal lamb appearing out of the uterus during caesarian section.
External view of fetal sac, necrotic distal part.
Internal view of fetal sac, before resection of distal necrotic part.
Internal view of fetal sac, the necrotic distal part is to the left.
External side of fetal sac, proximal end, with ovary and uterine horn.
Resected distal part of fetal sac, with attached placenta.
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External links[edit]
Classification
D
ICD-10: O00
ICD-9-CM: 633
MeSH: D011271
DiseasesDB: 4089
External resources
MedlinePlus: 000895
eMedicine: med/3212 emerg/478 radio/231
Patient UK: Ectopic pregnancy
Wikimedia Commons has media related to Ectopic pregnancy.
CT of the abdomen showing abdominal ectopic pregnancy

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Pathology of pregnancy, childbirth and the puerperium (O, 630–679)
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Puerperal mastitis

values: Systemic lupus erythematosus and pregnancy

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