the location of the pregnancy such as by ultrasound, laparoscopy or uterine evacuation. 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. in contrast, a relatively low and unresolving level of serum hcg indicates the possibility of an hcg-secreting tumour. differential diagnosis other conditions that cause similar symptoms include: miscarriage, ovarian torsion, and acute appendicitis, ruptured ovarian cyst, kidney stone, and pelvic inflammatory disease, among others. treatment expectant management most women with a pul are followed up with serum hcg measurements and repeat tvs examinations until a final diagnosis is confirmed. 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. low-risk cases of pul that are likely intrauterine pregnancies may have another tvs in two weeks to access viability. high-risk cases of pul require further assessment, either with a tvs within 48 h or additional hcg measurement. medical early treatment of an ectopic pregnancy with methotrexate is a viable alternative to surgical treatment which was developed in the 1980s. 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. 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. for nontubal ectopic pregnancy, evidence from randomised clinical trials in women with csp is uncertain regarding treatment success, complications and side effects of methotrexate compared with surgery (uterine arterial embolization or uterine arterial chemoembolization). the united states uses a multi dose protocol of methotrexate (mtx) which involves four doses of intramuscular along with an intramuscular injection of folinic acid to protect cells from the effects of the drugs and to reduce side effects. in france, the single dose protocol is followed, but a single dose has a greater chance of failure. surgery surgical treatment: laparoscopic view of an ectopic 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. surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected fallopian tube 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. it is estimated that an acceptable rate of puls that eventually undergo surgery is between 0.5 and 11%. people that undergo salpingectomy and salpingostomy have a similar recurrent ectopic pregnancy rate of 5% and 8% respectively. additionally, their intrauterine pregnancy rates are also similar, 56% and 61%. 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. published reports that a re-implanted embryo survived to birth were debunked as false. prognosis when ectopic pregnancies are treated, the prognosis for the mother is very good in western countries; maternal death is rare, but all 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). in 2006–2008 the uk confidential enquiry into maternal deaths found that ectopic pregnancy is the cause of 6 maternal deaths (0.26/100,000 pregnancies). 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%. future fertility fertility following ectopic pregnancy depends upon several factors, the most important of which is a prior history of infertility. 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. in comparison, the cumulative pregnancy rate of women under 40 years of age in the general population over two years is over 90%. methotrexate does not affect future fertility treatments. the number of oocytes that were retrieved before and after treatment with methotrexate does not change. in case of ovarian ectopic pregnancy, the risk of subsequent ectopic pregnancy or infertility is low. there is no evidence that massage improves fertility after ectopic pregnancy. epidemiology an opened oviduct with an ectopic pregnancy at about seven weeks' gestational age 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. between 93% and 97% of ectopic pregnancies are located in a fallopian tube. of these, in turn, 13% are located in the isthmus, 75% are located in the ampulla, and 12% in the fimbriae. 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. between 5% and 42% of women seen for ultrasound assessment with a positive pregnancy test have a pregnancy of unknown location, that is a positive pregnancy test but no pregnancy visualized at transvaginal ultrasonography. between 6% and 20% of pregnancy of unknown location are subsequently diagnosed with actual ectopic pregnancy. society and culture 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. 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. organisations exist that provide information and support to help those who experience ectopic pregnancy. studies show that people can experience post-traumatic stress, depression, and anxiety for which they would need specialist therapies. partners can also experience post-traumatic stress. live birth 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, saige, who had developed outside of the uterus. previous ultrasounds had not discovered the problem. "'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 saige within the amniotic membrane outside the womb ... ." "but what makes this case so rare is that not only did mother and baby survive—they're both in perfect health. the father, john dalton took home video inside the delivery room. saige 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." 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. 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. animals 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, five days after parturition signs. leg of fetal lamb appearing out of the uterus during caesarean 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