A healthy pregnancy grows inside the uterus (womb), but an ectopic pregnancy is one where the pregnancy grows outside of the uterus. This occurs in about 1 in 80 pregnancies. Unfortunately, a pregnancy that implants outside of uterus cannot survive. The most common place for an ectopic pregnancy to grow is inside the Fallopian tube (the pair of tubes along which eggs travel from the ovaries to the uterus), although it can occur in other places. It can be dangerous if the pregnancy continues to grow and bursts (ruptures) as this can cause life-threatening internal bleeding.
Why is this happening to me?
Many women have no risk factors for developing an ectopic pregnancy. Certain things do increase your risk such as: a previous ectopic pregnancy; a history of pelvic inflammatory disease or endometriosis affecting the Fallopian tubes; smoking; previous pelvic or fallopian tube surgery; use of emergency contraception; age (especially 35-40 years), a history of infertility, or a pregnancy conceived via assisted conception or fertility treatments. Pregnancy is very uncommon with an intrauterine device in situ (such as a copper coil or Mirena), or use of the progesterone-only pill, but if you were to fall pregnant with this type of contraception this can also increase your risk.
What happens next?
A diagnosis of ectopic pregnancy is usually made with a combination of an ultrasound scan and regular blood tests to look at your pregnancy hormone levels βHCG (beta human chorionic gonadotropin).
What worrying signs should I look out for?
Vaginal bleeding: this is often less than a usual period or the amount or colour is different to period. If you were not aware you were pregnant you may even mistake it as a normal period. However, bleeding in pregnancy is common and is not always a sign of something serious, but should always be investigated at your local Early Pregnancy Unit (EPU).Abdominal (tummy) pain: this typically occurs in the lower part of your abdomen often on one side and can develop gradually or suddenly and may be quite intense. The pain may come and go and may sometimes be confused with ‘trapped wind’. Pain should also always be investigated in early pregnancy.Shoulder tip pain: This is pain around the shoulder blades, and you should seek urgent medical help if this happens. It may be linked with internal bleeding in the abdomen and irritation of the nerves in this area leads to shoulder tip pain.Diarrhoea: This may also be linked with internal bleeding like shoulder tip pain, as described above. In such cases there will also be abdominal pain and you should also seek urgent medical help if this happens.Ectopic pregnancy rupture: in addition to the above, any of the following symptoms could be a sign of ectopic rupture and requires urgent A&E attendance: constant, severe abdominal pain; nausea/vomiting; dizziness/feeling faint; looking pale.
How is it treated?
There are three treatment options for ectopic pregnancy:
Expectant management (waiting to see if the ectopic pregnancy resolves by itself)
Medicine to prevent the ectopic pregnancy from developing further
Surgery to remove the ectopic pregnancy.
Treatment options will depend on many different factors including, the size and location of the ectopic pregnancy, your blood results, your symptoms, any previous medical and surgical treatments. A specialist will talk you through your options and together you can choose the most suitable management plan. It is important to highlight your future pregnancy plans in this discussion.
Expectant management
If you are suitable for this option and choose to have expectant management, you will be monitored to see if your ectopic pregnancy resolves by itself. This involves regular blood tests to check your pregnancy hormone levels (referred to as βHCG (HCG) until they fall and become negative. This can take up to 6 weeks (or longer in small number of cases). The success of expectant management is variable and ranges from 30-100%. It is more likely to be successful if the pregnancy is small and your starting βHCG levels are low. If it is unsuccessful you may require further treatment with medicine or surgery.
Medical management
If you are suitable for this method, you may be offered the option of a medicine called Methotrexate to treat the ectopic pregnancy. This is normally a single injection, however approximately 15 in 100 women require a second injection. In some cases, medical management may be unsuccessful, and 7 in 100 women will go on to require surgery.As with expectant management you will require regular follow up with blood tests to ensure your pregnancy hormone, βHCG levels fall. If medical treatment is successful it will result in a 15% fall in your βHCG level by 1 week after a single methotrexate injection. It may take up to 6 weeks for the βHCG levels to become negative.Side effects of the medication are rare but include nausea/ vomiting, feeling fatigued, skin rashes, mouth ulcers, abdominal cramping, diarrhoea, sensitivity to sunlight, temporary hair loss and lung inflammation. The medicine can briefly affect your liver, kidneys, and bone marrow (where important blood cells which help fight infection are made) and therefore you will need additional blood tests along with betaHCG levels during your follow up. You should avoid alcohol and vitamins containing folic acid.Once your βHCG levels become negative you can drink alcohol and you should restart folic acid to rebuild your folate levels during the 3-month washout period for methotrexate.It is very important that you do not fall pregnant for at least 3 months after having this medicine, if you were to fall pregnant there is a risk of birth defects to a developing baby; this risk is no longer present after 3 months. You should discuss contraception options with the doctor or nurse in the early pregnancy unit, or with your GP.
Surgical treatment
This may be offered as an option or recommended as the best course of treatment for you. This will involve general anaesthesia and the entry into the tummy can be done in two ways:
Keyhole surgery (laparoscopy) – this is the standard surgical approach for nearly all cases.
Open surgery (laparotomy) – this may be needed on an individual case basis, unique to your clinical circumstances.
Managing the ectopic pregnancy can be done in two ways and this will be influenced by the health of the other fallopian tube, the one without the ectopic pregnancy:
Salpingectomy, involves the removal of the entire fallopian tube that contains the ectopic pregnancy. This is recommended if the other tube looks healthy.
Salpingostomy is considered if the other tube (not containing the ectopic pregnancy) does not look healthy or is absent. This involves making an incision on the fallopian tube to remove the ectopic pregnancy. The fallopian tube is not removed in this operation.
Both procedures carry small risks associated with having a surgical procedure and general anaesthetic. This includes risk of damage to other organs inside the abdomen such as the bowel, bladder, ureters (tubes that connect the bladder and the kidneys) and blood vessels. The surgeon and anaesthetist will talk you through the risks involved in more details.
After the operation, if your blood group is Rhesus negative, you should be offered an injection called Anti-D to prevent a condition from Rhesus Isoimmunisation. Rhesus Isoimmunisation is where your body develops antibodies if your baby’s blood group is Rhesus positive in this pregnancy. The Anti-D injection prevents your body developing antibodies which can negatively affect a Rhesus positive baby in future pregnancies and is recommended to remove this risk.
What worrying signs should I look out for after expectant or medical treatment?
If you opt for expectant or medical management you will be able to return home. It’s important that you seek urgent medical attention and attend the A&E department, at any time of the day or night if you develop new symptoms including severe abdominal pain, shoulder tip pain, feeling unwell, faint or collapse. Inform A&E team of the diagnosis of ectopic pregnancy, who will arrange for an urgent review by gynaecology services. This is because there is still a small risk of the tubal pregnancy rupturing, which can potentially cause life-threatening internal bleeding.
When can I get pregnant again?
It is very important that you do not fall pregnant until you have completed your follow up after an ectopic pregnancy and your local Early Pregnancy Unit (EPU) confirm βHCG levels have become negative with blood or urine pregnancy tests.If you chose to have Methotrexate then you need to wait at least 3 months before trying to conceive again. If Methotrexate was not used and your EPU confirms you are no longer pregnant you should wait for at least one period before trying again to help reset your body clock.However, you should only try for another pregnancy again when you feel ready as the emotional recovery often takes longer than the physical recovery. In your next pregnancy it is most likely that the pregnancy will be in the correct place inside the uterus. However, 10-18 women per 100 will have another ectopic pregnancy. You should therefore contact your local EPU as soon as you know you are pregnant so you can get booked in for an early scan from 5-6 weeks to confirm the location of the pregnancy.
