What is an ectopic pregnancy?
The term ectopic pregnancy refers to a pregnancy growing outside the cavity of the womb. Unfortunately, there is no future for this pregnancy and patients suspected of having an ectopic pregnancy need management by a gynaecologist.
The possible locations of the pregnancy include the fallopian tube, ovary, cervix and the abdomen (see diagram) and they occur with a frequency of 1 in 100 pregnancies. The fallopian tube is the commonest site (98%), hence an ectopic pregnancy is often known as a tubal pregnancy.
What are the risk factors?
The following women have a higher chance of having ectopic pregnancies:
- Previous lower abdominal surgery including sterilisation
- Previous ectopic pregnancy
- Assisted conception techniques i.e. IVF
- Women over 40 years age
- Previous pelvic inflammatory disease
What are the symptoms of ectopic pregnancy?
Symptoms may include the following:
- Vaginal bleeding (you may or may not have a missed period)
- Vaginal bleeding may be heavier or lighter than normal
- Lower abdominal pain
- Urinary symptoms – frequency or pain on urination
- Bowel symptoms such as diarrhoea or vomiting
- Shoulder tip pain as a result of bleeding into the abdomen
- Collapse due to massive bleeding into the abdomen
What is the risk with ectopic pregnancies?
As ectopic pregnancies continue to grow within the fallopian tube, they can rupture causing bleeding into the abdomen. This can even be life threatening if not treated early.
How are ectopic pregnancies diagnosed?
A urine pregnancy test is the first investigation to be done. If this is positive, then an ultrasound will be arranged in order to locate the position of the pregnancy. The ultrasound will usually be done via the vaginal route.
This method is painless and allows better visualisation of the pelvic organs. Occasionally no pregnancy is identified on ultrasound. In these situations, two blood pregnancy hormone levels will be done 48 hours apart. This allows us to determine whether this is likely to be a pregnancy developing in the womb or not.
Pregnancy of Unknown Location
You may have been told that you are pregnant but that an ectopic pregnancy cannot be ruled out. You may have miscarried a pregnancy in the right place or you may have a very early pregnancy, which may still be an ectopic pregnancy.
Blood tests and ultrasound scans will have been organised for you, but you may be managed as an outpatient. You will be carefully monitored throughout your treatment, but you will usually not need to stay in hospital.
You will be given contact numbers and advised to return to hospital urgently if you have any concerns, such as pain or heavy bleeding or if you feel unwell is extremely important that you follow any advice given to you by the nursing and medical staff.
You should ensure you always have an adult with you, with access to a telephone and transport. This is in case you become unwell and need to be brought to hospital immediately.
How are ectopic pregnancies treated?
Decisions regarding treatment are taken by the senior doctors in the hospital. Depending on each individual case, the right option will be recommended for you.
Expectant treatment (wait and see option):
Women with a very early and failing ectopic pregnancy may be suitable for this conservative option. Sometimes the ectopic pregnancy fails and can be reabsorbed by the body in this situation. If this is associated with lowering of the pregnancy hormone level, then your doctor may opt to monitor your pregnancy hormone levels until they go back to safe levels.
During this time, you will be asked to report to the hospital if there is any abdominal or shoulder tip pain as this may mean there is bleeding from the ectopic. This is not a common occurrence. You will be carefully monitored throughout your treatment, but you will usually not need to stay in hospital. You will be given contact numbers and advised to return to hospital urgently if you have any concerns, such as pain or heavy bleeding or if you feel unwell.
There are strict hospital guidelines in place to ensure correct selection and management of women with an ectopic pregnancy with this treatment option.
Some women with an ectopic pregnancy may be suitable for this treatment after careful selection, using strict hospital guidelines to maintain patient safety. This option entails an injection with a drug (methotrexate) that destroys the pregnancy. This injection is usually given into your muscle as a single dose. You will then need to have blood test 4 and 7 days after the injection to ensure that the pregnancy hormone level is falling.
If it is falling, then you will be monitored until it returns to safe levels. This method is very successful and has the advantage of avoiding surgery and preserving your tube. However, the medication may occasionally cause nausea and a mild tummy pain. You will be carefully monitored throughout your treatment, but you will usually not need to stay in hospital.
You will be advised to avoid sexual intercourse as well as non-steroidal medications such as diclofenac or Ibuprofen. You will be given contact numbers and advised to return to hospital urgently if you have any concerns, such as pain or heavy bleeding or if you feel unwell.
Surgical treatment may involve open surgery or keyhole surgery. Open surgery is usually reserved for patients who have had significant bleeding into the abdomen. The surgery entails removal of the tube. Keyhole surgery (laparoscopic surgery) is used when patients are stable. The procedure will usually involve removal of the fallopian tube (salpingectomy). If the other tube is unhealthy then a salpingotomy (opening of the tube and removal of the pregnancy) will be performed.
There are strict hospital guidelines in place to ensure that the right management option is offered to the right patient.
What happens after an ectopic pregnancy?
It is not uncommon to feel grief and a sense of loss after this, as you have just been through not only a miscarriage and lost a baby but also may have had surgery. Do take time to ask questions when you are ready and take time to allow your body to recover, before going back to work.
The chances of having a successful pregnancy in the future are not significantly reduced after one ectopic pregnancy. Unfortunately, there is an increased risk of another ectopic pregnancy from 1% (1 in 100) to 10% (10 in 100). Women can try for another pregnancy after having one normal period, if they feel emotionally and physically ready for another pregnancy.
Some women will have problems conceiving and should contact their doctor if they have concerns. It is important to be referred early next pregnancy, so do contact your doctor as soon as you think you may be pregnant so there is enough time to organise blood tests and scans. This is important as you may have need checks earlier than normal to check that your pregnancy is going well
You may wish to have further counselling. Your questions should have been answered while you are in hospital, but you may wish to contact your doctor for further information or check reliable websites such as the UK Ectopic Pregnancy Trust: https://ectopic.org.uk/
Or the patient information leaflet from the Royal College of Obstetrics and Gynaecology (RCOG, UK).
Dr Nitu Bajekal FRCOG Dip IBLM
Consultant Gynaecologist and Women’s Health Expert
Lifestyle Medicine Physician
Updated January 2020