Ectopic pregnancy

An ectopic pregnancy is a pregnancy that develops outside the uterus (womb). Around 1 in 90 pregnancies in the UK is an ectopic pregnancy.

What is an ectopic pregnancy?

Normally when you become pregnant, the sperm fertilises the egg in one of your two fallopian tubes (the tubes that carry the egg to the womb). The fertilised egg then moves into the uterus, implants and grows. In an ectopic pregnancy this process does not happen and the pregnancy implants elsewhere.

Most ectopic pregnancies occur in the fallopian tube (95%) but they can rarely be found elsewhere including on the ovary, abdomen, cervix (neck of the womb) and scar of a previous Caesarean section. An ectopic pregnancy in non-viable, this means unfortunately the pregnancy cannot survive where it has implanted, often treatment is required to prevent serious harm.

NHS Choice Video: Ectopic pregnancy

Why does an ectopic pregnancy happen?

Any pregnant woman could have an ectopic pregnancy. However, some women are more at risk than others. These risks include:

Having had an ectopic pregnancy in the past.
Having damaged fallopian tubes. Causes of damaged tubes include: Previous pelvic infection, previous surgery to fallopian tubes including sterilisation, previous abdominal or pelvic surgery including appendicitis.
Getting pregnant with the intrauterine device (IUD/coil) or when on the progesterone only pill (minipill).
Having conceived by assisted reproduction such as IVF.

What are the symptoms of an ectopic pregnancy?

Some women with ectopic pregnancy do not get any symptoms at all and are diagnosed only when they have an ultrasound scan.

The symptoms women get when they have an ectopic pregnancy are vague and can make the diagnosis difficult to make. These symptoms usually occur between the 4th and 10th week of pregnancy and include:

Pain in the lower part of the abdomen - usually more on one side and normally progressively getting worse.
Pain at the tip of the shoulder(s).
Irregular vaginal bleeding- may be light or a brown vaginal discharge.
A missed or late period.
Bowel problems- diarrhoea as well as pain when going to the toilet for some women.
Feeling light-headed or fainting.
No symptoms at all.

How is an ectopic pregnancy diagnosed?

An ectopic pregnancy can be difficult to diagnose. One of the first things you will be asked for is a urine sample for a pregnancy test. A negative test means that it is very unlikely that your symptoms are due to an ectopic pregnancy

Usually a diagnosis of ectopic pregnancy is made using a combination of a medical review and examination and a pelvic ultrasound scan. Most women are offered a transvaginal ultrasound scan (where a probe is inserted into the vagina) to look at the uterus, ovaries and tubes. Sometimes you are asked to return for a repeat scan if a pregnancy cannot be seen on the first scan. Sometimes the diagnosis cannot be made without an operation called a Diagnostic Laparoscopy. A laparoscopy is a key-hole operation done under general anaesthetic (where you are put to sleep). A telescope is inserted into the belly button through a small cut to look at the womb, tubes and ovaries from the inside. If an ectopic pregnancy is found, it will be removed at the same time, usually with keyhole surgery techniques. Please see the patient information leaflet on laparoscopy if this is recommended to you.

How is an ectopic pregnancy treated?

There are different ways to treat an ectopic pregnancy. Not all options will be suitable for you. Your doctor will discuss the ones that are.

Medical management.
Surgical management.
Expectant management (wait, see and monitor) - this is only offered to women with small ectopic pregnancies which look like they will settle (be absorbed) by themselves, or where the diagnosis is not yet clear (also called Pregnancy of Unknown Location or PUL).
The options you are offered will depend on:
• The severity of your symptoms.
• If there is bleeding inside your abdomen.
• The level of your pregnancy hormone (hCG level).
Your scan result.
• Your general health.
• Your views and preference.

Medical Management

Ectopic pregnancies can sometimes be treated by medication. The fallopian tube is not removed.

The medication (methotrexate) prevents the pregnancy from developing and the ectopic pregnancy gradually disappears. Methotrexate is given as an injection into a muscle in your body e.g. bottom.

Methotrexate is not suitable if:

You are unwell and the doctors are concerned that you are bleeding internally.
You have a lot of pain in your abdomen.
Your pregnancy hormone levels are very high.
You have medical problems that mean you should not have methotrexate.
The advantages of methotrexate are:

It works in 70 - 80% of properly selected women.
You avoid having an operation with all its risks.
You usually do not need to stay in hospital more than a night, if at all.
The disadvantages of methotrexate are:
It may not work, or may not work well-enough first time.
You may need a further dose of methotrexate if yourpregnancy hormone levels aren’t falling (15% of women).
You may need surgery (less than 7% of women) if you become unwell.
Youmayexperienceside-effectsfromthetreatment: abdominal pain (common but brief), nausea (common but brief), mouth ulcers and skin rashes (uncommon).
You will be advised to wait for three months after the injection before trying for another pregnancy to make sure the medication is out of your system.
You will need to return for a blood test (hCG levels) twice in the first week and then until they return to pre-pregnancy levels. This takes an average of 6 weeks

Surgical Management

Surgical management of ectopic pregnancy is done under general anaesthetic (asleep).

This may be recommended treatment if:

You are unwell.
There is a live ectopic pregnancy.
Your hormone level is very high.
The diagnosis remains uncertain.

The procedure is either performed by:

Laparoscopy (key-hole surgery).This is the usual route and involves making three or four small cuts to the abdomen so that a camera can be inserted and the pelvis can be directly viewed. Instruments can then be used to remove the ectopic pregnancy.Laparoscopic surgery shortens the length of time you need to stay in hospital and your recovery when you get home compared to an open operation. Physical recovery is usually two weeks.
Laparotomy (open surgery usually through a bikini line cut in the lower part of the stomach) - This approach is used if you are too unwell, you have had previous abdominal surgery or there are technical difficulties with the operation that mean the doctors are unable to complete the procedure by key-hole route. Physical recovery is usually six weeks for open surgery

Please see separate information on diagnostic laparoscopy for more detail on the risks

Disposal of pregnancy tissue

When you have an operation to deal with a pregnancy complication you will be asked to sign a form giving instructions (consent) to the hospital about how you would like the tissue that is removed to be handled and disposed of. The doctor will explain your options. This may be done before or after the surgery, depending on how unwell you are.

Expectant Management

Ectopic pregnancies sometimes resolve on their own. It may be possible to monitor your HCG levels with blood tests every few days until these levels fall back to non-pregnancy levels. You do not need to stay in hospital, however, if you get any pain or significant bleeding you should call Ward J24 at St James’s University Hospital. (See page 17 for details).

Expectant management is not an option for all women. It is offered to women with very small ectopic pregnancies with low pregnancy hormone levels and mild or no symptoms.

Anti-D

Anti-D is an antibody injection given to women whose blood group is Rhesus-D negative to prevent them from producing antibodies to the current pregnancy which could cause problems to the baby in a future pregnancy. Your doctor can explain more if necessary.

When to expect your next period

Most women get a period about 6 - 8 weeks after completing treatment but it may take up to six months. Please seek advice from your GP if you have any concerns.You may not get a period if you have had the contraceptive implant or injection.When is it safe to start having sex again? Medically, it is safe to have sex once any vaginal bleeding and discharge have stopped. However, if you are feeling tired and/or you are still sore or in pain you may want to wait longer. Emotionally, you may want to wait longer.

Emotional recovery

Everyone copes differently following an ectopic pregnancy.You may feel some of the following:

• Upset or fear over the experience.
• Worry about getting pregnant again.
• Grief or shock.
• Guilt or blame over what has happened.

Please feel free to talk about these concerns with the gynaecology doctors and nurses on Ward J24, The Leeds Centre for Women’s Health.

How does this affect any future pregnancies?

The chance of having an ectopic pregnancy in the future is 7 - 10% (out of a hundred women who have had an ectopic pregnancy 7 to 10 of them will have another one). However the chance of a successful pregnancy in the future is good. Removal of a fallopian tube only slightly reduces your chance of falling pregnant particularly if the remaining tube is normal.

You will be advised to have an ultrasound scan at 6 to 8 weeks during your next pregnancy to confirm that the pregnancy is developing in your womb.

What contraceptives can I use?

You can become pregnant as early as ten days following the end of your pregnancy. If you do not want to become pregnant you can seek advice on forms of contraception from your GP.

However, you may choose to avoid using an intrauterine device in the future as the chance of a 2nd ectopic pregnancy is increased.

At the Leeds Centre for Women’s Health (Ward J24) we may be able to offer the hormonal contraceptive implant and injection. Ask the doctor or nurse caring for you for more details.