Ectopic Pregnancy

An ectopic pregnancy is a pregnancy outside the uterus (womb).
• In the UK, 1 in 90 pregnancies (just over 1%) is an ectopic pregnancy.
• Most ectopic pregnancies develop in the fallopian tubes (tubal pregnancy) but in rare cases they can develop at other sites.
• Diagnosis is made based on your symptoms, examination, blood tests, scan and other tests as appropriate.
• Treatment options vary depending on the location of your ectopic pregnancy and the results of your tests

An ectopic pregnancy is one that grows outside the uterus (womb). In the UK, 1 in 90 pregnancies (just over 1%) is an ectopic pregnancy. Women who have had a previous ectopic pregnancy are at higher risk. A pregnancy cannot survive in these situations and it can pose a serious risk to you. In a normal pregnancy, the fertilised egg moves from the fallopian tube into the uterus, where the pregnancy grows and develops. If this does not happen, the fertilised egg may implant and start to develop outside the uterus, leading to an ectopic pregnancy. An ectopic pregnancy can be life-threatening because as the pregnancy gets bigger it can burst (rupture), causing severe pain and internal bleeding.

Each woman is affected differently by an ectopic pregnancy. Some women have no symptoms, some have a few symptoms, while others have many symptoms. Most women get physical symptoms in the 6th week of pregnancy (about 2 weeks after a missed period). You may or may not be aware that you are pregnant if your periods are irregular, or if the contraception you are using has failed. Because symptoms vary so much, it is not always straightforward to reach a diagnosis of an ectopic pregnancy.

The symptoms of an ectopic pregnancy may include:

Pain in your lower abdomen. This may develop suddenly for no apparent reason or may come on gradually over several days. It may be on one side only.

Vaginal bleeding. You may have some spotting or bleeding that is different from your normal
period. The bleeding may be lighter or heavier or darker than normal.

Pain in the tip of your shoulder. This pain is caused by blood leaking into the abdomen and is a sign that the condition is getting worse. This pain is there all the time and may be worse when you are lying down. It is not helped by movement and may not be relieved by painkillers. You should seek urgent medical advice if you experience this.

Upset tummy. You may have diarrhoea, or feel pain on opening your bowels.

Severe abdominal pain/collapse. If the fallopian tube bursts (ruptures) and causes internal bleeding, you may develop intense abdominal pain or you may collapse. In rare instances, collapse may be the very first sign of an ectopic pregnancy. This is an emergency situation and you should seek urgent medical attention.

Management of Ectopic Pregnancy

Expectant management (wait and see)

Ectopic pregnancies sometimes end on their own – similar to a miscarriage. Depending on your situation, it may be possible to monitor the βhCG levels with blood tests every few days until these are back to normal. Although you do not have to stay in hospital, you should go back to hospital if you have any further symptoms (see the section above on What are the symptoms of an ectopic pregnancy?). You should be given a direct contact number for the emergency ward or gynaecology ward at your hospital. Expectant management is not an option for all women. It is usually only possible when the pregnancy is still in the early stages and when you have only a few or no symptoms. Success rates with expectant management are highly variable and range from 30% to 100%. This mainly depends on your pregnancy hormone levels, with higher serum βhCG levels associated with a lower chance of success.

Medical treatment

In certain circumstances, an ectopic pregnancy may be treated by medication (drugs). The fallopian tube is not removed. A drug (methotrexate) is given as an injection – this prevents the ectopic pregnancy from growing and the ectopic pregnancy gradually disappears. Most women only need one injection of methotrexate for treatment. However, 15 in 100 women (15%) need to have a second injection of methotrexate. If your pregnancy is beyond the very early stages or the βhCG level is high, methotrexate is less likely to succeed. Seven in 100 women (7%) will need surgery even after medical treatment. Many women experience some pain in the first few days after taking the methotrexate, but this usually settles with paracetamol or similar pain relief. Although it is known that long-term treatment with methotrexate for other illnesses can cause significant side effects, this is rarely the case with one or two injections as used to treat ectopic pregnancy. Treatment of ectopic pregnancy with methotrexate is not known to affect the capacity of your ovaries to produce eggs. You may need to stay in hospital overnight and then return to the clinic or ward a few days later. You will be asked to return sooner if you have any symptoms. It is very important that you attend your follow-up appointments until your pregnancy hormone levels are back to normal. You are also advised to wait for 3 months after the injection before you try for another pregnancy.

Surgical treatment

An operation to remove the ectopic pregnancy will involve a general anaesthetic.
The surgery will either be:

Laparoscopy (known as keyhole surgery). Your stay in hospital is shorter (24–36 hours) and physical recovery is quicker than after open surgery.
Laparoscopy might not be an option for some women and your doctor will discuss this with you.

Open surgery (known as a laparotomy). This is done through a larger cut in your abdomen and may be needed if severe internal bleeding is suspected. You will need to stay in hospital for 2–4 days. It usually takes about 4–6 weeks to recover. The aim of surgery is to remove the ectopic pregnancy. The type of operation you have will depend on your wishes or plans for a future pregnancy and what your surgeon finds during the operation (laparoscopy). To have the best chance of a future pregnancy inside your uterus, and to reduce the risk of having another ectopic pregnancy, you will usually be advised to have your affected fallopian tube removed (this is known as a salpingectomy). If you already have only one fallopian tube or your other tube does not look healthy, your chances of getting pregnant are already affected. In this circumstance, you may be advised to have a different operation (known as a salpingotomy) that aims to remove the pregnancy without removing the tube. It carries a higher risk of a future ectopic pregnancy but means that you are still able to have a pregnancy in the uterus in the future. You will be advised to have blood tests for checking your pregnancy hormone levels after salpingotomy as part of follow-up. Some women may need further medical treatment or another operation to remove the tube later if the pregnancy has not been completely removed during salpingotomy. The decision to perform salpingectomy or salpingotomy may sometimes only be made during laparoscopy under anaesthetic. There are risks associated with any operation: from the surgery itself and from the use of an anaesthetic. Your surgeon and anaesthetist will discuss these risks with you.