Ectopic pregnancy

• An ectopic pregnancy is one that grows outside the uterus (womb) , 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 advances it can burst (rupture), causing severe pain and internal bleeding.

From Ovulation to implantation

Most ectopic pregnancies develop in the fallopian tubes (tubal pregnancy) but, rarely (3–5 out of 100 ectopic pregnancies), can occur in other places.

• The image below shows some of these sites.

Sites for Ectopic pregnancy

• A pregnancy of unknown location (PUL) means that you have a positive pregnancy test but there is no identified pregnancy on an ultrasound scan.
• This may be due to three possible reasons:
  • You may have a very early pregnancy within the uterus that is too small to be seen on a scan
  • You may have early miscarriage (Chemical pregnancy – is a term used to describe a very early miscarriage which occurs before the fifth week of gestation and well before the fetus can be visibly detected on an ultrasound. A chemical pregnancy is believed to affect as many as 75 percent of pregnancies that end in miscarriage. ) ; your pregnancy test can remain positive for up to 2–3 weeks following miscarriage.
  • You may have an ectopic pregnancy.
  • Uncertainty about your pregnancy can be very stressful for you and your family. While it may take time, it is important to reach the correct diagnosis before your doctor discusses your treatment options with you.
  • With a PUL, you will be advised to have regular blood tests - βhCG to measure your pregnancy hormone levels and your treatment plan will be based on the results of these blood tests, ultrasound scan reports and clinical features.

• 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 straight forward 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.

• Yes. An ectopic pregnancy can pose a serious risk to your health. If you have had sex within the last 3 or 4 months (even if you have used contraception) and are experiencing these symptoms, you should get medical help immediately. Seek advice even if you do not think you could be pregnant.

• Any sexually active woman of childbearing age could have an ectopic pregnancy. You have an increased risk of an ectopic pregnancy if:
  • You have had a previous ectopic pregnancy.
  • You have a damaged fallopian tube.
  • You become pregnant when you have an intrauterine device (IUD/Cu-t).
  • Your pregnancy is a result of assisted conception, i.e. in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI).
  • Pregnancy after tubal recanalization surgery.

• Most ectopic pregnancies are suspected between 6 and 10 weeks of pregnancy. Sometimes the diagnosis is made quickly. However, if you are in the early stages of pregnancy, it can take longer (a week or more) to make a diagnosis of an ectopic pregnancy.

• Your diagnosis will be made based on the following:

  • Consultation and examination: Your doctor will ask about your medical history, symptoms, examination.
  • Urine pregnancy test: If you have not already had a positive pregnancy test, you will be asked for a urine sample so that this can be tested for pregnancy. If the pregnancy test is negative, it is very unlikely that your symptoms are due to an ectopic pregnancy.
  • Ultrasound scan: A transvaginal scan (where a probe is gently inserted in your vagina) is known to be more accurate in diagnosing an ectopic pregnancy than a scan through the tummy (transabdominal scan). Therefore, you will be offered a transvaginal scan to help identify the exact location of your pregnancy. However, if you are in the early stages of pregnancy, it may be difficult to locate the * pregnancy on scanning and you may be offered another scan after a few days.
  • Blood tests: A test for the level of the pregnancy hormone - βhCG (beta human chorionic gonadotrophin) & serial measurement of βhCG. This is usually checked every 48 hours because, with a pregnancy in the uterus, the hormone level rises by 75-100 % every 48 hours (known as the ‘doubling time’) whereas, with ectopic pregnancies, the levels are usually lower and rise more slowly or stay the same.
  • All the above mentioned tests are available at our SAAVI women’s hospital.

• Treatment options may include medical treatment with methotrexate or surgical operation.

• Because an ectopic pregnancy cannot lead to the birth of a baby, all options will end the pregnancy in order to reduce the risks to your own health.

• Your options depend upon:

  • How many weeks pregnant you are
  • Your symptoms and clinical condition
  • The level of βhCG
  • Your scan result
  • Your fertility status
  • Your general health

• The treatment options for tubal ectopic pregnancy are listed below –

A) 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.

• In a case of failure of medical treatment you may need to undergo surgical treatment.

• You will be asked to return sooner if you have any symptoms.

• If you have opted for medical treatment, it is advisable that you should be under monitoring of your doctor because in some cases you may have to undergo for surgery in an emergency situation.

B) Surgical treatment

Surgical treatment

• An operation to remove the ectopic pregnancy is another option.

• 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.

  • 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 for2–4 days. It usually takes about 4–6 weeks to recover. Options are salpingectomy/salpingotomy

• 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 salpingectomy).

• Salpingotomy - aims to remove the pregnancy without removing the tube. It carries a higher risk of a future ectopic pregnancy. 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 anaesthesia.

• This treatment modalities are available at our SAAVI women’s hospital.

• If the tubal or non-tubal pregnancy has burst, emergency surgery is needed to stop the bleeding. This operation is often life-saving.
• It is done by removing the ruptured fallopian tube and pregnancy.
• In this situation you may need a blood transfusion.

• The chances of having a successful pregnancy in the future are good. Even if you have only one fallopian tube, your chances of conceiving are only slightly reduced.
• For most women an ectopic pregnancy is a ‘one-off’ event.
• You should seek early advice from a doctor when you know you are pregnant. You may be offered an ultrasound scan at between 6 and 8 weeks to confirm that the pregnancy is developing in the uterus.
• If you do not want to become pregnant, seek further advice from your doctor as some forms of contraception may be more suitable after an ectopic pregnancy.

• An ectopic pregnancy is a pregnancy outside the uterus (womb).
• 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(s), 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.

• This information aims to helps you make the best decision regarding your care. It is not meant to replace advice from a doctor about your own situation.