What is an ectopic pregnancy?
Ectopic pregnancy is a rare, but serious complication of early pregnancy where a fertilized egg implants outside of the uterus. It affects approximately 11 pregnancies in 1000 (just over 1%), and can cause significant risk to the life of the pregnant woman. A pregnancy that implants outwith the uterus cannot survive and often the pregnancy needs to be removed using medication or a surgical procedure in order to protect the life of the mother.
In a normal pregnancy a fertilised egg moves down the fallopian tube and implants in the uterus. In an ectopic pregnancy the fertilized egg implants somewhere else, usually in the fallopian tube. It is rare for an egg to implant in another location but 3 - 5 in 100 ectopic pregnancies occur in another location, for example in one of the ovaries or the cervix.
What are the risk factors?
Most women who experience an ectopic pregnancy don’t have any of the risk factors, but there are some groups who have a higher chance of being affected, including:
What symptoms does ectopic pregnancy cause?
The symptoms can vary greatly from woman to woman, but symptoms often develop around 6 weeks of pregnancy (about 2 weeks after a missed period). The common symptoms of an ectopic pregnancy are vaginal bleeding (which can be heavier or lighter than a normal period) and lower abdominal pain, which in many cases is worse on one side of the abdomen. Pain in the shoulder tip may also be a sign of an ectopic pregnancy – the pain is constant, not affected by movement and may get worse with lying down.
If you experience these symptoms and you think you could be pregnant (if you have had sex in the past 3 months, even if you used contraception) then you should seek advice without delay. An ectopic pregnancy may be life threatening if untreated.
How is ectopic pregnancy diagnosed?
Assessment of a woman with a possible ectopic pregnancy will include asking questions about her general health, her periods and her current symptoms. An examination of the abdomen is often carried out, and a urine pregnancy test may be done to confirm pregnancy.
If your healthcare professional suspects an ectopic pregnancy the next step is to try and establish the location of an embryo. This is usually done with an ultrasound scan (with the probe inserted into the vagina in order to get the best view of the pelvic organs), but blood tests might also be helpful if a scan can’t be done immediately, or if the scan result is inconclusive. Sometimes it’s not possible to see an embryo on the scan, this may indicate a miscarriage, or it could be that the embryo is too small to be detected. In this situation, repeating the blood test or scan after a few days may reveal if there is a continuing pregnancy, and where it is located.
What treatment is available?
The treatment of an ectopic pregnancy will be tailored to each woman depending on a number of factors including: patient preferences, the location and stage of the pregnancy, the past history of the woman, the scan results and if the woman is well or if urgent medical treatment is necessary.
A “wait and see” approach may be appropriate for some women, as in a significant number of cases an ectopic pregnancy will stop developing and be reabsorbed by the body without any medical intervention. If the pregnancy is early on, and depending on the results of the blood tests and ultrasound scan, it may be possible to simply monitor the situation with regular checks. If your healthcare provider thinks this is a suitable option for you then you’ll be given clear information on what to do if your situation changes.
An injection of a drug called methotrexate can be given in order to end the pregnancy. Again, this option is only suitable for a portion of women. After the injection follow up is needed to ensure that the pregnancy has been terminated. In some instances this treatment may fail, and a second injection or surgery may be needed. If you receive a methotrexate injection you’ll be advised to avoid getting pregnant again for the next 3 months as there’s a chance that traces of the drug might still be in your system.
If medical treatment and expectant management are not appropriate then a surgical procedure will be offered. In many cases this will be done by keyhole (laparascopically), using a small cut to insert a camera and instruments to identify the location of a pregnancy and remove it. Usually the affected section of the fallopian tube will also be removed (salpingectomy) as this reduces the chance of a recurrence of ectopic pregnancy. In women who only have one functioning fallopian tube, for example, if they have had surgery in the past to remove the other tube, then the remaining tube may be preserved by doing a salpingotomy procedure: cutting open the tube and removing only the pregnancy. Your healthcare provider will discuss the options available to you and why one approach might be recommended over another. A general anaesthetic is required for these procedures, and the risks of surgery will be discussed with you beforehand.
In the event of a ruptured ectopic – where the ectopic pregnancy bursts, significant internal bleeding can occur which may be life threatening. Emergency surgery will be needed to stop the bleeding and remove the damaged tube and the pregnancy. Your doctors might need to make some decisions about life-saving treatment without discussing them fully with you and a blood transfusion may also be required.
However your ectopic pregnancy is managed, it’s essential that you attend for follow up to ensure the treatment has been successful and you are recovering well. Recovery time will vary depending on if you have surgery and the extent of the surgery needed.
After an ectopic pregnancy you may find it hard to come to terms with what happened and your emotions may be difficult to cope with. Whether it is the loss of the pregnancy, worries about your fertility, or recovering from surgery, it may take time to come to terms with the experience and other people around you could be affected too. If you feel that you are not coping and you need help or support then you should talk to your healthcare provider.
Women who have had one ectopic pregnancy have an excellent chance of getting pregnant again in the future, and fertility is only slightly reduced by having one fallopian tube. Most women will not have more than one ectopic pregnancy, but the risk of it happening in future is slightly increased (7 – 10%) compared to women who have never had an ectopic pregnancy and have a risk of just over 1%.
It might be a while before you feel ready to get pregnant again and that’s quite normal. You can discuss your contraceptive choices with your healthcare provider. If you do become pregnant after an ectopic pregnancy you should let your health care provider know as soon as you can: you may be offered an early scan so confirm the location of the pregnancy and additional support during your pregnancy.
Dr Emma Scott (MBChB, MRCGP) is a qualified GP and mummy to two young children. She works in a GP practice in Edinburgh and in the out of hours GP service in Livingston and she has experience in both obstetrics & gynaecology and paediatrics.
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