Ectopic pregnancy

What is an ectopic pregnancy?

An ectopic pregnancy is when the fertilised egg implants outside the uterus (womb), most commonly in the fallopian tube (the tube that connects the ovary to the uterus). Rarely, an ectopic pregnancy can happen in the ovary, cervix, abdominal cavity or a caesarean scar.

If a pregnancy is going to become ectopic, it usually happens in the first 12 weeks of pregnancy. Sadly, an ectopic cannot survive as it is not in the right place to develop normally.

Each year nearly 12,000 patients are diagnosed with an ectopic pregnancy (1 in every 80 pregnancies in the UK).

What are the possible causes of an ectopic pregnancy?

In most cases, the cause of the pregnancy developing outside the uterus is never known. It is known that the chances of having an ectopic pregnancy can be increased by the following:

• Previous ectopic pregnancy. There is a slight increased risk for future pregnancies.
• Damage to the fallopian tube caused by pelvic infection or previous tubal surgery such as sterilisation.
• Scar tissue or adhesions from previous abdominal surgery such as a caesarean section or appendicectomy.
• Becoming pregnant while using the coil or intra uterine contraceptive device (IUCD). However, pregnancy with an IUCD fitted is very rare.
• Fertility treatment – ectopic pregnancy can occur during the embryo transfer in an IVF cycle. The more embryos transferred the greater the risk of ectopic pregnancy.
• Endometriosis – women with endometriosis are at a higher risk of ectopic pregnancy, the cause for this is not known.
• Smoking – research suggests that smokers have a higher level of a type of protein in their fallopian tubes that helps pregnancies to implant. The presence of this protein in the fallopian tubes can affect the progress of a fertilised egg reaching the uterus (womb), increasing the risk of ectopic pregnancy.

What are the symptoms of an ectopic pregnancy?

Symptoms usually develop around the 6th week of pregnancy. This is about 2 weeks after a missed period, if you have regular periods. However, symptoms may develop anytime between 4 and 12 weeks of pregnancy and very rarely even later that that. Symptoms of ectopic pregnancy include the following:

• Pain on one side of the lower abdomen. The pain can develop suddenly or may start gradually, slowly getting worse over several days and becoming severe.
• Vaginal bleeding - this is often different to the bleeding of a period, for example, the bleeding may be heavier or lighter than a normal period. The blood may look darker (often described as ‘prune juice’) and you may think the bleeding is a late period.
• Change in bladder or bowel pattern including, diarrhoea, pain on passing faeces (stools) or pain when passing urine.
• Shoulder-tip pain (located where your shoulder ends and your arm begins). This is due to blood leaking into the abdomen and irritating the diaphragm (the muscle in your abdomen used to breathe).
• Collapse – this is usually as a result of the fallopian tube rupturing (splitting) causing internal bleeding.

If an ultrasound scan shows no evidence of a pregnancy, but the pregnancy test is positive, an ectopic pregnancy needs to be considered. It is not always possible to see an ectopic pregnancy on an ultrasound scan.

If you feel well, a blood sample will be taken to measure your pregnancy hormone and progesterone levels. The blood test may be repeated 48 hours later as it will help to make a diagnosis. More tests may be required to establish a diagnosis.

You will be advised about any follow-up apportionments needed.

What are the treatment options for early ectopic pregnancy?

When an ectopic pregnancy is diagnosed before rupture of the surrounding tissue, it is called early ectopic pregnancy. Your doctor will advise you about the treatment options, which may include the following:

Surgical management

A planned operation is the usual treatment to remove the fallopian tube and the ectopic pregnancy. Keyhole surgery is most commonly used. The terminology is explained below:

• Laparoscopy (keyhole surgery) - insertion of scope (camera) into the abdomen through your navel (belly button).
• Laparotomy - incision (open cut) into the abdominal cavity.
• Salpingectomy - removal of the fallopian tube.
• Salpingotomy - cutting open the tube and removing the ectopic pregnancy, saving the fallopian tube.

Medical management

A medicine called methotrexate may be an option. It works by destroying the cells of the pregnancy growing in your fallopian tube. This is normally only advised if the pregnancy is very early. The advantage of this treatment is that you do not need an operation. The disadvantage is that you will need close observation for several weeks with repeated blood tests to check that it has worked. Also, some women experience side-effects from the medication, please see patient information leaflet GHPI0975 ‘Treatment of ectopic pregnancy with Methotrexate’ for more details.

If this treatment is not successful, surgery to remove the fallopian tube may be necessary.

You may have some bleeding after surgery or medical treatment. This is because you have been pregnant and the lining of the womb associated with pregnancy comes away once the pregnancy is removed.

Conservative or expectant management (wait and see)

This is sometimes used for small (early) ectopic pregnancies.

Some ectopic pregnancies resolve themselves, often ending in a way similar to a miscarriage. A possible option is to see how things go if you have mild or no symptoms. You will need close observation and repeated scans and blood tests. Treatment will be given if your symptoms get worse.

A ‘wait and see’ approach is not always advised as there is the risk of a sudden rupture of the fallopian tube. This is a serious condition which would need emergency surgery. Your gynaecologist will discuss the options available to you.

What is the treatment for a ruptured fallopian tube?

Emergency surgery is needed if a fallopian tube ruptures as it will cause heavy internal bleeding. The main aim of the operation is to stop the bleeding. The ruptured fallopian tube and remains of the ectopic pregnancy are then removed. The operation is often life saving for the woman.

Can I request a baby loss certificate?

For any pregnancy loss before 24 weeks, you can now request a baby loss certificate in memory of your baby.

In order to request a certificate, you will need your NHS number or the postcode registered with your GP, your mobile phone number or email address registered with your GP and permission from the other parent together with their email address.

For more information or to request a certificate, please visit:

www.gov.uk/request-baby-loss-certificate

Can we arrange to have a blessing said for our baby?

A hospital chaplain will be available to support your spiritual needs and we will try to accommodate all religious beliefs.

There is a book of remembrance held within the hospital. The Trust also holds a yearly service in remembrance of the babies who die before and around birth, you are welcome to attend. If you wish to know more about either of these, please ask your nurse or doctor for further details.

What about future pregnancies?

Before trying again for a baby, it is best to wait until you and your partner are ready, both physically and emotionally. If you have had surgery, it is advisable to wait at least 4 to 6 weeks before having sexual intercourse. If you have had medical treatment for an ectopic pregnancy, you will be advised by your health care professional when it is safe to try for a future pregnancy.

It is not possible to prevent an ectopic pregnancy form happening. The chances of having a further ectopic pregnancy are around 10% but this does depend on personal factors including, the extent of damage to your fallopian tube(s) and other factors such as smoking.

Studies suggest that 65% of women will have conceived within 18 months of an ectopic pregnancy. This rises to 85% after 2 years. The time it takes to conceive following an ectopic pregnancy will again be dependent on personal circumstances including your age and general and reproductive health.

After having an ectopic pregnancy, as soon as you think you may be pregnant again, you must contact your GP or the local Early Pregnancy Assessment Clinic (the contact details are at the end of this page). You will be offered and early scan at around 6 to 7 weeks to make sure that the pregnancy is not ectopic.

Once an ectopic pregnancy has been ruled out, the pregnancy would be expected to continue normally and no further close monitoring would be needed.

What about returning to normal activities?

It is best to build up your strength slowly. Having an ectopic pregnancy can be traumatic because you are dealing with the loss of a pregnancy as well as trying to recover physically from any treatment you may have had.

It is common to feel anxious or have low mood for a while after treatment. Worries about possible future ectopic pregnancy, the effect on your fertility and sadness over the loss of pregnancy are normal. Please talk to your GP about this and any other concerns you may have, following treatment.

You will need 2 to 4 weeks to recover after keyhole surgery and 4 to 6 weeks if you have had an open (cut to the abdomen) procedure.

Contact information

After discharge, if you have any questions or concerns, please contact your GP. If you are still having treatment, please contact the:

Early Pregnancy Assessment Clinic

Gloucestershire Royal Hospital

Tel: 0300 422 5549

This line is open from 8:00am to 4:00pm, 7 days a week.

Further information

If you would like any further information, or would like to talk to someone who has been through the experience of an ectopic pregnancy, please contact the following organisations:

The Miscarriage Association

17 Wentworth Terrace, Wakefield, Yorkshire WF1 3QW

Tel: 01924 200 799

Monday, Tuesday and Thursday 9:00am to 4:00pm

Wednesday and Friday 9:00am to 8:00pm

Email: info@miscarriageassociation.org.uk

Website: www.miscarriageassociation.org.uk

The Ectopic Pregnancy Trust

483 Green Lanes, Palmers Green, London N13 4BS

Tel: 020 7733 2653 or 0300 102 0180

Website: www.ectopic.org.uk

Tommy’s Midwife Helpline

Tel: 0800 0147 800

Monday to Friday, 9:00am to 5:00pm

Email: midwife@tommys.org

Website: www.tommys.org/baby-loss-support

Other written information about ectopic pregnancy is available from the hospital.

Leaflet GHPI0975 ‘Treatment of ectopic pregnancy with Methotrexate’ - a copy will be provided by a member of the medical team.