Ectopic Pregnancy

Ectopic pregnancy is a serious condition where a fertilized egg implants and grows outside the uterus, most often in a fallopian tube. This pregnancy cannot continue normally and requires prompt medical treatment to protect the mother’s life.

Table of contents

• What Is Ectopic Pregnancy?
• Where Ectopic Pregnancy Occurs
• How Common Is This Condition?
• Signs and Symptoms
• When to Seek Emergency Help
• What Causes Ectopic Pregnancy
• Risk Factors
• How Doctors Diagnose Ectopic Pregnancy
• Treatment Options
• Physical Recovery
• Emotional Recovery and Support
• Future Pregnancies

What Is Ectopic Pregnancy?

An ectopic pregnancy happens when a fertilized egg implants and grows outside of the uterus instead of inside it. In a healthy pregnancy, the fertilized egg travels down the fallopian tube (the tube connecting the ovary to the uterus) and attaches to the lining of the uterus, where it can develop safely^[1].

In an ectopic pregnancy, the fertilized egg attaches somewhere else. The pregnancy cannot proceed normally because only the uterus is designed to support a growing baby^[2]. The fertilized egg cannot survive, and if left untreated, the growing tissue can cause life-threatening bleeding^[1].

• Fallopian tubes
• Uterus
• Ovaries
• Cervix
• Abdominal cavity

Where Ectopic Pregnancy Occurs

Most ectopic pregnancies occur in the fallopian tubes. About 90% to 97% of ectopic pregnancies happen in these tubes, which is why they are sometimes called tubal pregnancies^[2][4][5].

However, ectopic pregnancies can also occur in other locations, including the ovary, the lower part of the uterus called the cervix, the abdominal cavity, or in scars from previous cesarean sections^[1][4]. These pregnancies outside the fallopian tube are less common and can be particularly challenging to diagnose and treat^[4].

How Common Is This Condition?

Ectopic pregnancy affects approximately 1% to 2% of all pregnancies in the United States^[4][12]. In the United Kingdom, around 1 in every 90 pregnancies is ectopic, which equals about 11,000 pregnancies per year^[3].

While ectopic pregnancy is potentially life-threatening, the death rate has steadily declined over the past three decades. From 2011 to 2013, ruptured ectopic pregnancy accounted for 2.7% of pregnancy-related deaths in the United States^[4]. Deaths from ruptures are now extremely rare in the UK when the condition is dealt with quickly^[3].

Signs and Symptoms

An ectopic pregnancy may not always cause symptoms at first and might only be detected during a routine pregnancy scan^[3]. Some women who have an ectopic pregnancy experience the usual early signs of pregnancy, such as a missed period, breast tenderness, and nausea^[1]. If you take a pregnancy test, the result will be positive, but the ectopic pregnancy cannot continue as normal^[1].

If symptoms do appear, they tend to develop between the 4th and 12th week of pregnancy^[3][7]. The most common symptoms include^[2][7][11]:

• Vaginal bleeding or spotting, which may be red or brown and watery
• Pain in the lower abdomen, pelvis, or lower back, typically on one side
• Dizziness or weakness
• Shoulder pain
• Discomfort when urinating or having a bowel movement

The bleeding may be heavier or lighter than a usual period. Ongoing bleeding that is sometimes light and sometimes heavy is quite often seen in ectopic pregnancy and should always prompt a pregnancy test^[7]. These symptoms are not necessarily a sign of ectopic pregnancy and can sometimes be caused by other problems^[3].

When to Seek Emergency Help

If your fallopian tube ruptures (splits open), you may experience severe symptoms that require immediate emergency care. Call 999 or go to your nearest emergency department immediately if you experience^[3][11]:

• Sharp, sudden, and intense pain in your abdomen
• Feeling very dizzy or faint
• Feeling sick
• Looking very pale
• Fainting
• Low blood pressure

These symptoms could mean that your fallopian tube has ruptured. This is very serious and surgery to repair the tube needs to be carried out as soon as possible^[3]. A rupture (when the tube splits open) can cause major internal bleeding and is a life-threatening emergency^[11].

What Causes Ectopic Pregnancy

In most cases, conditions that slow down or block the movement of the fertilized egg down the fallopian tube cause ectopic pregnancy^[2]. This could happen for several reasons^[2]:

• Scar tissue, adhesions, or inflammation from previous pelvic surgery
• Damage to the fallopian tubes, such as from a sexually transmitted infection
• Being born with an irregularly shaped fallopian tube
• A growth blocking the fallopian tube

Almost all ectopic pregnancies that occur in the fallopian tube are commonly linked to underlying abnormalities in the tube^[4]. Such abnormalities may result from prior infections (such as gonorrhea or chlamydia), previous tubal surgeries including sterilization, previous ectopic pregnancies, or exposure to certain medications^[4].

Risk Factors

Several risk factors could increase your chance of developing an ectopic pregnancy^[2][11][12]:

• A previous ectopic pregnancy
• History of pelvic inflammatory disease (an infection that can cause scar tissue to form in the fallopian tubes, uterus, ovaries, and cervix)
• Surgery on the fallopian tubes, including tubal ligation, or on other pelvic organs
• History of infertility
• Treatment for infertility with in vitro fertilization (IVF)
• Endometriosis (a condition where tissue similar to the uterus lining grows outside the uterus)
• Sexually transmitted infections
• Having an intrauterine device (IUD) in place at the time of conception
• Cigarette smoking
• Age older than 35 years
• Use of progesterone-only contraceptives

The overall rate of pregnancy when a woman has an IUD is less than 1%. However, in the rare case that pregnancy does occur while an IUD is in place, the rate of ectopic pregnancy can be as high as 53%^[12].

It’s important to note that about one half of all women who have an ectopic pregnancy do not have known risk factors^[4][11]. This means that any pregnant woman should be alert to changes in her body, especially if she experiences symptoms of an ectopic pregnancy^[11].

How Doctors Diagnose Ectopic Pregnancy

If you are of childbearing age and have lower abdominal pain or vaginal bleeding, your doctor will do a pregnancy test^[6]. A pelvic exam can help your doctor identify areas of pain, tenderness, or a mass in the fallopian tube or ovary, but the exam alone cannot diagnose an ectopic pregnancy^[8].

If the pregnancy test is positive or you know you are pregnant, your doctor may^[11]:

• Perform an ultrasound exam to see where the pregnancy is developing
• Test your blood for a pregnancy hormone called human chorionic gonadotropin (hCG)

A transvaginal ultrasound allows your doctor to see the exact location of the pregnancy. For this test, a wand-like device is placed into your vagina. It uses sound waves to create images of your uterus, ovaries, and fallopian tubes^[8].

The blood test for hCG confirms that you are pregnant. Levels of this hormone increase during pregnancy. This blood test may be repeated every few days until ultrasound testing can confirm or rule out an ectopic pregnancy, usually about five to six weeks after conception^[8].

By doing an ultrasound, the doctor can usually see whether the pregnancy is in your uterus or not. However, if it is early in your pregnancy, the doctor may not be able to locate the pregnancy with ultrasound. In this case, your doctor will decide what to do based on your symptoms and how much pregnancy hormone is in your blood^[6].

Treatment Options

A fertilized egg cannot develop normally outside the uterus. To prevent life-threatening complications, the ectopic tissue needs to be removed^[8]. An ectopic pregnancy must be ended as soon as possible to save the life of the woman^[6].

There are three main treatment options for ectopic pregnancy^[3][9]:

Expectant Management

Expectant management means you are carefully monitored to see whether the pregnancy will dissolve by itself without treatment. If you have no symptoms or mild symptoms and the pregnancy is very small or cannot be found, this may be an option^[3][9].

During this time, you will have regular blood tests to check that the level of hCG in your blood is going down. These tests will be needed until the hormone is no longer found^[9]. The main advantage of monitoring is that you will not experience any side effects of treatment, though there is still a small risk of the fallopian tube rupturing^[9].

Medical Treatment with Methotrexate

If an ectopic pregnancy is diagnosed early but active monitoring is not suitable, treatment with a medicine called methotrexate may be recommended^[9]. This drug stops cells from growing, which ends the pregnancy. The pregnancy then is absorbed by the body over 4 to 6 weeks^[11].

The medicine is given as a single injection, usually into your buttocks. You will not need to stay in hospital after treatment, but regular blood tests will be carried out to check if the treatment is working^[9]. A second dose is sometimes needed, and surgery may be necessary if the methotrexate does not work^[9].

You need to use reliable contraception for at least 3 months after treatment, as methotrexate can be harmful for a baby if you become pregnant during this time^[9]. It is also important to avoid alcohol until you are told it is safe, as drinking soon after receiving methotrexate can damage your liver^[9].

Side effects of methotrexate include tummy pain (usually mild and should pass within a day or two), dizziness, feeling and being sick, and diarrhea^[9].

Surgery

In most cases, keyhole surgery called laparoscopy will be carried out to remove the pregnancy before it becomes too large^[9]. During a laparoscopy, you are given general anesthetic so you are asleep. Small cuts are made in your abdomen, and a thin viewing tube and small surgical instruments are inserted through these cuts^[9].

The entire fallopian tube containing the pregnancy is usually removed if your other fallopian tube looks healthy. Otherwise, removing the pregnancy without removing the whole tube may be attempted^[9]. Removing the affected fallopian tube is the most effective treatment and is not thought to reduce your chances of becoming pregnant again^[9].

If your fallopian tube has already ruptured, you will need emergency surgery. The surgeon will make a larger cut in your abdomen to stop the bleeding and repair your fallopian tube if possible^[9].

Most women can leave hospital a few days after surgery, although it can take 4 to 6 weeks to fully recover^[9].

Physical Recovery

Your recovery after an ectopic pregnancy varies depending on when the pregnancy was diagnosed and the treatments you received. For some women, the pregnancy terminates on its own and your body recovers without many side effects^[20].

If your ectopic pregnancy is treated with medication, you may feel tired for several weeks and can expect some abdominal pain. Other side effects include spotting or vaginal bleeding, nausea, diarrhea, and dizziness^[20].

If you have surgery for an ectopic pregnancy, you can expect to need to take it easy for 2 to 4 weeks. You will also experience some abdominal soreness, swelling, and vaginal spotting or bleeding^[20]. Most women can return to work and other daily activities about two weeks after surgery, but you should avoid exercise and heavy lifting until your surgeon gives you the all clear^[20].

Driving is usually not recommended during the first week after surgery. Before resuming driving, you need to be fully recovered from your surgical procedure and free from pain. You should feel comfortable to be able to do an emergency stop before taking control of any vehicle^[18].

Emotional Recovery and Support

Even after you have physically recovered from an ectopic pregnancy, it is normal to experience difficult emotions. Losing a pregnancy can be devastating, and many women feel the same sense of grief as if they had lost a family member or partner^[3].

It is not uncommon for these feelings to last several months, although they usually improve with time. Make sure you give yourself and your partner time to grieve^[3]. Many women experience feelings of guilt, anger, fear, and sadness^[20].

If you or your partner are struggling to come to terms with your loss, you may benefit from professional support or counseling. Speak to your doctor about this^[3]. Be sure to seek support from family and friends, or a mental health counselor, to help you emotionally recover from this traumatic experience^[20].

Support groups for people who have been affected by loss of a pregnancy can also help. These include The Ectopic Pregnancy Trust, Ectopic Pregnancy Foundation, Miscarriage Association, and Cruse Bereavement Care^[3].

You can help yourself recover emotionally by getting the support you need and taking care of your physical health by getting enough quality sleep, regular exercise, and good nutrition^[20]. You will also want to avoid drinking, drugs, and tobacco, which can take a toll physically and make it more challenging to recuperate emotionally^[20].

Future Pregnancies

Some women fear their future fertility after an ectopic pregnancy. Having an ectopic pregnancy once increases your risk for future ectopic pregnancy by about 10%^[20].

The good news is that most women who have had an ectopic pregnancy will be able to get pregnant again, even if they have had a fallopian tube removed^[3][20]. In fact, as long as the remaining fallopian tube is healthy, women can have healthy pregnancies in the future^[20]. Occasionally, it may be necessary to use fertility treatment^[3].

You may want to try for another baby when you and your partner feel physically and emotionally ready. You will probably be advised to wait until you have had at least 2 periods after treatment before trying again to allow yourself to recover^[3].

If you were treated with methotrexate, it is usually recommended that you wait at least 3 months before trying to conceive, because the medicine could harm your baby if you become pregnant during this time^[3].