Ectopic pregnancy

Approved by the BabyCenter Malaysia Medical Advisory Board Last reviewed: January 2012 [Show references]

What is an ectopic pregnancy? When is an ectopic pregnancy likely to happen? Why does an ectopic pregnancy happen? Who is at risk of an ectopic pregnancy? What are the symptoms of an ectopic pregnancy? What should I do if suspect I have an ectopic pregnancy? How is an ectopic pregnancy treated? Will the ectopic pregnancy affect my fertility? What are the chances of having another ectopic? How long should I wait before trying for another?

What is an ectopic pregnancy?

Ectopic means "in the wrong place", so it's a pregnancy that develops outside the womb. Most ectopic pregnancies (95 per cent) implant in one of the fallopian tubes which is why it is also known as a tubal pregnancy. As the pregnancy grows, it causes pain and bleeding and, if not recognised, the fallopian tube can rupture, causing internal bleeding. This is a medical emergency and can be life-threatening. The pregnancy itself never survives because it can't be moved to the womb. It has to be completely removed.

When is an ectopic pregnancy likely to happen?

An ectopic pregnancy is most commonly found between the fourth and tenth week of pregnancy. Symptoms often start about two weeks after a missed period.

Why does an ectopic pregnancy happen?

The fertilised egg normally spends five to six days travelling down the fallopian tube from the ovary to the womb where it implants and begins to develop. The most common reason for an ectopic pregnancy is when the tube has been damaged, and this causes a blockage or narrowing which prevents the egg from reaching its destination. Instead, it implants in the wall of the tube.

Who is at risk of an ectopic pregnancy?

An ectopic pregnancy can happen to any woman, but there are circumstances which make it more likely. These include:

If you've had pelvic inflammatory disease (PID) (which is most often caused by the sexually transmitted infection chlamydia) as this can cause damage and scarring to the fallopian tubes. There are signs of PID in about half of all ectopic pregnancies which are operated on.

If you have tubal endometriosis. You may be more at risk because this increases the risk of scarring and adhesions in the tubes.

If you've had any abdominal surgery, including an appendix removal or a caesarean section or surgery on your fallopian tubes, such as sterilisation reversal.

If you are pregnant as the result of IVF treatment. You should have an early scan to check where the embryo has implanted.

If you have a progesterone-releasing IUD fitted (IUS, also called Mirena coil) or if you are taking the contraceptive mini-pill. Both have been associated with a slightly higher rate of ectopic pregnancy.

If you smoke.

If you've had a previous ectopic pregnancy. Your risk increases from 1 in 100 to 1 in 10.

The risk of ectopic pregnancy also increases as you get older.

What are the symptoms of an ectopic pregnancy?

It can be difficult to recognise an ectopic pregnancy, as it may start with the sort of signs you associate with your period starting or a threatened miscarriage, such as cramping and slight bleeding. However, there are several early symptoms that can help identify an ectopic pregnancy including:

Unusual vaginal bleeding The blood is often different from your normal period, either heavier or lighter, and perhaps darker than usual and watery (some people describe it as "prune juice"). One-sided pain in the lower abdomen that is severe and persistent This is a common symptom. If you experience this and you could possibly be pregnant, you should see a doctor. If the ectopic pregnancy is not diagnosed early, and the tube is stretched by the growing embryo to the point where it ruptures, then you may have the following symptoms:

Sudden, severe pain gradually spreading out across the abdomen. Sweating, feeling light-headed or faint, diarrhoea or blood in your stool. Collapse or shock as a result of severe internal bleeding. Shoulder-tip pain. This can happen if there is internal bleeding which irritates other internal body organs, such as the diaphragm.

What should I do if suspect I have an ectopic pregnancy?

If you have any of the symptoms above, see your doctor immediately or go to hospital. If the tube has ruptured, you'll go straight to surgery, but in most cases ectopic pregnancies are caught early enough for some tests to be done and surgery, if needed, to be planned. You're likely to be given an internal examination to locate the pregnancy, and a sensitive pregnancy test. A blood test will measure the levels of human chorionic gonadotrophin (hCG) hormone. It will not only tell whether you are pregnant or not, but will also show whether the levels of hCG are lower than normal, which is a sign of ectopic pregnancy. A doctor may carry out a vaginal ultrasound examination, as the pregnancy may not show up using an abdominal scan. Sometimes, the scan isn't conclusive and you may need another scan a few days later. If doctors suspect an ectopic pregnancy but it has not been confirmed by ultrasound, you will probably be taken to the operating theatre for a laparoscopic examination. This is where a narrow viewing instrument is put into your abdomen through a tiny cut to inspect your tubes.

How is an ectopic pregnancy treated?

If an ectopic is discovered, the surgeon can use laparoscopy (keyhole surgery) to cut the fallopian tube and remove the pregnancy, leaving the tube intact if it can be repaired. Laparoscopy has advantages over open abdominal surgery, because:

the operation is quicker; less blood is lost during surgery; you don't need to stay in hospital for as long; less analgesia (pain killing medicine) is needed.

If the tube has ruptured, doctors usually recommend abdominal surgery, because it is the quickest way to reduce blood loss. In some cases a blood transfusion may be needed to replace lost blood. Whether the tube and pregnancy are removed altogether, or the pregnancy is removed and the tube repaired, depends on:

how damaged the tube is; the health of your other fallopian tube; your desire for future pregnancy.

In a small percentage of women, usually in cases where the tube has been saved (about 4 per cent with keyhole surgery and 8 per cent with open surgery) the pregnancy continues to grow and needs treatment with the drug methotrexate, which terminates pregnancy, or further surgery to remove it. Methotrexate can also sometimes be used to treat an ectopic pregnancy instead of surgery. This treatment is most effective in very early pregnancy, where levels of the pregnancy hormone are still fairly low, and it can be used where there is no bleeding and the tube has not ruptured. The pregnancy is lost and reabsorbed by the mother, who will then experience bleeding for a couple of weeks. In selected cases, where an ectopic pregnancy has been identified very early on but its exact location has not been discovered, no treatment will be offered. This is called expectant management or "wait and see". This is because many ectopic pregnancies miscarry naturally, especially those where there is no evidence of an egg sac and the pregnancy hormone levels are very low. In these cases, expectant management avoids surgery until it is shown to be absolutely necessary, which happens in about a quarter of these cases.

Will the ectopic pregnancy affect my fertility?

The answer to this is yes, possibly. If your fallopian tubes are undamaged after an ectopic pregnancy, then your chances of conceiving again remain the same. If one of the tubes ruptured or was badly damaged, your chances of conceiving again are reduced, particularly if your other tube has already been compromised by PID or endometriosis. In this case, whether it is more difficult to get pregnant but still possible, depends on your particular case. Some 65 per cent of women will conceive again within 18 months of an ectopic, but if both your fallopian tubes were damaged or ruptured, you may need to think about IVF treatment.

What are the chances of having another ectopic?

There's about a 10 to 15 per cent risk of having another one. However, the risk is difficult to generalise about because of the differences in individual circumstances and the extent of the damage that takes place. You should arrange for a follow-up appointment and ask for clear advice about your own

future pregnancies from your obstetrician. There is little you can do to prevent an ectopic pregnancy from happening in the future, although if your ectopic has been caused by a current chlamydia infection you can have a course of antibiotics to clear it up and reduce further damage to your tubes. When you do become pregnant again, see your doctor as soon as you can.

How long should I wait before trying for another?

Women who've had a laparoscopy should normally wait three to four months before trying to conceive again. If you have had abdominal surgery, it's best to wait for six months to allow scarring to heal.