Ectopic Pregnancy

What happens in an ectopic pregnancy

After fertilization in the fallopian tube, the embryo normally travels to the uterus over several days and implants in its lining. In an ectopic pregnancy it implants somewhere else:

A fallopian tube cannot stretch to hold a growing pregnancy. As the pregnancy grows, it can rupture the tube, causing internal bleeding. An ectopic pregnancy cannot be moved to the uterus or continue to a live birth.

Symptoms

Symptoms usually appear between 4 and 12 weeks of pregnancy. Some people do not yet know they are pregnant.

Early symptoms

• A missed period and positive pregnancy test
• Light vaginal bleeding or brown, watery discharge, which may be mistaken for a period
• Pain low in the abdomen or pelvis, often on one side, which may come and go
• Pregnancy symptoms such as breast tenderness and nausea
• Discomfort when passing stool or urine
• Pain at the tip of the shoulder, caused by blood irritating the diaphragm

Signs of rupture

• Sudden, sharp, severe pain in the abdomen or pelvis
• Shoulder tip pain
• Dizziness, fainting, feeling very unwell
• Pale skin, sweating, fast heartbeat
• Collapse

Early symptoms can resemble a miscarriage, a urinary infection, appendicitis or stomach upset, so anyone who could be pregnant with pelvic pain should take a pregnancy test and get checked.

Causes and risk factors

Most ectopic pregnancies happen because the fallopian tube is damaged or does not move the embryo along normally. However, about half occur in people with no known risk factor.

• Previous ectopic pregnancy
• Pelvic inflammatory disease, often from chlamydia or gonorrhea
• Previous surgery on the fallopian tubes, including tubal sterilization or its reversal
• Endometriosis
• Fertility treatment, including IVF
• Becoming pregnant with an IUD in place (IUDs prevent most pregnancies, but if one occurs it is more likely to be ectopic)
• Smoking
• Age over 35

Diagnosis

1. Pregnancy test: urine or blood test for hCG, the pregnancy hormone.
2. Transvaginal ultrasound: a probe in the vagina checks whether the pregnancy is in the uterus, and looks for a mass in the tube or free fluid (blood) in the pelvis.
3. Serial hCG blood tests: taken 48 hours apart. In a healthy early pregnancy, hCG usually rises by at least about 35 to 50% in 48 hours. A slow rise, plateau or slow fall suggests an ectopic or failing pregnancy.
4. Pregnancy of unknown location: when a test is positive but no pregnancy is seen on ultrasound, close monitoring with repeat scans and blood tests continues until the location is clear.

Treatment

The choice depends on symptoms, hCG level, ultrasound findings, whether the tube has ruptured, and personal preference.

Expectant management

If you are well, the hCG is low and falling, and the ectopic is small, it may resolve by itself. hCG is checked until it returns to zero.

Medicine (methotrexate)

An injection of methotrexate stops the pregnancy cells from growing so the body absorbs the tissue. It suits people who are stable, without rupture, with lower hCG levels and a small ectopic. Follow-up blood tests confirm hCG falls to zero, which can take several weeks. A second dose or surgery is sometimes needed. During treatment, avoid alcohol, folic acid supplements, NSAIDs and sex until advised, and avoid pregnancy for at least 3 months afterward because methotrexate can harm a developing baby.

Surgery

Keyhole surgery (laparoscopy) is used when the tube has ruptured, hCG is high, there is heavy bleeding or a large ectopic, or medicine is not suitable:

• Salpingectomy: removal of the affected tube. Usually preferred if the other tube is healthy.
• Salpingotomy: the pregnancy is removed and the tube preserved, considered when the other tube is damaged.

A ruptured ectopic with heavy bleeding needs emergency surgery and sometimes blood transfusion.

Rh(D) immunoglobulin

People with Rh-negative blood may be offered anti-D immunoglobulin after surgical treatment.

Recovery and future pregnancy

Physical recovery after keyhole surgery usually takes 2 to 4 weeks. Most people go on to have a healthy pregnancy later, even with one tube. The risk of another ectopic pregnancy is higher, about 10 to 15%, so an early ultrasound is advised in future pregnancies.

Losing a pregnancy can be very distressing, regardless of how early. Grief, anxiety and low mood are common, and support from partners, counselors or pregnancy loss organizations can help.

Frequently asked questions

What are the first signs of an ectopic pregnancy?

Early signs include a missed period, a positive pregnancy test, light vaginal bleeding or brown discharge, and pain low on one side of the abdomen or pelvis. Some people feel shoulder tip pain or discomfort when passing stool. Symptoms usually start between 4 and 12 weeks.

Can an ectopic pregnancy survive?

No. An ectopic pregnancy cannot develop into a healthy baby, and it cannot be moved into the uterus. It must be treated, or monitored until it resolves, to protect the health and life of the pregnant person.

What happens if an ectopic pregnancy ruptures?

A rupture causes internal bleeding, with sudden severe abdominal pain, shoulder tip pain, dizziness, fainting and shock. It is a life-threatening emergency that needs immediate surgery. Call 911 or your local emergency number.

How is an ectopic pregnancy treated?

Treatment options are monitoring if it is resolving on its own, an injection of methotrexate to stop it growing, or keyhole surgery to remove the pregnancy, often with the affected tube. Ruptured ectopic pregnancies need emergency surgery.

Can I get pregnant again after an ectopic pregnancy?

Yes. Most people can have a successful pregnancy afterward, even with one fallopian tube. The risk of another ectopic is higher, so an early ultrasound is recommended in your next pregnancy. After methotrexate, wait at least 3 months before trying.