Ectopic Pregnancy

A pregnancy is ectopic when a it occurs outside the uterus (womb). Ectopic means 'misplaced'.

An ovum (egg) is released from an ovary into a fallopian tube. This is called ovulation and usually occurs once a month about half way between periods. Sperm may be present in the fallopian tubes for a few days after having sex. A sperm may combine with the ovum (fertilisation) to make an embryo. The tiny embryo is 'wafted' along a fallopian tube to the uterus by tiny hairs (cilia). It normally attaches to the inside lining of the uterus and develops into a baby.

Most ectopic pregnancies occur when a fertilised egg attaches to the inside lining of a fallopian tube (a 'tubal ectopic'). Rarely, an ectopic pregnancy occurs in other places such as in the ovary or inside the abdomen. The rest of this leaflet deals only with tubal ectopic pregnancy.

A tubal ectopic pregnancy never survives. Possible outcomes include the following.

• The pregnancy often dies after a few days. About half of ectopic pregnancies probably end like this. You may have no symptoms, and you may never have known that you were pregnant. Sometimes there is slight pain and some vaginal bleeding like a miscarriage. Nothing further needs to be done if this occurs.
• The pregnancy may grow for a while in the narrow fallopian tube. This can stretch the tube and cause symptoms. This is when an ectopic pregnancy is commonly diagnosed.
• The narrow fallopian tube can only stretch a little. If the pregnancy grows further it will normally rupture (split) the fallopian tube. This can cause heavy internal bleeding.

Symptoms typically 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 10 weeks of pregnancy. You may not be aware that you are pregnant. For example, your periods may not be regular, or you may be using contraception and not realise it has failed. Also, symptoms may start about the time a period is due. At first you may think the symptoms are just a late period. Symptoms include one or more of the following.

• Pain on one side of the lower abdomen. It may develop sharply, or may slowly get worse over several days. It can become severe.
• Vaginal bleeding often occurs, but not always. It 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. However, you may think the bleeding is a late period.
• Other symptoms may occur such as diarrhoea, feeling faint, or pain on passing faeces (stools).
• Shoulder-tip pain may develop. This is due to some blood leaking into the abdomen and irritating the diaphragm (the muscle used to breathe).
• If the fallopian tube ruptures and causes internal bleeding, you may develop severe pain or 'collapse'. This is an emergency as the bleeding is heavy.
• Sometimes there are no warning symptoms (such as pain) before the tube ruptures. Therefore 'collapse' due to sudden heavy internal bleeding is sometimes the first sign of an ectopic pregnancy.

About 1 in 100 pregnancies in the UK are ectopic. Ectopic pregnancy can occur in any sexually active woman. However, the chance is higher than average in the following 'at-risk' groups.

• If you have already had an ectopic pregnancy you have about a 1 in 10 chance that a future pregnancy will be ectopic.
• If you have kinking, scarring, damage, or other abnormality of a fallopian tube. This is because a fertilised egg may become 'stuck' in the tube more easily. For example:
  • If you have had previous infection of the uterus or fallopian tube (pelvic infection). Infection can cause some scarring. Chlamydia and gonorrhoea are common causes of pelvic infection. If you have had a previous pelvic infection, you have about a 1 in 10 chance that a pregnancy will be ectopic.
  • Tubal tie (sterilisation). Pregnancy is rare as this is a very effective method of contraception. If a pregnancy does occur then about 1 in 20 are ectopic.
  • Any surgery to a fallopian tube or nearby structures.
  • If you have endometriosis (a condition of the uterus and surrounding area).
• If you use a progestogen releasing Intra Uterine Contraceptive Device (IUCD). Again, pregnancy is rare as this is an effective method of contraception.
• If you are using assisted conception (some types of infertility treatments).
• The risk of ectopic pregnancy increases the older you are when you become pregnant.

If you are in any of the above groups, see a doctor as soon as you think you may be pregnant. Tests can detect pregnancy as early as 7-8 days after fertilisation.

If you have symptoms that may indicate an ectopic pregnancy you will usually be admitted to hospital immediately.

• A urine test can confirm that you are pregnant.
• An ultrasound scan may confirm an ectopic pregnancy. However, the scan may not be clear if the pregnancy is very early. A few days of observation may be needed if symptoms are not severe. A repeat scan a few days later may clarify the site of the pregnancy.
• Blood tests that show changes in the pregnancy hormones are also helpful.
• A look inside the abdomen with a special telescope (laparoscopy) is sometimes advised to confirm an ectopic pregnancy.

What are the treatment options for ectopic pregnancy?

Ruptured ectopic pregnancy
Emergency surgery is needed if a fallopian tube ruptures with heavy bleeding. The main aim is to stop the bleeding. The ruptured fallopian tube and remnant of the early pregnancy are then removed. The operation is often life saving.

Early ectopic pregnancy - before rupture
Ectopic pregnancy is often diagnosed before rupture. Your doctor will advise on the treatment options, which may include the following.

• Surgery. A planned operation is the usual treatment. Removal of the tube and the ectopic pregnancy is the traditional treatment. More recently, better surgical techniques mean that it is sometimes possible to preserve the fallopian tube. Operations by 'keyhole surgery' are also becoming more popular.
• Medical treatment. A medicine called methotrexate may be an option. It works by killing the cells of the pregnancy growing in the fallopian tube. It is normally only advised if the pregnancy is very early. The advantage 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 it has worked. Also, side-effects affect some women.
• Expectancy ('wait and see'). Some ectopic pregnancies that have not ruptured clear without treatment. The pregnancy often dies in a way similar to a miscarriage. A possible option is to 'see how things go' if you have mild or no symptoms. You can have treatment if symptoms become worse. However, a 'wait and see' approach is not often advised. This is because there is a chance of a sudden rupture of the fallopian tube. This will need emergency surgery. Also, you will need close observation and repeated scans and blood tests to check on how things are developing.

The above is a brief description of treatment options. A gynaecologist will advise on the pros and cons of each treatment. One common question is "what is the chance of having a future normal pregnancy after an ectopic pregnancy?" Even if one fallopian tube is removed, you have about a 7 in 10 chance of having a future normal pregnancy. (The other fallopian tube will still usually work.)

It is common to feel anxious or depressed for a while after treatment. Worries about possible future ectopic pregnancy, the affect on fertility, and sadness over the loss of the pregnancy are normal. Do talk with a doctor about these and any other concerns following treatment.

• Ectopic pregnancy is common. The pregnancy never survives.
• The typical first symptom is pain in the lower abdomen after a recent missed period.
• As the pregnancy grows it may rupture the fallopian tube, requiring emergency surgery.
• Planned treatment before rupture occurs is best.
• Tell a doctor as soon as you think you are pregnant if you are in a 'risk' group listed above.

The Ectopic Pregnancy Trust
Maternity Unit, The Hillingdon Hospital, Pield Heath Road, Uxbridge, Middlesex, UB8 3NN
Tel: 01895 238025   Web: www.ectopic.org.uk

© EMIS and PIP 2004   Updated: November 2002   CHIQ Accredited