Understanding normal early pregnancy

An egg (ovum) is released from an ovary into a Fallopian tube. This is called ovulation and usually occurs once a month about halfway between periods. Sperm can survive in the Fallopian tubes for up to five days after having sex. A sperm may then combine with the ovum (fertilisation) to make an embryo. The tiny embryo is swept along a Fallopian tube to the womb (uterus) by tiny hairs (cilia). It normally attaches to the inside lining of the uterus and develops into a baby.

Where does an ectopic pregnancy develop?

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

What are the problems with an 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 split (rupture) the Fallopian tube. This can cause heavy internal bleeding and pain. This is a medical emergency.

What are the symptoms of an ectopic pregnancy?

Symptoms typically develop around the sixth week of pregnancy. This is about two weeks after a missed period if you have regular periods. However, symptoms may develop at any time 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. Symptoms can also 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 tummy (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 poo (faeces).
• 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.

Who gets ectopic pregnancy?

Ectopic pregnancy can occur in any sexually active woman. In the UK there are around 10,700 ectopic pregnancies each year.

The chance is higher than average in the following at-risk groups:

• If you have already had an ectopic pregnancy you have a slightly higher chance that a future pregnancy will be ectopic. If you have had two or more ectopic pregnancies, then your chances of another ectopic pregnancy are even greater.
• If you have kinking, scarring, damage, or other abnormality of a Fallopian tube. This is because a fertilised egg (ovum) may become stuck in the tube more easily. For example:
  • If you have had a previous infection of the womb (uterus) or Fallopian tube (pelvic inflammatory disease). This is most commonly due to either chlamydia or gonorrhoea. These infections can lead to some scarring of the Fallopian tubes. Chlamydia and gonorrhoea are common causes of pelvic infection.
  • Previous sterilisation operation. Although sterilisation is a very effective method of contraception, if a pregnancy does occur, about 1 in 20 is ectopic.
  • Any previous surgery to a Fallopian tube or nearby structures.
  • If you have a condition of the uterus and surrounding area (endometriosis).
• If you use a coil (intrauterine contraceptive device). Again, pregnancy is rare as this is a very effective method of contraception.
• If you are using assisted conception (some types of infertility treatments).
• The risk of ectopic pregnancy increases in women over the age of 35 years and also in smokers.

However, around one third of women with an ectopic pregnancy do not have any of these risk factors.

How is ectopic pregnancy confirmed?

If you have symptoms that may indicate an ectopic pregnancy you will usually be seen in the hospital immediately.

• A urine test can confirm that you are pregnant.
• An ultrasound scan may confirm an ectopic pregnancy. This is usually an internal (transvaginal) scan which is not painful and shows good views of the Fallopian tubes. However, the scan may not be clear if the pregnancy is very early. If this is the case, then a repeat scan a few days later is often done.
• Blood tests that show changes in the pregnancy hormones - human chorionic gonadotrophin (hCG) - are also usually done.

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 most often diagnosed before rupture. Your doctor will discuss the treatment options with you and, in many cases, you are able to decide which treatment is best for you. These may include the following:

• Surgery. Removal of the tube (either the whole tube or part of it) and the ectopic pregnancy is most commonly performed by keyhole surgery (a laparoscopic operation). Removal of the Fallopian tube containing the ectopic pregnancy (salpingectomy) is usually performed if the other tube is healthy. Removal of only a section of the tube with the ectopic pregnancy in it (salpingotomy) is usually performed if the other tube is unhealthy; for example, scarred from a previous infection. However, many women with an ectopic pregnancy do not need to have an operation.

• Medical treatment. Medical treatment of ectopic pregnancies is now more common and avoids the need for surgery. A medicine called methotrexate is often given, usually as an injection. 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 and scans to check it has worked. You will need to have a blood test for hCG every 2-3 days until your levels are low. Scans are usually repeated weekly. Methotrexate can cause side-effects which include nausea and vomiting in some women. It can be common for some abdominal pains to develop 3-7 days after having methotrexate.

• 'Wait and see' (expectancy). Not all ectopic pregnancies are life-threatening or lead to a risk to the mother. In many cases the ectopic pregnancy resolves by itself with no future problems. 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 would need to have treatment if symptoms become worse. Also, you will need close observation and repeated scans and blood tests to check on how things are developing.

If your blood group is rhesus negative, then you will need an injection of anti-D immunoglobulin if you have an operation for your ectopic pregnancy. You are rhesus positive if you have the rhesus factor (which is a protein on the surface of your red blood cells). If the protein is not present, you are rhesus negative. All pregnant women have a blood test to determine whether they are rhesus positive or negative. The injection of anti-D immunoglobulin simply prevents you from producing antibodies, which can be harmful in future pregnancies, if you are rhesus negative. You do not need this injection though if you receive medical treatment.

The above is a brief description of treatment options. A gynaecologist will advise on the pros and cons of each treatment with you. 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.) However, 1 in 10 future pregnancies may lead to another ectopic pregnancy. It is therefore important that if you have had an ectopic pregnancy in the past you should go to see your doctor early in future pregnancies.

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.

In summary

• Ectopic pregnancy is common. The pregnancy never survives.
• The typical first symptom is pain in the lower tummy (abdomen) after a recent missed period.
• As the pregnancy grows it may tear (rupture) the Fallopian tube, requiring emergency surgery.
• Planned treatment before rupture occurs is best.
• Most women with ectopic pregnancies do not need surgery