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What is ectopic pregnancy?

An ectopic pregnancy is when a fertilized egg implants itself outside of the womb, usually in one of the fallopian tubes.

The fallopian tubes are the tubes connecting the ovaries to the womb. If an egg gets stuck in them, it won't develop into a baby and your health may be at risk if the pregnancy continues.

Unfortunately, it's not possible to save the pregnancy. It usually has to be removed using medicine or an operation.

In the UK, around 1 in every 80-90 pregnancies is ectopic. This is around 12,000 pregnancies a year.

Who Is at Risk?

All sexually active women are at some risk for an ectopic pregnancy. Risk factors increase with any of the following:

• maternal age of 35 years or older
• history of pelvic surgery, abdominal surgery, or multiple abortions
• history of pelvic inflammatory disease
• history of endometriosis
• conception occurred despite tubal ligation or intrauterine device (IUD)
• conception aided by fertility drugs or procedures
• smoking
• history of ectopic pregnancy
• history of sexually transmitted diseases (STDs), such as gonorrhea or chlamydia
• having structural abnormalities in the fallopian tubes that make it hard for the egg to travel

If you have any of the above risk factors, talk to your doctor. You can work with your doctor or a fertility specialist to minimize the risks for future ectopic pregnancies.

Symptoms

Although you may experience typical signs and symptoms of pregnancy, the following symptoms may be used to help recognize a potential ectopic pregnancy:

• Sharp or stabbing pain that may come and go and vary in intensity. (The pain may be in the pelvis, abdomen, or even the shoulder and neck due to blood from a ruptured ectopic pregnancy gathering up under the diaphragm).
• Vaginal bleeding, heavier or lighter than your normal period
• Gastrointestinal symptoms
• Weakness, dizziness, or fainting

It is important to contact your doctor immediately if you are experiencing sharp pain that lasts more than a few minutes or if you have bleeding.

Causes

An ectopic pregnancy is often caused by damage to the fallopian tubes. A fertilized egg may have trouble passing through a damaged tube, causing the egg to implant and grow in the tube.

Things that make you more likely to have fallopian tube damage and an ectopic pregnancy include:

• Smoking. The more you smoke, the higher your risk of an ectopic pregnancy.
• Pelvic inflammatory disease (PID). This is often the result of an infection such as chlamydia or gonorrhea.
• Endometriosis, which can cause scar tissue in or around the fallopian tubes.
• Being exposed to the chemical DES before you were born.

Some medical treatments can increase your risk of ectopic pregnancy. These include:

• Surgery on the fallopian tubes or in the pelvic area.
• Fertility treatments such as in vitro fertilization.

Diagnosing an Ectopic Pregnancy

If you suspect you may have an ectopic pregnancy, see your doctor immediately. Ectopic pregnancies can’t be diagnosed from a physical exam. However, your doctor may still perform one to rule out other factors.

Another step to diagnosis is a transvaginal ultrasound. This involves inserting a special wand-like instrument into your vagina so that your doctor can see if a gestational sac is in the uterus.

Your doctor may also use a blood test to determine your levels of hCG and progesterone. These are hormones that are present during pregnancy. If these hormone levels start to decrease or stay the same over the course of a few days and a gestational sac isn’t present in an ultrasound, the pregnancy is likely ectopic.

If you’re having severe symptoms, such as significant pain or bleeding, there may not be enough time to complete all these steps. The fallopian tube could rupture in extreme cases, causing severe internal bleeding. Your doctor will then perform an emergency surgery to provide immediate treatment.

Treating ectopic pregnancy 

Unfortunately, the baby cannot be saved in an ectopic pregnancy. Treatment is usually needed to remove the pregnancy before it grows too large. 

The main treatment options are:

• expectant management – your condition is carefully monitored to see whether treatment is necessary
• medication – a medicine called methotrexate is used to stop the pregnancy growing 
• surgery – surgery is used to remove the pregnancy, usually along with the affected fallopian tube

These options each have advantages and disadvantages that your doctor will discuss with you.

They'll recommend what they think is the most suitable option for you, depending on factors such as your symptoms, the size of the pregnancy and the level of pregnancy hormone (human chorionic gonadotropin or hCG) in your blood.

Expectant management

If you have no symptoms or mild symptoms and the pregnancy is very small or can't be found, you may only need to be closely monitored, because there's a good chance the pregnancy will dissolve by itself.

This is known as expectant management and the following is likely to happen: 

• You'll have regular blood tests to check that the level of hCG in your blood is going down – these will be needed until the hormone is no longer found.
• You may need one of the treatments outlined below if your hormone level doesn't go down or it increases.
• You'll usually have some vaginal bleeding – use sanitary pads or towels, rather than tampons, until this clears up.
• You may experience some tummy pain – take paracetamol to relieve this.
• You'll be told what to do if you develop more severe symptoms.

The main advantage of monitoring is that you won't experience any side effects of treatment. A disadvantage is that there's still a small risk of your fallopian tubes splitting open (rupturing) and you may eventually need treatment.

Medication

If an ectopic pregnancy is diagnosed early but active monitoring isn't suitable, treatment with a medicine called methotrexate may be recommended.

This works by stopping the pregnancy from growing and is given as a single injection into your buttocks.

You won't need to stay in hospital after treatment, but regular blood tests will be carried out to check if the treatment is working. A second dose is sometimes needed and surgery (see below) may be necessary if it doesn't work.

You need to use reliable contraception for at least three months after treatment, because methotrexate can be harmful for a baby if you become pregnant during this time.

It's also important to avoid alcohol until you're told it's safe, as drinking soon after receiving a dose of methotrexate can damage your liver.

Other side effects of methotrexate include:

• tummy pain – this is usually mild and should pass within a day or two
• dizziness
• feeling and being sick
• diarrhoea

There's also a chance of your fallopian tubes rupturing after treatment. You'll be told what to look out for and what to do if you think this has happened.

Surgery

In most cases, keyhole surgery (laparoscopy) will be carried out to remove the pregnancy before it becomes too large.

During a laparoscopy:

• you're given general anaesthetic, so you're asleep while it's carried out
• small cuts (incisions) are made in your tummy
• a thin viewing tube (laparoscope) and small surgical instruments are inserted through the incisions
• the entire fallopian tube containing the pregnancy is removed if your other fallopian tube looks healthy – otherwise, removing the pregnancy without removing the whole tube may be attempted

Removing the affected fallopian tube is the most effective treatment and isn't thought to reduce your chances of becoming pregnant again. Your doctor will discuss this with you beforehand and you'll be asked whether you consent to having the tube removed.

Most women can leave hospital a few days after surgery, although it can take four to six weeks to fully recover.

If your fallopian tube has already ruptured, you'll need emergency surgery. The surgeon will make a larger incision in your tummy (laparotomy) to stop the bleeding and repair your fallopian tube, if that is possible.

After either type of surgery, a treatment called anti-D rhesus prophylaxis will be given if your blood type is RhD negative (see blood groups for more information). This involves an injection of a medicine that helps to prevent rhesus disease in future pregnancies.

Sources

nhs.uk, healthline.com, webmd.com, nhs.uk, americanpregnancy.org, verywell.com