Ectopic pregnancy
Read our guide below about ectopic pregnancies.
You can also download a PDF version of this patient information by following the link on the right.
What is an ectopic pregnancy?
It’s a common condition. In the UK it can affect 1 in 90 pregnancies.
In a normal pregnancy the egg is fertilised by sperm in the fallopian tube and then the fertilised egg implants in the cavity of the uterus (womb). If your fertilised egg doesn’t implant in the uterus it’s known as an ectopic pregnancy. It needs quick diagnosis and treatment as it can be life threatening.
The most common place for an ectopic pregnancy is the fallopian tube (97%). In rare cases, your egg may implant elsewhere. Some of these sites include:
- interstitial (2% of ectopic pregnancies) – the connection between the uterine cavity (cavity of the womb) and the fallopian tube
- abdominal (1.4%)
- cervical (0.2%) – in the cervix (neck of the womb)
- ovarian (0.2%) – in or on the ovary
- caesarean section scar – the pregnancy implants on or within the caesarean section scar
- heterotopic – a twin pregnancy where one places correctly in the womb, but one is ectopic.
Unfortunately, it isn’t possible to move your ectopic pregnancy to the correct location within the cavity of your womb.
As your ectopic pregnancy grows, it will stretch the thin wall of your fallopian tubes causing abdominal pain and vaginal bleeding. Your fallopian tube isn’t large enough to accommodate a growing pregnancy. If left untreated the tube may eventually burst (rupture) causing severe internal bleeding.
Why does it happen?
Often the reason for an ectopic pregnancy will never be determined. However, there are some known causes and risk factors including:
- a previous ectopic pregnancy
- damage to your fallopian tubes, which can be a result of a previous pelvic infection, or previous surgery to your fallopian tubes including a sterilisation
- fertility treatment: particularly in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI)
- contraception, if you became pregnant whilst using the mini pill or a copper contraceptive coil
- the morning after pill – you can get pregnant in the same cycle after trying to prevent pregnancy with emergency oral contraception
- abdominal surgery, for example, caesarean section or appendicectomy.
- endometriosis – cells like the ones lining the womb grow elsewhere in the body. They react to the menstrual cycle and bleed despite there being no way for the blood to leave the body. This can cause damage to the fallopian tubes
- cigarette smoking – smokers have increased levels of a protein in their fallopian tubes which can slow down movement of the fertilised egg as it makes its way towards the cavity of the womb to implant
- maternal age: the risk is higher amongst women over 35 years.
What symptoms should you look out for?
The symptoms of ectopic pregnancy can vary. Some women may have no symptoms, others may have mild symptoms whilst others will have severe symptoms.
These include:
- increasing abdominal pain (either one-sided or severe abdominal cramps) not responding to pain relief such as paracetamol or codeine. This can be a sudden onset of pain or happen gradually
- vaginal bleeding – this could be spotting or heavy bleeding which may seem different from a normal period. The blood can also seem darker
- shoulder-tip pain caused by internal bleeding irritating the diaphragm as you breathe in and out. It’s normally worse when lying down
- bowel or bladder problems (diarrhoea +/- vomiting, pain on opening bowels or passing urine)
- light-headedness/dizzy spells
- collapse – this may be the first sign and is an emergency which needs immediate attention.
If you have any of these symptoms, come to A&E as soon as possible.
How is an ectopic pregnancy diagnosed?
It can be difficult to diagnose as symptoms can be mistaken for irritable bowel syndrome, gastro-enteritis, miscarriage or appendicitis. Diagnosis can include:
Clinical history and examination
We’ll ask you about your history to understand your symptoms and look for risk factors for having an ectopic pregnancy
pregnancy test
We’ll check to see if your urine pregnancy test is positive. If your test result is negative, it’s unlikely that your symptoms are related to an ectopic pregnancy
Ultrasound scan
A vaginal scan, where the ultrasound probe is inserted into yourvagina, is the most accurate way of diagnosing the appearance and location of a
pregnancy at an early stage. If you’re in the very early stages of pregnancy it may be difficult to locate the pregnancy and we’ll discuss further management with you. This may include a blood test to measure pregnancy hormones and could also include a repeat ultrasound scan a few days later.
Blood test
Measuring the levels of the pregnancy hormone beta human chorionic gonadatrophin bhCG (the hormone produced by the placenta) and the progesterone hormone (the hormone which gives an indication of the health of the pregnancy regardless of location). It can help make the diagnosis and determine treatment options. The bhCG level may be repeated 48 hours later. This helps the Early Pregnancy Unit (EPU) team to assess the trend of bhCG level.
It may take a few days before making a decision. Other possibilities may mean that your pregnancy is too early to detect on ultrasound scan, or a very early miscarriage.
If so, it may be called a pregnancy of unknown location (PUL).
The pregnancy hormone bhCG in a normal early pregnancy doubles every two days. After a miscarriage, the levels drop quite quickly. In a failing pregnancy or an ectopic pregnancy, the levels are often lower and may plateau or rise slowly. Blood tests alone cannot determine where a pregnancy develops, but they can help monitor patients who may have a growing ectopic pregnancy.
Surgery
If the diagnosis isn’t clear or you have significant pain, we may do a laparoscopy under general anaesthetic. A small cut is made in your abdomen and a tiny camera is looks at your fallopian tubes and internal organs. A tubal pregnancy will be treated at the same time and on rare occasions no ectopic pregnancy may be seen.
This might be because there is a very early pregnancy developing in the womb or that the ectopic is too small to see at laparoscopy.
What are the different methods of treatment?
Once we diagnose an ectopic pregnancy, it can be managed conservatively (wait and see), medically or surgically. The treatment best suited for you will depend on the scan findings, physical symptoms, levels of hormone and your preferred choice.
Conservative management (watchful waiting)
This involves close monitoring by medical professionals instead of immediate treatment. In some cases, the ectopic pregnancy dies early and is absorbed. These pregnancies resolve without treatment and the pregnancy often dies in a way like miscarriage. This can be confirmed by falling pregnancy hormone levels and no active treatment is required.
This treatment will only be offered to you if:
- your hormone levels aren’t too high
- you’re clinically stable
- your ultrasound scan doesn’t show any evidence of internal bleeding or an ectopic pregnancy that is too large.
Generally, we only offer this treatment to women with an ectopic pregnancy in the fallopian tubes.
You’ll need to have repeated blood tests to ensure that your bhCG levels are dropping, initially 48 hours apart and then at regular intervals, until the levels have dropped to below 10 units/L.
How long it takes for your hormone levels to drop can vary considerably and can take between 2 weeks and 3 months. Most women’s bhCG levels reach a non-
pregnant state, less than 10IU/l, within 4 weeks.
If the bhCG levels consistently drop you can continue to be managed expectantly. You may need alternative treatment if your symptoms worsen or the bhCG levels plateau or rise.
Medical treatment
In early ectopic pregnancies an injection of methotrexate can stop the cells of the pregnancy growing in the fallopian tube. This form of medical treatment is an alternative to surgical treatment if:
- the bhCG levels are below 5,000 units/L (the risk of rupture is higher in pregnancies with levels greater than this)
- small size of ectopic pregnancies.
We’ll assess your general health for suitability for this treatment. There are some health conditions that may make this treatment unsuitable, particularly if you have an illness involving your liver or kidneys.
The treatment is a single injection into the muscle. We calculate the dose according to your height and weight. Before the injection, we do blood tests to check liver and kidney function and to ensure you aren’t anaemic.
Close follow-up with further scans and blood tests will be necessary. As with expectant management you’ll have regular blood tests to monitor bhCG levels until they drop to a normal level (below 10 units/L).
Avoid pregnancy for 3 months from the time of injection. There are some side effects with methotrexate. If you choose to have this treatment, we’ll explain this to you in detail.
Surgical treatment
Surgery may be your only option if:
- your bhCG hormone level is high
- we see significant internal bleeding on your scan
- you become unwell, and your health becomes at more immediate risk.
We may do surgery if expectant or medical management fail.
In most cases we do this by laparoscopy under general anaesthetic. It usually takes approximately 30 to 60 minutes. A small cut is made in your abdomen below the belly button. A tiny camera looks at your fallopian tubes and internal organs. We may need to make 2 to 3 further small incisions if we see an ectopic pregnancy. This is to allow access for instruments to remove it.
The operation usually involves removal of the fallopian tube containing the ectopic pregnancy, known as a salpingectomy. This is the recommended procedure if the other fallopian tube appears normal as there’s a concern that the affected tube is damaged.
Alternatively, we may remove the pregnancy only by making a small cut in the fallopian tube, taking away the pregnancy tissue and leaving the affected tube intact. This is known as a salpingotomy and is usually only done if the other fallopian tube is absent, for example from previous surgery or doesn’t appear normal at the time of surgery.
The reason for doing this is to try and preserve fertility.
In some cases, we don’t remove your ovaries.
What are the benefits of salpingectomy (removal of the tube)?
The tube containing an ectopic pregnancy is removed to prevent severe internal bleeding. In future pregnancies the risk of further ectopic is reduced, compared to when the tube isn’t removed. If the other tube looks healthy future pregnancy rates are the same whether the tube is removed or saved.
What are the risks/benefits of salpingotomy (removal of the pregnancy only)?
A small amount of pregnancy tissue may remain in the tube requiring further treatment, for example with methotrexate. The chance of this happening is between 5 to 10%. Generally, we’ll only do this procedure if the other fallopian tube looks abnormal. You’ll have follow ups until your hormone levels drop to a non-pregnant level.
How long will I stay in hospital?
This will vary from 1 to 4 days depending on the type of surgery, but most patients can expect to be discharged home within 24 hours of their operation. Stitches are usually dissolvable and should dissolve completely after 7 to 10 days.
Following methotrexate injection, you’ll need to stay for 1 to 2 hours for observation.
When should I return to work or resume my normal activities?
Complete recovery will vary from 2–6 weeks depending on the type of surgery.
It’s normal to experience pain for 1 to 2 weeks following surgery. Take regular pain relief such as paracetamol, codeine, or ibuprofen to help your recovery. If you had a laparoscopy, you’re likely to feel bloated for the first week with pain similar to trapped wind. This is due to the gas used during surgery to assist the surgeon in visualising the abdomen.
You may feel tired, particularly if you had significant bleeding during the procedure.
You should avoid heavy lifting or vigorous housework for around 2 weeks and only do gentle exercise such as walking. Once the wound sites have healed you can resume gentle swimming.
After keyhole surgery most women do not return to work for at least 2 weeks to enable their body and emotions to heal; after major abdominal surgery, this time frame increases to approximately 6 weeks.
If your blood group is Rhesus negative
You’ll have an injection of Anti-D after your surgery. We give this to all pregnant women who are rhesus negative to protect future pregnancies. Tell us if you would like a more detailed explanation of the benefits of anti-D.
What happens to the tissue removed at surgery?
We send it to the Histology lab for diagnosis under a microscope. The slides and blocks of wax in which the tissue is embedded are kept in the laboratory for 30 years as part of your hospital record (in line with national guidelines).
Tissue kept in the laboratory consists, wherever possible, of only small amounts of tissue.
If we see any foetal tissue it’s hospital policy to plan for this tissue (except for the small amounts processed by the laboratory for diagnosis) to be buried. We do this in a sensitive manner. We’ll ask you to give permission for the hospital to do this by signing a burial form.
When you consent for your operation, we’ll ask you if you agree that tissue in the laboratory can be used for teaching healthcare staff or for research. A separate information sheet is available to explain the importance of this. You don’t have to agree to this.
How will you feel afterwards?
Ectopic pregnancy can be a difficult experience. As well as recovering from your operation you must cope with the loss of your pregnancy and often the loss of part of your fertility. Sharing your feelings often helps. There are support networks available below.
Follow up appointment
All patients who have an ectopic pregnancy will be offered an appointment with a gynaecology consultant to discuss their case and the impact of this on potential future pregnancies. This appointment will happen once you’ve fully recovered from whichever treatment option you have chosen. You’ll also have the opportunity to have all your questions answered.
Future pregnancies
The chance of a healthy pregnancy is very good. 65% women become pregnant within 18 months after an ectopic pregnancy if they’re actively trying to conceive. Some studies have suggested that this figure rises to around 85% within 2 years. Your chance of conceiving is dependent upon the health of your tubes.
What do you do in your next pregnancy
See your GP as soon as you know you’re pregnant especially if you have any abdominal pain or bleeding. You must have an ultrasound scan when you’re
around 6 to 7 weeks pregnant, even if you have no symptoms, to confirm that the pregnancy is in the womb. You may refer yourself to the Early Pregnancy Clinic for this scan.
Side effects
This guide explains some of the most common side-effects that some people may experience but it’s not comprehensive. If you have any further concerns or questions
experience other side-effects and want to ask anything else related to your treatment, call the Surgical Assessment Unit on 01296 418110/811.
Contact us
Early Pregnancy Clinic, Stoke Mandeville Hospital
01296 316469 (Monday to Friday, 8am to 5pm)
Out of hours, Surgical Assessment Unit (Ward 15), Stoke Mandeville Hosiptal
01296 316500
Further support