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Ectopic pregnancy


Miss Shirin Irani, Consultant Gynaecologist
Next review due October 2022

An ectopic pregnancy is when a fertilised egg implants outside your womb (uterus). This is most often in one of your fallopian tubes. Unfortunately, the fertilised egg can’t survive and it’s not possible to save the pregnancy. For your own health, you may need treatment with medicine or surgery to remove the ectopic pregnancy.

An image showing the location of the womb and surrounding structures

What is an ectopic pregnancy?

In a healthy pregnancy, an egg released by your ovary is fertilised by sperm in one of your fallopian tubes. The fertilised egg travels to your womb where it implants in the lining and grows into a baby.

However, in about one in every 100 pregnancies, the fertilised egg implants in the wrong place. This is nearly always in one of your fallopian tubes, but it can be in your ovary, your cervix or even in your abdomen (tummy). The fertilised egg usually develops abnormally, and can’t grow into a baby in these places.

The pregnancy may end by itself or it could continue to grow. If it keeps growing, it may eventually split open (rupture) the tube and cause life-threatening internal bleeding. So, if you have an ectopic pregnancy, you may need immediate treatment to prevent complications like this happening.

Symptoms of ectopic pregnancy

Symptoms of ectopic pregnancy usually appear about six to eight weeks after your last period. They’re similar to symptoms of a miscarriage so you and your doctor may not be able to tell the difference at first.

Symptoms of an ectopic pregnancy may include:

  • not having periods
  • pelvic or abdominal (tummy) pain, which may be on one side only – the pain may develop gradually or it may come on suddenly
  • bleeding from your vagina, which may be different from your normal period – it may be lighter, heavier or darker, and may contain clots
  • pain in the tip of your shoulder – this is caused by bleeding into your abdomen, which irritates nerves that run to your shoulder
  • feeling dizzy or fainting if the ectopic pregnancy ruptures and you have serious internal bleeding
  • diarrhoea and vomiting
  • feeling a continual need to poo and feeling uncomfortable when you do go to the toilet

Not all women with an ectopic pregnancy get these symptoms. You may have no symptoms at all or you may just have one or two of these. Sometimes, an ectopic pregnancy is suspected when you have an early scan, even though you feel well. Each woman is different.

If you’ve missed a period or could be pregnant and have any of the symptoms described, contact your doctor immediately.

Diagnosis of ectopic pregnancy

Your GP will ask about your symptoms and medical history, and examine you. They’ll offer you a pregnancy test. If your pregnancy test is negative, it’s unlikely that your symptoms are being caused by an ectopic pregnancy.

If your pregnancy test is positive or your symptoms strongly suggest you have an ectopic pregnancy, your GP may refer you to a hospital specialist. This may be at a clinic called an early pregnancy assessment unit (EPAU). If you have severe symptoms of an ectopic pregnancy, your GP will call an ambulance to get you straight to hospital as an emergency.

At the clinic or hospital you’ll be offered some further tests, which usually include the following.

  • A transvaginal ultrasound scan. Sound waves from a probe inside your vagina help your doctor see where the pregnancy is. You may also have an abdominal (tummy) ultrasound. It can sometimes be hard to spot an ectopic pregnancy with an ultrasound scan and repeat scans may be helpful.
  • A blood test. This measures a pregnancy hormone called human chorionic gonadotrophin (hCG). Your doctor may repeat this test after two days to see how much the level of hCG goes up. It goes up less in an ectopic pregnancy than in a pregnancy which is growing inside the womb.
  • A laparoscopy (keyhole surgery). This may be needed when it’s still unclear whether or not you have an ectopic pregnancy, especially if you’re unwell. Your surgeon uses a narrow, tube-like, telescopic camera (called a laparoscope) to look at your fallopian tubes, ovaries and abdomen. They put the laparoscope into your abdomen through a small cut. You usually have a general anaesthetic for a laparoscopy, so you’ll be asleep during the procedure.

Treatment of ectopic pregnancy

All the options for treatment lead to the end of the ectopic pregnancy, which would not be able to develop normally.

Your treatment will depend on how severe your symptoms are, how advanced your pregnancy is and whether or not your fallopian tube has ruptured. Your doctor should also discuss with you if you plan to get pregnant again in the future.

Here we describe the treatment options for an ectopic pregnancy in the fallopian tubes – by far the most common kind. If you have an ectopic pregnancy in another site, your doctor will talk to you about the possible treatment options.

Watchful waiting (expectant management)

You might not need any treatment for an ectopic pregnancy because sometimes the pregnancy ends by itself. Before deciding that this is a safe option for you, your doctor will check that:

  • the mass in your fallopian tube is smaller than three-and-a-half centimetres
  • you have no pain and there isn’t anything else causing your doctor concern
  • your blood test shows the level of hCG is low and falling
  • you’re happy to agree to the necessary monitoring by the hospital

Your doctor will ask you to have regular blood tests for hCG until it is no longer detectable. You don’t have to stay in hospital, but you should go back if you have any more symptoms.

Expectant management is successful for between seven and nine out of every 10 women who have it. If it doesn’t work for you, you can go on to have medical treatment or even surgery if necessary.

Medicines

Medical treatment for ectopic pregnancy involves one or more injections of a medicine called methotrexate. This stops the growth of the embryo cells and the pregnancy is gradually absorbed by your body. Methotrexate treatment is only suitable if your pregnancy is still in the early stages.

After your injection, you’ll need to return for further monitoring of your hCG levels. Depending on the results, you may need another dose of methotrexate. You’ll have blood tests until hCG is no longer found in your blood. This can take up to eight weeks.

Treatment with methotrexate has side-effects. It often causes abdominal pain two or three days after the injection, and may cause sickness and diarrhoea.

It’s important not to get pregnant again within three months of having a methotrexate injection. If you become pregnant, methotrexate may harm your developing baby.

Some women can’t have treatment with methotrexate because of their general health. If you can’t have methotrexate or if treatment is unsuccessful, your doctor will suggest treatment with surgery.

Surgery

You may need surgery to remove your fallopian tube and ectopic pregnancy if:

  • medicines haven’t worked or you wouldn’t be able to keep going back for follow up tests after medical treatment
  • your pregnancy is larger than three-and-a-half centimetres across
  • you have severe pain
  • you are very unwell because your fallopian tube has ruptured and you have internal bleeding – this is a medical emergency

Usually, you’ll have keyhole surgery using a laparoscope and be under general anaesthesia. The laparoscope is put into your body through a small cut or cuts in your abdomen. However, in some circumstances, a larger cut is needed for your doctor to see the affected area directly. This is called open surgery or a laparotomy.

Surgery usually involves removing the whole affected fallopian tube (salpingectomy). This is usually the case if you don’t plan to become pregnant again or if you do want further pregnancies and your other tube is healthy.

If your other fallopian tube is damaged or you have other reasons for low fertility but do want another pregnancy, removing just the ectopic pregnancy may be an option. This is called a salpingotomy. It gives that tube a chance to work normally again in future.

If you have a salpingotomy, you’ll need to have follow-up tests to check your hCG levels. There’s a chance you’ll need to have the fallopian tube removed in future or have further treatment with methotrexate. See our medicines section for more information.

Causes of ectopic pregnancy

It’s often not clear why an ectopic pregnancy happens. But there are some factors that can make it more likely that you’ll have one. These include:

  • pelvic inflammatory disease– this can damage your fallopian tubes, making it harder for the egg to pass through
  • having had a previous ectopic pregnancy
  • a history of infertility (whether or not this was treated)
  • getting pregnant when using certain types of contraception – for further information, see our FAQ: Contraception and ectopic pregnancy
  • having had a sterilisation operation – if the surgery fails and you get pregnant, it’s possible this may be an ectopic pregnancy
  • smoking
  • being over 35

It isn’t possible to prevent an ectopic pregnancy but you can reduce your risk. This includes taking measures to protect yourself against sexually transmitted infections (STIs), which can damage your fallopian tubes.

Help and support

Having an ectopic pregnancy can affect you emotionally as well as physically. Every woman is different, but you may feel sadness and a sense of loss after having an ectopic pregnancy. It may have been a worrying or frightening experience, especially if you needed emergency treatment. You might find it upsetting to go back to the hospital for repeated blood tests. You might also have concerns about whether or not you’ll be able to get pregnant again in the future.

If you can, try to talk to someone about these feelings. This may be a friend or relative or perhaps a bereavement counsellor. Ask your doctor for information about support that’s available to you.

You may also find it helpful to look for information, advice and support online. In our ‘other helpful websites’ section, we have listed some organisations that can help. These have telephone helplines and internet support forums where you can talk to others about your experiences to help you recover.

Frequently asked questions

  • No, ectopic pregnancies aren’t able to develop normally. The pregnancy won’t survive if it implants outside your womb. Only your womb provides the right environment for a baby to grow and receive all the nutrition it needs.

    Because an ectopic pregnancy can’t survive, the most important thing to consider when deciding on treatment is your health.

  • All methods of contraception lower your risk of ectopic pregnancy. That’s because they make it much less likely that you’ll become pregnant at all.

    However, if you do become pregnant while using certain types of contraception, that pregnancy is more likely to be ectopic than if you weren’t using that contraception. These contraception methods include the intrauterine device (IUD), intrauterine system (IUS) and the progestogen-only pill (POP).

    So, if you’re using one of these forms of contraception and you think you might be pregnant, go and see your GP as soon as possible. If you do have an ectopic pregnancy, it is easier to treat and the risk of complications is lower if it‘s diagnosed early on.

  • For most women who have had an ectopic pregnancy, the chance of having a normal pregnancy afterwards is good. Even if you had your fallopian tube removed to treat the ectopic pregnancy, your chance of conceiving may only be slightly reduced. Around two out of three women who have had a tube removed are able to get pregnant normally afterwards. This is the same for those who have had medical treatment with methotrexate.

    Your periods may start again after four to six weeks. Ask your doctor when it’s safe to start having sex again. This may depend on what type of treatment you had, if any.

    If you’ve had one ectopic pregnancy, you’re more likely to have another one. Up to one in five women will have a second ectopic pregnancy. The risk is higher after two or more ectopic pregnancies. So, if you get pregnant again, it’s important to see your GP as soon as you find out to make sure you don’t have another ectopic pregnancy. You’ll need to have an ultrasound scan six to seven weeks into your pregnancy to check the embryo is developing in your womb.


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Related information

    • Ectopic pregnancy. BMJ Best practice. bestpractice.bmj.com, last reviewed September 2019
    • Ectopic pregnancy. Medscape. medicine.medscape.com, updated September 2017
    • Ectopic pregnancy. Patient. patient.info/doctor, last edited December 2015
    • Conception and prenatal development. The MSD Manuals. www.msdmanuals.com, last full review/revision July 2019
    • Ectopic pregnancy. NICE Clinical Knowledge Summaries. cks.nice.org.uk, last revised May 2018
    • Ectopic pregnancy and miscarriage: diagnosis and initial management. National Institute for Health and Care Excellence (NICE), April 2019. www.nice.org.uk
    • Ectopic pregnancy. Royal College of Obstetricians and Gynaecologists, November 2016. www.rcog.org.uk
    • Ectopic pregnancy. Miscarriage Association, 2014. miscarriageassociation.org.uk
    • Personal communication, Miss Shirin Irani, Consultant Gynaecologist, October 2019
  • Reviewed by Dr Kristina Routh, Freelance Health Editor, Bupa Health Content Team, October 2019
    Expert reviewer, Miss Shirin Irani, Consultant Gynaecologist
    Next review due October 2022



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