What is an ectopic pregnancy?
An ectopic pregnancy results when an early pregnancy becomes implanted anywhere outside the cavity of the uterus. It is a potentially serious condition affecting about 1 in 100 pregnancies. Most ectopic pregnancies develop in the fallopian tubes but some cases occur in the ovary, cervix or even the abdominal cavity. The early pregnancy cannot survive away from the protective, nourishing environment of the uterus although it may continue to develop for several weeks. As the fallopian tube is not large enough to accommodate a growing baby, the thin wall of the fallopian tube will stretch causing pain in the lower abdomen and often vaginal bleeding. If not diagnosed and treated the tube can sometimes rupture, causing severe abdominal bleeding.
Sadly, there is no possibility that your pregnancy can survive. The loss of your baby is likely to make you feel very sad. In addition this may be the first time you have heard of this condition and so you may also feel shocked, confused and anxious about the future. The purpose of this leaflet is to explain fully what an ectopic pregnancy is. It is important that you understand exactly what has happened to you, and why we may recommend a certain course of action.
What causes an ectopic pregnancy?
The very early pregnancy normally spends four to five days in the fallopian tube before travelling to the cavity of the uterus where it implants around six to seven days after fertilisation. Any damage to the fallopian tube can cause a blockage or narrowing. Hormonal imbalance, malfunction of the uterus and tube, and infection can all impair the tubes normal function and result in ectopic pregnancy. Some women are at an increased risk of an ectopic pregnancy such as those:
- with a history of previous ectopic pregnancy
- with a previous history of pelvic infection or and tubal damage
- with a history of infertility
- with previous history of pelvic surgery including sterilisation
- using or having previously used an intrauterine contraceptive device (IUCD)
- undergoing assisted conception such as invitro fertilisation (IVF).
How is an ectopic pregnancy diagnosed?
If an ultrasound scan shows an empty uterus but the pregnancy test is positive the possibilities are an ectopic pregnancy; a very early normal pregnancy or a miscarriage. The ectopic pregnancy may appear as a small pregnancy sac outside the uterus or as a mass. However, it is not usually easy to see an ectopic pregnancy on a scan. In such cases repeated blood tests are done to measure the pregnancy hormone levels. In ectopic pregnancy the levels are usually lower and rise more slowly.
Is it possible to remove the baby from the tube and put it into the uterus?
Although this has been tried, it has never been done successfully. Because the egg has implanted in the wrong place, often the baby isn't able to grow properly, and to try and transplant what has grown, sadly, wouldn't result in a baby.
What needs to happen now?
In some cases an ectopic pregnancy is absorbed and there are minimal or no symptoms (like pain or bleeding). Nothing needs to be done in these circumstances except to ensure that the pregnancy hormone levels quickly return to normal. Sometimes medicine is used to dissolve the early ectopic pregnancy. In other cases an operation is required. The staff in Mater's Early Preganancy Assessment Unit (EPAU) will advise you and help you to make a decision about what to do. You will find some more detailed information regarding these management options below.
Option A: Expectant management ("Wait and see" approach)
Expectant management is increasingly common. It means that you are observed closely and the ectopic pregnancy given the opportunity to resolve without treatment.
Isn’t this dangerous?
Not all ectopic pregnancies will cause bleeding in the abdomen. Some ectopic pregnancies do not rupture and they clear without treatment. The pregnancy often dies in a way similar to a miscarriage, but it is absorbed, and there is minimal pain or bleeding. In these circumstances, nothing further needs to be done. A "wait and see" approach is a safe and appropriate way to manage your ectopic pregnancy if:
- the pregnancy has already died
- the pregnancy is very small
- the pregnancy hormone level is low (and falling)
- there is no blood in the abdomen
- you have no pain.
You will, however, need close follow-up as there is still a very remote chance that the ectopic pregnancy may cause the fallopian tube to rupture and bleed. Being managed with no treatment can feel quite scary but we are giving your body the best chance to resolve this naturally without having to give you powerful drugs or invasive surgery. If we have suggested this method of treatment, then there is an almost 90 per cent chance that the ectopic pregnancy will resolve all by itself.
What would need to happen next?
You will be given some request forms for blood tests to measure your pregnancy hormone levels over the next week. We will phone you after each blood test to let you know the results. You may also require a further scan. We will let you know the specific follow-up plan for you. Please ask us if any of this information does not make sense to you.
What do I need to look out for?
You should expect a small amount of bleeding. If you have pain (or are worried for any reason) please contact the Early Pregnancy Assessment Unit (EPAU). If your pain is unrelieved with paracetamol, you should go to Mater's Emergency Department.
Option B: Medical management
Methotrexate is a medical treatment used to "dissolve" the ectopic pregnancy, providing an alternative to surgery.
Why use Methotrexate?
Until fairly recently, the only treatment that was widely available for ectopic pregnancy was an operation. If the ectopic pregnancy is small and the pregnancy hormone levels are not high, there is a 90 to 95 percent chance that using medical treatment will be all that you need. Although this is a relatively new treatment (it has been used for about nine to 10 years), it is one which has been found to be safe. It has the obvious advantage of not needing an open operation or even key-hole surgery, which commonly requires a hospital stay of a day or two and recovery time afterwards. Studies that look at how successful a subsequent pregnancy is following this treatment, have found that it is at least as good as following surgery and sometimes better. Surgery can cause scarring around the tube, and it may be that avoiding this is the reason why future pregnancies may be more likely to be successful after medical treatment.
How is the treatment given?
Methotrexate is given by a single injection in the leg or buttock. We will then need to keep a check on the pregnancy hormone levels, as before, to ensure they fall appropriately. This will mean several blood tests.
How successful is it?
As mentioned above, on average only one in 15 women will need surgery after treatment with methotrexate. Most women require only one injection, but very occasionally two may be necessary. The treatment works by interfering with an essential vitamin (folate) which is needed for the rapidly growing tissue of ectopic pregnancy.
Are there any side effects?
Sometimes you may notice some mild abdominal pain after the treatment, though this should not be severe. Other occasional side effects (affecting up to 15 percent of women) include nausea, vomiting, indigestion or feelings of fatigue. Very rarely it can affect the liver or blood counts, but this really is unusual, mild if it does occur and only transient. The follow-up blood tests will check for this.
Will this drug affect my chances of becoming pregnant again?
No. Generally your chances of having a successful pregnancy in the future are at least as good following medical management as compared to surgical management. Pregnancies following completion of methotrexate therapy are not associated with increased abnormalities, miscarriages or other pregnancy complications.
How long will it take to resolve?
The pregnancy hormone levels frequently rise in the first week and it will take between two and four weeks for them to fall to normal levels.
Is there anything else I need to know?
The following points are important:
- Avoid alcohol and vitamin preparations containing folic acid until your pregnancy hormone level is back to zero.
- Avoid aspirin or anti-inflammatory drugs (such as Ibuprofen, Nurofen, Voltaren, Naprosyn) for one week after treatment. Regular paracetamol is safe to use (up to two tablets, four times per day).
- It is likely that the pain may get a little worse in the first week after the injection and as the pregnancy dissolves and the hormone levels fall you will get some vaginal bleeding like a period. If you have severe pain or heavy vaginal bleeding, go to your nearest emergency department.
- It is important that you use adequate contraception until the methotrexate therapy has been completed. This is for three months after a single injection or six months after more than one treatment.
Option C: Surgical management
An operation is one way of treating an ectopic pregnancy. In some circumstances this may be the only choice available to you.
What is a laparoscopy (keyhole surgery)?
The operation is performed under a general anaesthetic. In this procedure the surgeon usually makes three small incisions in your abdomen—one inside your belly button and one or two lower incisions lower down on your abdomen. A small telescope is inserted through the hole in your belly button to allow the surgeon to see what they are doing. If an ectopic pregnancy is confirmed usually the tube is removed. Sometimes it may be possible to make a cut in the tube and remove the pregnancy leaving the tube intact.
The downside of this is that sometimes not all of the pregnancy tissue is removed. Further, this tube is now damaged and there is an increased chance of another ectopic in that tube in the future. We will have already discussed some of these issues with you.
What is a laparotomy (open surgery)?
This operation is very similar to a laparoscopy except that is done through a bigger cut on the skin. The cut is about 8 to 10 cm long and is usually made along the bikini line. While most operations for ectopic pregnancy are done using keyhole surgery, sometimes an open operation needs to be performed. This is more likely if you have had a lot of bleeding and are unwell, or if the keyhole surgery is not technically possible.
Are there any risks?
Like all operations, small anaesthetic and surgical risks are involved. There is a very small risk (approximately one chance in every 1000 procedures) of injury to the bowel or blood vessels when entering the abdomen using keyhole surgery. In such cases, we would usually change to performing open surgery. There is a very small risk of infection, although this is slightly higher if an open procedure is performed. Sometimes you may have had a lot of bleeding or there may be bleeding during the procedure. If you are very unwell from this blood loss we may, rarely, need to give you blood as a transfusion.
What to expect after the operation
In the 24-hour period after the anaesthetic you will probably feel tired. You may well feel fatigued for some days to weeks following the procedure (especially if you had lost a significant amount of blood).
After the operation you will have some pain. Following keyhole surgery, this pain is often worse if you breathe or cough and, peculiarly, it may hurt on the top of your shoulder. This is because of some undissolved air from the operation irritating nerve endings in your abdomen and chest. You will be given pain relief. You should expect to be sore for some days but it should always be improving. Following open surgery, you will have pain for some weeks and it will be sore to walk. You will take some weeks to recover following open surgery.
You will likely have a dressing on your wound(s). The staff looking after you will advise you on how to care for your wound. Usually the skin is closed with stitches which are under the skin and dissolvable. Infection is uncommon but should the wound become sorer, hot, red or become oozy, then you should ring EPAU or your local doctor.
How long will I be in hospital?
This will vary depending on the operation you need. It is normally just a day after keyhole surgery and two to four days following open surgery.
If the pregnancy is not in the uterus will I bleed?
Yes. Although the pregnancy is not in the uterus, the hormones produced by the early pregnancy cause the lining of the uterus to become thickened. Therefore after your ectopic pregnancy is treated, you should expect some heavy period-like bleeding for a week or so. While the bleeding continues, it is best to use sanitary pads instead of tampons, as this will reduce the risk of infection. Baths or showers can be taken as required.
Going back to work?
If you have had an operation, you are unlikely to feel fit enough for work as soon as you leave hospital, so make sure you rest. An absence from work of one to two weeks (following keyhole surgery) or four to six weeks (following open surgery) is usually enough but the decision to go back to work is up to you. In all cases, a medical certificate can be obtained on discharge from hospital.
Will I get a follow-up appointment?
No, unless there is a specific reason. We will ring you in the next week or so to see how you are going. If the fallopian tube is not removed during the operation there is some risk that some of the pregnancy remains in the tube. You will then be advised to have weekly blood tests to monitor pregnancy hormone levels as they decrease. You are very welcome to ring us at anytime if you feel things are not right. It is natural to feel low and depressed. Give yourself and your body time to recover. It may help to talk over things with your partner, friends and other family members. We will also provide you with a brochure regarding support following pregnancy loss which you may find helpful.
Will I be able to fall pregnant again?
The chances of conceiving and having a successful pregnancy after an ectopic pregnancy are slightly lower than normal, but generally very good. This will depend on the reasons behind having an ectopic pregnancy as well as your own gynaecological history. We will be able to give you specific information on this.
What are the chances of having another ectopic pregnancy?
Your chance of having another ectopic pregnancy is increased a little. However it is reassuring to know that nine out of 10 future pregnancies will NOT be ectopic next time. It is important that you confirm that any future pregnancy is developing inside with the uterus with an ultrasound scan and blood tests early in the pregnancy.
How long should I wait before trying for another baby?
When the bleeding stops and you are no longer sore, it is usually safe to start having sexual intercourse again. You may need a few weeks for your body to recover and then it depends on how you and your partner feel. You may not feel like having intercourse for a while or your sex drive might decrease. Your feelings and those of your partner need to be respected in this—be loving and understanding to each other. You may ovulate unpredictably after this pregnancy and hence the time of your next period may be less certain. You may try again when you feel ready however, it is sometimes better to wait a few months before trying again for a baby.
Natural Fertility Services
Mater Mothers’ Hospital
South Brisbane Qld 4101
Ph 07 3163 8437
Fax 07 3163 1830
Mater acknowledges consumer consultation in the development of this patient information.
Mater Doc Num: Hosp-011-2620
Last modified 18/11/2015.