Ectopic pregnancy
What is an ectopic pregnancy?
The word ectopic means something is out of place; happening in the wrong location. This can have serious implications in pregnancy, and if not detected early can even at times be life threatening. It is however, rare, and treatment does not always involve surgery. The majority of ectopic pregnancies occur within the fallopian tubes, however ectopics may also be implanted in other locations such as the cervix, the ovaries and within a caesarian section scar. If your symptoms and signs are suspicious of ectopic pregnancy you will be monitored very closely by your clinicians as symptoms can suddenly escalate.
What are the symptoms of ectopic pregnancy?
Ectopics may present with pain on one side of the lower abdomen. Often women may experience ongoing brown spotting, or a heavier bleeding. If symptoms escalate, women may also experience dizziness or referred shoulder tip pain.
How do you diagnose an ectopic pregnancy?
Ectopic pregnancies are often very difficult to diagnose, and clinicians will probably be looking very closely at your scan reports, and also may be monitoring your BHCG hormone in your blood. If the pregnancy is reasonably far along and continuing to develop, sometimes it can be clearly seen by the Sonographer during an ultrasound, and may even have a viable heartbeat. Other patients may present with symptoms that are suspicious of ectopic, but nothing is seen on scan, probably because the pregnancy is too tiny to visualize, even though it may already be causing problems which need to be managed quickly. If a pregnancy cannot be seen on scan, and you are stable with minimal symptoms then you will be asked to provide two blood samples taken 48 hours apart looking at your BHCG pregnancy hormone, to see if it rising well (and may be a healthy intrauterine pregnancy which is too early to see), falling rapidly (in which case the pregnancy has already failed and can be considered an early miscarriage) or somewhere in the middle ie inconclusive, requiring further monitoring as ectopic pregnancy cannot be ruled out.
How is an ectopic pregnancy treated?
If an ectopic pregnancy is very small and you are stable clinically then you may be treated with a medication called methotrexate which is usually administered as a one off injection into the buttock. This drug stops the pregnancy from continuing to develop. Your bloods will be closely monitored in the weeks following the injection to confirm if your pregnancy hormone is dropping and the methotrexate has been successful. Usually your BHCG levels start to drop within a week, and you will be continually monitored until you have tested negative. Most women bleed during the weeks following treatment. Due to the effects of methotrexate you must not take vitamins including folic acid as this can interfere with the medication. Very occasionally, methotrexate is not effective and the patient requires a second dose, or is taken for surgical management.
If your ectopic pregnancy is further along, and you are at risk of internal rupture, or your symptoms are of concern, or free fluid has been seen on ultrasound then you will be treated as an emergency and taken for surgery to remove the pregnancy. Surgery is usually performed laparoscopically, with small keyhole cuts in the abdomen. Frequently the tube will be have to be removed with the pregnancy.
Sometimes if an ectopic is suspected and the patient is stable, they may be managed conservatively as many ectopics do self resolve ie stop developing and are effectively treated as a miscarriage. In this scenario, clinicians will monitor you closely with regular BHCG blood tests to check if your pregnancy hormone is continuing to drop as the pregnancy fails and is expelled. If your symptoms change or escalate in any way during conservative management it is very important to seek help quickly and report any new problems. Your hospital may then wish to rescan you to see if alternative management is advisable. EPAU departments often offer these patients “open access” to the gynaecology ward so that they are able to contact specialist teams rapidly even out of hours.
Why does an ectopic pregnancy happen?
Usually there is no clear answer why a pregnancy has implanted in the wrong place, however certain risk factors may increase the possibility of this occurring. Ectopics are more likely to occur if you have a history of pelvic inflammatory disease or blockages in the fallopian tubes. Women who have had a previous ectopic are also at slightly higher risk of a second. Previous abdominal surgery and consequential scarring can increase your risk, as can a pregnancy which occurs despite having a coil in situ. Ectopic pregnancy is a random event and is not hereditary and not caused by previous terminations.
Can you prevent an ectopic pregnancy?
You cannot prevent an ectopic pregnancy, however you can lower your risk slightly by not smoking, and preventing any sexually transmitted diseases.
Can an ectopic pregnancy survive?
Unfortunately ectopic pregnancies cannot survive. Even if the embryo has a heartbeat and appears to still be developing, it cannot be transplanted to the uterus, and to continue the pregnancy would be life threatening for the mother. In extremely rare cases, caesarean scar ectopics and abdominal ectopics have been known to continue to develop, however this risks are significant and clinicians would not recommend continuing with the pregnancy.
What types of ectopic pregnancy are there?
The majority of ectopics (95%) occur in the fallopian tubes. A further 3% are classed as “interstitial”, referring to the area where the tube meets the uterus. The remaining cases, all vary rare, included caesarian scar ectopics, cervical ectopics, ovarian ectopics, corneal ectopics (within a horn shaped tuck in an unusual shaped uterus), intramural ectopics (growing in the muscle wall of the uterus rather than the uterus lining) and abdominal cavity ectopics.
How rare is ectopic pregnancy?
Ectopics occur in approximately 1 in every 80 pregnancies.
For further details on ectopic pregnancy, see the Ectopic Trust website.