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Ectopic Pregnancy

Gynaecology, Pregnancy, Fertility Professor Jason Abbott Associate

Ectopic pregnancy is where the developing pregnancy occurs outside the cavity of the uterus, most commonly in the fallopian tube. There are other places where an ectopic pregnancy can occur including on the ovary, in the wall of the uterus or caesarean scar, in the cervix or attached to other organs in the pelvis or abdomen including the lining of the abdomen. Tubal pregnancy makes up about 98% of all ectopic pregnancies, the other sites are all rare. Ectopic pregnancy occurs in approximately 1/100 pregnancies. It does appear to be increasing, probably due to better treatments for pelvic infections, and a higher rate of surgery performed in the pelvis and the abdomen.

How do I know if I have an ectopic pregnancy?

The most common symptoms arising from ectopic pregnancy are pain and/or vaginal bleeding during early pregnancy. The pain associated with an ectopic pregnancy can be mild or severe. The absence of pain does not exclude an ectopic pregnancy and occasionally they are found during a routine early ultrasound. The pain can be present in the centre of the pelvis or to the side of the abdomen. The other common symptom that may occur is vaginal bleeding. If you are in the early part of your pregnancy and there is vaginal bleeding or pain, then you should seek medical advice at the earliest possible time. Whilst a more common possibility with pain and bleeding in the early part of pregnancy is miscarriage, diagnosis of an ectopic pregnancy is important because it can be dangerous.

The main risk from an ectopic pregnancy is that the pregnancy may outgrow the site that it has settled and cause damage to that site and heavy bleeding. Such an event can be life-threatening and always requires immediate surgery. This is not common and most ectopic pregnancies are diagnosed and treated before they burst (or rupture).

How is an ectopic diagnosed?

If you have pain and bleeding in early pregnancy (usually between 4-12 weeks), then you should consult a medical professional at the soonest possible time. For severe pain you should always present to the Emergency Department of your nearest hospital if you cannot contact your doctor.  A history of your symptoms will be taken and your doctor will perform an examination of the cervix and the uterus (womb) by gently feeling them. If there is still doubt about the diagnosis then an ultrasound will often be performed. This is usually done with a thin probe that is gently inserted into the vagina. This allows better pictures to be taken and can diagnose a pregnancy inside the uterus, or elsewhere (an ectopic) more easily than an ultrasound performed through the abdomen.

Sometimes there can be doubt as to whether there is an early pregnancy inside the uterus or an ectopic pregnancy. If there is a low risk for complications such as bleeding, then a blood test may be performed to observe the pregnancy hormone level and/or further blood tests and an ultrasound may be arranged at a later time to observe what the likely diagnosis is. The diagnosis can take a few days to a few weeks and it is important to tell your doctor if there are any changes to your symptoms. If you have severe pain or heavy bleeding during this time of observation, then you should present immediately to the Emergency Department of your nearest hospital for assessment.

What are the treatments for ectopic pregnancy?

There are three possible types of treatment for ectopic pregnancy:

1. Conservative treatments (observation)

2. Medical treatments (medications such as methotrexate)

3. Surgical treatments

Conservative treatments: Conservative treatment is not often recommended, since the risk of having a significant complication such as rupture of the ectopic pregnancy and life-threatening bleeding is present. It is possible for an ectopic pregnancy to resolve spontaneously, though there are certain predictive factors that make this course of action more favourable, such as a low pregnancy hormone level, a small ectopic size (< 2 cm) and no obvious signs of bleeding (such as the diagnosis of blood in the pelvic cavity on ultrasound).

If you and your doctor decide to adopt conservative management, then it is important to have a follow-up plan involving blood tests and/or ultrasounds. If you have severe pain or heavy bleeding during this time of observation, then you should present to the Emergency Department immediately for assessment.

Medical treatments: Medical treatments such as methotrexate are suitable for some women with an ectopic pregnancy. Such treatment will depend on a number of factors including:

1. The level of the pregnancy hormone

2. Whether there are signs of rupture (such as fluid in the pelvis)

3. Whether the pregnancy is alive or not

4. The desire for pregnancy 6 months after treatment

Should you and your doctor decide on this treatment then it will be given to you as a single injection into the muscle of your buttock and you will require follow-up with blood tests and/or ultrasounds. It is important to follow the pregnancy hormone level to < 5 units to ensure that the treatment has been effective. Side effects that can occur after treatment with methotrexate include stomach upset and nausea, hair loss and skin rash. Local effects around the injection site such as pain and swelling may occur. It is possible for an ectopic pregnancy to rupture even after treatment with methotrexate and if there is a sudden increase in pain or change in symptoms then you should immediately present to the Emergency Department.

Surgical treatments: Surgery for an ectopic pregnancy will usually involve a laparoscopy. This is where a thin telescope is placed into the umbilicus (belly button) under general anaesthetic to look at the inside of the abdomen and pelvis.

The first step in the laparoscopy is to assess the pelvis, at which time the best treatment will be decided upon. Generally, if there is an ectopic in one fallopian tube, and the other is normal, then the tube with the ectopic in it will be surgically removed. This will ensure that there is a reduced chance of a further ectopic pregnancy and that all the pregnancy tissue is removed. Most women and their families are concerned that the loss of one of their tubes will mean a decreased chance of pregnancy. Research to date has shown that there is no change in the chance for a normal pregnancy if the tube with an ectopic is removed completely or if it is surgically opened, the pregnancy removed and the tube is left to heal.

If the tube is opened (called a salpingotomy), then there is an increased chance for a further ectopic pregnancy to occur in the same tube. The chance of an ectopic pregnancy occurring in the other (normal) tube is unchanged. If a salpingotomy is performed then it is possible that not all of the pregnancy tissue will be removed and further treatments, such as methotrexate or more surgery may be required. For these reasons, when the tube without the ectopic is normal then the best treatment appears to be removing the tube with the ectopic completely.

If the ectopic pregnancy has burst (ruptured), then there may be significant bleeding into the abdomen. This can be life-threatening. In such circumstances, the abdomen is usually opened through a large incision to control the bleeding. If there are no signs of shock due to large blood loss, then laparoscopy is a better form of treatment as there is less pain, a quicker recovery, fewer days in hospital, smaller scars and less risk of adhesions (scar tissue in the abdomen).