Ectopic Pregnancy

Ectopic Pregnancy is a common, life–threatening condition affecting one in 100 pregnancies. It occurs when the fertilised egg implants outside the cavity of the womb. As the pregnancy grows it causes pain and bleeding. If it is not treated quickly enough it can rupture the tube and cause abdominal bleeding, which can lead to maternal cardiovascular collapse and death.

What are the causes of Ectopic pregnancy?

The fertilised egg normally spends 4–5 days travelling down the tube from the ovary to the cavity of the womb where it implants in about 6–7 days after fertilisation. The most common reason for an ectopic pregnancy is damage to the fallopian tube, causing a blockage or narrowing. There could also be a problem with the wall of the tube, which should normally contract and waft the fertilised egg into the womb. Conditions such as appendicitis or pelvic infection can damage the tube by causing kinks or adhesions, thus delaying the passage of the egg, allowing it to implant in the tube. In most cases, however, the case of the tubal implantation is not known.

What are the possible outcomes?

In many cases the ectopic pregnancy dies quickly and is absorbed before a period is missed or after minor symptoms or signs of pain and bleeding. In such cases ectopic pregnancy is rarely diagnosed and a miscarriage is thought to have occurred. Nothing needs to be done in these circumstances.

If the ectopic does not die, the thin wall of the tube will stretch causing pain in the lower abdomen. There may be some vaginal bleeding at this time. As the pregnancy grows, the tube may rupture, causing severe abdominal bleeding, pain and collapse.

Before this happens the ectopic may be diagnosed by blood tests which show that the normal pregnancy hormones are not rising as fast as they should be.

What are the symptoms?

Any sexually active woman of childbearing age who has lower abdominal pain might be suspected of having an ectopic pregnancy until proved otherwise. The pain may have begun suddenly and there may or may not have been vaginal bleeding. Most cases present between the 4th and 10th week of pregnancy with any of the following symptoms:

• One–sided abdominal pain
  This can be persistent and severe, but may not be on the side of the ectopic.
• Shoulder–tip pain
  This may occur due to internal bleeding irritating the diaphragm.
• Pregnancy Test
  This may be positive but not always. Specialised blood tests are sometimes required to confirm this.
• Abnormal bleeding
  The woman may not know she is pregnant and may be experiencing an unusual period. She may have a coil fitted. The bleeding may be heavier or lighter than usual and prolonged. Unlike a period, this bleeding is dark and watery, sometimes described as looking like 'prune juice'.
• Missed or late period
  A pregnancy may be suspected and pregnancy symptoms experienced e.g. nausea, painful breasts or a swollen abdomen but no bleeding.
• Bladder or Bowel Problems
  Pain when moving the bowels or on going to the toilet.
• Collapse
  You may be feeling light–headed or faint, and often this is accompanied by a feeling of something being very wrong. Other signs such as paleness, increasing pulse rate, sickness, diarrhoea and falling blood pressure may also be present.

How is it managed?

If an ectopic pregnancy is suspected, the woman should attend the hospital. An ultrasound scan and a pregnancy test will be done. If the scan shows an empty uterus but the pregnancy test is positive, an ectopic pregnancy is likely although the pregnancy may be early or a miscarriage might have occurred. The best ultrasound scan is done with a modern intravaginal probe but it is not always possible to see an ectopic on scan. If the woman is well and not in severe pain, she may be investigated with a blood hormone test done repeatedly over two to three days to ascertain whether there is an ectopic or not. If there is a high suspicion or the woman develops worsening signs, a laparoscopy to inspect the tubes is done. If the diagnosis is obvious, however, abdominal surgery to remove the ectopic is more likely and blood transfusions may be required to replace lost blood.

If early diagnosis can be achieved before rupture of the tube and the appropriate facilities provided, less invasive treatment can be offered. Keyhole surgery or treatment with drugs can facilitate a speedier recovery and may increase the woman's chance of future fertility. Remember that the pregnancy is always going to be lost if it is ectopic. These treatments can ensure that the woman comes to the least harm.

• Before rupture of the tube, it may be possible for the surgeon, using laparoscopy, to cut the tube and remove the pregnancy, leaving the tube intact.
• Alternatively, the drug methotrexate which destroys pregnancy, could also be used. The drug can either be injected directly under ultra–sound or laparoscopic guidance of a needle into the ectopic pregnancy or injected into a muscle, and then absorbed into the bloodstream to reach the ectopic pregnancy thus avoiding any damage to the fallopian tube.

Obviously these modern treatments are dependant upon expert surgical skills, good ultrasound scanning and efficient laboratory testing. Also they are not widely available as they are undergoing research and evaluation.

Who is at risk?

Any sexually active woman of childbearing age is at risk of an ectopic pregnancy. However, ectopic pregnancies are more likely if you have had:

• Pelvic inflammatory disease
  If there is a past history of pelvic pain due to infection of the fallopian tubes (e.g. by Chlamydia Trachomatis – the commonest sexually transmitted infection which may also give no symptoms). Find out more about chlamydia
• Endometriosis
  Any previous abdominal surgery such as caesarean section, appendectomy or ectopic pregnancy can increase the risk.
• A Coil (IUCD) fitted
  The coil prevents a pregnancy in the uterus but is less effective in preventing a pregnancy in the tube.
• If you are on the progesterone–only contraceptive pill (mini–pill)
  The progesterone–only pill alters tubal motility and has been linked to a slightly increased rate of ectopic pregnancy.

The future pregnancy?

If one of the tubes ruptured or was removed, a woman will continue to ovulate as before, but here chances of conceiving will be reduced to about 50%.

The overall chances of a repeat ectopic are between 7–10% and this depends on the type of surgery carried out and any underlying damage to the remaining tube(s). When one fallopian tube is damaged (because of adhesions, for instance) there is an increased chance that the second tube may be damaged also. This means not only that the chance of conceiving is less than normal, but also that there is an increased risk of a further ectopic pregnancy. In cases associated with the IUCD (coil), there does not appear to be an increased risk of future ectopic pregnancy if the coil is removed.

What do I do in my next pregnancy?

In all cases, a woman who has had an ectopic pregnancy should consult her doctor immediately she suspects she might be pregnant again, so that she might be monitored closely. Similarly, if a period is late, if menstrual bleeding is different from normal or if there is abnormal abdominal pain, she should ask to be examined, reminding the doctor, if necessary, of the previous ectopic pregnancy.

Your emotions

Ectopic pregnancy can be a devastating experience: you are likely to be recovering from major surgery; you have to cope with the loss of your baby and often the loss of part of your fertility; and you may not have known you were pregnant in the first place.

Your feelings may vary enormously in the weeks and months after your loss. You may feel utterly relieved to be free from the pain and profoundly grateful to be alive, whilst at the same time be feeling desperately sad for your loss. It is likely you would have been rushed into the operating theatre with very little time for psychological adjustment. Much of what happens will have been out of your control, leaving you in a state of shock.

If there has been no clear medical explanation it is only natural you may want to search for a reason and you may even begin to blame yourself. Although this is understandable, it is important for you to realise you were not the cause.

The sudden end to your pregnancy will have left your hormones in disarray, and this can make you feel depressed and extremely vulnerable.

The distress and disruption to family life resulting from the abrupt ending to a pregnancy often combined with the need to recover from major surgery are not difficult to imagine.

Your Partner's emotions

The emotional reactions to ectopic pregnancy can put an enormous strain on a relationship. The experience may bring you and your partner closer together but on the other hand your partner may not be able to understand your feelings or support you in any way.

Many men do find it difficult to express their feelings and feel powerless to help, but remember he is likely to be suffering too. Undoubtedly your well–being is his main concern, so he may feel he should be strong for you and keep his feelings to himself. In today's society, however, it is recognised that it is acceptable to express your feelings whether you are male or female and you should encourage your partner to show how he really feels and to express his grief.

The Future

Before trying for another baby you should allow yourself time to recover both physically and emotionally. Doctors usually advise you to wait for at least three months to allow time for your body to heal. Feelings vary after the experience of ectopic pregnancy: some women want to get pregnant again immediately, while others are terrified at the thought and cannot cope with the stress of another anxious pregnancy.

It is important to remember that however terrifying the prospect of another ectopic pregnancy can be, you have a much greater chance of having a normal healthy pregnancy.

For further information advice please contact us at the address below:

EctopicPregnancy Trust
Maternity Unit, Hillingdon Hospital
PieldHeath Road
Uxbridge, Middlesex UB8 3NN
Tel: 01895 238025