Ectopic pregnancy

A normal pregnancy implants in the cavity of the uterus (womb), after the fertilised egg has travelled through one of the Fallopian tubes. An ectopic pregnancy occurs when a pregnancy implants outside the cavity of the uterus. Most commonly, this is in the Fallopian tube. This occurs in 1-2 out of every 100 pregnancies.

Less often, the pregnancy implants in other areas, such as previous Caesarean section scars, the ovary, the cervix or womb muscle (intramural pregnancy). If you have been diagnosed with one of these rarer types of ectopic pregnancies, treatment options will be discussed in detail with you by the doctors that you see, and are not covered in this leaflet.

Unfortunately, there is not enough space for a pregnancy to develop in the Fallopian tubes, and it is not possible for a baby in the Fallopian tube to survive. It is not possible to move the pregnancy from the tube into the correct location inside the uterus.

If the pregnancy continues to grow, it can cause the tube to rupture (burst), which can cause internal bleeding. This can be dangerous to your health.

It is not usually possible to diagnose an ectopic pregnancy from symptoms alone. The most common symptom is pain, which is often on one side of the abdomen, and can be sharp. There may also be vaginal bleeding or spotting. Other symptoms include shoulder-tip pain which is worse on lying down, diarrhoea, and dizziness or loss of consciousness. Many women will have no symptoms at all in the early stages of an ectopic pregnancy.

If you have severe pain or you feel faint at any time during your care (however the ectopic pregnancy has been managed) then you should attend your local A&E department urgently.

Many ectopic pregnancies do not cause serious health problems, and many resolve without the need for an operation.

However, some ectopic pregnancies can cause internal bleeding which could put a woman’s health at risk. This is why it is important that an ectopic pregnancy is diagnosed as early as possible, and that women know to seek help quickly if they develop pain.

Providing you attend your follow-up, and come to hospital quickly if you develop concerning symptoms, we are able to treat the vast majority of ectopic pregnancies without women becoming seriously unwell.

In many cases there is no obvious cause for an ectopic pregnancy. It is likely that the pregnancy implants outside the womb by chance. However, there are several things that may increase the chance of ectopic pregnancy. These include:

• Age: The incidence of ectopic pregnancy increases steadily with age, from 1-2 in 100 pregnancies at the age of 21 years, to 7 in 100 pregnancies at the age of 44 years. The reason for this is not clear.
• Previous abdominal surgery: Operations on the abdomen can form scar tissue in the pelvis. This scarring can damage the Fallopian tubes and increase the chance of a pregnancy implanting there. Previous surgery on the Fallopian tubes itself can also increase this risk.
• Previous pelvic infection: Pelvic infections, such as chlamydia, can damage the Fallopian tubes and increase the chance of a pregnancy implanting there. These infections are often silent, and women may not know they have had one.
• Endometriosis: Endometriosis is a condition where the lining of the womb is found outside the womb, most commonly in the pelvis. In some patients it can damage the Fallopian tubes and increase the chance of a pregnancy implanting there. Women may not know they have endometriosis until they are diagnosed with an ectopic pregnancy.
• Previous ectopic pregnancy: Women who have had an ectopic pregnancy in the past have a 1 in 10 chance of developing another one in a future pregnancy.
• Assisted reproduction: Ectopic pregnancy is more common after in vitro fertilisation (IVF).
• Smoking: Smoking can increase the chance of ectopic pregnancy

Ectopic pregnancy is usually diagnosed on transvaginal (internal) ultrasound scan.

Sometimes a very small ectopic pregnancy cannot be seen on the first scan. In this situation, we will make a diagnosis of ‘Pregnancy of Unknown Location’ (PUL) and arrange blood tests to check the levels of pregnancy hormones. Based on the results, you may be offered follow-up scans or further blood tests.

There are several factors that help us guide you towards the safest and most appropriate treatment. These include your symptoms, scan findings and hormone levels. We also consider your availability to attend the clinic for follow-up appointments.

The options for treatment are:

1. Expectant management – observation but no treatment
2. Medical management – an injection (not generally available at UCLH)
3. Surgical management – an operation

1. Expectant management

Expectant management involves waiting for the pregnancy to resolve on its own, without giving you any medicines or performing an operation. You will be asked to attend the clinic for regular blood tests (between every 2 and 7 days) until the pregnancy hormone levels drop to non-pregnant levels. For most women, pregnancy hormones clear within 3 weeks, but it can take up to 6 weeks. At University College London Hospital, we diagnose many ectopic pregnancies early, so expectant management is used more often than in other hospitals. In our unit, about 4 in every 10 ectopic pregnancies are successfully managed expectantly.

Expectant management is only suitable for women with mild symptoms, relatively low initial hormone levels, and no evidence of internal bleeding when scanned. We will ask you to return for repeat blood tests to monitor the trend of the pregnancy hormone levels, and contact you by telephone with the results and to discuss our recommended management plan. If the blood tests are taken late in the afternoon, the results may not be available until the following morning. If the pregnancy hormone level is going down, it is likely that the ectopic pregnancy is resolving, and that ongoing expectant management will be successful.

Sometimes the hormone levels rise slowly to start with and then decrease after a few days. We will determine how soon we need to see you again based on the speed of the rise or fall of your blood tests. Vaginal bleeding is common with expectant management and can be an indicator of the pregnancy resolving. We ask you to avoid strenuous physical activity (intense or high impact exercise), and not to have sex until you have completed your follow-up.

Unfortunately, expectant management is not always successful. If the pregnancy hormone levels continue to rise or if you develop significant pelvic pain, we will usually advise you to have surgical management (see below). If your pain increases suddenly, it is very important that you either attend our unit if we are open, or your nearest A&E department out of hours. This is because there is a small risk of significant internal bleeding that requires emergency surgery. We advise that you do not travel outside London, or far away from your local hospital, until your follow-up is complete, in case you need emergency surgical management.

2. Medical management

At University College London Hospital, we do not routinely offer medical management for ectopic pregnancies. This is because recent research suggests it may be no more effective than expectant management in women with low levels of pregnancy hormones, and there may occasionally be serious side-effects of the medication. We occasionally offer methotrexate to women in whom surgical management is not possible, or in women who have residual tissue after surgery (see next page). Medical management involves giving an injection of a drug called methotrexate. This can encourage pregnancy tissue to stop growing.

The most common side-effect of methotrexate is abdominal pain. It can be difficult to tell whether this pain is due to internal bleeding or the drug itself. If you have severe pain, it is always best to attend your nearest A&E. If you would like to consider medical management for a tubal ectopic pregnancy, we recommend that you seek care in an alternative hospital. We will provide you with your scan reports and hormone levels for your records.

3. Surgical management

Situations where we recommend surgery include:

• when there is significant internal bleeding seen on the scan
• ectopic pregnancy where the pregnancy structures including the embryo (baby) are developing, sometimes with a heartbeat
• if you have severe pain
• when hormone levels are high and/or rising quickly

Surgery is usually performed laparoscopically (as a keyhole procedure) under general anaesthesia. This means you will be asleep during the procedure. The surgery involves inserting a camera through the belly button and surgical instruments through two or three further small cuts in the lower abdomen. Frequent risks of laparoscopic surgery include abdominal and shoulder tip pain after the operation, bruising and wound infection.

Serious but uncommon complications include injury to the surrounding organs (for example the bowel or bladder or major blood vessels), and the need to perform a bigger cut on the abdomen (a laparotomy). The overall risk of serious complications is approximately 2 in 1000.

Surgery for tubal ectopic pregnancy is usually a salpingectomy (removal of the affected Fallopian tube) or salpingotomy (removal of the ectopic pregnancy from the tube, without removing the Fallopian tube).

Salpingectomy

This means removing the affected Fallopian tube completely. In general, salpingectomy is the recommended operation in women in whom the other Fallopian tube appears healthy, as there is evidence that this reduces your risk of having another ectopic pregnancy.

Salpingotomy

This means removing just the pregnancy through a cut in the Fallopian tube. A salpingotomy is carried out less commonly than salpingectomy for several reasons. The risk of complications at the time of a salpingotomy is higher than with a salpingectomy. In 2 in 10 cases, when we try and remove the ectopic pregnancy, there will be bleeding, and we will need to remove the whole tube to stop the bleeding. Sometimes, even if the bleeding can be stopped, it is clear that the tube has been severely damaged and is unlikely to help in getting pregnant in the future.

In 7 out of every 100 women after salpingotomy, there will be some pregnancy tissue left behind which might require further surgery or a methotrexate injection. For this reason, you would be asked to attend for a blood test a week after a salpingotomy to ensure that the operation has been successful.

Overall, there is no significant difference in future fertility between the two procedures. However, after salpingotomy, the risk developing another ectopic pregnancy is higher (8 in 100 women, compared to 5 in 100 women after removal of the tube).

Before any surgical procedure, we will have a detailed discussion with you about your choices, and the risks, and we will ask you to sign a written consent form to summarise and document this discussion.

After a surgical procedure, you will need an Anti-D injection if your blood group is Rhesus negative (e.g. O neg). This is to prevent you developing antibodies against the Rhesus group, which could cause problems in future pregnancies. It is not necessary after expectant management of ectopic pregnancies. You will usually stay in hospital for one night after the procedure.

If you are unsure about any aspect of the treatment proposed, please do not hesitate to ask to speak with a senior member of staff.

Pregnancy tissue that is removed during a surgical procedure is handled sensitively, and in accordance with your wishes. We recommend histology examination (where the tissue is examined under a microscope) to confirm the diagnosis of an ectopic pregnancy.

Many women then choose for the hospital to handle the pregnancy tissue by communal cremation. Other women prefer to take the pregnancy away with them. We need to discuss your options with you, and ask you to sign a form about your choices. More information about your options for handling pregnancy tissue at home or in hospital can be found in the leaflet entitled ‘Sensitive arrangements for pregnancy tissue after miscarriage and/or surgical management’.

You can also discuss your options with the bereavement midwife on 07539 215 484.

As an ectopic pregnancy is resolving, or after surgical management, it is common to get some relatively heavy vaginal bleeding. This is because the lining of the womb has thickened under the influence of pregnancy hormones, and sheds as the hormone level drops.

When you return to work depends on you and how you feel. If you have an operation, most women will need two weeks off work to recover physically.

Even when you are physically recovered from however your ectopic was treated, you may need more time to recover emotionally. You can ask the doctors in the early pregnancy unit, on the ward, or your GP, for a sick note if you need one.

If you have expectant management of your ectopic pregnancy, we will arrange a repeat scan 3 months after your pregnancy hormone levels have fallen to pre-pregnancy levels (i.e. after your last blood test). This is so we can check that the ectopic is no longer visible on ultrasound.

If you have surgical management with a salpingotomy (where a hole is made in the tube to remove the ectopic) rather than a salpingectomy (where the tube is removed) then we will follow you up with further blood tests to make sure that the hormone levels return to pre-pregnancy levels. We will advise you when to attend for these before you are discharged home after the operation.

If you have expectant management, we advise you to use reliable contraception until you are seen at 3 months. This is in case the risk of having another ectopic is higher while the tube still appears swollen.

Some women need time to recover emotionally and physically from the pregnancy loss, regardless of how it has been managed. You may want to wait some time until you and your partner feel ready to try again. There are several things you can do to increase your chance of having a healthy pregnancy (although nothing is known to reduce the risk of ectopic pregnancy):

• Take folic acid supplements
• Reduce alcohol intake
• Stop smoking
• Eat a healthy, balanced diet

The chance of having a normal pregnancy in the future depends on the condition of your remaining Fallopian tube/s, your age and any other factors which put you more at risk. Overall, a majority of women will conceive and have a successful pregnancy.

If there is found to be a lot of damage to your Fallopian tubes at surgery, or if you had been trying to become pregnant for a long time before your ectopic pregnancy, then our doctors may talk to you about being referred to a fertility clinic where you can discuss in vitro fertilisation (IVF). You can also discuss referral to fertility clinic with your GP after treatment, especially if you do not get pregnant within 12 months of trying after an ectopic pregnancy. You may wish to seek referral sooner if you are above the age of 38 years.

If you become pregnant again it is important that you attend our unit for an early scan at around 5 weeks’ gestation. This is to check that the pregnancy is in the right place. If we cannot see the pregnancy at first, you will be monitored closely.

Having had an ectopic pregnancy does not change your contraceptive options. You can start or continue any form of contraception available to you before you had the ectopic pregnancy.

It is common to experience profound sadness and grief after an ectopic pregnancy. Some women and their partners find that these feelings persist for a long time. Other people experience anxiety, depression, and post-traumatic stress after a pregnancy loss. If you are struggling emotionally, it is important that you discuss this with your healthcare professional in hospital and your GP.

You may find some of the support organisations listed at the end of this leaflet helpful. You may also need more formal support or treatment, for which your GP can help or refer you.

You can also self-refer to your local counselling service, via “NHS Talking Therapies”.

The Ectopic Pregnancy Trust
www.ectopic.org

The Miscarriage Association
www.miscarriageassociation.org.uk

PALS
The Patient Advice and Liaison Service (PALS) is a service that offers general support, information and assistance to patients, relatives and visitors. This is not specific to ectopic pregnancy. The PALS office is located on Ground Floor Atrium.
Telephone: 020 3447 3042
Email: uclh.pals@nhs.net
Address: PALS, Ground Floor Atrium, University College Hospital, 235 Euston Road, London NW1 2BU

Early Pregnancy Unit

Direct line: 020 344 76515 (please leave a voicemail)
Email: uclh.epunurses@nhs.net
Website: www.uclh.nhs.uk/our-services/find-service/womens-health-1/gynaecology/gynaecology-diagnostic-and-treatment-unit
Opening Times: Monday- Friday 09:00 – 12:30 and 14:00 – 15:00 Saturday and Sunday 09:00-12:30 (A&E referrals only)

The Early Pregnancy Unit is located on the lower ground floor of the Elizabeth Garrett Anderson Building. Follow signs to “Clinic 3”.

Make a note of your clinicians' names and the department's contact details, for future reference.