Ectopic pregnancy facts

An ectopic pregnancy is a pregnancy located outside the inner lining of the uterus. Risk factors for ectopic pregnancy include previous ectopic pregnancies and conditions (surgery, infection) that disrupt the normal anatomy of the Fallopian tubes. The major health risk of an ectopic pregnancy is internal bleeding. Diagnosis of ectopic pregnancy is usually established by blood hormone tests and pelvic ultrasound. Treatment options for ectopic pregnancy include both surgery and medication.

What is an ectopic pregnancy? An ectopic pregnancy (EP) is a condition in which a fertilized egg settles and grows in any location other than the inner lining of the uterus. The vast majority of ectopic pregnancies are so-called tubal pregnancies and occur in the Fallopian tube (98%); however, they can occur in other locations, such as the ovary, cervix, and abdominal cavity. An ectopic pregnancy occurs in about one in 50 pregnancies. A molar pregnancy differs from an ectopic pregnancy in that it is usually a mass of tissue derived from an egg with incomplete genetic information that grows in the uterus in a grape-like mass that can cause symptoms to those of pregnancy. The major health risk of ectopic pregnancy is rupture leading to internal bleeding. Before the 19th century, the mortality rate (the death rate) from ectopic pregnancies exceeded 50%. By the end of the 19th century, the mortality rate dropped to five percent because of surgical intervention. Statistics suggest with current advances in early detection, the mortality rate has improved to less than five in 10,000. The survival rate from ectopic pregnancies is improving even though the incidence of ectopic pregnancies is also increasing. The major reason for a poor outcome is failure to seek early medical attention. Ectopic pregnancy remains the leading cause of pregnancyrelated death in the first trimester of pregnancy. In rare cases, an ectopic pregnancy may occur at the same time as an intrauterine pregnancy. This is referred to as heterotopic pregnancy. The incidence of heterotopic pregnancy has risen in recent years due to the increasing use of IVF (in vitro fertilization) and other assisted reproductive technologies (ARTs). Ectopic pregnancy An ectopic pregnancy is a pregnancy that occurs outside the womb (uterus). It is lifethreatening to the mother.

Causes and risk factors In most pregnancies, the fertilized egg travels through the fallopian tube to the womb (uterus). Anything that blocks or slows the movement of this egg through these tubes can lead to ectopic pregnancy:

Birth defect in the fallopian tubes Scarring after a ruptured appendix Endometriosis Having an ectopic pregnancy before Scarring from past infections or surgery of the female organs

The following also increase your risk of an ectopic pregnancy:

Age over 35 Getting pregnant while having an intrauterine device (IUD) Had surgery to untie tubes (tubal sterilization) to become pregnant Having had many sexual partners Some infertility treatments Having your tubes tied (tubal ligation) - more likely 2 or more years after the procedure Had surgery to untie tubes in order to get pregnant

Sometimes the cause is unknown. Hormones may play a role. The most common site for an ectopic pregnancy is within one of the two fallopian tubes. In rare cases, ectopic pregnancies can occur in the ovary, abdomen, or cervix. An ectopic pregnancy can occur even if you use birth control. Symptoms You may have early pregnancy symptoms, such as breast tenderness or nausea. Other symptoms may include:

Abnormal vaginal bleeding Low back pain Mild cramping on one side of the pelvis No periods Pain in the lower belly or pelvic area

If the area around the abnormal pregnancy ruptures and bleeds, symptoms may get worse. They may include:

Fainting or feel faint Intense pressure in the rectum Low blood pressure

Pain in the shoulder area Severe, sharp, and sudden pain in the lower abdomen

Exams and Tests The health care provider will do a pelvic exam. This may show tenderness in the pelvic area. A pregnancy test and vaginal ultrasound will be done. HCG is a hormone normally produced during pregnancy. Checking the blood level of this hormone (quantitative HCG blood test) can diagnose pregnancy. If the blood level of HCG is not raising fast enough, your doctor may suspect an ectopic pregnancy. Treatment Ectopic pregnancy is life-threatening. The pregnancy cannot continue to birth (term). The developing cells must be removed to save the mother's life. You will need emergency medical help if the area of the ectopic pregnancy breaks open (ruptures). Rupture can lead to bleeding and shock, an emergency condition. Treatment for shock may include:

Blood transfusion Fluids given through a vein Keeping warm Oxygen Raising the legs

If there is a rupture, surgery is done to stop blood loss and remove the pregnancy. In some cases, the doctor may have to remove the fallopian tube. If the ectopic pregnancy has not ruptured, treatment may include:

Surgery Medicine that ends the pregnancy, along with close monitoring by your doctor

Outlook (Prognosis) One out of three women who have had one ectopic pregnancy are later able to have a baby. Another ectopic pregnancy is more likely to occur. Some women do not become pregnant again. The likelihood of a successful pregnancy after an ectopic pregnancy depends on:

The woman's age

Whether she has already had children Why the first ectopic pregnancy occurred

Prevention Most forms of ectopic pregnancy that occur outside the fallopian tubes are probably not preventable. But a tubal pregnancy may be prevented in some cases by avoiding conditions that might scar the fallopian tubes. The following may reduce your risk:

Practicing safer sex by taking steps before and during sex, which can prevent you from getting an infection Getting early diagnosis and treatment of all infections caused by sexual relations (STDs) Stopping smoking

What is an ectopic pregnancy? Up to 1 pregnancy in 50 is ectopic, which means out of place (1, 2). In an ectopic pregnancy, the fertilized egg implants outside of the uterus, usually in the fallopian tube, and begins to grow. Rarely, an ectopic pregnancy implants in the womans abdomen, on the outside of the uterus, on an ovary or in the cervix. What are the symptoms of an ectopic pregnancy? Some women with an ectopic pregnancy start out with typical early-pregnancy symptoms, such as nausea and tender breasts. Others have no early symptoms and may not know they are pregnant. However, about 1 week after a missed menstrual period, a woman may experience slight, irregular vaginal bleeding that may be brownish in color. Some women mistake this bleeding for a normal menstrual period. The bleeding may be followed by pain in the lower abdomen, often felt mainly on one side. A woman with these symptoms should contact her health care provider promptly or go to a hospital emergency room. Without treatment, these symptoms may be followed in several days or weeks by severe pelvic pain, shoulder pain (due to blood from a ruptured ectopic pregnancy pressing on the diaphragm), faintness, dizziness, nausea or vomiting. How is an ectopic pregnancy diagnosed? An ectopic pregnancy can be difficult to diagnose, so the woman needs to have several tests. These include:

A pelvic exam

A series of blood tests to measure the levels of a pregnancy hormone called human chorionic gonadotropin (hCG). Levels of this hormone often are low in an ectopic pregnancy. A vaginal or abdominal ultrasound to locate the pregnancy. A vaginal ultrasound often is used because it can show the pregnancy earlier than an abdominal ultrasound.

If these tests do not confirm an ectopic pregnancy, the provider may need to empty the uterus (a procedure called dilation and curettage or D&C) to determine whether the woman has had a miscarriage or an ectopic pregnancy. Occasionally, the provider may need to view the abdominal organs directly with a thin, flexible instrument called a laparoscope, which is inserted through a small incision in the abdomen while the woman is under general anesthesia. How is an ectopic pregnancy treated? If the provider finds an ectopic pregnancy, the embryo (which cannot survive) must be removed so that it does not endanger the womans life. If the embryo continues to grow, it can cause the fallopian tube to rupture, resulting in life-threatening internal bleeding. Most ectopic pregnancies are diagnosed in the first 8 weeks of pregnancy, usually before the tube has ruptured. There are two treatments for ectopic pregnancy: 1. Medication: If the pregnancy is small and the tube has not ruptured, a woman may be treated with a drug called methotrexate. The drug usually is given as a single shot, though some women may need more than one injection. Methotrexate stops growth of the pregnancy and saves the fallopian tube. The womans body gradually absorbs the pregnancy. 2. Surgery: When an ectopic pregnancy is diagnosed before the fallopian tube ruptures, the provider usually makes a tiny incision in the fallopian tube and removes the embryo, preserving the tube. If an ectopic pregnancy is diagnosed after the fallopian tube has become stretched, or if the tube has ruptured and bleeding has begun, the provider may have to remove part or all of the fallopian tube. After either of these treatments, the provider monitors the woman for several weeks with blood tests for hCG until levels of the hormone return to zero. What are the risk factors for ectopic pregnancy? The most significant risk factor for ectopic pregnancy is sexually transmitted diseases (STDs), such as chlamydia. STIs can lead to pelvic inflammatory disease and scarring of the fallopian tubes. Damage to the fallopian tubes increases the risk of ectopic pregnancy. Other risk factors include (1, 2, 3):

Previous ectopic pregnancy Fertility drugs and assisted reproductive techniques (such as in vitro fertilization) Pregnancy after failed tubal sterilization Previous operations on the fallopian tube Endometriosis (when uterine tissue implants outside the uterus) Exposure to the drug DES (diethylstilbestrol) in her mothers pregnancy Cigarette smoking

For most women, the cause of an ectopic pregnancy is unknown (3). What is the outlook for future pregnancies? Many women who have had an ectopic pregnancy can have healthy pregnancies in the future. Studies suggest that about 50 to 80 percent of women who have had an ectopic pregnancy are able to have a normal pregnancy (2, 3). The rates are about the same whether a woman has been treated surgically or with methotrexate (1). Women who have had an ectopic pregnancy have about a 10 percent chance of it happening again, so they need to be monitored carefully when they attempt to conceive again (2). An ectopic pregnancy occurs in about 1 in 100 pregnancies. Although many ectopic pregnancies are now treated without the need for an operation, you should always see a doctor urgently if you think you have an ectopic pregnancy. Symptoms are listed below but include lower abdominal pain which can become severe. A ruptured ectopic pregnancy is life-threatening, needing emergency surgery. A pregnancy is ectopic when it occurs outside the womb (uterus) womb. Ectopic means 'misplaced'. Understanding normal early pregnancy An egg (ovum) is released from an ovary into a Fallopian tube. This is called ovulation and usually occurs once a month about halfway between periods. Sperm can survive in the Fallopian tubes for up to five days after having sex. A sperm may then combine with the ovum (fertilisation) to make an embryo. The tiny embryo is swept along a Fallopian tube to the womb (uterus) by tiny hairs (cilia). It normally attaches to the inside lining of the uterus and develops into a baby. Where does an ectopic pregnancy develop? Most ectopic pregnancies occur when a fertilised egg attaches to the inside lining of a Fallopian tube (a tubal ectopic pregnancy). Rarely, an ectopic pregnancy occurs in other places such as in the ovary or inside the tummy (abdomen). The rest of this leaflet deals only with tubal ectopic pregnancy.

What are the problems with an ectopic pregnancy? A tubal ectopic pregnancy never survives. Possible outcomes include the following:

The pregnancy often dies after a few days. About half of ectopic pregnancies probably end like this. You may have no symptoms, and you may never have known that you were pregnant. Sometimes there is slight pain and some vaginal bleeding like a miscarriage. Nothing further needs to be done if this occurs. The pregnancy may grow for a while in the narrow Fallopian tube. This can stretch the tube and cause symptoms. This is when an ectopic pregnancy is commonly diagnosed. The narrow Fallopian tube can only stretch a little. If the pregnancy grows further it will normally split (rupture) the Fallopian tube. This can cause heavy internal bleeding and pain. This is a medical emergency.

What are the symptoms of an ectopic pregnancy? Symptoms typically develop around the sixth week of pregnancy. This is about two weeks after a missed period if you have regular periods. However, symptoms may develop at any time between 4 and 10 weeks of pregnancy. You may not be aware that you are pregnant. For example, your periods may not be regular, or you may be using contraception and not realise it has failed. Symptoms can also start about the time a period is due. At first you may think the symptoms are just a late period. Symptoms include one or more of the following.

Pain on one side of the lower tummy (abdomen). It may develop sharply, or may slowly get worse over several days. It can become severe. Vaginal bleeding often occurs, but not always. It is often different to the bleeding of a period. For example, the bleeding may be heavier or lighter than a normal period. The blood may look darker. However, you may think the bleeding is a late period. Other symptoms may occur such as diarrhoea, feeling faint, or pain on passing poo (faeces). Shoulder-tip pain may develop. This is due to some blood leaking into the abdomen and irritating the diaphragm (the muscle used to breathe). If the Fallopian tube ruptures and causes internal bleeding, you may develop severe pain or 'collapse'. This is an emergency as the bleeding is heavy. Sometimes there are no warning symptoms (such as pain) before the tube ruptures. Therefore, collapse due to sudden heavy internal bleeding is sometimes the first sign of an ectopic pregnancy.

Who gets ectopic pregnancy? Ectopic pregnancy can occur in any sexually active woman. In the UK there are around 10,700 ectopic pregnancies each year.

The chance is higher than average in the following at-risk groups:

If you have already had an ectopic pregnancy you have a slightly higher chance that a future pregnancy will be ectopic. If you have had two or more ectopic pregnancies, then your chances of another ectopic pregnancy are even greater. If you have kinking, scarring, damage, or other abnormality of a Fallopian tube. This is because a fertilised egg (ovum) may become stuck in the tube more easily. For example: o If you have had a previous infection of the womb (uterus) or Fallopian tube (pelvic inflammatory disease). This is most commonly due to either chlamydia or gonorrhoea. These infections can lead to some scarring of the Fallopian tubes. Chlamydia and gonorrhoea are common causes of pelvic infection. o Previous sterilisation operation. Although sterilisation is a very effective method of contraception, if a pregnancy does occur, about 1 in 20 is ectopic. o Any previous surgery to a Fallopian tube or nearby structures. o If you have a condition of the uterus and surrounding area (endometriosis). If you use a coil (intrauterine contraceptive device). Again, pregnancy is rare as this is a very effective method of contraception. If you are using assisted conception (some types of infertility treatments). The risk of ectopic pregnancy increases in women over the age of 35 years and also in smokers..

What is an ectopic pregnancy? How is ectopic pregnancy confirmed? If you have symptoms that may indicate an ectopic pregnancy you will usually be seen in the hospital immediately.

A urine test can confirm that you are pregnant. An ultrasound scan may confirm an ectopic pregnancy. This is usually an internal (transvaginal) scan which is not painful and shows good views of the Fallopian tubes. However, the scan may not be clear if the pregnancy is very early. If this is the case, then a repeat scan a few days later is often done. Blood tests that show changes in the pregnancy hormones - human chorionic gonadotrophin (hCG) - are also usually done.

What are the treatment options for ectopic pregnancy? Ruptured ectopic pregnancy

Emergency surgery is needed if a Fallopian tube ruptures with heavy bleeding. The main aim is to stop the bleeding. The ruptured Fallopian tube and remnant of the early pregnancy are then removed. The operation is often life-saving. Early ectopic pregnancy - before rupture Ectopic pregnancy is most often diagnosed before rupture. Your doctor will discuss the treatment options with you and, in many cases, you are able to decide which treatment is best for you. These may include the following:

Surgery. Removal of the tube (either the whole tube or part of it) and the ectopic pregnancy is most commonly performed by keyhole surgery (a laparoscopic operation). Removal of the Fallopian tube containing the ectopic pregnancy (salpingectomy) is usually performed if the other tube is healthy. Removal of only a section of the tube with the ectopic pregnancy in it (salpingotomy) is usually performed if the other tube is unhealthy; for example, scarred from a previous infection. However, many women with an ectopic pregnancy do not need to have an operation. Medical treatment. Medical treatment of ectopic pregnancies is now more common and avoids the need for surgery. A medicine called methotrexate is often given, usually as an injection. It works by killing the cells of the pregnancy growing in the Fallopian tube. It is normally only advised if the pregnancy is very early. The advantage is that you do not need an operation. The disadvantage is that you will need close observation for several weeks with repeated blood tests and scans to check it has worked. You will need to have a blood test for hCG every 2-3 days until your levels are low. Scans are usually repeated weekly. Methotrexate can cause side-effects which include nausea and vomiting in some women. It can be common for some abdominal pains to develop 3-7 days after having methotrexate. 'Wait and see' (expectancy). Not all ectopic pregnancies are life-threatening or lead to a risk to the mother. In many cases the ectopic pregnancy resolves by itself with no future problems. The pregnancy often dies in a way similar to a miscarriage. A possible option is to see how things go if you have mild or no symptoms. You would need to have treatment if symptoms become worse. Also, you will need close observation and repeated scans and blood tests to check on how things are developing.

If your blood group is rhesus negative, then you will need an injection of anti-D immunoglobulin if you have an operation for your ectopic pregnancy. You are rhesus positive if you have the rhesus factor (which is a protein on the surface of your red blood cells). If the protein is not present, you are rhesus negative. All pregnant women have a blood test to determine whether they are rhesus positive or negative. The injection of anti-D immunoglobulin simply prevents you from producing antibodies, which can be

harmful in future pregnancies, if you are rhesus negative. You do not need this injection though if you receive medical treatment. The above is a brief description of treatment options. A gynaecologist will advise on the pros and cons of each treatment with you. One common question is - 'What is the chance of having a future normal pregnancy after an ectopic pregnancy?' Even if one Fallopian tube is removed, you have about a 7 in 10 chance of having a future normal pregnancy. (The other Fallopian tube will still usually work.) However, 1 in 10 future pregnancies may lead to another ectopic pregnancy. It is therefore important that if you have had an ectopic pregnancy in the past you should go to see your doctor early in future pregnancies. It is common to feel anxious or depressed for a while after treatment. Worries about possible future ectopic pregnancy, the effect on fertility, and sadness over the loss of the pregnancy are normal. Do talk with a doctor about these and any other concerns following treatment. In summary

Ectopic pregnancy is common. The pregnancy never survives. The typical first symptom is pain in the lower tummy (abdomen) after a recent missed period. As the pregnancy grows it may tear (rupture) the Fallopian tube, requiring emergency surgery. Planned treatment before rupture occurs is best. Most women with ectopic pregnancies do not need surgery