Ectopic pregnancy | Hapūtanga i waho i te kōpū

The word ectopic means “not in the right place”. A pregnancy is meant to be in your uterus, but it can grow in other places. Your fallopian tube is the most common place for an ectopic pregnancy. However, in rare cases, an ectopic pregnancy can grow in other places. This could be at the junction of a fallopian tube and your uterus, your cervix, in the scar from a previous caesarean section or even outside your uterus completely.

When a pregnancy grows in the wrong place it will eventually cause bleeding inside your pelvic cavity. This can be very dangerous because you can bleed a lot internally before you even realise you're bleeding. 

Video: What is an ectopic pregnancy? Doctor explains risk factors, symptoms, & treatment | Stanford

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Damage to the fallopian tube

Most ectopic pregnancies occur in the fallopian tube. If your tube is damaged, the fertilised egg can get trapped in the tube and start growing there. Damage to the fallopian tube usually occurs after infection (commonly sexually transmitted infections or pelvic inflammatory disease), but it can also be caused by endometriosis or pelvic surgery.

Contraception

IUCDs and oral contraceptives don't specifically cause ectopic pregnancies to happen, but if you did become pregnant while using them, it's more likely to be an ectopic pregnancy than a pregnancy in your uterus. However, it is important to note that your chance of having an ectopic pregnancy is still higher if you are using no contraception (or only condoms) than with an IUCD or other contraceptive methods (jadelle, depo provera, oral contraceptives). 

Lower abdominal pain and vaginal bleeding are the 2 most common symptoms that occur with an ectopic pregnancy. The pain may be more localised to one side of your pelvis, or you may notice nausea/vomiting or more pain when you have a bowel motion. Many women don’t realise they’re pregnant because they may have irregular periods or think the bleeding from an ectopic pregnancy is a normal period.

Fainting, light-headedness and shoulder tip pain may occur because of bleeding inside your pelvic cavity. These are important symptoms because it means you have already had quite a lot of bleeding. This can be very dangerous because, if it’s not identified and managed appropriately, it can quickly lead to massive bleeding and collapse or even death.

Examination

Your healthcare provider will need to perform a gentle tummy and internal examination if they think you have an ectopic pregnancy. Your healthcare provider will also check your blood pressure and heart rate and decide what investigations are needed.

Investigations

Pregnancy test

If you have lower abdominal pain and vaginal bleeding, a pregnancy test should be performed even if you're taking contraception and don’t feel pregnant.

• A urine test is usually done to check for pregnancy and can easily be done by your healthcare provider.
• If the urine pregnancy test is positive then a pregnancy test is done with a blood test. This will measure the amount of a pregnancy hormone called beta-hCG.
• At the same time, your healthcare provider may also do the routine pregnancy blood tests that are performed at the beginning of a pregnancy.

Ultrasound

Ultrasound is the best way to identify where a pregnancy is located. A pregnancy inside your uterus can usually be seen by a putting a narrow ultrasound probe into your vagina from 5 weeks after your last period. If your periods are irregular or you’re not sure how pregnant you are, the beta-hCG level can be used to estimate how far on the pregnancy should be.

Sometimes even though you have a positive pregnancy test (raised beta-hCG), an ultrasound scan might not identify a pregnancy. In this case it’s referred to as a pregnancy of unknown location (PUL). This means it could be either an early pregnancy in your uterus or an early ectopic. Because it could still be an ectopic pregnancy, close follow-up with further investigations over time are usually recommended until it’s clear whether it’s growing in your uterus or not.

If your healthcare provider is concerned that you might have an ectopic pregnancy, but decides to wait until they can be sure, it’s important that you have an emergency phone number you can call at any time and that you're not too far from a hospital. This is in case you develop light-headedness, increased pain or bleeding.

Medical management

Methotrexate is a type of chemotherapy that stops the pregnancy from growing. Methotrexate is safe in the doses given for an ectopic pregnancy, but it's not suitable for everyone. If you do have methotrexate it's important that you have a phone available and you're not too far from a hospital. Methotrexate works well for most women, but sometimes further doses are needed. For a small number of women methotrexate doesn't work and surgery is still required to remove the ectopic pregnancy. 

If you're trying to conceive, it's important that you wait until you have been cleared by the medical team to try for another pregnancy. You will need to wait for at least 3 months after the methotrexate treatment as it can cause abnormalities to a developing pregnancy.

Surgery

If the ectopic pregnancy is too big, or if there are already signs of bleeding, then surgery will be required. This is usually done by a surgical technique called a laparoscopy (keyhole surgery) where a special telescope is passed through your stomach wall. Sometimes a slightly bigger cut low down on your bikini line is also needed. This is called a laparotomy. The recovery time from a laparoscopy is much quicker than from a laparotomy.

During this operation the ectopic pregnancy is removed – either with the fallopian tube (salpingectomy), or it may be possible to remove only the ectopic pregnancy (salpingotomy). Your surgeon will normally discuss the surgery options beforehand but it may not be clear what will be needed until they have started the surgery.  

Sometimes a combination of medical and surgical management is recommended. 

Most women will still be able to have a normal pregnancy after an ectopic pregnancy, even if one of the fallopian tubes has been removed. However, if you have been trying to get pregnant for more than 6 months after having an ectopic pregnancy, you should go and see your healthcare provider for further assessment. Studies have shown that the chances of having a successful pregnancy are not decreased if the tube is removed compared to just removing the pregnancy from the tube.

Losing a pregnancy can be very upsetting, even if the pregnancy is early. You may experience all sorts of difficult emotions after an ectopic pregnancy. This may not happen for a few weeks or even months after losing the pregnancy. Most hospitals can provide information about miscarriage support groups.

• Practice safe sex – sexually transmitted infection (STI) is the main cause of damage to the fallopian tubes, which can lead to an ectopic pregnancy.
• Get regular STI screening and treat any STIs.
• Quit smoking as smoking increases the risk of ectopic pregnancy.

Consider an ectopic pregnancy in all women with a history of amenorrhoea or a positive pregnancy test with abdominal pain and/or vaginal bleeding.

If suspected ectopic pregnancy, request acute early pregnancy assessment.

First trimester ultrasound(external link) Kosar Kamal, 2016

Continuing professional development

Video: Early Pregnancy Problems Webinar– Dr Kate Coffey

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(Mobile Health, NZ, 2020)