Overview

An ectopic pregnancy is when a fertilised egg implants itself outside of the womb, usually in one of the fallopian tubes.

The fallopian tubes are the tubes connecting the ovaries to the womb. If an egg gets stuck in them, it won't develop into a baby and your health may be at risk if the pregnancy continues.

Unfortunately, it's not possible to save the pregnancy. It usually has to be removed using medicine or an operation.

In the UK, around 1 in every 90 pregnancies is ectopic. This is around 11,000 pregnancies a year.

Symptoms of an ectopic pregnancy

An ectopic pregnancy doesn't always cause symptoms and may only be detected during a routine pregnancy scan.

If you do have symptoms, they tend to develop between the 4th and 12th week of pregnancy.

Symptoms can include a combination of:

• a missed period and other signs of pregnancy
• tummy pain low down on one side
• vaginal bleeding or a brown watery discharge
• pain in the tip of your shoulder
• discomfort when peeing or pooing

However, these symptoms aren't necessarily a sign of a serious problem. They can sometimes be caused by other problems, such as a stomach bug.

When to get medical advice

Contact your GP or call NHS 111 if you have a combination of any of the above symptoms and you might be pregnant – even if you haven't had a positive pregnancy test.

An ectopic pregnancy can be serious, so it's important to get advice right away.

Your GP will ask about your symptoms and you'll usually need to do a pregnancy test to determine if you could have an ectopic pregnancy.

You may be referred to a specialist early pregnancy clinic for further assessment, where an ultrasound scan and blood tests may be carried out to confirm the diagnosis.

When to get emergency help

Call 999 for an ambulance or go to your nearest accident and emergency (A&E) department immediately if you experience a combination of:

• a sharp, sudden and intense pain in your tummy
• feeling very dizzy or fainting
• feeling sick
• looking very pale

These symptoms could mean that your fallopian tube has split open (ruptured). This is very serious and surgery to repair the fallopian tube needs to be carried out as soon as possible.

A rupture can be life threatening, but fortunately they're uncommon and treatable, if dealt with quickly. Deaths from ruptures are extremely rare in the UK.

How an ectopic pregnancy is treated

There are 3 main treatments for an ectopic pregnancy:

• expectant management – you're carefully monitored and one of the treatments below is used if the fertilised egg doesn't dissolve by itself
• medication – an injection of a powerful medicine called methotrexate is used to stop the pregnancy growing
• surgery – keyhole surgery (laparoscopy) is performed under general anaesthetic to remove the fertilised egg, usually along with the affected fallopian tube

You'll be told about the benefits and risks of each option. In many cases, a particular treatment will be recommended based on your symptoms and the results of the tests you have.

Some treatments may reduce your chances of being able to conceive naturally in the future, although most women will still be able to get pregnant. Talk to your doctor about this.

Help and support after an ectopic pregnancy

Losing a pregnancy can be devastating, and many women feel the same sense of grief as if they had lost a family member or partner.

It's not uncommon for these feelings to last several months, although they usually improve with time. Make sure you give yourself and your partner time to grieve.

If you or your partner are struggling to come to terms with your loss, you may benefit from professional support or counselling. Speak to your GP about this.

Support groups for people who have been affected by loss of a pregnancy can also help.

These include:

• The Ectopic Pregnancy Trust
• The Ectopic Pregnancy Foundation
• The Miscarriage Association
• Cruse Bereavement Care

Trying for another baby

You may want to try for another baby when you and your partner feel physically and emotionally ready.

You'll probably be advised to wait until you've had at least 2 periods after treatment before trying again to allow yourself to recover.

If you were treated with methotrexate, it's usually recommended that you wait at least 3 months because the medicine could harm your baby if you become pregnant during this time.

Most women who have had an ectopic pregnancy will be able to get pregnant again, even if they've had a fallopian tube removed.

Overall, 65% of women achieve a successful pregnancy within 18 months of an ectopic pregnancy. Occasionally, it may be necessary to use fertility treatment such as IVF.

The chances of having another ectopic pregnancy are higher if you've had one before, but the risk is still small (around 10%).

If you do become pregnant again, it's a good idea to let your GP know as soon as possible so early scans can be carried out to check everything's OK.

What can cause an ectopic pregnancy?

In many cases, it's not clear why a woman has an ectopic pregnancy. Sometimes it happens when there's a problem with the fallopian tubes, such as them being narrow or blocked.

The following are all associated with an increased risk of ectopic pregnancy:

• pelvic inflammatory disease (PID) – inflammation of the female reproductive system, usually caused by a sexually transmitted infection (STI)
• previous ectopic pregnancy – the risk of having another ectopic pregnancy is around 10%
• previous surgery on your fallopian tubes – such as an unsuccessful female sterilisation procedure
• fertility treatment, such as IVF – taking medication to stimulate ovulation (the release of an egg) can increase the risk of ectopic pregnancy
• becoming pregnant while using an intrauterine device (IUD) or intrauterine system (IUS) for contraception – it's rare to get pregnant while using these, but if you do you're more likely to have an ectopic pregnancy
• smoking
• increasing age – the risk is highest for pregnant women who are aged 35-40

You can't always prevent an ectopic pregnancy, but you can reduce your risk by using a condom when not trying for a baby, to protect yourself from STIs, and by stopping smoking if you smoke.

Symptoms

Symptoms of an ectopic pregnancy usually develop between the 4th and 12th weeks of pregnancy.

Some women don't have any symptoms at first. They may not find out they have an ectopic pregnancy until an early scan shows the problem or they develop more serious symptoms later on.

Main symptoms

You may have an ectopic pregnancy if you miss a period, have a positive pregnancy test and/or have other signs of pregnancy, in addition to any of the symptoms listed below.

Contact your GP or call 111 if you have a combination of any of these symptoms and you think you might be pregnant – even if you haven't had a positive pregnancy test.

Vaginal bleeding

Vaginal bleeding tends to a bit different to your regular period. It often starts and stops, and may be watery and dark brown in colour.

Some women mistake this bleeding for a regular period and don't realise they're pregnant.

Vaginal bleeding during pregnancy is relatively common and isn't necessarily a sign of a serious problem, but you should seek medical advice if you experience it.

Tummy pain

You may experience tummy pain, typically low down on one side. It can develop suddenly or gradually, and may be persistent or come and go.

Tummy pain can have lots of causes, including stomach bugs and trapped wind, so it doesn't necessarily mean you have an ectopic pregnancy.

But you should get medical advice if you have it and think you might be pregnant.

Shoulder tip pain

Shoulder tip pain is an unusual pain felt where your shoulder ends and your arm begins.

It's not known exactly why it occurs, but it can be a sign of an ectopic pregnancy causing some internal bleeding, so you should get medical advice right away if you experience it.

Discomfort when going to the toilet

You may experience pain when going for a pee or poo. You may also have diarrhoea.

Some changes to your normal bladder and bowel patterns are normal during pregnancy, and these symptoms can be caused by urinary tract infections and stomach bugs.

But it's still a good idea to seek medical advice if you experience these symptoms and think you might be pregnant.

Symptoms of a rupture

In a few cases, an ectopic pregnancy can grow large enough to split open the fallopian tube. This is known as a rupture.

Ruptures are very serious and surgery to repair the fallopian tube needs to be carried out as soon as possible.

Signs of a rupture include a combination of:

• a sharp, sudden and intense pain in your tummy
• feeling very dizzy or fainting
• feeling sick
• looking very pale

Call 999 for an ambulance or go to your nearest accident and emergency (A&E) department immediately if you experience these symptoms.

Diagnosis

It can be difficult to diagnose an ectopic pregnancy from the symptoms alone, as they can be similar to other conditions.

Your GP may examine you and offer a pregnancy test.

If you have the symptoms of an ectopic pregnancy and a positive pregnancy test, you may be referred to an early pregnancy assessment service for further testing.

Some of the tests you may have are outlined below.

Vaginal ultrasound

An ectopic pregnancy is usually diagnosed by carrying out a transvaginal ultrasound scan.

This involves inserting a small probe into your vagina. The probe is so small that it's easy to insert and you won't need a local anaesthetic.

The probe emits sound waves that bounce back to create a close-up image of your reproductive system on a monitor.

This will often show whether a fertilised egg has become implanted in one of your fallopian tubes, although occasionally it may be very difficult to spot.

Blood tests

Blood tests to measure the pregnancy hormone human chorionic gonadotropin (hCG) may also be carried out twice, 48 hours apart, to see how the level changes over time.

This can be a useful way of identifying ectopic pregnancies that aren't found during an ultrasound scan, as the level of hCG tends to be lower and rise more slowly over time than in a normal pregnancy.

The results of the test can also be useful in determining the best treatment for an ectopic pregnancy.

Keyhole surgery

If it's still not clear whether you have an ectopic pregnancy, or the location of the pregnancy is unknown, a laparoscopy may be carried out.

This is a type of keyhole surgery carried out under general anaesthetic (where you're asleep) that involves making a small cut (incision) in your tummy and inserting a viewing tube called a laparoscope.

Your doctor uses the laparoscope to examine the womb and fallopian tubes directly.

If an ectopic pregnancy is found during the procedure, small surgical instruments may be used to remove it, to avoid the possible need for a second operation later on.

Treatment

Unfortunately, the foetus (the developing embryo) cannot be saved in an ectopic pregnancy. Treatment is usually needed to remove the pregnancy before it grows too large.

The main treatment options are:

• expectant management – your condition is carefully monitored to see whether treatment is necessary
• medication – a medicine called methotrexate is used to stop the pregnancy growing
• surgery – surgery is used to remove the pregnancy, usually along with the affected fallopian tube

These options each have advantages and disadvantages that your doctor will discuss with you.

They'll recommend what they think is the most suitable option for you, depending on factors such as your symptoms, the size of the foetus and the level of pregnancy hormone (human chorionic gonadotropin or hCG) in your blood.

Expectant management

If you have no symptoms or mild symptoms and the pregnancy is very small or can't be found, you may only need to be closely monitored, because there's a good chance the pregnancy will dissolve by itself.

This is known as expectant management.

The following is likely to happen:

• You'll have regular blood tests to check that the level of hCG in your blood is going down – these will be needed until the hormone is no longer found.
• You may need further treatment if your hormone level doesn't go down or it increases.
• You'll usually have some vaginal bleeding – use sanitary pads or towels, rather than tampons, until this clears up.
• You may experience some tummy pain – take paracetamol to relieve this.
• You'll be told what to do if you develop more severe symptoms.

The main advantage of monitoring is that you won't experience any side effects of treatment.

A disadvantage is that there's still a small risk of 1 of your fallopian tubes splitting open (rupturing) and you may eventually need treatment.

Medication

If an ectopic pregnancy is diagnosed early but active monitoring isn't suitable, treatment with a medicine called methotrexate may be recommended.

This works by stopping the pregnancy from growing. It's given as a single injection into your buttocks.

You won't need to stay in hospital after treatment, but regular blood tests will be carried out to check if the treatment is working.

A second dose is sometimes needed and surgery may be necessary if it doesn't work.

You need to use reliable contraception for at least 3 months after treatment.

This is because methotrexate can be harmful for a baby if you become pregnant during this time.

It's also important to avoid alcohol until you're told it's safe, as drinking soon after receiving a dose of methotrexate can damage your liver.

Other side effects of methotrexate include:

• tummy pain – this is usually mild and should pass within a day or 2
• dizziness
• feeling and being sick
• diarrhoea

There's also a chance of your fallopian tubes rupturing after treatment. You'll be told what to look out for and what to do if you think this has happened.

Surgery

In most cases, keyhole surgery (laparoscopy) will be carried out to remove the pregnancy before it becomes too large.

During a laparoscopy:

• you're given general anaesthetic, so you're asleep while it's carried out
• small cuts (incisions) are made in your tummy
• a thin viewing tube (laparoscope) and small surgical instruments are inserted through the incisions
• the entire fallopian tube containing the pregnancy is removed if your other fallopian tube looks healthy – otherwise, removing the pregnancy without removing the whole tube may be attempted

Removing the affected fallopian tube is the most effective treatment and isn't thought to reduce your chances of becoming pregnant again.

Your doctor will discuss this with you beforehand, and you'll be asked whether you consent to having the tube removed.

Most women can leave hospital a few days after surgery, although it can take 4 to 6 weeks to fully recover.

If your fallopian tube has already ruptured, you'll need emergency surgery.

The surgeon will make a larger incision in your tummy (laparotomy) to stop the bleeding and repair your fallopian tube, if that's possible.

After either type of surgery, a treatment called anti-D rhesus prophylaxis will be given if your blood type is RhD negative (see blood groups for more information)..

This involves an injection of a medicine that helps to prevent rhesus disease in future pregnancies.