Ectopic pregnancy

An ectopic pregnancy can be frightening and overwhelming, often unfolding quickly and unexpectedly.

An ectopic pregnancy is one that develops outside the womb. Most occur in a fallopian tube, where a pregnancy cannot safely grow. Around one in 80 pregnancies is ectopic, and for some people it becomes a medical emergency.

An Ectopic pregnancy can’t survive, and there is no way to move the pregnancy into the womb. This knowledge can be devastating, particularly when decisions must be made urgently or treatment begins before there has been time to process the loss.

What happens in an ectopic pregnancy

In a tubal ectopic pregnancy, the tube cannot stretch to accommodate a growing pregnancy. Without treatment, it can rupture and cause serious internal bleeding. For this reason, ectopic pregnancy is treated as a priority in medical care.

Rarely, (in around 5% of cases) an ectopic pregnancy can be found somewhere other than the tube. These types of ectopic pregnancy include:

an interstitial ectopic: the pregnancy implants in the top corner of the uterus near the Fallopian tube
a cervical ectopic: the pregnancy implants in the cervix (the neck of the womb)
a scar ectopic: the pregnancy implants in the scar from a previous Caesarean section
a cornual ectopic: the pregnancy implants in a corner of the uterus which itself has not formed normally
a heterotopic pregnancy: a twin pregnancy where one is in the correct place but one is ectopic
an ovarian ectopic: the pregnancy implants in an ovary
an abdominal pregnancy: the pregnancy implants somewhere within the abdomen These are all rare conditions with individualised treatment.

Why ectopic pregnancy happens

We don’t always know why an ectopic pregnancy occurs. Sometimes there are identifiable risk factors — such as previous ectopic pregnancy, infection, surgery, endometriosis or fertility treatment — but many people have no known risks at all.

Nothing you did caused this.

What are the symptoms of an ectopic pregnancy?

Ectopic pregnancy can be very difficult to diagnose as sometimes there are no obvious symptoms.

Symptoms can include:

Irregular vaginal bleeding – bleeding that is different from your normal period. It may be constant but light over a number of weeks or you may have a brown discharge or spotting. Occasionally, some women think they may have had a light period and then they start bleeding again 10-14 days later and do not realise that they are pregnan.
Pain low in your abdomen, perhaps just on one side. It might start suddenly or develop gradually and it can be constant and severe.
Shoulder-tip pain – this kind of pain will be very different to any pain you have felt before and often comes with other symptoms such as vaginal bleeding and abdominal pain.
Bowel or bladder problems – you may have diarrhoea and perhaps vomiting; or pain when opening your bowels or passing urine.
Collapse – you may feel lightheaded, dizzy and/or faint. You may have a feeling that something is very wrong. You might look very pale, have a racing pulse and feel sick.
No symptoms – you may have no symptoms at all.

How is an ectopic pregnancy diagnosed?

Ectopic pregnancy can be very difficult to diagnose. The symptoms can be mistaken for gastro-enteritis, irritable bowel syndrome, miscarriage or even appendicitis.

In hospital, unless you are extremely unwell, the first steps are usually:

A medical history – you will be asked about your symptoms, pregnancy history and your previous medical history
A pregnancy test (urine and/or blood)
An ultrasound scan – you are most likely to have a transvaginal (internal) scan, as this provides the clearest picture in early pregnancy. It will not damage your baby. The scan could show:
- A pregnancy that is developing normally in the womb. You probably won’t need further treatment unless your symptoms continue or get worse.
- A pregnancy that seems to be failing or has died. You will probably be offered an appointment for another scan or options for treating a miscarriage
- An empty womb. This finding is called a pregnancy of unknown location (PUL) and you will need further tests.
- A pregnancy developing outside the womb – an ectopic pregnancy. This often can’t be seen in the first weeks of pregnancy, but might be seen later.

“I had a feeling something wasn’t quite right with this pregnancy and at 6½ weeks I doubled up in excruciating pain.”

Because the symptoms of ectopic pregnancy can overlap with other conditions, diagnosis can sometimes be challenging. Unless you are very unwell, the first steps usually involve:

Discussing your symptoms and medical history with a healthcare professional
A urine or blood pregnancy test
An ultrasound scan, sometimes repeated
Blood tests over several days to track pregnancy hormone levels
In certain situations, a laparoscopy (a ‘keyhole’ procedure under general anaesthetic), which can also treat an ectopic pregnancy if one is found. A tiny camera is passed through a small cut in your abdomen so that your fallopian tubes and internal organs can be seen directly. If it is clear that there is a tubal pregnancy, it will usually be removed at the same time.

If you experience sudden, severe pain, shoulder pain, or heavy bleeding, seek urgent medical attention at your nearest A&E or Early Pregnancy Unit.

Treatment & What Comes Next

How is a tubal ectopic pregnancy managed (treated)?

If you are very unwell, the only safe option may be an urgent operation to confirm the diagnosis and to stop internal bleeding. In most cases, though, there may be several options, depending on your condition, the scan report and any additional blood tests, and you should have time to discuss these with your doctor.

Conservative or expectant management

This is sometimes described as “watchful waiting”. It means that you don’t have any active treatment, but are checked regularly to make sure that the ectopic pregnancy is ending naturally. You might be offered this treatment if:

you are well (you have a normal pulse and blood pressure and little or no pain).
there is no sign on the ultrasound scan that the tube has ruptured.
your ßhCG levels are relatively low and
during monitoring these levels continue to fall.

If you do have conservative management, you will need repeated visits to hospital to have your pregnancy hormone levels checked. Until your results are back to normal, there is still a risk that your tube might rupture.

During this time it is important to think of who you would contact in an emergency for support if you became unwell. It is also important not to have sexual intercourse as this can increase the risk of rupture, and to avoid alcohol as it may complicate the situation if you become unwell.

Medical management

Sometimes an ectopic pregnancy can be treated with drugs that stop the development of the pregnancy and allow it to be re-absorbed by the body. This may be offered if:

you are well (you have a normal pulse and blood pressure and little or no pain)
there is no sign on the ultrasound scan that the tube has ruptured
you have a small ectopic pregnancy with no heartbeat
your ßhCG levels are relatively low

The drug that is most often used is methotrexate and it is usually injected into a muscle. Methotrexate is a drug that is used for many conditions to stop the growth of rapidly dividing cells. It can cause abnormalities in a developing baby so it can only be given when the diagnosis of ectopic pregnancy is certain.

“I was able to have methotrexate as the ectopic was caught quite early. The injection was fine and I had no side-effects, but I needed two lots of treatment and repeated blood tests before the pregnancy was over.”

Medical management isn’t suitable for everyone, and especially not if:

your pregnancy hormone levels are very high
you have other medical problems that mean you should not use methotrexate (for example, kidney failure)

The advantage of medical management is that if it is successful (which it is in 90% of cases), you avoid having an operation and probably won’t need to stay in hospital. If it is unsuccessful, you may still need to have an operation.

After the injection you will need regular blood tests to measure your hormone levels and check that they are falling. The blood tests are usually done at the start of treatment, days 4 and 7 after treatment; then weekly after that until they are normal. This can take 4 to 6 weeks, depending on the level at the beginning.

About 15% of women will need a second injection and a smaller number may need surgery. Until your hormone levels are back to normal, it is important not to have sexual intercourse as this can increase the risk of rupture, and to avoid alcohol as it may complicate the situation if you become unwell.

Some women have mild side-effects from the treatment, such as mouth ulcers, abdominal pain, nausea or skin rashes. You are also more at risk of sunburn and a small amount of hair loss. If you have medical treatment, you will be advised to wait three months before trying for another pregnancy. This is because the drug can be harmful to an early pregnancy by reducing the amount of folic acid in your system.

It is important to make sure the drug is out of your system before you get pregnant again. Once your hormone levels are back to normal, it is also advisable to restart your folic acid if you plan to try again.

“I’m glad I avoided surgery but the treatment made me very sick and I was absolutely exhausted for about two weeks.”

Surgical management (under general anaesthetic)

This is the recommended treatment if:

you are acutely unwell, with severe pain or internal bleeding
there is a live ectopic pregnancy
your hormone level is very high
the diagnosis is uncertain

The advantage of surgical management is that it is a relatively quick treatment that does not usually require repeated hospital visits and blood tests. It may also be the treatment that you prefer when you compare it with the other options.

However, it is not usually offered if your hormone levels are very low unless there are other medical reasons to do so. In most hospitals, the operation is done by laparoscopy (key-hole surgery). This involves making two or three small cuts to the abdomen so that a camera can directly show the ectopic pregnancy and allow access for the instruments used to remove it. Laparoscopic (key-hole) surgery shortens the length of time you need to stay in hospital and you will recover physically more quickly than after open surgery.

But this might not be possible, because, for example:

you are too unwell or
you have had previous abdominal surgery or
you are very overweight or
the doctor operating is more skilled and experienced at performing open rather than key-hole surgery.

In this case, you will have an operation which leaves a scar along the pubic hair line (bikini line). In either operation, the doctor looks carefully at the fallopian tubes and other pelvic organs. This might give an idea of what caused the ectopic pregnancy, though this isn’t always clear. It might also help your doctor advise you about a future pregnancy.

If this is your first ectopic pregnancy, your doctor will advise removing the affected tube completely, with the pregnancy tissue inside. This is called a salpingectomy. If you have damaged tubes, however, or had a previous ectopic – and especially if you have already had one tube removed – there might be another option.

It might be possible to remove the ectopic pregnancy from the remaining tube, and leave the tube behind. This is called a salpingotomy. The advantage of this second option is that you will still have at least one tube left.

The disadvantages are that:

it increases the risk that not all the pregnancy tissue is removed, and
you will need additional follow-up checks to check your hormone levels, and
there is a higher risk of a future tubal pregnancy

Sadly for some women a further ectopic pregnancy will result in the loss of both fallopian tubes. This can have a huge emotional impact and the only option for a future pregnancy would be through IVF (in vitro fertilisation).

For further information, advice and support on the availability of this treatment it is best to see your GP.

“It was like a double loss. I lost my baby and I lost one of my tubes. It felt like the end of the world.”

How is a non-tubal ectopic pregnancy managed?

The management of non-tubal pregnancies depends on where the pregnancy has implanted and whether or not it is still alive. Each case needs to be considered separately, but most are managed surgically. You might find it helpful to read the patient guidance from the Royal College of Obstetricians and Gynaecologists:

You may also find the resources from The Ectopic Pregnancy Trust helpful.

After treatment

If you have surgical management, any tissue removed will be examined under the microscope to confirm that it was an ectopic pregnancy. That tissue is usually then disposed of by the hospital, in accordance with their sensitive disposal policy. If you prefer to take the remains of your pregnancy home to bury or to make your own arrangements, you can ask for them to be returned to you.

How long does it take to recover?

Recovering from an ectopic pregnancy is different for everyone. You might also find that you recover physically quite quickly, but that your feelings about what has happened stay with you for longer.

Physical recovery

When can I go back to work or my usual routine?

Once you are home from hospital, you’ll probably need to take things easy for at least a few days, whatever treatment you have had. If possible, it is best to return to work only when you feel ready both physically and emotionally. Your GP will be able to provide you with a certificate (a “fit note”) for work.

After surgical management

After key-hole surgery, you should recover physically after about two weeks. If you have open surgery it is likely to be up to six weeks.

You should get a period about 4 to 6 weeks after your treatment, but this can take longer, particularly if your usual cycle is longer than 4 weeks.

After medical management

You will need to wait for the results of your blood test on day 7 after treatment. If the results show that the hormone level is falling and the pregnancy is resolving, you can start to return to your normal routine.

You may still have bleeding for some time, and it is best to wear pads rather than tampons to reduce the risk of infection. Your period will not start until at least 4 weeks after your hormones have reached very low levels.

When is it OK to start having sex again?

This very much depends on how you are feeling after the ectopic pregnancy and what treatment you have had. After surgery, it is safe to have sexual intercourse once any bleeding and discharge have stopped. After conservative and medical management it is advisable to wait until your levels are returning to normal. You may want to wait longer, though, especially if you are feeling very tired and/or you are still sore or in pain. You might also be worried about the possibility of getting pregnant again.

Emotional recovery

Are my feelings normal?

Everyone is different, but many women say that ectopic pregnancy is a very upsetting and frightening experience, even if they weren’t planning to have a baby. There is no right or wrong way to feel and you’ll probably find that you have lots of ups and downs in the days, weeks and months after your loss.

You may have felt – or you might still feel – one or more of the following:
Shock – perhaps you didn’t know you were pregnant until your ectopic was diagnosed. You had to cope with finding out you were pregnant and that it couldn’t survive all at the same time. You might have been treated as an emergency, with everything happening very quickly. You might have been very frightened, especially if you knew your life was at risk. You may still be replaying those feelings of shock and fear in your mind. Perhaps you are shocked by thoughts about what might have happened – such as “What if I hadn’t been diagnosed in time?”.

This can be true for your partner too. You may feel very anxious – about what happened or about all sorts of things. And you may have difficulty sleeping. If this becomes a real problem for you, then it is probably a good idea to talk to your GP.

Loss and grief

You may feel very sad for the loss of your baby, and for the hopes and dreams you had for her or him. Those feelings might be very strong and last longer than you expect. It can be very difficult, especially if other people don’t understand that. You may find it helps to talk to other people who have had an ectopic pregnancy.

Feeling “in limbo”

If you have been treated with methotrexate or are waiting for the ectopic to resolve naturally, you may feel in a kind of “limbo” for several weeks. It can be very upsetting to have to go back to the hospital for repeated blood tests until your hormone levels are back to normal. If you have been advised to wait some months before trying again, you might feel that it is even harder to recover and to begin to move forward.

Anxiety about the future

You may worry about whether you’ll be able to get pregnant again. Or you might be frightened that if you do become pregnant, you might have another ectopic pregnancy. You may wonder whether you should try again, or whether you even want to. We provide some information about this in the next section. It may also be helpful to discuss your questions and concerns with your doctor. If you had surgery for the ectopic pregnancy, your doctor should be able to tell you about the condition of your womb, tube(s) and ovaries and how this might affect your future fertility – particularly if there is any obvious damage to the other tube. If you had problems getting pregnant this time, you may want to ask if you can see a specialist before trying again.

Pregnancy After an Ectopic

The chances of having a healthy pregnancy are still good after treatment for an ectopic, even if your tube is removed. You will ovulate (release an egg) as before, probably once a month. And even if you have just one fallopian tube, it’s possible to get pregnant even when you ovulate on the opposite side. 65% of women will fall pregnant within the first 18 months, 85% within two years, while some will need help to do so (e.g. fertility treatment) and others will decide not to try again.

What are the chances that I’ll have another ectopic pregnancy?

The overall chance of you having another ectopic is between 7% and 10% – so at most, 1 in 10. This will depend on the kind of treatment that you had and the health of your remaining tube or tubes. If you had surgical treatment but the tube was not removed (salpingotomy), the risk of another ectopic is slightly higher, at around 15%. When one fallopian tube is damaged (because of infection or scarring, for example), there is a higher chance than normal that the other tube may be damaged too.

This means that:

the chance of getting pregnant is less than normal
there is an increased risk of another ectopic pregnancy if you do become pregnant.
The chance of having another non-tubal ectopic pregnancy is very low, but if it was a cornual pregnancy and this was managed surgically, there may be other concerns in the next pregnancy. It is important to discuss this with your doctor at your followup appointment.

When is it best to try for another pregnancy?

This will depend on the type of ectopic pregnancy you have and the treatment you receive. There is no clear guidance on how long you should wait before trying again after an ectopic pregnancy and clinical opinion varies. The NHS advises waiting until you have had two periods before trying again.

After medical treatment, you will be advised to wait at least three months. You might want to get pregnant again as soon as possible or you may find the thought of another pregnancy very frightening. You and your partner are the best judges of when – or whether – to try again.

Will I need special care in my next pregnancy?

The most important thing in your next pregnancy is to find out early if it is developing in the right place. So once you have a positive pregnancy test, it is best to consult your GP or Early Pregnancy Unit so that they can arrange an early scan for you. It is not usually helpful to have a scan before six weeks as it can be too early to confirm where the pregnancy is developing.

However, if you have pain or bleeding, it is best to go to your local EPU for assessment even if it is before six weeks. If you see a GP or hospital doctor who doesn’t know your history, it is important to tell them about your ectopic pregnancy so they understand that an early scan is important.

It is helpful to tell them or the person scanning you which fallopian tube was affected and/or removed. It is also essential to talk to your doctor if you might be pregnant and have any symptoms that might mean another ectopic: a late period, bleeding that is different from usual or any of the other symptoms listed above.

If you are pregnant and an early scan shows a developing pregnancy in the womb, then you are unlikely to need any further special care or tests. You’ll be booked in for routine scans at around 12 and 20 weeks.

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