Condition Basics

What is an ectopic pregnancy?

In a small number of pregnancies, the fertilized egg attaches to an area outside of the uterus, rather than in the uterus. This is called an ectopic pregnancy or extrauterine pregnancy.

Nearly all ectopic pregnancies develop in a fallopian tube. These are often called tubal pregnancies. If left untreated, a tubal ectopic pregnancy can cause fallopian tube damage and cause heavy bleeding that could be deadly. So unless the pregnancy is miscarrying on its own, medicine or surgery is used to treat the ectopic pregnancy.

Ectopic pregnancy can also occur in an ovary, the cervix, or the abdomen. This is rare.

What causes it?

An ectopic pregnancy is often caused by damage to the fallopian tubes. A fertilized egg may have trouble passing through a damaged tube, causing the egg to implant and grow in the tube. Things that make this damage more likely include pelvic inflammatory disease, such as from a chlamydia or gonorrhea infection.

What are the symptoms?

In the first few weeks, an ectopic pregnancy usually causes the same symptoms as a normal pregnancy, such as a missed menstrual period, fatigue, nausea, and sore breasts.

The key signs of an ectopic pregnancy are:

• Belly pain or pelvic pain. It most often starts 6 to 8 weeks after a missed period. It may be sharp on one side at first and then spread through your belly. It may be worse when you move or strain.
• Vaginal bleeding. It may be light.

How is it diagnosed?

A urine test can show if you are pregnant. If you have symptoms of a possible ectopic pregnancy, your doctor will likely do a pelvic examination, a blood test, and an ultrasound. After your treatment, you will need blood tests to be sure the pregnancy is ending.

How is an ectopic pregnancy treated?

In most cases, an ectopic pregnancy is treated right away to avoid rupture and severe blood loss. Treatment may be medicine or surgery. Rarely, the doctor may recommend what's called expectant management. The decision about which treatment to use depends on how early the pregnancy is found and your overall condition.

What can help you cope after an ectopic pregnancy?

Losing a pregnancy can be hard, no matter how early it happened. Take time to grieve your loss, and get the support you need. Having an ectopic pregnancy doesn't mean that you can't have a normal pregnancy in the future.

Cause

Fallopian tube damage is a common cause of ectopic pregnancy. A fertilized egg can get caught in the damaged area of a tube and start to grow there. Some ectopic pregnancies occur without any known cause.

Common causes of fallopian tube damage that may lead to an ectopic pregnancy include:

• Smoking. It raises the risk for ectopic pregnancy. Smoking is thought to damage the fallopian tubes' ability to move the fertilized egg toward the uterus.
• Pelvic inflammatory disease (PID), such as from a chlamydia or gonorrhea infection. PID can create scar tissue in the fallopian tubes.
• Being exposed to the chemical DES before you were born.

Some medical treatments can increase your risk. These include:

• Surgery on the fallopian tubes or in the pelvic area.
• Fertility treatments such as in vitro fertilization.

Prevention

You may be able to prevent an ectopic pregnancy by reducing things that may put you at risk for having one.

If you smoke, quit. Smoking puts you at higher risk for ectopic pregnancy.

Use safer sex practices, such as using a condom every time you have sex. Use an external condom, which goes on the penis. Or use an internal condom, which goes into the vagina or anus. This will help protect you from sexually transmitted infections (STIs) that can lead to pelvic inflammatory disease (PID). PID is a common cause of scar tissue in the fallopian tubes, which can cause ectopic pregnancy.

If you have one or more risk factors for ectopic pregnancy, you and your doctor can closely monitor your first weeks of a pregnancy.

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Symptoms

In the first few weeks, an ectopic pregnancy usually causes the same symptoms as a normal pregnancy, such as a missed menstrual period, fatigue, nausea, and sore breasts.

The key signs of an ectopic pregnancy are:

• Belly pain or pelvic pain. It most often starts 6 to 8 weeks after a missed period.
• Vaginal bleeding. It may be light.

As an ectopic pregnancy progresses, though, other symptoms may develop. They include:

• Belly pain or pelvic pain that may get worse with movement or straining. It may be sharp on one side at first and then spread through your belly. It may be worse when you move or strain.
• Heavy or severe vaginal bleeding.
• Pain with intercourse or during a pelvic examination.
• Dizziness, light-headedness, or fainting (syncope) caused by internal bleeding.
• Signs of shock.
• Shoulder pain caused by bleeding into the belly under the diaphragm. The bleeding irritates the diaphragm and is felt as shoulder pain.

Symptoms of miscarriage often are similar to symptoms in early ectopic pregnancy.

What Happens

Normally, at the start of a pregnancy, the fertilized egg travels from the fallopian tube to the uterus, where it implants and grows. But in a small number of diagnosed pregnancies, the fertilized egg attaches to an area outside of the uterus. This results in an ectopic pregnancy (also known as a tubal pregnancy or an extrauterine pregnancy).

An ectopic pregnancy cannot support the life of a fetus for very long. But an ectopic pregnancy can grow large enough to rupture the area and cause heavy bleeding, which is dangerous. If you have signs or symptoms of an ectopic pregnancy, you need immediate medical care.

An ectopic pregnancy can develop in different locations. In most cases, the fertilized egg has implanted in a fallopian tube.

In rare cases:

• The egg attaches and grows in an ovary, the cervix, or the abdominal cavity (outside of the reproductive system).
• One or more eggs grow in the uterus, and one or more grow in a fallopian tube, the cervix, or the abdominal cavity. This is called a heterotopic pregnancy.

Getting pregnant after an ectopic pregnancy

It's common to worry about your fertility after an ectopic pregnancy. Having an ectopic pregnancy doesn't mean that you can't have a normal pregnancy in the future. But it does mean that:

• You may have trouble getting pregnant.
• You are more likely to have another ectopic pregnancy.

If you get pregnant again, be sure your doctor knows that you had an ectopic pregnancy before. Regular testing in the first weeks of pregnancy can find a problem early or let you know that the pregnancy is normal.

When to Call a Doctor

If you are pregnant, be alert to the symptoms that may mean you have an ectopic pregnancy, especially if you are at risk. If you have symptoms of or are being treated for an ectopic pregnancy, avoid strenuous activity until your symptoms have been checked by a doctor.

Call 911 or other emergency services immediately if:

• You passed out (lost consciousness).
• You have severe vaginal bleeding.
• You have sudden, severe pain in your belly or pelvis.

Call your doctor now or seek immediate medical care if:

• You are dizzy or light-headed, or you feel like you may faint.
• You have vaginal bleeding.
• You have new cramps or new pain in your belly or pelvis.
• You have new pain in your shoulder.

Examinations and Tests

A urine test can show if you are pregnant. If you have symptoms of a possible ectopic pregnancy, you will have:

• A pelvic examination to check on the size of your uterus and feel for growths or tenderness in your belly.
• A blood test that checks for the level of the pregnancy hormone (hCG). This test is repeated 2 days later. During early pregnancy, the level of this hormone doubles every 2 days. Low levels suggest a problem, such as an ectopic pregnancy.
• An ultrasound. This test can show pictures of what's inside your belly. With ultrasound, a doctor can usually see a pregnancy in the uterus 6 weeks after your last menstrual period.

During the week after treatment for an ectopic pregnancy, your hCG blood levels are tested several times. In some cases, hCG testing continues for weeks to months until hCG levels drop to a low level.

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Treatment Overview

In most cases, an ectopic pregnancy is treated right away to avoid rupture and severe blood loss. The decision about which treatment to use depends on how early the pregnancy is found and your overall condition.

Medicine can be used if the pregnancy is found early, before the tube is damaged. In most cases, one or more shots of a medicine called methotrexate will end the pregnancy. Taking the shot lets you avoid surgery, but it can cause side effects. You will need to see your doctor for follow-up blood tests to make sure the shot worked.

For a pregnancy that has gone beyond the first few weeks, surgery is safer and more likely to work than medicine. If possible, the surgery will be laparoscopy. This type of surgery is done through one or more small cuts (incisions) in your belly. If you need emergency surgery, you may have a larger incision.

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Self-Care

• Rest when you feel tired. You may be more tired than normal for a few weeks.
• If you are treated with methotrexate:
  • Your doctor will let you know if you can take over-the-counter pain medicine, such as acetaminophen (Tylenol), ibuprofen (Advil, Motrin), or naproxen (Aleve). Read and follow all instructions on the label.
  • Do not take two or more pain medicines at the same time unless the doctor told you to. Many pain medicines have acetaminophen, which is Tylenol. Too much acetaminophen (Tylenol) can be harmful.
  • Do not drink alcohol.
  • Do not take vitamins that contain folic acid, such as prenatal vitamins.
• Use pads instead of tampons until your doctor says it is okay.
• Try talking with family, friends, or a counsellor if you are having trouble dealing with the loss of your pregnancy. If you feel sad or depressed for longer than 2 weeks, talk to a counsellor or your doctor.
• Do not have sex until your doctor says it is okay.
• Talk with your doctor about any future pregnancy plans.

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Medicines

A medicine called methotrexate is usually the first treatment choice for ending an early ectopic pregnancy. But it's not an option if the fallopian tubes have ruptured.

Medicine is most likely to work when an early ectopic pregnancy isn't causing bleeding and:

• Your pregnancy hormone (hCG, or human chorionic gonadotropin) level is low (less than 5,000).
• The embryo has no heart activity.

Methotrexate is usually injected into a muscle. After the shot, you'll need follow-up blood tests for several weeks. These tests are to make sure that the medicine worked.

Methotrexate can cause unpleasant side effects. These include nausea, indigestion, and diarrhea.

For an ectopic pregnancy that is more developed, surgery is a safer and more dependable treatment. Sometimes methotrexate is used after surgery. It's to make sure that all ectopic cell growth has stopped.

Surgery

Surgery is the fastest way to treat an ectopic pregnancy. The two types of surgery are:

Salpingostomy.

The doctor removes the ectopic growth through a small cut in the fallopian tube. This is called linear salpingostomy. The cut is left to close by itself. Or it may be stitched closed.

Salpingectomy.

The doctor removes a part of the fallopian tube. The remaining healthy fallopian tube may be reconnected. This surgery is needed when the fallopian tube is so stretched that it may rupture. It's also used when the tube has already ruptured or is very damaged.

These surgeries can be done in two ways. The first is through a small incision using laparoscopy. The second is called laparotomy. It's done through a larger incision in the belly. Laparoscopy takes less time than laparotomy. And the hospital stay is usually shorter.

If the fallopian tube that isn't part of the ectopic pregnancy is healthy, then both surgeries have about the same effect on future fertility. But if that other fallopian tube isn't healthy, then your doctor may try to do a salpingostomy.

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