If you are worried about a possible ectopic pregnancy or have been diagnosed with one, this information may be helpful.
What Is An Ectopic Pregnancy?
The word “ectopic” is derived from the Greek word “ektopos” which means “out of place”. Therefore an ectopic pregnancy is one that is “out of place” and not inside the womb. This happens in about 1% or less of pregnancies.
An ectopic pregnancy is a potentially life-threatening complication caused by the implantation of the embryo outside the womb.
Normally the sperm and egg meet up in the lower end of the fallopian tube and start dividing as the zygote becomes a morula and then a blastocyst which then implants in the uterus (womb).
In an ectopic pregnancy, this happens either in the fallopian tube (also called a tubal pregnancy), the abdomen, ovaries or the cervix. The majority (about 98%) occur in the fallopian tubes and only a very small percentage occurs elsewhere.
Ectopic tubal pregnancies commonly occur in the lower end or ampulla (about 80%) followed by the isthmus (middle), fimbria (opening) and cornua (top end) of the fallopian tube.
Why Does Implantation Occur Outside The Uterus?
Possible causes of an ectopic pregnancy include:
- Blockage or narrowing of the fallopian tube due to defects, previous infections or surgery causing scarring, endometriosis or previous ectopic pregnancy.
- Pregnancy with an intrauterine device (IUD) in place.
- Surgery to reverse a tubal ligation.
- Previous pelvic surgery causing adhesions.
However, sometimes no underlying cause can be found.
What Is A Tubal Pregnancy?
A tubal pregnancy is an ectopic pregnancy that has occurred in one of the fallopian tubes.
During implantation, the blastocyst burrows into the tubal lining (as it normally would do in the uterus) and may invade blood vessels which will cause bleeding and the spontaneous expulsion of the tubal pregnancy (also called a tubal abortion but is more comparable to a miscarriage).
If the tubal pregnancy continues to grow, because the fallopian tube is not designed to stretch to accommodate a pregnancy, the threat of a rupture occurring increases. This is potentially life-threatening to the mother as the risk of haemorrhage is high with a ruptured ectopic pregnancy.
What Are The Signs Of A Tubal Pregnancy?
Early signs include:
- Pain in the lower abdomen which can vary from mild to strong cramps.
- Pain while urinating or having a bowel movement.
- Slight to moderate vaginal bleeding.
Late signs include:
- Recent onset pain in the lower abdomen, lower back and/or shoulder tip that gets worse. Pain in the shoulder tip is a sign of internal bleeding that is irritating the diaphragm.
- Vaginal bleeding.
- Nausea and vomiting.
- Weakness, dizziness or fainting.
Signs of a possible ruptured ectopic pregnancy include:
- Onset of sudden severe sharp pain,
- Shoulder tip pain,
- Nausea or diarrhoea,
- Dizziness or fainting.
How Is An Ectopic Pregnancy Diagnosed?
Early ectopic pregnancies may be difficult to diagnose as they can mimic the symptoms of gastroenteritis, appendicitis, miscarriage or even a urinary tract infection.
An ectopic pregnancy is considered in any woman who has had a positive pregnancy test and then presents with pelvic pain and/or vaginal bleeding.
An transvaginal or abdominal ultrasound and the Human Chorionic Gonadatrophin (hCG) levels in the blood are used to diagnose an ectopic pregnancy. There is no definitive blood hCG level that correlates with an ectopic pregnancy. What is considered is that in a normal pregnancy, at a blood hCG level of 700-1000 mIU/ML, a gestational sac should be visible in the uterus on transvaginal ultrasound and ≥ 6000 mIU/ml on an abdominal ultrasound.
The diagnosis is made on the correlation of a positive pregnancy test, physical signs and symptoms, physical findings on examination, ultrasound results and blood hCG levels.
As the ability to diagnose ectopic pregnancy improves, doctors will be able to intervene sooner to prevent tubal damage and possible life-threatening situations and preserve future fertility.
What Is The Treatment For An Ectopic Pregnancy?
Some (approximately half) resolve without treatment as a tubal abortion.
Early treatment with methotrexate for an ectopic pregnancy stops the growth of the embryo which may then be passed as a tubal abortion or reabsorbed by the woman’s body. Methotrexate is administered intramuscularly (IM) either in a single or multiple doses, depending on your hCG levels.
For example, if your hCG levels have not started dropping by day 7 after the first injection of methotrexate, a second dose or surgery may be considered.
Feeling tired after methotrexate treatment is one of the side effects of the drug.
When is methotrexate treatment offered to a patient with an ectopic pregnancy? Patients have to meet the following criteria:
- Medically stable with no signs or symptoms of active bleeding or evidence of tubal rupture,
- Must be complaint and reliable for follow up care,
- No evidence of a fetal heartbeat on ultrasound,
- The size of the gestational sac should be ≤ 4 cm (1.575 inches) on ultrasound,
- A beta hCG level < 5000 mIU/ml,
- And no contraindications to the use of methotrexate such as kidney, liver, lung or blood disorders, sensitivity to methotrexate and breastfeeding.
If the fallopian tube has ruptured, or is in danger of rupturing, surgical intervention is required. This may be through a laparoscopy (keyhole surgery) or laparotomy (open surgery). Depending on where in the fallopian tube the ectopic pregnancy is situated and the danger of rupture, either a salpingostomy (removing the ectopic pregnancy only) or a salpingectomy (removing the fallopian tube) is performed.
What Happens After Treatment?
It is not unusual to have spotting or intermittent bleeding for up to 6 weeks after treatment. There should be no pain associated with the bleeding or spotting.
You could still have a feeling of being pregnant after treatment. This will subside as the hCG levels drop.
Depending on whether you had medical or surgical treatment, mild pain and discomfort could persist for a few weeks.
Fertility After An Ectopic Pregnancy
This depends on the type of treatment, a history of infertility, the reason for the ectopic pregnancy and how long it takes for hCG levels to drop.
Having an intrauterine pregnancy following methotrexate treatment is higher compared to surgical treatment and better after having a salpingotomy compared to a salpingectomy.
It will also depend on the health of your fallopian tubes. It is important that you discuss this with your health care provider so that you know what to expect.
If you had medical treatment only (your fallopian tubes are still intact), on average, you have a 60% to 65% chance of an intrauterine (normal) pregnancy within the following 18 months.
How Soon After An Ectopic Pregnancy Can I Try To Conceive Again?
Your menstrual cycle will resume sometime within the 2nd and 10th week after surgery and within 4 weeks after your hCG levels have dropped to <5 mIU/ml after treatment with methotrexate.
Your body needs time to recover and you need time to recover emotionally too, therefore it is recommended that you wait for at least 2 full menstrual cycles or 3 months.
After methotrexate treatment it is recommended that you wait at least the full 3 months.
Methotrexate is a powerful drug used in cancer treatment and may diminish the levels of folic acid in your body. If you fall pregnant with a low folate level, the risk of a neural tube defect such as a cleft palate or lip is higher.
Therefore it is recommended that you wait until your hCG levels have dropped to <5 mIU/ml before starting with a folate supplement. You should then take a folate supplement for approximately 12 weeks before trying to conceive again.
Coping With The Emotional Side Of An Ectopic Pregnancy
Knowing that you were pregnant but that it was just growing in the wrong place and then having to go through the treatment can be an emotionally difficult, fearful and stressful period in your life. What began as a very joyful experience has been taken away so abruptly.
You need time to heal emotionally and physically and you need time to grieve. Don’t be afraid to ask for help and support. Take your time easing back into your normal routine and work.
Do not blame yourself as chance may be the only culprit. Remember there is no possibility that the pregnancy would have survived and that your life could have been at risk too.
When you are ready, start planning ahead by getting all the relevant information from your health care provider regarding if and how your ectopic pregnancy and treatment have affected your fallopian tubes.
In the wrong place at the right time
Hoping, praying for such a long time
for the someday baby who would be mine
Month after month failing the test
trying so hard refusing to rest
But then came a day when the lines became two
at last my dream was about to come true
With my hand on my belly I was touching my baby to be
and looking forward to the day when you I would see
But then came the pain so sharp and so strong
I couldn’t believe that things could go wrong
My baby is growing the heartbeat echoes in my heart
but baby was not where baby should start
How could this happen, when for so long I had dreamed
Please don’t take my baby I begged and I screamed
Can you not fix this, can you save the life?
the pain cuts through me as sharp as a knife
They tell me that I will die if it is not done
so instead of two I once again become one
I will always remember that you wanted to be
but you had to go because instead they saved me
I loved you so, and I think of you every day
my teeny tiny baby who got lost on the way
In heaven there is angel of mine
who was in the wrong place at the right time.