Ectopic pregnancy

What is an ectopic pregnancy?

An ectopic pregnancy happens when a fertilized egg grows outside the main cavity of a woman's uterus. Most commonly an ectopic occurs inside a fallopian tube. (This is known as a tubal pregnancy.) Sometimes, the fertilized egg will implant itself in other areas of the body, such as in the abdominal cavity or ovary. An ectopic pregnancy is a medical emergency. As the egg grows, it can cause the tube to burst or damage surrounding organs, which can cause major internal bleeding and require immediate surgery.

Ectopic pregnancy signs and symptoms

If you have an ectopic pregnancy, you may have some of the same symptoms you'd have during a normal early pregnancy, like sore breasts, fatigue, and nausea. However, many women have no symptoms at all until the ectopic pregnancy ruptures. Call your provider immediately if you have:

• Abdominal or pelvic pain or tenderness. You may feel it only on one side, but the pain can be anywhere in your abdomen or pelvis. It may be mild and intermittent early on, but it can also be sudden, persistent, and severe. It may be dull or sharp, and you may also have nausea and vomiting. You may find that the pain gets worse when you're active or when you move your bowels or cough. If the fallopian tube has ruptured, your abdomen may be distended and swollen. You may also feel pain in your lower back.
• Vaginal spotting or bleeding (if you've had a positive pregnancy test result). It may look like the start of a light period. The blood may be red or brown, like the color of dried blood, and it may be continuous or intermittent, heavy, or light.
• Shoulder pain. Pain in your shoulder, especially when you lie down, is a red flag for a ruptured ectopic pregnancy, and it's critical to get medical attention immediately. The cause of the pain is internal bleeding, which irritates nerves that go to your shoulder area.

It's also important to seek early care if you know you have a high risk for an ectopic pregnancy and think you're pregnant.

If you're having fertility treatments and get pregnant, your healthcare provider will monitor your pregnancy carefully, but alert them immediately if you have any symptoms of a possible ectopic pregnancy.

Risk factors for ectopic pregnancy

An ectopic pregnancy can happen to any woman, and about half of all women who have an ectopic pregnancy have no known risk factors. Here are the risk factors we know can make an ectopic pregnancy more likely:

• Pelvic inflammatory disease (PID) and certain STIs. PID is a bacterial infection in the uterus, ovaries, or fallopian tubes that often results from untreated sexually transmitted infections (STIs), such as gonorrhea or chlamydia. PID doesn't always cause symptoms, so having had either of these STIs also increases your risk for an ectopic pregnancy, even if you don't think you have PID.
• Endometriosis. In this condition, the tissue that normally lines your uterus grows elsewhere in your abdomen, such as your ovaries, intestines, or fallopian tubes. If the tissue grows on your fallopian tubes, it causes inflammation and scarring, increasing your risk of an ectopic pregnancy.
• Getting pregnant with an intrauterine device (IUD) in place. Although the chance of this happening is rare, you have a higher-than-average risk of an ectopic pregnancy if you have a hormonal IUD (rather than a copper IUD). An IUD works by preventing an egg from implanting in the uterus, but in very rare cases, it may implant outside it.

  Of course, while using an IUD, your overall risk of ectopic pregnancy is much lower than that of the general population. (And having used an IUD in the past doesn't raise your risk of an ectopic pregnancy.)

• Smoking. Some experts theorize that smoking cigarettes may impair normal functioning of the fallopian tubes.
• Surgery. Tubal ligation for sterilization, tubal ligation reversal, or surgery to correct a problem with your fallopian tubes can increase your ectopic pregnancy risk. (If you've had other pelvic or abdominal surgery, your risk may also be higher, though to a much lesser degree.)
• A previous ectopic pregnancy. In a review of studies, researchers found that in women who had one ectopic pregnancy, the chance of having another ranged from 5 to 25 percent, depending on how the previous ectopic pregnancy was treated.
• Fertility issues. Damaged fallopian tubes can cause infertility. If you needed in vitro fertilization (IVF) or fertility drugs because of damaged tubes, there's a slightly higher than average chance that the pregnancy will be ectopic. If you used IVF or fertility drugs for other reasons, you're not at higher risk.
• Advancing maternal age. Women who are 39 years or older have about a nine-fold risk of ectopic pregnancy compared with women who are 26 years or younger. You may have accumulated risk factors over time, such as pelvic infections or changes in how well your fallopian tubes work.
• Taking progestin-only hormonal contraceptives. Some studies suggest that this somewhat increases your chance of an ectopic pregnancy.

Causes of ectopic pregnancy

After conception, the fertilized egg travels down one of your fallopian tubes on its way to your uterus, where it needs to implant in the thick uterine lining.

Normally the internal lining of the tubes aids the one-way flow of the embryo to the uterus. (The inside of the tubes is covered in a soft, brush-like lining that propels the embryo along.) If the tube is damaged or blocked and fails to move the egg toward your womb, the egg may implant in the tube and continue to divide and grow there. (Almost all ectopic pregnancies occur in a fallopian tube, so they're often called "tubal" pregnancies.) Eventually it can burst through the thin tubal wall.

It's also possible to have one embryo implant normally in your uterus and another implant in a tube or elsewhere. This condition, called a heterotopic pregnancy, is extremely rare. Experts estimate that it happens in about 1 out of 30,000 spontaneous pregnancies. The rate is higher, about 1 in 4,000, for pregnancies that are the result of assisted reproductive technology (ART).

Though it also rarely happens, an egg can also implant in an ovary, in the cervix, directly in the abdomen, or even in a c-section scar.

An ectopic pregnancy that isn't recognized and treated quickly could result in a ruptured fallopian tube, causing severe abdominal pain and bleeding. This can lead to permanent tube damage, tube loss, or even death if very heavy internal bleeding is not treated right away.

Diagnosing an ectopic pregnancy

An ectopic pregnancy can be tricky to diagnose. If you're not having symptoms, your provider may suspect an ectopic pregnancy if you have pain during an abdominal or pelvic exam at your first prenatal visit.

If your provider suspects an ectopic pregnancy, they will:

• Calculate how far along you are (if you don't already know).
• Give you a blood test to determine your hCG level to see if it matches what it should be at your stage of pregnancy.
• Perform an ultrasound to look for an embryo.

If the ultrasound shows no embryo in your uterus, your practitioner will look for one in the fallopian tubes or a mass that may contain tissue from an embryo that has died. By examining your tubes and uterus using ultrasound, your practitioner may be able to diagnose an ectopic pregnancy as early as six or seven weeks.

If there's still some question about the diagnosis and you're not in pain, you'll have another ultrasound and blood test in two days. If your hCG level doesn't increase as it's supposed to, this may indicate an ectopic pregnancy, a pregnancy in the uterus that isn't viable, or a miscarriage.

Your provider will continue to monitor your condition closely with blood tests and ultrasounds until they can confirm the diagnosis, or your symptoms get worse.

If it remains unclear whether you've miscarried or have an ectopic pregnancy, your provider may continue to monitor your hCG level every other day or weekly to make sure it goes down. If it doesn't, you may be given a medicine called methotrexate to shrink the ectopic tissue.

To make sure they know where the pregnancy is, your provider may do a surgical procedure called dilation and curettage (D&C) to rule out that you've miscarried. Once they confirm that the pregnancy is not in the uterus, they'll provide further treatment.

Ectopic pregnancy treatment

Unfortunately, there's no way to save an ectopic pregnancy or transplant it into your uterus.

Treatment depends on whether the diagnosis is conclusive, the size of the embryo, and whether you're experiencing pain, internal bleeding, or other concerning symptoms. Treatment will involve medication or surgery.

Medication for ectopic pregnancy

If the pregnancy is clearly ectopic and early, and the embryo is still relatively small, your provider may give you the drug methotrexate. This medication is injected into a muscle and reaches the embryo through your bloodstream. It shrinks the pregnancy tissue and the tiny embryo is reabsorbed into your body over time.

Your doctor will give you directions for taking the drug, including avoiding heavy exercise, sexual intercourse, alcohol, certain vitamins (folic acid supplements), foods, and pain medications (ibuprofen). They'll provide pain medication that's safe for you to take.

As the drug begins to work, you may have abdominal pain or cramps and possibly nausea, vomiting, diarrhea, or dizziness. Your provider will monitor you carefully.

Afterward, you'll have a series of blood tests to check your hCG levels and make sure that the treatment worked. You'll continue to have this test until your level of hCG reaches zero. (This can take as long as six weeks.)

If you have any signs of shock or tube rupture during this process (see the above section on symptoms), call 911 right away.

Surgery for ectopic pregnancy

Medication is the preferred treatment, and surgical treatment isn't usually needed.

You'll only need surgery to treat an ectopic pregnancy if:

• You're too far along to get methotrexate (that's if a heartbeat can be seen in the tube and your hCG level is above 50K).
• You're in severe pain.
• You're bleeding internally.

If you're in stable condition and the embryo is small enough, it can usually be removed through laparoscopic surgery, a low-risk, minimally invasive procedure that requires only small incisions. Often your provider can remove the embryo or remaining tissue while preserving your tube. It takes about a week to recuperate after surgery.

As with drug treatment, you'll have a series of blood tests after the surgery to monitor your hCG levels and make sure that the procedure was successful.

In some cases, laparoscopy may not be an option. For example, if you have heavy bleeding, extensive scar tissue in the abdomen, or if the embryo is too large. In this case, you may need a laparotomy, an incision low down in your abdomen, like a c-section incision. This procedure requires general anesthesia.

As with laparoscopic surgery, your tube may be preserved or may need to be removed, depending on your individual situation.

Afterward, you'll need about six weeks to recuperate. You may feel bloated and have abdominal pain or discomfort as you heal. It's important to eat well and get plenty of iron if you've lost blood. (Your caregiver may recommend an iron supplement.)

Note: If your blood is Rh-negative, you'll need a shot of Rh immune globulin after being treated for an ectopic pregnancy (unless the baby's father is also Rh-negative). For more information, see our article on Rh status and why you need to know yours.

Can I have a successful pregnancy after I've had one ectopic pregnancy?

Yes. While having an ectopic pregnancy does put you at higher risk of having another one, chances are you'll have a normal intrauterine pregnancy next time. The earlier you end an ectopic pregnancy, the less damage you'll have in the affected tube and the greater chance of a future successful pregnancy. Even if you do lose one of your tubes, you can still get pregnant without fertility treatment as long as your other tube is normal.

However, if your first ectopic pregnancy was the result of tube damage from an infection or tubal ligation reversal, there's a greater chance that the other tube is damaged as well. This may reduce your chances of conceiving and increase your chances of another ectopic pregnancy. Most providers won't discourage you from trying, though, and will monitor you closely if you do become pregnant.

If you're unable to conceive naturally because of damaged tubes, you may be a good candidate for fertility treatments such as IVF.

Coping with loss after an ectopic pregnancy

You may feel devastated by your experience. You've not only just lost a pregnancy, but now it also may be more difficult for you to conceive again. You may also be recovering from major surgery, which can make you exhausted and numb, or experiencing hormonal ups and downs that leave you feeling depressed and vulnerable. You may be eager to try again, or you may be frightened and wary.

In any case, you need time to recuperate both emotionally and physically before trying to get pregnant again. When you're ready, talk with your provider about the best time to try to conceive.

Your partner may also be feeling sad or helpless and may have trouble figuring out how to express those feelings while still being supportive. This experience may bring you closer together, or it may strain your relationship. Consider counseling if you think it will help you or your partner recover. Just ask your provider for a referral if you don't have someone in mind.