Ectopic pregnancy | Hapūtanga i waho i te kōpū

The word ectopic means “not in the right place”. A pregnancy is meant to be in your uterus, but it can grow in other places. Your fallopian tube is the most common place for an ectopic pregnancy. However, in rare cases, an ectopic pregnancy can grow in other places, such as the junction of a fallopian tube and your uterus, your cervix, in the scar from a previous caesarean section or even outside your uterus completely.

When a pregnancy grows in the wrong place it will eventually cause bleeding inside your pelvic cavity. Unfortunately, even though it can be very heavy and dangerous, at first you won’t know you are bleeding.

Damage to the fallopian tube

Most ectopic pregnancies occur in the fallopian tube. If your tube is damaged, the fertilised egg can get trapped in the tube and start growing there. Damage to the fallopian tube usually occurs after infection, but it can also be caused by endometriosis or pelvic surgery.

Contraception

Most forms of contraception protect against both normal pregnancy and ectopic pregnancy, but some types of contraception are better at preventing normal pregnancy than ectopic pregnancy, for example, the IUCD.

IUCDs

IUCD stands for intrauterine contraceptive device. There are two main types of IUCD. They are hormonal IUCDs and copper IUCDs. Older types of IUCDs that may have increased the risk of tubal infection and ectopic pregnancy are no longer used in New Zealand.

• Hormonal IUCDs, such as Mirena, are very effective at preventing both normal pregnancy and ectopic pregnancy. They also decrease the amount of bleeding you have with your period, but they are more expensive than copper IUCDs.
• Copper IUCDs are good at preventing normal pregnancy but not as good at preventing ectopic pregnancy; however, they do not cause ectopic pregnancy.

Lower abdominal pain and vaginal bleeding are the two most important symptoms that occur with an ectopic pregnancy. These are often the only symptoms you have. Many women do not realise they are pregnant because they have irregular periods, or think the bleeding from an ectopic pregnancy is a period.

You are less likely to have or notice pregnancy symptoms such as morning sickness, because the amount of pregnancy hormone with an ectopic pregnancy is less than with a normal pregnancy.

Fainting, giddiness and shoulder tip pain may occur because of bleeding inside your pelvic cavity. These are important symptoms because it means you have already had quite a lot of bleeding.

Examination

Your doctor will need to perform a gentle tummy and internal examination if he or she thinks you have an ectopic pregnancy. Your GP will also check your blood pressure and decide what investigations are needed.

Investigations

Pregnancy test

If you have lower abdominal pain and vaginal bleeding, a pregnancy test should be performed even if you are taking contraception and don’t feel pregnant.

• A urine test is usually good enough to exclude a pregnancy and can be easily done by your GP.
• If the urine pregnancy test is positive then a blood pregnancy test is done. This will measure the amount of pregnancy hormone called bHCG.
• At the same time, your doctor may also do the routine pregnancy blood tests that are performed at the beginning of a pregnancy.

Ultrasound

Ultrasound is a very good way of identifying that a pregnancy is in the right place. A pregnancy inside your uterus can be seen by a transvaginal ultrasound scan at 5 weeks from your last period. It is very rare for an ectopic pregnancy to cause heavy bleeding before 6 weeks, so if you are more than 5 or 6 weeks from your last period and there is no pregnancy seen inside your uterus, you almost certainly have an ectopic pregnancy. If you are not sure how pregnant you are, the bHCG level can be used to estimate how far on the pregnancy should be.

Conservative therapy

When a pregnancy is very early it may be necessary to wait and see where the pregnancy is and whether it could be a normal early pregnancy. This is called a pregnancy of unknown location (PUL).

If your doctors think there might be an ectopic pregnancy, but decide to wait to be sure, it is important that you have an emergency phone number you can call at any time and that you are not too far from a hospital in case the ectopic pregnancy does cause bleeding.

Medical treatment

Methotrexate is a type of chemotherapy that will stop an early pregnancy from growing. Methotrexate is safe in the doses given for an ectopic pregnancy, but not every woman is suitable for this treatment. It is important that you have a phone contact and are not too far from a hospital. Methotrexate works well for most women but about 1 in 5 women will still need surgery to remove the ectopic pregnancy.

Surgery

If the ectopic pregnancy is too far advanced, or if there are already signs of bleeding, then surgery will be required. This is usually done by a surgical technique called a laparoscopy where a special telecscope is passed through your stomach wall. Sometimes a cut low down on your bikini line is needed. This is called a laparotomy. The recovery time from a laparoscopy is much quicker than a laparotomy.

During this operation, the damaged tube may be removed. Your surgeon will normally discuss the surgery beforehand but may not know for sure what will need to be done until after the surgery has started and the condition of the tube examined.

Most women will still be able to have a normal pregnancy after an ectopic pregnancy even if one of the fallopian tubes has been removed. However, if you have been trying to get pregnant for more than 6 months after having an ectopic pregnancy, you should go and see your doctor as you may need fertility treatment. Studies have shown that the chances of having a successful pregnancy are not decreased if the tube is removed compared to just removing the pregnancy from the tube.

Losing a pregnancy can be very upsetting, even if the pregnancy is early. You may experience all sorts of negative feelings after an ectopic pregnancy. This may not happen for a few weeks or even months after losing the pregnancy. Most hospitals can provide information about miscarriage support groups.

• Practice safe sex. sexually transmitted infection is the main cause of damage to the fallopian tubes, which can lead to an ectopic pregnancy.
• Quit smoking. Smoking increases the risk of ectopic pregnancy.

Learn more

Ectopic pregnancy National Women’s Health, Auckland District Health Board, NZ, 2015

Related topics

Pregnancy | Tiaki hapūtanga
Miscarriage | Whakatahe
Smoking and pregnancy
Overview of contraception methods | Rongoā ārai hapūtanga

Consider an ectopic pregnancy in all women with a history of amenorrhoea or a positive pregnancy test with abdominal pain and/or vaginal bleeding.

If suspected ectopic pregnancy, request acute early pregnancy assessment.

First trimester ultrasound(external link) Kosar Kamal, 2016

Continuing professional development

Early Pregnancy Problems Webinar - Dr Kate Coffey

(Mobile Health, NZ, 2020)