What is an ectopic pregnancy?

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An ectopic pregnancy is a pregnancy where the embryo implants outside of the uterus. The most common type of ectopic pregnancy is a tubal ectopic pregnancy, where the pregnancy implants in the fallopian tube. Ectopic pregnancies will not progress normally and are at risk of rupturing.  Ectopic pregnancies happen in 1-2% of all pregnancies.

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What are the signs and symptoms of an ectopic pregnancy?

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• Missed period: At first, an ectopic pregnancy will look like a normal pregnancy. You will have a missed period, positive pregnancy test and other signs of pregnancy like nausea and breast tenderness.

• As an ectopic pregnancy grows it may cause:

  • i. Pain: Usually in the lower belly, pelvis or lower back.

  • ii. Cramping: can happen on one of both sides of the belly or lower belly

  • iii. Vaginal Bleeding: Vaginal bleeding may be light or heavy, constant or on and off.

• If you are experiencing any of these symptoms, you should seek medical attention and see your family physician, midwife, or obstetrician. If none of these options are available to you in the next one to three days, you should go to your local emergency department.

 

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Is an ectopic pregnancy dangerous?

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As the pregnancy continues to grow outside of the uterus, it may cause a fallopian tube to burst (rupture) and cause serious bleeding. This is a medical emergency and can be life threatening. If this happens, the pregnant person will require an emergency operation to stop the bleeding and remove the ectopic pregnancy. 

 

If the ectopic pregnancy is detected early, the pregnancy is small, and the fallopian tube is intact, treatment may prevent rupture and in some cases, it may be managed medically, without an operation.

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If an ectopic pregnancy ruptures, it causes more severe symptoms such as:

• i. Pain/cramping: Severe pain anywhere in the belly

• ii. Weakness, dizziness, fainting

• iii. Shoulder pain

 

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What caused me to develop an ectopic pregnancy?

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These are difficult situations, but it is important for you to know that this is not your fault.

 

There are certain risk factors that can increase the risk of ectopic pregnancy, but many people who have an ectopic pregnancy do not have any risk factors at all:

• i. Previous ectopic pregnancies

• ii. Previous pelvic or abdominal surgery

• iii. Previous sexually transmitted infections (STIs) or pelvic inflammatory disease (PID)

• iiii. Endometriosis

• v. Used of assisted reproductive technology such as in-vitro fertilization (IVF)

• vi. Cigarette smoking

• vii. History of infertility

• viii. Older age in the pregnant person (>35 years old)

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I’m experiencing bleeding/pain during pregnancy, how do I find out if I am experiencing an ectopic pregnancy?

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Your health care provider will likely perform:

• 1) A physical exam, which may include a pelvic exam

• 2) An ultrasound (a medical scan) should be performed to locate where the pregnancy is developing.

• 3) A blood test for a pregnancy hormone (beta-hCG) that may need to be repeated after two days.(48 hours)

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How are ectopic pregnancies treated?

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An ectopic pregnancy will not develop like a normal pregnancy and unfortunately, will always need to be treated or removed. There are no medications or treatments that can be used to move the pregnancy into the uterus.

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It can be treated by:

• i. Surgical management

• ii. Medical management - with medications

• iii. Expectant management - “watchful waiting” (Only safe in certain circumstances under very close guidance with a physician.)

 

The choice of what treatment to use depends on your specific case and your options will be discussed with you. Not all management options are appropriate for every person, as these options will be dependent on the size and location of the ectopic pregnancy, the level of beta hCG in the blood, and symptoms. 

 

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If medical management is an option, what kind of medication is used to treat an ectopic pregnancy?

 

A medication called methotrexate is used and is ordered by an obstetrician/gynecologist. It is given by an injection into the muscle of the arm (like a flu shot). This medication stops the cells of the pregnancy from growing and in most cases, prevents the ectopic pregnancy from rupturing. The body is able to reabsorb the pregnancy after 4-6 weeks. If this works well, surgical removal of the pregnancy or fallopian tube will not be needed.

 

However, you will not be able to use methotrexate if you are breastfeeding or have certain health problems.

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What happens after I get this medication?

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After receiving this medication, you will need very close monitoring with a gynaecologic specialist. Two follow-up beta-hCG measurements should be taken on days 4 and 7 after treatment, and then weekly until they reach zero. If the beta-hCG levels do not decrease over this time, your gynecologist may recommend another dose of methotrexate or surgery.

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What are side effects of this medication?

• Most women have some abdominal pain and vaginal bleeding/spotting after taking this medication.

• You may also experience:

  • Nausea

  • Vomiting

  • Diarrhea

  • Dizziness

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Is there anything I should avoid while taking methotrexate?

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Yes. During treatment with methotrexate you should avoid the following:

• i. Heavy exercise

• ii. Sexual intercourse

• iii. Alcohol

• iiii. Vitamins and foods that contain folic acid, including fortified cereal, enriched bread and pasta, peanuts, dark green leafy vegetables, orange juice, and beans

• v. Prescription pain medication and non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. These medications can affect the way methotrexate works in the body.

• vi. Prolonged exposure to sunlight. Methotrexate can cause sun sensitivity.

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When is surgery used to treat an ectopic pregnancy?

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If a pregnancy is too large or if the fallopian tube has burst, urgent surgical management may be considered for a tubal ectopic pregnancy.  

 

This surgery is usually done laparoscopically. Laparoscopic surgery uses a thin tools and tubes with cameras, inserted through small cuts in the belly to either remove the ectopic pregnancy from the fallopian tube (salpingotomy) or remove the entire fallopian tube (salpingectomy). Your surgeon will speak with you about possible complications and side effects of surgery and which is the appropriate operation for you. Often, the fallopian tube is removed.

 

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When is expectant management an option?

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If the ectopic pregnancy is detected very early, the gynaecologist may recommend very close monitoring, or expectant management. Expectant management is an option for pregnant people who are clinically stable, with an ultrasound diagnosis of tubal ectopic pregnancy and a decreasing beta-hCG level, at a low level detected in the blood.

 

If expectant management is chosen, close follow-up with a gynaecologist and awareness of any changes in signs or symptoms are essential to ensure your safety.

 

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Red flags?

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At any time after a diagnosis of ectopic pregnancy, if you experience any red flags (see below at bottom of page for symptoms), you should go to your nearest Emergency Department. Please make sure you tell the triage nurse that you have an ectopic pregnancy and are experiencing new and worrisome symptoms so that you can be triaged appropriately.

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Feeling down? Needing support or resources?

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People who have an ectopic pregnancy often describe feeling fear, grief, and sadness related to the unexpected loss of the pregnancy. Talk with your health care providers about these feelings, because while you may be physically recovering, an ectopic pregnancy can be very scary, at times, and can cause tremendous grief. More information about grief and pregnancy loss can be found here.

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Experiencing pregnancy loss can be very difficult for you and your loved ones. The experience is different for everyone, and yours may be different from those of your friends and family. It is important to talk to a doctor or counselor if you are feeling low or depressed following a pregnancy loss.