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A Pregnancy in the wrong location

Roughly, 1 in 80 pregnancies will occur outside of the uterus. A fertilised egg in a normal pregnancy will implant itself into the wall of the uterus. In ectopic pregnancies, 98% of the time it mistakenly implants itself into the part of the fallopian tube known as the ampulla. (1)

Rarely, it can implant onto the other areas of the fallopian tube, ovaries, cervix, abdomen or caesarean section scars. Sadly, ectopic pregnancies are not viable, meaning that they can’t survive in any place besides the uterus as the environment is not suitable. 

Figure 1 – Ectopic pregnancy – Wikipedia

In very rare cases, 1 in 30,000 women (2), there may be one fertilised egg in the uterus and another outside the uterus. There is a 1% chance of this occurring in In-vitro fertilisation, where more than one fertilised egg is transferred. (3)

Is it preventable?

Several risk factors can increase the risk, such as:

    • Any previous damage to your tubes e.g. from surgery or infection (e.g. from sexually transmitted diseases)
    • Previous ectopic pregnancy 
    • Endometriosis
    • Older age 
    • Smoking
    • If pregnant despite being on the coil or mini-pill
    • Assisted conception such as in-vitro fertilisation
    • However, 1 in 2 have no risk factors at the time of an ectopic pregnancy.

 

How will I know if I have an ectopic pregnancy?

Initially, it may present very similarly to a normal pregnancy e.g. missed period, feeling sick, vomiting, tender breasts etc. 

Symptoms of ectopic pregnancy usually arise 6-8 weeks of pregnancy, which may include: 

    • Pain in the lower belly – usually constant and may feel crampy, can be one-sided
    • Vaginal bleeding – usually less than a normal period, and brown
    • Pain in your shoulder tip or when going to the toilet – this is rare and usually presents if the pregnancy is in the abdominal space

 

Why is an ectopic pregnancy dangerous?

There is a low threshold for suspecting ectopic pregnancy when women of child-bearing age present to A&E with abdominal pain and/or vaginal bleeding. The reason is that although rare, the ectopic pregnancy may cause your tube to rupture if not treated quickly, which can lead to life-threatening bleeding. Signs of rupture may include dizziness, fainting and sickness. Therefore, if you experience any of these symptoms, especially if you know you are pregnant, get it checked out by a doctor immediately in A&E.

What can I expect in A&E?

In many cases, women may present without knowing that they are pregnant. In these situations, doctors ask sensitive questions to assess the likelihood of being pregnant and examine your tummy for any tenderness. To test for pregnancy, they will check the hormone hCG in your blood. A transvaginal ultrasound is used to check the location of the ectopic pregnancy. In 40% of cases, the doctors might not be able to find where the pregnancy is located. hCG is then used to guide diagnosis and treatment. 

How are ectopic pregnancies managed?

As ectopic pregnancies are not viable, they will need to be terminated. There are 3 options, which depend on the symptoms and ultrasound findings:

    • Awaiting natural termination of pregnancy
      • Preferred in cases where there is no significant pain and no fetal heartbeat.
      • It is important that follow up is attended, as the hCG hormone is checked 48 hours after to see if it’s declining.
    • Using medication to hasten the termination  
      • If hCG levels are higher than normal and/or there are distressing symptoms, a drug called methotrexate injection can be used. 
      • It is teratogenic, meaning it disturbs the growth of the embryo.
      • Yet again, follow-up is needed weekly until hCG levels are undetectable. 
      • As with all drugs, methotrexate comes with its side effects e.g. vaginal bleeding, nausea, vomiting, abdominal pain, sensitivity to light etc. 
      • It is important to avoid the sun during this period, and not get pregnant for at least 3 months (to ensure your system is clear of the medication.)
    • Surgically removing the ectopic pregnancy 
      • Surgery may be preferred in cases where there is;
        • Significant pain 
        • Signs of OR high risk of rupture 
        • Fetal heartbeat on ultrasound
        • Very high levels of hCG
        • There is another pregnancy inside the uterus
      • Surgery usually involves the removal of the tubes along with the ectopic pregnancy, under general anaesthetic.
      • However, if the other tube is damaged because of known causes, it may not be removed to maintain fertility. If the tube is kept, there is a ⅕ chance that further treatment will be needed.

 

Experiencing an ectopic pregnancy can be both physically and emotionally distressful, therefore it is important to be kind to yourself and allow others to support you during this period. If you are struggling, there are counselling services and support groups available through the NHS – Ectopic pregnancy – NHS.

References:

      1. Sivalingam VN, Duncan WC, Kirk E, Shephard LA, Horne AW. Diagnosis and management of ectopic pregnancy. Journal of Family Planning and Reproductive Health Care [Internet]. 2011 Jul 4;37(4):231–40. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3213855/
      2. Ludwig M, Kaisi M, Bauer O, Diedrich K. Heterotopic pregnancy in a spontaneous cycle: do not forget about it! European Journal of Obstetrics & Gynecology and Reproductive Biology. 1999 Nov;87(1):91–3.
      3. Habana A, Dokras A, Giraldo JL, Jones EE. Cornual heterotopic pregnancy: Contemporary management options. American Journal of Obstetrics and Gynecology. 2000 May;182(5):1264–70.

 

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