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Home , Ectopic pregnancy

Ectopic Ectopic pregnancy can be a very frightening and upsetting experience. This leaflet aims to explain what it is and to answer some of the most common questions about both facts and feelings. We hope this will help at what can be a very difficult time.

What is an ectopic In rare cases, the fertilised egg can pregnancy? implant in one of the , in the top corner of the , in the An ectopic pregnancy is one that (neck of the womb) or even in the develops in the wrong place (the word . It is also possible, but very “ectopic” means “out of place”.). rare, to have a pregnancy, where Around 1 in 100 in the one twin is in the correct place but UK is ectopic and for some women, one is ectopic. this can be a life-threatening condition. In this leaflet, we focus on Usually in pregnancy, a sperm and an the most common kind of egg meet in one of the two tubes (the ectopic pregnancy, which is Fallopian tubes) that connect the in the . It is ovaries to the womb (uterus). The sometimes called a “tubal fertilised egg then moves down the pregnancy”. tube into the womb where it implants, attaching itself to the womb lining and A tubal pregnancy cannot lead to the continuing to grow and develop. of a baby. The Fallopian tube cannot expand as the womb does to In an ectopic pregnancy however, a make room for a developing embryo fertilised egg implants outside of the and there is currently no way of womb, usually in one of the Fallopian transferring the early pregnancy safely tubes. to the womb.

ectopic pregnancy (pregnancy growing in the wrong place) fallopian tubes

ovary

uterus (womb) (where the pregnancy should grow)

2 Why does it happen? What happens when a pregnancy is ectopic? In a normal pregnancy, the fertilised egg takes four to five days to travel Not every case of ectopic pregnancy down the Fallopian tube from the is the same. It can be that: ovary to the womb. It implants there between six and seven days after The pregnancy stops . developing and is gradually re- absorbed back into the body, as in an With an ectopic pregnancy, the early . The ectopic fertilised egg’s journey is slowed down pregnancy resolves (ends) naturally, and it implants in the tube itself, and no further treatment is needed. before it reaches the womb. This is usually because of damage to the tube, Your doctor may not be able to tell so it gets narrowed or blocked. This whether this was an ectopic pregnancy might be due to conditions like or a very early miscarriage. It may be or pelvic infection. called a pregnancy of unknown location (PUL). There might be a problem with the walls of the tube, where tiny hairs There is a tubal miscarriage would normally “waft” the fertilised The pregnancy cannot continue egg into the womb. growing in the tube and is miscarried naturally. The tube contracts (tightens Anything that makes it harder for the and releases) to push the pregnancy fertilised egg to pass through the tube out from the tube into the abdomen. means that it might still be in the tube Your body gradually absorbs the when it is ready to implant. pregnancy tissue, but an ultrasound scan may show or fluid in your pelvis. You may need further tests and perhaps treatment. The pregnancy continues to grow , stretching the thin wall of the

tube. If untreated, the tube may

rupture (burst or tear open) and this needs to be dealt with urgently. The scan showed that the baby was in“ the tube instead of the womb. I asked if it could be moved “but was told it was impossible.

3 What are the symptoms of an ectopic I had a feeling pregnancy? something wasn’t

“quite right with

You may have had one or more of the the pregnancy and at six and a half symptoms listed below, probably “ between the fourth and tenth week of weeks I doubled your pregnancy – but sometimes there up in excruciating are no obvious symptoms. This can pain. make ectopic pregnancy difficult to diagnose, especially if you do not know or even suspect that you are • Collapse You may feel light- pregnant. headed, dizzy and/or faint. You may also have a feeling that something is Symptoms can include: very wrong. You might look very • Pain low in your abdomen , pale, have a racing pulse and feel perhaps just on one side. It might sick. start suddenly or develop gradually • No symptoms You may have and it can be constant and severe. no symptoms at all. • Shoulder-tip pain Pain where your shoulder meets your arm. This If you are or could happens if there is possibly be pregnant into your abdomen. now and you have • Irregular • or Bleeding that is different from your normal period. It may be constant • shoulder-tip pain or but light over a number of weeks • feel dizzy or faint or you may have a brown discharge or spotting. – you should seek medical advice immediately , even if you are A missed or late period • using contraception and don’t You may suspect you are pregnant think you could become and have other pregnancy pregnant. symptoms (like sickness or sore breasts). If you have any of the other • Bowel or bladder symptoms listed on this page and problems You may have your is positive, diarrhoea and perhaps ; or you should speak to your doctor pain when opening your bowels or or midwife within 24 hours. passing urine.

4 How is an ectopic – A pregnancy developing outside pregnancy diagnosed? the womb – an ectopic pregnancy. This often can’t be seen in the Ectopic pregnancy can be very difficult first weeks of pregnancy, but to diagnose. The symptoms can be might be seen later. mistaken for gastro-enteritis, irritable • Blood tests bowel syndrome, miscarriage or even Repeated after 48 hours, these are appendicitis. to measure levels of the pregnancy In hospital, unless you are extremely hormone HCG. In early pregnancy, unwell, the first steps are usually: the levels βshould double roughly A medical history every 48 hours. After a miscarriage, • they drop quite quickly. If they rise You will be asked about your slowly, or stay around the same symptoms and your pregnancy level over this time, this can mean history an ectopic pregnancy. • A pregnancy test (urine or blood) • This investigation is done under • An ultrasound scan general anaesthetic. A small camera You are most likely to have a trans- is passed through a cut in your vaginal (internal) scan, as this abdomen so the tubes can be seen provides the clearest picture in early directly. If it is clear that there is a pregnancy. It will not damage your tubal pregnancy, you will probably pregnancy. The scan could show: be treated as part of the same – A pregnancy that is developing operation. normally in the womb. You probably won’t need further treatment unless your symptoms I did not have any continue or get worse. of the typical “symptoms and – A pregnancy that seems to be failing or has died. You will only minimal pain

probably be offered an but had I not

appointment for another scan or pushed for blood tests, there is little options for treating a miscarriage “ – An empty womb. This might be a doubt that the complete miscarriage, where ectopic would have there is no need for further ruptured. treatment. But if the symptoms continue or if the scan shows other signs, such as fluid or blood in the pelvis, this finding is called a pregnancy of unknown location (PUL) and you will need further tests.

5 How is ectopic You won’t be offered this treatment if pregnancy treated? a live ectopic pregnancy is seen on the scan, in case the tube ruptures and If you are very unwell, the only safe causes internal bleeding. option may be an urgent operation to confirm the diagnosis and to stop It is also not advised if internal bleeding. • your hormone levels are higher than 1,000 and/or do not drop In most cases, though, there may be consistently several treatment options and you should have time to discuss these with • there is a large mass seen next to your doctor. We describe these over the womb the next few pages. If you do have conservative treatment, Conservative or expectant you will need repeated visits to treatment hospital to have your pregnancy This is sometimes described as hormone levels checked. Until they are “watchful waiting”. It means that you back to normal, there is still a risk that don’t have any active treatment, but your tube might rupture. are checked regularly to make sure that the ectopic pregnancy is ending naturally. I was given plenty

of information You might be offered this treatment if:

“throughout the • you are well (you have a normal process but I think pulse and blood pressure and little this was becau“ se as or no pain) an ex-nurse I knew and was not afraid • there is no sign on the ultrasound to ask. scan that the tube has ruptured • your HCG levels are less than 1,000β units/ml and • these levels continue to fall

6 Medical treatment After the injection you will need Sometimes an ectopic pregnancy can regular blood tests to measure your be treated with drugs that stop the hormone levels and check that they development of the pregnancy and are dropping. About 15% of women allow it to be re-absorbed by the need a second injection and a smaller body. number may need surgery.

The drug that is most often used is You will continue to have your and it is usually injected hormone levels checked until they into a muscle. return to normal, and this can take 4 to 6 weeks. Medical treatment isn’t suitable for everyone, and especially not if: Some women have side-effects from the treatment, such as mouth ulcers, • you are acutely unwell abdominal pain, and skin rashes. • the pregnancy is large or If you have medical treatment, you will • your pregnancy hormone levels are probably be advised to wait three high months before trying for another • you have other medical problems pregnancy, to make sure the drug is that mean you should not use out of your system before you get methotrexate pregnant again.

The advantage of medical treatment is that if it is successful, you avoid having an operation and probably won’t need to stay in hospital. If it is unsuccessful, you may still need to have an operation.

I was able to have methotrexate as the “ ectopic was caught quite

early. The injection was

fine and I had no side- effects, but I needed two lots of treatment “ and repeated blood tests before the pregnancy was over.

7

Surgical treatment

(under general anaesthetic). It was like a double This is the recommended treatment if: loss. I lost my baby “ and I lost one“ of • You are acutely unwell my tubes. It felt • There is a live ectopic pregnancy like the end of the world. • Your hormone level is very high • The diagnosis is uncertain In either operation, the doctor looks It may also be the treatment that you carefully at the Fallopian tubes and prefer. other pelvic organs. This might give an In most hospitals, the operation is idea of what caused the ectopic done by laparascopy (key-hole pregnancy, though this isn’t always surgery). This involves making two or clear. It might also help your doctor three small cuts to the abdomen so advise you about a future pregnancy. that a camera can directly show the If this is your first ectopic pregnancy, pregnancy in the tube and instruments your doctor will advise removing the can then be used to remove it. affected tube completely, with the Laparoscopic (key-hole) surgery pregnancy tissue inside. But if you have shortens the length of time you need had a previous ectopic, and especially to stay in hospital and you will recover if you have already had one tube physically more quickly than after removed, it might be possible to open surgery. remove the ectopic pregnancy from the remaining tube, and leave the tube But this might not be possible, behind. because, for example: The advantage of this second option is • you are too unwell or that you will still have at least one • you have had previous abdominal tube left. The disadvantages are that: surgery or • it increases the risk that not all the • you are very overweight or pregnancy tissue is removed and • the doctor operating is more skilled • you will need additional follow-up and experienced at performing to check your hormone levels and open rather than key-hole surgery. • there is a higher risk of a future In this case, you will have an operation tubal pregnancy. which leaves a along the pubic hair line (bikini line).

8 How long does it take After medical treatment to recover? You will need to wait for the results of your blood test on day 7 after Recovering from an ectopic pregnancy treatment. If the results show that the is different for everyone. You might hormone level is dropping and the also find that you recover physically pregnancy is resolving, you can start to fairly soon, but that your feelings return to your normal routine. about what has happened stay with you for longer. You may still have bleeding for some time, and it is best to wear pads Physical recovery: rather than tampons to reduce the risk of infection. your body Your period will not start until at least When can I go back to 4 weeks after your hormones have work or my usual reached very low levels. routine? When is it OK to start Once you are home from hospital, having sex again? you’ll probably need to take things easy for at least a few days, whatever This very much depends on how you treatment you have had. If possible, it are feeling after the ectopic pregnancy is best to return to work only when and what treatment you have had. you feel ready both physically and Medically, it is safe to have sexual emotionally. Your GP will be able to intercourse once any bleeding and provide you with a certificate (a fit discharge have stopped. note) for work. But you may want to wait longer, After surgical treatment especially if you are feeling very tired After key-hole surgery, you should and/or you are still sore or in pain. recover physically after two weeks. You might also be worried about the If you have open surgery it is likely to possibility of getting pregnant again be six weeks. (see page 13).

You should get a period about 6 to 8 weeks after your treatment, but this can take longer. The surgery wa“ s the easy part and I recovered quickly. It was the emotional recovery that was “ hardest.

9 Emotional recovery: You may have felt – or you might still your feelings feel – one or more of the following: Are my feelings normal? Perhaps you didn’t know you were Everyone is different, but many women pregnant until your ectopic was say that ectopic pregnancy is a very diagnosed. You had to cope with upsetting and frightening experience, finding you were pregnant and that it even if they weren’t planning to have a couldn’t survive all at the same time. baby. There is no right or wrong way to feel You might have been treated as an and you’ll probably find that you have emergency, with everything happening lots of ups and downs in the days, very quickly. You might have been very weeks and months after your loss. frightened, especially if you knew your

life was at risk. You may still be

The question I asked replaying those feelings of shock and everyone was when fear in your mind. “will the pain g“ o away and when will I feel Perhaps you are shocked by thoughts normal. about what might have happened – such as “What if I hadn’t been diagnosed in time?”. This can be true for your partner too.

You may feel very anxious – about what happened or about all sorts of things. And you may have difficulty sleeping. If this becomes a real problem for you, then it is probably a good idea to talk to your GP.

Everything happened so quickly

I never had time to think about

“ it until after my operation. Once I was discharged from hospital I was left feeling very “ alone with so many “what ifs” running through my head.

10 Loss and grief You may feel very sad for the loss of I’m glad I kept the your baby, and for the hopes and tube but in some “ways I feel the dreams you had for her or him. Those feelings might be very strong and last treatment made the longer than you expect. process longer. I think there was It can be very difficult if other people always a tiny hope “ don’t understand that. that the pregnancy was still viable. You may find it helps to talk to other people who have had an ectopic pregnancy (see page 15). Guilt and blame Feeling “in limbo” You might wonder whether you are If you have been treated with somehow to blame for what has methotrexate or are waiting for the happened. This may be especially true ectopic to resolve naturally, you may if you find that you have or had an feel in a kind of “limbo” for several infection, such as . weeks. It is important to know that infections It can be very upsetting to have to go like chlamydia are easily transmitted back to the hospital for repeated and often have no symptoms, so can blood tests until your hormone levels stay hidden for many years. They are are back to normal. also easy to treat.

If you have been advised to wait some You may feel angry with some of the months before trying again, you might health professionals who treated you, feel that it is even harder to recover especially if it took some time before and to begin to move forward. your ectopic pregnancy was diagnosed. You may feel that had they been more

alert or aware, you might have been

Everyone tells me spared some of what you went how lucky I am to be through. “alive. But I’ve lost “ my baby and I just You might want to talk this through feel so empty. with someone whom you feel you can trust (see page 15).

11

Your partner I was so worried The experience of ectopic pregnancy “ can put a real strain on a relationship. that I wouldn’t be “able to get pregnant It might bring you and your partner closer together but you might find again. that he or she doesn’t seem to understand how you feel and doesn’t react in the way you want or expect. It may be helpful to discuss your questions and concerns with your You may feel differently about what doctor. has happened. Your partner may focus on your health, especially if s/he saw If you had surgery for the ectopic you in pain and distress and perhaps pregnancy, your doctor should be able felt powerless to help. to tell you about the condition of your womb, tube(s) and ovaries and how Partners sometimes think they need this might affect your future fertility – to be strong and supportive, rather particularly if there is any obvious than show any feelings of loss or damage to the other tube. sadness. If you had problems getting pregnant It may just be that you deal with things this time, you may want to ask if you or express yourself differently and this can see a specialist before trying again. can lead to misunderstandings, anger and hurt, especially at a vulnerable time. Getting support Many women who have had an ectopic It may be that you do not have a pregnancy – and their partners too – partner, and feel very alone. find that it can help to talk to Anxiety about the future someone who understands what they are going through. This may be a You may worry about whether you’ll friend or relative, or perhaps a be able to get pregnant again. Or you bereavement nurse or midwife or might be frightened that if you do counsellor. become pregnant, you might have another ectopic pregnancy. You may You may prefer to talk to someone wonder whether you should try again, you don’t know personally, perhaps by or whether you even want to. phone or by using an Internet support forum. See page 15 for some We provide some information about suggestions. this on page 13.

I felt completely powerless and wasted. Vicki was terribly upset and having a lot of pain too. I w“ anted “ to rescue her or take away the pain,and I couldn’t do a damn thing except watch her cry.

12 Thinking about the In cases where the ectopic pregnancy future is associated with having an IUCD (coil), there doesn’t seem to be an What about future increased risk of another ectopic pregnancies? pregnancy if the coil is removed. The chances of having a healthy When is it best to try for pregnancy are still good after another pregnancy? treatment for an ectopic, even if your tube is removed. This will depend on the type of ectopic pregnancy you have and the You will ovulate (release an egg) as treatment you receive. before, probably once a month. And even if you have just one Fallopian If you have had surgical treatment, tube, it’s possible to get pregnant even your doctor will probably advise you when you ovulate on the opposite to wait until you have had at least one side. period before trying again. After medical treatment, you will usually be Overall about two thirds (64%) of advised to wait at least three months. women will get pregnant again naturally, while some will need help to You might want to get pregnant again do so (e.g. fertility treatment) and as soon as possible or you may find others will decide not to try again. the thought of another pregnancy very frightening. You and your partner are What are the chances that the best judges of when – or whether I’ll have another ectopic – to try again. pregnancy? The overall chance of you having another ectopic is between 7% and The next time 10% – so at most, 1 in 10. This will I fell pregnant I

“ was full of fear, depend on the kind of treatment that you had and the health of your but an early scan reassured me, remaining tube or tubes. “ showing the baby When one Fallopian tube is damaged safely in the (because of infection or scarring, for womb. example), there is a higher chance than normal that the other tube may be damaged too. This means: • That the chance of getting pregnant is less than normal • There is an increased risk of another ectopic pregnancy if you do become pregnant

13 What about contraception? Finally: If you don’t want to get pregnant, you The experience of ectopic pregnancy may want to talk to your doctor or can be extremely distressing. You may family planning clinic about what kind feel very relieved to be alive and free of contraception is best for you to use of pain, yet still feel deeply sad at the and what to avoid. After an ectopic loss of your baby and anxious about pregnancy an IUCD (coil) is not the future. recommended; and some types of -only contraception can Whatever your feelings and anxieties, increase the chance of having another you don’t have to bear them alone. ectopic. We hope that reading this leaflet has Will I need special care in my been of some help and that you can next pregnancy? use some of the resources opposite to help on your journey to recovery. The most important thing in your next pregnancy is to find out early if it is developing in the right place. So Just talking to

once you have a positive pregnancy people that

test, it is best to consult your GP so “ understand what that he or she can arrange for an I’ve been through ultrasound scan at around six to seven and how I’m feeling “ weeks. makes me feel like If you see a GP or hospital doctor I’m not alone. who doesn’t know your history, it is important to tell them about your ectopic pregnancy so they understand that an early scan is important.

It is also important to talk to your doctor if you might be pregnant and have any symptoms that might mean another ectopic: a late period, bleeding that is different from usual or any of the other symptoms listed on page 4.

If you are pregnant and an early scan shows a developing pregnancy in the womb, then you are unlikely to need any further special care or tests. You’ll be booked in for routine scans at around 12 and 20 weeks.

14 Information and Useful reading support Books: The Miscarriage Association Small Sparks of Life , by Lysanne Sizoo has a telephone helpline, a volunteer Gopher Publishers, 2001; support service, an online support ISBN 90-76953-26-0 forum and a range of helpful leaflets on pregnancy loss. Hidden Loss: Miscarriage and Ectopic Helpline: 01924 200799 Pregnancy , edited by V. Hey, C. Itzin, www.miscarriageassociation.org.uk L. Saunders and M.A. Speakman 17 Wentworth Terrace, Wakefield Women’s Press 1995, 1996; WF1 3QW ISBN 0-7043-44572 Ectopic Pregnancy Trust Other leaflets from the Miscarriage Association: provides information and support on ectopic pregnancy Men and miscarriage www.ectopic.org.uk Pregnancy loss and When the trying stops For advice on symptoms and/or your nearest hospital: Thanks NHS Direct (England & Wales) Our sincere thanks to Dr Jayne 0845 4647 Shillito, Consultant Obstetrician and NHS24 (Scotland) Gynaecologist, Leeds Teaching 08454 242424 Hospitals NHS Trust, for her help in writing this leaflet; and to everyone For a list of Early Pregnancy Units: who shared their thoughts and www.earlypregnancy.org.uk experiences with us. (Association of Early Pregnancy Units)

Need to talk to someone who understands? Call our support line on 01924 200799. Monday to Friday, 9am-4pm Or email [email protected]

15 The Miscarriage Association 17 Wentworth Terrace Wakefield WF1 3QW Telephone: 01924 200799 e-mail: [email protected] www.miscarriageassociation.org.uk

© The Miscarriage Association 2013 Registered Charity Number 1076829 (England & Wales) SC039790 (Scotland) A company limited by guarantee, number 3779123 Registered in England and Wales

EP/07/13