Ectopic pregnancy
By the BabyCenter editorial staff

Reviewed by Natan Haratz-Rubinstein, M.D. and Ann Linden, CNM
September 2005

What is an ectopic pregnancy?
If a fertilized egg implants outside the uterus, it's called an ectopic pregnancy. One in 50 pregnancies ends this way.

Here's how it happens: After conception, the fertilized egg travels down your fallopian tube on its way to your uterus. If the tube is damaged or blocked and fails to propel the egg toward your womb, the egg may become implanted in the tube and continue to develop there. Because almost all ectopic pregnancies occur in one of the fallopian tubes, they're often called "tubal" pregnancies.

Much less often, an egg implants in an ovary, in the cervix, directly in the abdomen, or even in a c-section scar. In rare cases, a woman has a normal pregnancy in her uterus and an ectopic pregnancy at the same time. This is called a heterotopic pregnancy and it's more likely to happen if you've had fertility treatments, such as in-vitro fertilization.

There's no way to transplant an ectopic (literally, "out of place") pregnancy into your uterus, so ending the pregnancy is the only option. In fact, if an ectopic pregnancy isn't recognized and treated, the embryo will grow until the fallopian tube ruptures, resulting in severe abdominal pain and bleeding. It can cause permanent damage to the tube or loss of the tube, and if it involves very heavy internal bleeding that's not treated promptly, it can even lead to death. Fortunately, the vast majority of ectopic pregnancies are caught in time.

How can I tell if I'm at risk for an ectopic pregnancy?
An ectopic pregnancy can happen to any sexually active woman, but certain women are more at risk than others. Your odds of having an ectopic pregnancy are higher if:

• You get pregnant despite having had a tubal ligation (surgical sterilization).

• You've had surgery on your fallopian tubes to correct a problem or to reverse a tubal ligation. (Your risk is also higher, though to a much smaller degree, if you've had other pelvic or abdominal surgery, such as the removal of an ovarian cyst or fibroids, an appendectomy, or a cesarean section.)

• You had a previous ectopic pregnancy.

• Your mother took the drug DES while pregnant with you.

• You have an intrauterine device (IUD) in place when you get pregnant. Although IUDs are close to 99 percent effective at preventing pregnancy, if you do get pregnant while using one, it's more likely that the pregnancy will be ectopic. An IUD doesn't cause an ectopic pregnancy, it's just better at preventing an egg from implanting in your uterus than outside it. (Having used an IUD in the past won't raise your risk for ectopic pregnancy.)

• You're taking progestin-only hormonal contraceptives when you get pregnant. As with an IUD, taking these pills doesn't increase your risk for an ectopic pregnancy, but if you do get pregnant while taking them, the likelihood that it will be ectopic is higher than usual.

• Your tubes were damaged by an infection in your upper reproductive tract (this is called pelvic inflammatory disease or PID). PID is often caused by untreated sexually transmitted infections (STIs) such as gonorrhea or chlamydia. It sometimes has no symptoms, so having had either of these STIs also increases your risk for an ectopic, even if you don't think you've had PID.

• You're being evaluated or treated for infertility. Infertility is often caused by damaged tubes, and if you get pregnant while being treated for infertility, there's a higher than average chance that the pregnancy will be ectopic.

Older women also have higher rates of ectopic pregnancy. And a few studies suggest you may also have a slightly increased risk for ectopic pregnancy if you smoke cigarettes or douche regularly.

What symptoms may indicate an ectopic pregnancy?
Ectopic pregnancies are usually discovered when a woman has symptoms at about six or seven weeks, though you may notice symptoms as early as four weeks. In some cases, there are no symptoms and the ectopic is discovered during a first trimester ultrasound.

Symptoms can vary greatly from person to person, and depending on how far along you are and whether the ectopic pregnancy has ruptured — a true obstetric emergency. To prevent rupture, it's critical to get diagnosed and treated as soon as there's even a hint of a problem, although sometimes rupture occurs without much advance warning. Ectopic pregnancies don't always register on home pregnancy tests, so if you suspect there's a problem, don't wait for a positive pregnancy test to contact your caregiver.

Call your practitioner immediately if you have any of the following symptoms:

• Abdominal or pelvic pain or tenderness. It can be sudden, persistent, and severe but may also be mild and intermittent early on. You may feel it only on one side, but the pain can be anywhere in your abdomen or pelvis and is sometimes accompanied by nausea and vomiting.

• Vaginal spotting or bleeding. If you're not sure you're pregnant yet, you may think you're getting a light period at first. The blood may look red or brown like the color of dried blood, and may be continuous or intermittent, heavy or light.

• Pain that gets worse when you're active or while moving your bowels or coughing.

• Shoulder pain. Cramping and bleeding can mean many things, but pain in your shoulder, particularly 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.

• If a fallopian tube has ruptured, you may also have signs of shock, such as a weak, racing pulse; pale, clammy skin; and dizziness or fainting. In that case, call 911 without delay.

How is it diagnosed?
Ectopic pregnancy can be tricky to diagnose. If your symptoms suggest this type of pregnancy, your caregiver will do several tests to try to confirm the diagnosis:

• A blood test to check your level of the pregnancy hormone human chorionic gonadotropin (hCG). If it's high enough to suggest pregnancy, but not as high as it should be at your stage, the pregnancy may be ectopic. If you're not in pain and there's still some question about the diagnosis, the test may be repeated in two to three days. If your hCG level doesn't increase as it's supposed to, this probably indicates either an ectopic pregnancy or a miscarriage.

• A vaginal exam. If the vaginal area is very tender or your caregiver detects a mass or an enlarged fallopian tube, an ectopic is likely the cause.

• An ultrasound. If the sonographer can see an embryo in the fallopian tube, you definitely have an ectopic pregnancy. But in most cases, the embryo will have died early in the process and be too small for the sonographer to find. Instead, she may notice that a fallopian tube is swollen, and may see blood clots as well as tissue that remains from the embryo.

If a pregnancy test is positive but the embryo (or evidence of an embryo) can't be found, you may have an ectopic pregnancy — but it's also possible that the pregnancy is still in the very early stages or that you have miscarried. As long as you're not in pain, your caregiver will continue to monitor you very closely through hormone tests and ultrasounds until she can confirm the diagnosis or your symptoms become more severe.

If the diagnosis remains unclear, your tubes may be examined more closely by using laparoscopic surgery, a procedure that may also be used to treat an ectopic pregnancy and remove the embryo (see below).

How is it treated?
That depends on how clear the diagnosis is, how big the embryo is, and what techniques are available.

If the pregnancy is clearly ectopic and the embryo is still relatively small, you may be given the drug methotrexate. The drug is injected into a muscle and reaches the embryo through your bloodstream, where it ends the pregnancy by stopping the cells of the placenta from growing. (Over time, the tiny embryo is reabsorbed into your body.) As the drug begins to work you may have some abdominal pain or cramps and possibly nausea, vomiting, and diarrhea.

You'll need to avoid alcohol and sex for a while, as well as any multivitamins or supplements that contain folic acid, which can interfere with the action of the methotrexate. And you'll need to come back in for blood testing to make sure that the pregnancy has really been terminated because it doesn't always work. If you experience any signs of rupture (such as severe abdominal pain, heavy bleeding, or signs of shock) during this process, call 911 right away.

If you're too far along for methotrexate to be used, you're in severe pain or bleeding internally, or you're breastfeeding or have certain health conditions that make the medication a bad choice, you'll need surgery. (If you're bleeding heavily you may need a blood transfusion as well.)

If you're in stable condition and the embryo is small enough, it can be removed through a procedure called laparoscopic surgery. An ob-gyn can examine your tubes with a tiny camera inserted through a small cut in your navel and can often remove the embryo or remaining tissue while preserving your tube. (However, if there's extensive damage to the tube or you're bleeding profusely, the tube may need to be removed.) Laparoscopic surgery requires general anesthesia, special equipment, and a surgeon experienced in the technique, and you'll need about a week to recuperate.

In some cases — for example, if you have extensive scar tissue in the abdomen or heavy bleeding, or the embryo is too large — it may not be possible or expedient to use laparoscopic technology. If this is the case, you'll need major abdominal surgery. You'll be given general anesthesia and an ob-gyn will open your abdomen and remove the embryo. (As with laparoscopic surgery, your tube may be preserved or may need to be removed, depending on the situation.) Afterward, you'll need about six weeks to recuperate. You may feel bloated, and have abdominal pain or discomfort as you heal.

Note: If your blood is Rh-negative, you'll need a shot of Rh immunoglobulin after being treated for an ectopic pregnancy (unless the baby's father is also Rh negative).

Can I have a successful pregnancy after I've had an ectopic one?
Yes. The earlier you end an ectopic pregnancy, the less damage you'll have in that tube and the greater your chances will be of carrying another baby to term. And even if you do lose one of your tubes, you can still have a normal pregnancy as long as your other tube is normal. If and when you do conceive again, call your health practitioner as soon as you suspect that you might be pregnant so that she can schedule you for an early sonogram and monitor you closely.

If, on the other hand, you're unable to conceive because of ectopic pregnancies or damaged tubes, the good news is that you're likely to be an excellent candidate for fertility treatments such as in vitro fertilization (IVF), in which your healthy embryos are implanted directly in your uterus.

What are my chances of having another ectopic pregnancy?
Overall, your chances of having another ectopic pregnancy are about 10 to 15 percent, depending on what caused the first one and what type of treatment you had. That means that your overall chances of having a normal pregnancy next time are still very high — about 85 to 90 percent. However, if your first ectopic pregnancy was the result of damage to the tube from an infection, tubal ligation, or DES exposure, 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.

How can I deal with my sense of loss?
You may feel devastated by your experience. You've just lost a pregnancy and it may now be more difficult for you to conceive again. You may also be recovering from major surgery, which can leave you exhausted and numb, or suffering from hormonal ups and downs that can leave you feeling depressed and vulnerable. You'll need time to recuperate emotionally and physically before trying for another baby. Most caregivers will advise you to wait at least three months after major abdominal surgery for your body to heal. (Your risk of having another ectopic is also higher while you're healing.) You may be eager to try again, or you may be frightened and wary.

Your partner may also be feeling sad or helpless and may have trouble figuring out how to express those feelings or how to be supportive. This experience may bring you closer together or it may strain your relationship. It's perfectly okay to seek counseling if you think it will help you or your partner recover.