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It happens to more women than you may think and it can be life-threatening. Here’s how to spot the symptoms
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Ectopic pregnancy is a huge source of anxiety for pregnant women, and one of the most searched for terms in pregnancy. It’s hardly surprising, as undiagnosed ectopic pregnancies can be life-threatening as the embryo begins to grow.
A 2022 report showed that ectopic pregnancy remains the most frequent cause of maternal death in early pregnancy. An average of three women a year die from the condition in the UK and Ireland.
Here’s our guide to ectopic pregnancy symptoms, signs, risks and treatment.
An ectopic pregnancy is where the fertilised egg has implanted outside the cavity of the uterus. Ninety-five per cent of the time this is within one of the fallopian tubes, but it also occurs in the ovaries, abdomen and cervical canal. Occasionally an embryo may attach to a Caesarean scar, and 3 per cent of ectopic pregnancies are termed “interstitial”, meaning they occur in the part of the fallopian tube that crosses into the uterus.
An ectopic pregnancy cannot be saved and can be hugely traumatic. GPs and health professionals are advised by The National Institute for Health and Care Excellence (Nice) to recommend and signpost counselling to those experiencing an ectopic pregnancy.
One in 80 pregnancies is ectopic, with 12,000 women in the UK diagnosed every year, according to The Ectopic Pregnancy Trust, a charity established to raise awareness and inform and support patients and professionals. Anecdotally, the number is thought to be much higher.
There are several common misconceptions surrounding ectopic pregnancy, with much unhelpful disinformation online – for example, ectopic pregnancy is not hereditary and there is no evidence to support the ideas that it is linked to intense exercise or flying.
So what do we know? Prof Tom Bourne, a consultant gynaecologist at Queen Charlotte’s and Chelsea Hospital and the chair in gynaecology at Imperial College London, explains: “Our current understanding suggests anything that has damaged the fallopian tube or caused it not to function properly increases risk. Damage can be a consequence of previous infection or surgery, and dysfunction can be a consequence of age, smoking or, rarely, even use of emergency contraception.
“We know that endometriosis and pelvic inflammatory disease can cause both damage and dysfunction. IVF may increase the risk of ectopic pregnancy in those with pre-existing tubal damage. However, it’s important to note that for many, if not most women, ectopic pregnancies occur without any known risk factors.”
Over-35s are considered at greater risk, simply because the body has had longer in which to have incurred potential damage. But anyone capable of conceiving, who is sexually active or undergoing assisted reproduction, can suffer an ectopic pregnancy.
Consultant gynaecologist and obstetrician Shikha Kapur explains that while many patients have no identifiable risk factor, a previous ectopic pregnancy increases your risk of another. She adds: “You’re also at increased risk if you’ve had PID secondary to a pelvic infection, have had STDs such as chlamydia, or previous pelvic surgery [sterilisation, C-section or tubal reconstruction].” Assisted reproductive techniques such as IVF and having an intrauterine contraceptive device (IUD) also pose a risk.
Smokers are another “at risk” group. Research by the University of Edinburgh shows they have an increased level of the protein PROKR1 in their fallopian tubes that can hinder the progress of a fertilised egg, increasing the chances of ectopic pregnancy.
Some women don’t experience symptoms or mistake them for other issues. Kapur says it’s important to know what to look for. “The first question to ask yourself is ‘Have I missed a period?’ If the answer is yes, ectopic pregnancy is always a possibility,” she says. “An ectopic pregnancy will show up as a positive pregnancy test. Common symptoms include vaginal bleeding or spotting – this may appear different from normal bleeding in that it could be watery or brownish in colour and may stop and start, so it is sometimes mistaken for a late normal period by women not realising they are pregnant.
“It’s the same with tummy pain, which can either be low down or on one side and which may come and go – this is also sometimes wrongly dismissed as severe period pain or trapped wind by women not realising they could be pregnant. Lesser known red flags that A&E doctors are trained to spot but you should be aware of include pain or pressure when going to the toilet, diarrhoea, feeling faint or ‘shoulder tip’ pain.” The latter is an unusual pain felt at the point where your shoulder meets your arm and can be a sign of internal bleeding.
It is reassuring to learn that there are over 200 early pregnancy assessment units across the UK dedicated to caring for women with complications in early pregnancy, including ectopic pregnancy. The Association of Early Pregnancy Units’ website has a location tool to help find your nearest centre. Referrals are usually made by a GP, but some units allow self-referral.
“If you have mild symptoms but feel generally well, your first port of call should be either your GP or your local early pregnancy unit,” advises Bourne. “Early pregnancy units will carry out a scan to check the location of the pregnancy, possibly blood tests to measure the level of the pregnancy hormone hCG (human chorionic gonadotrophin) and arrange any follow-up or treatment that may be required.”
Both consultants emphasise the need to seek immediate help if symptoms worsen. “If you feel unwell, dizzy, nauseous or have shoulder tip pain, do not delay being seen,” says Bourne. “Go immediately to your nearest hospital emergency department – they can then contact the gynaecology services within that hospital for prompt review and appropriate treatment.”
Almost all ectopic pregnancies are diagnosed using an internal (transvaginal) ultrasound scan, explains Bourne. “A thin probe is inserted into the vagina in order to scan the cervix, womb, fallopian tubes and ovaries in detail. A vaginal rather than abdominal scan is used to obtain much more detailed images. In some cases (about 10-15 per cent), we will not be able to see the location of the pregnancy on the scan. This may be because the ectopic pregnancy is relatively small because the scan has been carried out very early or because the pregnancy has ended. In these circumstances, we measure levels of the pregnancy hormone hCG 48 hours apart to decide how often to arrange follow-up – and repeat scans until it is clear where the pregnancy is located.”
Once diagnosed, there are three types of treatment available, but what you will be offered will be specific to your case and will depend on the location and progression of the pregnancy. If an ectopic pregnancy is detected in the early stages, you may be offered a “watch and wait” option called “expectant management”. This means you will be monitored through blood tests to check levels of the pregnancy hormone hCG in the hope that the pregnancy dissolves by itself.
If, however, your hCG levels increase, or if you are in some pain, you could be offered medical intervention to stop the pregnancy growing and prevent the body from maintaining it. You’ll be given an injection of a drug called methotrexate, usually into the muscle of your buttocks. The pregnancy tissue is then reabsorbed by the body.
If you develop significant pain, or if doctors are concerned about internal bleeding, you are likely to be offered laparoscopic (keyhole) surgery to remove the pregnancy – with the affected fallopian tube sometimes having to be removed at the same time. If the ectopic pregnancy is more complex – for example, not in the fallopian tube – there is a chance you could need open surgery.
Most women recover relatively quickly after treatment. Following non-surgical management, the ectopic pregnancy mass is soon reabsorbed, while after surgery, women usually require two to six weeks to physically heal. However, there are serious implications.
“Having an ectopic pregnancy increases the risk of having another in the future due to fallopian tube damage from scarring,” says Bourne. “There may also be a slight reduction in fertility following expectant or medical management, but the previously affected fallopian tube may still function well. Operating on or removing a tube does reduce fertility – although data is not clear cut and this is thought to be by more like 30 per cent than 50 per cent.”
The psychological impact of such a pregnancy loss is profound. “Ectopic pregnancy has a huge impact, so we refer couples to The Ectopic Pregnancy Trust, and we advise seeing their GP for a follow-up and to talk through fears around getting pregnant again,” says Shakur. “A GP should also signpost counselling services for long-term support.”
“Critically we know that a significant proportion of women suffer from anxiety and depression following miscarriage and ectopic pregnancy, with post-traumatic stress the most problematic and persistent issue,” says Bourne. “We are working hard as a research group to better support these women and investigate potential screening treatment strategies.”
If you are worried about an ectopic pregnancy, have symptoms or pain, or need urgent advice or care, contact your GP, call NHS 111 or go to your nearest hospital A&E department. For non-urgent and comprehensive information and advice around ectopic pregnancy, visit The Ectopic Pregnancy Trust.
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