What is an ectopic pregnancy, where does it occur, and how dangerous is it? In this article, we explain the potential causes, risk factors, symptoms, and treatment approaches for ectopic pregnancy.

What is an ectopic pregnancy, where does it occur, and how dangerous is it? In this article, we explain the potential causes, risk factors, symptoms, and treatment approaches for ectopic pregnancy.

What is an ectopic pregnancy?

An ectopic pregnancy is when a fertilised egg (ovum) implants outside the uterus. In 90% of cases, this happens in the fallopian tube, known as a tubal pregnancy, but 10% of cases are reported in the cervix, ovary, outer layer of the uterus, the space between the uterus and fallopian tube, abdominal cavity, and even within cesarean scar tissue.

Ectopic pregnancy is estimated to affect 1–2% of all reported pregnancies; however, a lack of data on cases in developing countries may mean this value is underestimated. It can be a life-threatening condition and one of the leading causes of fetal and maternal death within the first trimester, but most cases are low risk.

In recent years, the incidence has increased, but this is suggested to be due to more awareness of the condition and more medical advances for early detection. In addition, in recent decades, an increase in sexually transmitted infections has contributed to an increased risk of ectopic pregnancy, as has the increased use of assisted reproductive technology (ART).

Is it a form of miscarriage?

The term 'miscarriage' is defined as the spontaneous death of an embryo or fetus before it is able to survive independently, usually before the 20th week of pregnancy.

Ectopic pregnancy also involves the loss of the embryo or fetus, either spontaneously or by assisted means. It therefore is a form of pregnancy loss. If the ectopic pregnancy resolves on its own (usually in the very early phase), the embryo will break down and come away as a miscarriage, leaving the mother and doctor unaware that it was an ectopic pregnancy. However, if the pregnancy continues, more medicated or surgical methods are needed to remove the ectopic pregnancy.

The main difference is that an ectopic pregnancy can be fatal, due to embryo growth rupturing the fallopian tube leading to severe internal bleeding; for this reason, an ectopic pregnancy requires emergency medical assistance. In the US, it is estimated that ruptured ectopic pregnancies account for 2.7% of pregnancy-related deaths. Miscarriages are not usually fatal for the mother and are often due to genetic or severe developmental abnormalities which do not allow the fetus to survive, so that it dies within the uterus.

Causes of ectopic pregnancy

It is still unknown why an ectopic pregnancy arises. Normally, fertilisation occurs in the fallopian tube and the embryo subsequently travels down the tube towards the uterus, where it implants into the uterine lining (endometrium). An ectopic pregnancy occurs when this process is disrupted; the embryo doesn’t travel to the uterus and implants in the fallopian tube instead. Often the causes of an ectopic pregnancy involve problems with the embryo itself or the fallopian tubes. There are several factors that can cause it to happen, but half of women who experience an ectopic pregnancy have no known cause of why it happened. Some known causes are:

  • Blocked, narrowed or damaged fallopian tubes can be caused by sexually transmitted diseases (e.g. Chlamydia), pelvic or abdominal surgery, peritonitis, or endometriosis.
  • Hormonal imbalances can cause abnormalities in the developing fertilised egg or prevent it from moving along the fallopian tube to the uterus.
  • Contraception failure. Ectopic pregnancy has been reported in women whose contraception method has failed, such as an intrauterine device (IUD), progestin-only oral contraceptive, and tubal ligation (sterilization). However, exactly how often this happens is unknown. The chance of ectopic pregnancy in emergency contraceptive pill use is 0.6–1%, similar to the rate in the general population; therefore, this option doesn’t cause ectopic pregnancy.
  • A misshapen uterus can impair normal functioning and promote ectopic pregnancies.

Risk factors

In recent years, more awareness and research into the factors that could increase the risk of developing an ectopic pregnancy have come to light. Some known risk factors include:

  • History of ectopic pregnancy - there is a 5–25% risk of recurrence, and this risk is not apparently affected by how the previous ectopic pregnancy was treated.
  • Age >35 years
  • Previous spontaneous or induced abortion
  • Damage to fallopian tubes. Due to previous tubal surgery (female sterilization), pelvic surgery (caesarean section and ovarian cystectomy), abdominal surgery (appendicectomy or bowel surgery), genital infection and pelvic inflammatory disease caused by a sexually transmitted infection e.g. chlamydia.
  • Contraceptive failure. Pregnancy occurring while using an IUD or the use of progesterone-only contraceptive pill.
  • Infertility – known causes of tubal disease, endometriosis, and unexplained infertility.
  • Fertility treatment. Assisted reproductive technology (ART) can increase the risk of ectopic pregnancy but depends on the type of procedure, the woman’s reproductive health status, and the estimated embryo implantation potential. One study of nearly 95,000 ART pregnancies showed that 2.1% were ectopic.
  • Smoking

Symptoms

Initially, the symptoms of an ectopic pregnancy mimic that of a normal pregnancy, with a missed period, fatigue and nausea being common. However, early signs of problems include:

  • Vaginal bleeding
  • Pelvic pain, which could be on one side, and cramping
  • Shoulder pain
  • Urge to defecate
  • Feeling light-headed or dizzy, potentially due to low blood pressure

If left untreated, the fallopian tube can rupture due to a build up of pressure and lead to severe bleeding. Emergency medical treatment is required. If you have any of these symptoms, speak immediately with your doctor.

Diagnosis

A thorough medical assessment of your condition is essential to diagnose, reduce the risk of rupture, and improve treatment success. Until a full diagnosis is made, a doctor will closely monitor you, especially if you are suffering from vaginal bleeding with or without abdominal pain. The doctor will perform the following:

  • Pregnancy test – to confirm the pregnancy. Even if it is ectopic, the test will be positive. However, this doesn’t confirm the location of the embryo.
  • Pelvic examination
  • Transvaginal ultrasound – to visualise the uterus, ovaries and the developing embryo. The ultrasound can localise if the embryo is in the uterine cavity; this can be detected usually between 5 and 6 weeks of pregnancy. The doctor may perform multiple scans to monitor the pregnancy, but these are often done in combination with serial blood tests and potentially a uterine aspiration.
  • Blood tests – are usually performed alongside the ultrasound to check for human chorionic gonadotropin (hCG) levels (a hormone produced by the growing embryo after implantation). This test may be repeated several times to see how the levels change with the pregnancy and treatment. A slower than expected rate of increase or a decrease of hCG levels suggests loss of early pregnancy or an ectopic pregnancy.
  • Pregnancy of unknown location – if the ultrasound cannot locate an intrauterine or ectopic pregnancy, but a woman is still testing positive on a pregnancy test, the pregnancy is classed as a pregnancy of unknown location. The doctor will continue to monitor and do further tests, such as serial hCG levels every 24 hours and uterine aspiration.

Outcomes

Ectopic pregnancies can often resolve by themselves as the body detects the problem and aborts the pregnancy. It will result in a miscarriage, or the reabsorption of the embryo by the body.

Ectopic pregnancies will not survive past a few months, and it is not possible to save the pregnancy. This is why treatment is often required if it doesn’t resolve itself.

Managing an ectopic pregnancy: Treatment

Treatment is essential, and in some instances, it is a medical emergency. Treatment will be tailored to your current status once the doctor thoroughly evaluates and diagnoses an ectopic pregnancy. Principally, there are non-surgical and surgical approaches.

Non-surgical approach

Non-surgical approaches cover the expectant management method – a wait-and-see approach, which includes close monitoring (essential to monitor whether the pregnancy continues and if there is a risk the embryo will rupture the tube) to see if the ectopic pregnancy will resolve itself. This option is rare and available for low-risk women, who have none of the above risk factors. Close follow-up will be required.

Alternatively, another common treatment is to medically manage the ectopic pregnancy with an intramuscular injection of the drug methotrexate – a drug administered either as single, double or multiple doses. Methotrexate is a folic acid antagonist and stops the embryo from developing by preventing the cells from dividing, resulting in the pregnancy being aborted, and eventually, reabsorbed by the body. One or two doses are usually enough, and surgery is not required. It is also suitable for ectopic pregnancies that are located in the cervix or cesarean scar. The doctor will do another ultrasound to confirm the embryo is no longer there or test on various days after treatment for hCG levels (declining levels mean the pregnancy has been aborted).

Surgical approaches

In high-risk cases, where a woman is experiencing signs of a ruptured ectopic pregnancy (vaginal and internal bleeding, low blood pressure, extreme pain), or if methotrexate hasn’t worked, or if there is fetal cardiac activity outside of the uterus, surgical management is required.

Laparoscopic surgery (keyhole surgery) or open surgery is required to remove the ectopic pregnancy from the fallopian tube (also known as a salpingostomy) and if need be, remove the part of the fallopian tube where the pregnancy is implanted (also known as a salpingectomy). Laparoscopy involves making several incisions in the abdomen to access the pelvic region and insert the appropriate instruments to perform the procedure. It is done under general anaesthesia.

Recovery

You must allow your body time to recover from the ectopic pregnancy and any intervention you’ve had to remove the pregnancy. Your doctor will offer you a care plan, which will include taking time to rest and guidelines for wound care if you underwent surgery.

Future pregnancies

Many women who experience an ectopic pregnancy can have a normal pregnancy afterward. How you were treated for the previous ectopic pregnancy (methotrexate or laparoscopic fallopian tube surgery) does not affect the rates of future intrauterine pregnancy or increase the risk of future ectopic pregnancy.

It is advised to wait a few months after the ectopic pregnancy before trying to conceive again, allowing your body and reproductive organs to recover.

Emotional support and therapy

Losing a pregnancy is a traumatic experience, especially if the pregnancy leads to a surgical intervention to remove the fetus. You will feel a mix of emotions, from sadness and loss to anger and confusion. It is completely normal. Your body will still be responding to your hormones fluctuating from the pregnancy.

It is important to have a support network around you—your partner, friends and family—who understand what you’ve gone through and to seek counselling or psychological therapy to deal with the loss and situation. Discuss this with your doctor and healthcare team.

Take home message

Ectopic pregnancy occurs in 1–2% of pregnancies. Medical treatment is usually required, and a dedicated healthcare team should follow you until the pregnancy is resolved. If you suspect an ectopic pregnancy or are trying to conceive after suffering from one, it is essential to understand the risk factors mentioned and discuss everything with your specialist doctor. They will monitor you closely in the initial stages of the pregnancy.

Subsequent pregnancies after an ectopic pregnancy are often normal and go full-term without complications, but a small increased risk of it occurring again does exist, and your doctor will monitor you to ensure you have a healthy pregnancy.

If you have any concerns or questions about ectopic pregnancy or are trying to conceive after suffering one, contact our compassionate team of fertility experts who can assist you on your pregnancy journey. Reserve your spot for a free consultation today.