Ectopic Pregnancy

What an ectopic pregnancy is

An ectopic pregnancy is a pregnancy that implants and grows outside the uterus. The RCOG describes it plainly: "An ectopic pregnancy is one that grows outside the uterus (womb)... A pregnancy cannot survive in these situations and it can pose a serious risk to you."

Most are in a fallopian tube. The RCOG notes that in a small minority — around 3 to 5 out of every 100 ectopic pregnancies — the pregnancy sits somewhere else, and its leaflet illustrates those non-tubal sites. Treatment for those is decided case by case rather than from a standard protocol.

It is not rare. Both the NHS and the RCOG put the figure at about 1 in every 90 UK pregnancies, which the NHS translates to roughly 11,000 pregnancies a year.

Nothing you did caused it, and nothing can move the pregnancy to the right place. That second point is the one people most often ask about, and it is worth stating without softening: there is no procedure anywhere that relocates an ectopic pregnancy into the uterus.

The symptoms, including the ones that get missed

NICE tells clinicians two things up front: "atypical presentation for ectopic pregnancy is common", and ectopic pregnancy "can present with a variety of symptoms. Even if a symptom is less common, it may still be significant."

The symptoms NICE lists as common are abdominal or pelvic pain, a missed period, and vaginal bleeding with or without clots. The ones it flags as also reported, and which are far more easily dismissed, are breast tenderness, gastrointestinal symptoms, dizziness or fainting, shoulder-tip pain, urinary symptoms, passing tissue, and rectal pressure or pain when opening your bowels.

That last group is why ectopic pregnancy gets mistaken for a stomach bug, a urine infection or constipation. NICE makes the point directly: the symptoms and signs "can resemble the common symptoms and signs of other conditions".

Timing varies. The NHS says symptoms tend to develop between the 4th and 12th week of pregnancy; the RCOG says most people get physical symptoms in the 6th week, about two weeks after a missed period. Some have no symptoms at all and it is found on a scan.

Shoulder-tip pain deserves its own line. The RCOG explains that it "is caused by blood leaking into the abdomen and is a sign that the condition is getting worse. This pain is there all the time and may be worse when you are lying down. It is not helped by movement and may not be relieved by painkillers."

When this is an emergency

Call 999 in the UK and Ireland (911 in the US and Canada, 000 in Australia, 111 in New Zealand), or go straight to your nearest emergency department, if you could be pregnant and you have a combination of:

• sharp, sudden, intense pain in your tummy
• feeling very dizzy, or fainting
• feeling sick
• looking very pale
• pain in the tip of your shoulder

The NHS lists those first four together as possible signs that a fallopian tube has ruptured. It is honest about the stakes and about the odds: "A rupture can be life threatening, but fortunately they're uncommon and treatable, if dealt with quickly."

Contact your GP, an early pregnancy assessment unit or your local urgent care line the same day if you have tummy pain low down on one side, unusual vaginal bleeding or brown watery discharge, or discomfort when passing urine or opening your bowels, and you could be pregnant. The NHS says to seek advice "even if you haven't had a positive pregnancy test".

Do not wait for risk factors to justify the call. NICE instructs clinicians to exclude ectopic pregnancy "even in the absence of risk factors... because about a third of women with an ectopic pregnancy will have no known risk factors."

How it is diagnosed, and why it can take days

Diagnosis usually happens in an early pregnancy assessment service. NICE recommends a transvaginal ultrasound scan to find where the pregnancy is, and describes the scan features that point to a tubal ectopic — most reliably an adnexal mass containing a gestational sac with a yolk sac or fetal pole, moving separately from the ovary.

Blood tests are used alongside the scan, not instead of it. NICE is explicit: "Do not use serum hCG measurements to determine the location of the pregnancy", and in a pregnancy of unknown location, "place more importance on clinical symptoms than on serum hCG results". Where hCG is measured, NICE recommends two samples as close as possible to 48 hours apart.

The RCOG explains the reasoning behind that interval: in a pregnancy inside the uterus the hormone level rises by about 63% every 48 hours, whereas with an ectopic pregnancy the levels are usually lower and rise more slowly or stay the same.

If the pregnancy is very early, the RCOG says it can take a week or more to reach a diagnosis. Waiting is normal. Deterioration while waiting is not — go back in.

The three treatments

Expectant management

NICE says expectant management should be offered to people who are clinically stable and pain free, with a tubal ectopic under 35 mm with no visible heartbeat, an hCG of 1,000 IU/L or less, and who can return for follow-up. It is considered where hCG is between 1,000 and 1,500 IU/L. Follow-up hCG is taken on days 2, 4 and 7.

Methotrexate

NICE recommends systemic methotrexate where there is no significant pain, an unruptured tubal ectopic smaller than 35 mm with no heartbeat, an hCG below 1,500 IU/L, no intrauterine pregnancy on scan, and the ability to attend follow-up. The RCOG's figures are worth knowing before you choose: 15 in 100 people need a second injection, and 7 in 100 will still need surgery afterwards. Both the NHS and the RCOG advise waiting at least 3 months after methotrexate before trying again.

Surgery

NICE recommends surgery as first-line treatment if you cannot return for follow-up, or if there is significant pain, a mass of 35 mm or more, a visible fetal heartbeat, or an hCG of 5,000 IU/L or above. It should be done laparoscopically wherever possible. Usually the affected tube is removed (salpingectomy); sometimes, if the other tube is absent or unhealthy, the pregnancy alone is removed (salpingotomy), which carries a higher chance of another ectopic.

Afterwards

The RCOG puts the future-pregnancy picture like this: your chance of another ectopic is increased, at around 7 to 10 in 100 compared with just over 1% in the general UK population — which also means most next pregnancies are not ectopic. NICE says you can self-refer to an early pregnancy assessment service in future pregnancies if you have any early concerns.

Grief after an ectopic pregnancy is not proportional to how many weeks you were. The NHS says many people "feel the same sense of grief as if they had lost a family member or partner", and that it is not uncommon for those feelings to last several months.

Where to get support

The Ectopic Pregnancy Trust runs information and peer support specifically for this. Miscarriage UK, formerly the Miscarriage Association, has a staffed support line. Tommy's has an ectopic pregnancy support section, and the RCOG also points people to the Association of Early Pregnancy Units to find a local service. If you are not coping, your GP can refer you — that is a reasonable thing to ask for, not an overreaction.