What is ectopic pregnancy?

Your doctor thinks you may have an ectopic pregnancy. This means that a fertilized egg has attached to a place outside the uterus. In most of these cases, the egg grows in a fallopian tube. This is also called a tubal pregnancy. In rare cases, the egg grows in an ovary or another place in the belly.

An ectopic pregnancy cannot develop normally. It can be painful and very dangerous. Sometimes an ectopic pregnancy stops on its own and the body absorbs it over time. But if it doesn't, you will need treatment.

You may have expectant management. This means your doctor monitors your pregnancy hormone levels to check if they are dropping on their own. Or you may have treatment right away. But it may or may not be legal to treat a suspected ectopic pregnancy where you live. In some places the diagnosis of an ectopic pregnancy must be certain before treatment can be started. Talk to your doctor about your options.

The doctor has checked you carefully. But you may need to come back for more tests. Problems can develop later. Watch carefully for belly pain or bleeding. Call your doctor right away if you have any new or increased pain or bleeding. If you have other symptoms, such as shoulder pain, dizziness, lightheadedness, or fainting, get medical care right away. These could be signs of internal bleeding.

Normally, at the start of a pregnancy, the fertilized egg travels from the fallopian tube to the uterus, where it implants and grows. But in a small number of pregnancies, the fertilized egg attaches to an area outside of the uterus. This results in an ectopic pregnancy (also known as a tubal pregnancy or an extrauterine pregnancy).

An ectopic pregnancy cannot support the life of a fetus for very long. But an ectopic pregnancy can grow large enough to rupture the area and cause heavy bleeding, which is dangerous. If you have signs or symptoms of an ectopic pregnancy, you need immediate medical care.

An ectopic pregnancy can develop in different locations. In most cases, the fertilized egg has implanted in a fallopian tube.

In rare cases:

• The egg attaches and grows in an ovary, the cervix, or the abdominal cavity (outside of the reproductive system).
• One or more eggs grow in the uterus at the same time as one or more eggs grow in a fallopian tube, the cervix, or the abdominal cavity. This is called a heterotopic pregnancy.

In the first few weeks, an ectopic pregnancy may cause the same symptoms as a normal pregnancy, such as a missed menstrual period, fatigue, nausea, and sore breasts.

The key signs of an ectopic pregnancy are:

• Belly, pelvic, or shoulder pain. It most often starts 6 to 8 weeks after a missed period. The belly pain may be sharp on one side at first and then may spread.
• Vaginal bleeding. It may be light.

In most cases, an ectopic pregnancy is treated right away to avoid rupture and severe blood loss. Treatment may be done with medicine or surgery. The decision about which treatment to use depends on how early the pregnancy is found and your overall condition.

Medicine

Methotrexate is usually the first choice for treating an early ectopic pregnancy. But it is not an option if the pregnancy has grown too big or the fallopian tube has ruptured. The medicine is usually given as one or more shots injected into a muscle. Using this medicine spares you from an incision and general anesthesia. But it does cause side effects. And you will need follow-up blood tests for several weeks to make sure that the treatment worked.

Surgery

Surgery may be used if the ectopic pregnancy is found later or is causing severe symptoms, internal bleeding, or high hCG levels. That's because medicine is less likely to work. And a rupture becomes more likely as time passes. For a ruptured ectopic pregnancy, emergency surgery is needed. Surgery may be your only treatment option if you have internal bleeding.

There are different types of surgery for a tubal ectopic pregnancy. As long as you have one healthy fallopian tube, salpingostomy (small tubal slit) and salpingectomy (part of a tube removed) have about the same effect on your future fertility. But if your other tube is damaged, your doctor may try to do a salpingostomy. This may improve your chances of getting pregnant in the future.

If possible, the surgery will be laparoscopy (say "lap-uh-ROSS-kuh-pee"). This type of surgery is done through one or more small cuts (incisions) in your belly. If you need emergency surgery, you may have a larger incision.

Surgery is a faster treatment. But it can cause scar tissue that could cause future pregnancy problems. Tubal surgery may damage the fallopian tube. Whether there's damage depends on where and how big the embryo is and the type of surgery needed.

Expectant management

For an early ectopic pregnancy that seems to be miscarrying (aborting) on its own, you may not need treatment. Your doctor will regularly test your blood to make sure that your pregnancy hormone (hCG) levels are dropping. This is called expectant management.

Further treatment

Ectopic pregnancies can be hard to treat.

• If hCG levels don't drop or if bleeding doesn't stop after you take methotrexate, your next step may be surgery.
• If you have surgery, you may take methotrexate afterward.

If your blood type is Rh-negative, Rh immunoglobulin may be used. It can protect any future pregnancies against Rh sensitization.

You may be able to prevent an ectopic pregnancy by reducing things that may put you at risk for having one.

Smoking or vaping tobacco increases your risk for ectopic pregnancy. If you need help quitting, talk to your doctor about stop-smoking programs and medicines. These can increase your chances of quitting for good.

Try to use safer sex practices, such as using a condom every time you have sex. Use an external condom, which goes on the penis. Or use an internal condom, which goes into the vagina or anus. This will help protect you from sexually transmitted infections (STIs) that can lead to pelvic inflammatory disease (PID). PID is a common cause of scar tissue in the fallopian tubes, which can cause ectopic pregnancy.

If you have one or more risk factors for ectopic pregnancy, you and your doctor can closely monitor your first weeks of a pregnancy.

A urine test can show if you are pregnant. If you have symptoms of a possible ectopic pregnancy, you will have:

• A pelvic exam to check on the size of your uterus and feel for growths or tenderness in your belly.
• A blood test that checks for the level of the pregnancy hormone (hCG). This test is repeated 2 days later. Low or slowly increasing levels suggest a problem, such as an ectopic pregnancy.
• An ultrasound. This test can show pictures of what's inside your belly. With ultrasound, a doctor can usually see a pregnancy in the uterus 6 weeks after your last menstrual period.

During the week after treatment for an ectopic pregnancy, your hCG blood levels are tested several times. In some cases, hCG testing continues for weeks to months until hCG levels drop to a low level.

• Your doctor might want you to use sanitary pads if you have vaginal bleeding. Using pads makes it easier to keep track of your bleeding. You may use tampons during your next period. It should start in 3 to 6 weeks.
• Ask your doctor when you can have vaginal sex again.
• Get plenty of rest. You may be more tired than normal for a few weeks.
• Avoid moving quickly or lifting anything heavy until your doctor tells you it is safe to do your normal activities.
• Follow your doctor's instructions about taking over-the-counter pain medicine, such as acetaminophen. Don't take NSAIDs like ibuprofen or naproxen. Read and follow all instructions on the label.
  • Do not take two or more pain medicines at the same time unless the doctor tells you to. Many pain medicines have acetaminophen, which is Tylenol. Too much acetaminophen (Tylenol) can be harmful.
• Do not drink alcohol.
• Avoid foods that may give you gas, such as beans, broccoli, cabbage, and apples.
• Do not take vitamins that contain folic acid, such as prenatal vitamins.
• Avoid direct sunlight. It can cause skin problems while the medicine is in your body.
• Pay attention to your feelings. If you're sad and it's not getting any easier, talk with your doctor or a counselor.
• Talk to your doctor if you want to try to get pregnant soon. The doctor can tell you when it's safe to do so.
• If you don't want to get pregnant, ask your doctor about birth control. It's safe to use it during your treatment. It's possible to get pregnant again before your next period starts.
• Go to all follow-up appointments and tests. This helps your doctor make sure that your treatment is working.

The following health professionals can evaluate you for an ectopic pregnancy:

• Certified nurse-midwife
• Obstetrician/gynecologist
• Family medicine physician
• Nurse practitioner (NP)
• Physician assistant (PA)
• Emergency medicine specialist

A diagnosed ectopic pregnancy is treated by a gynecologist.

• Rest when you feel tired. You may be more tired than normal for a few weeks.
• Avoid moving quickly or lifting anything heavy until your doctor tells you it is safe to do your normal activities.
• Ask your doctor when you can have vaginal sex again.
• Your doctor might want you to use sanitary pads if you have vaginal bleeding. Using pads makes it easier to keep track of your bleeding.
• If you are treated with methotrexate:
  • Follow your doctor's instructions about taking over-the-counter pain medicine, such as acetaminophen. Don't take nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen. Read and follow all instructions on the label.
  • Do not take two or more pain medicines at the same time unless the doctor told you to. Many pain medicines have acetaminophen, which is Tylenol. Too much acetaminophen (Tylenol) can be harmful.
  • Do not drink alcohol.
  • Do not take vitamins that contain folic acid, such as prenatal vitamins.
  • Avoid direct sunlight. It can cause skin problems while methotrexate is in your body.
  • Avoid foods that may give you gas, such as beans, broccoli, cabbage, and apples.
• Pay attention to your feelings. If you're sad and it's not getting any easier, talk with your doctor or a counselor.
• Talk to your doctor if you want to try to get pregnant soon. The doctor can tell you when it's safe to do so.
• If you don't want to get pregnant, ask your doctor about birth control. It's possible to get pregnant again before your next period starts.
• Go to all follow-up appointments and tests. This helps your doctor make sure that your pregnancy hormone levels are dropping.

Surgery is the fastest way to treat an ectopic pregnancy. The two types of surgery are:

Salpingostomy.

The doctor removes the ectopic growth through a small cut in the fallopian tube. This is called linear salpingostomy. The cut is left to close by itself. Or it may be stitched closed.

Salpingectomy.

The doctor removes a part of the fallopian tube. The remaining healthy fallopian tube may be reconnected. This surgery is needed when the fallopian tube is so stretched that it may rupture. It's also used when the tube has already ruptured or is very damaged.

These surgeries can be done in two ways. The first is through a small incision using laparoscopy. The second is called laparotomy. It's done through a larger incision in the belly. Laparoscopy takes less time than laparotomy. And the hospital stay is usually shorter.

If the fallopian tube that isn't part of the ectopic pregnancy is healthy, then both surgeries have about the same effect on future fertility. But if that other fallopian tube isn't healthy, then your doctor may try to do a salpingostomy.

You may have many different emotions after an ectopic pregnancy. If you need help coping with any feelings, consider meeting with a support group. You also may want to read about others' experiences or talk with a friend, family member, or counselor. If you're sad and it's not getting any easier, tell your doctor.

In many cases, an ectopic pregnancy happens when a person does not have any known risk factors. But some things that can increase your risk of having an ectopic pregnancy include:

• A previous ectopic pregnancy.
• A history of pelvic inflammatory disease (PID), often caused by chlamydia or gonorrhea.
• Endometriosis, which can cause scar tissue in or around the fallopian tubes.
• Past or present cigarette smoking. The more you smoke, the higher the risk.
• Your age. The risk is higher at age 35 and older.

Medical treatments and procedures that can increase your risk of having an ectopic pregnancy include:

• Previous fallopian tube surgery to treat infertility or to reverse a tubal ligation.
• A tubal ligation failure. In rare cases when pregnancy happens after a sterilization surgery, there is a higher-than-usual risk that the pregnancy is ectopic.
• An intrauterine device (IUD). Pregnancy is rare when using an IUD. But pregnancies that do develop may have a greater chance of being ectopic.
• Treatment with assisted reproductive technology (ART), such as in vitro fertilization (IVF). This may result from the passing of the fertilized egg into a fallopian tube after it is transferred to the uterus.
• Infection after any kind of surgery done on the uterus or fallopian tubes. This can lead to scar tissue.

If you become pregnant and are at high risk for ectopic pregnancy, you will be closely watched by your doctor.

It's common to worry about your fertility after an ectopic pregnancy. Having an ectopic pregnancy doesn't mean that you can't have a normal pregnancy in the future. But it does mean that:

• You may have trouble getting pregnant.
• You are more likely to have another ectopic pregnancy.

If you get pregnant again, be sure your doctor knows that you had an ectopic pregnancy before. Regular testing in the first weeks of pregnancy can find a problem early or let you know that the pregnancy is okay.

An ectopic pregnancy can damage the fallopian tube, which can make it difficult to become pregnant in the future. It's usually detected early enough to prevent serious complications such as severe bleeding. A ruptured ectopic pregnancy requires emergency surgery to prevent heavy bleeding into the abdomen. The affected tube is partially or fully removed.

Fallopian tube damage is a common cause of ectopic pregnancy. A fertilized egg can get caught in the damaged area of a tube and start to grow there. Some ectopic pregnancies occur without any known cause.

Common causes of fallopian tube damage that may lead to an ectopic pregnancy include:

• Smoking. It raises the risk for ectopic pregnancy. Smoking is thought to damage the fallopian tubes' ability to move the fertilized egg toward the uterus.
• Pelvic inflammatory disease (PID), such as from a chlamydia or gonorrhea infection. PID can create scar tissue in the fallopian tubes.

Some medical treatments can increase your risk. These include:

• Surgery on the fallopian tubes or in the pelvic area.
• Fertility treatments such as in vitro fertilization.