An ectopic pregnancy is a pregnancy where the fertilised ovum (egg) implants outside the cavity of
the uterus (womb). This occurs in approximately 1% of pregnancies. The most common place that an
ectopic pregnancy implants is in the fallopian tubes. However, ectopic pregnancies can implant in
other places, such as the wall of the womb (intramural), the portion of tube as it enters the womb
(interstitial), the ovary, and, rarely, into a previous caesarean section scar.
An ectopic pregnancy unfortunately cannot develop normally, and the pregnancy cannot continue. It
cannot move into the right place. Sometimes ectopic pregnancies will ‘miscarry’ just like pregnancies
inside the womb, and don’t require any treatment. However, if the pregnancy grows and stretches the
tissue around it, it can cause internal bleeding, which can be serious.
In most cases there is no obvious cause for an ectopic pregnancy. However we know that there are
certain factors that increase the risk of having one. These include:
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previous surgery on the fallopian tubes
sexually transmitted infections, such as chlamydia
a history of appendicitis
previous ectopic pregnancy - 10% of women who have had an ectopic will have another
ectopic
smoking
use of the intra-uterine contraceptive device (coil) or progesterone-only mini-pill
fertility treatment.
The symptoms vary from woman to woman and are dependent on a variety of factors, including how
many weeks pregnant they are, how big the pregnancy is, and where it is.
Generally, however, symptoms may include:
 a missed or late period, and a positive pregnancy test
 bleeding or a brown discharge
 general pelvic pain or pain on one side of you lower abdomen
 referred pain into the tips of your shoulders
 diarrhoea
 fainting.
Many women are unaware they are pregnant when the symptoms start.
An ectopic pregnancy is usually confirmed on ultrasound scan.
In addition to the ultrasound scan, we will usually need to know the levels of your hormones by doing
blood tests (HCG and progesterone). Sometimes we will want to know how an ectopic pregnancy is
behaving (i.e. if it is growing or miscarrying) by repeating these blood tests at regular intervals. These
blood tests often help us determine which treatment is best for you.
Sometimes, women become very unwell with ectopic pregnancies, and may lose a lot of blood inside.
In these situations, when we suspect an ectopic, we may need to do an operation without waiting for
an ultrasound scan.
Your doctor will help to guide you as to which treatment is best for you, depending on your
symptoms, your blood results, and your preferences. If you are unwell, you are likely to need surgery
as an emergency.
Surgical treatment
We may suggest performing an operation to remove the ectopic pregnancy. In most cases, keyhole
surgery (laparoscopy) is performed, and the fallopian tube is removed (called a salpingectomy). You
need to be put to sleep (have a general anaesthetic) for this procedure.
A laparoscopy is a procedure where a telescope (called a laparoscope) is inserted into the abdominal
cavity through a small incision (cut) at the umbilicus (navel). The abdominal cavity is filled with gas
(carbon dioxide) to allow us to look at the pelvic and abdominal organs. Other small incisions may be
made in the abdomen just above the pubic bone or on either side of the abdomen in order to perform
the operation.
During the operation, the surgeon will check both tubes. If the other tube is normal then the affected
tube containing the ectopic pregnancy will be removed. This is done because, once an ectopic
pregnancy has occurred, there is a high chance it will happen again on the same side in a
subsequent pregnancy if the tube is not removed. In addition, the tube has to be removed if severely
damaged by the ectopic pregnancy or if there is heavy bleeding that cannot be stopped. Removal of
a fallopian tube is called a salpingectomy. On occasion, the affected tube can be repaired after the
ectopic pregnancy has been removed. This is called a salpingotomy.
At the end of the procedure, small dissolvable sutures (stitches) will be put in the incision sites, and
they normally dissolve within 7 days. Occasionally you may need to get the sutures removed by the
practice nurse at your GP (you will have to arrange this). Depending on the type of operation you
had, and whether the ectopic had ‘ruptured’ (spilled into abdomen), we may need to arrange followup of your blood tests. We’d routinely see you after 2 weeks.
If you come into hospital acutely unwell, and seem to have lost a lot of blood, or if the surgery is
complicated, then we may need to perform the operation though a bigger incision (‘open’ surgery as
opposed to ‘keyhole’, otherwise known as a ‘laparotomy’ instead of a ‘laparoscopy’). The main
disadvantage of this is that women experience more post-operative pain, and need to stay in hospital
for longer.
Medical treatment – methotrexate injection
In some cases where an early ectopic pregnancy is diagnosed, when the pregnancy hormone levels
are low and the woman has very few symptoms, it may be possible to use a medication called
methotrexate. This aims to stop the ectopic pregnancy growing, and, ultimately, to miscarry. There
are strict guidelines for using this treatment and your doctor will advise whether you are suitable for
this. To monitor the response to the treatment, your hormone levels will be followed up closely, four
and seven days after the injection.
Please see our information leaflet on Methotrexate for more information.
Expectant management
A small ectopic pregnancy may resolve spontaneously without the need for any intervention. Again,
there are strict criteria to help us choose which women will be suitable for this ‘watch and wait’
approach. It involves regular review for blood tests until the hormone level drops to normal.
If you have either medical or conservative management you must be aware that internal bleeding can
occur even with very low pregnancy hormone levels. If you experience sudden lower abdominal pain,
you must go to the Accident & Emergency department as soon as possible.
The treatment you’ve had will determine how you need to be followed up, and we’ll make sure you
have a clear plan. As the hormone levels drop, you should expect to see some vaginal bleeding,
which may be heavier than your normal period, and often lasts up to two weeks. This represents the
shedding of the lining of your womb that became thickened in response to the pregnancy hormone.
Providing you have not had treatment with methotrexate (in which case we advise you to wait at least
three months), you can start trying for a baby again once you feel physically and emotionally ready
to. We advise that you wait until after your next normal period (which does not include the initial bleed
as your hormone levels are dropping). Statistically, after an ectopic, your chances of having a
successful, normal pregnancy are good (up to 85% over two years of trying). This chance does
depend on the health of your fallopian tubes. Sometimes, if you have needed surgery and the doctors
have found lots of scar tissue around the remaining tube, your chances of conceiving naturally will be
lower, and you may wish to consider being referred for fertility treatment. Your doctor will tell you if
they think this might be necessary.
Following one ectopic, there is a 1 in 10 risk of having another ectopic pregnancy. It is very important,
when you become pregnant again, that you ask you GP to arrange an ultrasound scan at
approximately 6 to 7 weeks (2 to 3 weeks after your period was due), to check that the pregnancy is
in the right place. You should also be vigilant for the signs and symptoms of an ectopic, and get
referred urgently, or come to A&E, if you experience these.
If you want to delay a subsequent pregnancy, you may want to consider your contraceptive options.
Having an ectopic pregnancy does not alter which contraceptives you can use.
Ectopic pregnancies represent the loss of a pregnancy. Many women, and their partners, will find this
emotionally very difficult to deal with. This may be the case whether or not it was a planned
pregnancy. Furthermore, you may be left feeling very anxious about future pregnancies. These
feelings are very natural. You may find it helps to talk to the team who looked after you, your GP, or
your family and friends. The organisations at the end of this leaflet may also be very helpful. Some
women will find that feelings of sadness and anxiety persist for longer than they expect them to, or
make it difficult to get back to work or other commitments. They may benefit from counselling, and
should see their GP to arrange this.
The Gynaecology Emergency Room (at St Mary’s) number is 0203 312 2185 and EPAGU (at Queen
Charlotte’s) is 0203 313 5131. Both units are open from 9.00am to 5.00pm Monday to Friday.
Out of hours you should go to Accident & Emergency. Please note there is no A&E department at
Hammersmith Hospital. Once you have been initially seen and assessed, our gynaecology team will
review you.
The Ectopic Pregnancy Trust
www.ectopic.org.uk
[email protected]
The Miscarriage Association: 01924 200 799
www.miscarriageassociation.org.uk
[email protected]
(open Mon-Fri 09.00-16.00)
We aim to provide the best possible service and staff will be happy to answer any questions you may
have. If you were pleased with your care and want to write to let us know we would appreciate your
time in doing so. However, if your experience of our services does not meet your expectations and
you would like to speak to someone other than staff caring for you, please contact the patient advice
and liaison service (PALS) on 020 3313 0088 for Charing Cross, Hammersmith, and Queen
Charlotte’s and Chelsea Hospitals or 020 3312 7777 for St Mary’s and Western Eye Hospitals. You
can also email PALS at [email protected]. The PALS team will listen to your concerns,
suggestions or queries and are often able to solve problems on behalf of patients.
Alternatively, you may wish to express your concerns in writing to:
The Chief Executive
Imperial College Healthcare NHS Trust
Trust Headquarters
The Bays, South Wharf Road
London W2 1NY
This leaflet can be provided on request in large print, as a sound recording, in Braille, or in alternative
languages. Please contact the communications team on 020 3312 5592.
Gynaecology and reproductive medicine
Published: September 2014
Review date: September 2017
Reference no: 77v2
© Imperial College Healthcare NHS Trust