Having an ectopic pregnancy can affect women in different ways. It can be deeply distressing and there is no single 'best way' to cope with it. It is important that women and their families receive support and get appropriate and sensitive care.

An ectopic pregnancy is where the fertilised egg implants outside the womb. About 98 percent of ectopic pregnancies implant in the Fallopian tube (this carries the egg to the womb). Rarely they may implant on the ovary (where the egg is produced), in caesarean section scars, in the neck of the womb and in the abdomen.

When the pregnancy is ectopic sadly the baby cannot be saved. If undiagnosed an ectopic pregnancy can also be dangerous. The Fallopian tube (which links the ovary to the womb) is not an environment designed for pregnancy. If the ectopic pregnancy invades into the wall of the Fallopian tube and then a blood vessel, it can cause bleeding. If the bleeding is severe and into the abdomen, it can put a woman into shock. In some rare cases this can be fatal. Fortunately, this is very rare and between 2006 and 2008 (a period of three years) 6 deaths in the UK were caused by ectopic pregnancy. Sadly, in the developing world, the rate is much higher.

 Causes   

The exact causes of ectopic pregnancy still require further investigation and research. Wellbeing of Women researcher, Dr Andrew Horne from the MRC Centre for Reproductive Health in Edinburgh (www.crh.ed.ac.uk) has just completed a project looking into why some factors make women more at risk for the condition .

Risk factors that can increase the risk of having an ectopic pregnancy, these include:
 

• Previous abdominal surgery - this raises the risk by up to 4 times
• Sexually transmitted infection - e.g. Chlamydia - increases risk by up to 2 times
• Smoking - increases risk by up to 2 times (even if ceased prior to the pregnancy)
• Fertility treatment may also increase the risk

For a lot of women the exact cause of the ectopic pregnancy is unknown and they may not have any of the risk factors.

 Symptoms

Around 6-7 weeks into the pregnancy women tend to get symptoms that may indicate an ectopic pregnancy. Unfortunately for many women the symptoms can easily be mistaken for other common problems as they include:

• Lower abdominal or pelvic pain, which can vary from mild to severe. The pain can be constant (all the time), intermittent (on and off), sharp and one sided.
• Abnormal vaginal bleeding - not usually more than a normal period, but often intermittent and either bright or dark red. There may also be bleeding at the time when the next period was due (even if there has been a positive pregnancy test).
• Shoulder tip pain
• Fainting or dizziness
• Vomiting and/or diarrhoea

Some women do not have any symptoms, and subsequently an ectopic pregnancy may only be picked up during a routine pregnancy scan.

It is important to seek immediate advice from a health professional if you are worried or experience any of these symptoms.

  Diagnosis

  In most cases, if a doctor suspects an ectopic pregnancy, the diagnosis is made using a combination of an ultrasound scan and a series of blood tests looking at a specific pregnancy hormone (human chorionic gonadotrophin, hCG). This can take some time, can require multiple hospital visits, and may be stressful for women and their families. However, if a woman is already going into shock, the diagnosis is made quickly just based on the clinical history.

 Treatment


Once the ectopic pregnancy is diagnosed there are three ways in which it can be managed:

All these options depend on how severe the symptoms are: (if severe emergency surgery may be required)

Surgical - most commonly using key-hole surgery - to remove the pregnancy, and usually the Fallopian tube in which it was implanted.

Medical - using a drug called methotrexate, given by injection. This does have side effects, but not the risks associated with surgery. Following medical treatment there must be a gap of at least three months before trying for a baby again but it should not affect getting pregnant successfully and naturally.

Expectant - meaning ‘wait and see’. Ectopic pregnancies can resolve themselves through tubal miscarriage. There is a risk that the miscarriage does not occur and one of the other treatments will be needed, especially if severe symptoms develop.

Lee's story-

“The third time I became pregnant, we thought “third time lucky”, but unfortunately when going for a scan at the Early Pregnancy centre they discovered I had an ectopic pregnancy.”

“They had to operate and I had my right Fallopian tube removed.”

“We were still wondering why this was happening to us and why we had no answers to all our questions. We kept hearing the same answers ‘It’s bad luck!’ I didn’t feel I was being supported and no-one could tell me what to do next. I didn’t know if there were more tests that could be done other than those that I’d already had. We were really baffled by all this.”

Lee’s story shows how important it is that more information is known about this condition and that research into it continues.

If you would like to tell us your story so we can help and inform other women; there is more information available HERE

This interview was recorded in April 2011 

Ectopic Pregnancy: Text Version

Good morning, I am speaking to Dr Andrew Horne, clinician scientist and honorary consultant in gynaecology at the University of Edinburgh. You’ve just done some research into ectopic pregnancy which we helped to fund with the grant from Wellbeing of Women. So, we wondered if today you would talk to us a bit about ectopic pregnancy generally, and then a bit later on about your specific research.

So firstly, one of the questions, just to start us off, could you tell us exactly what an ectopic pregnancy is?

An ectopic pregnancy is a pregnancy that is an out of place pregnancy, a pregnancy which has been implanted outside the womb. The most common sites are in the fallopian tube, in fact about 98 % are implant the fallopian tube, but more rarely in places like the ovary, caesarean section scars, the neck of the womb or even within the abdominal cavity itself.

How do they actually come about? How do they occur?

Well that’s something we don’t really understand, and that was partly the purpose of the research. But we’ve been working along the hypothesis that they implant in the fallopian tube because of a combination of factors, a combination of failure of the mechanisms which sort of propel the pregnancy along the fallopian tube into the womb and also change in the environment in the fallopian tube that allows early implantation to occur.

Okay, and what are some of the signs that suggest to a woman that she is having an ectopic pregnancy? Is there anything that would alert her to that?

Ectopic pregnancy is difficult to diagnose and can often be missed. Sometimes patients get no signs at all; but the most common signs are abdominal pain, maybe some irregular bleeding in early pregnancy and in later stages they can present with shock or they can present with pain in their shoulder and this is due to referred pain and due to irritation from bleeding within the abdomen which affects the diaphragm, the muscle underneath the lungs, and this gets referred into the shoulder. But in the majority of cases it’s very insidious symptoms which can be mixed up with other clinical problems.

So what time in the pregnancy would this typically occur?

Commonest time is usually 6-7 weeks, so early in the first stages of pregnancy.

And if you suspected that you had an ectopic pregnancy, if you had these symptoms and you were concerned about this, what sort of tests would be carried out to check that?

Usually the first thing that would happen is that the woman would be referred for a scan, to look and see where the pregnancy is implanted. The problem is that very early on in pregnancy often you can’t see the pregnancy because it’s so tiny, so often the scan is what we call unequivocal and in that situation we have to rely at the moment on looking at the pregnancy hormone HCG, or Human Chorionic Gonadotropin and what we do is measure the level of that hormone 48 hours apart. In a normal pregnancy you expect the levels to double every 48 hours, with an ectopic pregnancy often that pattern is quite different it still goes up, but doesn’t go up following that.

Ah right, okay. So, they would certainly need to be referred to a specialist to have those tests done.

Yes, yes.

What would happen once you have established that there is an ectopic pregnancy? How would that be treated? What would the woman have to go through next?

It can be treated 3 ways; it can be treated either surgically, or what we call medically or expectantly. Surgical management, or most commonly by key hole surgery where we remove the pregnancy and the fallopian tube if that’s where it is implanted or sometimes we have to do it by open abdominal surgery. Medical management is using a drug called Methotrexate, which is a bit like a very mild form of chemotherapy which is given by an intramuscular injection. Usually that’s just a one off injection but occasionally that has to be repeated. The problem with the medical management is that it needs quite a lot of follow up afterwards, and often the patients require follow-up for several weeks, until the pregnancy is resolved.

Would that have side-effects as well?

Yeah, it can have side effects a bit like mild side effects of chemotherapy so...

So Nausea…

…so things like nausea, a bit of hair loss that sort of thing. They’re usually only temporary effects but you have to warn patients about that, and then expectant management is where we just wait and see and hope that the pregnancy itself will resolve and miscarry within the fallopian tube. Often that in itself carries risks because if the pregnancy doesn’t resolve then it is difficult.

What are the risks if it doesn’t resolve itself naturally and doesn’t get managed?

Well the problem is, when a pregnancy implants outside of the uterus, or outside the womb, the environment isn’t prepared for that pregnancy so it actually invades into the wall of the fallopian tube and then invades into the blood vessel, and that can often cause very brisk bleeding, and that is when patients bleed a lot into the abdomen and present with shock and I suppose in the worst scenario patients can die. Between 2006 and 2008 there were 6 deaths in the UK. In the developing world the rate of death is thought to be much higher as many as 1 in 10 women who are admitted with a diagnosis of ectopic pregnancy die from the condition.

Presumably because they don’t have as many ranges of, and probably waiting all on expectancy rather than on surgical or medical?

Yes that’s right, they certainly don’t have the opportunity to use medical management.

Okay that’s very interesting. In some ways that answers our question which was can an ectopic pregnancy survive outside the womb, presumably not?

Well there are rare instances if it’s implanted within the abdomen, which is very rare where pregnancy has progressed at a term and been delivered abdominally, but these are very rare cases.

And would the baby survive in that case?

They have done, yes.

Is it because they can get the nutrients straight from the…

…well often its where they’ve been implanted somewhere with a very rich blood supply right near to the bowel, but as I say these are very rare cases…

…presumably not great for the woman?

No, very dangerous.

Very dangerous.

How common is it, how common is an ectopic pregnancy?

In the UK it’s quoted as 1 in every 80 pregnancy’s…

1 in every 80?

… which is as common as a twin pregnancy. In the states, interestingly it’s more common, it’s about 1 in 50 pregnancies and in developing countries probably more common still, but we don’t have figures for that.

Yeah, and are there any ways of telling whether you might be at risk of it, is it hereditary? Are there risk factors that you could understand in advance of getting pregnant to know whether to look out for these symptoms?

It’s not to our knowledge hereditary, but there are risk factors which we would ask about in a patient presented with symptoms suggesting of an ectopic pregnancy. If you’ve had previous abdominal surgery say you’ve had your appendix removed or had a caesarean section your risk is said to be increased up to 4 times. If you’ve had a sexually transmitted infection like Chlamydia then your risk is increased up to 2 and 3 times. If you’re a smoker again your risk is increased between 2 and 3 times. And interestingly if you’ve had fertility treatment such as IVF then your risk is increased as well.

That is interesting. That’s very helpful. If you have had an ectopic pregnancy once is it likely to recur assuming that was left to resolve itself naturally, and you haven’t removed the fallopian tube that it was in.

You’ve got an increased risk of it occurring, but you’ve actually still got a very good chance of having a normal pregnancy. It depends slightly on what treatment you’ve had. As you say, if you’ve had expectant treatment and the pregnancy has just resolved itself then your chances of having a pregnancy inside the womb again is much higher. We tend to try and advise people who have surgical management to have the tube removed as well as well as the pregnancy assuming the tube on the other side looks normal because that then reduces the risk of it happening again in the tube.

Yeah, okay. So I think that probably answers the next question was whether it would be more difficult to get pregnant again, and presumably again that is dependent on what type of management you had of it. Does the medical management affect fertility at all?

It doesn’t affect fertility; again, we’re very positive to women who have had medical management about the chance of having a normal pregnancy inside the womb. The only thing is they have to wait for 3 months before they try and get pregnant again until the drug has cleared from their system.

Now a lot of the research that you have done is on the risk factors of smoking and Chlamydia perhaps you can tell us a little more about what you have found out from that and what that might lead on to in terms of other areas to look at, other ways of managing this problem.

Well as I said, we don’t understand fully what causes ectopic pregnancies particularly pregnancies that implant inside the fallopian tube so the purpose of the research was to try and understand what causes this to occur and also to look at the contribution of risk factors practically smoking and Chlamydia trachomatis infection, what we found in our studies was that a group of proteins called prokineticins were expressed in the fallopian tube, and women who had been smokers or had been exposed to Chlamydia infections in the past had increased productions of these proteins. We know that these proteins are important for implantation normally, and we know that normally altered in women with ectopic pregnancies. So, the whole of this project brought together this knowledge and gave us an explanation or a mechanism of explaining why these risk factors were so important. And I think understanding what causes an ectopic pregnancy is important not just to understand these types of mechanisms but it can then lead on to helping us work out ways to better diagnose the condition and better treat the condition. What it’s lead on to do is to apply for more funding to develop more funding to develop these two areas, in particular looking at better tests to diagnose ectopic pregnancy. So I would like to see in the future women to be able to come in if they’ve had some bleeding or some pain in pregnancy, and be told immediately whether or not they’ve got an ectopic pregnancy with a simple blood test. By understanding what’s happening when implantation occurs we have been able to identify other genes which are produced in the blood stream, which we can use as tests. We have also, again, by looking at what’s happening when implantation is occurring in the fallopian tubes identified part of a collaboration with Melbourne, another gene which has allowed us to develop a drug which we are starting as a trial in Edinburgh and Melbourne. Which we hope will improve the treatment of ectopic pregnancy by reducing the number of follow up visits that the patients have to have. And ultimately allow patients to potentially have a drug they can take as a tablet rather than an injection to treat ectopic pregnancy.

And how will that drug work? Is that when they actually have an ectopic pregnancy; so an alternative medical treatment?

I think it’s a long time that we can give a drug that will prevent an ectopic pregnancy occurring, but I suppose part of the problem is people will be very loathed to give drugs to patients before they got pregnant in case it had a long time effect on the pregnancy and the baby. So I think at the moment the big stumbling blocks are finding something to diagnose it quickly and early, and then give a treatment that is simple, fast and effective.

And the treatment will be less toxic than the current one and have less side effects?

Yes, medically, the advantage of medical management is as it stands is that you don’t have to undergo the risks of surgery the general aesthetic the risks of the procedure itself but as I said to you earlier, there are side effects and a long follow up time afterwards.

So that’s really interesting. So the trial is going on now?  Are you recruiting for it now? 

We’ve started recruiting in Melbourne, it’s been led by a group in Melbourne, and we are the second centre. And we’re hoping to start recruiting by the end of this week in Edinburgh so we’re very excited about that.

Ah right okay, so if anybody’s listening in Edinburgh, they can get in touch!

Yeah, you’ll be given the opportunity to take part.

That’s great. So, your hope for ectopic pregnancy in the future would presumably be this faster test and better treatment…

… and better treatment, yes.

That’s brilliant. Is there anything else you would like to add?

No, I would just like to say thank you to Wellbeing of Woman for giving us the opportunity to do this research and as I say, it’s been a fantastic opportunity, and has led to new studies and a new trial and hopefully we’ll see changes in the management of ectopic pregnancies in the future.

Well thank you, and thank you for coming to talk to us today and also for such great results that are hopefully going to lead to something really good in the future. Thanks a lot.

To find out about our research follow these links:
 

• Improving our understanding of ectopic pregnancy

• The Royal College of Obstetricians and Gynaecologists website has a wide range of information and guidelines on many women’s health topics. This can be found at: http://www.rcog.org.uk/womens-health/patient-information 

• NHS Choices website also has a range of health information. This can be found at: http://www.nhs.uk/Pages/HomePage.aspx