Ectopic pregnancy

An ectopic pregnancy, also called an extrauterine pregnancy, happens when a fertilized egg implants outside the main cavity of the uterus. Most occur in a fallopian tube, which normally carries an egg from an ovary to the uterus.

Less often, a pregnancy implants in the cervix, an ovary, a previous caesarean scar, or the abdomen. Rarely, a pregnancy develops inside and outside the uterus at the same time. This is called a heterotopic pregnancy.

An ectopic pregnancy cannot be moved into the uterus or continue safely. As it grows, it may cause internal bleeding. Early diagnosis and treatment reduce this risk.

Symptoms can overlap with miscarriage, urinary or bowel problems, and normal changes in early pregnancy. Some people initially have no symptoms, so medical assessment and testing are needed.

Symptoms often begin during the early weeks of pregnancy. Pain may develop gradually or suddenly.

Possible symptoms include:

• Pain low in the abdomen or pelvis, sometimes mainly on one side
• Vaginal bleeding or brown, watery discharge
• Pain at the tip of the shoulder
• Discomfort when passing urine or opening the bowels
• Pressure or pain in the rectum
• Dizziness, weakness, or faintness

Shoulder-tip pain can happen when internal bleeding irritates the diaphragm. Nerves may make the pain feel as though it comes from the shoulder.

Bleeding may be lighter or heavier than a usual period and may stop and start. Bleeding alone cannot show whether a pregnancy is ectopic.

A ruptured ectopic pregnancy may cause sudden, severe abdominal or pelvic pain, marked dizziness, fainting, looking very pale, or collapse. This is an emergency.

Ectopic pregnancy usually occurs because the fertilized egg does not reach the uterus before implanting. The reason is not always known.

Factors that may damage a fallopian tube or affect movement through it include:

• A previous ectopic pregnancy
• Previous surgery involving the fallopian tubes or nearby pelvic organs
• Pelvic inflammatory disease, often linked to a past sexually transmitted infection
• Endometriosis
• Pregnancy following fertility treatment, including in vitro fertilization
• Becoming pregnant while using an intrauterine device or after sterilization
• Smoking
• Increasing age

Intrauterine devices and sterilization are highly effective, so pregnancy is uncommon. However, if pregnancy occurs, its location should be checked promptly.

Many people with an ectopic pregnancy have no known risk factors. It is not caused by exercise, sex, working, stress, or something you did during pregnancy.

Assessment usually includes questions about symptoms, pregnancy history, last menstrual period, and risk factors. A clinician may examine your abdomen and, when appropriate, perform a pelvic examination.

The main tests are a transvaginal ultrasound and blood tests for human chorionic gonadotropin, or hCG. A transvaginal ultrasound uses a narrow probe placed gently inside the vagina to view the uterus, ovaries, and fallopian tube areas.

One scan may not give a definite answer, especially early in pregnancy. If a pregnancy test is positive but no pregnancy is seen inside or outside the uterus, this is called a pregnancy of unknown location. It does not automatically mean the pregnancy is ectopic.

Blood hCG may be measured again after about two days. The pattern helps guide care but cannot confirm the pregnancy's location by itself. Repeat blood tests and another ultrasound may be needed.

If symptoms are severe or the diagnosis remains uncertain, keyhole surgery called laparoscopy may be required to examine the abdomen and treat an ectopic pregnancy. Other blood tests may check for anemia and identify your blood group. Treatment should not be delayed for routine testing if there are signs of significant internal bleeding.

Treatment depends on symptoms, ultrasound findings, hCG levels, general health, and evidence of internal bleeding. Your preferences and ability to attend follow-up also matter.

Expectant management means monitoring without immediate medicine or surgery. It may be suitable if you are well, symptoms are mild or absent, and hCG levels are low and falling. Blood tests continue until the pregnancy tissue has resolved. Treatment may become necessary if hCG stops falling or symptoms develop.

Methotrexate stops pregnancy tissue from growing. It may be offered by injection when the ectopic pregnancy has not ruptured and clinical findings make medical treatment appropriate.

Follow-up blood tests are essential. hCG can take several weeks to fall. Pain may occur during treatment, but new or worsening pain needs urgent assessment because rupture remains possible until the pregnancy has resolved.

Methotrexate may cause nausea, tiredness, mouth soreness, or abdominal discomfort. Your care team will explain which medicines, supplements, alcohol, and activities to avoid, and when it is safe to try for another pregnancy.

Surgery is needed if the ectopic pregnancy has ruptured, internal bleeding is suspected, or other treatment is unsuitable or unsuccessful.

Most operations use keyhole surgery under general anesthesia. The affected fallopian tube may be removed, called salpingectomy. Sometimes the pregnancy is removed while leaving the tube in place, called salpingotomy. Further hCG monitoring is essential after salpingotomy because tissue can remain.

Emergency surgery may require a larger abdominal incision, and major bleeding may require a blood transfusion. If you have Rh-negative blood, your team will decide whether anti-D immunoglobulin is appropriate.

The most serious complication is rupture of the fallopian tube or another implantation site, causing internal bleeding that requires emergency treatment.

Other complications include:

• Persistent pregnancy tissue after medicine or tube-preserving surgery
• A need for additional methotrexate or surgery
• Damage to or loss of a fallopian tube
• A higher chance of another ectopic pregnancy
• Reduced fertility, particularly if both tubes are damaged
• Anemia following blood loss

Pregnancy loss can also cause grief, anger, anxiety, numbness, or guilt. Partners may grieve differently. Pregnancy-loss services, counseling, or peer support may help.

Ectopic pregnancy cannot always be prevented. Many cases occur without a clear cause.

Reducing sexually transmitted infections may lower the risk of pelvic inflammatory disease and damage to the fallopian tubes. Condoms, appropriate testing, and prompt treatment of infections can help. Not smoking may also reduce risk.

If you become pregnant after a previous ectopic pregnancy, contact a pregnancy care service early. hCG testing and ultrasound may be offered to confirm the pregnancy's location. Monitoring cannot prevent another ectopic pregnancy, but it may identify one sooner.

Physical recovery may take days to weeks, depending on whether you had monitoring, methotrexate, keyhole surgery, or emergency abdominal surgery. Tiredness, mild discomfort, and vaginal bleeding may continue for a time.

Follow-up is important after expectant management, methotrexate, and tube-preserving surgery. Blood tests usually continue until hCG reaches a non-pregnant level. Missing follow-up could allow persistent ectopic tissue to go unnoticed.

Periods usually return after hCG has fallen. The first may be different from usual. Seek advice if bleeding is very heavy, pain is increasing, or you are concerned about your recovery.

Many people later have a pregnancy inside the uterus, including those with one remaining fallopian tube. Future fertility depends on the other tube's health, age, previous fertility problems, and treatment. A previous ectopic pregnancy increases the chance of another one.

There is no single waiting period for trying again. Surgery recovery, hCG follow-up, and methotrexate affect when it is safe. Follow the treatment-specific advice from your care team.

Emotional recovery may take longer than physical healing. Anniversaries, periods, and later pregnancies may bring back difficult feelings. Follow-up appointments can include emotional as well as physical support.

Get same-day medical advice if you might be pregnant and have one-sided pelvic or abdominal pain, unusual vaginal bleeding, shoulder-tip pain, or increasing pressure when opening your bowels. This is especially important after a previous ectopic pregnancy, even without a positive pregnancy test.

If you are being monitored for a pregnancy of unknown location or confirmed ectopic pregnancy, promptly report new or worsening symptoms. A previously reassuring hCG result does not make severe symptoms safe to ignore.

Seek emergency medical care now for:

• Sudden or severe abdominal or pelvic pain
• Fainting, collapse, severe dizziness, or marked weakness
• Shoulder-tip pain with abdominal pain or faintness
• Looking very pale, feeling clammy, or having a rapid heartbeat
• Heavy bleeding or symptoms that are worsening quickly

Do not drive yourself if you feel faint or seriously unwell. Use local emergency services.

Can an ectopic pregnancy give a positive pregnancy test?

Yes. Ectopic pregnancy tissue produces hCG, so urine and blood tests are usually positive. A negative result makes ectopic pregnancy less likely, but very early or falling hormone levels can complicate interpretation.

Can an ectopic pregnancy be moved into the uterus?

No. There is no treatment that can safely relocate an implanted pregnancy. Treatment allows the tissue to resolve or removes it to protect your health.

Will I lose my fallopian tube?

Not always. Some ectopic pregnancies can be managed with monitoring or methotrexate. If surgery is needed, the approach depends on bleeding, tubal damage, the condition of the other tube, and the safest option.

Can I get pregnant again after an ectopic pregnancy?

Many people do. One healthy fallopian tube may still allow pregnancy without fertility treatment. Individual chances depend on tubal health, age, fertility concerns, and treatment.

How soon can I try to become pregnant again?

Timing depends on treatment and whether follow-up is complete. Methotrexate requires particular care because it affects how the body uses folate. Follow the timeframe provided by your care team.

Does bleeding mean the ectopic pregnancy has ended?

Not necessarily. Bleeding does not confirm that all tissue has resolved or that rupture cannot occur. Continue scheduled hCG tests and scans until your care team confirms follow-up is complete.