The good news is that it can be managed either medically or surgically, but the challenge is making the right diagnosis in early pregnancy before the fallopian tube ruptures.

What’s An Ectopic Pregnancy?

An ectopic pregnancy is a rare pregnancy complication that happens when the fertilized egg implants outside of the uterus. Fertilization usually occurs in the fallopian tubes. The fertilized egg usually travels down to the uterus for implantation by around 6-12 days after conception. But with an ectopic pregnancy, the egg simply implants along the way. Because fallopian tubes aren’t designed for a growing embryo, they could rupture.

Where Does An Ectopic Pregnancy Happen?

About 98% of ectopic pregnancies occur in the fallopian tube. (1) In very rare cases, ectopic pregnancy could happen in the following: (1)

Ovary Cervix Abdominal cavity Spleen Liver Cesarean section scar

When Do You Suspect An Ectopic Pregnancy?

It’s usually diagnosed or discovered in the first trimester, especially the first weeks. The problem with having an ectopic pregnancy is that its signs and symptoms, such as pain and vaginal bleeding at around six weeks of pregnancy, are similar to implantation bleeding (pregnancy spotting caused by the embryo’s implantation). (1) About a third of pregnant women also experience pregnancy spotting, and not all of these are due to an ectopic pregnancy or will lead to pregnancy loss. (1)

How Serious Is It?

It’s a very serious condition considered a medical emergency. In an ectopic pregnancy, the pregnancy isn’t viable and should be terminated immediately because a ruptured fallopian tube can cause massive blood loss. If left untreated, it could be fatal to the mother.

Symptoms Of An Ectopic Pregnancy

Early Warning: What Are The First Signs Of An Ectopic Pregnancy?

You might experience abdominal pain, diarrhea, vomiting, and dizziness after a missed period. However, these symptoms might also be mistaken for morning sickness or other common early pregnancy symptoms.

The Most Common Symptoms

Some studies showed that about 9% of women with an ectopic pregnancy show no symptoms, while a third don’t show clinical signs such as pain and adnexal tenderness (pain in the area of the uterus). (1) Still, two-thirds of patients could show the following common symptoms: (1)

Vaginal bleeding Stomach or abdominal pain Shoulder pain Discomfort in the toilet

Vaginal Bleeding

Spotting or vaginal bleeding at around 6-10 weeks’ gestation is one of the most common signs of an ectopic pregnancy. (1) If you experience any form of heavy bleeding during pregnancy, with or without pain, be sure to immediately seek immediate medical advice or attention from you OB-GYN or fertility doctor. An ectopic pregnancy might require emergency surgery, depending on the situation: (1)

Where the fertilized egg implanted Current size of the embryo Situation in the fallopian tube (e.g., ruptured tubes)

If the embryo is still small, it might be possible for the pregnancy to be terminated using medication instead of surgery, but only your doctor can determine what’s right for you.

Abdominal Pain: What Do Ectopic Pregnancy Pains Feel Like?

Not all women with an ectopic pregnancy can experience pain. Others might have severe, persistent, unilateral pain (just on one side). (1) Abdominal tenderness may be experienced by more than 75%. (1)

Discomfort On The Toilet

Symptoms might differ among patients, but these are commonly reported: (1)

Pain or discomfort while urinating or pooping Changes in your pooping or peeing patterns Possible diarrhea

Danger Signs & Emergency Symptoms

Signs Of A Fallopian Tube Rupture

If not discovered early, the embryo could continue growing in the fallopian tube, causing it to split or rupture. This is a medical emergency.

Severe, Unilateral Pelvic Pain

In most cases, severe pelvic pain could signify something is wrong with your pregnancy, but unilateral (one-sided) pain might indicate an ectopic pregnancy. (1)

Bleeding or Hemorrhage

This type of bleeding could appear heavier than your menstrual period and may contain clots.

Shoulder Pain

Not all women experience vaginal bleeding because some might have internal bleeding instead. Surprisingly, this could be indicated by shoulder tip pain (where your arm begins and your shoulder ends). (3) Even as early as the 1920s, pain at the shoulder’s tip has been considered as one of the most common indicators of a ruptured ectopic pregnancy. (3) Researchers believe this pain is due to irritation of the phrenic nerve in your diaphragm. This irritation could cause referred pain (felt elsewhere than the actual nerve location) on your shoulder blade. (3)

Signs Of Shock

Some women might also show signs of shock: (1)

Collapse or falling unconscious Tachycardia (heart rate over 100 beats a minute) Pallor (unhealthy pale appearance)

When To See Your Doctor & Where Can You Get Help

Call your healthcare professional or rush to the ER if you experience any of the symptoms above.

What Are The Common Causes & Risk Factors For An Ectopic Pregnancy?

Previous ectopic pregnancy and miscarriage history Previous or current inflammation and infection Fertility treatments (more details below) and other issues like endometriosis History of surgery in the pelvic area Birth control Smoking Advanced maternal age (35+ years old)

Previous Ectopic Pregnancy & Miscarriage History

Pregnant women with a previous ectopic pregnancy or spontaneous abortion (miscarriage) have a higher risk of experiencing an ectopic pregnancy. (1)(4) A 2012 study in the Journal of Family Planning and Reproductive Health Care showed that women with one previous ectopic pregnancy can have a 12.5% risk, while the risk increases to 76.6% for those who have had two. (1) So, if you have a medical history for any of these, it’s best to consult your doctor and get a pelvic exam as early as possible.

Previous Or Current Inflammation & Infection

Related risk factors: (1)

Confirmed genital infection PID (pelvic inflammatory disease) Chlamydial infection (a common STI or sexually transmitted infection caused by chlamydia)

It’s estimated that infection with Chlamydia trachomatis could account for as many as 30-50% of all ectopic pregnancies. (1) The exact mechanisms are unknown, but researchers believe these infections could distort tubal architecture and affect the tubal microenvironment. (1)

Fertility Treatments & Issues

The following are also considered risk factors: (1)(4)

Unexplained infertility Endometriosis (tissues that usually line the inside of the uterus grow outside) Documented tubal disease Assisted reproductive technology, including IVF (in vitro fertilization)

Studies have also shown that ectopic pregnancy risk could be higher in women receiving reproductive treatment, with or without a history of tubal disease. (5) The rate is slightly higher, at around 3.6%, for those undergoing ZIFT (zygote intrafallopian transfer) and much lower (0.9%) with a gestational surrogate carrying the pregnancy. (5)

History Of Surgery In The Pelvic Area

Scars from a previous surgery might also increase your risks: (1)(4)

Tubal surgery, including tubal ligation for female sterilization Pelvic surgery, including ovarian cystectomy and cesarean section Abdominal surgery, including bowel surgery and appendectomy

Birth Control

These birth control methods might also increase your risks: (1)

Progestogen-only contraception Intrauterine contraceptive device, such as an IUD (intrauterine device)

Smoking

Studies show that smoking could be associated with as much as a third of ectopic pregnancy cases. (1)(4) Researchers believe that smoking might lead to the following, increasing smokers’ risks for a tubal pregnancy: (4)

Altered tubal or uterine microenvironment Altered immunity Delayed ovulation

These studies also show that there’s a dose-effect relationship. This means that those who smoke more (over 20 cigarettes a day) have a higher risk than those who only smoke occasionally. (1)

Advanced Maternal Age

Women older than 35 years old also have a higher risk of ectopic pregnancy. The risk appears to increase with age. (4) Researchers believe this could be due to: (1)

A higher probability of exposure to other risk factors with advancing age An increase in chromosomal abnormalities Age-related changes in a woman’s tubal function might lead to a delay in ovum transport which could result in a tubal pregnancy

Prevention & Risk Reduction

In most cases, ectopic pregnanciescan’t be prevented, but you can reduce some risks, such as quitting smoking or talking to your OB-GYN about your birth control options.

Tests & Diagnosis

Early Screening

Early detection could save your life. Although it isn’t likely to save the pregnancy because the embryo still needs to be removed, early diagnosis can help prevent tubal rupture and bleeding. (1) It also allows the use of medication and other conservative medical treatments or interventions. For example, laparoscopy (surgery with a smaller incision) is preferred over laparotomy (open surgery with a larger incision). (1)

How Early Can You Detect An Ectopic Pregnancy?

It’s usually detected around the eighth week of pregnancy, although bleeding might start as early as the sixth week.

How Can You Detect An Ectopic Pregnancy At Home?

It’s difficult to detect an ectopic pregnancy at home because you’re likely to have a positive pregnancy test even if the embryo had implanted outside your womb. There are currently no test kits to detect ectopic pregnancy at home.

Hospital & Clinical Tests

Urine Tests

These are the fastest tests you can take to confirm your pregnancy, but they can’t determine whether the pregnancy is healthy or viable. An ectopic pregnancy is often detected through a combination of ultrasound exams and blood tests after pregnancy has been confirmed.

Ultrasound Exams

Since the embryo is too small during the early weeks of pregnancy, it might be difficult to detect it using an abdominal ultrasound. Instead, transvaginal ultrasonography (ultrasound scanning) is used to check for the location of the embryo and other factors relevant to your pregnancy. It’s also possible for a transvaginal ultrasound to fail in identifying the actual location of the embryo. It could be listed as a PUL (pregnancy of unknown location). (1) Your doctor will discuss your possible diagnosis and/or further tests needed, especially if the ultrasound results come back as PUL.

Blood Tests

Your OB-GYN might also order tests to check for serial serum beta-human chorionic gonadotropin or β-hCG levels. (1) This is done by measuring your hCG levels on day one, then checking for changes in these levels in follow-up tests. The serial hCG level measurements can help determine the viability of the pregnancy or threatened abortion. In a normal pregnancy, the minimal hCG increase for two days was established at 66%. (1) Still, the acceptable 48-hour increase in hCG levels is 50% and 66% in practice, and some researchers suggest that 35% might still be viable. (1) A very low and rapid decline (down to 21-35%) or an exponentially high increase over two days could indicate a non-viable pregnancy. (1)

Ectopic Pregnancy Treatment

Medication: Methotrexate

Methotrexate treatment is the first option for treatment if: (1)

The patient is hemodynamically stable (with a stable pumping heart and good blood circulation) The tube hasn’t ruptured yet or isn’t in imminent danger of rupturing

Usually administered in a single dose, this drug targets rapidly dividing cells and prevents cytotrophoblast cells from growing. (1) When that happens, hCG secretion will be reduced, and the body will stop producing progesterone to support the pregnancy. (1) With reduced cell viability and growth, the ectopic pregnancy will be terminated. You’re likely to experience vaginal bleeding as your body removes the embryo. Studies show that a single-dose methotrexate treatment has a 93% success rate. (1)

Possible Side Effects Of Methotrexate

Most women are unlikely to experience side effects after methotrexate treatment, except for some discomfort and abdominal bloating around 1-3 days after treatment. (1) However, these rare and potentially serious side effects have also been reported: (1)(6)

Alopecia (hair loss) Significant hepatotoxicity (liver injury or damage) Bone marrow toxicity (reduction in the production of blood cells) Confusion Excessive tiredness Weakness Sore throat, fever, chills, or other signs of infection Difficulty falling asleep or staying asleep Fast heartbeat Unusual bruising or bleeding Changes in skin color Swollen, tender gums Blurred vision Seizures

What To Avoid While Taking Methotrexate

It’s best to avoid the following while you’re taking methotrexate: (6)

Alcohol Folic acid Certain antibiotics, including penicillin

Surgery

Surgical Options

Laparoscopy is a surgery with a smaller incision done using smaller surgical tools with the aid of a camera. This laparoscopic surgery is preferable to the open approach because it usually has: (1)

Shorter operative or surgery duration Lower analgesia (anesthesia) requirements Less intraoperative blood loss Shorter hospital stays

It’s performed on hemodynamically stable patients. This is an open surgery with a larger incision. It’s usually performed after a rupture and when the patient is in a state of shock due to severe blood and fluid loss. (1)

When Is Surgery Needed?

Emergency surgery is needed when the tube ruptures. However, it’s also possible for your doctor to recommend surgery even with an unruptured fallopian tube. Depending on the situation, these options will be considered for removal: (1)

Only the affected section The entire tube

Surgery Risks & Possible Side Effects

Both surgeries are performed under general anesthesia. Side effects can include:

Bleeding Fatigue Infection Infertility (especially if the tube is removed and the other one might also have some issues) Increased risk of another ectopic pregnancy in the future

Home Care After Surgery

Your healthcare provider will provide instructions to help you recover from surgery. Staying infection-free and controlling bleeding are your main goals at home. So, it’s best to keep your surgical wounds dry and clean. Signs of infection after an ectopic pregnancy surgery can include: (7)

Redness Swelling Foul-smelling pus or drainage from the site Excessive bleeding Pain Dizziness or fainting Vomiting Nausea Fever (100.4°F or higher)

Some do’s and don’ts to follow at home:

Don’t lift anything heavier than 10 lbs because that can strain your incisions and lead to bleeding. Climb stairs slowly, but avoid them as much as possible. Avoid exercise and other strenuous activities until you get your doctor’s approval. Ask your doctor when it’s alright to resume sex. Avoid constipation by drinking at least eight glasses of water a day and eating more fiber.

Outlook & Complications Of An Ectopic Pregnancy

Prognosis: Can My Embryo Survive An Ectopic Pregnancy?

No. The tissues outside your uterus can’t provide the necessary blood supply and support for your embryo. So, even if it grows initially, ultimately, the embryo won’t survive.

How Long Can An Ectopic Pregnancy Last?

Most ectopic pregnancies typically only last the first trimester, but some rare cases have been discovered in the second semester. (8)

How Will I Feel After Ectopic Pregnancy Treatment?

You’re likely to feel tired and experience some abdominal discomfort after treatment.

Can I Still Get Pregnant After Experiencing Ectopic Pregnancy?

Yes. Your ovary will continue producing eggs that could still be fertilized as long as your fallopian tubes aren’t blocked.

Can I Still Get Pregnant If My Fallopian Tube Was Removed?

Yes, if the other tube is healthy. Or if you undergo assisted reproductive treatments.

Can My Ectopic Pregnancy Affect Any Future Pregnancies?

Unfortunately, yes. Possible risks for women with a previous ectopic pregnancy: (1)

12.5% risk after one pregnancy 76.6% risk after two pregnancies

Can I Still Experience A Healthy Pregnancy After An Ectopic Pregnancy?

Yes. A history of ectopic pregnancy doesn’t pose a 100% risk of a repeat for future pregnancies. (1) Many women are able to conceive a viable, intrauterine pregnancy (normal pregnancy) and give birth to healthy babies despite a previous tubal pregnancy. (1)

How Long Must I Wait Before Getting Pregnant Again?

Talk to your OB-GYN about future pregnancies because it’s best to wait until your fallopian tubes are fully healed to reduce the risks of another ectopic pregnancy.

Where Can I Find Emotional Support?

Your healthcare provider can recommend a counselor or support group. REFERENCES (1) https://srh.bmj.com/content/37/4/231.full (2) https://www.researchgate.net/publication/344549970_Ruptured_Tubal_Ectopic_Pregnancy_at_Fifteen_Weeks_Gestational_Age (3) https://www.nejm.org/doi/pdf/10.1056/NEJM192412111912404 (4) https://www.researchgate.net/publication/10936428_Risk_Factors_for_Ectopic_Pregnancy_A_Comprehensive_Analysis_Based_on_a_Large_Case-Control_Population-based_Study_in_France (5) https://journals.lww.com/greenjournal/Abstract/2006/03000/Ectopic_Pregnancy_Risk_With_Assisted_Reproductive.11.aspx (6) https://www.ucsfhealth.org/education/faq-methotrexate (7) https://www.saintlukeskc.org/health-library/after-laparoscopic-treatment-ectopic-pregnancy (8) https://casereports.bmj.com/content/2017/bcr-2017-221433