Pl - 524.1 - Ectopic Pregnancy

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We are sorry that you were found to have an ectopic

pregnancy today. We have compiled this leaflet to provide

you with information to help you to understand the causes of

ectopic pregnancy and its implications on your health.

What is an ectopic pregnancy?

An ectopic pregnancy is apregnancy which is implanted

outside the uterus (womb). Thisoccurs in approximately 2% of allpregnancies. The most commonsite for ectopic pregnancyimplantation is in the fallopiantube, which transports the eggfrom the ovary to the womb.

The normal process of implantationoccurs after the fertilised eggtravels along the fallopian tubeinto the womb. The fertilised eggusually implants in the womb sixto seven days after conception.However, with an ectopic

pregnancy the fertilised egg doesnot reach the womb in time andimplants in the fallopian tube.Unfortunately, once the pregnancyimplants in the tube, it can nevermove into the womb. In mostectopic pregnancies, the baby does

not grow normally or develop aheartbeat. This is like a miscarriagethat happens in the tube.

What causes ectopicpregnancy?

In many cases there is no obvious

cause for an ectopic pregnancyand it is likely that the pregnancyimplants outside the womb bychance. However, it is also knownthat there are several risk factorswhich increase the chance ofectopic pregnancy.

Pelvic infection:Women whohave previously experienced aninfection in the pelvis have a higherrisk of developing an ectopicpregnancy. Sometimes infectionsmay be silent and they can onlybe detected at the operation to

remove ectopic pregnancy. Pelvicinfections can cause scar tissue(adhesions) within the pelvis. Thiscan damage fallopian tubes andincrease the chance of a pregnancyimplanting there.


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Previous abdominal surgery:Operations on the abdomen tendto form scar tissue (adhesions) in asimilar manner to pelvic infection.For this reason, previous operations

such as an appendicectomy orovarian cystectomy may increasethe chance of developing anectopic pregnancy.

Age:The incidence of ectopicpregnancy increases steadily withage from 1.4% of all pregnanciesat the age of 21 years to 6.9% ofpregnancies in women aged 44years. The reason for this rise is notclear.

Previous ectopic pregnancy:Women who have had an ectopic

pregnancy in the past have abouta one in 10 chance of developinganother one.

Is ectopic pregnancy a serioushealth problem?

Most ectopic pregnancies do notcause significant health problemsand they do not require anymedical intervention. However, anumber of ectopic pregnanciescan cause severe abdominal pain

and bleeding, which could put awomens health at serious risk.

It is therefore important that anectopic pregnancy is diagnosed asearly as possible in order to detectthose ectopic pregnancies thatcould lead to health problems.

Surgery or medical treatment ofectopic pregnancy also carries asmall risk of complications, whichcould affect womens health. It isalso important to remember thatwomen who have suffered anectopic pregnancy are at increasedrisk of having another ectopicand may experience difficulties ingetting pregnant again.

Can an ectopic pregnancy resultin a birth of a healthy baby?

There are reports of healthy babiesdelivered in women with anundiagnosed ectopic pregnancy.However, these cases are very rareand the vast majority of ectopicpregnancies cannot develop

beyond a very early stage ofpregnancy.

If an ectopic pregnancy continuesto grow it poses a severe risk tothe mothers health and the onlysafe option is to remove it by

surgery as soon as possible.


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What are the symptoms of anectopic pregnancy?

It is not usually possible todiagnose an ectopic pregnancy

from symptoms alone. The mostcommon symptoms are pain,which is typically accompaniedby vaginal bleeding or spotting.However, some women will haveno symptoms at all in the earlystages of ectopic pregnancy.

How is an ectopic pregnancydiagnosed?

Ectopic pregnancy is routinelydiagnosed on transvaginal(internal) ultrasound scan.

However, sometimes a very smallectopic pregnancy cannot beseen on the scan. In these cases ablood sample is taken to measurepregnancy hormones in womensblood.

Occasionally ectopic pregnancywill be first diagnosed duringsurgery if a women presents to theEmergency Department (casualty)with signs of severe internalbleeding.

How are ectopic pregnanciesmanaged?

If you are diagnosed with anectopic pregnancy there several

factors that help us guide youtowards the safest treatment.

These include your: symptoms scan fndings hormone levels

and of course what you wouldprefer to do.

The options for treatment are:

1. Surgical management2. Expectant management

3. Medical management

1. Surgical management

This means operating to removethe ectopic pregnancy. Surgery

to remove the ectopic pregnancyis the most well-establishedtreatment. Situations where werecommend surgery include:

internal bleeding detected onthe scan

ectopic pregnancy with a heartbeat severe pain.


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We will also recommend surgery ifeither expectant management ormedical management fail.

Surgery traditionally involved

laparotomy or an open cut onthe lower abdomen. This route isstill occasionally used when thereis heavy internal bleeding or lots ofscar tissue. The modern techniqueis by laparoscopy or keyholesurgery which allows you to gohome sooner.

You will be asleep for theprocedure (given a general

anaesthetic), which involvesinserting a camera throughthe belly button and insertinginstruments through two smallcuts in the lower abdomen. Thismay involve removing the affectedfallopian tube (salpingectomy),

or just the ectopic itself(salpingotomy).

The fertility rate following asalpingotomy is slightly higherat 65% than following asalpingectomy (55%). Althougha salpingotomy has a more

favourable fertility rate, the riskof women developing anotherectopic is slightly increased (15%)compared with a salpingectomy(10%).

Both methods, therefore, carrysimilar risks. In many cases, asalpingectomy is the only optionas the affected tube is alreadydamaged. There is also a risk ofbleeding from the tube with asalpingotomy and a chance thatnot all of the placental tissue willbe removed. Therefore closer

follow up is required after this typeof operation.

2. Expectant management

This means observing you closely

to see if the ectopic pregnancy is afailing pregnancy and will resolvewithout treatment. At Kings wediagnose a lot of early ectopicpregnancies so this managementis used more often than in otherhospitals. In our unit, about 40%

of ectopic pregnancies will resolvenaturally through expectantmanagement.


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Women who have mild symptomsor no symptoms at all and whohave no internal bleeding foundon scan will have a blood test tofind out the level of pregnancy

hormone present.

The blood result is available thesame day and women often gohome and are contacted by thenurse later that day by phone.From the pregnancy hormonelevel the nurse can tell you thelikelihood of the pregnancyresolving spontaneously. Generally,the lower the hormone level, themore likely this will happen.

If the hormone levels are withina safe range then expectant

management will be offered toyou. This means that you will needto return to the unit regularly tomonitor the blood hormones.If these levels are decreasing,expectant management iscontinued until the levels are back

to normal; this can take anythingfrom two six weeks.

Sometimes the levels will riseslowly to start with and thendecrease after a few days.

Unfortunately, expectantmanagement isnt alwayssuccessful. If the pregnancyhormone levels continue to rise orif you develop pelvic pain, we willusually advise you to have surgery.

If your pain increases suddenly, itis very important that you eitherattend our Early Pregnancy Unit(EPU) immediately or, if out ofhours, your nearest EmergencyDepartment.

During expectant managementyou may also experience vaginalbleeding. This is normal and can bea good indicator of the pregnancyresolving.


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3. Medical management

This involves injecting you with adrug called methotrexate, whichstops placental tissue growing and

therefore stops the development ofan ectopic pregnancy.

We only advise this treatment ina small number of cases, mostoften for the rarer types of ectopicpregnancies. It cannot be usedif the diagnosis of an ectopicpregnancy is at all uncertain,as it will usually terminate thepregnancy. Before you are giventhe drug you will have blood teststo check if you are suitable for thistype of treatment.

Follow up blood tests are carriedout for two six weeks afterwardsto check that the treatment hasbeen successful and to monitorany side effects.

The most common side effect

of methotrexate is abdominalpain and it can be difficult to tellwhether this pain is due to internalbleeding or the drug itself. Pleasenotify us of any abdominal painexperienced. If you complain ofpain and are otherwise well, we

will do a scan to check for internalbleeding.

If you have severe pain it isalways best to come to the unitfor assessment or your nearestEmergency Department if it is outof hours.

The other occasional side effectsare conjunctivitis, sore mouth anddiarrhoea.

You should stop taking folicacid, avoid alcohol and sexualintercourse until the hCG isnegative. Aspirin and ibuprofenshould be avoided for a weekfollowing the administration ofthe drug. Paracetamol is safe (twotablets, up to four times a day).

You will need to use a reliable

method of contraception for threemonths afterwards this treatment,as there is a small risk of the babydeveloping abnormalities if youconceive too soon.

Both expectant and medicalmanagement carry a small riskthat the ectopic pregnancy canrupture, even with fallinghormone levels. We thereforeadvise that you stay within easytravelling distance of Kings

or your local hospital, until yourfollow up is complete.


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Consent

We must obtain by law yourwritten consent to any operationand some other proceduresbeforehand. Staff will explain allthe risks, benefits andalternatives before they ask youto sign a consent form. If youare unsure about any aspect ofthe treatment proposed, pleasedo not hesitate to ask to speak

again with a senior member ofstaff from EPAGAU.

Emotions and feelings

It can be easy for people to forgetduring all of the investigations andtreatment that a pregnancy hasbeen lost; and for many womenand their partners, a much wantedpregnancy.

Women who were unsure aboutwhether to continue with thepregnancy or who did not realisethey were pregnant also have

complex emotions to cope with.In addition to this, anaestheticsand pregnancy hormones affectfeelings and moods.

What are the risks and benefits of the different options?

Advantages Disadvantages

Surgical: Quickest and most Risks of surgical

salpingectomy effective complications

Surgical: Saves affected tube Risks of surgical salpingotomy complications.

Residual ectopic tissue may need further

treatment

Expectant No risk from surgery Longer follow up. No hospital stay May still need surgery Saves affected tube

Medical No risk from surgery Longer follow up. May No hospital stay still need surgery (10%) Saves affected tube Side effects of the drug


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It is not surprising that somewomen experience a period ofdepression or grief following anectopic pregnancy.

Common expressions of griefinclude tearfulness, anger andguilt. These are normal and tendto ease with time. If these feelings

continue or you feel that youand/or your partner would benefitfrom psychological support, pleasecontact the senior nurse in EPUwho will discuss this with you.A counselling service is availablewhich you can be referred to.

Future pregnancies and tryingagain

If you would like to try for anotherpregnancy we advise that you

wait for your next period beforetrying again. If you should getpregnant before this, this shouldnot increase you chance of havinganother ectopic pregnancy.

Some women may need a littlemore time to recover emotionallyand physically. The best time tostart again is when you and yourpartner feel ready to do so.

The chance of having a normalpregnancy in the future dependson the condition of your remaining

fallopian tube/s and your age. Ingeneral women who suffer anectopic pregnancy have reducedchances of becoming pregnantagain, but the majority womenwill conceive and have a successfulpregnancy.

If you undergo surgery, thesurgeon will discuss with you thestate of your unaffected tube andovaries. It is reassuring if these allappear normal.


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Becoming pregnant again afteran ectopic pregnancy may seemdaunting and women often feelscared and anxious that it willhappen again. Although, the risk

of developing another ectopicpregnancy is higher next time, it isimportant to remember that manywomen go on to have normalpregnancies next time round.

If you become pregnant again itis very important that you attendour unit for an early scan as soonas you find that you are pregnant.This is to check that the pregnancyhas implanted in the womb. If wecannot see the pregnancy initially,you will be monitored closely todetect another ectopic as early as

possible.

Unfortunately, if there is alreadydamage to your fallopian tubes,there is very little that can be doneto reverse this damage. If thisdamage is severe, our doctors may

talk to you about being referred toa fertility clinic. We have a clinic atKings, which is called the AssistedConception Unit. If you have anyqueries about the referral processplease discuss it with your GP orcontact the staff in EPU.

Contraception

The progesterone only pill(mini pill) and IUCD (coil) arenot recommended methods of

contraception for women whohave had an ectopic pregnancyin the past. If you need advice ona suitable method please consultyour GP or local reproductive andsexual health clinic (family planningclinic).

Queries and concerns

Should you have any questionsplease contact the staff in ourclinic on 020 3299 3168 who

will be happy to talk to you.

Early Pregnancy Unit openingtimes:

Monday Friday:9am 12pm (walk-in clinic)

2pm 5pm (emergencies only)


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PALS

The Patient Advice and LiaisonService (PALS) is a service thatoffers support, information and

assistance to patients, relatives andvisitors. They can also provide helpand advice if you have a concernor complaint that staff have notbeen able to resolve for you.The PALS office is located on theground floor of the HambledenWing, near the main entranceon Bessemer Road - staff will behappy to direct you.

Tel: 020 3299 3601Textphone: 020 3299 1878Fax: 020 3299 3626Email: [email protected]

If you would like this leaflet ina different format or languageplease contact PALS on020 3299 3601

External sources of further helpand advice

Leaflets for both of these supportgroups are available in our unit.

The Ectopic Pregnancy TrustC/O 2nd Floor,Golden Jubilee WingKings College HospitalDenmark HillLondon, SE5 9RS

Helpline: 020 7733 2653www.ectopic.org.uk

The Miscarriage AssociationC/O Clayton Hospital

NorthgateWakefieldWest Yorkshire, WF1 3JS

Tel: 01924 200799Fax: 01924 298834www.miscarriageassociation.org.uk


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Your notes:

www.kch.nhs.uk Corporate Comms: 0190PL524.1 January 2012 Review date January 2015

Pl - 524.1 - Ectopic Pregnancy

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