Ectopic Pregnancy: Symptoms, Treatment and What Comes Next

The test has been positive for a few days. Then a dull pain appears, on one side of the lower abdomen, with a little brown discharge. This picture is not always serious, but it should make you think of an ectopic pregnancy, which needs to be seen by a doctor the same day.

Treated properly and in time, it can be dealt with and usually leaves the door open to a future pregnancy. Here are the signs to know, what happens at the hospital, and what comes afterwards, including emotionally.

What is an ectopic pregnancy?

It is a pregnancy that implants outside the cavity of the womb. In the vast majority of cases, the fertilised egg settles in a fallopian tube, the small duct that connects the ovary to the womb. More rarely, it attaches to an ovary, in the abdomen or on the cervix. In French it is called grossesse extra-utérine (GEU), which you may see on Moroccan medical reports.

Such a pregnancy cannot develop into a baby. The UK’s NHS says it clearly: it cannot be saved, and usually has to be ended with medication or surgery. As it grows, it can make the tube rupture and cause internal bleeding. That is why diagnosis and treatment must not be delayed.

It is not exceptional: about 2% of pregnancies in France, according to a review in La Revue du Praticien, and one pregnancy in 90 in the United Kingdom. The NHS also points out that ruptures, if treated quickly, can be managed well.

Who is at higher risk?

In many cases, no cause is found. Some factors do raise the risk:

• a previous ectopic pregnancy, the main factor;
• a past pelvic infection (salpingitis), often caused by a sexually transmitted infection such as chlamydia;
• surgery on the tubes or in the pelvis, endometriosis;
• smoking;
• age, with the risk highest after 35;
• a pregnancy achieved through IVF or after ovulation stimulation;
• a pregnancy that happens despite a coil (IUD) or while taking the progestogen-only pill.

To reduce the risk, the NHS mentions two things: condoms when you are not trying for a baby, to protect against sexually transmitted infections, and stopping smoking.

What are the symptoms of an ectopic pregnancy?

The signs usually appear between 4 and 12 weeks of pregnancy, counted from the first day of your last period. Sometimes there are none, and a routine scan discovers it. The most common signs are:

• a late period, or signs of pregnancy;
• pain in the lower abdomen, often on one side, dull with sharper peaks;
• light bleeding, dark, almost blackish, or brown watery discharge;
• pain at the tip of the shoulder, typical but often not recognised;
• discomfort when peeing or opening your bowels.

These symptoms can have other causes, a simple stomach bug for instance. But if you could be pregnant, even without a positive test, see a doctor the same day. The other causes of bleeding in early pregnancy are explained in our article on bleeding during pregnancy.

These last signs can indicate a ruptured tube, which needs emergency surgery.

How does the doctor make the diagnosis?

It all starts with confirming the pregnancy, through a urine or blood test. A negative test done by the doctor makes an ectopic pregnancy very unlikely. But a home test is not enough to reassure you if you are in pain or bleeding: see a doctor anyway, who can measure the hormone in your blood. Our article on pregnancy tests explains how to read one. Then come two further tests.

The blood test measures the pregnancy hormone, hCG. In a normal pregnancy, its level roughly doubles every 48 hours. A level that stalls between two tests taken two days apart is a warning sign.

The vaginal ultrasound shows an empty womb, sometimes a mass near a tube or fluid in the abdomen. The gynaecological examination often finds tenderness on the affected side.

It sometimes takes several days, and several blood tests, to be sure. This wait is hard, but it avoids jumping to conclusions, because a normal pregnancy may still be too small to see. The role of each scan is set out in our article on early pregnancy scans.

What are the possible treatments?

The choice depends on your symptoms, the size of the pregnancy and your hCG level. Your doctor will explain the benefits and risks of each option.

Methotrexate stops the pregnancy from developing. It works in 70 to 80% of cases, according to La Revue du Praticien. The hCG level often takes about a month to become negative. Possible side effects: abdominal pain for a day or two, dizziness, nausea, diarrhoea. The NHS asks you to avoid alcohol until your doctor says otherwise, and reminds you that the tube can still rupture after treatment: keep the emergency signs in mind. The dose is calculated by the medical team, never at home.

Laparoscopy (keyhole surgery) allows the surgeon either to open the tube to remove the pregnancy while keeping the tube (salpingotomy), or to remove the tube (salpingectomy). In France, keeping the tube is preferred when it is only slightly damaged, when the other tube is missing, or depending on your wish for a future pregnancy. In the United Kingdom, the whole tube is more readily removed if the other one is healthy. Either way, the team will discuss it with you beforehand and ask for your consent. You usually leave hospital within a few days, but full recovery can take 4 to 6 weeks. If there is a rupture, surgery is done as an emergency, sometimes through a larger incision.

If you are Rhesus negative, you may be offered an anti-D injection, depending on the case.

Afterwards: fertility, the next pregnancy, emotions

Most women can get pregnant again, even when a tube has been removed. According to La Revue du Praticien, later fertility does not differ between keeping and removing the tube. Fertility treatment is sometimes needed.

The risk of it happening again is real but limited: about 10% according to the NHS, between 10 and 30% according to the French publication. Hence a simple habit: as soon as you get your next positive test, tell your doctor. An early scan, at around 6 to 7 weeks, will check that the pregnancy is in the right place.

Before trying again, the NHS advises waiting for at least two periods, and three months after methotrexate. French doctors tend to speak of one month after hCG levels return to normal: follow your team’s advice. To spot your fertile days afterwards, see our article on ovulation.

Then there is what cannot be seen. Losing a pregnancy, even very early and even before telling anyone, can be devastating. The NHS notes that many women go through grief comparable to losing a loved one, and that these feelings can last for several months. Worries about fertility sometimes add to it. Ask your doctor all your questions; they can also refer you to a psychologist. Ways to get through this sorrow, alone or as a couple, are in our article on miscarriage and the grief that follows.