Also known as a tubal pregnancy, an ectopic pregnancy is a heartbreaking—and potentially dangerous—complication. Obstetric technology has made detecting and treating the condition much more effective.
Normally, conception occurs not in the uterus but in the fallopian tubes. The fertilized egg then moves into the uterus where it should implant in the lining of the uterus. When the embryo implants anywhere other than the uterine lining it is called an ectopic pregnancy. “This type of pregnancy is estimated to happen in two percent of all pregnancies,” explains Dr. Mark P. Trolice, MD, director of Fertility C.A.R.E., in Winter Park, Florida. “Ninety percent of all ectopics occur in the fallopian tube. More infrequently they can occur in the cervix, ovary, or abdomen. Ectopic pregnancies can also occur with in vitro fertilization (IVF), about three to five percent of the time,” he says.
As the embryo grows outside of the uterus it is usually in a confined space, such as the fallopian tube. Eventually, the embryo enlarges the tube to the point of rupturing it, which causes hemorrhaging and loss of the fetus. This hemorrhaging can be so severe as to cause shock and death. Thankfully, diagnosis can occur before something so drastic occurs.
Ectopic pregnancies are more common than people often think, according to Dr. Susan Klugman, MD, an OB-GYN and reproductive geneticist at Montefiore Medical Center, Bronx, New York.
Because ectopic pregnancy is potentially a life-threatening situation, women need to be aware of the signs and symptoms. These include lower abdominal pain and bleeding in early pregnancy. “These are very common symptoms so it is important to have an obstetric provider prior to conceiving. It is also important to get early prenatal care, and if there are any issues at all, an early sonogram to check for the location and viability of the pregnancy,” Dr. Klugman advises.
Women most at risk include those who have had sexually transmitted diseases, women who have had pelvic inflammatory disease, those who use an intrauterine device (IUD), and women who have had surgery, such as tubal ligation and reversal. These situations can all leave a scarred path that the fertilized egg may get hung up on while trying to navigate its way to the uterus for implantation. “Women who have had a previous ectopic are at the greatest risk, with about 10 to 15 percent recurrence,” Dr. Klugman says. Dr. Trolice emphasizes that it is important for women who have had a prior ectopic to have close monitoring in the first trimester of any subsequent pregnancies.
The diagnosis and treatment of ectopic pregnancy has changed in the last century. “In the beginning of the 20th century, ectopic pregnancy was almost completely a fatal diagnosis. At the end of the century, we were so in tune with early diagnosis we were preserving a woman’s fertility,” he says, explaining that now a major concern is not just saving the woman but also preserving her ability to have children in the future. “It is really remarkable the change that has occurred in a tubal pregnancy.”
With medical advances, such as transvaginal ultrasound (using a smaller probe inserted directly into the vagina) and sensitive hormone assays, doctors can zero in on this type of pregnancy as much as one week earlier than previously. To help determine the health of pregnancy, the pregnancy hormone human chorionic gonadotropin (hCG) is measured. This is the hormone that is only secreted during pregnancy or, rarely, in a tumor.
“If a patient is without symptoms we can use the actual level of the hormone as a ‘discriminatory zone’ to indicate an ectopic pregnancy. What that means is that when it is above a certain level, if we don’t see a pregnancy inside the uterus, it is an ectopic pregnancy until proven otherwise,” Dr. Trolice explains.
Once a pregnancy is discovered to be ectopic, doctors work with patients to determine the best course of action to remove the fetus without further harming the fallopian tube. Several different treatments exist, including medication and surgery. Dr. Klugman points out, “Medications, such as methotrexate, are used much more frequently lately as we are ‘catching’ ectopic pregnancies earlier with the more frequent use of early sonograms and early pregnancy tests. Treatments are based on the patient’s symptoms.”
While some patients experience abdominal pain and bleeding (or hemorrhage) and head to their gynecologist, other women, especially those seeking fertility treatment, may have no obvious symptoms in the beginning of an ectopic pregnancy. Other women miscarry these pregnancies. This may appear as an “ordinary” miscarriage.
“If the patient is without symptoms, her hormone level is not too high, and if the gestational sac is not too large, methotrexate is used to help break up the pregnancy tissue. This treatment, which is [used for] 90 percent of patients, may take several weeks to resolve.” Dr. Trolice says, adding that early treatment is always better. Patients are followed closely with blood work, to make sure the hormone levels are dropping, which indicates the ectopic pregnancy is not continuing.
Surgery for ectopic pregnancy is either laparoscopy or laparotomy, which is used to remove the ectopic tissue and hopefully spare the fallopian tube, notes Dr. Trolice.
Doctors consider surgery if a patient has acute pain or hemorrhage, a prior or recurrent ectopic pregnancy in the tube, or the patient wants tubal sterilization which requires surgery. “Surgical management is usually laparoscopy. It can be an incision in the fallopian tube and removal of the ectopic, and then the tube is closed or allowed to heal on its own. More radically, surgery is used to remove the entire tube if it is ruptured,” Dr. Trolice explains.
“The subsequent ability to conceive is really going to be based on what the other tube looks like. If the first pregnancy a patient has is a tubal pregnancy, that is usually a poor prognosis for pregnancy inside the uterus because whatever caused the tubal pregnancy is [still] going to compromise her ability to get pregnant,” he says.
Experts recommend that women who experience ectopic pregnancy seek grief counseling. “Any patient who loses pregnancy at any time should be offered grief counseling. Most patients have hopes and dreams for their future child and their family, and those are destroyed with a pregnancy loss,” says Dr. Klugman.
After an ectopic pregnancy and a subsequent miscarriage, BabyZone reader Terri Frances “spiraled down into a huge depression,” she says on our online Mom to Mom conversation. “Once I got professional help, my mood started to lift.”
Dr. Trolice agrees. “I don’t think enough people realize that an ectopic pregnancy is a loss like a miscarriage or like a stillbirth. This is a pregnancy that most people have been trying for and it is not being realized. I think it is very appropriate to acknowledge the loss, allow them to grieve, and to help them with counseling,” he says.
Life (and Conception) after Ectopic Pregnancy
Terri Frances went on to conceive a daughter 16 months after she sought help—and another child since then. So, yes, it is possible to bring a baby to term after an ectopic pregnancy. While women who have had one ectopic pregnancy are at greater risk to have another, it all depends upon the condition of the tube that made you prone to an ectopic pregnancy in the first place, says obstetrician/gynecologist Dr. Gerald DiLeo, MD, author of The Anxious Parent’s Guide to Pregnancy. On the other hand, if you ovulate and conceive on the other side and there is no tube damage there, you may be in luck. But it may not be easy.
BabyZone reader Alison Franzen shares, “I had a miscarriage, followed by an ectopic pregnancy that ruptured and left me with one fallopian tube.” After many rounds of Clomid, a “chemical pregnancy,” a 14-week miscarriage, and months of injectable FSH, Franzen did finally conceive and give birth to a healthy boy. How did she and her partner get through it? “I did isolate myself from many friends who all bore children while we were trying, but they were all understanding, considering our circumstances,” she admits. She stresses, however, that the main ingredients to their survival and success were “a lot of hope, tears, talking, togetherness, and faith.”