How to know an ectopic pregnancy

This guide was originally published on May 3, 2019 in NYT Parenting.

An ectopic pregnancy occurs when a fertilized egg implants and grows in the wrong place. Instead of implanting in the uterus, it lands elsewhere — almost always in a fallopian tube, but rarely in other unusual locations, such as in the cervix or ovary. Left untreated, a growing ectopic pregnancy can cause life-threatening internal bleeding, and could eventually rupture the fallopian tube it’s housed in.

The good news is that ectopic pregnancies are relatively uncommon, occurring in just about 1 to 2 percent of pregnancies in the United States. “For someone without the risk factors, chances are they are not going to have an ectopic pregnancy,” said Dr. Jeffrey Ecker, M.D., chief of the department of obstetrics and gynecology at Massachusetts General Hospital. Still, it’s important to know if you’re at risk, and to understand the signs and symptoms, and what to do if you experience them.

For this guide, I spoke with four obstetrician-gynecologists and three psychologists who specialize in pregnancy loss to help you understand how to watch for an ectopic pregnancy, how you might be treated if you have one and what to do afterward.

In a healthy pregnancy, an egg typically gets fertilized in the fallopian tube and then travels to the uterus, where it implants. In an ectopic pregnancy, however, experts generally agree that something impedes this journey, essentially blocking “the normal progress of the fertilized egg,” said Dr. Ecker. It can be due to scarring in the fallopian tubes or other nearby organs, for instance. This can result from past infection with certain S.T.I.s (like chlamydia or gonorrhea), pelvic inflammatory disease (an infection of the reproductive organs) or previous fallopian tube surgery or surgery on nearby organs.

Other risk factors can include:

• a previous ectopic pregnancy

• history of infertility

• use of assisted reproductive technology, including in vitro fertilization

• endometriosis, a condition in which the type of tissue that ordinarily forms the uterine lining grows outside of the uterus

• smoking cigarettes

• being older than 35

The classic and first signs of an ectopic pregnancy, regardless of where it occurs, are often abdominal or pelvic pain, and abnormal vaginal bleeding. These warning signs typically occur early — between weeks 6 and 8 of pregnancy. “The fallopian tube is narrow,” explained Dr. Khady Diouf, M.D., an associate ob-gyn at Brigham and Women’s Hospital in Boston. “For a pregnancy to start there and get really advanced or big before someone has a sign is rare.”

However, symptoms may occur later if the fertilized egg has implanted in a more unusual location, such as in the abdominal cavity. (This can occur when the embryo breaks through a tear in the ovary, fallopian tube or uterine wall and implants in the abdominal cavity; though it’s exceedingly rare.) Some patients may get pain elsewhere, such as in the back. “It’s different for everyone,” said Dr. Ecker. Not all women with an ectopic pregnancy experience these symptoms; some might have no symptoms at all. Others may mistake them for something else, like a miscarriage.

“I think it’s a pretty decent rule that if you’re having bleeding and pain that’s not very brief and is more than just mild, then you need to see a health care provider,” explained Dr. Ecker.

If an ectopic pregnancy grows and causes the fallopian tube or other organ its growing in to rupture or bleed heavily, you might have more intense abdominal pain and bleeding; and also dizziness, light-headedness, pain in your shoulder or low blood pressure.

If your provider suspects an ectopic pregnancy, she’ll typically first measure the level of the pregnancy hormone hCG, or human chorionic gonadotropin, in your blood. The level will help your doctor figure out if it is a normal pregnancy, as well as if you’re pregnant at all, said Dr. Loretta Strachowski, M.D., a clinical professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco. Your doctor may repeat the blood test later, to see if the hormone is rising at the expected rate of a normal pregnancy or not. In an early normal pregnancy, the hCG level is expected to double in 48 hours; if it’s an ectopic, it won’t rise at that rate.

If you’re pregnant, your provider will likely also do an ultrasound at the same time (or refer you to a lab or imaging center that does it) to see if your pregnancy is where it should be — in your uterus. Under normal circumstances, doctors can spot a pregnancy in the uterus when your hCG level has reached a certain threshold. “If we don’t see a pregnancy in the uterus at that level, then we become more concerned about an ectopic pregnancy,” said Dr. Diouf. You may need to come in again for more blood tests so your doctor can monitor your hCG level and do another ultrasound. “Diagnosis isn’t always made on the first visit,” explained Dr. Strachowski.

Because doctors can’t move an ectopic pregnancy to the correct location in your uterus, you’ll most likely need treatment to remove the pregnancy— either with medication or with surgery.

Medication. The less invasive option is medication, which your doctor will likely try if you’re stable and don’t have certain medical conditions, such as kidney or liver disease. Methotrexate, a chemotherapeutic drug, is most commonly used and is typically injected into your upper arm or buttocks in one dose (or possibly multiple doses). It “basically stops the ectopic pregnancy from growing,” explained Dr. Andrew Horne, M.B., Ch.B., a professor of gynecology and reproductive Science at the University of Edinburgh. Common side effects include mouth sores and skin inflammation.

Follow-up appointments — which are typically scheduled two or three days after treatment, and again a few days after that — will ensure your hCG level is dropping and that the drug is working. If it is, you’ll then have weekly visits until your provider has determined that the hormone level has diminished to the point where you’re no longer considered pregnant.

In 7 to 14 percent of cases, the ectopic pregnancy will still rupture the organ where it occurs, even with treatment. It’s also possible that the drug won’t completely resolve the ectopic pregnancy, and you might still end up needing surgery. For these reasons, it’s important to attend follow-up visits. If you can’t, methotrexate may not be the right option for you.

Surgery. If you’re not a candidate for methotrexate, or if the ectopic pregnancy has already ruptured, you’ll probably need surgery.

This will likely entail a minimally invasive laparoscopic surgery, which involves making a small incision in the abdomen, removing the ectopic pregnancy and closing the tube. In some cases, your surgeon may decide it’s necessary to remove the whole fallopian tube. Less often, your surgeon may need to perform a more invasive surgery, such as if your fallopian tube has ruptured, you’re bleeding heavily and you’re unstable, explained Dr. Strachowski.

Pregnancies that implant in more atypical locations (such as in the cervix or abdomen) may get treated a little differently, said Dr. Strachowski.

From a medical perspective, there’s not much to do after you’re treated. If you received methotrexate, your doctor will likely direct you to abstain from heavy exercise and vaginal intercourse for some time to help prevent the possibility of rupture. She will also probably tell you to avoid foods with folic acid, which counter methotrexate, as well as certain medications, such as NSAIDs (aspirin and ibuprofen). Avoid the sun to limit skin irritation and damage; as well as alcohol to decrease the burden on your liver. Experts also advise not getting pregnant for at least three months following the injection to ensure that the drug has completely cleared your system, and to avoid breastfeeding. Discuss these potential side effects and precautions to take (and how long to take them) with your provider.

If you had a straightforward laparoscopic surgery, you’ll likely recover within a couple weeks. You may have a small amount of vaginal bleeding post-surgery, though it should clear within a week. “Pain is usually not a big issue, and most can get by with Tylenol and ibuprofen for a few days,” said Dr. Diouf. If you had a more invasive surgery, you may need stay in the hospital for a day or two, and recovery may take several weeks.

Having an ectopic pregnancy can be a traumatic experience, both because of the pregnancy loss and the potentially life-threatening condition. You may feel sad, angry, depressed, anxious, irritable, worried or like you’re detached or have lost interest in life. You might also experience sleeplessness, nightmares or intrusive memories of the experience, which could be unsettling.

These feelings are normal, said Dr. Kristin Calverley, Ph.D., a clinical assistant professor of psychology at the University of Texas in Houston. “I would encourage people to allow their emotions, to let them out and recognize that it’s O.K. to feel a variety of different ways,” she explained. It’s also important to not blame yourself for the ectopic pregnancy and to remember that it’s never your fault.

Still, if you’re struggling emotionally, reach out to family, friends, your partner or even join a support group or seek out counseling, if possible. It’s also important to prioritize self-care, such as eating healthfully, exercising and getting enough sleep.

Psychological symptoms will mostly resolve within three to six months for many women, said Dr. Pamela Geller, Ph.D., an associate professor of psychology, obstetrics and gynecology, and public health at Drexel University. “However grieving is very individualized, so the timeline is variable and it is not uncommon to experience grief symptoms up to about 18 to 24 months post-loss,” Dr. Geller explained. Experts also note that future pregnancies may re-trigger symptoms, so that’s something to watch for.

Many women who have had an ectopic pregnancy go on to have healthy, normal pregnancies later on. But according to Dr. Ecker, an ectopic pregnancy — which can damage your fallopian tube, or might signal an already existing issue — can increase your risk for future fertility troubles (regardless of where your ectopic pregnancy occurred, whether it ruptured or how it was treated). Studies suggest that if you previously had an ectopic pregnancy, your risk for having another will increase from 1- to 2-percent up to as much as 15 percent.

If you do become pregnant again, the best thing you can do, according to Dr. Diouf, is to alert your doctor as soon as possible so she can monitor you early on for ectopic pregnancy (since you’re at higher risk). Talk with your doctor about your individual case.

If you experience any of the early symptoms of ectopic pregnancy — abdominal pain or abnormal vaginal bleeding — call your doctor.

If the pain is severe and acute in onset, contact your doctor immediately — especially if you’re also experiencing dizziness, light-headedness, pain in your shoulder or neck, or nausea and vomiting. If you can’t reach your doctor, go to the emergency room. “Very rarely, things can come on in a severe and sudden way, and absolutely, if you don’t think there’s a safe alternative, then you need to go to an E.R.,” said Dr. Ecker.

In many cases, noted Dr. Ecker, the symptoms present early enough that you and your doctor will be able catch the ectopic pregnancy before it becomes an emergency.

If you were treated with methotrexate, pay attention to any pain after the injection. A little pain and discomfort is normal, said Dr. Diouf, but if it’s not going away or is worsening, “you should come to the emergency room because you could have a pregnancy that’s rupturing.”

[Read our guide to five common childbirth complications.]

Annie Sneed is a science journalist who has written for Scientific American, Wired and Fast Company.