The EPT

What should I do in my next pregnancy?

In all cases a woman who has suffered an Ectopic pregnancy should contact her GP as soon as she knows she is pregnant. Usually you will be referred to an Early Pregnancy Unit. Here it is normal to arrange an ultrasound scan at around 6 weeks to check the pregnancy is in the womb. If your period is late, if menstrual bleeding is different from normal or if there is abnormal abdominal pain, you should ask to be examined and remind the doctor if necessary that you have had a previous ectopic pregnancy.

How do I find an Early Pregnancy Unit?

The Association of Early Pregnancy Units runs the Early Pregnancy Information Centre which provides information on how to find your nearest unit.

I can’t get an early scan, what can I do?

There are no rules that a gynaecologist or EPU are required to follow in respect of the follow up of women who have a history of ectopic pregnancy.

Ectopic pregnancy can be notoriously difficult to diagnose as it can often present with symptoms which can be suggestive of gastroenteritis, miscarriage or even appendicitis. However, where ectopic is being considered, the EPT and the specialist doctors who advise us suggest that the following is the gold standard. A woman with a history of ectopic pregnancy should be offered an early scan at around six weeks – this is based on the fact that at six weeks there is a reasonable chance of a uterine pregnancy being detected on an ultrasound when it might be difficult to see this any earlier. This should be followed up with beta hCG blood tests 48 hours apart if the scan is inconclusive. Doctors are at liberty to follow their own protocols but in UK it is recommended that they follow the RCOG’s Greentop Guidelines.

If you are unhappy about how your hospital is responding to you, the PALS department at your hospital should also be able to assist you by liaising with the departments to see what can be arranged. You can find your PALS contact details here.

I have had an inconclusive early scan and have been told that I have to wait a week for another scan. Why are they making me wait so long?

It is normal to wait a week between scans.

If the blood levels are not doubling or rising by at least 66% then you should expect a further blood test in that week period but another scan any sooner than a week will not tell the doctors any more than they already know, which is that the uterus is either empty, or there is no evidence of a uterine pregnancy at this point (which doesn’t mean there isn’t one, just that it is too early to see).

The only reason we might expect a woman to be rescanned within the 7 day period, is if she presents with a deterioration of her overall condition. This would be characterised by increased (severe) pain, a feeling of being unwell, and possibly increased bleeding (soaking a pad in less than a couple of hours). The scan would be done simply to confirm that there is blood in the abdomen.

Therefore, if your pregnancy is less than 7 weeks (since the first day of your last menstrual period), you have been scanned and the scan was inconclusive at that point, your beta hCGs are doubling or rising by at least 66% and you have no clinical signs of compromised haemostasis (your blood pressure is within normal limits, your pulse within normal limits and your abdomen not rigid or the patient guarding – tensing to prevent the abdomen from being pressed/palpated by an investigating clinician) then you really are encouraged to wait the week out, so that your next assessment can be a conclusive one.

It is always difficult to make generalisations about individual cases and it stands to reason that if anyone genuinely feels something is wrong they should of course go back to hospital.

What are hcg levels?

The hormone human chorionic gonadotropin (better known as hCG) is produced during pregnancy. It is made by specialised trophoblast cells, which are only found in the body as a result of a fertilised egg implanting, and which eventually would develop into the placenta, which nourishes the egg, after it has been fertilized and becomes attached (ideally) to the uterine wall. hCG can first be detected by a normal blood test about 11 days after conception and about 12 – 14 days by a urine test. In general, the hCG level will double every 48 to 72 hours. The levels will reach their peak somewhere between 8 to 11 weeks of pregnancy (the end of the second beginning of the third month) and then will decline and level off for the remainder of the pregnancy.

About 85% of normal pregnancies will have the hCG level double every 48 – 72 hours. As the pregnancy progresses and the hCG level gets higher, the time it takes to double can increase to about 96 hours.

What do they tell us?

They tell us that a fertilised egg has implanted. If levels are rising normally, they can give a suggestion (but not a certain answer) that the pregnancy is implanted in the uterus. If they are rising by less than 66% over 48 hours this suggests (but is not a certain indication) that the pregnancy may be ectopic. If they are falling over this time period, it tells us that the pregnancy has ended and will be miscarried over the next days or weeks.

Why do women need to wait until hCG levels are a certain number before they start trying to conceive again after an ectopic pregnancy or other loss?

If a woman has hCG levels in her system because of a growing pregnancy, then the hCG naturally suppresses ovulation. It is not possible to become pregnant a second time until the hCG levels have fallen to a level of less than 5mIU/mL

Should I know what my level is?

Your hCG would only need to be tested if you have reached 6 weeks pregnant and the scan does not clearly show a developing pregnancy in the uterus. The hCG can then indicate a failing pregnancy or ectopic pregnancy as described above.

How many scans will I have, and when?

According to NICE Antenatal Clinical Guidance, all women should be offered 2 scans in the first half of pregnancy. The first is a dating scan that is done between 10 and 18 weeks (but the earlier the better) in terms of accuracy of an estimated date of delivery and an anomaly scan between 18-21 weeks to determine that the baby is developing and growing as would be expected and there is nothing out of the ordinary in terms of development of organs, arms legs and head.

It is only usual to offer further scans if there are any concerns about your baby’s growth, development or position, or if there is any concern about placental position. If further scans are arranged your Midwife or Obstetrician should explain the reasons why.

Is spotting normal in pregnancy?

It is actually very common for women to report spotting in early pregnancy – around 30% of women who do begin to bleed or spot early on do actually go on to have healthy pregnancies, so spotting does not necessarily mean that anything is wrong.

Some doctors suggest that between day 20 and day 28 of a cycle women might experience implantation bleeding – although there is little research to underpin this.

It is known that at the point of ovulation, a corpus luteum is formed and this can go on to develop into a (healthy) cyst which actually helps to stimulate the ovary to produce progesterone. This in turn sustains the pregnancy whilst the placenta is growing to take over the job of balancing hormones. Sometimes these cysts can rupture and this can result in a little spotting or bleeding.

Women who go on to have healthy babies often report spotting or bleeding on or around the day their period was actually due (and this is how some women are fooled into believing they are less pregnant than they actually are). Sometimes the bleed can be so significant that the woman believes she is not pregnant.

Recent research has suggested that as many as one in eight of us begins life as twins. However, the second pregnancy may end very early, which could be another cause for bleeding in an early pregnancy which then results in a healthy baby.

Miscarriage, however, is very common in early pregnancy  and spotting and bleeding this early can often be an indication that the pregnancy is not continuing.

What about heavier bleeding?

• Bleeding during early pregnancy is not unusual, although in most cases the reason for bleeding is unknown. It is thought that although the hormones of your cycle are suppressed, variations in this cycle continue. This could explain why some women report spotting around the time a period would have been due.
• If the bleeding is light, and is not accompanied by abdominal cramping or pain then it is unlikely that there is anything to worry about. If it continues and you have abdominal cramps or any pain, you should see your midwife or doctor who should arrange for you to be scanned.
• Bleeding later in pregnancy can be due to a cervical ectropian. This is when the surface of the cervix becomes raw and is a result of hormonal changes. Sexual intercourse can aggravate cervical ectropian, stimulating bleeding. A doctor can diagnose the condition by inserting a speculum into the vagina and looking at the cervix. Bleeding from a cervical ectropian is not harmful for the baby.
• Bleeding, especially during later pregnancy, may be due to:

1. placental abruption – when the placenta partially, or totally, detaches from the wall of the womb. If it is a very small area that comes away, it need not affect the baby, but if it is a larger area, the transfer of oxygen and nourishment can be impaired which is more serious. Symptoms of abruption can also include sudden abdominal pain with a hard and tender uterus.
2. placenta praevia – where the placenta covers, or partially covers, the cervix. As the cervix begins to change and prepare for labour, it can cause partial detachment of the placenta, which leads to bleeding. Bleeding due to placenta praevia is not usually accompanied by abdominal pain.

• If you lose a mucusy discharge tinged with blood during late pregnancy, you may be having a ‘show’. This is when the plug of mucus which seals the cervix during pregnancy comes away. You can have more than one show as the plug of mucus is coming away. It is perfectly normal to experience this, and it can mean that labour isn’t far away.
• It is very important that you seek medical advice for any type of bleeding at any stage of pregnancy. Serious causes for bleeding must always be ruled out.

Is it normal to have pelvic pain early in pregnancy?

Pelvic pain is quite common in pregnancy. It is linked to the soft area that supports your pelvis, the symphysis pubic joint. The joint can swell or separate, which then causes considerable pain. It is thought to be caused by the hormones of pregnancy, although no one is really certain. It is less common in early pregnancy, but not unheard of.

Pain in this area is commonly termed Symphysis Pubis Dysfunction or SPD. Some areas have a specialist physiotherapist who cares for pregnant and postnatal women. Your GP or midwife should be able to refer you. Even if your area does not have a specialist, a referral to the physiotherapy team may be useful.

Most women feel the pain most when walking and lying down. You may need to change your footwear to make walking less painful. Some women find the use of pillows to support the hips and legs when in bed to be a great help.

Is it OK for me to have the occasional glass of wine?

The NHS standards watchdog, the National Institute for Health and Clinical Excellence (NICE) looks at the available evidence on the best way of treating or managing a condition and makes recommendations based on this evidence. Doctors, nurses and other healthcare professionals in the NHS are expected to follow NICE’s clinical guidelines. NICE has changed its advice for pregnant women, recommending they should drink no alcohol during the first three months of pregnancy, and if they choose to drink after this period, to have a maximum of two units once or twice a week. This recommendation about drinking alcohol during pregnancy came about as part of an update to its antenatal guidelines. This provides advice about all stages of pregnancy care, including screening, testing and check-ups.

NICE’s wording is as follows:

* Pregnant women and women planning a pregnancy should be advised to avoid drinking alcohol in the first three months of pregnancy if possible because it may be associated with an increased risk of miscarriage.
* If women choose to drink alcohol during pregnancy they should be advised to drink no more than one to two UK units once or twice a week (one unit equals half a pint of ordinary strength lager or beer, or one shot [25 ml] of spirits. One small [125 ml] glass of wine is equal to 1.5 UK units). Although there is uncertainty regarding a safe level of alcohol consumption in pregnancy, at this low level there is no evidence of harm to the unborn baby.
* Women should be informed that getting drunk or binge drinking during pregnancy (defined as more than five standard drinks or 7.5 UK units on a single occasion) may be harmful to the unborn baby.

Until 2008 the EPT advised that consuming alcohol  in moderation when planning a pregnancy was OK. However, research over the last 3 years refutes this and so we have no alternative but to suggest that women planning pregnancy or in their first trimester, should abstain from alcohol.

I’m not sure what I can and can’t eat whan I am pregnant.

The Food Standards Agency offers good advice about what foods should be avoided and why.

Are sunbeds safe in pregnancy?

No one knows for sure whether sun beds are safe during pregnancy. There is no evidence-based research available to confirm that sun beds cause harm to the unborn baby, but it has been reported that a raise in the core temperature of the mother may in turn increase the temperature of the foetus. Having an elevated body temperature during pregnancy (eg in a tanning bed, hot tub, or sauna) has been linked with spinal malformations in developing babies. If this rise in temperature were maintained for long enough it has been suggested that it may also cause brain damage.

Your own health needs to be considered too. Generally the advice is to limit sun bed use and exposure to the sun, whether pregnant or not, because of the increased risk of skin damage leading to higher incidences of skin cancer. Tanning beds/booths pose the same dangers as the sun, emitting ultraviolet (UV) radiation, which causes skin cancer. Studies suggest that tanning increases the chance of developing melanoma, which is one of the most deadly types of cancer.

We would advise that you stop or limit your sun bed sessions, and take extra precautions when sunbathing, use a higher factor sun cream and limit exposure to the sun, particularly when it is at its strongest around midday and early afternoon.

Is it OK to smoke during pregnancy? I’m finding it hard to stop – is cutting down OK?

Smoking involves inhaling carbon monoxide and nicotine which then pass out of your lungs and into your bloodstream. The nicotine makes it harder for your baby to get oxygen and so causes its heart to beat beat faster. This means that your baby may not grow at the rate that it should do. Cigarette smoke contains toxic substances which change the blood’s ability to work in a healthy and normal manner. This can affect the placenta which feeds your baby.

Passive smoking during pregnancy can still affect your baby. After birth, babies exposed to smoke are more likely to suffer from conditions such as asthma, and frequent chest infections. There is also a significantly higher risk of sudden infant death, also known as cot death, if either you or your partner smokes. It is never too late to stop smoking. Every cigarette you decide not to smoke will help you and your baby’s health.

It may be tempting just to cut down, but many smokers find they inhale more deeply when smoking fewer cigarettes. So although the number of cigarettes decreases, the intake of damaging substances does not decrease significantly.

Stopping smoking is extremely difficult. However, there is suport and advice available. You can phone Quit, the national quit line on 0800 00 22 00. Your midwife or practice nurse from your local health centre can also offer lots of support, advice and help. Evidence shows that counselling by qualified health professionals can double quit rates for pregnant women.

Is it safe to colour my hair when pregnant?

Chemical dyes that contain ammonia, oxides and or peroxide result in traces of chemicals and metals or heavy metals being detected in the mother’s liver up to 12 hours after the hair has been treated with colour.

Unfortunately, to design a study that would prove or disprove that there is a danger or a risk, would be utterly unethical (because you would have to colour the hair of a large number of women with chemical dye and find a way of testing the unborn baby’s liver either by a biopsy or foetal blood sample and the risks would FAR outweigh the benefits of such a study).

If you must colour your hair, then the sensible thing would be to avoid peroxides, oxides or ammonia. Opt for plant based dyes rather than chemical ones – and if you can bear to go without a full colour, go for lots of highlights, where a protective ‘cap’ is applied over the scalp and hair and the hair is then pulled through the cap preventing the dye from touching the scalp. This reduces the opportunity for it to be absorbed through the skin and carried about the mothers blood stream, to the liver and perhaps (or as explained otherwise, we simply don’t know) on to our unborn babies.

NHS Direct’s view is as follows: -

Can I use hair dye when I am pregnant or breastfeeding?

The chemicals in permanent and semi-permanent hair dyes are not highly toxic. Most research, although limited, does show that it is safe to colour your hair while pregnant. Some studies have found that very high doses of the chemicals in hair dyes may cause harm however, these doses are massive in comparison to the very low amount of chemicals that a woman colouring her hair is exposed to.

Many women decide to wait to dye their hair until after the first 12 weeks of pregnancy, when the risk of chemical substances harming the baby is much lower. You can reduce the risk further by making sure that (if you are colouring your hair yourself) you wear gloves, leave the dye on for the minimum time, and work in a well-ventilated room.

Highlighting your hair also reduces any risk, as the chemicals used are only absorbed by the hair itself, and not by your scalp and into your bloodstream. Semi-permanent pure vegetable dyes, such as henna, are a safe alternative.

Do remember that pregnancy can affect the normal condition of your hair. Your hair may react differently to colouring or perming, becoming more or less absorbent, frizzy or unpredictable. Its always a good idea to do a strand test first using the treatment(s) you intend to use. Speak to your hairdresser for advice.

Information about hair treatments while breastfeeding is limited, but it is very unlikely that a significant amount of the chemicals that are used in hair dyes will be passed on to your breast milk. This is because very little enters the mother’s bloodstream and, in the past, many women have received hair treatments while breastfeeding and there have been no known negative results.

How can I find out about maternity benefits?

This is the UK government resource for benefits information.