Many thanks to Laura Abbott, RGN,RM,Dip.N,BA, BSc (hons), an Independent Midwife, for giving us permission to reproduce her article, which originally appeared in in "Association for Improvements into Maternity Services Journal" (AIMS) Vol.14, No.3, 2002.

Note from the Ectopic Pregnancy Trust

Since Laura's article was published in 2002, there has been further research-based evidence, showing that a woman's fertility is not in fact reduced by around 50%. The loss of a tube does reduce success rates, but women can still become pregnant and have a successful pregnancy with only one tube intact. Overall, 65% of women will become pregnant within 18 months after an ectopic, and this increases to around 85% after 2 years.

An ectopic pregnancy is where the fertilised egg becomes implanted outside of the womb, usually in the fallopian tube but, occasionally, in the ovaries cervix or abdomen. This is a life threatening condition that, as the pregnancy grows, can cause pain, bleeding and rupture, and can lead in rare cases to death.

Every year in the UK, there are more than 20,000 emergency admissions to hospital for ectopic pregnancy. The surgery has an impact on the woman’s fertility usually decreasing it by 50% or more.

The failure to diagnose this serious condition is not acceptable and something that needs to be changed.

Ectopic pregnancy affects 1; 80 pregnancies and is a life threatening condition. Most ectopic pregnancies implant in the fallopian tube and as the pregnancy grows it causes bleeding and pain and if not treated in time, the tube can rupture and cause severe bleeding, which can cause collapse and death. It is a sad fact that 5 women a year die from ectopic pregnancy. It is reported in the confidential enquiry into maternal deaths (CEMD) 2001 that one of the main problems was substandard care and the failure to suspect ectopic pregnancy in the first place. Indeed, the CEMD’s last two reports have been very clear that the awareness of the possibility of ectopic pregnancy in any woman of childbearing age is essential. With this in mind it is essential that any woman of childbearing age be investigated for ectopic pregnancy as soon as any symptoms of the condition arise. Thus it is important to be aware of the risk factors and to recognise the signs of ectopic pregnancy.

Deaths due to ectopic pregnancy should be a thing of the past. With greater vigilance from health professionals and women, this may not be such an idealistic concept.

Common causes of ectopic pregnancy

• Damage to the fallopian tube causing blockage or narrowing so the eggs cannot move into the uterus;

• Previous pelvic infection;

• Previous appendicitis;

• Infertility;

• Caesarean section;

• In many instances the cause is not known.

Symptoms

• Abdominal pain: this is usually one sided, but not necessarily the side of the ectopic.

• Bleeding usually abnormal bleeding. Could be some spotting. The blood is often darker than a normal period and can be described as “watery or prune juice coloured” (Walker, 2001). The woman may not know she is pregnant or may think she is having an unusual period. She may have been fitted with a coil.

• Shoulder Tip pain: this can be caused by irritation to the diaphragm caused by internal bleeding.

• Bladder/ bowel problems: pain when going to the toilet.

• Pregnancy test: this may be positive but not always.

• Collapse: feeling dizzy and light headed. Looking pale and feeling sick.

• A feeling that something is very wrong: often with a feeling of impending doom. Walker, 2001.

Management of an ectopic pregnancy

If an ectopic pregnancy is suspected the women should attend the hospital. An Ultrasound scan and a pregnancy test should be performed. If the test is positive and the scan shows an empty uterus an ectopic pregnancy is likely and needs to be ruled out. This can be done by serial blood tests every 48hours to check the level of the pregnancy hormone beta HCG if the woman is well. Or a laparoscopy needs to be performed. If diagnosis is made early before the tube ruptures, keyhole surgery or drug treatment can be used which will help with a quicker recovery time and increase the women’s chances of future fertility.

In the latest guidelines for health professionals, Professor James Walker of the EPT states that “waiting to see if symptoms settle can put the woman at great danger by increasing morbidity and mortality”. Worryingly the CEMD 1997 to 1999 reports that the majority of women who died from ruptured tubal pregnancy were “Known to have sought medical help before death” and often had symptoms that suggested a urinary or gastro-intestinal disease. I reiterate again the importance of vigilance of signs and symptoms. Any woman with one-sided pain and a positive pregnancy test should be treated as having an ectopic pregnancy until proven otherwise. An early scan to confirm that the baby is in the womb can have a dramatic effect.

It is important to be aware of the risk factors and to be able to recognise the signs of ectopic pregnancy. The CEMD`s last two reports have been very clear that the awareness of the possibility of ectopic pregnancy in any woman of childbearing age is essential. Deaths from ectopic pregnancy need to be a thing of the past. With greater vigilance from health professionals and women perhaps this is not such an idealistic concept.

Ectopic Pregnancy: A personal account by Laura Abbott

My partner and I had been trying to conceive for over 3 years when we discovered I was pregnant with the help of fertility treatment.

We were delighted and began to talk of the hopes and dreams that we had been frightened to share over the years due to the constant disappointment of not getting pregnant.

I was 51/2 weeks pregnant when I had some slight spotting. I wasn’t worried about this as I had the same experience with my son 7 years ago. However, when I began to have one-sided pain a day later I became slightly concerned, as I knew that this could be a sign of ectopic pregnancy. I hadn’t planned in seeing anyone but a midwife during pregnancy but knew that I needed to rule out the chance of ectopic. Being a midwife I felt I might be being over sensitive to early pregnancy symptoms but thought I should check it out just to be on the safe side. My G.P was great: “you know the procedure,” he said and off to casualty I went.

After being seen in casualty after the ubiquitous 3-hour wait I was sent home again to return in the morning for a scan. My pregnancy test was positive and a beta HCG test was taken. Home I went, still in pain and worrying about the morning ahead with the scan.

Little did I know that the nightmare was just beginning in a hospital I knew and trusted, where I had worked as nurse and did my midwifery training.
I sat waiting with the other women in a corridor. There I was with my husband, nervous, scared and worried about this scan. I knew something was wrong and the pain hadn’t ceased. “You’re the midwife aren’t you?” I heard the nurse say to a woman a few feet from me. “No” she said, the nurse insisted “But it says in your notes Laura Abbott”. “That’s not me,” says the woman sounding annoyed. I pipe up then “I think you mean me”. “Oh, so you’re the midwife”, “Yes” I say sheepishly as now all the other “scan women” are looking at me. The where do you work conversation ensued and I politely but bluntly gave one word answers. At that moment the last thing on my mind was my midwifery and now the whole waiting room knew what my job was I felt very uncomfortable.

I was called for my scan. “Nothing in your uterus, take a seat outside”. Tears were choking me but I couldn’t let them out as the other women in the waiting area were all looking at “the midwife” to see any signs of disaster. I knew then the baby was in my tube and not in my uterus and that it meant I would be admitted.

After another long wait, now in a cubical a consultant came to see me. I was a midwife after all and this was the honour that health professionals receive. Prior to this I had prepped my shocked husband that I would be admitted and for him not to worry, they would probably do a laparoscopy that day because of the dangers of ectopics. We had even sat and written a list of things I would need for my hospital stay. I was prepared for the worse.

The consultant came in, once again the midwifery conversation ensued, “Oh an independent midwife, why don’t you want to work in the NHS”. Midwifery was far from my mind at that moment. I was frightened, dreadfully disappointed but had a stoic face on due to not wanting to let my professional side of me down. I told the consultant that I felt this pregnancy was ectopic, with my history of infertility and my symptoms. I assured him that I was sure of my dates, which he disputed. I knew I was 6 weeks pregnant, I knew when I ovulated as any woman does when she has been trying for a baby for such a long while. He felt I couldn’t be more than 4 weeks. His opinion was that I must have ovulated later.

The consultant proceeded to tell me that I would be in much more pain if it was ectopic and that it was probably a urinary infection. I didn’t think it was but this was the little bit of hope we clung onto, we wanted this baby so badly and for someone to reassure us that it was all ok was good enough for my non-medical husband and also for me.

So home we went again, for the second time. I remember speaking to Jane, my midwife partner in our Independent practice and saying if its not in my uterus then where the @@$$ is it. Jane told me about this website all about ectopic pregnancies. We looked at it and yes, I had the symptoms, all there but I had been sent home. A consultant would `nt do that if there was any risk surely? The pain continued as before, I went through the night and the next day. The spotting continued and so did the one sided pain but no worse or no better than before. That evening Graham and I were meant to be going out with friends. My son was at his father’s. I felt like staying in so I ordered a curry for myself while they went out. I ate my dinner and then went upstairs to get something. I started to bleed, not heavily but the colour was “prune juice” like the ept website had talked about. I began to feel very dizzy and faint and fell on the floor finding it hard to breathe. I managed to get to the phone and rang Jane who immediately rang an ambulance for me. I thought I was dying, I was very dizzy and felt as though my life was over. No golden light or angels visiting, just pure fear. I couldn’t breathe and I was slipping away. The paramedic arrived and gave me oxygen and shipped me in to my nearest A&E. My husband had come back and followed behind. I was seen quickly and scanned again, no pregnancy in the uterus, fluid in the pouch of Douglas. They had to take me to theatre. I was anaesthetised with cricoid pressure because I had eaten and operated on. I was numb and thought I was going to die. I felt nothing as to start thinking would have caused me too much pain. How could I think about my precious 7-year-old without a mother?

When I came round I was in agony. A pain worse than anything I could ever describe. I put my hand down and felt a dressing all the way across my lower abdomen. I knew what that meant. The emotional pain was searing. They had taken my baby, where was it, I want it back. I think I must have got very panicky at that point as they knocked me out again with something.

I had had a laparoscopy and they had found that I was bleeding as I had ruptured. They cut me open and took out”the ectopic”, (MY baby) and “the tube”, (MY fertility).

The reg. came to see me and told me that my tube had ruptured and I was lucky to be alive. An hour later and I would have been in a much worse state. I didn’t feel very lucky. My life had been saved but my baby had been sacrificed in the process. The pain was so bad but it allowed me to cry like a baby for my lost baby, yes baby, not ectopic but baby, as this is what it was to me. I had loved her for years and yearned for her, as only a woman who yearns for a child can understand.

The vomiting started. With a scar and agony that I was in being unable to move this was horrendous. I was given anti emetics but they made little difference due to the anaesthetic on a full stomach of a curry the previous night. To puke whilst in so much pain anyway was just awful. I couldn’t even sit up. So pain, vomiting, no baby and no tube with staples across my tummy. I was a sorry state. Not to mention the trauma of a near death experience. Days past, dragging slowly as pethidine in its wisdom makes time tick slower than a car in a traffic jam. After 7 days I was freed to go home still in pain and now furious at the consultant for misdiagnosing such a life threatening situation.

The implications of having an ectopic pregnancy have hit me 10 fold. The complaint I have against the hospital consultant for misdiagnosing a condition that kills 5 women per year is on going. I have not received an apology or an assurance that this will not happen to other women. You can be rest assured that I will not leave this unresolved and I am now involved with the Ectopic pregnancy Trust in highlighting the dangers and education of doctors. This is a good outlet for my anger, which swells on a daily basis through the grief and loss that has cut through me. It is a loss. To my husband and me this was our baby. Not “the ectopic”, the “ruptured tube”, the “ball of cells”. Not the it was “never meant to be” or the “good clear out” that I have heard from well meaning people who never meant to hurt me but still served to negate the grief I felt/ feel for our lost child.

An ectopic pregnancy hits in many ways. I had my live baby cut from me. As in my head this was my child, my future as a mother. A sibling for my little boy. The second child for me, the first child for my husband. The start of having a large family. The family an earth mother like me dreams of all sitting around at the end of the day sharing their news. The second child to my plan of having 5 children. My homebirth, something I strive to facilitate for other women which I so want to achieve too. An ectopic pregnancy is a termination without consent, a life taken that by journeying a few inches longer would be sitting in me now, wriggling and hiccoughing and growing. Instead, she was cut out of me. I am a woman who would never consider termination for myself, but have had one because that is what it is like to have an ectopic pregnancy cut out of you. It is inevitable I know. I am not so sentimental that I don’t know that this was the only option. I would have died if she had stayed. This is the cruel twist really. So again I am “lucky”. Another hour and I would have been a goner. Guilt is a big part of this. Guilt for the lost child. Guilt for even being alive. Guilt for feeling so self absorbed in all of this that my life since April has been turned into turmoil.

“Better luck next time”, that is what I have heard again and again. “It will happen”, “Next time….”. Next time? There won’t be a next time. I can’t conceive! I have to explain myself over and over again to again well meaning people who believe they are being comforting. I have only one very blocked tube left. I can’t conceive naturally. I have to have IVF. I don’t want that! So instead I have spent the remaining credit left on my credit card for an exotic holiday in the Far East! I am not being rail roaded down a path of hormone injections and test tubes. Its not fair, I don’t want to have to work so hard for my babies. Anyway, I have put on all the weight I lost in my 3-year bid of trying to conceive.I have already done all the hard work and don’t want to revisit all of it again to lose everything again. I am a risk taker. I believe in experiencing and living and going after what you want until you achieve it. I am ambitious and the type of person who wants to change the world. But this? Maybe I’m just not ready or maybe I will never be ready. Maybe it is because I still want the baby I will never hold but will always love and dream about. How can I think about another baby? She cannot be replaced ever in my mind.

There are 20,000 Ectopic pregnancies a year in the UK alone. This is more than double the cases of cervical cancer.An ectopic pregnancy is where the fertilised egg implants outside the womb, usually in the fallopian tube but occasionally in the ovaries, cervix or abdomen.It is a life threatening condition which as the pregnancy grows can cause pain and bleeding, can cause rupture and can lead to collapse and in rare cases death.

For further information please call the Ectopic Pregnancy Trust's helpline on 01895 238 025. Donations for the trust are always gratefully received and much needed.

Laura's own website is at www.homebirths.net.

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