Treating an ectopic pregnancy

If you have been diagnosed as having an ectopic pregnancy and are stable, with pulse and blood pressure within normal limits, and there is no heavy bleeding or severe pain, and if there are no signs of dizziness or fainting, the doctor will be able to discuss various treatment options with you.

Unfortunately, a number of women have no early symptoms so present for assessment after a time when there are still options available for treatment.  If you are bleeding heavily, in severe pain or have signs of dizziness or fainting, the doctor will probably suggest only an exploratory surgical operation called a laparoscopy which is done via ‘keyhole surgery’ to allow him or her to take a look inside your abdomen to see what might be happening.

New methods of treatment are being developed but these are the treatment options you are likely to be given currently. Please click on any of them and they will expand to provide more information.

Surgical management

Surgical Management

Surgical management is the most established form of treatment and means performing an operation to remove the ectopic pregnancy while you are under general anaesthetic. If your hormone being made by the pregnancy (beta hCG) is high or significant internal bleeding has been seen on your scan, the doctors cannot consider less invasive treatments for you because your health may be at immediate risk and therefore surgery becomes the only option available. Surgery may also be performed if expectant management or medical management have failed.

Traditionally, surgery involved Laparotomy (an open cut) on the lower abdomen in the same area where you would expect to see a C-Section cut. This is still occasionally used if there is heavy internal bleeding/rupture or a lot of scar tissue and is performed in an emergency situation. If there is extensive bleeding, a blood transfusion may need to be given. In non-emergency circumstances you will be operated on using a technique called laparoscopy (keyhole surgery). This involves inserting a camera through the navel (belly button) and inserting instruments through two small cuts in the lower abdomen (tummy).  A small amount of gas is put into your abdominal cavity to inflate it to enable the surgeon to see inside the abdomen. Both techniques will enable the surgeon to examine the abdominal cavity.

There are then two courses of action for the surgeon and the one chosen will depend upon the damage to the affected tube and the condition of the other tube. If there is a lot of damage or bleeding, the affected tube will be removed (salpingectomy). If the damage is minimal, then the ectopic can be removed from the tube by making a small cut, leaving the tube intact (salpingotomy). With a salpingotomy there is a very small risk that some of the pregnancy remains in the tube and you will be advised to have weekly blood tests to monitor hCG levels as they decrease and the pregnancy is fully resolved. In a very small number of cases, treatment with a drug called methotrexate may also be required, or a further operation needed if the hCG levels are not decreasing.

You are likely to stay in hospital for one to two days after surgery by laparoscopy (keyhole) or for three to five days after a laparotomy (cut to lower tummy). When you are discharged, the ward staff will give you all the necessary advice on aftercare, exercise and diet. Stitches are usually dissolvable and should dissolve completely after 1 week.

How will I feel after the surgery?

Most women experience pain during the first 1-2 weeks after surgery which can be treated with painkillers. If you have had a laparoscopy, you are likely to feel bloated for the first week with pain similar to trapped wind. This is due to the gas which is used during the surgery. You will feel tired, particularly if you lost a lot of blood during the procedure. If you had to have a blood transfusion, you may also be offered iron tablets which will turn you stools (poo) black coloured and may make you a little constipated (find it hard to poo). More information can also be found in the section about Your Body after an Ectopic Pregnancy

What can I do to help me recover from the surgery?

In the first days after surgery it is important to try to keep moving gently. Make sure you walk around regularly and increase the short distances you walk as each day passes.

Your nurses will tell you anything you need to know about managing your wound sites, for example, if the stitches are dissolvable or if you need to return to have them removed and when. You need to keep your wound site clean. You can shower regularly and you can safely take a bath 48 hours after the operation unless you have been told otherwise. It’s a good idea to make sure you have someone with you in the house when you first take a bath in case you need help to get out again.

You should not do any heavy lifting or vigorous housework for around 2 weeks and should only undertake gentle exercise such as walking, and possibly gentle swimming, once the wound sites on the skin have healed.

The staff at the hospital should also advise you about pelvic floor (Kegel) exercises, as these can greatly help you to recover your normal tummy and bladder tone in the weeks to come.

In the first few days it’s important to take the painkillers that have been prescribed for you, as they will help you to manage your pain and feel more comfortable after an operation.

Most people take time off from work initially and do not return to work for at least two weeks to give their body and emotions time to heal after keyhole surgery and this timeframe increases to approximately six weeks for major abdominal surgery. Your hospital can give you a certificate to refrain from work (sick note) for your employers or the Department of Social Security, so you can claim sickness benefit if you are entitled to it.

How will my doctors keep me monitored?

If you had a salpingotomy (fallopian tube left in place), or if there was any doubt that all of the placental tissue was removed, your doctors will usually test your hCG levels to ensure that they are dropping. In this instance, it may be necessary to check your blood hCG levels again after a week, and possibly beyond. If you had a salpingectomy (fallopian tube removed) no follow-up is needed although many hospitals ask you to return for an outpatient appointment about 6 weeks after surgery to ensure that your tummy has healed properly and to answer any questions you may have. If you are not offered a follow-up appointment, your GP would probably like to see you at around 6 weeks, or before you return to work, to undertake a postoperative check to make sure that you are healing well.

Medical management with Methotrexate

Medical management with Methotrexate

The term ‘medical management’, when used in relation to ectopic pregnancy, means using a drug called methotrexate. Folate is an essential vitamin needed to help rapidly dividing cells in pregnancy and methotrexate is a powerful drug which works by temporarily interfering with the processing in the body of folate. The drug stops the pregnancy developing any further and the pregnancy is gradually reabsorbed by the body leaving the fallopian tube complete.

Methotrexate is most effective in the earlier stages of pregnancy, usually when the pregnancy hormone ‘beta hCG’ level is below 5000 mIU/mL. The risk of rupture is higher in pregnancies with levels greater than this. However, in cornual ectopic pregnancy it is not unusual to try to treat ectopic pregnancy with the drug with higher levels of hCG in the body. With ectopic pregnancy, it is not really the stage of pregnancy (as in the number of weeks gestation), but the size of the ectopic, which can vary over the first few weeks depending on the rate of growth, that is important.

For a more detailed understanding of when Methotrexate might be considered, looking at the medical professionals RCOG Greentop Guideline 21 and the NICE Ectopic Pregnancy and Miscarriage pathway might be helpful.

The treatment is given by means of an injection, usually given by a single injection into the muscle.  However, if it needs to be administered by any other route, this will be discussed with you. The dose is calculated according to your height and weight. Before the injection, blood tests are done to check liver and kidney function and to ensure that you are not anaemic.

This method has been developed to avoid surgery. However, it does require careful monitoring and follow-up. This means that you will have to attend the hospital regularly for blood tests to monitor your hCG levels until the tests are negative. This can take several weeks and this will be explained by your doctor. Your hospital will make arrangements for you to have the hormone level checked. Your doctors will usually test your hCG levels on the day the medicine is given, again on day four, and on day seven after the injections.

The hCG level often rises on the day four blood test because the action of Methotrexate is not instantaneous and so the cells will have continued to divide for two or three days after the injection was given. Your doctors are looking to see a drop in your hCG value of at least 15% between days four and seven. If there hasn’t been a 15% drop, this is when the doctors will consider a second dose of Methotrexate or surgery.

A few days after the injection, it is usual to begin to bleed and this bleeding can last between a few days and up to 6 weeks.
Every 2-3 days, beta hCG levels will continue to be monitored to ensure that they are falling appropriately. Most women only need one injection but in up to a quarter of cases a further injection may be required if serum hCG levels are not decreasing.
Methotrexate is at least as good as surgery in terms of subsequent successful pregnancies. This may be due to the fact that medical treatment is non-invasive, whereas surgery may cause some scarring around the tube.

What are the risks of being managed like this?

The risk associated with treating being treated medically is that the medicine may not work as the cells of the ectopic pregnancy may continue to divide, which could result in there still being a need for surgery. Success rates do vary depending on the circumstances in which methotrexate is given and studies report success rates of 65-95%. Success rates tend to be higher with lower serum hCG levels. Your doctor should be able to tell you the success rate of methotrexate in their unit. Doctors can tell if the specialised cells of a pregnancy that produce the hCG hormone are still dividing because the hCG level will continue to rise and not fall. This will be monitored through blood tests.

Occasionally, an ectopic pregnancy can rupture despite low hCG levels. Your hospital should have given you a number to contact for health advice if you feel that anything is changing, or you will have been told to report to the Accident and Emergency (A&E) department. If you have not been told what to do and need to speak to someone ring the hospital department which is treating you or the NHS 111 Service by dialling 111.

What are the side effects?

The most common side effects of Methotrexate are:

  • cramping abdominal (tummy) pain is the most common side effect, and it usually occurs during the first 2 to 3 days of treatment. Because abdominal pain is also a sign of a ruptured ectopic pregnancy, report any abdominal pain to your health professional;
  • fatigue – Many people feel very tired and are shocked by the sheer exhaustion that they encounter during treatment;
  • vaginal bleeding or spotting;
  • nausea, vomiting, and indigestion;
  • light-headedness or dizziness – Again, because this is also a sign of a ruptured ectopic pregnancy, please report it to your health professional;
  • A numb or sore bottom from the injection.

Other rarer side effects from Methotrexate treatment for ectopic pregnancy, include:

  • Skin sensitivity to sunlight.
  • Inflammation of the membrane covering the eye.
  • Sore mouth and throat.
  • Temporary hair loss.
  • Severe low blood counts (bone marrow suppression).
  • Inflammation of the lung (pneumonitis).

Is this method of treatment suitable for me?

This method of treatment is more suitable for some women than others and is more likely to be successful in the following circumstances:

  • You are in good health
  • Your tube has not ruptured
  • Your hCG level is low enough (your hospital will probably have a level above which this method will not be used)
  • There is no significant abdominal bleeding.

Because it does not entail an operation, this method has a particular advantage over keyhole (or open) surgery if:

  • You have other medical problems that may increase the risks of a general anaesthetic
  • If you have adhesions in the abdomen or pelvis (as a result of previous surgery or infection)
  • The ectopic pregnancy is situated in the neck of the womb or as the tube enters the womb.

Treatment of ectopic pregnancy with methotrexate is not appropriate if you suffer from any of the following conditions:

  • An ongoing infection
  • Severe anaemia or shortage of other blood cells
  • Kidney problems
  • Liver problems
  • Active infection
  • HIV/AIDS
  • Peptic ulcer or ulcerative colitis.

What can I do to help the treatment work?

You should stop taking any vitamins, minerals or other medicines unless you have been told by the doctors treating you to continue with them, as some medicines interfere with the effects of methotrexate. It is particularly important that you do not take any folic acid supplements until your doctors are sure that the drug has worked.

You should not do any heavy lifting or housework until the hCG levels are dropping consistently and should only undertake gentle exercise, such as walking, until the hCG levels are below 100<mIU/mL.

You should avoid sexual intercourse until your levels are down to less than 100<mIU/mL.

Most people take time off from work initially and do not return to work for at least two weeks while the treatment begins to work. Your hospital can give you a certificate to refrain from work for your employers or the Department of Social Security, so you can claim sickness benefit if you are entitled to it.

In the first week it is important to avoid pain killers which fall into the NSAID group such as ibuprofen. The preferred painkiller is paracetamol and you should refrain from drinking alcohol until the levels have fallen to a non-pregnant state.

More information can also be found in the section about Your Body after an Ectopic Pregnancy.

My hospital will not offer Methotrexate, although I think I should be eligible for that treatment. What should I do?

The use of Methotrexate for treatment of ectopic pregnancies across the UK is still varied. It may be that in one authority they use it and in the next they don’t. The decision ultimately lies with your medical team within the health authority you are under, but there is never any harm in making it clear what your wishes are and asking to be assessed by someone who does use Methotrexate.

If you would like it to be considered as a treatment, you certainly are within your rights to ask to be referred to a centre of treatment where it is available. You should ask to be referred to a consultant within the Primary Care Trust who can assess your suitability for this kind of treatment or on to another treatment centre.

If you need any help with this you need to contact the Patient Advice and Liaison Services (PALS) at the hospital where you are being treated. They can help you locate an assessment or new consultant if you need to.

Expectant management

Expectant Management

The term ‘expectant management’ is usually defined as watchful waiting or close monitoring by medical professionals instead of immediate treatment.

Research has shown that, in patients with an ectopic pregnancy who are properly assessed and their pregnancy hormone level (beta hCG) is dropping, up to 50% of these pregnancies will end naturally and there will be no need for an operation or a drug to treat the condition.

In deciding whether expectant management was appropriate, doctors would first of all look at the results of blood tests, ultrasound scan(s) and undertake an assessment of your general health. Expectant management would then be considered for treatment when:

  • The hormone being made by the pregnancy (beta hCG) is low
  • General health appears to be stable
  • Pain levels are considered to be acceptable
  • An ultrasound scan shows a small ectopic pregnancy with no worrying bleeding into the abdomen.

Doctors would then want to test your blood repeatedly to ensure that your hCG levels are dropping, usually twice in the first week and then weekly thereafter, until the levels have dropped to below 5<mIU/mL. It is not usually necessary to do another ultrasound scan unless you present with other symptoms, in which case your doctors will undertake a reassessment.

How long you need to keep going for repeat tests will depend upon how long it takes for your hCG levels to drop to below 5<mIU/mL and this can vary quite considerably from woman to woman. As a general rule, as long as your hCG levels are dropping between blood tests, your doctors will continue to monitor you and manage you expectantly. It can take anything between two weeks and three months, for your hCG levels to fall back to a non-pregnant level but, for most women, hCG levels have reached a non-pregnant state within around four weeks.

In these circumstances, your hospital would give you a number to contact for health advice if you feel that anything is changing, or you will have been told to report to the Accident and Emergency Department (A&E). If you have not been told what to do and need to speak to someone ring the hospital department which is treating you or the NHS 111 Service by dialling 111.

Why does my doctor want to treat me this way and not give me medication or surgery?

Doctors always consider the least invasive form of treatment or management first where they can. Research-based evidence has shown that in properly selected patients, a proportion with a diagnosed or suspected ectopic pregnancy will need no active treatment and it will resolve on its own if we watch and wait. Although this can feel quite frightening and as though no one is doing anything, if the pregnancy does resolve on its own, avoiding surgery or powerful drug treatments, means your recovery will be faster. At the EPT we strongly believe in patient choice and that you should also be given the right to elect for treatment rather than watching and waiting if you do not feel this option is emotionally suitable for you.

What are the risks of being managed like this?

The main risk associated with expectant management is that the cells of the ectopic pregnancy might continue to divide, which could result in there still being a need for medical treatment or surgery after a period of expectant management. Around 25% of women, who are expectantly managed initially, go to on to need medical or surgical treatment. Doctors can tell if the specialised cells of a pregnancy that produce the hCG hormone are dividing because the hCG level will rise and not fall.
Occasionally an ectopic pregnancy can rupture despite low hCG levels. If you are concerned about your level of pain, please contact your hospital.

How will I know if there is a problem and I need a different treatment?

Your doctors will be able to tell if your pregnancy is not resolving, as this will be shown in the results of the regular blood tests. If this is the case, they will suggest other forms of treatment for you. The signs of a deteriorating ectopic pregnancy, which include severely increased pain levels; vaginal bleeding; shortness of breath; and pain in the tip of the shoulder among others may become noticeable. If you suffer any of these symptoms you will need to be reassessed. Your hospital would give you a number to contact for health advice if you feel that anything is changing, or you will have been told to report to the Accident and Emergency Department (A&E). If you have not been told what to do and need to speak to someone ring the hospital department which is treating you or the NHS 111 Service by dialling 111.

What can I do to help this kind of management work for me?

It is important that you do not undertake any strenuous exercise or lift heavy weights while the hCG levels are dropping.

You should also avoid sexual intercourse until your doctor is confident that the pregnancy is resolving.

You should stop taking your folic acid supplements and avoid any other vitamin and/or mineral supplements until the hCG levels confirm that the ectopic pregnancy has ended.

It is important to take things gently in the first few days after your diagnosis, until it can be established that the hCG levels are dropping on their own.