Your body after an ectopic pregnancy

Your body is likely to go through a whole process of recovery following an ectopic pregnancy and it is important that you be gentle with yourself and give yourself time to heal. Because such an invasive and frightening thing has happened, it is not unusual to become very worried about any symptom you may experience and to have many questions racing through your mind. You may also find that you have different questions about your body at different stages after treatment.

Please click on any of the questions below that interest you and they will expand into a detailed answer. If there are any questions that you don’t see the answers to here, you may find them on our ectopic pregnancy discussion forums or you could email us at ept@ectopic.org.uk.

Pain

Pain

Should I expect any pain or discomfort after my treatment and how long will it last?

Depending on what treatment you have had, a varying amount of pain or discomfort may continue for several weeks afterwards as the healing process continues and scarring continues to heal. This should lessen as time progresses. However, it is not unusual to still report some discomfort several months after an abdominal operation. This pain can sometimes be caused by adhesions.

Also, after an operation, people often get aches and pains in places they did not expect to, such as the back, neck, hips and legs can all be very sore. The staff in the operating theatre take great care of you when you are asleep and try to move you into the positions they need you to be in very gently. However, because your muscles are very relaxed as a result of the anaesthetic, sometimes muscles can ache for several days after your surgery. Take it easy, take the pain relief you were given in hospital and your aches should resolve over a few days.

I am experiencing abdominal pain several weeks/months after an ectopic pregnancy, is this normal?

Following an ectopic pregnancy, it is not unusual to feel pain and discomfort in the abdomen for some time after your treatment. Awareness of such feelings can also be heightened as a result of the experience of losing a pregnancy and because of the frightening and distressing experience you had to go through. There are a number of reasons why you may be aware of the aches in your abdominal area:

  • It could be that your normal cycle is trying to resume and the pain you are experiencing may be due to your body preparing to ovulate, or your period might be about to arrive.
  • It could be that your awareness of your menstrual cycle and your ovulation have been heightened. Many women report that they are aware of ovulation pain after an ectopic, when they have never experienced it before.
  • It might simply be down to heightened perception and awareness because of the experience you have been through.
  • If, after two or three months, you have continuing abdominal pain, this could be being caused by scarring known as adhesions (scar tissue that connects two or more body structures together) and may settle over time.

What are adhesions?

An adhesion is scar tissue that binds two parts of your tissue together that should ordinarily remain separate. It may appear inside the body as a thin sheet of tissue similar to plastic wrap or as thick fibrous bands. The tissue develops when the body’s repair mechanisms respond to any tissue disturbance, such as surgery, infection, trauma, or radiation. Although adhesions can occur anywhere, the most common locations are within the stomach, the pelvis, and the heart.

Abdominal adhesions are a common complication of surgery, occurring in up to 93% of people who undergo abdominal or pelvic surgery and even in 10.4% of people who have never had surgery. Most adhesions are painless and do not cause complications, but they can contribute to the development of chronic pelvic pain or even restrict the motion of the small intestines.

Adhesions typically begin to form within the first few days after surgery, but they may not produce symptoms for months or even years. Often they produce no symptoms at all. In some cases they produce no symptoms until someone is pregnant again and then they are felt as the body changes during the early stages of pregnancy so the woman, naturally, worries they are pains from another ectopic pregnancy.

Do I need to keep a pain diary?

Pain is unique to the individual and if it is persistent and is becoming worrying, we would suggest that you keep a pain diary. Record in your diary when your period starts, when the pain is experienced and how the pain would be scored on a scale of 0 to 10 (0 being no pain, 10 being pain requiring a trip to hospital). Keep a record of what helps the pain, for example, heat (hot water bottle), exercise, rest, pain relievers (make a note of what kind e.g. paracetamol). After about eight weeks, make an appointment to go see your doctor to discuss the diary records you have been keeping.

Keeping this diary enables you to go to your doctor with dates, times and evidence of how it is affecting you. This can be very helpful to medical practitioners when deciding upon how to manage the symptoms.

How can I tell if the pain I have means there is something wrong?

Pain is most usually the body’s way of telling you to rest. Whether you were treated with a major abdominal operation or a keyhole procedure, some pain is normal and you should expect to take things very easily for the first week or two after keyhole surgery and for around six weeks after the major abdominal operation.

Many hospitals discharge their patients with some kind of pain relief. If yours did not, then take over the counter pain remedies, a pharmacist can advise you and these are usually sufficient to help you through the first few days. Pain is, however, unique to everyone and if your pain is severe and not responding to over the counter pain relief then call your doctor or the NHS 111 Service for advice.

If your pain is associated with other symptoms, you may also need to consult with a doctor. Any of the following signs, might suggest the pain you have needs further medical assessment:

  • a rise in your normal body temperature greater than 37° C (98.6° F);
  • increased vaginal discharge that smells fishy or offensive;
  • raised lumps and bumps over the puncture sites or scar that are redder and hotter to touch than the rest of the surrounding skin;
  • wound site which is not only weeping but appears to be oozing thick, creamy or white discharge.
The wound site

The Wound Site

What should I know about my stitches?

There are a variety of ways to close a wound after surgery. By far the most common is to use sutures or stitches and, after any kind of abdominal surgery, you are likely to find stitches, even in a puncture wound from keyhole surgery. It is most likely that your stitches are dissolvable but sometimes stitches that need to be removed are still used.

If you are not sure what your stitches are made of and weren’t told whether you had to get them removed or if they will dissolve on their own, call the hospital ward that treated you and they should tell you. Dissolvable stitches are supposed to dissolve on their own between about 10 and 21 days after surgery but, unfortunately, sometimes don’t dissolve.

What if my dissolvable stitches don’t dissolve?

Dissolvable stitches are supposed to dissolve on their own between about 10 and 21 days after surgery but, unfortunately, sometimes don’t dissolve. If after 21 days they are still there and you have been soaking in the bath (preferably) or showering, then you should contact the practice nurse at your surgery and ask them to perform a wound check and remove them for you.

Removing a stitch takes a second and is relatively painless. You should never pull at them yourself as this can result in complications such as a wound infection. If you think your stitches are stuck, when soaking in the bath you can wipe firmly over them with a clean damp flannel, once each in a north, south, east and west direction but be careful to do no more than that.

Do I have stitches inside me?

If you had a major abdominal operation, yes you do. These stitches will dissolve on their own and you are unlikely to be aware of them. The muscle that they are uniting will take between four to six weeks to knit together in the same way a wound on the surface of the skin does after a few days. This is one of the key reasons you should be taking it easy and not lifting anything for six weeks after surgery.

I don’t have stitches. What do I need to know?

There are other ways of closing a wound after surgery. Clips and staples need to be removed by a nurse or doctor and you are normally given an appointment before you leave or have them removed before you leave hospital. Sometimes the wound will be sprayed with a special adhesive that seals the skin. This kind of dressing has different names but you might hear it called “opsite” dressing or plastic skin. It is a liquid plastic that sets when sprayed on to the skin and comes into contact with the air. This wears off after a few days.

Can I take a shower or bath following surgery?

Normally, you can shower 24 hours after an operation on your abdomen (tummy) and take a bath after 48 hours. It is a good idea to make sure someone is around when you get into the bath, in case you find it uncomfortable or tricky to get out. If for some reason it is not advisable to take a bath, you will usually be told this as part of your discharge information. If you are in any doubt, ring the ward from which you were discharged and ask them.

Whilst you have an open wound or stitches, you should avoid using bath oils or other strongly scented bath treats. Until the wound is healed and the stitches are gone, warm water and very gentle soap are all you should be using for your bathing needs. Other than a daily shower or bath, there should be no need to clean your wound with anything else. You should not use any antiseptic or cream type preparations on a new scar unless it has been prescribed by a doctor.

Don’t rub or wash the scars; gentle washing in warm water with a mild soap or body wash gel, avoiding the actual scars, is all that is needed. Dissolvable stitches often rely on the patient taking regular baths to help the stitches dissolve.

Should I put a plaster on my wounds?

It is better to leave the wound site uncovered. However, if the stitches pull or rub on your clothing then covering them with some low adherent dressing, which is available from most pharmacies and supermarkets, is recommended. You should not use any antiseptic or cream type preparations on a new scar unless it has been prescribed by a doctor.

When will my wounds have healed?

As a general rule you should expect the wound to be clean and dry with no evidence of weeping after 10 days. If you are in any doubt about your wound site, ask your doctor or practice nurse to take a look.

Once the skin has healed, the scar can look quite raised and red for some weeks and months. This is not unusual and, although hard to believe at the start, it will fade with time from red to pink and then eventually to a silvery white and become almost unnoticeable. As long as the wound site is comfortable, does not become sore to touch, does not begin to feel warmer than the surrounding skin and remains closed then you can be confident the wound is healed.

I have bruising, is this normal?

After surgery, it is not uncommon for the area below your tummy button right down in to your pubic hair line to be very bruised. The bruising can be very noticeable indeed. However, it is usually not anything to worry about and gradually fades over about six weeks.

Is there likely to be scar tissue inside me and will this affect my future chances?

After any abdominal operation there is some scar tissue. The abdominal scars should make no difference to your future chances of having a baby. The tube that was operated on may have been removed, or at least damaged, from the operation but pregnancy is usually achieved through the other tube anyway irrespective of whether or not the tube was salvaged. Sometimes adhesions form in the abdomen as a result of surgery and these can occasionally compromise the remaining tube, but only time will tell. Even so, overall, 65% of women are pregnant again within 18 months of an ectopic pregnancy and some studies suggest that 85% are pregnant after two years.

Other symptoms

Other Symptoms

I still feel pregnant, is this normal?

Women often report still feeling pregnant sometimes two or three weeks after surgery and for longer after treatment with Methotrexate or expectant management. Even after surgery, where the fallopian tube is partially or completely removed, it can take some time for the hCG Levels (pregnancy hormone in the body) to drop which, along with the raised level of progesterone in your bloodstream, can make some women feel pregnant even after they have lost their baby. These feelings of still being pregnant usually subside as the hCG levels drop.

Is it normal to still have sore breasts a few weeks after my operation?

You may get sore breasts immediately after and for some weeks after the operation as they get used to not being pregnant. They may get sore again leading up to the next period.

Is it normal to feel this tired?

Anything that compromises our immune system will leave us feeling tired. Surgery is a huge event for your body to cope with and, in the first weeks after your surgery, your immune system will be pouring all of its resources into healing your wounds and keeping infection out. During this time, women often report feeling very tired. Those treated with Methotrexate can feel especially tired as the medicine depletes the body of one of the essential vitamins (folate) which helps maintain our energy levels. Taking it easy, eating small healthy meals often, and rest will all help to combat the tiredness and fatigue.

Some people take longer to recover than others. It depends on how much blood you lost and what treatment you had. The bigger the operation and the more blood lost, the longer it takes to feel yourself again. Usually you should be fully recovered physically by six weeks, but in some people it may take longer. As long as you are making progress, you should not worry.

Why am I bloated and how long will this last?

Bloatedness is a reaction to the operation and the inflammation following this. The length of time it continues varies, but it should settle within six weeks. If it continues for longer it may be a sign that you have some ongoing infection and you should see your GP.

Doing ‘Normal’ Things

Doing ‘Normal’ Things

When can I start to do exercise?

This depends on how you were treated and, if you had an operation, the type of surgery you had. If you had keyhole surgery, you could start gentle exercise within two weeks of the operation. If you had open surgery then you should wait six weeks for your abdomen to heal. If you were treated with Methotrexate or Expectant Management you should not resume exercise until your hCG levels are falling consistently and are in the low 100′s. Exercise, like swimming, is usually safe as long as the wounds are healing or your hCG levels are low, as this is a non-impact sport.

Will I be safe to drive?

Driving is not prohibited after medical treatment with Methotrexate or expectant management but you should feel comfortable to be able to do an emergency stop before you take control of any vehicle.

With surgery, however, you are very likely to be advised by medical professionals not to drive. The length of time you are advised not to drive for will depend upon the surgery you had. You will also need to check with your insurers when they consider it safe for you to drive after the more major procedure of laparotomy (open cut to the tummy rather than keyhole) because different brokers’ and underwriters’ policies vary.

When can I return to work?

This depends on how you were treated and what type of work you do. In general, after six weeks you should be able to return to most jobs from a physical point of view, but many women need to take more time off to help them deal with the psychological (emotional) impact of the loss of their baby and the frightening experience they felt being diagnosed with and treated for an ectopic pregnancy.

In some cases, you could return to work within a few weeks if you had keyhole surgery and your job is not too strenuous, but you may feel tired and find it difficult to cope emotionally. Coming back part-time, if this is an option, may be a good idea.

Women treated with Methotrexate sometimes choose to work through their treatment but many find managing the loss of a baby in this way too difficult to work through and need some emotional recovery time after treatment. Being treated with Methotrexate is also very tiring and work can therefore be exhausting.

The important thing is to be gentle with yourself. Although you may have made a good physical recovery, you may not be ready emotionally and you should never feel embarrassed to approach your GP and ask for a ‘sick note’ if you need more time of work to emotionally recover. This is very common and doctors are supportive and very sympathetic to how you are feeling and are likely to write a note without any hesitation.

Why should I avoid alcohol after Methotrexate?

Drinking alcohol is advised against after Medical Management treatment because Methotrexate is metabolised in the liver in a similar way to alcohol and is known to alter liver enzymes in the short term. Traces of the drug can, therefore, be found in the liver up to 100 days after the last dose. Because the liver is already very stretched through having to work too hard, alcohol can cause you to feel very ill, especially during the first couple of weeks after your treatment. It could also potentially damage your liver.

When should I start taking pre-natal vitamins after Methotrexate?

If you have had either one or two injections of Methotrexate you should wait until your hCG levels have fallen to below 5mIU/mL (your doctor will advise you when this is through blood tests) and then take a folic acid supplement for 12 weeks before you try to conceive.

This is because the Methotrexate may have reduced the level of folate in your body which is needed to ensure a baby develops healthily. The Methotrexate is metabolised quickly but it can affect the quality of your cells, including those of your eggs and the quality of your blood for up to three months after it has been given. The medicine can also affect the way your liver works and so you need to give your body time to recover properly before a new pregnancy is considered. A shortage of folate could result in a greater chance of a baby having a neural tube defect such as hare lip, cleft palate, or even spina bifida or other NT defects.

When can I have sex?

If you are being treated with Medical Management (Methotrexate) or are being Expectantly Managed, you should avoid sexual activity which involves penetration until your hCG blood levels are down to less than 5 <mIU/mL. As hCG levels drop, the risk of rupture diminishes but, unfortunately, the risk remains even with very low hCG levels. For this reason we advise anything that increases intra-abdominal pressure, such as sexual intercourse, is best avoided.

Allowing the body to recover, ovulation to occur and the first period to arrive is often suggested by doctors as the ideal waiting period before women begin to have full penetrative intercourse (sex) again, which means waiting until around six weeks. This allows for healing of the muscles and gives you more confidence that your body is returning to its normal rhythm. Some couples, however, feel they want to have sex before this time and, ultimately, the decision about when to have sexual intercourse again is one for you and your partner and should be based on when you both feel ready. If you choose to wait, it does not mean that you cannot find other ways to be intimate should you choose to.

It is important to remember that medical professionals recommend that you do not get pregnant for two menstrual (period) cycles or three months after an ectopic pregnancy and, if you do want to have sex before this time, the issue of contraception needs to be considered. Questions about contraception are answered further down the page.

Is it safe to breastfeed following Methotrexate?

The advice given to mothers who are taking regular oral doses of Methotrexate as long-term treatment, not for an ectopic pregnancy but to treat another entirely different condition, is NOT to breastfeed during their treatment. This is because Methotrexate is excreted into breast milk in low concentrations and may accumulate in neonatal tissues. The American Academy of Paediatrics therefore considers Methotrexate to be contraindicated during breastfeeding citing several potential problems, including immune suppression, neutropenia, adverse effects on growth, and carcinogenesis.

However, the advice for women who have had Methotrexate for the treatment of ectopic pregnancy is different. In treating ectopic pregnancy, Methotrexate is usually given as a one off dose (or occasionally two doses) by injection into a large muscle to antagonise and deplete folic acid (vitamin B9). The dosage is lower than treating other conditions and does not have the opportunity to accumulate in the neonatal tissues.

If your baby is less than a year old and if breast milk is the sole source of nutrition, we advise avoiding breast feeding for at least four weeks following treatment with Methotrexate. If your child has been weaned, and is taking a balanced diet of mixed foods with an occasional breast feed for comfort, you may choose to start feeding again sooner than this.

In ectopic pregnancy, when one dose of Methotrexate has been given, the risk is not the accumulation in neonatal tissues, rather the risk is that the milk will be of poor quality and of little nutritional use, due to the missing essential vitamins on which the body depends to support the division of rapidly dividing cells. This is very significant in small children as they are growing and relying on this crucial process.

Bleeding and Periods

Bleeding and Periods

Is the bleeding after treatment/monitoring of my ectopic pregnancy my period?

The bleeding you have after surgery, after treatment with Methotrexate, or if you are managed expectantly, is not actually classed as your first period after the ectopic pregnancy. This is your body expelling the thickened lining of the uterus because you are, sadly, no longer pregnant.

Once the beta hCG levels (pregnancy hormones) in your body have dropped, the chemical signals to retain the thickened uterine lining that has built up in preparation for pregnancy, are no longer being produced and so the lining of the uterus is shed. The process involves vaginal bleeding and the material may be clotty, heavy, dark in appearance or appear just like one of your normal period bleeds.

How long will the bleeding last?

The length of time anyone bleeds varies from woman to woman greatly, as the bleeding is from the lining of the womb and is hormonally controlled. It will probably last a week or two, changing in colour from red to brown and diminishing. Some women report bleeding and spotting for up to six weeks.

Providing you aren’t soaking a pad in less than an hour or the pain is so severe you can’t manage it with over the counter pain relief, such as paracetamol, you should not worry. If you have any concerns, you should seek reassessment.

I haven’t bled following my treatment with Methotrexate, what is wrong?

It is not uncommon for women who have been treated with Methotrexate not to have any bleeding.

Should my bleeding have all these clots in it?

The bleeding that follows an ectopic pregnancy, particularly when treated with Methotrexate, can be very heavy and clotty and result in the passing of what we call a decidual cast. This decidual cast can cause confusion and worry, and women can often mistake it for the tissue of their baby.

The lining of the uterus when we are pregnant, other than that which is taken up by the placenta, is called the decidua. The appearance of the normal lining of the uterus by the presence and action of progesterone (hormone that prepares the uterus for a fertilised egg) becomes decidualised. When an area of the decidua is shed we call it a decidual cast. It is thought to occur as a result of the lack of stability of the integrity of the lining and this lack of stability is because the hormones aren’t functioning properly in an ectopic pregnancy.

The sudden drop in hormones can cause the material inside the uterus to be shed in layers and the material that is passed can be grey, pink or white as well as appear like a clot or dark or frank red blood.

When can I expect a period after my ectopic and will it be painful?

Your periods can take a while to re-establish and they can re-start anything between two and ten weeks after surgery, or once hCG levels have fallen below about 100mIU/mL. Most women find that their period arrives sometime around week six or seven after surgery, and at some time in the four weeks after their hCG levels have fallen to 0 if treated with Methotrexate.

The body is a very clever thing and before you can have a period you have to ovulate. It is perfectly possible to ovulate within 14 days after surgical treatment and almost as soon with Methotrexate treatment, so it is important to be aware that it is possible to become pregnant without having a proper period first if you are not using some form of contraception.

The first period may be more painful or less so than usual, heavier or lighter, last for longer or shorter than usual – there really is no set pattern. You should be able to manage the discomfort with over-the-counter pain relief and should not be soaking a pad in less than an hour. If this is not the case, you should seek medical attention.

Will I still have a period every month after removal of one/both of my tubes?

You will continue to have normal periods every month after the removal of one or both fallopian tubes. The menstrual cycle is controlled by hormones produced in different sites in the body, predominantly in the ovaries, and a period is the shedding of the lining of the womb. The tubes play no part in controlling your period cycle. Periods usually continue normally even in the very rare cases when one of the ovaries is removed as part of the surgical process.

Will my period cycle return to normal after my ectopic? – Before they were 25/26 days but this time I’m 30 days (I’ve checked I’m not pregnant) is this all right?

The first period can occur up to six weeks after the ectopic pregnancy although it may not be like your normal period. It might be heavier or lighter and it may be more painful than normal. The period after that is usually more like your normal pattern. However, although there is no medical reason for it, women do very often report some irregularity to their cycle for several months after an ectopic pregnancy.

Broadly speaking, doctors consider menstrual (period) cycles of between 23 to 42 days to be within normal parameters. If the first day of your last period was more than 42 days ago, make an appointment with your doctor to discuss the possible reasons for this.

Is it normal to have pain during ovulation after my ectopic?

After surgery for an ectopic pregnancy you may have some adhesions which might cause some pelvic pain and pain at ovulation but this usually settles. Some women do report that they can feel themselves ovulate, often because we become acutely more aware of our bodies after suffering an ectopic pregnancy.

Can an ectopic pregnancy affect my menopause?

There is no evidence that an ectopic pregnancy affects or changes the timing of menopause. However, if it was necessary to undertake surgery on the ovary or remove one of the ovaries, this can result in menopause developing slightly earlier although the impact does not appear to be significant.

My ovary was removed at the time of surgery does this mean my periods will change?

It is unlikely that your periods will change following the removal of your ovary. Typically, the remaining ovary compensates and produces sufficient hormones to control the menstrual cycle so your periods are likely to settle into a regular cycle over the next few months even though one of your ovaries has been removed.

Following Up With The Hospital

Following up with the Hospital

Other people had their blood monitored since leaving hospital. Should I?

If you are treated medically with Methotrexate or if you had your tube salvaged (surgery where they left the fallopian tube in place), you need to have your blood monitored as the risk of persistent ectopic is greater. If you had your tube removed, the risk is low and blood testing is not normally necessary, although some doctors do check it once either prior to the woman leaving hospital, or after a week or so, to make sure levels are dropping.

Do I need a check-up with my GP, practice nurse or hospital after my ectopic?

You do not have to have a follow up appointment once it is confirmed that you are no longer at risk from your ectopic pregnancy. However, it is useful to check around six weeks to make sure all is well and that your periods are starting again.

Many hospitals, but not all, offer a follow up appointment. If you haven’t been given a follow up appointment at the hospital, your GP can do a post-operative check-up for you, but as long as you feel OK, there is no real medical need to see a doctor. You may find it beneficial to talk through what happened with a medical professional, and this is the most usual reason for wanting to see a doctor at this stage. If you have been allocated a follow up appointment at hospital this usually involves the doctor reviewing your medical notes, enquiring as to your health and recovery since the operation and discharging you. Only rarely will the doctor examine your tummy or look at your scars.

I am having a follow-up appointment, what should I ask?

We find that many women cannot remember the questions they were going to ask or even much of what was discussed at follow-up appointments. Do not be hard on yourself about this, as this is such an emotionally difficult time and there is so much to take in that it is usual to find the situation quite overwhelming.

We therefore recommend taking someone supportive with you to help remember what was discussed and also recommend you write any questions down. You could even write them out twice and give one list of questions to the doctor and keep the other yourself and mark them off, noting the replies as the doctor answers you.

Some useful questions people often forget to ask are:

  • did the doctor see any obvious reason why you had suffered the ectopic pregnancy at the time of surgery? For example, was there any damage to the fallopian tube?
  • was there any evidence of scar tissue or adhesions elsewhere in your abdomen?
  • did your remaining tube look healthy and intact?
  • how long would the doctor consider it reasonable for you to try to conceive without success before he/she would see you again?
  • will you need a separate referral for this?
  • if and when you are next pregnant, what sort of support or early pregnancy screening will be available to you? For example, can you self-refer directly to the Early Pregnancy Assessment Unit (EPAU) as soon as you find out you are pregnant again?
Contraception

Contraception

Why should I use contraception in the first three months after an ectopic pregnancy?

All women who suffer an ectopic pregnancy are advised to avoid becoming pregnant for at least two proper menstrual (period) cycles after their treatment, which is normally about three months. This allows there to be a clear LMP (Last Menstrual Period/ conception) date, to date a new pregnancy from. It also allows the internal inflammation and bruising to heal and for the necessary process of grief to surface and be worked through.

This ‘wait’ is particularly important if you have been treated with Methotrexate because the Methotrexate may have reduced the level of folate in your body, which is needed to ensure a baby develops healthily. A shortage of folate could result in a greater chance of a baby having a neural tube defect such as hare lip, cleft palate, or even spina bifida or other NT defects. Even though the drug is metabolised quickly, it can affect the quality of your cells, including those of your eggs and the quality of your blood for up to three months after it has been given. Methotrexate can also affect the way your liver works and so you need to give your body time to recover properly and to have taken folic acid supplements before a new pregnancy is considered. The current advice is to take folic acid for several months before you conceive but you must not begin to take folic acid supplements until the hCG levels have fallen to below 5<mIU/mL.

Some studies suggest that women who conceive immediately after treatment for ectopic pregnancy are more at risk of suffering a subsequent ectopic.

Which contraception can I use immediately after my ectopic pregnancy?

If you are still waiting for your first period but decide to have intercourse, then the suggested method of preventing pregnancy is one of the barrier methods (cap, condom, diaphragm or femidom). Introducing a synthetic hormone in the form of a contraceptive pill before this prevents the body from ovulating and establishing a normal pattern.

After the first period has arrived, either continuing with barrier methods or the combined contraceptive pill are usually the methods of choice.

Which contraceptive can I use in the longer term?

This question presents a considerable dilemma at some point in life for almost all post-ectopic women because of their increased risk of ectopic pregnancy and the risks associated with some contraceptive methods. With all contraception, you and the prescribing clinician need to ask the same question – Do the benefits of this to the individual outweigh the risk? Doing this means that you can decide upon the most suitable method of contraception for you as an individual and it might be that you decide on one of the methods which is usually advised against. The issue really is about what suits you and how much you need to prevent pregnancy.

For women with a history of ectopic pregnancy, unless the risk outweighs the potential benefits, we suggest that the barrier methods (cap, condom, diaphragm, femidom), the combined oral contraceptive or Natural Family Planning are the most suitable alternatives for contraception.

IUDs (Intra Uterine Device) or coils are not recommended for those who have suffered an ectopic pregnancy as they are renowned for preventing pregnancy in the uterus but are not effective in preventing pregnancy elsewhere.  With a coil in place, the sperm and egg can still meet in the fallopian tube and fertilisation can, and often does, take place. When things then progress as they should and the egg arrives in the uterus, the coil makes it a ‘hostile’ place and so conception does not continue because implantation cannot happen. The egg expires and is passed in normal menstrual blood (you can’t see it as it’s smaller than a pinprick and is not visible to the naked eye).

If a woman has suffered an ectopic pregnancy she has indicated that there was damage to the tube that was affected and there could therefore be damage to the remaining tube. The problem with a coil is that, if you have a damaged tube(s) and the fertilised egg gets stuck, the fallopian tube will temporarily be an environment where implantation can take place (although it shouldn’t) and it can result in a subsequent tubal ectopic pregnancy.

A Mirena coil is thought to be more suitable than other coils because it releases a small dose of progesterone, preventing ovulation in many instances. Unfortunately, it is not fool proof, and women do become pregnant with a Mirena in situ. You would need to discuss your suitability for this with your doctor though as a Mirena coil is a progesterone only contraceptive.

Progesterone Only Contraceptives (POCs), including contraceptive implants, the mini-pill or progesterone only pill, contraceptive injections and the Mirena Coil are associated with a higher incidence of ectopic pregnancy.

In control groups, women on the combined oral contraceptive were no more likely to suffer ectopic pregnancy, when they stopped taking it, than women who were not on the pill in the first place, thus suggesting that the oral combined contraceptive pill is NOT linked to ectopic pregnancy. However, there was a noted increase in the rate of women who suffered ectopic pregnancy if they became pregnant whilst taking the progesterone only contraceptive pill and it is now listed as one of the precautions in the product data. Likewise, the morning after emergency contraceptive pill is now available as a progesterone only pill and there is an increased risk of ectopic pregnancy with this form of contraception. Again this is noted in the product data.

Chlamydia

Chlamydia

What is Chlamydia?

Chlamydia is a hidden bacterial infection which affects the neck of the womb (cervix), womb lining, fallopian tubes and pelvis in women. It is sexually transmitted, affecting the urethra in men and women, and occasionally it causes eye infections (conjunctivitis). It can persist for many years and, if left untreated, it can lead to pelvic infection, fertility problems, ectopic pregnancy and chronic pelvic pain. It is thought to be responsible for about half of all ectopic pregnancies, particularly in women under 25 years of age.

It is transmitted through sexual intercourse and, the more people have sex with an infected partner, the more likely they are to get it but they only need to have unprotected sex once to be at risk. It’s important to understand that sexually transmitted infections are NOT necessarily diseases of people who are promiscuous, but a simple consequence of unprotected sexual intercourse between two otherwise healthy people. Making sure you are checked out, especially if you believe you might be at risk of infection, will protect your fertility and wider sexual health.

Who is at risk?

Anyone who has been sexually active is at risk of getting Chlamydia. It is most common at the ages when people are most likely to change partners, with about 1 in 10 twenty year olds infected at any time. By the age of 40, at least one-third to half of all women and men will have had it at some time. The number of new cases has doubled in the past 5 years probably because more people are being tested, with more accurate tests.

Approximately 80% of people infected with Chlamydia are unaware that they have the infection as there are rarely any obvious symptoms. It can therefore remain undetected for many years. If you have, or have had, Chlamydia, you probably wouldn’t know it, and nor would your partner, so most people who have Chlamydia get it from someone else who didn’t know they had it! Thus Chlamydia is widespread precisely because it can be silent.

What are the symptoms of Chlamydia?

Even though 80% of people don’t get any signs of the infection when they have Chlamydia you may notice some changes 1-3 weeks after having sex. You might have noticed:

  • spot bleeding between periods or after sex;
  • irregular periods;
  • discomfort or soreness when you urinate (wee) or a need to urinate more frequently;
  • increased or changed vaginal discharge (different colour, smell or amount);
  • lower abdominal pain or pain during sex;
  • pain in the upper part of the tummy, on the right side.

The difficulty in trying work it out yourself is that these symptoms can also be caused by lots of other things as well. Guesswork cannot give you an answer so you need to ask yourself, am I actually at risk of having caught Chlamydia or any other sexually transmitted infection in the last year or so? If the answer is yes, then get checked out.

How can I protect myself from Chlamydia?

Using condoms during sexual intercourse is the only way of preventing the transmission of sexually transmitted infections (STIs). Other methods of birth control, like ‘the pill’ and diaphragms only protect against pregnancy. However, condoms only protect if you use them every time, in short-term or one-off situations. If you have a new partner, remember Chlamydia is symptomless, so ensure that you are both checked out for Chlamydia before you stop using condoms.

How is Chlamydia treated?

You and your partner must take a simple course of antibiotics simultaneously (both at the same time). This ensures that you are not re-infecting each other. You will also be asked for your sexual history so that your contacts can be traced and treated to prevent the spread of this infection. Treatment is free at sexual health/genitourinary (GU) clinics and there are no prescription charges. These services are totally confidential and you don’t need to be referred by your GP. Find your nearest clinics.

How do I tell my partner?

The most difficult thing is often telling your partner. At the time of the ectopic pregnancy, it is often difficult to identify Chlamydia by testing, and Chlamydia may not have caused YOUR ectopic. Among male partners of women proven to have Chlamydia, up to 90% are infected with no symptoms. Remember that Chlamydia can persist for a long time, and either of you might easily have acquired the infection before you met. It is impossible to tell from tests how long the infection may have been there.

How does Chlamydia cause an ectopic pregnancy?

Anything which damages the fallopian tubes, such as endometriosis or previous pelvic surgery, can cause an ectopic pregnancy. Chlamydia causes inflammation within the tubes, damaging the tiny hairs which waft the eggs down the tube. The egg gets stuck and this is how an ectopic pregnancy occurs.

How will I know if Chlamydia caused MY ectopic pregnancy?

It is normal to look for a reason why you experienced an ectopic pregnancy but, for more than half of the UK’s ectopic pregnancies, there is no link, risk or factor known to cause the condition associated with the ectopic pregnancy.

For any woman who has had Chlamydia, it may have contributed to tubal ectopic pregnancy but it is impossible to tell if this was the case because the only way we would know would be to remove the tube and examine it to see if there was evidence of scarring associated with the infection.

Could I have had Chlamydia and not even know it?

The short answer to this is yes. Chlamydia is a bacteria and our bodies are designed to fight bacteria very effectively so our bodies can successfully overcome Chlamydia without treatment. Given the infection is symptomless in 80% of cases and that the infection can self-resolve, it is possible to have had Chlamydia without realising it.

If an ectopic pregnancy was caused by Chlamydia, the infection that did the damage may be long gone and so will not be detectable on a Chlamydia test which is done by testing urine or taking swabs. There will be evidence of antibodies in the blood in anyone whose had Chlamydia but, because testing blood will not alter the doctors assessment or treatment or give them any more information than they already have, testing for antibodies isn’t routinely available. What’s more, even if you did have the blood test and it showed positive antibodies, it doesn’t mean that it was the cause of your ectopic pregnancy.

I have had Chlamydia, will my remaining tube after an ectopic pregnancy be affected?

It is important to remember that even after an ectopic pregnancy there is a chance that your remaining tube is unaffected, even if the tube you lost was damaged by the disease. Chlamydia does not necessarily cause damage equally to both tubes.

Should I test for Chlamydia after I have had an ectopic pregnancy?

If there is a chance you have been infected with Chlamydia then it is always worth taking a test. Although treatment will not correct the damage already done, it may prevent further damage. Some hospitals routinely take swabs after an ectopic pregnancy but many do not.

If I have Chlamydia does it mean I will become infertile or will have an ectopic pregnancy?

Most women who get Chlamydia do not become infertile or suffer an ectopic pregnancy. The reasons for this are unclear, but women’s bodies react differently, similar to an allergy. Risk of ectopic pregnancy is increased by repeated infection with Chlamydia or lack of treatment.

The more times that you get Chlamydia the higher your chances of not being able to have a baby (even if treated). If left untreated, there is evidence to suggest that Chlamydia may affect men’s fertility as well.

Read our Chlamydia leaflet

What about other Sexually Transmitted Infections (STIs)?

Sexually transmitted infections (STIs) are diseases passed on through intimate sexual contact. They can be passed on during vaginal, anal and oral sex, as well as through genital contact with an infected partner. Common STIs in the UK include chlamydia, genital warts and gonorrhoea.

It’s important to understand that sexually transmitted infections are NOT necessarily diseases of people who are promiscuous, but a simple consequence of unprotected sexual intercourse between two otherwise healthy people. Making sure you are checked out, especially if you believe you might be at risk of infection, will protect your fertility and wider sexual health

You can find out more about each STI by clicking on the links below:

About my baby

About my baby

WARNING: This is an emotional issue and this section can be difficult for some bereaved women to read whereas others feel they need the answers to these types of questions. Please understand we need to support everyone’s individual needs so we have included the questions but ask that you ask yourself whether you would like to read this information before clicking on the sections. You may also not feel ready now but want to read these at a later point in time.

Was my ectopic pregnancy a healthy baby?

In an ectopic pregnancy, there is often a pregnancy sac but, in more than 90% of ectopic pregnancies, the foetus has never been viable and there has never been a heartbeat. This is because, as the egg has implanted in the wrong place, it is unable to source a good blood supply and, as a result, our baby can’t grow properly.

It doesn’t mean that it isn’t our baby who we love though and, for us emotionally, this is still the loss of our baby and is as equally emotionally traumatic as any other baby loss experience. It is not possible to move an ectopic pregnancy.

What happened to my baby when I was treated with Methotrexate?

It should first be said that, in ectopic pregnancy, because the egg has implanted in the wrong place, it is unable to source a good blood supply. As a result the ‘trophoblasts’ (that nourish the embryo and form the placenta) are trying to ‘burrow’ in to the walls of the structure the egg is stuck in rather than the uterus and all energy and growth is occurring there. It is these trophoblasts that will eventually cause the rupturing if not treated. This means that our babies are not growing and so, for more than 90% of us, in ectopic pregnancy our babies do not, and have ever had, a heartbeat.

Methotrexate is a ‘folate antagonist’. This means it interferes with the folate in our body and causes an essential substance needed to help trophoblast cells to divide to be released from the body. The cells can no longer divide because this essential substance is missing.

Once these cells no longer divide, the pregnancy is ended and the whole pregnancy sac, including any cells that might eventually have grown into a baby, is usually reabsorbed by the mother. This happens because it is our own DNA and cellular material and so the body treats it like the reassignment of resources. This is normal and happens in many cases of miscarriage. The ‘reabsorption’ can take weeks and sometimes months to be complete and is monitored through beta hCG blood tests.

In some instances, the fallopian tube may remain blocked by the pregnancy tissue which can take some time to shrink and, occasionally, it may not shrink and will leave a blockage in the tube by way of a small cyst. However, the use of Methotrexate does not reduce the chances of successful future pregnancy, whatever the outcome in the affected tube.

Occasionally, the tissue can separate from the tubal wall and be passed in the blood which is flowing out of the uterine cavity into the vagina.

You may feel pain after being given Methotrexate but this is due to the pregnancy sac swelling and not due to effects on the baby.

What happened to my baby when I was treated with surgery?

There are several guidelines for medical professionals to follow regarding the sensitive treatment of your baby. As a result, many hospitals have adopted arrangements with local crematoria for the sensitive disposal but they are guidelines, and procedures vary from hospital to hospital.

The detail for these guidelines can be found by clicking on each of the links but please be aware that medical terminology like “foetal remains” may be used which some readers may find upsetting:

We recommend that for local information about your hospital, you contact the Patient Advice and Liaison Service (PALS) department and ask what the hospital policy is on the sensitive disposal of foetal remains.

The hospital chaplain will do whatever they can to accommodate your needs in relation to your honouring your loss. They will almost certainly have a baby loss service of some kind and you might also like to see what the Baby Loss Awareness Campaign has organised in your area for the next celebrations and acts of remembrance.

Is ectopic pregnancy an abortion?

In medicine, an “abortion” is the generic term used for the premature exit of the products of conception (the foetus, foetal membranes, and placenta) from the uterus before 28 weeks, but is becoming less commonly used because of the confusion the term creates and the insensitivity of its use. The term refers to the loss of a pregnancy and does not refer to why that pregnancy was lost. A “spontaneous abortion”, albeit insensitive, is a medical term used to describe a miscarriage. The miscarriage of three or more consecutive pregnancies is termed, in medicine, as habitual abortion.

Ectopic pregnancy is not and never could be regarded as an abortion in the more widely understood meaning of the word where somebody chooses to terminate their pregnancy. Ectopic pregnancy is a life threatening condition which, if not medically managed and/or treated, can end the life of the mother. It should not be confused with miscarriage which is not usually life threatening, or with an elective termination of pregnancy which is a surgical procedure to end a viable pregnancy or with one which ends a pregnancy where the foetus has a condition which is not compatible with life.  An ectopic pregnancy is an out of place pregnancy and so does not fit the medical definition of premature exit of the products of conception from the uterus. In over 90% of instances of ectopic pregnancy the foetus has never been viable and there has never been a heartbeat.

Some doctors use the term ‘tubal abortion’ to explain why no products of conception can be found in a ruptured tube, when it is examined after the diagnosis and treatment of ectopic pregnancy but again, this is not the same as the premature exit of the products of conception from the uterus. Tubal abortion refers to the products of conception separating from the wall of the fallopian tube to be passed in much the same way they might be in a miscarriage.