Ectopic Pregnancy: Diagnosis, Treatment and Follow-Up

An ectopic pregnancy is a pregnancy that implants outside the uterine cavity, most often in the fallopian tube. A pregnancy developing outside the womb cannot progress healthily; if the tube ruptures, life-threatening internal bleeding can occur. For this reason, if your pregnancy test is positive and you have pain or spotting, it is important that you are assessed without delay. If the diagnosis is made early, your treatment options also widen. The information below offers a general framework; it does not replace a diagnosis or treatment recommendation specific to you.

Where can an ectopic pregnancy implant?

Most ectopic pregnancies are in the fallopian tube and are also called "tubal pregnancy". Less often, implantation may be seen in the cervix, in a caesarean scar, in the part of the tube close to the womb (interstitial/cornual), in the ovary or in the abdominal cavity. Assessment and treatment of these rare locations need a more specialised approach.

How common is it?

Ectopic pregnancy is relatively uncommon among all pregnancies, but it is a condition that must be taken seriously. Its frequency varies between countries and communities; there is no single, current rate specific to Turkey. Bleeding from a ruptured ectopic pregnancy is among the important causes that threaten the mother's health in the first three months of pregnancy.

Which risk factors are known for ectopic pregnancy?

Known risk factors include infections that can damage the tubes (pelvic inflammatory disease) and tubal surgery, a previous ectopic pregnancy, smoking, pregnancy with an intrauterine device in place, and assisted reproductive techniques. Endometriosis is also mentioned among the risk factors.

An important point is that many people who have an ectopic pregnancy have no identifiable risk factor. For this reason, having no risk factor is not enough to rule it out.

Why is the beta-hCG blood test repeated?

The level of beta-hCG, the pregnancy hormone, is measured with a blood test. A single value cannot on its own confirm or rule out an ectopic pregnancy; values are interpreted together with the ultrasound findings. When a pregnancy cannot be seen inside the womb, repeating the test a few days apart shows how the hormone changes over time.

What does a transvaginal ultrasound assess?

A transvaginal ultrasound is used to assess whether the pregnancy is inside the womb and any accompanying findings (such as a mass around the tube or fluid in the abdomen). In very early weeks the gestational sac may not yet be visible; this does not automatically mean there is no pregnancy.

What does "pregnancy of unknown location" mean?

When the pregnancy test is positive but the location of the pregnancy cannot be determined on ultrasound, this picture is called "pregnancy of unknown location". It is not a diagnosis but a temporary stage of assessment. The pregnancy may be an early pregnancy inside the womb, a pregnancy that is not developing, or an ectopic pregnancy. During this process your doctor follows your hormone values and symptoms and, when needed, asks you to come back for a check.

How is an ectopic pregnancy told apart from a miscarriage and an anembryonic ("empty") pregnancy?

Bleeding and pain in early pregnancy can also be seen in a pregnancy inside the womb. The differential diagnosis is made by the doctor.

What is the choice of treatment in ectopic pregnancy based on?

The choice of treatment does not depend on a single rule. The doctor decides by looking at the symptoms, signs of bleeding, general condition, ultrasound findings, hormone level and the possibility of follow-up. The headings below summarise the general reasoning behind this decision.

When can expectant monitoring under a doctor's supervision be considered?

In selected people who are stable and whose hormone level is low, some ectopic pregnancies can be monitored under a doctor's supervision. This approach is considered only if regular blood test follow-up and quick access in an emergency are possible. It cannot be generalised as "it passes by itself, so we wait"; whether monitoring can be carried out safely depends on the doctor's assessment.

When is drug treatment with methotrexate considered?

In people who meet certain criteria, have no signs of bleeding and can attend follow-up regularly, treatment with a medicine called methotrexate may be an option. With drug treatment, hormone levels are checked regularly; if there is not a sufficient fall, an additional dose or surgery may be needed. The points to watch afterwards (check-up intervals, how long to avoid pregnancy, interaction with some medicines and supplements) are set by the doctor, based on the medicine's patient information leaflet. The dose and the schedule of administration are determined by the doctor for each person.

In which situations may surgical treatment be needed?

Surgery is considered when there is marked pain, bleeding or suspicion of rupture, an unstable general condition, an insufficient fall in hormone level after treatment, or when follow-up cannot be carried out safely. In a person with signs of rupture and an unstable condition, emergency surgical intervention is a medical emergency. Surgery can often be planned laparoscopically.

How is it decided which option is suitable?

No option is superior for every person. The success of the method and its effect on the next pregnancy vary according to the person's situation. The decision is made by the doctor by talking through the findings and preferences; the person should understand the benefits and limits of the treatment and the need for follow-up.

How does hormone follow-up continue after treatment?

After drug treatment or some surgical treatments, the beta-hCG level is followed until it approaches zero. The check-up schedule is planned by the doctor according to the treatment method and the person. Keeping to these appointments is important for the treatment to be completed safely.

What assessment is done in Rh-negative blood group?

In people whose blood group is Rh negative, a treatment called anti-D may be considered in order to protect later pregnancies. Your doctor assesses your blood group and your treatment method on this subject.

Can you get support after losing an ectopic pregnancy?

An ectopic pregnancy is a pregnancy loss; the end of a wanted pregnancy can bring sadness, anxiety or a feeling of guilt. These feelings are understandable. An ectopic pregnancy is not the person's choice or the result of something they did; a pregnancy developing outside the womb cannot progress healthily. Getting support and talking with those close to you or with your doctor can be helpful.

How is another pregnancy planned after an ectopic pregnancy?

In most people a pregnancy inside the womb is possible after an ectopic pregnancy. However, having had an ectopic pregnancy before raises the likelihood of another ectopic pregnancy in a later pregnancy, and this risk varies from person to person according to the condition of the tubes, the treatment method and other factors. Research has not shown a clear and consistent advantage for either drug or surgical treatment in terms of a later pregnancy inside the womb; for this reason it cannot be said that "this method is better".

How long to wait for a new pregnancy is determined by the doctor according to the treatment method. In a later pregnancy, it is important to see a doctor early and to have the location of the pregnancy confirmed early. If the condition of the tubes needs to be assessed, tests such as HSG (hysterosalpingography) may also be considered.

Can an ectopic or heterotopic pregnancy occur after IVF?

"Ectopic pregnancy does not happen in IVF because the embryo is placed in the womb" is a common misconception. An ectopic pregnancy can be seen after assisted reproductive techniques too. In addition, a pregnancy both inside and outside the womb at the same time (heterotopic pregnancy) is reported more often in this group than in natural pregnancies, although the rates vary greatly between studies. It can rarely be seen even in people whose tubes have been removed.