Download Ectopic Pregnancy

PATIENT INFORMATION SHEET
Westmead Hospital Early Pregnancy Assessment Clinic (EPAC)
Ectopic Pregnancy Management Options
GENERAL INFORMATION
If you are reading this booklet, it is likely that you or someone you care about has been diagnosed with an ectopic
pregnancy [EP]. Women, their partners, families and friends often feel sad and also a bit frightened about the
diagnosis, its treatment and the future. This is completely normal.
Ectopic pregnancy is reasonably common, occurring in 1 - 2% of pregnancies. While ectopic pregnancy is more
common in women with a previous ectopic pregnancy, previous surgery to the fallopian tubes (including having the
‘tubes tied’), a past infection in the fallopian tubes, an intrauterine contraceptive device (IUCD) in the uterus at the
time of pregnancy and some fertility treatments – the fact is that any woman can have an ectopic pregnancy. In
fact, thousands of Australian women have an ectopic pregnancy each year.
About 95% of ectopic pregnancies are in the fallopian tube and this information sheet only deals with these. Ectopic
pregnancies can also occur in other rare locations – the interstitium (narrow space between the uterus and the
fallopian tube), scar site from a previous caesarean, cervix, ovary and abdomen - but these may need a different
approach to treatment than what is discussed in this information sheet. Your doctor will advise you on this.
Our Early Pregnancy Assessment Clinic (EPAC) staff are available to help women and their families through this
time. Further support from our social workers is available if needed.
KEEPING IN CONTACT WITH EPAC STAFF DURING ECTOPIC MANAGEMENT
Most women have no significant issues during their ectopic pregnancy care. However, some women can have
serious problems, including problems requiring fairly urgent surgery. If you feel seriously unwell at any time you
should immediately go to the emergency department (ED). See also page 9 for symptoms of tubal rupture.
If you feel mildly unwell or you need information,
you should contact the Early Pregnancy Assessment Clinic (EPAC).
Phone: 9845 9193 (open 365 days a year)
Monday- Friday
7.30am - 7.30pm
Saturday, Sunday and Public Holidays
7.30am - 6.30pm
You will be asked to leave a message and your phone number.
We also need some phone numbers for you so we can contact you with results and other information. To make
sure we can get through to you quickly, it’s a good idea for us to have 3 phone numbers - 2 for you and 1 for
someone else who can find you if you are not answering your phone(s).
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WHAT IS AN ECTOPIC PREGNANCY?
An ectopic pregnancy is a pregnancy developing outside the uterus (womb) instead of inside the uterus.

A normal pregnancy begins when the sperm and egg come together in the fallopian tube to form an
embryo (the tiniest beginning of a baby).

The embryo then normally moves into the uterus after a few days, and develops there as a growing baby
for the next 9 months.

If an embryo fails to move into the uterus, this is called an ectopic pregnancy. With most ectopic
pregnancies, the embryo remains in the fallopian tube. This is not a healthy place for a baby to grow.
Unfortunately, a pregnancy in the tube cannot:

Develop to become a baby

Be moved from the tube into the uterus.
OR
There are three possible outcomes for ectopic pregnancies:

Some will resolve (go away) by themselves without treatment.

Some will resolve after an injection of methotrexate to ‘dissolve’ the pregnancy.

Some will need surgery, including, in a few cases, reasonably urgent surgery for heavy internal bleeding.
Image courtesy of www.invitra.com
WHAT ARE THE SYMPTOMS OF AN ECTOPIC PREGNANCY?
Each ectopic presents differently and some women have no symptoms at all. As a result, it is not always
straightforward to make the diagnosis of an ectopic pregnancy. The symptoms of an ectopic pregnancy may
include:

Vaginal bleeding – this may be similar to a period or quite different from a period (lighter or heavier). It
may be only spotting.

Pain in the lower abdomen – this may develop suddenly or come on gradually over several days. It can
be mild or severe. It is often only on one side of the abdomen.

Pain in the tip of the shoulder – this pain may be worse when lying down. It can be a sign that blood is
leaking into the abdomen from an ectopic pregnancy.

Feeling very faint – if the ectopic in the fallopian tube causes heavy internal bleeding, either by rupturing
(bursting) or by growing into a blood vessel, a woman may feel very faint and sweaty. This is an
emergency situation. Rarely, these symptoms may be the first clue to an ectopic pregnancy.
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HOW IS AN ECTOPIC PREGNANCY DIAGNOSED?
An ectopic pregnancy [EP] is usually diagnosed via a combination of pregnancy hormone (bHCG) blood levels and
ultrasound (generally with the ultrasound probe inserted into the vagina to give the clearest pictures). However it is
quite common to need more than one ultrasound as an EP can be very hard to see in some cases, being hidden by
the other organs and tissues in the pelvis. In fact, in a few women the EP itself is never definitely seen on
ultrasound. In these cases, blood in the pelvis together with no pregnancy in the uterus may make the diagnosis
highly likely and the situation is therefore often treated as an EP.
WHAT ARE THE TREATMENT CHOICES FOR A PREGNANCY IN THE FALLOPIAN TUBE?
A pregnancy in the fallopian tube cannot lead to the birth of a baby. Therefore, all treatments focus on bringing the
pregnancy to an end to reduce the risks to the woman.
TREATMENT CHOICES
Surgical Treatment
Usually this involves removal of the tube containing the ectopic pregnancy
via keyhole surgery (see next page)
Medical (methotrexate) An injection of methotrexate is given into a muscle to dissolve the
pregnancy in the tube (see next page)
Expectant (‘wait and see’)
With this option you do nothing, just wait and see what happens:
NOTE: Most ectopic
pregnancies are not
suitable for expectant
management.
 Only suitable for a small number of ectopic pregnancies - those which
appear to be resolving (going away) by themselves as shown by a low
and falling pregnancy hormone level (bHCG). Otherwise, this option is
usually not safe.
 In expectant management, the bHCG is tested regularly until it is back to
normal. If it stops falling well, methotrexate or surgery are needed.
The chance of a successful pregnancy in the future seems to be the same with all of these treatments
Women with Rh Negative
Blood Type
Whichever treatment is given, Rh Negative women will be offered an Anti-D
injection to prevent them making antibodies that may cause problems in a
future pregnancy.
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WHAT IS METHOTREXATE?

Methotrexate is a medication that works by blocking one of the enzymes needed to make genetic material
(DNA). This stops the multiplication of living cells. It is used in small doses to treat ectopic pregnancies
(and in much larger doses to treat some cancers).

In appropriately-chosen ectopic pregnancies, there is a 90% chance of avoiding surgery with methotrexate.

It is given by injection into a muscle. This acts to ‘dissolve’ the ectopic pregnancy in the fallopian tube.

In the low doses used for ectopic pregnancies, methotrexate is a very safe medication with few side effects.
SURGERY IS PREFERABLE TO METHOTREXATE IN SOME CASES
While many ectopic pregnancies are highly suitable for successful treatment with an injection of methotrexate, in
some situations, surgery is a better option. These include the following:

Higher chance of methotrexate failure: If the estimated chance of success with methotrexate treatment
is less than 90%, we generally recommend surgery, although there will be some situations where
methotrexate is still a reasonable option. In such cases, we may give more than one dose of methotrexate.

Heavy internal bleeding: If it seems likely that heavy internal bleeding is occurring due to the ectopic
pregnancy eroding into a blood vessel or causing the fallopian tube to rupture (burst), urgent surgery is
necessary. On the other hand, a small amount of internal bleeding is common and is generally not a
reason to choose surgery.

Women refusing a blood transfusion: The risk of needing a blood transfusion is slightly higher with
methotrexate than surgery (2-3% vs. 0-1%), so that a woman who would never consent to a blood
transfusion eg. Jehovah’s Witness faith, is better off having surgery.

Severe pain: Severe pain is usually best managed with surgery (mild pain is normal and the ectopic can
be managed with methotrexate).

Wanting permanent contraception : If a woman would like the fallopian tubes tied (permanent
contraception), this can be done at the time of surgery for the ectopic pregnancy.

Currently breast-feeding : Methotrexate is not given to breast-feeding women.

Other health problems: Surgery is better if there is a serious health problem which might be affected by
methotrexate - immunity problem, serious infection, severe disease of liver, kidneys, lungs, and blood cells.

Difficulty with follow up after methotrexate :
o
A few weeks longer follow up is required after methotrexate than after surgery, plus some extra
visits and blood tests are involved.
o
In addition, vaginal intercourse must be avoided after methotrexate until the bHCG levels are back
to normal (to reduce the chance of the tube rupturing).
o
Finally, it is necessary to wait 3 months before getting pregnant again after methotrexate. After that
time, it is completely safe to fall pregnant again. With surgery, it may be possible to try for another
pregnancy after 1 - 2 months.
o
Women who would have difficulty with any of these follow-up recommendations are better off
having surgery.
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SURGICAL MANAGEMENT OF TUBAL ECTOPIC – WHAT YOU NEED TO KNOW
Arranging Surgery
Usually there is no urgency and we organise for hospital admission in the next day or
two.

However, if you are in a lot of pain and/or if we think heavy internal bleeding is
occurring or is about to occur, we will organise emergency admission
Note though, it is not possible to absolutely predict tubal rupture or heavy bleeding and
this will occasionally occur in a small number of women while waiting for surgery.
Anaesthetic
You are asleep (general anaesthetic) for the surgery
Incision (cut)
There is one or more incision (cut) on the abdomen (tummy)
Remove the
fallopian tube

This is usually keyhole surgery (laparoscopy) using 3 or 4 small incisions, each
about 0.5 to 1 cm long

Sometimes, however, a longer cut is needed (laparotomy)
If the other fallopian tube appears normal, we usually take the whole tube that contains
the ectopic (salpingectomy).
or

Research shows this is generally better for the woman.
Leave the
fallopian tube

The chance of having a normal pregnancy in the future is the same if we take the
fallopian tube or leave the tube. But short term problems are less if we take the
tube with almost no chance of accidentally leaving some pregnancy tissue
behind
However, if the other fallopian tube appears unhealthy or has already been removed

We usually try to remove the ectopic and leave the tube (salpingotomy).

This is mostly successful, but not always successful.

It is also associated with a bit more internal bleeding than taking the whole tube.

Saving the fallopian tube also requires follow-up blood tests (bHCG) until they
are back to normal, because some pregnancy tissue might accidentally be left
behind (about 10% of cases).

In these cases, methotrexate or further surgery may be required.
Stay in hospital
Usually 12 - 24 hours, occasionally longer.
Time off work
Usually 1 - 3 weeks.
Rh Negative (blood)
If you are Rh negative blood group, we offer an injection of Anti-D before you go home
from hospital
Follow up
Fallopian tube removed: usually just one check-up in EPAC 1 - 2 weeks after surgery.
Fallopian tube left behind: pregnancy hormone test (bHCG) weekly until back to normal.
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POSSIBLE COMPLICATIONS AND SIDE EFFECTS WITH SURGERY
Surgical treatment of ectopic pregnancy is very safe and most women have no problems apart from a few days
of pain after the surgery.
Anaesthetic and
surgery
complications
Pain after surgery
Both the operation and anaesthetic are very safe with a low rate of serious
complications (less than 1%, but not zero, as an occasional complication will occur).
Almost 100% of women will have some discomfort in the surgery wounds for a few
days after surgery.
Shoulder tip pain can also occur for a few days after the surgery.
Simple painkillers such as ibuprofen or paracetamol are usually adequate but
occasionally a few doses of something stronger may be needed.
Wound infection after
surgery
After surgery, the wounds often look a little bit red, especially if a ‘dissolving’ stitch is
used. True infection is uncommon but can occasionally occur.
Contact EPAC if you are concerned at all.
Vaginal bleeding after
surgery
 A few days after the surgery you will generally have an increase in vaginal
bleeding and this may last for several days. Usually, it is only slightly heavier
than a period. It is due to the lining of the uterus coming away as the pregnancy
hormone falls.
 Sometimes, the entire lining of the uterus can pass as one larger piece of tissue
(a decidual cast). Passing this can be quite painful for a few hours.
If you have any concerns about bleeding, please phone EPAC or come to the
hospital’s Emergency Department.
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METHOTREXATE MANAGEMENT OF TUBAL ECTOPIC PREGNANCY
WHAT YOU NEED TO KNOW
Methotrexate
works best for
these ectopic
pregnancies
Methotrexate therapy is very suitable for many ectopic pregnancies. However, for some
ectopic pregnancies and some women, it is less suitable than surgery (see page 4). The
best success with methotrexate occurs when:
 No heart beat is seen in the pregnancy on ultrasound;
 The pregnancy hormone test (bHCG) is less than 5,000 IU/L; and
 bHCG is going up only slowly (not doubling every 2-3 days like a healthy pregnancy)
Overall success
With no heartbeat seen, and a bHCG level less than 5,000 IU/L which is not rising quickly,
there is about 90% chance that 1–2 doses of methotrexate will successfully ‘dissolve’ the
ectopic without need for surgery.
With a bHCG level 5,000–10,000 the success is lower, about 80–85%, possibly even lower
if there is fetal heartbeat present.
We usually advise that surgery is the better option if the bHCG is above 5,000 IU/L.
 However, while it is not what we usually advise, you may still choose methotrexate
even when the chance of success less than 90% (bHCG above 5,000 IU/L and/or a
heartbeat present), as long as you have a full discussion with the team and understand
the increased risk of urgent surgery and blood transfusion in making such a choice.
 In such situations, a second dose of methotrexate is sometimes given around 3 days after
the first dose to increase your chance of success.
Need for a
second dose
To achieve success in dissolving the ectopic pregnancy without need for surgery, most
women will only need one dose of methotrexate. However, about 15% will need a second
dose one week later.
Need for surgery
10% will be unsuccessful and will need surgery (some will need urgent surgery)
Safety for your
family
You do not pose a risk to anyone else after methotrexate but you should wash your hands
well after using the toilet and close the lid.
Usual activities
Most women are able to continue with work/study and usual activities but some will need to
take leave for a few days.
Having sex
You should avoid sexual intercourse until your bHCG returns to normal to reduce the
chance of fallopian tube rupture.
Medications to
avoid for 2 days
after
methotrexate
If possible, try and avoid these medications (if you need them, take them, the chance of any
problem with them is extremely small). After 2 days, all medications can be taken.
 some antibiotics – penicillin, trimethoprim, cotrimoxazole, sulphonamides, tetracycline
 phenytoin, salazopyrine, diabetes tablets
 painkillers - aspirin, ibuprofen, naproxen, diclofenac and similar
For one week
after
methotrexate
 Make sure you drink lots of water to flush the methotrexate from your body.
Folic acid
There is no need to stop taking folic acid tablets, as they do not interfere with treatment. If
you are planning to get pregnant again in the next few months, stay on folic acid so it’s
already in your system on the day you conceive – this timing is very important.
Rh Negative
If you are Rh negative we offer an injection of Anti-D on the day methotrexate is given.
 Reduce alcohol intake to a maximum of 1–2 small alcoholic drinks per day.
 Do not sunbake – sunburn can be more common for a few days after methotrexate.
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METHOTREXATE TREATMENT SCHEDULE
METHOTREXATE
SCHEDULE
The day
methotrexate is
given is
Day 1
WHAT IS INVOLVED
 Baseline blood tests are taken (kidneys, liver, bone marrow/anaemia, bHCG,
blood group) before the injection to make sure it is safe for you.
 The dose of methotrexate is calculated based on your height and weight.
o
Note - pharmacy takes several hours to make up the medication, so you
may want to go home and come back.
o
You sign a consent to receive the methotrexate.
 A single injection is given into a muscle in the thigh, arm or bottom.
o
You remain in hospital for about 15 minutes and then go home.
(some women feel faint for a short while after an injection)
 Anti-D is also given if your blood group is Rh negative.
Day 4
 bHCG level is checked – this often goes up between Day 1 and Day 4 as the
pregnancy tissue dissolves and releases its hormones, so don’t worry about
that. What matters is what happens between Day 4 and Day 7.
 By Day 4 you may experience pain or other side effects (see next table).
Day 7
 bHCG level is checked and the blood tests from Day 1 are also repeated.
 If the bHCG level drops by 15% or more between Day 4 and Day 7

the bHCG level is checked weekly until back to normal.
 If the bHCG level does not drop enough between Day 4 and Day 7, a
second dose of methotrexate is usually given, as long as the other blood tests
are still reasonably normal.
o If there was quite a big bHCG drop between Day 1 – Day 4, the team may
decide a further dose is not necessary.
o Occasionally, surgery is a better option than a second dose of
methotrexate, but usually methotrexate is chosen.
o The day of the second dose of methotrexate becomes the new Day 1 of a
new schedule and the follow up is repeated as above.
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POSSIBLE COMPLICATIONS AND SIDE EFFECTS WITH METHOTREXATE
Low dose methotrexate treatment of ectopic pregnancy is very safe and most women have no problems
apart from 1–2 days of pain between Day 4 and Day 12. However, it is important that women having methotrexate
are aware of the possible complications below.
Heavy internal
bleeding
About 7% of women will have a rupture of the fallopian tube or other heavy internal
bleeding and need urgent surgery.
Some women may also need a blood transfusion (about 2 - 3% will need this compared to
0 - 1% who undergo surgery as their first choice of treatment).
Symptoms of
fallopian tubal
rupture
Rupture is mostly impossible to predict, although it is more likely in ectopic pregnancies
with high bHCG, quickly rising bHCG or a heartbeat seen in the pregnancy on ultrasound.
Symptoms that might suggest rupture is occurring include:

Feeling very weak, dizzy, sweaty;

Feeling generally unwell;

Severe pain in the abdomen (mild to moderate pain after methotrexate is normal);
and/or

Pain in the shoulders.
If you have any of these symptoms, you should go to the hospital’s Emergency Department
Vaginal bleeding
after methotrexate
A week or more after the methotrexate, you may experience an increase in vaginal
bleeding which may last for several days. Usually it is only slightly heavier than a period. It
is due to the lining of the uterus coming away as the pregnancy hormone falls.

Sometimes, however, the entire lining of the uterus can pass as one larger piece of
tissue (a decidual cast). Passing this can be quite painful for a few hours.
If you have any concerns about bleeding, please phone EPAC or come to the hospital’s
Emergency Department.
Other Symptoms
with methotrexate
Most women will not have any symptoms after methotrexate however, about 30% will have
some mild side effects for a few days including:

Tummy upset (feeling gassy or windy) – manage with De-Gas or similar chemist
product if necessary;

Feeling sick on the stomach - having vomiting or diarrhoea;

Tiredness, mild dizziness;

Eye irritation or sore mouth ulcers;

Increased tendency to sunburn; and/or

Uncommon complications involving liver, kidneys, bone marrow, lungs.
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PAIN AFTER METHOTREXATE
Pain after
methotrexate
75% of women will experience some low abdominal pain after methotrexate. This is because
the pregnancy bleeds into the fallopian tube as it ‘dissolves’ and the tube becomes swollen
and tender with this blood for a few days, causing pain.
 The pain usually occurs between Day 4 and Day 12 after the injection.
 For most women, the pain is mild to moderate and lasts 1–2 days.
 Usually the pain is well controlled by taking paracetamol and ibuprofen.
o
Paracetamol 500 mg tablets x 2 repeated every 4–6 hours as necessary
(max 8 tablets per day)
o
Ibuprofen 200 mg tablets x 2 repeated every 4–6 hours as necessary
(max 8 tablets per day)
 Because severe pain can sometimes mean the fallopian tube is about to rupture and you
may need surgery, you need to phone EPAC or come to the Emergency Department if:
o
The pain is severe (pain score 8–10 on a scale of 1-10).
o
The pain is moderate (4–7 on a scale of 1-10), but is not getting better with the
paracetamol and ibuprofen.
 A small number of women will be admitted to hospital for pain, but only 25% of these will
need surgery. For most women, the pain will settle and the bHCG will be falling well and
they will be discharged home without surgery.
 On the other hand, occasionally a woman will need surgery for pain even if the bHCG is
falling well.
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PREPARING FOR THE NEXT PREGNANCY AFTER AN ECTOPIC PREGNANCY
Trying for pregnancy again
The timing of when you can try to get pregnant varies with the treatment given:

Surgery: once you have had a normal period and are feeling well again.

Methotrexate: You should not fall pregnant for 3 months after the methotrexate. Beyond that time, it is
safe to try for a pregnancy

Expectant: Once the bHCG is back to normal and you have had a normal period.
Where the pregnancy will be next time?
This varies from woman to woman and depends a lot on the condition of the other fallopian tube and the pelvis
generally. After the first ectopic pregnancy, the usual next pregnancy is:

Pregnancy in the uterus (the right place) next time – 65%

Another ectopic next time – 15%

Difficulty getting pregnant next time – 20%
Testing for Chlamydia and Gonorrhoea

Chlamydia is common in young women, present at any one time in 5% of women aged 15 - 29 years.
Gonorrhoea is less common.

These infections can cause fallopian tube damage and increase the risk of an ectopic pregnancy.

Most women with an ectopic pregnancy do not have a chlamydia or gonorrhoea infection. However, since
these infections mostly cause no symptoms, women don’t know they have the infection without testing.

Testing and treatment are extremely simple - we advise that all patients with an ectopic pregnancy should
have a test for chlamydia and gonorrhoea. Please talk to the EPAC midwife about this.
Rubella immunity
You should make sure you are immune to rubella virus (german measles) before you try to get pregnant again.

The test for your rubella immunity level will often have already been done by your GP or EPAC, so ask
our staff about the result.

If you are not immune, we will give you the vaccine.

After the vaccine, you should avoid pregnancy for one month, but after that it is safe to try for a baby.
Folic Acid

Folic acid is necessary to make genetic material (DNA), and folic acid tablets (or a high folic acid diet)
prevent some (but not most) of the major abnormalities that can occur in a baby.

Folic acid needs to be in your system for one month (ideally 3 months) before you get pregnant if it is to
successfully work in preventing abnormalities.

If you are planning another pregnancy soon, stay on your folic acid tablets - a dose of 500 micrograms
every day is usually adequate
Contraception

Some women do not want to get pregnant again soon (or ever again).

If you need contraception advice, please discuss this with your GP or the EPAC staff.
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