How Long Did It Take to Get Pregnant After Ectopic

Ectopic pregnancy

We would like to express our sincere sympathy to you and your family. This booklet has been designed to include a range of information that may be of use to you and your family and friends. It is intended to guide you through some ofthe decisions and emotions you may be feeling at this time.

What is an ectopic pregnancy?

An ectopic pregnancy results when an early pregnancy becomes implanted anywhere outside the cavity of the uterus. It is a potentially serious condition affecting about 1 in 100 pregnancies. Most ectopic pregnancies develop in the fallopian tubes but some occur in the cervix, caesarean section scar, ovary or even the abdominal cavity. The early pregnancy cannot survive away from the protective, nourishing environment of the uterus although it may continue to develop for several weeks. As the fallopian tube is not large enough to accommodate a growing baby, the thin wall of the fallopian tube will stretch causing pain in the lower abdomen and often vaginal bleeding. If not diagnosed and treated, the tube
can sometimes rupture, causing severe abdominal bleeding.

This event can be life threatening.

Sadly, there is no possibility that your pregnancy can survive. The loss of your pregnancy is likely to make you feel very sad. In addition this may be the first time you have heard of this condition and you may also feel shocked, confused and anxious about the future.

What causes an ectopic pregnancy?

The very early pregnancy normally spends four to five days in the fallopian tube before travelling to the cavity of the uterus where it implants around six to seven days after fertilisation. Any damage to the fallopian tube can cause a blockage or narrowing. Hormonal imbalance, malfunction of the uterus and tube, and infection can all impair the tubes normal function and result in ectopic pregnancy. Some women are at an increased risk of an ectopic pregnancy such as those:

with a history of previous ectopic pregnancy
with a previous history of pelvic infection or and tubal damage
with a history of infertility
with previous history of pelvic surgery including sterilisation
using or having previously used an intrauterine contraceptive device (IUCD)
undergoing assisted conception such as invitro fertilisation (IVF).

How is an ectopic pregnancy diagnosed?

If an ultrasound scan shows an empty uterus but the pregnancy test is positive the possibilities are:

an ectopic pregnancy
a very early normal pregnancy
or a miscarriage.

The ectopic pregnancy may appear as a small pregnancy sac outside the uterus or as a mass. However, you may not see
evidence of the pregnancy location on a scan. In such cases repeated blood tests are done to measure the pregnancy
hormone levels. In ectopic pregnancy the levels are usually lower and rise more slowly.

Is it possible to remove the pregnancy from the tube and put it into the uterus?

Although this has been tried, it has never been done successfully. Because the egg has implanted in the wrong place, often the baby isn't able to progress normally.

What needs to happen now?

Sometimes, an ectopic pregnancy is absorbed and there are minimal or no symptoms (like pain or bleeding). Nothing needs to be done in these circumstances except to ensure that the pregnancy hormone levels quickly return to normal. Sometimes medicine is used to dissolve the early ectopic pregnancy. Sometimes, an operation is required. The staff in Mater's Pregnancy Assessment Centre (PAC) will advise you and help you to make an informed decision about what to do. You will find some more detailed information regarding these management options below.

Option A: Expectant management ("Wait and see" approach)

Expectant management is increasingly common. It means that you are observed closely and the ectopic pregnancy given the opportunity to resolve without treatment.

Isn't this dangerous?

If monitored correctly, this is not dangerous as not all ectopic pregnancies will cause bleeding in the abdomen. Some ectopic pregnancies do not rupture and they clear without treatment. The pregnancy often dies in a way similar to a miscarriage, but it is absorbed, and there is minimal pain or bleeding. In these circumstances, nothing further needs to be done. A "wait and see" approach is a safe and appropriate way to manage your ectopic pregnancy if:

the pregnancy has already died
the pregnancy is very small
the pregnancy hormone level (Hcg) is low (and falling)
there is no blood in the abdomen
you have no pain.

You will, however, need close follow-up as there is still a very remote chance that the ectopic pregnancy may cause the fallopian tube to rupture and bleed. Being managed with no treatment can feel quite scary but we are giving your body the best chance to resolve this naturally. If we have suggested this method of treatment, then there is an almost 90 per cent chance that the ectopic pregnancy will resolve all by itself.

What would need to happen next?

You will be given some request forms for blood tests to measure your pregnancy hormone levels over the next week. We will phone you after each blood test to let you know the results. You may also require a further scan. We will let you know the specific follow-up plan for you. Please ask us if any of this information does not make sense to you.

What do I need to look out for?

You should expect a small amount of bleeding. If you have pain (or are worried for any reason) please contact the Pregnancy Assessment Centre (PAC). If your pain is unrelieved with paracetamol, you should present to the Pregnancy Assessment Centre (PAC) at Mater Mothers' Hospital or your nearest Emergency Department.

Option B: Medical management

Methotrexate is a medical treatment used to 'dissolve' the ectopic pregnancy, providing an alternative to surgery. It is a chemotherapy drug which stops the pregnancy from growing. Only a small dose is used so it is extremely unlikely that you will lose your hair or experience any of the other side effects often associated with chemotherapy.

Why use Methotrexate?

Until recently, the only treatment that was widely available for ectopic pregnancy was an operation. If the ectopic pregnancy is small and the pregnancy hormone levels are not high, there is a 90–95% chance that using medical treatment will be all that you need. Although this is a relatively new treatment (it has been used for about 10 years), it is one which has been found to be safe. It has the obvious advantage of not needing an open operation or even key-hole surgery, which commonly requires a hospital stay of a day or two and recovery time afterwards. Studies that look at how successful a subsequent pregnancy is following this treatment, have found that it is at least as good as following surgery and sometimes better. Surgery can cause scarring around the tube, and it may be that avoiding this is the reason why future pregnancies may be more likely to be successful after medical treatment.

How is the treatment given?

Methotrexate is given by a single injection in the arm. In certain situations, an infusion via a drip into the vein may be required. This is done over one to two days and a short stay in hospital is required. The doctor will discuss with you which treatment option is best in your individual situation. We will then need to check the pregnancy hormone levels, as before, to ensure that they fall appropriately. This will mean several blood tests over the following month.

How successful is it?

The success rate is about 90–95%. Most women require only one injection or infusion, but very occasionally two may be necessary.

Are there any side effects?

You may notice some mild abdominal pain after the treatment, though if you do, this should not be severe. Other occasional side effects (affecting up to 15 percent of women) include nausea, vomiting, indigestion, mouth ulcers, sensitivity to light, or feelings of fatigue. Very rarely it can affect the liver or blood counts, but this really is unusual if it does occur and should only last a short time.

Will this drug affect my chances of becoming pregnant again?

No. Generally your chances of having a successful pregnancy in the future are at least as good following medical management as compared to surgical management. Pregnancies following completion of methotrexate therapy are not associated with increased abnormalities, miscarriages or other pregnancy complications. However, you will need to avoid pregnancy for four months after treatment because of the possible effects on the developing baby.

How long will it take to resolve?

The pregnancy hormone levels frequently rise in the first few days and will then start to drop, it will take between three to five weeks to fall to normal levels.

Is there anything else I need to know?

The following points are important:

Avoid alcohol and vitamin preparations containing folic acid until your pregnancy hormone level is back to zero.
Avoid anti-inflammatory medicines such as ibuprofen (Nurofen®), diclofenac (Voltaren®) and aspirin for one week after treatment. It is safe to use simple pain medicines such as paracetamol (Panadol®) according to the directions on the pack.
It is likely that the pain may get a little worse in the first week after the injection and as the pregnancy dissolves and the hormone levels fall you will get some vaginal bleeding like a period. If you have severe pain or heavy vaginal bleeding, go to your nearest Emergency Department.
It is important that you use adequate contraception until the methotrexate therapy has been completed and for four months afterwards.

Option C: Surgical management

An operation is one way of treating an ectopic pregnancy. In some circumstances this may be the only choice available to you.

What is a laparoscopy (keyhole surgery)?

The operation is performed under a general anaesthetic. In this procedure the surgeon usually makes three small incisions in your abdomen—one inside your belly button and one or two lower incisions lower down on your abdomen. A small telescope is inserted through the hole in your belly button to allow the surgeon to see what they are doing. If an ectopic pregnancy is confirmed usually the tube is removed.

Sometimes it may be possible to make a cut in the tube and remove the pregnancy leaving the tube intact. The downside of this is that sometimes not all of the pregnancy tissue is removed. Further, this tube is now damaged and there is an increased chance of another ectopic in that tube in the future. We will have already discussed some of these issues with you.

What is a laparotomy (open surgery)?

While most operations for ectopic pregnancy are done using keyhole surgery, sometimes an open operation needs to be performed. This is more likely if you have had a lot of bleeding and are unwell, or if the keyhole surgery is not technically possible.

Are there any risks?

Like all operations, small anaesthetic and surgical risks are involved. There is a very small risk (approximately one chance in every 1000 procedures) of injury to the bowel or blood vessels when entering the abdomen using keyhole surgery. In such cases, we would usually change to performing open surgery. There is a very small risk of infection, although this is slightly higher if an open procedure is performed. Sometimes you may have had a lot of bleeding or there may be bleeding during the procedure. If you are very unwell from this blood loss we may, rarely, need to give you blood as a transfusion.

What to expect after the operation

Tiredness

In the 24-hour period after the anaesthetic you will probably feel tired. You may well feel fatigued for some days to weeks following the procedure (especially if you had lost a significant amount of blood).

Pain

After the operation you will have some pain. Following keyhole surgery, it is very common to experience shoulder-tip pain as well as pain in your abdomen. This is because of some undissolved air from the operation irritating nerve endings in your abdomen and chest. The best way to manage this pain is to mobilise early and your nurses will help you with this. You will be given pain relief. You should expect to be sore for some days but it should always be improving. Following open surgery, you will have pain for some weeks and it will be sore to walk. You will take some weeks to recover following open surgery.

Wound

You will have a dressing on your wound(s). The staff looking after you will advise you on how to care for your wound. Usually the skin is closed with stitches which are under the skin and dissolvable. Infection is uncommon but should the wound become sorer, hot, red or become oozy, then you should see your GP.

How long will I be in hospital?

This will vary depending on the operation you need. It is normally just a day after keyhole surgery and two to four days following open surgery.

If the pregnancy is not in the uterus will I bleed?

Yes. Although the pregnancy is not in the uterus, the hormones produced by the early pregnancy cause the lining of the uterus to become thickened. Therefore after your ectopic pregnancy is treated, you should expect some heavy period-like bleeding for a week or so. While the bleeding continues, it is best to use sanitary pads instead of tampons, as this will reduce the risk of infection. Baths or showers can be taken as required.

Going back to work?

If you have had an operation, you are unlikely to feel fit enough for work as soon as you leave hospital, so make sure you rest. An absence from work of one to two weeks (following keyhole surgery) or four to six weeks (following open surgery) is usually enough but the decision to go back to work is up to you. In all cases, a medical certificate can be obtained on discharge from hospital.

Will I get a follow-up appointment?

No, unless there is a specific reason. We will ring you in the next week or so to see how you are going. If the fallopian tube is not removed during the operation there is some risk that some of the pregnancy remains in the tube. You will then be advised to have weekly blood tests to monitor pregnancy hormone levels as they decrease. You are very welcome to ring us at any time if you feel things are not right. It is natural to feel low and depressed. Give yourself and your body time to recover. It may help to talk over things with your partner, friends and other family members.

Will I be able to fall pregnant again?

The chances of conceiving and having a successful pregnancy after an ectopic pregnancy are slightly lower than normal, but generally very good. This will depend on the reasons behind having an ectopic pregnancy as well as your own gynaecological history. We will be able to give you specific information on this.

What are the chances of having another ectopic pregnancy?

Your chance of having another ectopic pregnancy is increased a little. However it is reassuring to know that 9 out of 10 future pregnancies will not be ectopic next time. It is important that you confirm that any future pregnancy is developing inside with the uterus with an ultrasound scan and blood tests early in the pregnancy through your GP.

How long should I wait before trying for another baby?

You are able to resume sexual relations with your partner once your hormone level reaches zero for either Expectant or Medical Management options. If you have had surgery, you should wait until the bleeding and pain has stopped, usually two to three weeks. You may not feel like having intercourse for a while or your sex drive might decrease. Your feelings and those of your partner need to be respected—be loving and understanding to each other. You may ovulate unpredictably after this pregnancy and hence the time of your next period may be less certain. You may try for another pregnancy when you feel ready; however, we advise that you wait a few months after surgery or expectant management and four months after methotrexate.

Is it normal to feel upset by having an ectopic pregnancy?

An ectopic pregnancy is considered a form of early pregnancy loss, and it is normal for women and families to experience grief at the loss of their pregnancy. You may ask to speak with a pastoral care worker during your hospital stay to help you navigate this time.

Grieving for your baby

We are sorry that you have experienced the loss of your baby in early pregnancy. Usually an ectopic pregnancy does not get to the stage of a baby developing. However, you are still likely to experience the same feelings of grief and loss whether there was a baby seen on scan or not. Don't expect too much of yourself, some women recover quickly, others take a long time. You may experience a range of feelings such as sadness, anger, bitterness or guilt. You may worry that some activities such as exercise, going to work, or sexual intercourse caused the ectopic pregnancy. This is a normal reaction, but it is very seldom that anything you have done, or not done, has caused an ectopic to occur.

Experiencing an early pregnancy loss can lead to feelings of isolation and loneliness, particularly when other people around you are having babies. Any resentment that you may feel is common and normal. It is important to acknowledge and accept your feelings and experience, as a part of the grieving process.

Partners

Partners are likely to feel upset because of your distress, as well as for the loss of the pregnancy. You may be able to support each other and may even feel that this experience has brought you closer together. However, grief can put a strain on even the closest relationships. You and your partner may both be upset but in different ways or at different times. Your partner may also feel guilty because you are the one who has experienced the physical aspects of the ectopic pregnancy.

Children

Children often notice when something is wrong, especially if a parent or someone close to them is upset. You may want to think about telling them what has happened, even very simply, especially if they knew you were pregnant. There are brochures and books available to assist you in understanding how children grieve and how to explain what has happened. Pastoral care is also available to provide you with support and guidance with how to approach the conversation.

What happens to your baby now?

All babies and pregnancy tissue will be treated with the reverence and dignity required by the philosophy and Mission of the Mater and the Sisters of Mercy.

Cremation and burial

Many parents want to know what happens to their baby's remains after an ectopic pregnancy. Mater arranges a group cremation for all babies who died in early pregnancy, unless otherwise notified by parents. These collective ashes are then placed in a reserved memorial garden located away from the hospital at Eco Memorial Park, 21 Quinns Hill Road West, Staplyton. Please be aware that we cannot give you any indication of the timing for when this will take place. We invite you to visit the garden at any time.

However, if you choose to have your own private ceremony or burial (this is not a legal requirement) please contact the Early Pregnancy Nurse/Midwife at the Mater Pregnancy Assessment Centre (PAC) within 28 days of your miscarriage to arrange collection.

Honouring your pregnancy

When you go home from hospital you may find it difficult to grieve or experience a delayed grief due to the complexity of an ectopic pregnancy. For this reason, you may like to create some memories of your pregnancy/baby, such as planting a tree or shrub or creating your own personal memorial.

Service of remembrance

The service is held each year on the third Wednesday in March at 10 am in Mater Chapel, level 3, Salmon Building, Raymond Terrace, South Brisbane 4101 QLD. For further information or to RSVP, please contact Mater's Pastoral Care team via email pastoralcare@mater.org.au or phone 07 3163 6729.

International pregnancy loss day – service of remembrance

This service is held each year on 15 October at 7 pm, in the Corbett Room in the Whitty Building. For further information or to RSVP, please contact Mater's Mothers' Hospital Bereavement team via email mmh.bereavement.support@mater.org.au or phone 07 3163 3467.

Ongoing support

Counselling services

It is likely that you will feel sad following your loss. For a small group of women, the sadness seems to grow deeper and deeper, and they are left with feelings that they find difficult to cope with and talk about. This is something which is more than grief and help is needed to get back on track. Please speak to your GP if you feel you may need counselling. You are entitled to Medicare funded counselling by a psychologist due to your pregnancy loss and your GP can arrange this for you.

Pastoral Care

Mater's Pastoral Care Department is available to provide spiritual and emotional support. The pastoral care workers are professionals trained in the skills of supportive and person-centred listening. Privacy, confidentiality and the rights of individual choices without discrimination are honoured and respected. Pastoral Care can be contacted Monday to Friday between 7.30 am and 4 pm:

Phone: 07 3840 8111
Phone (Pastoral Care Department): 07 3163 6729
Email: pastoralcare@mater.org.au.

Perinatal Support Group – Circle of Hope

We recognise the need for support for parents after experiencing a loss is essential and ongoing. Therefore, we would like to invite our parents who are requiring further support after leaving the hospital to join us in our 'Circle of Hope' group. The group is open to all parents who have experienced a loss. We meet monthly over a cuppa to provide a safe space for parents to share their story. Our purpose is to encircle our parents with hope and encouragement. This is an opportunity for parents to meet in a secure environment to enable the group process of parents supporting each other to take place. Please contact pastoral pastoralcare@mater.org.au or phone 07 3163 6729 for further details and to RSVP.

Community support

SANDS

Stillbirth and Neonatal Death Support Group (Qld) are a volunteer organisation that provides support for parents and families who have experienced miscarriage, stillbirth or neonatal death. You may be asked to leave a telephone message, so please leave your name and number and they will return your call as soon as possible.

Phone: 07 3254 3422 or 1800 228 655 (outside the Brisbane metropolitan area)
Email: sandsqld@powerup.com.au
Website: www.sandsqld.com

Lifeline

Lifeline provides 24 hour access to crisis support services.
Phone: 13 11 14
Web: www.lifeline.org.au

Beyond Blue

Beyond Blue provides support for people suffering from depression and anxiety.

Phone: 1300 22 4636, 24 hours a day, seven days a week.
Web: www.beyondblue.org.au

Further information

For further information, please contact:

Pregnancy Assessment Centre (PAC)
Early Pregnancy Unit
Level 5, Mater Mothers' Hospital
Raymond Terrace
South Brisbane Qld 4101

Phone:07 3163 5132
matermothers.org.au

Mater acknowledges consumer consultation in the development of this patient information.

Mater Doc Num: PI-CLN-430048

Last modified 04/3/2020.
Consumers were consulted in the development of this patient information.
Last consumer engagement date: 30/3/2017

For further translated health information, you can visit healthtranslations.vic.gov.au/ supported by the Victorian Department of Health and Human Services that offers a range of patient information in multiple languages.

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How Long Did It Take to Get Pregnant After Ectopic

Source: http://brochures.mater.org.au/brochures/mater-mothers-hospital/ectopic-pregnancy