Sadly, you have been told that your pregnancy is either an ectopic pregnancy, which is when a fertilised egg implants itself outside of the womb, usually in one of the fallopian tubes, or a pregnancy of unknown location (PUL), where the pregnancy hormone is raised but we have not identified a pregnancy on an ultrasound scan.
You have discussed options for treatment with your doctor and together you have decided on the option of medical management.
The information in this leaflet gives advice on medical treatment for ectopic pregnancy, or PUL with a medication called Methotrexate.
If you have any questions, please do not hesitate to ask the doctors or nursing staff for advice.
What is an ‘ectopic pregnancy’?
When you become pregnant the egg and sperm meet in the fallopian tube, (this is the tube which carries the egg from the ovary to the womb). Typically, the fertilized egg then moves to the womb and the pregnancy will mature.
If the fertilized egg does not move and stays in the fallopian tube, an ectopic pregnancy could begin to develop. Ectopic pregnancies can also occur in other areas, such as the abdomen or ovary, but this is rare. Ectopic pregnancy affects around one in ninety pregnancies.
What is a pregnancy of unknown location?
In this condition, there is a positive pregnancy test with no sign of pregnancy either inside or outside of the womb.
What is Methotrexate?
Methotrexate is a cytoxic drug, which has been used to treat various conditions for many years. It is used to treat an ectopic pregnancy, as it works, in most cases, by temporarily interfering with the processing in the body of the vitamin folate. This is essential for rapidly growing cells like those in an ectopic pregnancy. Methotrexate stops the pregnancy from developing any further, and the body then gradually reabsorbs the cells.
What are the risks of medical treatment?
There is a 7% risk that the ectopic pregnancy could rupture. If this happens you may feel faint or dizzy, have abdominal pain, shoulder tip pain and/or have a heavy vaginal bleed. If you do experience any of these symptoms, you should seek medical advice immediately. In this situation you will require emergency surgery to remove the ruptured tube.
There is a risk that the injection of Methotrexate will not work. If this happens you may require a second treatment. Fifteen out of a hundred women (15%), will need to have a second injection of Methotrexate. Even after a second injection of Methotrexate, 7 in 100 women (7%) will need surgery.
What are the side effects of Methotrexate?
Side effects include mild abdominal pain, nausea, diarrhoea, hair loss and skin rashes. Methotrexate can also affect the blood count (one of the effects is that fewer blood cells are made) making you prone to infections. Methotrexate is not appropriate if you suffer from any of the following conditions:
● Infection
● Impaired kidney function
● Severe anaemia
● Liver disease
● HIV/AIDS
Before treatment is commenced
Your doctor will check that you are medically suitable for the treatment, and that you are able to attend follow up appointments in order to monitor the pregnancy hormone in your blood. Blood tests are required to be taken on day 4 and day 7 following the administration of Methotrexate (day 1) and it is important that you are able to attend.
How is Methotrexate given?
It is given into the large muscles of your buttocks. Depending on the dose, it may be given as two injections.
Each dose of Methotrexate is calculated and prepared by the pharmacy department. In order to do this, we will have to measure your height and weight. Blood will be taken from you to check that your blood count, liver and kidney functions are normal.
You do not need any form of anaesthetic for this procedure.
Do I need to stay overnight?
After the injection, nursing staff will observe you for 30 – 60 minutes for any reactions to the medication. If you are well, and showing no side effects, you may be discharged home, once you have been given your follow up appointments. If you do feel unwell or are showing any effects from the medication, you will be admitted to the gynaecology ward for observation.
What will happen after treatment?
We advise that you are not left alone after treatment and that you have somebody with you when you are discharged.
We ask you to monitor your level of pain and bleeding and if it becomes excessive to seek medical advice.
After your medication you will require follow up appointments so that we can observe the effects of the treatment and monitor the pregnancy hormone levels in your blood.
You will be given follow up for repeat beta human chorionic gonadotropin (BHCG) blood tests on day 4 and day 7 after your treatment. After the results of the second blood test we will consider if further treatment is needed and advise you on your future plan of care.
If you have Methotrexate, we will need to monitor your BHCG until it is below 25. It can take up to 6 weeks for your blood levels to be within a normal range. It is important that you attend all follow-up appointments.
What to expect when you get home
The bleeding you have after treatment with Methotrexate, 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.
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.
It is not uncommon for women who have been treated with Methotrexate not to have any bleeding.
What to avoid after treatment
● Avoid alcohol and folic acid until your blood levels have returned to normal
● Avoid direct sunlight during treatment
● Avoid Aspirin and medication such as Ibuprofen for 1 week after treatment,(if you need to take these medications, please discuss this with your doctor)
● Do not have sexual intercourse until you have finished bleeding
● Avoid getting pregnant for three months
When to seek medical advice
You should seek immedidate medical advice if you develop any of the following:
● Severe abdominal pain
● Severe bleeding
● Feeling dizzy or generally unwell
● Sore throat
● Fever
● Symptoms of infection
● Unexplained bruising or bleeding
● Jaundice (eyes or skin turning yellow)
If symptoms are severe you need to attend your nearest Accident and Emergency department. In an emergency call 999 for an ambulance.
Follow up
Once your hormone levels are back within range unless there is a clinical need no further follow up will be necessary. As this is such an emotionally difficult time and there is so much to take in you will be offered a telephone appointment 6 weeks after your ectopic pregnancy, you may find it beneficial to talk through what happened.
What about the future?
It is advised that you do not become pregnant for 3 months after your BHCG is negative. To avoid becoming pregnant you should use a form of contraception. This can be discussed with your doctor.
Most women who experience an ectopic pregnancy do not have a repeat experience, however there is a small chance that this could occur again.
If or when you do become pregnant again you should be referred early in pregnancy to the gynaecology assessment unit (GAU) for an assessment, to ensure that the pregnancy is in the womb.
In most cases a scan at 5-6 weeks gestation will be able to identify a very early intrauterine pregnancy.
When is it safe to have sex again?
It is recommended that you wait until you have finished bleeding. It is advised that you use a form of contraception to avoid pregnancy and you should discuss this with your doctor or family planning clinic. Resuming a sexual relationship may be quite stressful for both of you. It is important to give each other time and to talk openly about your feelings.
When is it safe to resume normal activities?
You may feel tired and emotional and you may need to discuss going back to work with your doctor. In general, as long as you are felling well and your hormone levels are dropping you can resume normal activities. Strenuous activities should be avoided for around a month.
How long before your next period?
Some vaginal bleeding may occur after treatment with Methotrexate. For some women this lasts for only a few days, for others there may be spotting for up to 6 weeks. When bleeding has stopped, the average time for the first period to arrive is 4 weeks, but it could be anytime between 2 and 10 weeks. The first period may be lighter or heavier than usual and may be more or less painful. There are no hard and fast rules. Periods may also be a little irregular in the early cycles after treatment and can occur between 23 and 42 days. If this irregularity persists after 3 cycles, you should speak to your doctor.
Can anything be done to prevent another ectopic pregnancy?
As ectopic pregnancy is more related to past tubal damage than the present, there is little to be done to prevent it from happening again. However, if you feel there may be ongoing problems of pelvic infection, such as chlamydia then testing and antibiotic treatment for this could help to reduce the risk of future ectopic pregnancy.
Counselling
We understand that this is an emotional time for you and your family. If you feel that you need to talk to someone about your emotions and feelings you can contact our women and children's counsellor on 0161 720 2969.
Contact numbers
We are here 24 hours a day for support and advice. You can speak to a member of staff at:
Gynae Assessment Unit (GAU) Oldham
Telephone - 0161 627 8855
Ward F5, Oldham
Telephone - 0161 656 1431/1432
Sr Laura Howarth, Early Pregnancy Specialist Nurse/Bereavement Specialist Nurse can be contated via GAU.
For further advice please contact:
The Ectopic Pregnancy Trust at www.ectopic.org.uk
Miscarriage Association at www.miscarriageassociation.org.uk
Mariposa Trust www.mariposatrust.org
Date of Review: May 2024
Date of Next Review: May 2026
Ref No: PI_WC_851 (Oldham)