Gynaecology - Surgical Management of Ectopic Pregnancy

What is an ‘ectopic pregnancy’?

An ectopic pregnancy is when a fertilised egg implants itself outside of the womb, usually in one of the fallopian tubes.
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.

Unfortunately, an ectopic pregnancy cannot survive and there is no way to transfer the pregnancy safely to the uterus.

Surgical Management

Surgical management is the most established form of treatment and means performing an operation to remove the ectopic pregnancy while you are under general anaesthetic.

If your hormone being made by the pregnancy (beta hCG) is high, the ectopic is large or significant internal bleeding has been seen on your scan, the doctors cannot consider less invasive treatments for you because your health may be at immediate risk and therefore surgery becomes the only option available. Surgery may also be performed if expectant management or medical management have failed.

In most circumstances you will be operated on using a technique called laparoscopy (keyhole surgery).

This involves inserting a camera through the navel (belly button) and inserting instruments through two small cuts in the lower abdomen (tummy). A small amount of gas is put into your abdominal cavity to inflate it to enable the surgeon to see inside the abdomen.

Traditionally, surgery involved Laparotomy (an open cut) on the lower abdomen in the same area where you would expect to see a C-Section cut.

This is still occasionally used if there is heavy internal bleeding/ rupture or a lot of scar tissue and is performed in an emergency situation. If there is extensive bleeding, a blood transfusion may need to be given.

Both techniques will enable the surgeon to examine the abdominal cavity.
 
The aim of surgery is to remove the ectopic pregnancy. The type of operation you have will depend on your wishes or plans for a future pregnancy and what your surgeon finds during the operation (laparoscopy).

To have the best chance of a future pregnancy inside your uterus, and to reduce the risk of having another ectopic pregnancy, you will usually be advised to have your affected fallopian tube removed (this is known as a salpingectomy).

If you already have only one fallopian tube or your other tube does not look healthy, your chances of getting pregnant are already affected. In this circumstance, you may be advised to have a different operation (known as a salpingotomy) that aims to remove the pregnancy without removing the tube.

Due to high risk of a future ectopic pregnancy this procedure will only be offered in certain circumstances. It means the remaining tube does allow for future opportunity of natural pregnancy.

You will be advised to have blood tests for checking your pregnancy hormone levels after salpingotomy as part of follow- up.

Some women may need further medical treatment or another operation to remove the tube later if the pregnancy has not been completely removed during salpingotomy. The decision to perform salpingectomy or salpingotomy may sometimes only be made during laparoscopy under anaesthetic.

There are risks associated with any operation: from the surgery itself and from the use of an anaesthetic. Your surgeon and anaesthetist will discuss these risks with you.
 
You are likely to stay in hospital for one or occasionally two days after surgery by laparoscopy (keyhole) or for two to three days after a laparotomy (cut to lower tummy).

When you are discharged, the ward staff will give you all the necessary advice on aftercare, exercise and diet. Stitches are usually dissolvable and should dissolve completely after 1 week. Sometimes they dissolve slower and if they are irritating you they can be removed after 1 week.

In an emergency situation

If the tubal or non-tubal pregnancy has burst, emergency surgery is needed to stop the bleeding. This operation is often life-saving. It is done by removing the ruptured fallopian tube and pregnancy.

Your doctors will need to act quickly and this may mean that they have to make a decision on your behalf to operate. In this situation you may need a blood transfusion.

What can I do to help me recover from the surgery?

In the first days after surgery it is important to try to keep moving gently. Make sure you walk around regularly and increase the short distances you walk as each day passes.

Keep your wound site clean. You can shower regularly and you can safely take a bath 48 hours after the operation unless you have been told otherwise.

It’s a good idea to make sure you have someone with you in the house when you first take a bath in case you need help to get out again.
 
It is most likely that your stitches are dissolvable but sometimes stitches that need to be removed are still used. Dissolvable stitches are supposed to dissolve on their own between about 10 and 21 days after surgery.

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.

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 is recommended.

The bleeding you have after surgery 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.

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. The length of time anyone bleeds varies. 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.

You should not do any heavy lifting or vigorous housework for around 2 weeks and should only undertake gentle exercise such as walking, and possibly gentle swimming, once the wound sites on the skin have healed.

Most people take time off from work initially and do not return to work for at least two weeks to give their body and emotions time to heal after keyhole surgery and this timeframe increases to approximately six weeks for major abdominal surgery.

Will I need anti-D?

If you have a rhesus negative blood group you should be given medication known as anti-D to prevent your blood system from developing antibodies which may affect the blood cells of any future babies.

Follow Up

If you had a salpingotomy (fallopian tube left in place), or if there was any doubt that all of the pregnancy tissue was removed, your doctors will usually test your hCG levels to ensure that they are dropping. In this instance, it may be necessary to check your blood hCG levels again after a week, and possibly beyond.

If you had a salpingectomy (fallopian tube removed) no follow- up is needed. As this is such an emotionally difficult time and there is so much to take in, you will be offered a telephone appointment 3 weeks after your ectopic pregnancy, you may find it beneficial to talk through what happened.

You will be offered a telephone appointment 3 weeks after your surgery. This appointment is with a specialist nurse and is to provide you with support following your pregnancy loss.

How will I feel afterwards?

The impact of an ectopic pregnancy can be very significant. It might mean coming to terms with the loss of your baby, with the potential impact on future fertility, or with the realisation that you could have lost your life.

Each woman copes in her own way. An ectopic pregnancy is a very personal experience. This experience may affect your partner and others in your family, as well as close friends.
 
It is important to remember that the pregnancy could not have continued without causing a serious risk to your health.

Before trying for another baby, it is important to wait until you feel ready emotionally and physically. However traumatic your experience of an ectopic pregnancy has been, it may help to know that the likelihood of a normal pregnancy next time is much greater than that of having another ectopic pregnancy.

What about future pregnancies?

The chances of having a successful pregnancy in the future are good. Even if you have only one fallopian tube, your chances of conceiving are only slightly reduced.

For most women an ectopic pregnancy is a ‘one-off’ event. However, your overall chance of having another ectopic pregnancy is increased and is around 7–10 in 100 (7–10%) compared with 1 in 90 (just over 1%) in the general UK population.

You should seek early advice from a healthcare professional when you know you are pregnant and you may be offered an ultrasound to confirm that the pregnancy is developing in the uterus.

If you do not want to become pregnant, seek further advice from your doctor or family planning clinic to discuss contraception.

Advice and Support

There is support available to help you, your partner and your family deal with your loss. You will be offered a telephone appointment at our pregnancy loss clinic, and bereavement support from our early pregnancy specialist nurses.

Contact Numbers

●    Gynaecology Assessment Unit The Royal Oldham Hospital - 0161 627 8855
●    Early Pregnancy Specialist Nurses, GAU, The Royal Oldham Hospital – 07855 162205
●    Your own GP, they often have access to local counselling services
●    The Ectopic Pregnancy Trust at www.ectopic.org.uk
●    The Cradle Charity at www.cradlecharity.org
●    The Miscarriage Association (miscarriageassociation.org.uk). Information and support can be offered to both partners. A telephone helpline (01924 200799) is available Monday to Friday 9am – 4pm.
●    Hospital Spiritual & Emotional Team - 0161 778 5259
●    www.mariposatrust.org
●    NHS Choices www.nhs.uk