Ectopic Pregnancy: Symptoms, Causes, Treatment, and What Comes Next

An ectopic pregnancy is one of the most frightening experiences a woman can face in early pregnancy. It happens without warning, often when a pregnancy is still newly discovered, and it can feel completely at odds with the hope that was building just days before. If you have been told you have an ectopic pregnancy, or if you are trying to understand what happened after one, this article is for you. If you are trying to conceive and want to understand your risks and warning signs, this is for you too. Ectopic pregnancy affects approximately 1 in 80 pregnancies in Australia, and it accounts for a significant proportion of first-trimester maternal complications. It is far more common than most women realise (Mullany et al., 2023).

What Is an Ectopic Pregnancy?

In a healthy pregnancy, a fertilised egg travels along the fallopian tube and implants in the lining of the uterus. An ectopic pregnancy occurs when that fertilised egg implants somewhere outside the uterus, most commonly in the fallopian tube itself. This is why you may hear the term tubal ectopic pregnancy.

The fallopian tube is not designed to stretch and grow the way the uterus can. As the embryo develops, the tube comes under increasing pressure. Left untreated, a tubal ectopic pregnancy can rupture, causing severe internal bleeding that becomes a medical emergency.

Less commonly, ectopic pregnancies can implant in the ovary, the cervix, on a previous caesarean scar, or in the abdominal cavity. These non-tubal ectopic pregnancies are rarer, but they carry similar risks and require urgent medical attention (Long et al., 2020).

Key fact: An ectopic pregnancy cannot be moved to the uterus. It cannot result in a healthy birth. Treatment, either medication or surgery, is always necessary.

How Common Is Ectopic Pregnancy?

Ectopic pregnancy occurs in approximately 1 to 2 percent of all pregnancies and accounts for 5 to 10 percent of all pregnancy-related deaths in the first trimester (Mullany et al., 2023). Despite being relatively uncommon, it is one of the most important early pregnancy complications to be aware of, because early recognition genuinely saves lives.

The incidence of ectopic pregnancy has increased over recent decades, likely due to higher rates of pelvic inflammatory disease, increased use of assisted reproductive technologies, and improved diagnostic sensitivity identifying cases that may previously have gone undetected.

What Are the Symptoms of Ectopic Pregnancy?

This is where ectopic pregnancy becomes particularly difficult: the early symptoms often overlap with normal pregnancy symptoms. There is no single symptom that definitively signals an ectopic pregnancy in its early stages. What matters is knowing which combinations of symptoms should prompt immediate medical attention.

Early symptoms (before rupture)

• A missed period or a positive pregnancy test
• Mild to moderate pelvic or abdominal pain, often on one side
• Vaginal bleeding or spotting, which may be lighter or darker than a typical period
• Shoulder tip pain, which is a specific symptom caused by internal bleeding irritating the diaphragm and one that should never be ignored
• Nausea, breast tenderness, and other common pregnancy symptoms

Emergency symptoms (possible rupture)

If you experience any of the following, seek emergency care immediately. Do not wait:

• Sudden, severe pain in the abdomen, pelvis, or lower back
• Shoulder tip pain that comes on suddenly
• Feeling faint, dizzy, or collapsing
• Heavy vaginal bleeding
• Feeling very unwell with no clear explanation

One of the most important things to understand is that symptoms can escalate very quickly. A woman can feel relatively well one hour and be in a medical emergency the next. If you are in early pregnancy and experience any combination of one-sided pain, unusual bleeding, and shoulder pain, please present to an emergency department rather than waiting for a GP appointment.

What Causes an Ectopic Pregnancy?

Ectopic pregnancy occurs when something interferes with the normal passage of the fertilised egg through the fallopian tube. In many cases, there is no single identifiable cause, but several factors are known to increase the risk.

Risk factors for ectopic pregnancy

Research has consistently identified the following as risk factors (American College of Obstetricians and Gynecologists, 2018; Chen et al., 2014):

1. Previous ectopic pregnancy. This is the strongest risk factor. Women who have had one ectopic pregnancy have a significantly elevated risk of another.
2. Pelvic inflammatory disease (PID). Infection that causes scarring and damage to the fallopian tubes, which can impair the egg's normal transit.
3. Previous pelvic or abdominal surgery. Including surgery on the fallopian tubes, ovaries, or for conditions like endometriosis, which may cause adhesions affecting tubal function.
4. History of sexually transmitted infections. Particularly chlamydia and gonorrhoea, which can cause tubal damage even when asymptomatic and untreated (Hocking et al., 2023).
5. Smoking. Evidence suggests smoking impairs tubal motility, slowing the movement of the egg.
6. Assisted reproductive technologies (ART). Women undergoing IVF have a higher rate of ectopic pregnancy, likely due to the underlying fertility conditions that led to ART in the first place.
7. Intrauterine device (IUD) use at time of conception. An IUD significantly reduces the overall chance of pregnancy, but in the rare case that pregnancy does occur, the risk of it being ectopic is elevated.
8. Age over 35. Associated with a modestly increased risk, likely reflecting accumulated pelvic health history.

It is important to note that many women who experience ectopic pregnancy have none of these risk factors. Having no known risk does not protect against it, which is precisely why awareness of symptoms matters for every woman in early pregnancy.

How Is Ectopic Pregnancy Diagnosed?

Diagnosis typically involves two tools used together: transvaginal ultrasound and blood tests measuring beta-hCG (the pregnancy hormone).

In a healthy intrauterine pregnancy, beta-hCG levels roughly double every 48 to 72 hours in early pregnancy. In an ectopic pregnancy, these levels often rise more slowly or plateau. Serial beta-hCG measurements, taken over 48 hours, can help identify an abnormal pattern even before the ectopic location is visible on ultrasound (Mullany et al., 2023).

Ultrasound is used to confirm whether there is a gestational sac in the uterus. The absence of an intrauterine pregnancy on ultrasound, combined with a positive pregnancy test and symptoms, raises strong suspicion for an ectopic pregnancy even if the ectopic site itself cannot yet be seen.

In some cases, diagnosis is straightforward. In others, it requires careful monitoring over several days, which can be a deeply anxious waiting period. If you are in this situation and being monitored for a possible ectopic pregnancy, please speak with your healthcare provider about what you can expect from the process and what signs should prompt you to present to hospital immediately.

How Is Ectopic Pregnancy Treated?

Treatment depends on how far the pregnancy has progressed, whether rupture has occurred, your beta-hCG levels, and your individual circumstances. There are three main approaches (American College of Obstetricians and Gynecologists, 2018; Mullany et al., 2023):

1. Expectant management

In a small number of cases where beta-hCG levels are low and declining on their own, and the ectopic pregnancy shows no signs of rupture risk, a watch-and-wait approach may be appropriate. This involves close monitoring with serial blood tests. It is not suitable for everyone and requires careful clinical assessment.

2. Medical management (methotrexate)

Methotrexate is a medication that stops the growth of the ectopic pregnancy, allowing the body to absorb the tissue over time. It is given by injection and is most appropriate when the ectopic pregnancy has been detected early, beta-hCG levels are below a certain threshold, and there are no signs of rupture. Follow-up blood tests are required over several weeks to confirm the treatment has worked.

3. Surgical management

Surgery is required when rupture has occurred or is imminent, when beta-hCG levels are high, or when methotrexate is not appropriate. The most common procedure is a laparoscopy (keyhole surgery) in which the ectopic pregnancy is removed. In some cases this involves removing the affected fallopian tube (salpingectomy); in others, the tube can be preserved (salpingotomy). The decision depends on clinical factors and is made by your surgeon based on what they find.

If rupture has already occurred, emergency open surgery may be necessary. This is a medical emergency with significant blood loss risk, which is why early diagnosis is so critical.

Will I Be Able to Get Pregnant Again?

This is usually the question that sits at the centre of everything after an ectopic pregnancy. The answer for most women is yes, but it depends on several factors: what treatment was received, whether one or both fallopian tubes remain functional, and the underlying conditions that may have contributed to the ectopic in the first place.

Research suggests that for women who have had an ectopic pregnancy treated with either salpingotomy (tube preserved) or salpingectomy (tube removed), subsequent intrauterine pregnancy rates are comparable over time, though the pathway to conception may differ (Kumar and Gupta, 2015). Women with one functioning fallopian tube can still conceive naturally, though it may take longer. For women with damage to both tubes, IVF may be the most appropriate path.

What is well-established is that a previous ectopic pregnancy increases the risk of a subsequent one. If you conceive again after an ectopic pregnancy, it is important to have an early ultrasound, typically around 6 weeks, to confirm the pregnancy is intrauterine.

If you have questions about your personal fertility outlook after an ectopic pregnancy, please discuss them with a specialist. A gynaecologist, fertility specialist, or experienced naturopath with a focus in this area can help you understand your specific situation and options.

The Emotional Reality of Ectopic Pregnancy

Ectopic pregnancy is a pregnancy loss. It is also, for many women, a frightening medical experience that happens very fast, often before they have had time to process the pregnancy itself. The grief can feel complicated. Some women feel profound sadness for the pregnancy they have lost. Others feel shocked, disoriented, or numb. Some feel guilt, even though there is absolutely nothing that causes or prevents an ectopic pregnancy in any meaningful sense. All of these responses are valid.

Research has found that women experience significant rates of anxiety, depression, and post-traumatic stress symptoms following early pregnancy loss, including ectopic pregnancy. A multi-centre prospective cohort study published in BMJ Open found that all women who experience early pregnancy loss should be considered at risk of psychological distress, regardless of the specific type of loss (Farren et al., 2022). Women with a prior mental health history or previous pregnancy losses may be at elevated risk.

Research reviewing psychological distress in women following ectopic pregnancy identified anxiety and depression as the most common presentations, with the life-threatening nature of the experience and reproductive concerns acting as key contributing factors (Ren et al., 2023).

If you are struggling after an ectopic pregnancy, please reach out for support. You do not need to process this alone. Speak with your GP, ask for a referral to a counsellor or psychologist who works with pregnancy loss, or connect with a community of women who have been through the same experience. Organisations such as SANDS Australia and Bears of Hope provide support specifically for women and families navigating pregnancy loss in Australia.

Key Takeaways

• Ectopic pregnancy occurs when a fertilised egg implants outside the uterus, most commonly in the fallopian tube.
• It affects approximately 1 to 2 percent of all pregnancies and is a leading cause of first-trimester maternal complications.
• Early symptoms include one-sided pelvic pain, vaginal bleeding, and shoulder tip pain. These warrant immediate medical attention in early pregnancy.
• Risk factors include previous ectopic pregnancy, pelvic inflammatory disease, STI history, smoking, and prior pelvic surgery. Many women with no known risk factors still experience ectopic pregnancy.
• Treatment is always necessary and may involve medication, laparoscopic surgery, or open surgery in an emergency.
• Most women are able to conceive again after an ectopic pregnancy, though early monitoring in a subsequent pregnancy is essential.
• The emotional impact is real and significant. Please seek support.

All content and media on the Mother Natal website are created and published online for informational purposes only. It is not intended to substitute professional medical advice and should not be relied on as health or personal advice.

Frequently Asked Questions

Can an ectopic pregnancy be mistaken for a miscarriage? Yes, and this is one of the reasons ectopic pregnancy can be delayed in diagnosis. Both can involve vaginal bleeding and cramping in early pregnancy. The key difference is that ectopic pregnancy often presents with one-sided pelvic pain, and the shoulder tip pain associated with internal bleeding is specific to ectopic pregnancy. If you are unsure, seek medical assessment rather than waiting.

How quickly can an ectopic pregnancy rupture? This varies. Some ectopic pregnancies grow slowly and can be detected before rupture. Others rupture with little warning. Research suggests that gestational age beyond 8 weeks and high beta-hCG levels are associated with a significantly elevated rupture risk (Goksedef et al., 2011). Early diagnosis is the best protection.

Is ectopic pregnancy more common in women who have had an STI? Research indicates that untreated chlamydia and gonorrhoea can cause scarring and damage to the fallopian tubes, which increases the risk of ectopic pregnancy (Hocking et al., 2023). Regular STI screening, particularly for women under 25, is recommended precisely because these infections are often asymptomatic.

Does having one fallopian tube removed mean I cannot get pregnant naturally? Not necessarily. Women with one functioning fallopian tube can and do conceive naturally. The remaining tube can pick up eggs released from either ovary. Conception may take longer, and early pregnancy monitoring is important. Speak with your doctor or a fertility specialist for guidance tailored to your situation.

What is the recovery time after ectopic pregnancy treatment? This depends on the treatment. Physical recovery from laparoscopic surgery is typically 1 to 2 weeks, though this varies. Methotrexate treatment requires several weeks of follow-up blood tests to confirm resolution and physical restrictions (no strenuous exercise, no alcohol, no folic acid supplementation) during that period. Emotional recovery follows its own timeline and is not tied to physical healing.

When can I try to conceive again after an ectopic pregnancy? General guidance is to wait at least 3 months after methotrexate treatment before trying to conceive, as the medication can affect folate metabolism. After surgery, your healthcare provider will advise based on your specific circumstances. Emotionally, there is no right or wrong timeline. Many women find it helpful to discuss the timing with both their doctor and a counsellor or psychologist who specialises in pregnancy loss.

Does an ectopic pregnancy affect my risk of another one? Yes. A previous ectopic pregnancy is the single strongest risk factor for a subsequent ectopic pregnancy. The risk is estimated to be elevated compared to women with no ectopic history. This does not mean a second ectopic is inevitable, but it does mean that early monitoring in any subsequent pregnancy is essential.

Are there any warning signs I should know before getting a positive pregnancy test? Ectopic pregnancy symptoms typically begin after a missed period and a positive test. The most important thing you can do before that point is to know your risk factors, have any STIs treated promptly, and seek early pregnancy care so that monitoring can begin as soon as possible.

References

American College of Obstetricians and Gynecologists 2018, 'ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy', Obstetrics and Gynecology, vol. 131, no. 3, pp. e91-e103, https://doi.org/10.1097/AOG.0000000000002560

Chen, J, Qiu, J, Teng, Y, Zou, W & Yang, Y 2014, 'Clinical analyses of risk factors related to ectopic pregnancy', Zhonghua Yi Xue Za Zhi, vol. 94, no. 43, pp. 3429-3431.

Farren, J, Jalmbrant, M, Falconieri, N, Mitchell-Jones, N, Bobdiwala, S, Al-Memar, M, Parker, N, Van Calster, B, Timmerman, D & Bourne, T 2022, 'Prognostic factors for post-traumatic stress, anxiety and depression in women after early pregnancy loss: a multi-centre prospective cohort study', BMJ Open, vol. 12, no. 3, p. e054490, https://doi.org/10.1136/bmjopen-2021-054490

Goksedef, BP, Kef, S, Akca, A, Bayik, RN & Cetin, A 2011, 'Risk factors for rupture in tubal ectopic pregnancy: definition of the clinical findings', European Journal of Obstetrics, Gynecology, and Reproductive Biology, vol. 154, no. 1, pp. 96-99, https://doi.org/10.1016/j.ejogrb.2010.08.016

Kumar, V & Gupta, J 2015, 'Tubal ectopic pregnancy', BMJ Clinical Evidence, vol. 2015, p. 1406.

Long, Y, Zhu, H, Hu, Y, Shen, L, Fu, J & Huang, W 2020, 'Interventions for non-tubal ectopic pregnancy', Cochrane Database of Systematic Reviews, issue 7, CD011174, https://doi.org/10.1002/14651858.CD011174.pub2

Mullany, K, Minneci, M, Monjazeb, R & Coiado, OC 2023, 'Overview of ectopic pregnancy diagnosis, management, and innovation', Women's Health (London), vol. 19, p. 17455057231160349, https://doi.org/10.1177/17455057231160349

Ren, N, Dela Rosa, RD, Chen, Z, Gao, Y, Chang, L, Li, M & Peng, D 2023, 'Research progress on psychological distress in patients with ectopic pregnancy in China', Neuropsychiatric Disease and Treatment, vol. 19, pp. 1633-1639, https://doi.org/10.2147/NDT.S410320