Abdominal discomfort is very common during pregnancy and can have many causes, especially in the early months.
Lower abdominal pain can have a more serious cause, such as ectopic pregnancy. The vast majority of women with lower abdominal pain in early pregnancy do not have an ectopic pregnancy. Under these circumstances a transvaginal scan or internal scan is the best way to exclude an ectopic pregnancy. In our hands, transvaginal ultrasound can detect more than 90% of ectopic pregnancies. OMNI ensures that any woman who presents with lower abdominal pain in the first trimester has access to the most up to date early pregnancy care.
An ectopic pregnancy is the situation where the fertilised egg implants outside the womb, usually in the fallopian tube (95% of the time). As a rule, this is not a normal developing pregnancy and it does not contain a fetus. Ectopic pregnancies are commonly called “tubal pregnancies.” As the ectopic pregnancy grows, the tube may eventually burst (this is because it has not got the same capability as the womb to grow and accommodate a pregnancy). This can cause severe bleeding inside the “tummy” and endanger the mother’s life.
The presentation of ectopic pregnancy can be varied from minor non-specific symptoms of bleeding and/or pain to sudden collapse in a woman. The symptoms very often mimic miscarriage and therefore it is important for the clinician to be aware of the possibility of ectopic pregnancy. A urinary pregnancy test is mandatory and if positive, these women need to then have a transvaginal, not transabdominal, ultrasound scan performed.
Greater awareness of symptoms and risk factors by General Practitioners and Emergency Physicians can increase the number of women referred for an early scan and in turn potentially decrease maternal morbidity and even mortality.
Risk factors for ectopic pregnancy include:
- Women over the age of 35
- Previous ectopic pregnancy
- Previous tubal surgery (including sterilisation)
- Documented tubal pathology
- Previous chlamydia or gonorrhoea infection
- Previous PID (pelvic inflammatory disease)
- Previous infertility
- Women who conceive using:
- Ovulation induction or ovarian stimulation, IVF, ICSI, GIFT and other Assisted Reproductive Techniques (ARTs)
- Copper and Mirena Intra-uterine contraceptive devices (IUCD)
- Progesterone only contraception
- Emergency hormonal contraception previously called the “morning after pill”
- In-utero diethylstilbestrol (DES) exposure
If a woman who conceives has any of the aforementioned risk factors, she should be referred to OMNI for an early scan to confirm the location of the pregnancy.
Tubal ectopic pregnancy
Most women with a tubal ectopic pregnancy will need to undergo surgery in the form of laparoscopic (keyhole) surgery. At OMNI, selected women can be managed non-surgically or conservatively. This means that the woman can avoid hospital admission, general anaesthetic as well as preserve her fallopian tube. Up to one third of women are suitable for non-surgical approaches. These approaches can be either expectant or medical management.
As tubal ectopic pregnancies are being detected earlier and earlier through the use of advanced ultrasound technology, more women are eligible for expectant management. Expectant management means just that: a “watch and wait” approach to see if the ectopic pregnancy resolves by itself. 10 – 15% of women with a tubal ectopic pregnancy can be managed expectantly and avoid surgery.
Women who are selected for a “watch and wait” approach will be followed-up closely by the OMNI team with blood tests (pregnancy hormone levels known as hCG) and ultrasound. The levels of serum hCG need to fall to non-pregnant levels for successful expectant management to occur. Close monitoring is important as there is a small possibility that the tubal ectopic pregnancy can rupture and cause internal bleeding, despite falling hCG levels. If at any time during expectant management there are signs of this, then surgery will be arranged.
Some women who are not eligible for expectant management can be managed medically. This is another way of avoiding surgery. This means giving the woman an injection of methotrexate. Methotrexate has been used since the 1980s as an alternative to surgery for some ectopic pregnancies. 20 – 25% of women with a tubal ectopic pregnancy can be managed medically with methotrexate.
Strict guidelines apply to the use of methotrexate. Methotrexate used in very low doses stops the pregnancy cells from dividing, ending the pregnancy and conserving the tube where the pregnancy implants.
Methotrexate is given as a single injection into the muscle. Again, women who are selected for methotrexate therapy will be followed-up closely by the OMNI team with serum hCG levels and an ultrasound. As is the case with expectant management, under rare circumstances, tubal ectopic pregnancy can rupture despite falling hCG levels. Should this be the case, surgery will be arranged.
Non-tubal ectopic pregnancy
OMNI offers expertise in the diagnosis and management of these rare forms of ectopic pregnancy. Non-tubal ectopic pregnancies account for only 5% of all ectopic pregnancies. Treatment of these ectopic pregnancies has to be individualised based on the location of the non-tubal ectopic pregnancy, the level of pregnancy hormone or serum hCG and the viability of the pregnancy.
Non-tubal pregnancies include:
- interstitial or cornual pregnancies
- cervical pregnancies
- ovarian pregnancies
- caesarean section scar pregnancies
As a rule, interstitial and cervical pregnancies should be managed non-surgically. In these cases, high dose methotrexate and close follow-up is the mainstay of treatment.
Ovarian pregnancies are even rarer and these pregnancies can be difficult to diagnose on ultrasound as they mimic ovarian cysts. Laparoscopic (keyhole) surgery is usually the most appropriate way to treat this type of non-tubal ectopic pregnancy.
Caesarean section scar pregnancies are becoming more common and this is related to the increase in caesarean section rates. The mainstay of treatment for women with this type of ectopic pregnancy is ultrasound-guided dilatation and curettage (D&C). This means having a general anaesthetic and emptying the womb under ultrasound vision.
Pregnancies of unknown location (PULs)
PULs account for 10% of all early pregnancy scans. In this clinical situation there is no sign of pregnancy inside or outside the womb (uterus) on scan. A PUL does NOT mean that you have an ectopic pregnancy. Close hormonal follow-up and ultrasound form the cornerstone of management for women with a PUL.
Under these circumstances, there are three possible outcomes:
- Failing pregnancy (either complete miscarriage or self-limiting form of ectopic pregnancy)
- Ongoing intra-uterine pregnancy
- Ongoing extra-uterine or ectopic pregnancy
At OMNI, expectant management in conjunction with measurements of the pregnancy hormone hCG over 48 hours has been shown to be safe. This approach also allows us to predict the most likely outcome for your early pregnancy.
If the serum hCG levels fall over 48 hours, then this represents a failing pregnancy and repeat serum hCG levels will be arranged 7 days later to confirm the diagnosis. If the serum hCG levels increase over 48 hours, then a repeat scan will be arranged 7 days later to confirm the location of the pregnancy. Most women with increasing levels of serum hCG at 48 hours will go on to have a normal pregnancy and not an ectopic pregnancy.
In selected cases of ectopic pregnancy, OMNI offers non-surgical management strategies which include methotrexate and even expectant management.