Ectopic pregnancy is another 'not rare' situation that is worthwhile knowing something about. This comes from a listener's request where she felt lost after being diagnosed with an ectopic pregnancy at an early 6 week dating scan.
And we see women feeling lost after a diagnosis of an ectopic pregnancy. Suddenly you are in the system as you start your medical treatment. All while you are also trying to cope with the grief of your miscarriage.
In this podcast we talk about:
A little anatomy
Symptoms of an ectopic pregnancy
Different treatment options
Whether your fertility is impacted after an ectopic
The chance of another ectopic pregnancy
Why it happens
What you can do to prevent it
Brigid [00:00:36] Hello, everyone. Well, this is episode 31. Welcome back. Welcome back to us too. We haven't done an episode since the shutdown now.
Patrick [00:00:45] We're still in the in the Coronavirus shutdown and we're here in our little studio. But we're allowed to be in this little room together because we're in the same family.
Brigid [00:00:54] Yeah. And thank God because it's nice and snug in it, isn't it?
Patrick [00:00:57] Snug. I don't know that I'd want to be in here with a whole bunch of other people.
Brigid [00:01:00] And I don't think we would be allowed. So, you know, thank you to the studio to let us in.
Brigid [00:01:05] And today we're talking about ectopic pregnancy. So this is actually a request from somebody on our Instagram DMs. And it's a really good topic to cover because it's pretty common, isn't it?
Patrick [00:01:18] Yeah. And we like covering things that people have requested as well. Yeah. So have we got a review up front?
Brigid [00:01:25] Oh gosh. Look at you go. Yes, we do. All right. We've got lots of reviews. I won't get too many out today. I'll just do it one at a time.So this on our i-Tunes from RobynKA. "Thank you for this wonderful podcast. I've been feeling quite nervous, especially in isolation, about a range of things to do with my pregnancy and birth. I'm feeling so much better informed and calmer for listening". And we've been getting that a lot, haven't we? You know, it is incredibly distressing for people in isolation during this coronavirus shutdown.
Patrick [00:01:59] Yeah, that's exactly what we're going for, to help people feel informed. And then because they feel more informed, a bit calmer in a, you know, in crazy times. Yes.
Brigid [00:02:08] And everyone who's following us on Instagram probably saw us post something about a woman who had an induction in the U.K. all by herself, basically, because in the U.K. it's a bit different and they can't take their partner in. Yeah.
Brigid [00:02:20] And she said she listened to us about three or four times.
Patrick [00:02:23] During the labour? How awesome is that?
Brigid [00:02:28] And yes, we were having to calm her nerves. So it's just that's fantastic. I love that. Yeah. All right. Let's get onto ectopic pregnancy, Pat. What is ectopic pregnancy?
Patrick [00:02:40] Okay. So an ectopic pregnancy is a sad situation where, you know, the the sperm and the egg all meet up in the in the tube like they normally do. And you'll get a fertilized egg that unfortunately doesn't implant in a good place. And there's only one good place which is in the in the top half of the uterus. And if it implants anywhere else, like in the tube itself or outside the end of the tube, near the ovary or down in the cervix in the lower part of the uterus,.
Brigid [00:03:08] No way, can it travel all the way down to your cervix?
Patrick [00:03:10] Yes. So those are all dangerous places where where it won't implant properly and where it can't grow properly and where it's likely to cause a lot of bleeding once it bursts out of where it where it's implanted.
Brigid [00:03:24] Because it grows too big and it can't be contained within the tube? Is that it?
Patrick [00:03:27] Yeah, that's right.
Patrick [00:03:28] So they're bits that won't stretch like the upper part of the uterus will.
Brigid [00:03:32] And why doesn't it travel all the way down into the uterus? What's happening?
Patrick [00:03:36] Look, sometimes it's just a bit of bad luck, that we think that sometimes it just doesn't go right. But also, there might be a problem with the tube itself. OK. So, for example, if a woman's had a tube that's been partially blocked, and instead of a nice smooth road, it's a crooked, bumpy road. Then the fertilized egg might be more likely to get stuck in there?
Brigid [00:04:03] And what would cause it to be, you know, blocked or not smooth?
Patrick [00:04:08] A history of chlamydia infection would be the main one.
Brigid [00:04:11] Oh, really?
Patrick [00:04:11] Yes. So someone who's had maybe a bad chlamydia infection, it's been treated. Sperm and egg were able to to meet up. So the tube is not blocked. But maybe it's crooked and that's promoted that the pregnancy implanting in the wrong spot.
Brigid [00:04:26] And I mean, this is probably a strange question, but can you like re-bore the tube or you know straighten it out?
Patrick [00:04:33] A lot of people have tried that over the years in various different ways. But that's not a thing, unfortunately.
Brigid [00:04:37] They can do it for men who have prostate problems.
Patrick [00:04:39] It's not like a prostate. No. Okay.
Brigid [00:04:42] All right. So if you do have an ectopic pregnancy, how can you how can you tell? Like what? What do you have? Normal early pregnancy symptoms like sore boobs, nausea?
Patrick [00:04:52] Yes. So you'll have normal pregnancy symptoms because the presence of a implanted fertilized egg, you'll start making that pregnancy hormone, that beta hCG, and that'll happen no matter where the pregnancy is located. So nausea, tiredness, breast tenderness, all of the things that you get an early pregnancy, you'll get those anyway. And until something goes wrong or some testing is done, you won't know whether it's ectopic or not.
Brigid [00:05:21] So you'll still get a positive two lines on a pee on a stick?
Patrick [00:05:24] Absolutely. Yeah. Right. In exactly the same way. Yes. And that can be a little misleading thinking. Okay, great. If I'm pregnant, everything's things fine. But an ectopic pregnancy sooner rather than later will start to cause some problems typically vaginal bleeding, and that will usually take a woman to her doctor or the hospital where an ultrasound might be done and the ultrasound might show a picture that isn't in keeping with a normal pregnancy. For example, if the bleeding happens at seven weeks, we would absolutely expect to see in the uterus a pregnancy sack with a little fetal pole and maybe a heartbeat. And if someone comes to the hospital at seven weeks of pregnancy with bleeding and we do a scan and there's nothing in the uterus, then that's an ectopic until proven otherwise, because your hormone levels are coming from somewhere. And yet there's nothing to see in the uterus itself.
Brigid [00:06:21] So, I mean, we've covered early bleeding in pregnancy and one of the earlier episodes, so I can't remember what we said. So somebody had early bleeding. Do they go where do they go, first off? Emergency department, to the GP. What was their first port of call?
Patrick [00:06:36] It depends what's going on and what services are available. But if someone's in early pregnancy with heavy bleeding and and a lot of pain, then that might be better dealt with in a hospital emergency department rather than through the local doctor.
Brigid [00:06:50] All right. So what are the most common symptoms that somebody might present with if they've got an ectopic pregnancy?
Patrick [00:06:57] Well, sometimes it's just sort of picked up by accident and without any symptoms at all. And that might be that somebody has a scan at six weeks just to see whether there's anything to see yet, to date the pregnancy, to make sure it's not twins, or those sort of things that we might do an early pregnancy scan for, and we might see a situation that where it just doesn't add up. So we know the woman's six weeks, there's nothing in the uterus. And maybe by then we can even see a little bulge halfway along the tube. And she may be have absolutely no symptoms yet. Okay. And and we pick up a lot that way because we do a lot of early pregnancy scans for various reasons.
Brigid [00:07:39] You like during early pregnancy scans, don't you?
Patrick [00:07:41] Well, I do. I mean you don't have to have one, but I do if someone's had had a pregnancy loss the previous pregnancy because they're really keen to see it. Yeah.
Brigid [00:07:51] It does reassure people that, you know, six weeks. Mm hmm. Yeah.
Patrick [00:07:55] Yep. Or if they've been trying for ages or all sorts of reasons why it might be a good idea to to have a look early. So occasionally we'll pick up ectopic before it ruptures and before it causes major trouble. And then of the ones that are already starting to cause trouble, by far the most most common situation would be bleeding in early pregnancy.
Brigid [00:08:15] And are you talking about any type of bleeding? Like is it bright red? Dark red?
Patrick [00:08:19] Yeah, you read that. I don't think that's a thing.
Brigid I did read that. I think I was doing my research on the Internet.
Patrick [00:08:25] I don't think you can pick an ectopic from a miscarriage yet. But what the bleeding looks like. Absolutely not. It's an ultrasound diagnosis.
Brigid [00:08:35] All right. And what other symptoms does somebody have? So they started bleeding, are they in pain?
Patrick [00:08:40] Yeah, well, pain. So in particular, if like most ectopic, it's in the tube, then by the time it starts bleeding down the tube, through the uterus, through the cervix and down the vagina, there'll also be some bleeding that comes out the other end of tube. The opening near the ovary and that's gonna bleed fresh blood out into the woman's insides. And that's and that's painful.
Brigid [00:09:03] And is it serious?
Patrick [00:09:05] Yeah, they're serious if they rupture. And thankfully, you know in our country with and with a developed healthcare system, we're able to pick that up and operate quickly. But, yes, they're serious. And globally and in developing countries and so forth, there's still a major problem.
Brigid [00:10:04] I've done my research. I know you don't like it when people say, I've done my research, which just means I've just jumped onto Google.
Patrick [00:10:46] Oh, that's just me. I'm not sure that reading about something on the Internet is the same. If I was a researcher, if I worked in a lab and have dedicated my life to that. It might annoy me at parties if other people called their Internet research, research.
Brigid [00:11:00] Yeah, well, my Internet research led me to shoulder tip pain. Some people complain of having pain in their shoulder. Yeah, that's a thing.
Patrick [00:11:07] So if you've got bleeding on your insides in the pelvis, sometimes that will be interpreted by your brain as pain coming from the tip of your shoulder.
Brigid [00:11:20] How weird! I don't know, we've got a nerve connection between.
Patrick [00:11:26] Yeah, it's a little short-circuiting there in our nervous system where the brain can easily confuse internal pain from the pelvis and abdomen as coming from the shoulders. And we most commonly say that after laparoscopic surgery. So we you know, we're doing a laparoscopic surgery for endometriosis or appendix or whatever, we filll the person's inside with carbon dioxide so we can see what we're doing. And that will irritate the lining of the of the peritoneal cavity of our insides. And on the ward afterwards, everyone's rubbing their shoulder. There's nothing wrong with everyone's shoulder. It's just a mistake your brain's making that thinks the pain's coming from there.
Brigid [00:12:05] Oh, my God. Human bodies are just fascinating. I get so fascinated. So what other sort of symptoms? I know we've sat at a table before when you've suspected that a person complaining of pain was experiencing an ectopic pregnancy, you picked it straight away.
Patrick [00:12:20] Oh, yeah. That's just. That's just my gynecologist instinct.
Brigid [00:12:24] She had told anyone that they were pregnant. But you will like whispered. "Do you think you might be pregnant?
Patrick [00:12:30] Yeah. So, you know, it hurts and it really hurts. Yeah. And so that's sort of severe pain in early pregnancy needs to be checked out.
Brigid [00:12:38] Straight to the emergency department.
Patrick [00:12:39] Yeah, absolutely. And then, of course, if it's already ruptured and there's significant bleeding out out into the woman's insides, then she'll have shock and likely low blood pressure. Look, pale sick. Yeah. And that's a very serious situation. Yeah.
Brigid [00:12:54] So what about going back to the person who maybe at six weeks wasn't experiencing any symptoms? But you've suspected an ectopic pregnancy. What's the treatment for that woman?
Patrick [00:13:03] Well, for that woman where the ectopics are unruptured. We do actually have an opportunity to treat that without surgery. And this is getting a little more popular. You know, in recent years. So there's a drug called methotrexate, which is a drug in common use for all sorts of other conditions. And in the setting of an unruptured ectopic, it works. It works a bit like chemotherapy for cancer.
Patrick [00:13:32] Yes elsewhere but using it for this purpose, chemotherapy drugs work by attacking cells that are rapidly dividing and cancer cells are rapidly dividing. So that's how chemo knows to attack mostly those and to leave most of your other cells alone. With methotrexate for an unruptured ectopic pregnancy. It'll attack the pregnancy cells cause they're the ultimate rapidly dividing cells. And it can destroy the tissue from the ectopic without, you know, and treat the whole situation without the need for surgery. It's often misunderstood that it's better than having an operation. The operation involves removing the tube with the ectopic inside it. And if we use methotrexate instead, it's tempting to think of the methotrexate, washing that tube clean, washing the pregnancy out. And the the tube is still fine. And we don't think that's really what happens. We think that the methotrexate, sorry the ectopic pregnancy, probably still destroys the usefulness of that tube and all the methotrexate really does is save your from having an operation. But certainly you get to keep the tube if you have methotrexate. But how useful that tube is to conceive again? We don't really know. Yeah.
Brigid [00:15:01] Again, this is probably a naive question, but can we have a transplant a fetus that's formed in the a tube into the uterus?
Patrick [00:15:13] No.Someone once claimed to have done it right. And it was fraud. That the claim was fraudulent.
Brigid [00:15:19] All right. Because it's just that the fetus, the baby, just does not survive, doesn't it?
Patrick [00:15:25] No. So no. And that's that's a good point. In all of the drama of an ectopic pregnancy and the need for surgery and hospital visits and everything, it gets forgotten that this is a pregnancy loss. Yeah. Like a miscarriage. And this happens all the time. People say everyone paid all the fuss to my ectopic and my need to have an operation and so forth. And nobody said, I'm sorry, I lost the baby. Yeah. Yeah. It's still the same pain, isn't it? That's right. So the rules about responding appropriately to somebody who's had a miscarriage still apply.
Brigid [00:15:58] To someone who's had an ectopic, absolutely.
Brigid [00:16:01] All right. So you mentioned that you have to remove the fallopian tube. Like, does that decrease your fertility?
Patrick [00:16:08] It's a good question. Not by much, it turns out. So it's tempting to think that if you're if you've had one tube removed, that your fertility might drop by 50 percent. Yeah, but it doesn't really work that way. The one on the other side does a good job. Yeah. And like a lot of the paired organs in our body, we cope pretty well with just one. So if you lose one kidney, your renal function doesn't drop by 50 percent. Yeah. If you lose one eye, you're not half blind
Brigid [00:16:36] But does it mean that you're only ovulating every second month?
Patrick [00:16:39] No, you keep that ovary. You've still got both. Oh yeah. Yeah. So you still ovulate every month. And and so you can easily pick up the eggs on the side that's got the remaining tube. Yeah. And the remaining two will also work pretty well to siphon an egg from the other side.
Brigid [00:16:59] No way!
Patrick [00:17:00] Across the pelvis and down the remaining tube.
Brigid [00:17:02] Wow. So it just sort of like y sends out like a little magnet or something. Come here little eggy.
Patrick [00:17:07] That's what the little fingers on the end are for.
Patrick [00:17:10] So if you think of a diagram of a fallopian tube, it's got those little fingers on the end and they sort of work, you know, a little suction motion to suck the egg in because the tube isn't even attached to the ovary on its own side. Only next to it. Yeah. And the ovary pops the egg out into into space around the ovary and the. And the little fingers suck it in and it's quite possible for the tube. The remaining tube to suck an egg from the other side.
Brigid [00:17:39] Fascinating. I always you know, in my mind I had that the fallopian tube anchored the ovary and once the fallopian tube was gone that ovary was just floating around. But it's it's got its own anchor point. Yeah.
Patrick [00:17:50] Yeah, it's got its own stalk. Yeah. It's usually not shown on those diagrams but it's got its own stalk. So if we look at the reduction in fertility, it's relatively modest if you've lost one tube.
Patrick [00:18:03] And the problem is of course if you lose both
Brigid [00:18:06] And if the tube that is remaining is in good nick.
Patrick [00:18:10] Yeah. We want that. Yes. Exactly what the remaining tube to be in good nick. And the only way to really tell that is to try for another pregnancy and see how you go. Yeah. But in a woman having a pregnancy, that's her first after a previous ectopic. We can be watching that situation pretty closely.
Brigid [00:18:25] And how do you watch someone closely?
Patrick [00:18:27] Early ultrasound. Yeah. So with early ultrasound, we can we can pick another ectopic, which is higher risk in that woman if she's had one before. Yeah, right. And we can pick that by looking on early ultrasound and looking for those precious signs of the pregnancy being inside the uterus and not stuck in the other tube.
Brigid [00:18:50] Because then you would treat with methotrexate because you know, a bit of a shitty tube is better than no tube?
Patrick [00:18:55] You might, but but you know, you would make that decision on a number of grounds. But, you know, if someone's lost both tubes or the effective function of both tubes to to perhaps, you know, a bad chlaymidial infection followed by two ectopics, then that's an IVF situation.
Brigid [00:19:17] Yeah, right. Yeah. And we've talked about it before that if you've still got good ovary function. Yeah. IVF for those people is usually very successful isn't it.
Patrick [00:19:28] Oh absolutely. So yeah. If tubal disease was your only problem, then the success rates are very good because you know, the one of the limiting factors to assisted reproduction is the is being able to get the eggs in the first place. Yeah. And if you've got a problem with egg production then it's likely to work quite well.
Brigid [00:19:48] Is there anything that I could be doing to prevent an ectopic pregnancy?
Patrick [00:19:54] I think there's not a lot. It's one of the reasons why we should be careful with chylamidial infection. And it's a good idea in that late teens, early 20s age group to be screened for chlamydia, especially when you're going to see your local doc for a women's health checkup, pill prescription. Cervical screening test yeah.
Brigid [00:20:21] Pregnancy consultation.
Patrick [00:20:22] Yeah, absolutely. Because the chlamydia in that age group is notoriously asymptomatic, as is sitting there.
Brigid [00:20:28] Oh, god. I was just about to say, how do we know who we've got clymadia.
Patrick [00:20:31] And we don't, we've got to get screened for it. That's sort of a primary prevention thing you could do, is make sure that is, you know, decrease the chances of you having that problem in the first place. Yeah, right. And beyond that, no trying to, you know, every time we get pregnant, we just hope it's in the right place. Yes. And get a proper diagnosis. Who fits in the wrong place? Okay, good.
Brigid [00:20:55] So if I have had like surgery and I might have lost a fallopian tube or whatever, how long before I start trying again?
Patrick [00:21:05] Look, it's really it's not a it's not really a physical limitation. You want to be over the surgery. It's more about being over the loss of the pregnancy.
Brigid [00:21:14] Yes. So the same thing applies as you go back and listen to our miscarriage episode
Patrick [00:21:17] But, you know, it's every bit like a miscarriage. So I say people at two weeks. Yeah. I'd like to say to people at two weeks because I like to see the early signs of them making a normal emotional recovery. Yeah. And and then people will often want to have at least one other cycle, if only to know where their dates are. Right. Yeah. Yeah. So that so if they wait for at least the first period that's the new day one, couple of weeks later is the new day 14 fertile time again. And you could you could try again as early as that.
Brigid [00:21:49] Right. Good. Well I think I've asked all my questions. So we might wrap it up there. Okay.
Patrick [00:21:55] That's good. I like talking about the ectopic. I think this is this is this is not a rare situation. Ask. How common is it? One percent. 1 percent. Yeah. So, I mean, it's not very likely to happen to any individual person, but it's something that we see back when I worked at the Royal Women's. We did an ectopic in theater every day. Every day. Yeah. In a big hospital like that. So. Yeah. One percent's not a small number. Across the whole community. Yeah. And most people are likely to know somebody who's had an ectopic pregnancy if they haven't had one themselves. And that's why I think it's it's one of those things that's worthwhile having a passing knowledge about. Yeah. If you're in the pregnancy space.
Brigid [00:22:39] Well everyone, thank you for joining us. It's been fun to get back into the podcasting studio and record another episode. And we'll catch you next week with our next episode. So if you can, please leave us a review. Give us a little five star. We love those. And drop into our Instagram @grow_my_baby
Patrick [00:23:01] And if you want to hear something and have a topic of interest, then maybe just send us a DM. Thanks for listening, everybody.