When pain or bleeding occurs in early pregnancy, it can have many causes. One of these is an ectopic pregnancy (tubal pregnancy), in which the pregnancy develops outside the uterus in the fallopian tube. It should be detected and treated early, as it can lead to a rupture of the fallopian tube and internal bleeding as it progresses.
As a fertility center, we also support women in the event of abnormalities in early pregnancy and with questions regarding further desire to have children. In this guide, we explain which signs can indicate an ectopic pregnancy, how the diagnosis is made, how the ectopic pregnancy is treated, and what it means for a later desire to have children.
- What is an ectopic pregnancy?
- Typical signs of an ectopic pregnancy
- Pregnant despite bleeding?
- Diagnostics in early pregnancy
- Treatment of an ectopic pregnancy
- When is a new pregnancy possible again?
- Frequently asked questions about ectopic pregnancy
What is an ectopic pregnancy?
In an ectopic pregnancy, the fertilized egg does not implant in the uterine cavity, but in the fallopian tube. It is thus the most common form of a so-called extrauterine pregnancy, i.e., a pregnancy outside the uterus. Ectopic pregnancies account for about 1–2% of all pregnancies.
The risk may be increased in women with:
- A previous ectopic pregnancy
- Previous inflammation in the pelvic area
- Endometriosis
- Previous chlamydia infections
- Previous surgical interventions
- Smoking
However, many ectopic pregnancies also occur without known risk factors.
After a previous ectopic pregnancy, the risk of recurrence for another ectopic pregnancy is increased. The magnitude is stated to be about 7–10%; nevertheless, the probability that a normal pregnancy will occur in the uterus during a subsequent pregnancy is significantly higher.
After several previous ectopic pregnancies, the risk increases significantly further and can be about 25–30% or more after two ectopic pregnancies.
Symptoms
Typical symptoms and first signs (5th to 7th week of pregnancy)
An ectopic pregnancy can initially proceed entirely without symptoms. Symptoms often only appear during the course of early pregnancy and can vary greatly in severity.
Possible signs include:
- One-sided or increasing lower abdominal pain
- Spotting or unusual vaginal bleeding
- Dizziness, weakness, or circulatory problems
- Pain during bowel movements or urination can also occur
One should be particularly attentive to the combination of a positive pregnancy test, pain, and bleeding.
Important: If an ectopic pregnancy is suspected, a gynecological evaluation should be carried out promptly. In the event of severe pain or circulatory problems, immediate medical evaluation is necessary.
The following applies: “Even if an ectopic pregnancy is only suspected, a prompt evaluation is always very important.”
Pregnant despite bleeding? Why a period is not an all-clear signal
Bleeding can also occur in early pregnancy. It can have very different causes and cannot be reliably categorized based on color or intensity alone.
Possible causes include, for example:
- Bleeding in a healthy, intact early pregnancy
- A small hematoma
- Contact bleeding, for example after sexual intercourse
- An impending miscarriage
- An ectopic pregnancy
Bleeding can also occur with an ectopic pregnancy and be mistaken for menstruation.
Our advice: If you have a positive pregnancy test and bleeding or pain occurs at the same time, you should seek medical advice quickly.
Diagnostics in early pregnancy – when to see a doctor?
In the event of a positive pregnancy test and simultaneous symptoms such as lower abdominal pain or bleeding, a gynecological evaluation should be carried out promptly. This applies particularly if risk factors for an ectopic pregnancy are already known.
For diagnostics, we combine transvaginal ultrasound with follow-up checks of the pregnancy hormone hCG. The decisive factor is not a single value, but the joint assessment of symptoms, ultrasound findings, and hCG progression. This usually allows for early detection of whether the pregnancy is developing regularly in the uterus or whether further checks are necessary.
Treatment of an ectopic pregnancy
Treatment depends on your individual situation, the symptoms, the ultrasound findings, and the progression of the pregnancy hormone hCG.
Expectant management
In the case of very early, stable findings and already declining hCG, close monitoring can be carried out in selected cases to see if the pregnancy regresses on its own.
Medical treatment with methotrexate
In the case of a reliably diagnosed, non-ruptured ectopic pregnancy, methotrexate can be used under certain conditions. The medication inhibits the further development of the pregnancy tissue. Subsequently, regular hCG checks are necessary.
Surgical treatment
Surgery is necessary, in particular, in the event of severe pain, circulatory instability, suspicion of a rupture, or certain ultrasound findings. If possible, the procedure is performed minimally invasively as part of a laparoscopy.
When is a new pregnancy possible again?
After an ectopic pregnancy, a new pregnancy is possible in most cases. When you can try to get pregnant again depends on how the ectopic pregnancy was treated and how well you have recovered physically and emotionally.
After treatment with methotrexate, it is recommended to wait at least three months before a new pregnancy. Methotrexate interferes with folic acid metabolism and can harm an early pregnancy.
After surgical treatment, the recommended interval depends on the healing process and your individual situation.
HyCoSy examination
After an ectopic pregnancy, it may be useful to check the patency of the fallopian tubes if there is a renewed desire to have children – especially if there are risk factors for damage to the fallopian tubes or if pregnancy is taking a long time to occur.
A HyCoSy/HyFoSy examination allows for a gentle assessment of whether one or both fallopian tubes are patent, without the use of X‑rays. The examination is performed via ultrasound and can usually be carried out without anesthesia.
It is important to note: HyCoSy shows whether a fallopian tube is open, but it cannot reliably assess how well its function actually is or whether there are finer changes in the fallopian tube lining.
Well-supported for a renewed desire to have children
After an ectopic pregnancy, questions often arise regarding further family planning and a possible new pregnancy. In our fertility center, we take the time to categorize and discuss your history and existing findings and to determine which examinations or next steps may be useful.
Our experienced fertility doctors will advise you in an understandable and personal manner – with a view to your medical situation and your questions.
Frequently asked questions about ectopic pregnancy
When do you notice an ectopic pregnancy?
An ectopic pregnancy can initially proceed entirely without symptoms. Symptoms often only appear during the course of early pregnancy. Typical indications are one-sided lower abdominal pain, vaginal bleeding or spotting, circulatory problems, or an abnormal hCG progression.
Who has an increased risk for an ectopic pregnancy?
The risk is increased, among other things, after a previous ectopic pregnancy, with previous inflammation or operations on the fallopian tubes, endometriosis, IVF/ICSI, smoking, and with increasing age. However, it is important to note: An ectopic pregnancy can occur even without known risk factors.
What does bleeding look like in an ectopic pregnancy?
The bleeding can be very different, ranging from light spotting to menstruation-like bleeding. The cause cannot be reliably identified based on color or intensity. It can occur with or without accompanying pain and should always be medically evaluated.
When does an ectopic pregnancy become dangerous?
An ectopic pregnancy becomes dangerous primarily when internal bleeding or a rupture of the fallopian tube occurs. Warning signs are sudden severe pain, pronounced dizziness, or circulatory problems. Immediate medical evaluation is necessary.
How high is the hCG in an ectopic pregnancy?
There is no typical single hCG value by which an ectopic pregnancy can be reliably identified. The decisive factors are the progression of the hCG, the ultrasound findings, and the symptoms. An ectopic pregnancy can be present even with low or falling hCG values.
Can an ectopic pregnancy be ruled out in the 5th week of pregnancy?
Not always. In the 5th week of pregnancy, it may still be too early to reliably assess the location of the pregnancy via ultrasound. In the case of unclear findings, follow-up checks with transvaginal ultrasound and hCG are helpful.
Can an ectopic pregnancy regress on its own?
Yes. In the case of very early findings, minor symptoms, and declining hCG, an ectopic pregnancy can regress on its own in some cases. In such instances, a closely monitored expectant management approach is possible.
How high is the risk of recurrence?
After an ectopic pregnancy, the risk for another ectopic pregnancy is increased and lies approximately in the range of 7–10%. After several previous ectopic pregnancies, it increases significantly further and can be about 25–30% or more after two ectopic pregnancies.
Can you get pregnant again after an ectopic pregnancy?
Yes. In most cases, a new pregnancy is possible. Depending on the history and the desire to have children, it may be useful to check the fallopian tube patency, for example with a HyCoSy/HyFoSy, before a further pregnancy.
Can an ectopic pregnancy be present despite a normally rising hCG?
Yes. Even an initially unremarkable hCG increase does not reliably rule out an ectopic pregnancy. The location of the pregnancy is ultimately assessed by ultrasound and progression.
Can you see an ectopic pregnancy on an ultrasound?
The diagnosis can often be made via transvaginal ultrasound. However, very early on, the location of the pregnancy may still be unclear. In that case, follow-up checks are necessary.
Does an ectopic pregnancy always have to be operated on?
No. Depending on the findings, expectant management, treatment with methotrexate, or surgery may be considered. The decision depends on symptoms, circulatory stability, ultrasound findings, and hCG progression.
