Ectopic Pregnancy in Singapore

What is an ectopic pregnancy?

An ectopic pregnancy is a pregnancy outside of the uterus (womb). This happens in about 1 of 100 pregnancies. Over 90% of ectopic pregnancies are in the fallopian tube; uncommonly, it can also grow on the ovary, cervix or previous caesarean scars. An ectopic pregnancy is abnormal and cannot be sustained or converted into a normal pregnancy. It can cause pain and/or life-threatening bleeding when the fallopian tube bursts; this is because no place other than the uterus can carry a pregnancy. Even after treatment of an ectopic pregnancy, there is a 10-15% chance of having another ectopic pregnancy in the future.

How does an ectopic pregnancy happen?

An ectopic pregnancy is often caused by damage to the fallopian tubes. When a fertilised egg cannot pass through the fallopian tube to reach the uterus, it implants itself in the fallopian tube and grows there. 

You are more likely to have fallopian tube damage and an ectopic pregnancy if you have: 

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How soon would you know if you have an ectopic pregnancy?

You may not know you have an ectopic pregnancy at first since symptoms usually only develop within 4-12 weeks of the pregnancy. Some women only discover they have an ectopic pregnancy through a scan or when they develop serious symptoms later on, such as:

Vaginal bleeding

Vaginal bleeding should not be confused with a regular period. The blood may be watery, dark brown and often starts and stops.

Abdominal pain

You may experience lower abdominal pain, typically on one side of your stomach. The pain can develop suddenly or gradually and may come and go.

Shoulder tip pain

If blood leaks from the fallopian tube, you may feel pain around your shoulder tip.

Change in bowel movements

You may experience diarrhoea or pain when you poop or pee. Take note that changes in bladder and bowel patterns may be caused by urinary tract infections or stomach bugs, so it’s best to seek advice from a doctor. 

Symptoms of a regular pregnancy

Some women with an ectopic pregnancy go through the early signs of a regular pregnancy, including a missed period, breast tenderness and nausea. Their pregnancy test may show a positive result too. However, an ectopic pregnancy cannot continue as normal.

How is an ectopic pregnancy treated in Singapore?

Ectopic pregnancy is treated with methotrexate (MTX) treatment. MTX is a medication that stops pregnancy cells from growing. It is given as a single intramuscular injection in your upper arm or buttock. This causes the cells to shrink and be absorbed naturally by the body. It is sometimes used in cancer treatment, but the dose used to treat ectopic pregnancy is much lower.

It is successful in treating ectopic pregnancies in 90% of the time. 15% of women may require a 2nd MTX Injection if the response to the 1st injection is insufficient. The ectopic pregnancy can still burst anytime before it is fully resolved – in these cases, and in those who do not respond to MTX, surgery is usually required.

You will need blood tests before MTX to check your blood count and type, as well as kidney/liver function.

You are suitable for MTX if:
  • You have no severe pain or bleeding
  • Your blood pressure and heart rate is normal
  • Your pregnancy hormone level (b-hcg) is <5000IU
  • Your ectopic pregnancy measures <3.5cm on ultrasound and there is no yolk sac/heartbeat seen
  • You are willing to return for frequent blood tests and follow-ups (at least 3 times in the first week then weekly for about 4-6 weeks minimum)
You are not suitable for MTX if:
  • You do not fulfil the criteria above
  • You have kidney, lung, liver or blood disease (e.g. low blood counts)
  • You have stomach/intestinal ulcers
  • You have a weak immune system e.g. HIV/AIDS
  • You have an active infection
  • You are breastfeeding
  • You are unable to return for frequent checks

Are there any side effects of MTX?

Most women tolerate MTX well. The most common side effects include pain at the injection site, mild lower abdominal cramps, and slight vaginal bleeding. Uncommon side effects include nausea, diarrhea, mouth ulcers, conjunctivitis, photosensitivity, low blood count and fatigue.

Do not get pregnant for 3 months after MTX injection as your body will require some time to clear it. Avoid alcohol, sunlight (use sunscreen). Use with caution with non-steroidal anti-inflammatory drugs (aspirin, ponstan, arcoxia, synflex, voltaren).

Are there other options besides MTX?

Other ways of treating an ectopic pregnancy include;

Surgery

  • This is performed under general anesthesia. In Singapore, most of it can be performed as gynae laparoscopy surgery, however if there is a lot of internal bleeding or if blood pressure/heart rate is unstable then a laparotomy (open) may be considered.

Salpingectomy

  • The affected fallopian tube is removed together with the pregnancy.

Salpingostomy

  • A hole is made in the affected fallopian tube and as much of the ectopic pregnancy as possible is removed. Weekly b-hcg blood tests will still be required as there is a risk of persistence of the ectopic pregnancy requiring further treatment. This is generally not recommended as there is a much higher chance of another ectopic pregnancy in the future.