How they are diagnosed and what happens if they are not
A planned and wanted pregnancy should be a happy time for any expectant mother however unfortunately, for some women, what should be such a happy and exciting time can turn into an upsetting and potentially life threatening experience if they are diagnosed as having an ectopic pregnancy.
An ectopic pregnancy occurs when a fertilised egg starts to develop outside of the womb. Most commonly this occurs within the fallopian tubes however it can occur elsewhere in the body. Whilst there are factors which can increase the likelihood of an ectopic pregnancy occurring such as previous surgery on the fallopian tubes, becoming pregnant whilst using a coil or the mini pill or undergoing IVF many woman experience an ectopic pregnancy without being subject to any of these risk factors. About 1 in 200 pregnancies will be ectopic and once a woman has suffered from one ectopic pregnancy her likelihood of suffering from a further ectopic pregnancy is increased. If an ectopic pregnancy is not caught in time it can be life threatening if it ruptures and causes internal bleeding.
Symptoms and diagnosis of an ectopic pregnancy
It is likely, particularly if a woman is trying to conceive, that she will know that she is pregnant due to having missed a period and/or having a positive pregnancy test. If a pregnancy is ectopic as well as the usual pregnancy symptoms a woman may find that she suffers from abdominal pain, particularly on one side and bleeding. In the later stages of an ectopic pregnancy the woman is likely to experience shoulder pain. This is due to the fact that the blood irritates the diaphragm and the diaphragms nerves are felt in the shoulder.
The diagnosis of an ectopic pregnancy would be done by the following tests being completed at hospital:-
- a pregnancy test
- a transvaginal (internal) ultrasound
- a pelvic exam
Following these tests the doctor should be able to confirm if there is an ectopic pregnancy, whereabouts it is and also the approximate gestation.
Treatment of an ectopic pregnancy
There is no real alternative for an ectopic pregnancy other than termination of the pregnancy. If the pregnancy is not terminated then the likelihood is that the fertilised egg would continue to grow and, assuming that it is within the fallopian tube, rupture and this would be life threatening for the mother.
There are two options for the termination of the pregnancy:-
The choice between the two options really depends on the stage of the pregnancy at the time of diagnosis.
If the pregnancy is caught in the early stages, the location of the fertilised egg is known and the mother is stable, then a drug called methotrexate can be used. This can only be used in situations where the mass is 3.5cm in diameter or less due to the way in which the drug works. The drug is either injected or put in a drip and has minimal side effects, especially when compared with the surgical options detailed below. The benefit is that there is no need to remove the fallopian tube and the need for an operation and resulting recovery and scarring is avoided. Therefore the sooner an ectopic pregnancy is diagnosed the better both in terms of the effects of the treatment on the woman, the risks to her overall health and also in terms of the effect on her future fertility.
If the pregnancy is diagnosed in the later stages and/ or the fertilised egg can not be located or the mothers health is compromised then surgery will be the only option. Within this option there are two different surgeries which can be undertaken, one involves the removal of only part of the fallopian tube and the other involves the removal of all of the fallopian tube.
Salpingostomy is the removal of only the part of the fallopian tube where the fertilised egg is lodged. The two ends of the tube are then rejoined after the ends have healed. The purpose of this is to decrease the effects on fertility. However even with this procedure the woman’s fertility will still be decreased and she has a higher than average risk of a further ectopic pregnancy.
Salpingectomy is where the whole fallopian tube is removed on the side where the ectopic pregnancy occurred. This option is most likely to be used if the mother's health has already been significantly compromised as it is the most straightforward of the procedures. Fertility is decreased more than after a salpingostomy but the risk of suffering further ectopic pregnancies in the future is less than with a salpingostomy.
Following the termination of an ectopic pregnancy, by whichever method, a woman will need to be monitored closely to ensure that the pregnancy has indeed been terminated. If the procedure has been unsuccessful then the mother's health could still be at risk. This is done by monitoring the woman’s HCG levels. This is the hormone which indicates whether or not a woman is pregnant. The levels will need to be checked every 48 hours initially and then once a week until they return to a normal level. In the event that they do not return to normal a dose of methotrexate may be required to ensure that any remaining element of the pregnancy has been removed.
It is also not advisable for a woman to try to conceive again for at least three months in order to give her body the opportunity to heal itself. It will also be necessary for a woman to seek medical advice as soon as she misses another period due to the increased risk that any subsequent pregnancy may also be ectopic. As a rough guide after one ectopic pregnancy 20% of women will experience another ectopic pregnancy, 30% will not become pregnant again and 50% will have a successful pregnancy. Upon missing a period a woman is likely to require an early transvaginal ultrasound to ensure that the fertilised egg has implanted in her womb.
When a claim may occur
A clinical negligence claim for an ectopic pregnancy may occur when the treatment provided to the woman is either incorrect and/or inappropriate. Some of the ways in which this may happen are as follows:-
- A woman suspects an ectopic pregnancy when still in it's early stages. However the treating doctors either dismiss her concerns or incorrectly diagnose another cause for her symptoms. This would result in the ectopic pregnancy being diagnosed at a later stage which would mean that surgery would be the only option which carries more risks and also affects a woman's future fertility.
We recently acted for a client who suspected that she was experiencing an ectopic pregnancy but the diagnosis was not made for a further 12 days. As a result the only option for termination available to our client was the complete removal of her fallopian tube. This resulted in significant scarring due to the procedure not being able to be done as keyhole surgery and also resulted in her future fertility being decreased.
- During surgery either the wrong fallopian tube is removed or both fallopian tubes are removed. This would have the effect of significantly reducing a woman's fertility such that she may require fertility treatment to conceive. In addition if the incorrect fallopian tube has been removed she is likely to require further surgery to remove the affected fallopian tube.
An example of a case where one of our clients has been the subject of such an error arose when she attended A&E with vaginal bleeding whilst pregnant. The diagnosis was that she was miscarrying and she was advised to re-attend for a scan 10 days later. However due to the severity of her symptoms she re-attended A&E the following day and she was referred for scans. The results were unclear and our client was therefore simply monitored for a further 6 days. After this time the diagnosis of an ectopic pregnancy was made and our client had surgical removal the following day. During this procedure both of our client's fallopian tubes were removed however upon further investigation it is alleged that in actual fact there was no clinical need for both tubes to be removed. If only one of the tubes had been removed then our client would still have the possibility of becoming pregnant without the need for intervention. However now her only option, if she wishes to conceive, is IVF.
- The removal of the pregnancy fails or is incomplete and there is a failure to adequately monitor the woman post treatment. This could lead to the pregnancy continuing to exist thereby threatening the mother's health and, due to late treatment, compromising her future fertility even further.
The above list is not exhaustive. Surgical termination of an ectopic pregnancy also carries with it the usual negligent and non-negligent risks of surgery and recovery.