- Reference Number: HEY-581/2022
- Departments: Gynaecology
- Last Updated: 1 May 2022
Introduction
This leaflet has been produced to give you general information about your procedure. Most of your questions should be answered by this leaflet. It is not intended to replace the discussion between you and your doctor but may act as a starting point for discussion. If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team who has been caring for you.
Why have I been offered surgical management of an ectopic pregnancy?
There are a number of reasons why you will be offered surgical management of an ectopic pregnancy which include:
- If you presented with significant symptoms (severe abdominal pain, bleeding, shoulder tip pain) and/or you have been unwell or collapsed. These signs suggest that the ectopic pregnancy has ruptured, requiring urgent assistance.
- If an ectopic pregnancy was seen on the scan and was above certain size/gestation.
- If there are contraindications to give you medication to deal with ectopic pregnancy or that approach has failed.
- Surgery may also be performed if expectant management or medical management has failed.
Why do I need surgery for an ectopic pregnancy?
No matter what type of surgery is used, the main aim is to remove the ectopic pregnancy and the risk it is posing on your health.
If you go for surgery, you will sign a consent form for the operation and be told the risks/ complications and be explained by the doctor about the surgery and also either a nurse or doctor will do a consent form regarding fetal remains.
Fetal remains if you go for surgery for ectopic pregnancy
Sometimes this option will not be available straight away following surgery as most of the time the fetal remains will need to go for histology, to check it was an ectopic pregnancy. Once the histology has been performed you still have the choices below.
These are the choices available to you:
- The hospital will arrange a shared cremation with your consent, this is carried out at the crematorium in a sensitive and respectful manner. If you would like details of when this will happen this information can be given to you.
- However, if you wish to have an individual cremation/burial you may of course make your own arrangements, but the hospital is unable to contribute to the costs.
- If you are unsure of your wishes, you can contact the hospital within 4 weeks of your procedure.
- In all cases the staff will ensure that your cultural and/or religious needs are respected.
- You are also legally allowed to take your pregnancy remains home to bury yourself. There are certain legal requirements that must be adhered to if you wish to do this, which are as follows:
- The burial must not cause any danger to others.
- It must not interfere with any rights other people may have on the land.
- There must be no danger to water supplies or watercourses.
- There must be no chance of bodily fluids leaking onto adjoining land.
- The remains must be buried to a depth of at least 18 inches (45cm).
- Permission must be obtained from the landowner if you do not own the land.
- Careful thought needs to be given when considering burial in a garden, taking into account what would happen if you chose to move.
How will the ectopic pregnancy be treated?
Key-hole surgery (laparoscopy) is performed under general anaesthetic. A laparoscope (a telescope like instrument) is passed through your belly button, your pelvis is inspected, and ectopic pregnancy once identified is removed. You will have a small (about 1 cm long) incision in your belly button and may have another two to three small incisions on your stomach.
There are two courses of action, but this will depend on the damage to the affected tube.
- Salpingectomy – If there is a lot of damage or bleeding, the affected tube will be removed
- Salpingotomy – If the damage is minimal, then the ectopic can be removed from the tube by making a small cut leaving the tube intact. This entails a very small risk that some of the pregnancy remains in the tube. You may be advised to have weekly blood tests to monitor human chorionic gonadotropin (hCG) levels as they decrease, and the pregnancy is fully resolved
Some women do require open surgery (laparotomy) through a larger cut in your lower abdomen (‘bikini line’), again under general anaesthetic. It is usually done if severe internal bleeding is suspected or when key-hole surgery has been tried but it has been technically impossible to remove the ectopic pregnancy.
If there is severe bleeding before or during operation you may require a blood transfusion to replaced blood lost.
Can there be any complications or risks?
All operations requiring a general anaesthetic carry with them a small chance of complication. Every care is taken to keep the risks as low as possible.
Serious occurring risks includes:
- Damage to bowel, bladder, uterus or major blood vessels which would require immediate repair by laparoscopy or laparotomy (uncommon); however, up to 15% of bowel injuries might not be diagnosed at the time of laparoscopy
- Failure to gain entry to abdominal cavity and complete intended procedure laparoscopically, requiring laparotomy instead
- The overall risk of serious complications from diagnostic laparoscopy is approximately 2 in 1000
- Three to eight women in every 100,000 undergoing laparoscopy die as a result of complications (very rare)
Frequent occurring risks include:
- Inability to identify an obvious cause for presenting complaint
- Bruising
- Shoulder-tip pain
- Wound gaping
- Wound infection
- Persistent pregnancy tissue, when salpingotomy performed (4 to 8 in every 100)
- Hernia at site of entry
How do I prepare for surgery?
Please read the information leaflet. Share the information it contains with your partner and family (if you wish) so that they can be of help and support. There may be information they need to know, especially if they are taking care of you following this surgery.
This operation is often done as an emergency and you will be admitted to hospital as an emergency, occasionally your surgery will most likely be the same day but sometimes if you are well and stable may be done the next day, but you will normally be admitted to hospital for observation.
What will happen?
You will be admitted to the ward for surgery and the staff will prepare you for surgery.
How long does the procedure take?
It will normally take between thirty minutes to one hour, however if a laparotomy needs to be performed it may take longer. You should return to the ward one to two hours following a short time in recovery.
What does the surgery involve?
A laparoscope is a small flexible tube (telescope) which contains a fibre-optic light and camera. The camera relays images of the inside of the abdomen or pelvis to a television monitor. Small incisions (cuts) are made near the belly button (umbilicus), and possibly on either side of the lower part of the abdomen allowing the laparoscope to be inserted. Carbon dioxide gas is pumped into the abdomen which expands allowing the pelvic organs to be seen clearly. The surgeon will be able to examine the abdomen and decide on the best option for treatment. Pictures may be taken during the procedure to provide a visual record of the findings.
What happens afterwards?
After your operation you will wake up in the recovery room before returning to the ward. You may still be very sleepy and be given oxygen through a clear face mask to help you breathe comfortably immediately after your operation.
Discomfort or Pain
It is normal to expect some mild abdominal, leg or shoulder tip pain after your operation. You will be given pain relief medication. Your nurse will explain what they are and how often to take them. If you were not given any pain relief on discharge please use over the counter pain relief medication, such as paracetamol or ibuprofen based products, but always read the label / instructions before taking them. If the pain persists or worsens you many need to contact the ward or your GP.
Pain due to wind is common problem experienced following a laparoscopy. This is due to the gas put into your tummy. The use of heat packs or drinking peppermint tea can help and keeping mobile after your surgery.
Is vaginal bleeding normal after the surgery?
It is common to have mild vaginal bleeding for up to two weeks after your operation.
Do not use tampons during this period, only sanitary towels.
Tampons may increase your risk of developing an infection. If you feel your bleeding is very heavy, prolonged or has an offensive smell, please seek advice from your GP or contact the Early Pregnancy Assessment Unit (EPAU).
How do I care for my wound?
Your wounds will be closed with a very small suture (stitch). Sutures will usually dissolve within 10 to 14 days. If they do not and are causing discomfort please seek advice from your GP or Practice Nurse who may be able to remove them for you.
Always make sure you wash your hands before and after caring for your wounds. Keep your wound clean and dry, daily shower or baths are advised. Do not put talcum powder or creams (e.g. baby lotion, moisturiser) on your wound. If you notice any redness, swelling or discharge, ask your practice nurse or GP to check it for you. If you have any stitches that need removing, this will be explained to you before you go home.
Will I have a scar?
The incisions made are very small and the scars will barely be visible after a few months.
How long will I be in hospital?
After a laparoscopy your stay will be shorter than one day. If you have open surgery you may be in hospital for two days.
How much can I do when I go home?
This will depend on the type of surgery you have had. When you go home you should try to rest but continue to do exercises shown to you. You should avoid:
- Standing for long periods
- Lifting heavy objects
- Doing heavy house work
- Walking long distances
Increase your level of activity gradually until you are back to normal.
When can I return to work?
If you have had a laparoscopy you should be able to return to work in one to two weeks, full recovery takes usually two to four weeks, if however you have had a laparotomy you will need four to six weeks off work. Your nurse will discuss this with you before you go home.
When can I drive?
Depending on the type of surgery you have had and how comfortable you feel. You must be able to do an emergency stop effectively. It is important to check with your insurance company.
When can I have sexual intercourse again?
When your bleeding has settled and you feel comfortable you may resume sexual intercourse. Contraception can be discussed with your nurse or doctor prior to discharge or you may prefer to visit your GP or family planning clinic.
When can I expect a period?
Every woman is different regarding how soon after the operation to expect a period. Sometime in the next four to six weeks is considered usual. Often this first period may be heavier or lighter than normal, but they should return to normal within two to three months.
What about future pregnancies?
Before trying for another baby you should allow yourself time to recover both physically and mentally. It would be advised that you wait at least three months to allow time for your body to recover. You and your partner should decide when you are both ready to try again.
Any preconception care you have been following should continue, such as:
- Taking folic acid
- Reducing your alcohol and caffeine intake
- Stopping smoking
What are my chances of having another ectopic pregnancy?
For most women an ectopic pregnancy is a ‘one off’ event and does not occur again. The chance of having a successful pregnancy in the future is good. Even if you have only one fallopian tube, your chance of conceiving only slightly reduces. The chance of having another ectopic pregnancy is between 7 and 10 in 100 (7% to 10%). This depends upon the type of surgery carried out and any underlying damage to the remaining tube and pelvic organs. When one fallopian tube is damaged (for example, by adhesions), there is an increased chance that the second tube may also be damaged. This means that not only is the chance of conceiving less than normal, but there is also an increased risk of a further ectopic pregnancy. In cases associated with the use of a coil, there does not appear to be an increase in risk if the coil is removed.
Your next pregnancy
If you have had an ectopic pregnancy you can refer yourself to EPAU for assessment when you are six weeks pregnant.
This is so you can have an early pregnancy scan at six weeks, to check that the pregnancy is in the right place this time. If you have pain or bleeding and are less than six weeks pregnant you can ring EPAU / Ward 30 for advice as you may need to attend for a blood test if less than six weeks pregnant.
Your emotions
Ectopic pregnancy can be a devastating experience. You may feel relieved to be free from pain and out of danger, but also grieve the loss of your baby. Due to the seriousness of your condition you may also have the feelings that everything has been rushed – tests, scans, an operation and that there has been little time to adjust.
It may help to know that the possibility of a normal pregnancy next time is much greater than the possibility of having another ectopic pregnancy.
Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the:
Early Pregnancy Assessment Unit (EPAU) /Emergency Gynaecology Unit (EGU), Women and Children’s Hospital – (01482) 608767
Gynaecology Ward, Women and Children’s Hospital – (01482) 604387
Useful contacts and websites
The Ectopic Pregnancy Trust
Phone Helpline 020 77332653 PO Box 485, EN6 9FE, www.ectopic.org.uk
Miscarriage Association 01924 200799 (Monday to Friday 9am to 4pm) C/o Clayton Hospital, Northgate, Wakefield West Yorkshire WF1 3JS www.miscarriageassociation.org.uk
Information on Gynaecology Services at Hull University Teaching Hospitals NHS Trust can be found at: https://www.hey.nhs.uk/content/services/gynaecology
General Advice and Consent
Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.
Consent to treatment
Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.
The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:
- you must be able to give your consent
- you must be given enough information to enable you to make a decision
- you must be acting under your own free will and not under the strong influence of another person
Information about you
We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.
We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.
Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.
If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.
