Ectopic Pregnancy

Q:  I am a 23-year-old married woman with a one and a half- year-old son. My husband and I decided that we would like another child and I got pregnant in August. I took a home pregnancy test that came back positive and a few days later I began spotting. I went to my doctor who did a pregnancy test that came back negative and then slowly turned positive.

To make a long story short, I miscarried when I was six weeks pregnant. I knew I was losing the baby because after my visit with him, my bleeding had gotten very heavy. When I went to the hospital emergency room, they did a pelvic exam and ultrasound test and confirmed that I indeed had miscarried and that I had an ectopic pregnancy. This scared the daylights out of me because even though I wasn't too familiar with ectopic pregnancies, I knew they could be deadly. Since my diagnosis of miscarriage, I have not had another pelvic exam, no surgery, no nothing. They've only been drawing blood every other day to check my Beta HCG hormone level. At one point it was slowly rising, and so the doctor told me that to avoid surgery he was going to give me a shot, a type of chemotherapy, that would make my body expel the remains of the pregnancy. I had the shot and I did not bleed like he said I would. All I did was cramp and felt very nauseated for the first two days. He said that all of my symptoms were normal and that some women do not bleed at all. From the way he was talking and explaining this to me, it sounds like this procedure is fairly new. My Beta HCG is going down and I now only have to have my blood tested once a week. I constantly question my doctor how he can be sure that my tubes are okay, since he hasn't looked inside of me to be sure. My husband and I still want to have another child and I'm scared that I may miscarry again or have a still-born child or just not be able to get pregnant at all. When I question him about this, he tries to reassure me with the same answers that still tell me nothing and I'm just very frustrated right now. I did go to the library to try and find out more about ectopic pregnancies and I didn't find too much information there either. In the book that I read, it said that surgery was done right away to clean the tube of the pregnancy and to try to save the tube. A D & C is done as well. I've asked my doctor about a D & C from the very beginning and he said that it would not be necessary since I had a tubal pregnancy and not a uterine pregnancy. I still feel that I need to be cleaned out regardless. I am seeking a second opinion because I don't feel that my doctor is answering my questions to where I can feel somewhat at ease about my situation and about what's going on inside of my body. It is almost two months later and I feel that I haven't had any type of closure with this miscarriage so I can move on and allow my body to recover and rest so we can try again for another baby. I know that every woman's body is different from the next, but could you please give me some type of idea of what is usually done when a woman has an ectopic pregnancy and if there are any new procedures? Shouldn't a woman be cleaned out regardless of what type of miscarriage she has had and at least have a follow-up pelvic exam?

A:  Your pain, fear, and frustration as a result of your recent loss are understandable. Wanting answers is certainly important for your peace of mind before another pregnancy.

The rate of ectopic pregnancy in the United States is approximately 17 for every 1,000 pregnancies. A woman's risk is increased if she is being treated for infertility, has had tubal surgery, pelvic inflammatory disease, or a previous ectopic pregnancy, so it is true that you are at slightly more risk for another ectopic pregnancy. When a pregnant woman, in the first trimester, presents to her doctor with bleeding, the doctor must determine where the pregnancy is located. If it is in the uterus, she may be having some form of miscarriage or if it is in the fallopian tube then it is called an ectopic pregnancy and must be treated to prevent rupture and serious complications for the patient. This determination is usually made with the help of a pelvic examination, an ultrasound, and a hormone level (beta hcg). A dilation and curettage (D&C ) or "cleaning out of the uterus" is NOT necessary unless the doctor is unsure if the pregnancy is in the uterus or fallopian tubes. I shared your letter with Amy Meg Autry, MD, formerly an Assistant Professor of Obstetrics and Gynecology at the Medical College of Wisconsin, who told me that it is very rare to have both a miscarriage from your uterus and an ectopic pregnancy simultaneously. The likelihood of having a pregnancy in your uterus and your tube at the same time (if you are not being treated with infertility medicine) is about 1 in 30,000. Dr. Autry also provided the following information on how ectopic pregnancies are managed. There are two accepted methods of treatment: medical (methotrexate injection) or surgical (generally through the laparoscope). Surgical treatment usually involves cutting a hole in the tube to remove the pregnancy or taking out a part of the tube. It is not necessary to have surgery or be "cleaned out" if your hormone level goes down to zero. To be a candidate for methotrexate therapy, the patient must be stable and compliant and the ectopic cannot be over a certain size (3.5 cm). Medical treatment has been used for the last 10 years and has the advantages of avoiding the risks of surgery which include the risks of anesthesia, bleeding, and inadvertent injury to other structures. Medical treatment is as successful as surgical treatment and has comparable rates of future fertility (about 70-80%). If you have problems getting pregnant, your doctor may suggest a radiologic study called a hysterosalpingogram to see if your tubes are open. Finally, many women have problems coping with miscarriages or pregnancy losses. There is a national organization called "Resolve through Sharing" which is an excellent resource for women in these difficult situations. It appears that your doctor managed your ectopic pregnancy by medically acceptable standards. He just may not be as good at answering questions or providing reasurrance. I wish you a smooth next pregnancy.

"Dear Doctor" is a compilation of patient questions answered by doctors from the Medical College of Wisconsin.