One Ectopic Often Predicts Another

Your chances of having a normal pregnancy are excellent, but your chances of having another ectopic pregnancy have also increased.

I had an ectopic pregnancy two years ago, and they treated it with a medication called methotrexate. What are my chances of having a normal pregnancy now, and what I should watch out for?

Answer: Jan. 22, 2001 -- Your chances of having a normal pregnancy are excellent, but your chances of having another ectopic pregnancy have also increased. An ectopic pregnancy -- one that's developing outside the uterus -- is diagnosed in about one in every 100 pregnancies. More than 95% develop in the fallopian tube, but these pregnancies can also occur in an ovary, the cervix, or even the abdomen. Risk factors for them include a previous ectopic pregnancy; tubal surgery such as tubal ligation or sterilization reversal; a past tubal infection; use of an intrauterine device (IUD); use of the "morning-after" pill; use of the progesterone-only or "mini" pill; and fertility treatments including in vitro fertilization and gamete intrafallopian transfer.

Ectopic pregnancy has traditionally been treated with surgery, which may involve removing the fallopian tube or removing the embryo. Nonsurgical treatment can be used in cases where the ectopic pregnancy is early and hasn't ruptured. It involves the injection of a chemotherapeutic medication, methotrexate, which halts the pregnancy's development.

In general, after one ectopic pregnancy your chances of having a future pregnancy that is in the uterus are about 60-70%. But women with a history of ectopic pregnancy often have difficulty getting pregnant again, and as many as 20-30% of them end up being infertile, especially if they have any of the risk factors noted above. Your risk of having another ectopic pregnancy is much higher once you've had the first; as many as one in 10 women will have a second ectopic pregnancy. The increased risk is probably about the same whether your ectopic was treated with surgery or medication, though it's too early to have much data on this.

Because the risk of a second ectopic pregnancy is so high, you should take precautions when you get pregnant again. If you miss a period and might be pregnant, let your doctor know right away. The first step is to find out if you are pregnant and where the pregnancy is located. This may be difficult early in the pregnancy, so be aware of the early signs of an ectopic pregnancy, such as pain and vaginal bleeding or spotting.

With your history, your doctor may assume you're having another ectopic pregnancy until an intrauterine pregnancy can be clearly seen on ultrasound. Your doctor will examine you, do a transvaginal ultrasound, and draw your blood for an hCG level if a pregnancy is not yet visible. When the hCG rises above 2,000 mIU/mL, your doctor should be able to see an intrauterine pregnancy; the same is true around 28 days after you last ovulated (about six weeks after your last period). Sometimes an additional blood sample for hCG level is taken 48 hours after the first and compared with the first level. An hCG level that increases but is less than double the previous one is considered abnormal and suspicious of an ectopic pregnancy.

Otherwise, your doctor will prescribe additional observation and testing. Once the pregnancy is confirmed to be inside the uterus, there's usually no further need for concern about an ectopic pregnancy

Amos Grünebaum is a practicing obstetrician and gynecologist in New York specializing in high-risk pregnancies.