Pregnancy After Previous Ectopic Pregnancy

Pregnancy after a previous ectopic pregnancy carries a recurrence risk of about 10 to 15 percent after one ectopic and about 25 percent after two or more. The risk comes from persistent tubal damage and shared risk factors. It matters because early localisation of the pregnancy allows treatment before rupture.

• Risk factors: tubal surgery, pelvic infection, smoking, assisted reproduction.
• Most women have a normal intrauterine pregnancy later.
• Early scan at 5 to 6 weeks is the main safeguard.

Women are usually well with early pregnancy symptoms. Any lower abdominal pain, spotting or shoulder tip pain should prompt review for recurrence.

• Often asymptomatic.
• Pain or bleeding at 5 to 8 weeks.
• Differential diagnosis: recurrent ectopic pregnancy, threatened miscarriage, early normal pregnancy, corpus luteum cyst, urinary tract infection.
• Complications: recurrent ectopic pregnancy, rupture, tubal loss, anxiety, infertility.

The approach is early localisation of the pregnancy.

• Urine pregnancy test at a missed period, then transvaginal ultrasound at 5 to 6 weeks.
• Serum hCG if no intrauterine sac is seen; repeat at 48 hours.
• Screen for chlamydia and gonorrhoea with nucleic acid test or swabs.
• Blood group and Rhesus status, haemoglobin.

The principle is early scanning, treatment of infection and urgent action if the pregnancy is not in the uterus.

• Supportive: explain symptoms that need urgent review; advise stopping smoking; give a written plan with contact details; admit if pain is severe or the scan is unclear.
• Pharmacological: folic acid 400 micrograms oral daily to 12 weeks; if chlamydia is found, give azithromycin 1 g oral as a single dose; if gonorrhoea is found, give ceftriaxone 500 mg IM as a single dose plus azithromycin 1 g oral single dose; treat the partner; avoid doxycycline in pregnancy; if recurrent ectopic is confirmed, treat with methotrexate 50 mg/m2 IM single dose if stable and hCG is below 5000 IU/L, or surgery.
• Procedures: none.
• Special groups: Rhesus negative women with bleeding after 12 weeks give anti-D immunoglobulin 250 IU IM within 72 hours.
• Red flags: unilateral pain, shoulder tip pain, collapse, heavy bleeding, no sac on scan with positive test.
• Follow-up: scan at 5 to 6 weeks; booking visit at 8 to 12 weeks; routine antenatal care if intrauterine pregnancy is confirmed; counsel on assisted reproduction if repeated tubal damage.