What I learnt from my ectopic pregnancy: through the eyes of a general practitioner obstetric registrar

Acknowledging the loss can go a long way towards healing the complex grief related to ectopic pregnancies

One in four women in Australia experience an early pregnancy loss,1 but I never for one second thought I would be one of them. My partner and I made the decision to try for a family and were delighted to fall pregnant in the first cycle of trying. However, during week 7 of my pregnancy, as I stood in the operating theatre assisting with a caesarean delivery, I began to bleed. My β‐human chorionic gonadotropin (β‐HCG) level was somewhat reassuring as it doubled in 48 hours and there was perhaps hope that this was going to develop into a normal pregnancy. A scan done one week later, along with a suboptimal rising β‐HCG level and continued bleeding, was highly indicative of an ectopic pregnancy. I was a good candidate to try surgery‐sparing methotrexate, but a follow‐up blood test showed a rising β‐HCG level. The following day, I underwent a laparoscopic right salpingectomy, which confirmed a right fallopian tube ectopic pregnancy.

What have I learnt from this and how can I turn my own experience into something that can help me to become a better physician and advocate for the women I see? Well, firstly I now know that it is impossible not to blame yourself. I have always made a conscious effort to tell women with ectopic pregnancies (or miscarriages) that this is in no way their fault and there was nothing they could have done differently to prevent this from happening. And yet, as I sat at home recovering from surgery, I could not help feeling that my body had in some way failed me. The questions “why me?” and “why my body?” ran on loop around my head for days.

The medical and surgical implications of an ectopic pregnancy were exhausting and, during that time, I would not have believed a single person who told me I was not to blame. I needed time to process the uncertainties that were unfolding on a weekly basis before I had the emotional capacity to enter a rational discussion with myself about how this was unavoidable. Therefore, I think there is a clear role for directing women to educational resources and written literature to refer to later. Yes, by all means tell the woman at the time of diagnosis that this was not her fault, plant the seeds, but know that it may not be until a few months later that she is truly ready to process the whys.

An ectopic pregnancy remains a direct leading cause of maternal morbidity and mortality in Australia.2 As such, it is understandable that, as clinicians, our primary concern often lies with stabilising the mother. Nevertheless, I would urge clinicians to return to the patient following the emergency event and take a moment to acknowledge the pregnancy as a loss. I was fortunate that my ectopic pregnancy did not rupture and I was able to have urgent but not emergency surgery to manage my pregnancy. Nonetheless, I struggled hugely with the medical and surgical implications of the pregnancy that cast a dark shadow over the core of this event, a wanted pregnancy. I found that it was not until nearly a month after my surgery, when the dust of my 48 hourly blood tests, invasive ultrasounds, injections, clinic appointments, cannulas and anaesthetic had settled, that I felt able to sit and grieve for my pregnancy. I now set aside a time to return to the woman and her partner once she is clinically stable and take a moment to recognise the loss of their pregnancy. A simple “I see your loss and acknowledge it” can go a long way towards healing the complex grief that is so inevitably and inextricably entangled in our medical and often surgical microcosm of ectopic pregnancies.

After 3 months, my partner and I began to look tentatively to the future and started trying again for a pregnancy. It is true that the fear continues long after the ectopic pregnancy has dissolved and arguably rightly so, as women who have experienced one ectopic pregnancy have a one in ten risk of developing another.3 Therefore, we do not find ourselves thinking on whether we are ready for a baby but rather on whether we have the emotional strength to go through another ectopic pregnancy. And of course, are we prepared to start playing Russian roulette with my remaining fallopian tube? With my own experience, I am now more aware than ever of the life‐changing impact an ectopic pregnancy can have and the weeks of uncertainty and of not daring to get your hopes up too early and how this can bleed on into the next pregnancies. Reflecting on when I have seen women with an ectopic pregnancy in their reproductive history, I admit that I have not always fully acknowledged the impact this past experience may be having on their current pregnancy. Adjusting my consultation and counselling to make space for these anxieties is now a commonplace in my consults, especially with women in the early pregnancy clinic. In my experience, an ectopic pregnancy does not end when the β‐HCG level is less than 5 mUI/mL, its effects can be found in the shift of mindset that seeps into future pregnancies and this is something we should be mindful of in consults.

Ultimately, I am of the opinion, more now than ever, that we simply do not talk about early pregnancy loss enough. I am witness daily to the devastating effects that pregnancy loss has on women and their families and have now experienced that pain. And yet I turn on my social media and I am flooded with pregnancy announcements and gender reveals, and in that moment, in my own home, even I can begin to trick myself that I am the only woman to have experienced a pregnancy loss. I cannot help but think if I have these feelings despite the exposure I have at work and the medical expertise that tells me this is simply not true, what hope can I have that the women I see at the clinic can go home and not feel alone and isolated? I have made a point of sharing my experience with colleagues at work and with family and friends. This was not something I did lightly or something that came easily, but was born out of a place deep inside me that said “if I cannot talk about this, how on earth can I expect my patients to talk about it?” Overall, the reception has been overwhelmingly positive, and women in my social circle have rallied around me and my partner, sending thoughtful gifts of tea, flowers, and bath goodies as well as cards offering any help they can. One cousin spoke to me about her own experience of an ectopic pregnancy and another admitted that she had never heard of an ectopic pregnancy before. Work colleagues who asked why I had been off for 3 weeks seemed generally surprised to hear my honest and heartfelt reply of “I lost a pregnancy, an ectopic, and have been recovering from the surgery and grief also”. Their shock at my honesty served only as a re‐enforcement to me that I needed to continue to speak openly about my experience, even when it hurt. To not do this felt like a dishonour to all the other women who have experienced early pregnancy loss.

I strongly feel that as women’s health doctors, as doctors, as women and partners of women, we have a duty to speak about early pregnancy loss. In doing so, we allow a space to grieve and to remind women they are not alone. We need to continue to facilitate access for all women to high quality educational resources, to foster open and honest conversations, and be mindful in our daily clinical practice of the angst, pain and lingering anxiety that early pregnancy loss can leave long after the scars have healed.