Ectopic pregnancy: a loss that happens all at once

“In the morning I was still looking at a test with two lines. By the evening I was waking up after surgery, and a nurse told me I had been lucky.”

Many stories of ectopic pregnancy begin like this, or something close to it. In a single day — sometimes in a few hours — everything happens at once: sudden pain or bleeding, A&E, an ultrasound, faces turning serious, a decision you can barely follow, and at the end a sentence about being lucky in your misfortune. By the time you have gathered yourself enough to think, the loss is already behind you. There was no time to prepare for it, and often there is nobody who asks how you are now.

This piece is not about medicine. What happens in the body during an ectopic pregnancy, how it is treated and what it means for future pregnancies are questions for the gynaecologist who treated you, or the one you see regularly. What interests me here is something else: what happens to a person and to a couple when hope and danger arrive at the same moment — and why this loss is so often overlooked, even by those who live through it.

Two losses in one day

Ectopic pregnancy is not rare. Clinical guidelines estimate it at roughly one to two in every hundred pregnancies. And yet almost nobody talks about it until it happens to them or to someone very close.

What sets it apart from most other pregnancy losses is that two stories are woven together. The first is the loss of a pregnancy — a child who already had a place in your thoughts, in your plans, perhaps already in a name. The second is the experience of danger to your own health, and sometimes to your life. The two stories jostle for room. When fear for your life is in the foreground, grief gets no space. When grief arrives, it seems it shouldn’t be there, because “the main thing is that you’re alive”.

Many women describe spending the first weeks in a kind of numbness. The body was healing, the people around them were relieved, and they did not know what they felt. Only later — on the date the baby would have been due, at the sight of a pregnant woman on the bus, at an innocent “so when are you two…?” — did the realisation come that they had lost something and had never been given permission to grieve it.

When a loss is also an emergency

There is a difference between a loss you live through at home, slowly coming to understand it, and a loss that arrives as an emergency. In the second, the body first has to survive. Attention narrows to the pain, the doctors’ questions, the signatures and what happens next. Such an experience has every ingredient of what we call trauma: suddenness, helplessness, fear for your life and little or no control.

A research team led by Jessica Farren in London followed women after early pregnancy loss — miscarriage or ectopic pregnancy. A month after the loss, almost a third of the women reported symptoms consistent with post-traumatic stress: intrusive memories, avoidance of anything that reminded them of the event, and constant tension. In almost a fifth these symptoms were still present nine months later. Anxiety was common too, and depression somewhat less so.

This does not mean that every woman develops post-traumatic stress disorder after an ectopic pregnancy. It does mean that images from A&E returning at night, unease at the smell of a hospital, or avoiding a gynaecological check-up are understandable reactions, not a sign of weakness. The body remembers that it was in danger, even when the mind knows the danger has passed. I have written more about how this happens in How trauma stays written in the body.

“It wasn’t a real baby anyway”

The language surrounding ectopic pregnancy is often cold. Medical reports speak of “ectopic gestation”, “tissue” and “procedure”. Doctors have good reasons for this — in an emergency they have to think clearly and precisely. But for someone who, a day earlier, was still counting weeks, it can feel as though they are being told that what they lost never existed.

The people around you often carry on in the same tone. “It couldn’t have developed anyway.” “Good thing they caught it in time.” “You’ll get pregnant again.” Each of these sentences may be medically accurate and kindly meant. But each in its own way says the same thing: your loss doesn’t count.

Kenneth Doka used the term disenfranchised grief for grief like this — grief that others do not see, do not respect, or consider excessive. The piece The grief nobody acknowledges covers it more broadly, and Pregnancy loss: the grief others don’t acknowledge looks at pregnancy loss in general. With ectopic pregnancy the lack of acknowledgement is even sharper, because the outcome seems “purely medical”. You will also find a short explanation in the knowledge base under pregnancy loss.

For grief, it does not matter how far the pregnancy had developed or whether it could have. What matters is what this pregnancy meant to you. For one person it was a pregnancy they and their partner had waited years for. For another it was unplanned, yet within a few weeks they had grown used to the idea. For someone else it was confusing and mixed. All of this can be worth grieving.

A decision that wasn’t a decision

An ectopic pregnancy cannot continue into a healthy pregnancy. How it ends is a medical matter, decided and explained by your doctor — but it often involves treatment for which the woman signs a consent form, and in doing so formally “agrees” to the end of a pregnancy she may have wanted.

This is where guilt likes to settle. The mind knows there was no other option. And yet the thought keeps circling: “I decided”, “I signed”, “I let them take it”. For some, guilt turns back in time: why didn’t I see a doctor sooner, why didn’t I take the pain seriously, what did I do wrong that this happened to me of all people.

Guilt plays an important role in grief — it offers an illusion of control. If it was my fault, then I could have changed something, and the world is not as unpredictable as it seems. But the price of that illusion is high. If these thoughts keep returning, you may find Guilt after a loss: “I could have done more” helpful. Medical questions — whether anything could have been noticed earlier, what the results mean, what this means for the future — are worth writing down and asking your gynaecologist at your follow-up appointment. Answers do not remove the sadness, but they can ease the guilt that feeds on uncertainty.

A body you no longer trust

After an ectopic pregnancy many women describe a changed relationship with their own body. A body that used to be taken for granted did something unpredictable and dangerous. There is a scar, sometimes a missing part of the body you had never even noticed before. And there is the question of whether it could happen again.

This loss of trust is quiet, but it can last a long time. It shows up as hyper-vigilance to every twinge in the abdomen, as avoiding sex, as a sense that the body is something foreign that has to be monitored. Some women describe having “withdrawn from the lower half of the body”, as if they had stopped thinking about it altogether.

There is nothing abnormal about this. A body that has been in danger needs time to feel safe again — and it often needs information too. What an ectopic pregnancy means for your fertility and what the risks are in a future pregnancy are questions for a gynaecologist or a fertility clinic, not for a search engine at two in the morning. The internet will give you the worst stories; a doctor who knows your results can tell you what applies to you.

What happens between partners

An ectopic pregnancy happens in the woman’s body, but both partners live through it. And they often live through it very differently.

The partner is the one who sat in the waiting room while she was taken to theatre. His first fear was not for the pregnancy but for her. When it all turned out well, what he felt above all was relief — and that relief can later hurt her, because it seems as if he isn’t grieving. She, meanwhile, while she was in danger, also knew the whole time that she was losing a child.

“You’re just glad it’s over.”
“I’m glad you’re alive. I thought I was going to lose you.”
“And I lost him. And you don’t even talk about him.”
“Because I don’t know if I’m allowed to. Because I don’t want to make you cry again.”

(The dialogue is composite; it is not about a real person.)

In a conversation like this, nobody is wrong. He lived through the fear of losing his partner; she lived through the loss of a pregnancy. Both were grieving, each for something different. The trouble begins when each locks their experience away so as not to burden the other. I have written about why each partner grieves differently and how that need not break the relationship in Grieving as a couple.

In relational family therapy, in which I am training, we pay particular attention to exactly this: when one partner’s loss hides the other’s. It often helps simply for each to tell the story of that day from their own point of view, while the other listens to the end without correcting it. That way each of them carries two stories, not just their own.

Giving the loss a place

Because an ectopic pregnancy brings no funeral, no farewell and often not even a word you could say out loud, grief has nowhere to go. It stays in the body and in the mind, without shape. That is why many people find it helps to give it a shape themselves.

Some couples light a candle on the day they found out about the pregnancy, or on the day the baby would have been due. Some plant a tree or a plant. Some give the pregnancy a name, even if they never tell anyone what it is. Some women write a letter. None of this is compulsory and none of it is “right”. What matters is that grief gets a place where it can be visited — and where it can also be left.

It also helps to tell the story. Not to “process” it, but so that it exists outside of you as well. Even one person who listens to the end without correcting it can change how you carry it. If you don’t know what you could even ask of others, a good start might be What to say to someone grieving, and what not to — you can show it to the people who love you but don’t know what to say.

Exercise: the story of that day in three parts

This exercise is for anyone who feels that everything happened too fast to understand what actually happened. Take half an hour when nobody will disturb you, and a sheet of paper. If you feel overwhelmed while writing, stop, breathe out slowly a few times and come back to it later.

1. Before. Write down what this pregnancy meant to you before anything went wrong. What did you imagine? Who did you tell? What did it feel like when you found out?
2. That day. Write down what happened, in the order you remember it. It doesn’t need to be complete. If there are gaps, leave them. Next to each part, write one word in the margin for what you felt at that moment.
3. What was left unsaid. Write down at least one thing you couldn’t say or feel at the time — to the doctor, to your partner, to yourself or to the pregnancy itself.
4. Now. Read it all through and add one sentence you would say to a good friend if she told you this story.
5. Share or keep. Decide whether you will read it to your partner or someone close, or keep it for yourself. Both choices are fine.

If your partner has their own story of that day, suggest they do the same. You can read your pieces to each other — slowly, without comment, until the other has finished. The exercise is not meant to make the pain disappear, but to turn the experience from chaos into a story with a beginning, a middle and an end. Self-compassion helps here too — the way you speak to yourself when things are hard.

The next pregnancy

For many couples the question of the next pregnancy comes up very quickly, sometimes while still in hospital. For some it is hope, for others fear. Often it is both at once.

When it makes sense medically to try again and which tests are needed is a question for your gynaecologist. Emotionally, though, it helps to know that a new pregnancy does not erase the earlier loss. It can even reawaken it. Many women describe being on high alert for almost the whole time until the first scan showed that the pregnancy was in the right place. Every pain was an alarm. Pregnancy after loss: the fear that lasts until birth looks at this fear, which can last right up to the birth.

There is no rule about how long you have to “wait” in order to grieve. What matters more is allowing the loss to exist even when a new pregnancy is already here — and that the two of you tell each other where each of you stands.

Where this piece does not apply

Not every ectopic pregnancy is experienced as the loss of a child. Some women only found out they were pregnant in A&E. Some were surprised by the pregnancy and felt mostly relief when it ended. Some were so frightened for their own lives that this fear was the only thing that counted. All of this is legitimate. Please don’t read this piece as instructions on what you ought to feel. If you don’t feel sadness, you don’t need to go looking for where it is hiding.

Equally, not everyone who feels bad after a loss has “just grief”. If after several weeks you still cannot rest, the intrusive memories do not settle, you avoid everything that reminds you of the event, or you feel that nothing makes sense any more, talk to your GP or a psychiatrist. This kind of distress can be treated, and you don’t have to carry it alone. When grief doesn’t pass and When loss needs professional help may also help.

If you are ever overwhelmed by thoughts of not wanting to live, call: in Slovenia, the crisis line Klic v duševni stiski on 01 520 99 00 (every day from 7 pm to 7 am), the Samaritans helpline Samarijan on 116 123 (24 hours a day), or in an emergency 112.

One more thing: therapy is not a substitute for medical care. Questions about the body, fertility and future pregnancies belong with your gynaecologist. Therapy is a place for what remains once the medical questions have been answered — or when there is no answer.

What to remember

• An ectopic pregnancy is often a double experience: the loss of a pregnancy and, at the same time, sudden danger to your own health.
• Symptoms of post-traumatic stress after early pregnancy loss are more common than we think, and they are an understandable reaction, not weakness.
• For grief, what matters is not how far the pregnancy had developed, but what it meant to you.
• Partners may grieve for different things — he for the fear of losing you, you for the child. Both stories need room.
• Medical questions belong with your gynaecologist; distress that does not ease belongs with a doctor or psychiatrist.