it is recommended that a discriminatory level as high as 3,500 mIU per mL (3,500 IU per L) be used to avoid misdiagnosis and interruption of a viable pregnancy, although most pregnancies will be visualized by the time the -hCG level reaches 1,500 mIU per mL. If hCG levels have not decreased enough after the first dose, another dose of methotrexate may be recommended. As an ectopic pregnancy grows, more serious symptoms may develop, especially if a fallopian tube ruptures. Methotrexate often is given by injection in one dose. Your doctor will order the human chorionic gonadotropin (HCG) blood test to confirm that you're pregnant. My hCG levels at five weeks were 150 and then 352 two days later. An intra-uterine pregnancy can usually be seen by 5-6 weeks gestation or when the HCG level is more than 1000 IU/l. Next, your doctor uses a thin tube equipped with a camera lens and light (laparoscope) to view the tubal area. If you have sudden, severe pain; shoulder pain; or weakness, you should go to an emergency room. Sign up for free, and stay up to date on research advancements, health tips and current health topics, like COVID-19, plus expertise on managing health. Ononuju CN, Ogbe AE, Changkat LL, et al. Terms and Conditions of Use, Get the latest on COVID-19, pregnancy, and breastfeeding. Accessed Dec. 29, 2017. . An ectopic pregnancy is when the fertilized egg remains in the fallopian tube and continues to develop. In a normal pregnancy, the egg is fertilized by a sperm. The most common drug used to treat ectopic pregnancy is methotrexate. Theres some overlap between the possible trends in hCG levels for normal and ectopic pregnancies. information and will only use or disclose that information as set forth in our notice of
The female body normally has two fallopian tubes. Burnett TL (expert opinion). Make a donation. If you've had an ectopic pregnancy, your risk of having another one is increased. However, since they may go on to develop severe complications, they also require urgent medical attention. If you are a Mayo Clinic patient, this could
. Pregnancy of unknown location describes the scenario in which a pregnancy test is positive, but neither intrauterine nor ectopic pregnancy is shown on ultrasonography. If hCG levels plateau or rise, reassess the woman's condition for further treatment. Sometimes it can be difficult to remember all of the information provided, especially in an emergency situation. Hemorrhage was the leading cause of death. 25th ed. PID is usually caused by a sexually transmitted infection that spreads from the vagina to the uterus and fallopian tubes. 2015;112(41). An hCG level that is lower than expected is one reason to suspect an ectopic pregnancy. An ectopic pregnancy occurs when a fertilized egg implants and grows outside the main cavity of the uterus. https://www.uptodate.com/contents/search. This process is called implantation.. Cunningham FG, et al., eds. There are specific findings on an ultrasound that can show that the pregnancy is ectopic. Mayo Clinic does not endorse companies or products. Symptoms may include the following: Sudden, severe pain in the abdomen or pelvis. Advertising revenue supports our not-for-profit mission. A Cochrane review found that medical management with misoprostol (Cytotec) in women with incomplete abortion does not improve rates of completed abortion or decrease the need for unplanned surgical procedures compared with expectant management.22 In contrast, medical management is more effective than expectant management for the treatment of anembryonic gestation or embryonic demise.25 The most effective regimen for medical management is 200 mg of oral mifepristone (Mifeprex) followed 24 hours later by 800 mcg of vaginally administered misoprostol.26 Success rates at two days with this regimen are 84% vs. 67% in those treated with misoprostol alone. Expectant management can be considered for patients whose peak -hCG level is below the discriminatory zone and is decreasing, but has plateaued or is decreasing more slowly than expected for a failed intrauterine pregnancy.30 In cases where the initial -hCG level is 200 mIU per mL (200 IU per L) or less, 88% of patients will have successful spontaneous resolution of the pregnancy; however, rates of spontaneous resolution decrease with higher -hCG levels.31 Patient counseling must include the risks of spontaneous rupture, hemorrhage, and need for emergency surgery. Do you plan to become pregnant in the future? Progestin Therapy Not Likely to Be Harmful in Women with First Trimester Bleeding. Accessed Dec. 4, 2019. However, if a persons hCG level is rising slowly or decreasing, this suggests that the pregnancy may be ectopic. Depending on exactly how many weeks pregnant you are, it may or may not be possible to see the pregnancy on an ultrasound or detect a heartbeat. Copyright 2020 by the American Academy of Family Physicians. Some experience a small amount of vaginal bleeding or spotting, but others dont. In a typical pregnancy, your hCG levels double every 48 to 72 hours. Mayo Clinic. A glossary of terms used in this article is available in Table 1.36. Once you have had an ectopic pregnancy, you are at higher risk of having another one. . This site complies with the HONcode standard for trustworthy health information: verify here. In the United States, the estimated prevalence of ectopic pregnancy is 1% to 2%, and ruptured ectopic pregnancy accounts for 2.7% of pregnancy-related deaths. Expectant management, medical management, and uterine aspiration are safe methods for treating anembryonic gestations and fetal demise. If so, is it more or less than your typical period? If products of conception are visible on speculum examination, the diagnosis of incomplete abortion can be made and treatment offered. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. Overall, surgical management has a higher success rate for ectopic pregnancy than methotrexate.5 The initial -hCG level at which to transfer a patient for possible surgical treatment depends on local standards, although a level of 5,000 mIU per mL (5,000 IU per L) is commonly used.5,11 Ultrasound visualization of an embryo with fetal cardiac activity outside of the uterus is an indication for urgent transfer for surgical management.5,25 Additionally, social factors that preclude frequent laboratory testing (e.g., poor telephone access, work and family obligations, lack of transportation) can make surgical management the safer option5 (Table 55,11). The discriminatory level varies with the type of ultrasound machine used, the sonographer, and the number of gestations. Signs of ectopic pregnancy (e.g., adnexal mass, fluid in the cul-de-sac) can be seen on ultrasonography well below the discriminatory level. Before you take methotrexate, blood tests will be done to measure the level of hCG and the functions of certain organs. Sexually active women should be alert to changes in their bodies, especially if they experience symptoms of an ectopic pregnancy. Dec. 4, 2019. Copyright 2023 American Academy of Family Physicians. Copyright 2023 by the American College of Obstetricians and Gynecologists. At first, an ectopic pregnancy may feel like a typical pregnancy with some of the same signs, such as a missed menstrual period, tender breasts, or an upset stomach. Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. In 95% of ectopic pregnancy cases, a good transvaginal ultrasound examination can actually image the ectopic pregnancy in the Fallopian tube. Most women have some abdominal pain. In most normal pregnancies, at hCG levels below 1,200 mIU/ml, the hCG level usually doubles every 48-72 hours and normally increases by at least 60% every two days. It uses sound waves to create images of your uterus, ovaries and fallopian tubes, and sends the pictures to a nearby monitor. Miscarriage. Search for doctors near you. Vaginal bleeding in early pregnancy requires prompt attention. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. During a transvaginal ultrasound, you lie on an exam table while a health care provider or a medical technician puts a wandlike device, known as a transducer, into the vagina. This cutoff level of -hCG varies by institution but ranges from 1500 to 2500 mIU/ml. This content is owned by the AAFP. In a patient with a -hCG value above this level, failure to visualize an intrauterine pregnancy strongly suggests ectopic pregnancy. Compared with sharp curettage, vacuum aspiration is associated with decreased pain, shorter procedure duration, and less blood loss.28 Office-based uterine aspiration is safe, less expensive, and often more convenient than treatment in the operating room.29,30 Choices about analgesia during the aspiration procedure should be made with the patient's input. What are my chances of having a healthy pregnancy in the future? Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. Ectopic pregnancies and normal pregnancies require very different medical management. You will definitely need to be followed closely until your health care provider can determine if your pregnancy is in the uterus or if its ectopic. This content does not have an English version. Heres what to know. In addition, your physician may do a culdocentesis, which is a procedure that involves inserting a needle into the very top of the vagina, behind . As an ectopic pregnancy grows, more serious symptoms may develop, especially if a fallopian tube ruptures. Pelvic Inflammatory Disease: An infection of the uterus, fallopian tubes, and nearby pelvic structures. Patients may switch to medical management or uterine aspiration at any time. Vaginal bleeding or spotting also may occur. Ectopic pregnancies remain an important cause of morbidity and mortality in women of reproductive age. In some cases, the fallopian tube can be saved. A rupture can cause major internal bleeding. In these procedure, a small incision is made in the abdomen, near or in the navel. Slowly rising hCG levels may be the first clue . Blood tests and ultrasound testing can alert your doctor if another ectopic pregnancy is developing. Patients should be counseled to avoid taking folic acid supplements and nonsteroidal anti-inflammatory drugs, which can decrease the effectiveness of methotrexate, and to avoid anything that may mask the symptoms of ruptured ectopic pregnancy (e.g., narcotic analgesics, alcohol) and activities that increase the risk of rupture (e.g., vaginal intercourse, vigorous exercise). Have you been pregnant before? The risk factors for ectopic pregnancy include the following: Certain sexually transmitted infections (STIs). Review/update the
These are called quantitative hCG tests, and they can be used to determine if hCG levels are increasing or decreasing, and how fast. The discriminatory -hCG level used at different. Other factors that may increase a womans risk of ectopic pregnancy include: Use of assisted reproductive technology, such as in vitro fertilization (IVF). Ruptured ectopic pregnancy is associated with peritoneal signs and requires emergency surgery, although most patients present with bleeding or pain before rupture.39, Surgical treatment options include salpingectomy or salpingostomy, which are appropriate if the location of the pregnancy is the fallopian tube, but not if there is a less common location. Implantation and placental development. Niger Postgrad Med J. Women with an ectopic pregnancy may have irregular bleeding and pelvic or abdominal pain, often on one side. At-home urine tests require higher levels of hCG to detect a pregnancy, typically at least 20 mIU/mL. Ectopic pregnancy should be considered in any pregnant patient with vaginal bleeding or lower abdominal pain when intrauterine pregnancy has not yet been established (Table 2).10 Vaginal bleeding in women with ectopic pregnancy is due to the sloughing of decidual endometrium and can range from spotting to menstruation-equivalent levels.10 This endometrial decidual reaction occurs even with ectopic implantation, and the passage of a decidual cast may mimic the passage of pregnancy tissue. If your ectopic pregnancy isnt detected or treated early, you can experience severe health complications, including excessive bleeding, rupture of a fallopian tube, and death. It can take time for the level of hCG in your body to drop after treatment for an ectopic pregnancy. Further evaluation is needed unless a definitive nonobstetric cause of bleeding is found or products of conception are seen (Figure 1).8, The subunit of human chorionic gonadotropin (-hCG) can be detected in the plasma of a pregnant woman as early as eight days after ovulation.9 Quantitative -hCG levels can provide useful information in early pregnancy. These can be referred to as tubal pregnancies. Ectopic pregnancies can also occur in the cervix, abdomen, or ovary, but these are much rarer than tubal pregnancies. If so, where does it hurt? The embryologic events of early pregnancy occur in a predictable, stepwise fashion. A single copy of these materials may be reprinted for noncommercial personal use only. A meta-analysis evaluating the accuracy of a single progesterone test to predict pregnancy outcomes for women with first trimester bleeding showed that a progesterone level less than 6 ng per mL (19.1 nmol per L) reliably excluded viable pregnancy, with a negative predictive value of 99%. People who have had a history of pelvic inflammatory disease (PID) also have a higher risk for an ectopic pregnancy. The discriminatory level is the -hCG level above which an intrauterine pregnancy is expected to be seen on transvaginal ultrasonography.14 When combined with -hCG levels greater than the discriminatory level, ultrasonography that does not show an intrauterine pregnancy should raise concern for early pregnancy loss or ectopic pregnancy. Sometimes, there has been a positive pregnancy test, but no embryo can be seen in the uterus via ultrasound. Human chorionic gonadotropin (hCG) is a glycoprotein hormone composed of 2 dissimilar subunits, alpha and beta, joined non-covalently. Talk about your feelings and allow yourself to experience them fully. The pregnancy then is absorbed by the body over 46 weeks. Pregnancy of unknown location. This does not require the removal of the fallopian tube. Both bleeding and fallopian tube rupture can cause you to become clinically unstable. 2020;30(2). With this procedure, mature eggs are fertilized in a lab and then implanted into the uterus. Treatment failure is assumed if the -hCG level plateaus or increases from days 4 to 7. The most common gestational age of diagnosis is between 6 to 10 weeks. You will have careful follow-up over time until hCG is no longer found in your blood. Here are some questions you might want to ask your doctor: In addition to your prepared questions, don't hesitate to ask questions anytime you don't understand something. "hCG helps the body produce hormones to support pregnancy," explains John Zhang, M.D., founder. There is insufficient evidence to support the use of progestin for the prevention of early pregnancy loss.3,18 Bed rest does not improve outcomes and may cause psychological harm in patients with subsequent early pregnancy loss.19 Patients should be reassured that nothing they did caused the bleeding. Bilateral ectopic pregnancy is extremely rare, with a tremendous maternal mortality and morbidity risk, requiring rapid diagnosis and management. One of the most important factors is your ability to follow up with blood tests that check your blood levels of hCG. The rate of increase slows as pregnancy progresses and typically plateaus around 100,000 mIU per mL (100,000 IU per L) at 10 weeks' gestation.16 A decrease in -hCG of at least 21% over 48 hours suggests a likely failed intrauterine pregnancy, whereas a smaller decrease should raise concern for ectopic pregnancy.17, The discriminatory level is the -hCG level above which an intrauterine pregnancy is expected to be seen on transvaginal ultrasonography; it varies with the type of ultrasound machine used, the sonographer, and the number of gestations. It is done in a hospital with general anesthesia. The nature, location, and severity of pain in ectopic pregnancy vary. Risk factors include a history of pelvic inflammatory disease, cigarette smoking, fallopian tube surgery, previous ectopic pregnancy, and infertility. Author disclosure: No relevant financial affiliations. Tulandi T. Ectopic pregnancy: Epidemiology, risk factors, and anatomic sites. Interventions for non-tubal ectopic pregnancy. Rho(D) immune globulin (Rhogam) is indicated within 72 hours for all Rh-negative patients with abdominal trauma or ectopic pregnancy, and in those who undergo uterine aspiration. Patient satisfaction, mental health outcomes, infection rates, and future fertility are similar between these treatments.2022 Mental health outcomes are better when patients are included in the decision-making process, and shared decision making should guide management.23. Treatment for incomplete abortion should rely on shared decision making. The discriminatory level (1,500 to 3,000 mIU per mL) is the -hCG level above which an intrauterine pregnancy should be visible on transvaginal ultrasonography. The laparoscope is used to view the pelvic organs. Randomized trials have shown no difference in sequelae between methotrexate administration and fallopian tubesparing laparoscopic surgery, including rates of future intrauterine pregnancy and risk of future ectopic pregnancy.29 The decision whether to remove the fallopian tube or leave it in place depends on the extent of damage to the tube (evaluated intraoperatively) and the patient's desire for future fertility. Huang CC, Huang CC, Lin SY, et al. See permissionsforcopyrightquestions and/or permission requests. To provide you with the most relevant and helpful information, and understand which
I just went in for the second ultrasound at six weeks.. However, if a person's hCG level is rising slowly or decreasing, this suggests that the pregnancy may be ectopic. Online forums also can be a place to get support from other women who have had ectopic pregnancies. PMID: 36122984. Rely on your partner, loved ones and friends for support. The first measurement helps the clinician decide between the one- and two-dose protocols. Patients undergoing expectant management must receive extensive counseling on the risk of tubal rupture and the importance of close surveillance. Hormone: A substance made in the body by cells or organs that controls the function of cells or organs. If your hCG level does not drop by at least 15 percent between the fourth to seventh day after treatment, a second dose is required. In a viable intrauterine pregnancy with an initial -hCG level less than 1,500 mIU per mL (1,500 IU per L), there is a 99% chance that the -hCG level will increase by at least 49% over 48 hours.15 As the initial -hCG level increases, the rate of increase over 48 hours slows, with an increase of at least 40% expected for an initial -hCG level of 1,500 to 3,000 mIU per mL (1,500 to 3,000 IU per L) and 33% for an initial -hCG level greater than 3,000 mIU per mL.15 A slower-than-expected rate of increase or a decrease in -hCG levels suggests early pregnancy loss or ectopic pregnancy. If the ectopic pregnancy has ruptured a tube, emergency surgery is needed. Levels commonly increase between days 1 and 4, but should decrease by at least 15% between days 4 and 7. In early pregnancy, a 48-hour increase of hCG by 35% can still be considered normal. February 03, 2023 | by haleyerin1229. 1 While there have been rare, well-publicized cases where an ectopic pregnancy has been brought to term, pregnancies of this sort are almost universally considered nonviable. Ultrasound findings diagnostic of early pregnancy loss include a mean gestational sac diameter of 25 mm or greater with no embryo and no fetal cardiac activity when the crown-rump length is 7 mm or more. 2019;14(8):e0219351. Some people have no symptoms at all. McGraw-Hill Education; 2018. https://accessmedicine.mhmedical.com. You might also seek the help of a support group, grief counselor or other mental health provider. It's important to avoid alcohol, folic acid (in both vitamins and foods) and pain . Multiple treatment options exist depending on the characteristics and gestational age of the pregnancy, which your health care provider can discuss with you. Other potential symptoms include presyncope, syncope, vomiting, diarrhea, shoulder pain, lower urinary tract symptoms, rectal pressure, or pain with defecation.11, The physical examination can reveal signs of hemodynamic instability (e.g., hypotension, tachycardia) in women with ruptured ectopic pregnancy and hemoperitoneum.12 Patients with unruptured ectopic pregnancy often have cervical motion or adnexal tenderness.13 Sometimes the ectopic pregnancy itself can be palpated as a painful mass lateral to the uterus. It may take a few cycles for your periods to return to normal. Association of pelvic inflammatory disease (PID) with ectopic pregnancy and preterm labor in Taiwan: A nationwide population-based retrospective cohort study. PMID: 31621664. Bleeding equal to or heavier than a menstrual period and bleeding accompanied by pain are associated with an increased risk of early pregnancy loss.2,7 Patients should be assessed for signs and symptoms of hypovolemia. Sometimes, an embryo is visible in or around the fallopian tube; this confirms an ectopic pregnancy. Accessed Dec. 4, 2019. Abstract. https://www.uptodate.com/contents/search. They can even be life-threatening. Four weeks postoperatively, serum -HCG levels had a . However, in the rare case that a woman does become pregnant while she has an IUD, the prevalence of ectopic pregnancy is as high as 53%.7,8 There is no difference in ectopic pregnancy rates between copper or progestin-releasing IUDs.9. Pregnancy that develops outside the uterus is called ectopic pregnancy. This content does not have an Arabic version. A transvaginal ultrasound allows your doctor to see the exact location of your pregnancy. Nonviable intrauterine pregnancy within the first 12 6/7 weeks of gestation: Ectopic pregnancy: . In this case, a repeat dose of methotrexate may be given, although surgery may be required if the patient is symptomatic. Pregnancy FAQ 155. The hCG levels in an ectopic pregnancy often rise slower than usual, meaning they will not double every two to three days in early pregnancy. Bed rest does not improve outcomes, and there is insufficient evidence supporting the use of progestins. Only the uterus is physically able to carry a growing fetus. Copyright 2019 by the American Academy of Family Physicians. Ultrasound Transvaginal ultrasound A transvaginal ultrasound allows your doctor to see the exact location of your pregnancy. Also searched were the Cochrane database, DynaMed, and the National Guideline Clearinghouse. An ectopic pregnancy is a pregnancy that happens outside of your uterus. In Vitro Fertilization (IVF): A procedure in which an egg is removed from a womans ovary, fertilized in a laboratory with the mans sperm, and then transferred to the womans uterus to achieve a pregnancy. Cunningham FG, et al., eds. Sexually Transmitted Infections (STIs): Infections that are spread by sexual contact, including chlamydia, gonorrhea, human papillomavirus (HPV), herpes, syphilis, and human immunodeficiency virus (HIV, the cause of acquired immunodeficiency syndrome [AIDS]). The doctor might recommend an office visit or immediate medical care. Several factors go into the decision to use methotrexate. . However, most ectopic pregnancies do not reach this stage. Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. manual vacuum aspiration of the uterus can evaluate for chorionic villi that differentiate intrauterine pregnancy loss from ectopic pregnancy. Abdominal ultrasound, in which an ultrasound wand is moved over your belly, may be used to confirm your pregnancy or evaluate for internal bleeding. This blood test may be repeated every few days until ultrasound testing can confirm or rule out an ectopic pregnancy usually about five to six weeks after conception. Additionally, a PubMed search was completed in Clinical Queries using the following key terms: first trimester bleeding, threatened abortion, miscarriage, ectopic pregnancy, and discriminatory zone. When that happens, lower amounts of hCG are produced and the embryo can't develop normally. Prolonged exposure to sunlight. Your doctor may also test your progesterone levels because low levels could be a sign of an ectopic pregnancy. Approximately 25% of pregnant women experience bleeding before 12 weeks' gestation.1,2 The differential diagnosis includes nonobstetric causes, bleeding in a viable intrauterine pregnancy, early pregnancy loss, and ectopic pregnancy. However, those who have a viable intrauterine pregnancy after an ectopic pregnancy have similar reproductive outcomes compared with patients who have not had a previous ectopic pregnancy.41 -hCG levels in patients with ectopic pregnancy should be followed to zero, after which no further workup is indicated.15, This article updates a previous article on this topic by Deutchman, et al.6. American Family Physician. information highlighted below and resubmit the form. Patients should be informed that expectant management is more than 90% effective. Early blood tests are recommended for all women who've had an ectopic pregnancy. Pregnancy of unknown location refers to a transient state in which a pregnancy test is positive but ultrasonography shows neither intrauterine nor ectopic pregnancy. 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