Management of these pregnancies has changed dramatically over the years. Before you take methotrexate, blood tests will be done to measure the level of hCG and the functions of certain organs. Ectopic pregnancy should be considered in any patient presenting early in pregnancy with vaginal bleeding or lower abdominal pain in whom intrauterine pregnancy has not yet been established. Bilateral ectopic pregnancy is extremely rare, with a tremendous maternal mortality and morbidity risk, requiring rapid diagnosis and management. Your ob-gyn or other health care professional will talk with you about the possible side effects and risks of surgery for ectopic pregnancy. Complications Is an Ectopic Pregnancy Dangerous? hCG levels can help health care providers diagnose ectopic pregnancies, when interpreted together with ultrasound, and therefore help people get the care they need quickly. Interventions for non-tubal ectopic pregnancy. However, your doctor can't diagnose an ectopic pregnancy by examining you. PloS One. Sometimes, an embryo is visible in or around the fallopian tube; this confirms an ectopic pregnancy. Tulandi T. Ectopic pregnancy: Clinical manifestations and diagnosis. Published online July 1, 2020. doi:10.1002/14651858.cd011174.pub2, Taran FA, Kagan KO, Hbner M, et al. hCG is present in a pregnant persons blood and urine, and its the hormone that makes most pregnancy tests possible. This can be done laparoscopically or through an abdominal incision (laparotomy). Other signs may include: At this stage, it may be hard to know if you are experiencing a typical pregnancy or an ectopic pregnancy. manual vacuum aspiration of the uterus can evaluate for chorionic villi that differentiate intrauterine pregnancy loss from ectopic pregnancy. Mayo Clinic on Incontinence - Mayo Clinic Press, NEW The Essential Diabetes Book - Mayo Clinic Press, NEW Ending the Opioid Crisis - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Book: Mayo Clinic Guide to a Healthy Pregnancy, Book: Your Guide to Miscarriage and Pregnancy Loss. Pain and heavy bleeding are associated with an increased risk of early pregnancy loss. In stable patients, close monitoring of symptoms, serial quantitative -hCG testing, and ultrasonography are recommended4 (Figure 28,10,14,15 ). In cases where methotrexate is contraindicated or not preferred by the patient, surgical management can usually be performed laparoscopically if the patient is hemodynamically stable. Data Sources: An evidence summary generated from Essential Evidence Plus was reviewed and relevant studies referenced. A ruptured fallopian tube can cause life-threatening internal bleeding. Abstract. If we combine this information with your protected In 95% of ectopic pregnancy cases, a good transvaginal ultrasound examination can actually image the ectopic pregnancy in the Fallopian tube. Signs of ectopic pregnancy (e.g., adnexal mass, fluid in the cul-de-sac) can be seen on ultrasonography well below the discriminatory level. Patients undergoing expectant management must receive extensive counseling on the risk of tubal rupture and the importance of close surveillance. It can also possibly indicate an ectopic pregnancy that is 'self-resolving'. In a desired pregnancy, -hCG levels and serial ultrasonography combined with patient reports of pain or bleeding guide management.20 In an undesired pregnancy or when the possibility of a viable intrauterine pregnancy has been excluded, manual vacuum aspiration of the uterus can evaluate for chorionic villi that differentiate intrauterine pregnancy loss from ectopic pregnancy. There are two methods used to treat an ectopic pregnancy: 1) medication and 2) surgery. Are you being treated for any other medical conditions? In these cases, the ectopic pregnancy can be removed from the tube, or the entire tube with the pregnancy can be removed. Huang CC, Huang CC, Lin SY, et al. Ask a loved one or friend to come with you, if possible. The pregnancy then is absorbed by the body over 4-6 weeks. Molecular Reproduction and Development. More often, patient symptoms combined with serial ultrasonography and trends in beta human chorionic gonadotropin levels are used to make the diagnosis. In-vitro fertilization (IVF) also increases the chance of an ectopic pregnancy. It does not explain all of the proper treatments or methods of care. Deutsches Aerzteblatt Online. The search included meta-analyses, guidelines, and reviews. If ectopic pregnancy has been diagnosed, the patient is deemed clinically stable, and the affected fallopian tube has not ruptured, treatment options include medical management with intramuscular methotrexate or surgical management with salpingostomy (removal of the ectopic pregnancy while leaving the fallopian tube in place) or salpingectomy (removal of part or all of the affected fallopian tube). ERIN HENDRIKS, MD, RACHEL ROSENBERG, MD, AND LINDA PRINE, MD. Next, your doctor uses a thin tube equipped with a camera lens and light (laparoscope) to view the tubal area. This is why hCG levels alone aren . It often begins as a colicky abdominal or pelvic pain that is localized to one side as the pregnancy distends the fallopian tube. Serial beta human chorionic gonadotropin levels, serial ultrasonography, and, at times, uterine aspiration can be used to arrive at a definitive diagnosis. 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. This process is called implantation.. This pain can be managed expectantly as long as there are no signs of rupture.5 Gastrointestinal adverse effects (e.g., abdominal pain, vomiting, nausea) and vaginal spotting are common. 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. You might also seek the help of a support group, grief counselor or other mental health provider. Slowly rising hCG levels may be the first clue . My hCG level was on the lower end for someone 4 to 5 weeks . The medication is given by injection. February 03, 2023 | by haleyerin1229. The clinical diagnosis of ectopic pregnancy is based on a combination of serum quantitative human chorionic gonadotropin levels and transvaginal ultrasound findings. The female body normally has two fallopian tubes. It can take time for the level of hCG in your body to drop after treatment for an ectopic pregnancy. information highlighted below and resubmit the form. other information we have about you. Pregnancy of unknown location can be diagnostically challenging because the increase in -hCG level can be similar among women with an early viable pregnancy, ectopic pregnancy, or early pregnancy loss.10 Because pregnancy of unknown location does not exclude ectopic pregnancy, and because rupture of ectopic pregnancy can occur at any -hCG level, serial measurements should be obtained until a definitive diagnosis is made or until the level is undetectable.16 Patients should be counseled about warning signs of ectopic pregnancy, including shoulder pain, pelvic pain, and dizziness. the unsubscribe link in the e-mail. Most ectopic pregnancies are diagnosed between six and nine weeks of pregnancy. 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. Human chorionic gonadotropin (hCG) is a glycoprotein hormone composed of 2 dissimilar subunits, alpha and beta, joined non-covalently. health information, we will treat all of that information as protected health Levels of hCG should be increasing by at least 60% every 2-3 days, but ideally doubling every 48-72 hours. Multiple treatment options exist depending on the characteristics and gestational age of the pregnancy, which your health care provider can discuss with you. include protected health information. Advanced ectopic pregnancy (high -hCG level, large mass, embryonic cardiac activity) The most common drug used to treat ectopic pregnancy is methotrexate. A single copy of these materials may be reprinted for noncommercial personal use only. Pregnancy tests look for hCG (human chorionic gonadotropin) which is excreted in pregnancy. information is beneficial, we may combine your email and website usage information with 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. Treatment of diagnosed ectopic pregnancy includes medical management with intramuscular methotrexate, surgical management via salpingostomy or salpingectomy, and, in rare cases, expectant management. There are different treatment protocols, but the single-dose regimen is most common.15 This includes an intramuscular injection of 50 mg of methotrexate per m2, followed by close monitoring of symptoms and measurement of -hCG levels four and seven days after injection. When Low hCG Levels Suggest Ectopic Pregnancy . During pregnancy, it can be used to examine the fetus. 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. Vital signs indicating hemodynamic instability or peritoneal signs on physical examination require emergent evaluation. Cochrane Database of Systematic Reviews. 2016;83(12):1083-1091. doi:10.1002/mrd.22747. To provide you with the most relevant and helpful information, and understand which Symptoms most often appear 6 to 8 weeks after the last normal menstrual period. At around 8 to 11 days after conception, your blood still has low levels of hCG. Very early in pregnancy, the embryo can grow within the fallopian tube without causing any symptoms. https://www.aafp.org/pubs/afp/issues/2020/0515/p599.html. If you are pregnant, you can detect it in your urine. Correa-de-Araujo R, Yoon SS (Sarah). 1.6.11 For women with ectopic pregnancy who have had methotrexate, take 2 serum hCG measurements in the first week (days 4 and 7) after treatment and then 1 serum hCG measurement per week until a negative result is obtained. [2012] Confirming pregnancy Association of pelvic inflammatory disease (PID) with ectopic pregnancy and preterm labor in Taiwan: A nationwide population-based retrospective cohort study. Once you have had an ectopic pregnancy, you are at higher risk of having another one. This does not require the removal of the fallopian tube. Pregnancy of unknown location describes the scenario in which a pregnancy test is positive, but neither intrauterine nor ectopic pregnancy is shown on ultrasonography. Accessed Dec. 4, 2019. Expectant management, medical management, and uterine aspiration are safe and effective treatments for early pregnancy loss. Watchful waiting is recommended as first-line treatment for patients with incomplete abortion; more than 90% of these patients will complete the process spontaneously within four weeks.24 Watchful waiting is less effective in patients with an anembryonic gestation or embryonic demise, with completion rates at one month of 66% and 76%, respectively.24 Patients who choose expectant management over uterine aspiration experience more days of bleeding, longer time to completion, and higher rates of unplanned surgical intervention.20,21 Serious complications are rare, and patients who opt for expectant management should be informed that it is safe to wait as long as they wish as long as there are no signs of infection or hemorrhage. 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. Thus, a history of bleeding and passage of tissue cannot be relied on to differentiate ectopic pregnancy from early intrauterine pregnancy failure. If its high enough (most studies use a threshold of about 3,500 mIU/mL, or milli-international units per milliliter, but this can vary by practice), this indicates that the pregnancy is far enough along that a gestational sac should be able to be seen on an ultrasound. 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. With this procedure, mature eggs are fertilized in a lab and then implanted into the uterus. Neither ultrasound showed an egg or even a sac. If you are a Mayo Clinic patient, this could 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 so, what was the outcome of each pregnancy? People who have had a history of pelvic inflammatory disease (PID) also have a higher risk for an ectopic pregnancy. Search dates: August 3, 2017, to October 21, 2018. My hCG levels at five weeks were 150 and then 352 two days later. A combination of -hCG level greater than the discriminatory level and ultrasonography that does not show an intrauterine pregnancy should raise concern for early pregnancy loss or an ectopic . A fertilized egg can't develop normally outside the uterus. It is safe to try to conceive again immediately; those who attempt to conceive within the first three months after early pregnancy loss have higher rates of pregnancy and live birth compared with those who wait longer.33,34 Although a Cochrane review found insufficient evidence that psychological support after pregnancy loss improves well-being, the decision to refer for counseling should be made on an individual basis.35, The incidence of ectopic pregnancy is 1% to 2% in the United States.36 Ruptured ectopic pregnancies account for 6% of all maternal deaths, with a higher rate in black patients.36 Risk factors include pelvic inflammatory disease, previous tubal surgery, previous ectopic pregnancy, and in utero exposure to diethylstilbestrol.37 Criteria for surgical, medical, or expectant management are described in Table 3.6,15,38,39, -hCG level < 1,000 mIU per mL and decreasing, Ectopic or adnexal mass < 3 cm or not detected, Patient reliable for follow-up and has no barriers to accessing health care, No medical contraindication (hematologic dysfunction; liver, kidney, or pulmonary disease; immunodeficiency; peptic ulcer disease; breastfeeding; sensitivity to methotrexate; alcohol abuse), Advanced ectopic pregnancy (high -hCG level, large mass, embryonic cardiac activity), Contraindications to observation or methotrexate, Patient unreliable for follow-up or has barriers to accessing health care (individualization of intervention), Unstable vital signs or signs of hemoperitoneum, Surgical management is indicated for patients with contraindications to medical treatment or failed medical treatment, and for patients who are hemodynamically unstable. See permissionsforcopyrightquestions and/or permission requests. Ectopic pregnancy in Dalhatu Araf Specialist Hospital Lafia Nigeria - A 5-year review. Treatment options for early pregnancy loss include expectant management, medical management with mifepristone and misoprostol, or uterine aspiration. A combination of -hCG level greater than the discriminatory level and ultrasonography that does not show an intrauterine pregnancy should raise concern for early pregnancy loss or an ectopic pregnancy.5 The discriminatory zone was previously defined as a -hCG level of 1,000 to 2,000 mIU per mL (1,000 to 2,000 IU per L); however, this cutoff can miss some intrauterine pregnancies that do not become apparent until a slightly higher -hCG level is achieved. Treatment for incomplete abortion should rely on shared decision making. The first measurement helps the clinician decide between the one- and two-dose protocols. The behavior of this hormone can help detect a dangerously abnormal pregnancy. Declining or low rate of increase in hCG over 48 hours can be a sign of an ectopic pregnancy or miscarriage. Most often this occurs in one of the fallopian tubes (called a tubal pregnancy) but it can also happen on the cervix or elsewhere in the abdominal region. An hCG level that is lower than expected is one reason to suspect an ectopic pregnancy. Dec. 4, 2019. People who are older at the time of pregnancy also have an increased risk of ectopic pregnancy. 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. Skip to primary navigation . Clinicians should expect to see a gestational sac on transvaginal ultrasonography when -hCG levels reach 1,500 to 3,000 mIU per mL. Some people with ectopic pregnancies are more stable at the time theyre diagnosed. Depending on your symptoms and when the ectopic pregnancy is discovered, this may be done using medication, laparoscopic surgery or abdominal surgery. Implantation and placental development. 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. Laparotomy is reserved for patients who are hemodynamically unstable. 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]). This can also help determine whether a pregnancy is healthy or ectopic, but it should be interpreted together with ultrasound findings. A speculum examination can help identify nonobstetric causes of bleeding, such as vaginitis, cervicitis, or a cervical polyp. 2020;101(10):599-606. https://www.aafp.org/pubs/afp/issues/2020/0515/p599.html, Long Y, Zhu H, Hu Y, et al. 2015;112(41). Tonick S, Conageski C. Ectopic Pregnancy. Did you notice anything unusual about it? A hCG level that is rising by less than 66% over 48 hours when the hCG is below 1,200 IU means it is likely, but not a certainty, that the pregnancy is ectopic. A Cochrane review found no difference in success rates between laparoscopic salpingostomy and medical treatment with systemic methotrexate, as well as no differences in tubal patency or subsequent fertility rates.40. This site complies with the HONcode standard for trustworthy health information: verify here. Copyright 2023 American College of Obstetricians and Gynecologists, Privacy Statement 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. Dr. Ewan is a physician with a background in pediatrics. Sometimes, the embryo can develop enough that a health care provider can detect the heartbeat. The prevalence of ectopic pregnancy in the United States is estimated to be 1% to 2%, but this may be an underestimate because this condition is often treated in the office setting where it is not tracked.1,2 The mortality rate for ruptured ectopic pregnancy has steadily declined over the past three decades, and from 2011 to 2013 accounted for 2.7% of pregnancy-related deaths.1,3 Risk factors for ectopic pregnancy are listed in Table 14,5; however, one-half of women with diagnosed ectopic pregnancy have no identified risk factors.46 The overall rate of pregnancy (including ectopic) is less than 1% when a patient has an intrauterine device (IUD). Blood tests can determine how high the hCG level is. To prevent life-threatening complications, the ectopic tissue needs to be removed. Ultrasound Transvaginal ultrasound A transvaginal ultrasound allows your doctor to see the exact location of your pregnancy. 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