Ectopic pregnancies remain an important cause of morbidity and mortality in women of reproductive age. Approximately one-fourth of pregnant women will experience bleeding in the first trimester. Patients should be informed that expectant management is more than 90% effective. You may be dealing with many emotions after an ectopic pregnancy, even if you were not planning to become pregnant. A wide variety of symptoms are associated with an ectopic pregnancy. 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. You will not be able to use methotrexate if you are breastfeeding or have certain health problems. Sometimes, an embryo is visible in or around the fallopian tube; this confirms an ectopic pregnancy. A complete blood count will be done to check for anemia or other signs of blood loss. All rights reserved. Setting a low -HCG cutoff value increases the sensitivity of ultrasound and -hCG at diagnosing an ectopic . 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. For some women, ectopic pregnancy can be traumatic. They can even be life-threatening. In a salpingostomy, the ectopic pregnancy is removed and the tube left to heal on its own. This procedure uses a slender, lighted camera that is inserted through small cuts in the abdomen. . How long should I wait before trying to become pregnant again? After this . These medications can affect the way methotrexate works in the body. Are you being treated for any other medical conditions? This can be done laparoscopically or through an abdominal incision (laparotomy). This can also help determine whether a pregnancy is healthy or ectopic, but it should be interpreted together with ultrasound findings. Patient preference should guide treatment decisions. Therefore, in a desired pregnancy, 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.18,19. Tulandi T. Ectopic pregnancy: Clinical manifestations and diagnosis. An ectopic pregnancy occurs when a fertilized egg grows outside of the uterus. Laparoscopy: A surgical procedure in which an instrument called a laparoscope is inserted into the pelvic cavity through a small incision. A pelvic exam can help your doctor identify areas of pain, tenderness, or a mass in the fallopian tube or ovary. Published online July 1, 2020. doi:10.1002/14651858.cd011174.pub2, Taran FA, Kagan KO, Hbner M, et al. Cigarette smoking and having more than one sexual partner also increase the risk for an ectopic pregnancy. 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]). Early blood tests are recommended for all women who've had an ectopic pregnancy. Obstet Gynecol Clin North Am. 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. Tulandi T. Ectopic pregnancy: Epidemiology, risk factors, and anatomic sites. In early pregnancy, a 48-hour increase of hCG by 35% can still be considered normal. If you have pain that does not respond to over-the-counter medication, talk with your ob-gyn or other health care professional. Levels commonly increase between days 1 and 4, but should decrease by at least 15% between days 4 and 7. Symptoms may include the following: Sudden, severe pain in the abdomen or pelvis. An ectopic pregnancy is a pregnancy that happens outside of your uterus. Have you been pregnant before? Levels of hCG should be increasing by at least 60% every 2-3 days, but ideally doubling every 48-72 hours. Guidelines for ultrasound diagnosis of early pregnancy loss have been established to decrease the likelihood of false diagnosis and of intervening in a desired viable pregnancy. 25th ed. Terms and Conditions of Use, Get the latest on COVID-19, pregnancy, and breastfeeding. This occurs when a fertilized egg implants in a location that can't support its growth. Depending on your symptoms and when the ectopic pregnancy is discovered, this may be done using medication, laparoscopic surgery or abdominal surgery. 1 Once levels zero out, this indicates that the body has readjusted to its pre-pregnancy stateand is likely primed for conception to occur again. This cutoff level of -hCG varies by institution but ranges from 1500 to 2500 mIU/ml. PMID: 36122984. The pain may become more generalized once the tube ruptures and hemoperitoneum develops. Seek care right away if you have symptoms of a rupture, including sudden abdominal pain, shoulder pain, or weakness. Correa-de-Araujo R, Yoon SS (Sarah). To provide you with the most relevant and helpful information, and understand which Accessed Dec. 4, 2019. All Rights Reserved. Read copyright and permissions information. Expectant management, medical management, and uterine aspiration are safe and effective treatments for early pregnancy loss. Uterine aspiration should be considered to evaluate for intrauterine chorionic villi in patients with a pregnancy of unknown location. Your ob-gyn or other health care professional will talk with you about the possible side effects and risks of surgery for ectopic pregnancy. The most common gestational age of diagnosis is between 6 to 10 weeks. 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. Have you taken a pregnancy test? Hendriks E, Rosenberg R, Prine L. Ectopic Pregnancy: Diagnosis and Management. Rely on your partner, loved ones and friends for support. Bed rest or progestins should not be recommended to prevent early pregnancy loss in patients with first trimester bleeding because these interventions have not been proven effective. 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. In some cases, an ectopic pregnancy may resolve on its own. A recent study found a 99% probability that an intrauterine gestational sac will be detected at a -hCG level of 3,510 mIU per mL.14 Currently, a discriminatory level of 1,500 to 3,000 mIU per mL is typically used.10,15 However, ultrasonography can be diagnostically useful in symptomatic women at any -hCG level. Ectopic pregnancies occur in approximately 1.3 to 2.4% of pregnancies. Could You Have Subclinical Hypothyroidism? Read ACOGs complete disclaimer. No specific range of decrease is considered normal as long as the patient is asymptomatic and the decrease continues.39 Surgical management is indicated if the patient experiences increased abdominal pain or if -hCG levels increase.38, Patients with previous ectopic pregnancy have higher rates of ectopic pregnancy and early pregnancy loss in subsequent pregnancies. 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. -hCG levels should decrease by at least 15% from days 4 to 7; once this occurs, levels should be monitored weekly until undetectable, which may take five to seven weeks. It is not a substitute for the advice of a physician. 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). In an ectopic pregnancy, the fertilized egg implants somewhere other than the lining of the uterus. An ectopic pregnancy occurs when a fertilized egg implants and grows outside the main cavity of the uterus. 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. Because ectopic pregnancies can be life-threatening, early diagnosis is essential. Huang CC, Huang CC, Lin SY, et al. American Family Physician. Mayo Clinic does not endorse companies or products. After six weeks, the levels will double about every 96 hours. To prevent life-threatening complications, the ectopic tissue needs to be removed. Ectopic pregnancies and normal pregnancies require very different medical management. A discriminatory -hCG level as high as 3,500 mIU per mL (3,500 IU per L) should be used when a woman wishes to avoid unnecessary intervention in a potentially viable intrauterine pregnancy. Fallopian Tube: Tube through which an egg travels from the ovary to the uterus. Sound waves from the transducer create images of the uterus, ovaries and fallopian tubes. Ask your ob-gyn or other health care professional to recommend a counselor. The typical hCG level around four weeks of pregnancy is around 140 mIU/ml 5, so a high hCG level can be generally considered to mean you are pregnant. Human chorionic gonadotropin (hCG) is a hormone normally produced by the placenta. Whether you were treated with methotrexate or surgery, you may feel tired for several weeks while you recover. In fact, a 2017 study into hCG found that "the slowest or minimal rise for a normal viable intrauterine pregnancy was 24% at one day and 53% at two days. Serial beta human chorionic gonadotropin levels, serial ultrasonography, and, at times, uterine aspiration can be used to arrive at a definitive diagnosis. Vital signs indicating hemodynamic instability or peritoneal signs on physical examination require emergent evaluation. Prescription pain medication and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. Both bleeding and fallopian tube rupture can cause you to become clinically unstable. The estimated mortality of ectopic pregnancy is between 2 and 4/1000. Abdominal ultrasound, in which an ultrasound wand is moved over your belly, may be used to confirm your pregnancy or evaluate for internal bleeding. Four weeks postoperatively, serum -HCG levels had a . Levels of this hormone increase during pregnancy. Your hCG level can inform your doctor whether there is a risk of an ectopic pregnancy or whether a miscarriage has occurred. An intra-uterine pregnancy can usually be seen by 5-6 weeks gestation or when the HCG level is more than 1000 IU/l. As your pregnancy progresses, the hCG level increase slows down significantly. If you do not have the symptoms of a fallopian tube rupture but your ob-gyn or other health care professional suspects you may have ectopic pregnancy, he or she may: Perform an ultrasound exam to see where the pregnancy is developing, Test your blood for a pregnancy hormone called human chorionic gonadotropin (hCG). Patients with suspected or confirmed ectopic pregnancy who exhibit signs and symptoms of ruptured ectopic pregnancy should be emergently transferred for surgical intervention. This combination should make an obstetrician-gynecologist consider the possibility of an ectopic pregnancy. 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. Treatment for incomplete abortion should rely on shared decision making. Women with an ectopic pregnancy may have irregular bleeding and pelvic or abdominal pain, often on one side. It is not intended as a statement of the standard of care. 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. Another possibility is that you could be experiencing a miscarriage. When Low hCG Levels Suggest Ectopic Pregnancy . If the hCG level is high and no gestational sac is seen in the uterus, this makes it highly likely that there is an ectopic pregnancy. The definitive diagnosis of ectopic pregnancy can be made with ultrasound visualization of a yolk sac and/or embryo in the adnexa. 2015;112(41). Sometimes surgery is needed even if the fallopian tube has not ruptured. What are my chances of having a healthy pregnancy in the future? In a normal pregnancy, the egg is fertilized by a sperm. | Patients should be asked about pain and the amount of bleeding. Urine tests. Copyright 2019 by the American Academy of Family Physicians. This site complies with the HONcode standard for trustworthy health information: verify here. For symptomatic women with a viable intrauterine pregnancy, initial -hCG levels of less than 1,500 mIU per mL, 1,500 to 3,000 mIU per mL, or more than 3,000 mIU per mL will increase over 48 hours by at least 49%, 40%, or 33%, respectively.10 A slower rate of increase suggests early pregnancy loss or ectopic pregnancy. If your hCG levels don't continue to rise rapidly during the first few weeks or if they start to drop, this can signal a problem such as an ectopic pregnancy or miscarriage. Other signs may include: At this stage, it may be hard to know if you are experiencing a typical pregnancy or an ectopic pregnancy. If an ultrasound doesnt show an embryo in your uterus, it could be that its too early in pregnancy to see the embryo, or it could be an ectopic pregnancy. However, since they may go on to develop severe complications, they also require urgent medical attention. It often begins as a colicky abdominal or pelvic pain that is localized to one side as the pregnancy distends the fallopian tube. In: Williams Obstetrics. 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. A single-dose methotrexate protocol is recommended for medical management of patients with ectopic pregnancy and low initial -hCG levels. It is appropriate for family physicians to treat hemodynamically stable patients in conjunction with their primary obstetrician. Tonick S, Conageski C. Ectopic Pregnancy. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). Human chorionic gonadotropin (hCG) is a glycoprotein hormone composed of 2 dissimilar subunits, alpha and beta, joined non-covalently. Molecular Reproduction and Development. A rupture can cause major internal bleeding. In this instance, a health care provider can order a test for the hCG level. Clinicians should expect to see a gestational sac on transvaginal ultrasonography when -hCG levels reach 1,500 to 3,000 mIU per mL. 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. In 95% of ectopic pregnancy cases, a good transvaginal ultrasound examination can actually image the ectopic pregnancy in the Fallopian tube. Slowly rising hCG levels may be the first clue . If chorionic villi are seen, further workup is unnecessary, and exposure to methotrexate can be avoided. Vaginal bleeding in early pregnancy requires prompt attention. Levels of this hormone increase during pregnancy. The laparoscope is used to view the pelvic organs. A fertilized egg can't develop normally outside the uterus. Ultrasonography shows gestational sac with mean diameter 25 mm and no yolk sac or embryo, Complete passage of all products of conception, Nonviable intrauterine pregnancy within the first 12 6/7 weeks of gestation, A pregnancy outside the uterine cavity (most commonly in a fallopian tube), Ultrasonography shows embryo with crown-rump length 7 mm and no cardiac activity, Some, but not all, of the products of conception have passed, Intrauterine pregnancy of uncertain viability, Transvaginal ultrasonography shows intrauterine gestational sac with no embryonic cardiac activity (and no findings of definite pregnancy failure [, Pregnancy that cannot result in live birth (e.g., ectopic pregnancy, early pregnancy loss), Positive urine or serum pregnancy test with no intrauterine or ectopic pregnancy shown on transvaginal ultrasonography, More than two consecutive pregnancy losses, Spontaneous loss of pregnancy before 20 weeks' gestation, Bleeding before 20 weeks' gestation in the presence of an embryo with cardiac activity and a closed cervix, Pregnancy that can potentially result in a live birth, Gestational sac (measured by mean sac diameter), Appears four to five weeks after last menstrual period, Mean sac diameter of 16 to 24 mm and no embryo, Appears 5.5 weeks after last menstrual period, Absence of embryo with cardiac activity seven to 10 days after ultrasonography shows gestational sac and yolk sac, Absence of embryo withcardiac activity 11 days after ultrasonography shows gestational sac and yolk sac, Embryo (measured by crown-rump length and embryonic cardiac activity), Appears six weeks after last menstrual period; embryonic cardiac activity appears at 6.5 weeks, Crown-rump length < 7 mm and no embryonic cardiac activity, Crown-rump length 7 mm and no embryonic cardiac activity. Very early in pregnancy, the embryo can grow within the fallopian tube without causing any symptoms. If so, was the test positive? 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. An hCG level that is lower than expected is one reason to suspect an ectopic pregnancy. Uterine aspiration is the preferred procedure for surgical management of early pregnancy loss. See permissionsforcopyrightquestions and/or permission requests. 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. My hCG level was on the lower end for someone 4 to 5 weeks . You may feel abdominal discomfort or pain. Treatment of diagnosed ectopic pregnancy includes medical management with intramuscular methotrexate, surgical management via salpingostomy or salpingectomy, and, in rare cases, expectant management. Pregnancy of unknown location describes the scenario in which a pregnancy test is positive, but neither intrauterine nor ectopic pregnancy is shown on ultrasonography. Abstract. information is beneficial, we may combine your email and website usage information with doi:10.3238/arztebl.2015.0693, Pereira PP, Cabar FR, Gomez T, et al. Intrauterine pregnancy visualized on transvaginal ultrasonography essentially rules out ectopic pregnancy except in the exceedingly rare case of heterotopic pregnancy.5 The definitive diagnosis of ectopic pregnancy can be made with ultrasonography when a yolk sac and/or embryo is seen in the adnexa; however, ultrasonography alone is rarely used to diagnose ectopic pregnancy because most do not progress to this stage.5 More often, the patient history is combined with serial quantitative -hCG levels, sequential ultrasonography, and, at times, uterine aspiration to arrive at a final diagnosis of ectopic pregnancy. Dr. Ewan is a physician with a background in pediatrics. I just went in for the second ultrasound at six weeks.. Threatened abortion should be managed expectantly. the single-dose protocol should be used in patients with -hCG levels less than 3,600 mIU per mL (3,600 IU per L), and the two-dose protocol should be considered for patients with higher initial -hCG levels, especially those with levels greater than 5,000 mIU per mL. Ectopic pregnancy. The Diagnosis and Treatment of Ectopic Pregnancy. 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. Your doctor may also test your progesterone levels because low levels could be a sign of an ectopic pregnancy. Blood tests can determine how high the hCG level is. If so, is it more or less than your typical period? An ectopic pregnancy is when a fertilized ovum implants outside of the uterus. You might show signs of being in shock, such as a very high heart rate and very low blood pressure. Counseling may be helpful. If chorionic villi are seen, further workup is unnecessary, and exposure to methotrexate can be avoided(Figure 1).5,1517,21 If chorionic villi are not seen after uterine aspiration, it is imperative to initiate treatment for ectopic pregnancy or repeat -hCG measurement in 24 hours to ensure at least a 50% decrease. In viable intrauterine pregnancies with initial -hCG levels of less than 1,500 mIU per mL, 1,500 to 3,000 mIU per mL, or greater than 3,000 mIU per mL, there is a 99% chance that the -hCG level will increase by at least 49%, 40%, and 33%, respectively, over 48 hours. The search included meta-analyses, guidelines, and reviews. As an ectopic pregnancy grows, more serious symptoms may develop, especially if a fallopian tube ruptures. Many regimens for using misoprostol alone have been studied, and none has been proven optimal.22 One common regimen is 800 mcg vaginally, with a repeat dose in 24 to 48 hours if the first dose is unsuccessful.27 Besides the expected cramping and vaginal bleeding, common adverse effects include nausea and diarrhea.22. A transvaginal ultrasound allows your doctor to see the exact location of your pregnancy. . However, most ectopic pregnancies do not reach this stage. 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. In this case, the pregnancy is called a pregnancy of unknown location. There is no consensus about the next steps if a pregnancy is of unknown location. Risk factors include a history of pelvic inflammatory disease, cigarette smoking, fallopian tube surgery, previous ectopic pregnancy, and infertility. You will have careful follow-up over time until hCG is no longer found in your blood. Deutsches Aerzteblatt Online. There is a problem with In-vitro fertilization (IVF) also increases the chance of an ectopic pregnancy. manual vacuum aspiration of the uterus can evaluate for chorionic villi that differentiate intrauterine pregnancy loss from ectopic pregnancy. PloS One. Patients may switch to medical management or uterine aspiration at any time. This can be a life-threatening emergency that needs immediate surgery. Copyright 2023 American Academy of Family Physicians. 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).
