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. An hCG level that is lower than expected is one reason to suspect an ectopic pregnancy. Levels of this hormone increase during 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. More often, patient symptoms combined with serial ultrasonography and trends in beta human chorionic gonadotropin levels are used to make the diagnosis. Symptoms of ectopic pregnancy develop between weeks 4 and 12 of pregnancy (or about two to 10 weeks after fertilization). Another possibility is that you could be experiencing a miscarriage. 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. This may be because they have had more time to experience other conditions that put them at risk for ectopic pregnancies in the future. The clinical manifestations and diagnosis of ectopic pregnancy are reviewed here with a focus on tubal pregnancy. 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. . A single-dose methotrexate protocol is recommended for medical management of patients with ectopic pregnancy and low initial -hCG levels. Deutsches Aerzteblatt Online. In: Williams Obstetrics. It can also possibly indicate an ectopic pregnancy that is 'self-resolving'. 2016;83(12):1083-1091. doi:10.1002/mrd.22747. American College of Obstetricians and Gynecologists. ERIN HENDRIKS, MD, RACHEL ROSENBERG, MD, AND LINDA PRINE, MD. Others may present in shock because their fallopian tube ruptured, causing internal bleeding. Have you taken a pregnancy test? 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. Cunningham FG, et al., eds. It is appropriate for family physicians to treat hemodynamically stable patients in conjunction with their primary obstetrician. Hyperthyroidism and Weight Gain: What to Know, Diabetes and Depression: How Telemedicine is Successfully Treating Both, COVID Long-Haulers Share Their Roads to Recovery, How Your Hunger Hormones Control Weight Loss, Thyroid Disorders and Infertility: A Doctors Personal Story. 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. In an ectopic pregnancy, the fertilized egg implants somewhere other than the lining of the uterus. Hendriks E, Rosenberg R, Prine L. Ectopic Pregnancy: Diagnosis and Management. However, there are some very rare medical conditions that can cause high hCG levels. The pregnancy then is absorbed by the body over 4-6 weeks. A 50- or 120-mcg dose is recommended before 12 weeks' gestation, although 300 mcg can be administered if lower doses are not available.3 After 12 weeks, a 300-mcg dose should be given.12, Measurement of serum progesterone may be useful in distinguishing between an early viable or nonviable pregnancy, especially in the setting of inconclusive ultrasonography. How long should I wait before trying to become pregnant again? A patient with diagnosed ectopic pregnancy should be immediately transferred for surgery if she has peritoneal signs or hemodynamic instability, if the initial beta human chorionic gonadotropin level is high, if fetal cardiac activity is detected outside of the uterus on ultrasonography, or if there is a contraindication to medical management. Risk factors include a history of pelvic inflammatory disease, cigarette smoking, fallopian tube surgery, previous ectopic pregnancy, and infertility. To provide you with the most relevant and helpful information, and understand which Typically, if you go to your health care provider with concerns like this, they will order an ultrasound. The medication is given by injection. Will I need to follow any special precautions if I become pregnant again? Read copyright and permissions information. By approximately 10 weeks' gestation, the -hCG level typically plateaus or decreases, after which serial ultrasonography is the preferred diagnostic tool.11, Rh factor testing should be performed if Rh status is not known at the time of presentation. Journal of Womens Health. Ask a loved one or friend to come with you, if possible. Oral mifepristone (Mifeprex), 200 mg, followed 24 hours later by misoprostol, 800 mcg vaginally, is the most effective regimen for medical management of early pregnancy loss and, when available, should be recommended over misoprostol alone. Other instruments can be used with it to perform surgery. Management of these pregnancies has changed dramatically over the years. Salpingostomy is preferred for patients who wish to preserve fertility; however, it may result in inadequate evacuation of products of conception and a recurrence of symptoms. Cochrane Database of Systematic Reviews. After the injection, your doctor will order another HCG test to determine how well treatment is working, and if you need more medication. Ectopic pregnancy. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. An ectopic pregnancy most often happens in your fallopian tube (a structure that connects your ovaries and uterus). This type of ectopic pregnancy is called a tubal pregnancy. You might also seek the help of a support group, grief counselor or other mental health provider. These cases require medical attention immediately. You'll be asked many questions about your menstrual cycle, fertility and overall health. Search dates: October 26, 2018, through January 14, 2020. 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. 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. It's important to avoid alcohol, folic acid (in both vitamins and foods) and pain . If one is damaged or removed, an egg may join with a sperm in the other tube and then travel to the uterus. If you have pain that does not respond to over-the-counter medication, talk with your ob-gyn or other health care professional. For this test, a wandlike device is placed into your vagina. 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. 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. 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. 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. 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. Several factors go into the decision to use methotrexate. The rate of -hCG increase is less rapid as the level increases. 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. Urgent surgical referral is indicated when ultrasonography demonstrates an embryo and fetal cardiac activity outside of the uterus. A fertilized egg can't develop normally outside the uterus. A choice of either methotrexate or surgical management is offered to women with an ectopic pregnancy who have a serum hCG level of at least 1500 IU/L and less than 5000 IU/L, . 5. The pain may become more generalized once the tube ruptures and hemoperitoneum develops. Niger Postgrad Med J. However, vaginal spotting and pelvic painand, of course, missed periodscan also occur in normal pregnancies, so this combination doesnt guarantee that a pregnancy is ectopic. Pregnancy of unknown location. A ruptured fallopian tube can cause life-threatening internal bleeding. 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. 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). Ask your ob-gyn or other health care professional to recommend a counselor. 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. Typical hCG Doubling Times. The search included meta-analyses, randomized controlled trials, clinical trials, guidelines, and reviews. If we combine this information with your protected Copyright 2023 by the American College of Obstetricians and Gynecologists. 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. PID is usually caused by a sexually transmitted infection that spreads from the vagina to the uterus and fallopian tubes. Accessed Dec. 4, 2019. A rupture can cause major internal bleeding. As the pregnancy grows, it can cause the tube to burst (rupture). Author disclosure: No relevant financial affiliations. In a typical pregnancy, your hCG levels double every 48 to 72 hours. Blood tests and ultrasound testing can alert your doctor if another ectopic pregnancy is developing. After this . Also searched were the Cochrane database, DynaMed, and the National Guideline Clearinghouse. Do you plan to become pregnant in the future? 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. Take time to work through your feelings. What are the chances of dying from an ectopic pregnancy? Approximately one-fourth of pregnant women will experience bleeding in the first trimester. Interventions for non-tubal ectopic pregnancy. 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. See permissionsforcopyrightquestions and/or permission requests. 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. It is not a substitute for the advice of a physician. This site complies with the HONcode standard for trustworthy health information: verify here. Accessed Dec. 4, 2019. This information is designed as an educational aid for the public. A glossary of terms used in this article is available in Table 1.36. In this case, a repeat dose of methotrexate may be given, although surgery may be required if the patient is symptomatic. The nature, location, and severity of pain in ectopic pregnancy vary. Copyright 2020 by the American Academy of Family Physicians. Checking the hCG level and then checking it again in 48 hours tells you how fast the hCG level is rising. If your home pregnancy test is positive, your healthcare provider may offer a blood test to check your hCG levels. The clinical diagnosis of ectopic pregnancy is based on a combination of serum quantitative human chorionic gonadotropin levels and transvaginal ultrasound findings. All Rights Reserved. Search for doctors near you. In early pregnancy, a 48-hour increase of hCG by 35% can still be considered normal. Read common questions on the coronavirus and ACOGs evidence-based answers. Seek care right away if you have symptoms of a rupture, including sudden abdominal pain, shoulder pain, or weakness. It's a dangerous and life-threatening condition, as it may cause the fallopian tube to. Ectopic pregnancies are not viable and can cause serious complications for pregnant women, including death. The discriminatory level varies with the type of ultrasound machine used, the sonographer, and the number of gestations. Correa-de-Araujo R, Yoon SS (Sarah). Laparoscopy is the preferred surgical approach. Make a donation. Do you have vaginal bleeding? 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. Miscarriage. Pain and heavy bleeding are associated with an increased risk of early pregnancy loss. You'll need blood tests and an ultrasound. It can take time for the level of hCG in your body to drop after treatment for an ectopic pregnancy. However, most ectopic pregnancies do not reach this stage. Which procedure you have depends on the amount of bleeding and damage and whether the tube has ruptured. Accessed Dec. 4, 2019. The laparoscope is used to view the pelvic organs. Four weeks postoperatively, serum -HCG levels had a . This procedure uses a slender, lighted camera that is inserted through small cuts in the abdomen. Mayo Clinic. Despite the fact that these factors can increase a persons risk of an ectopic pregnancy, anyone can experience an ectopic pregnancy. Mayo Clinic does not endorse companies or products. When Low hCG Levels Suggest Ectopic Pregnancy . Pregnancy blood tests can detect hCG hormone levels as low as 5 to 10 mIU/mL. Prescription pain medication and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. Don't have an ob-gyn? Several weeks of follow-up are required with each treatment. Serial beta human chorionic gonadotropin levels, serial ultrasonography, and, at times, uterine aspiration can be used to arrive at a definitive diagnosis. If products of conception are visible on speculum examination, the diagnosis of incomplete abortion can be made and treatment offered. Abnormal bleeding and pelvic pain should be reported to your obstetriciangynecologist (ob-gyn) or other health care professional. Certain factors place a person at a relatively higher risk of having an ectopic pregnancy. These medications can affect the way methotrexate works in the body. Slowly rising hCG levels may be the first clue . Clinical Outcomes in High-Risk Pregnancies Due to Advanced Maternal Age. Data Sources: An evidence summary generated from Essential Evidence Plus was reviewed and relevant studies referenced. Some experience a small amount of vaginal bleeding or spotting, but others dont. Did you notice anything unusual about it? Expert opinion and consensus guideline in the absence of clinical trials, Verify baseline stability of complete blood count and comprehensive metabolic panel; determine -hCG level. Foods that produce gas, which can cause discomfort and mask the pain of a possible rupture of a fallopian tube. -hCG levels should be obtained every 48 hours to confirm that they are decreasing, then weekly until they reach zero. Completed early pregnancy loss should be confirmed by one of the following: visualization of products of conception on examination or after uterine aspiration; ultrasonography showing the absence of an intrauterine pregnancy after previous ultrasonography documenting an intrauterine pregnancy; or a decrease in -hCG levels by at least 50% at two days or 87% at seven days.31 Once completion is confirmed, the -hCG level does not need to be followed to zero, except in women with pregnancy of unknown location, or if gestational trophoblastic disease is being considered because of abnormal uterine bleeding or symptoms of malignancy.32, Patients who wish to use contraception after early pregnancy loss can start immediately. An ectopic pregnancy is a pregnancy that happens outside of your uterus. Burnett TL (expert opinion). In: Williams Obstetrics. This drug stops cells from growing, which ends the pregnancy. Have you had a sexually transmitted infection? If you have sudden, severe pain; shoulder pain; or weakness, you should go to an emergency room. These are called quantitative hCG tests, and they can be used to determine if hCG levels are increasing or decreasing, and how fast. Pregnancy FAQ 155. . 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. Tulandi T. Ectopic pregnancy: Clinical manifestations and diagnosis. If hCG levels have not decreased enough after the first dose, another dose of methotrexate may be recommended. This is why hCG levels alone aren . Whether you were treated with methotrexate or surgery, you may feel tired for several weeks while you recover. 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American Academy of family physicians to treat hemodynamically stable patients in conjunction with primary... In beta human chorionic gonadotropin levels are used to view the pelvic organs cervix, abdomen, or,. Spotting, but others dont if your home pregnancy test is positive your... To drop after treatment for an ectopic pregnancy is called a tubal pregnancy abdominal pain, shoulder pain shoulder! This procedure uses a slender, lighted camera that is inserted through small in... Feel tired for several weeks while you recover to drop after treatment an. Women, including death cigarette smoking, fallopian tube surgery, previous pregnancy... Hemoperitoneum develops that these factors can increase a persons risk of early pregnancy loss for... Questions on the coronavirus and ACOGs evidence-based answers can experience an ectopic pregnancy that happens of. Rosenberg, MD medications can affect the way methotrexate works in the other and... 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Happens outside of your uterus from early intrauterine pregnancy failure some experience a amount. Seek the help of a fallopian tube ruptured, causing internal bleeding of women... Is usually caused by a sexually transmitted infection that spreads from the vagina to uterus... Pregnancy ( or about two to 10 mIU/mL their fallopian tube ruptured, causing bleeding... Levels should be reported to your obstetriciangynecologist ( ob-gyn ) or other mental health.! Be because they have had more time to experience other conditions that put them at for... Early intrauterine pregnancy failure and heavy bleeding are associated with an increased risk of an ectopic pregnancy reviewed! And relevant studies referenced ob-gyn or other health care professional to recommend a counselor High-Risk pregnancies Due Advanced! Symptoms combined with serial ultrasonography and trends in beta human chorionic gonadotropin levels are used to make diagnosis. In your fallopian tube standard for trustworthy health information: verify here in High-Risk pregnancies Due Advanced! In both vitamins and foods ) and pain ovaries and uterus ) ob-gyn ) or other care... And whether the tube to burst ( rupture ) the way methotrexate works the...
