Others may present in shock because their fallopian tube ruptured, causing internal bleeding. However, emergency medical help is needed if you develop these warning signs or symptoms of an ectopic pregnancy: Call 911 (or your local emergency number) or go to the hospital if you have the above symptoms. -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. You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. A history of ectopic pregnancies or a history of surgery on the fallopian tubes are the factors that most increase the risk. A folate antagonist, it interrupts the rapidly dividing cells of the ectopic pregnancy, which are then resorbed by the body.22 Its success rate decreases with higher initial -hCG levels (Table 3).23 Contraindications to methotrexate include renal insufficiency; moderate to severe anemia, leukopenia, or thrombocytopenia; liver disease or alcoholism; active peptic ulcer disease; and breastfeeding.5 Therefore, a complete blood count and comprehensive metabolic panel should be obtained before it is administered. These medications can affect the way methotrexate works in the body. If you're diagnosed with an ectopic pregnancy, your doctor may also order tests to check your blood type in case you need a transfusion. Obstet Gynecol Clin North Am. Some people with ectopic pregnancies are more stable at the time theyre diagnosed. This site complies with the HONcode standard for trustworthy health information: verify here. If hCG levels have not decreased enough after the first dose, another dose of methotrexate may be recommended. 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. 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. Terms and Conditions of Use, Get the latest on COVID-19, pregnancy, and breastfeeding. In an ectopic pregnancy, the hCG level may increase less than 66% in 48 hours. It uses sound waves to create images of your uterus, ovaries and fallopian tubes, and sends the pictures to a nearby monitor. An ectopic pregnancy is when the fertilized egg remains in the fallopian tube and continues to develop. It is done in a hospital with general anesthesia. See permissionsforcopyrightquestions and/or permission requests. As an ectopic pregnancy grows, more serious symptoms may develop, especially if a fallopian tube ruptures. Several weeks of follow-up are required with each treatment. All patients should be instructed to seek care if they have symptoms of anemia or heavy bleeding, quantified as soaking through more than two sanitary pads per hour for two consecutive hours.3. Established criteria should be used to determine treatment options for ectopic pregnancy, including expectant management, medical management with methotrexate, or surgical intervention. Trends in quantitative subunit of human chorionic gonadotropin (-hCG) levels provide useful information when distinguishing normal from abnormal early pregnancy. Treatment failure is assumed if the -hCG level plateaus or increases from days 4 to 7. This drug stops cells from growing, which ends the pregnancy. In an ectopic pregnancy, the fertilized egg implants somewhere other than the lining of the uterus. Have you had a sexually transmitted infection? If you've had an ectopic pregnancy, your risk of having another one is increased. Urine pregnancy tests work by turning positive if they detect the presence of hCG. In the case of an ectopic pregnancy, the hCG level may just plateau or increase at a very slow rate, but . Molecular Reproduction and Development. Hemorrhage was the leading cause of death. Have you taken a pregnancy test? After the injection, your doctor will order another HCG test to determine how well treatment is working, and if you need more medication. 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. Abdominal ultrasound, in which an ultrasound wand is moved over your belly, may be used to confirm your pregnancy or evaluate for internal bleeding. The search included meta-analyses, guidelines, and reviews. 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. Ectopic pregnancies and normal pregnancies require very different medical management. 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). Ultrasound Exam: A test in which sound waves are used to examine internal structures. Frequently asked questions. 2020;30(2). hCG levels at 6 weeks: 1,080-56,500 mIU/ml hCG levels at 7-8 weeks: 7,650-229,000 mIU/ml hCG levels at 9-12 weeks: 25,700-288,000 mIU/ml hCG levels at 13-16 weeks: 13,300-254,000 mIU/ml hCG levels at 17-24 weeks: 4,060-165,400 mIU/ml hCG levels at 25-40 weeks: 3,640-117,000 mIU/ml hCG levels if not pregnant: 0-5 mIU/ml This can be a life-threatening emergency that needs immediate surgery. 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. Cunningham FG, et al., eds. | In: Williams Obstetrics. Explore ACOG's library of patient education pamphlets. Some people have no symptoms at all. Many people who have an ectopic pregnancy had no risk factors at all. Ectopic pregnancies are uncommon, but theyre very serious and can be life-threatening. Your ob-gyn or other health care professional will talk with you about the possible side effects and risks of surgery for ectopic pregnancy. https://www.uptodate.com/contents/search. When Low hCG Levels Suggest Ectopic Pregnancy . PloS One. 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. Human chorionic gonadotropin, or hCG, is a hormone produced by the placenta during pregnancy. 2019 Oct-Dec;26(4):235-238. doi:10.4103/npmj.npmj_105_19. Also searched were the Cochrane database, DynaMed, and the National Guideline Clearinghouse. When an intrauterine pregnancy is detected on ultrasonography but viability is uncertain, repeat ultrasonography should be performed in seven to 10 days to confirm viability.3,5 In these cases, a normal increase in the -hCG level or a normal progesterone level can be reassuring. Laparoscopy: A surgical procedure in which an instrument called a laparoscope is inserted into the pelvic cavity through a small incision. It's very important that the diagnosis of ectopic pregnancy is certain before receiving this treatment. Depending on your symptoms and when the ectopic pregnancy is discovered, this may be done using medication, laparoscopic surgery or abdominal surgery. Also searched were the Cochrane database, the Agency for Health-care Research and Quality, DynaMed, and the National Guideline Clearinghouse. Copyright 2023 American Academy of Family Physicians. Advanced ectopic pregnancy (high -hCG level, large mass, embryonic cardiac activity) An ectopic pregnancy is when a fertilized ovum implants outside of the uterus. 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. HCG levels alone do not diagnose an ectopic pregnancy. 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. An intra-uterine pregnancy can usually be seen by 5-6 weeks gestation or when the HCG level is more than 1000 IU/l. Make a donation. 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. In stable patients, close monitoring of symptoms, serial quantitative -hCG testing, and ultrasonography are recommended4 (Figure 28,10,14,15 ). Search for doctors near you. information highlighted below and resubmit the form. Ask your ob-gyn or other health care professional to recommend a counselor. A meta-analysis evaluating the accuracy of a single progesterone test to predict pregnancy outcome in women with first trimester bleeding showed that a level less than 6 ng per mL (19.1 nmol per L) reliably excludes viable pregnancy, with a negative predictive value of 99%.13 A low progesterone level cannot distinguish intrauterine pregnancy from ectopic pregnancy.13, A baseline hemoglobin level should be documented for all women with bleeding during pregnancy. Theres some overlap between the possible trends in hCG levels for normal and ectopic pregnancies. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. Author disclosure: No relevant financial affiliations. The most common drug used to treat ectopic pregnancy is methotrexate. An hCG level between 6 and 24 mIU/mL is considered a grey area, and you'll likely need to be retested to see if your levels rise to confirm a pregnancy. PID is usually caused by a sexually transmitted infection that spreads from the vagina to the uterus and fallopian tubes. Ectopic pregnancies remain an important cause of morbidity and mortality in women of reproductive age. Setting a low -HCG cutoff value increases the sensitivity of ultrasound and -hCG at diagnosing an ectopic . Ultrasound Transvaginal ultrasound A transvaginal ultrasound allows your doctor to see the exact location of your pregnancy. information submitted for this request. If hCG levels plateau or rise, reassess the woman's condition for further treatment. Serial beta human chorionic gonadotropin levels, serial ultrasonography, and, at times, uterine aspiration can be used to arrive at a definitive diagnosis. Mayo Clinic does not endorse companies or products. Seek care right away if you have symptoms of a rupture, including sudden abdominal pain, shoulder pain, or weakness. The medication is given by injection. Dec. 4, 2019. Neither ultrasound showed an egg or even a sac. The clinical diagnosis of ectopic pregnancy is based on a combination of serum quantitative human chorionic gonadotropin levels and transvaginal ultrasound findings. the unsubscribe link in the e-mail. This condition is usually diagnosed during surgery, as radiologists may not pay enough attention to the contralateral side of interest. 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. 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. In a normal pregnancy, the egg is fertilized by a sperm. There are two methods used to treat an ectopic pregnancy: 1) medication and 2) surgery. 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. It can also possibly indicate an ectopic pregnancy that is 'self-resolving'. About one half of all women who have an ectopic pregnancy do not have known risk factors. What are my chances of having a healthy pregnancy in the future? Expectant management, medical management, and uterine aspiration are safe and effective treatments for early pregnancy loss. Blood tests can determine how high the hCG level is. 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. Blood tests measuring hCG levels can also be used to check how well your pregnancy is progressing. 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. Levels should then double every 48 hours from weeks four to six, but that isn't the case for everyone. 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. By 6 to 7 weeks gestation doubling time decreases to roughly every 3 days. Several factors go into the decision to use methotrexate. In-vitro fertilization (IVF) also increases the chance of 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. 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. Nonviable intrauterine pregnancy within the first 12 6/7 weeks of gestation: Ectopic pregnancy: . In some cases, the fallopian tube can be saved. Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. Patients should be counseled that the risk of rupture persists until -hCG levels are undetectable, and that they should seek emergency care if signs of ectopic pregnancy occur. It is appropriate for family physicians to treat hemodynamically stable patients in conjunction with their primary obstetrician. In a healthy pregnancy, the hCG level typically doubles every 48 hours. In early pregnancy, a 48-hour increase of hCG by 35% can still be considered normal. Known risk factors at all than the lining of the uterus a counselor cutoff value increases the of! With the HONcode standard for trustworthy health information: verify here the risk to. 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