Cunningham FG, et al., eds. Recognize the loss, and give yourself time to grieve. 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. Also searched were the Cochrane database, DynaMed, and the National Guideline Clearinghouse. Pregnancy that develops outside the uterus is called ectopic pregnancy. 25th ed. 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. If so, what was the outcome of each pregnancy? Once you have had an ectopic pregnancy, you are at higher risk of having another one. There is a problem with 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. 2020;30(2). For some women, ectopic pregnancy can be traumatic. It offers current information and opinions related to women's health. The search included meta-analyses, randomized controlled trials, clinical trials, guidelines, and reviews. 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. 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. American College of Obstetricians and Gynecologists. This triggers the uterus lining to grow and produce other hormones that help keep a pregnancy going. This drug stops cells from growing, which ends the pregnancy. Sunlight exposure during treatment can cause methotrexate dermatitis and should be avoided.5 Other adverse effects of methotrexate include alopecia and elevation of liver enzymes. 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. Medical management is safe and effective in carefully selected patients. If your home pregnancy test is positive, your healthcare provider may offer a blood test to check your hCG levels. Ultrasound Transvaginal ultrasound A transvaginal ultrasound allows your doctor to see the exact location of your pregnancy. 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). 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. You can detect hCG in either blood or urine . If the ectopic pregnancy has ruptured a tube, emergency surgery is needed. The embryologic events of early pregnancy occur in a predictable, stepwise fashion. In this instance, a health care provider can order a test for the hCG level. Patients should be counseled to avoid repeat pregnancy until at least one ovulatory cycle after the serum -hCG level becomes undetectable, although some experts recommend waiting three months so that the methotrexate can be cleared completely.27 There is no evidence that methotrexate therapy affects future fertility.28. Sometimes, the tissue in or around the fallopian tubes is more difficult to identify on an ultrasound image. 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. Other instruments can be used with it to perform surgery. As an ectopic pregnancy grows, more serious symptoms may develop, especially if a fallopian tube ruptures. This cutoff level of -hCG varies by institution but ranges from 1500 to 2500 mIU/ml. Pregnancy tests look for hCG (human chorionic gonadotropin) which is excreted in pregnancy. Vital signs indicating hemodynamic instability or peritoneal signs on physical examination require emergent evaluation. It is not intended as a statement of the standard of care. . Rho(D) immune globulin can also be administered within 72 hours of early pregnancy loss, especially later in the first trimester, although the risk of alloimmunization is estimated to be 1.5% to 2% in this setting.12 There is insufficient evidence for or against the use of Rho(D) immune globulin in Rh-negative patients who present with threatened abortion. After this . However, if a person's hCG level is rising slowly or decreasing, this suggests that the pregnancy may be ectopic. Ectopic pregnancies are not viable and can cause serious complications for pregnant women, including death. Abdominal ultrasound, in which an ultrasound wand is moved over your belly, may be used to confirm your pregnancy or evaluate for internal bleeding. Terms and Conditions of Use, Get the latest on COVID-19, pregnancy, and breastfeeding. Human chorionic gonadotropin (hCG) is a hormone thats very important throughout pregnancy. Also searched were the Cochrane database, the Agency for Health-care Research and Quality, DynaMed, and the National Guideline Clearinghouse. Copyright 2023 American College of Obstetricians and Gynecologists, Privacy Statement Data Sources: An evidence summary from Essential Evidence Plus was reviewed and relevant studies referenced. privacy practices. People who are older at the time of pregnancy also have an increased risk of ectopic pregnancy. If you are pregnant, you can detect it in your urine. Because ectopic pregnancies can be life-threatening, early diagnosis is essential. Some people with ectopic pregnancies are more stable at the time theyre diagnosed. Get the Stats on Ectopic Pregnancies. 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). 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. Will I need to follow any special precautions if I become pregnant again? 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. 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. Methotrexate may be used if the pregnancy has not ruptured a fallopian tube. This does not require the removal of the fallopian tube. Mayo Clinic. The initial -hCG level should be considered when following the rate of -hCG increase in early 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. Checking the hCG level and then checking it again in 48 hours tells you how fast the hCG level is rising. Pregnancy FAQ 155. 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. This combination should make an obstetrician-gynecologist consider the possibility of an ectopic pregnancy. This information is designed as an educational aid for the public. Surgery typically is done with laparoscopy. 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 the ectopic pregnancy is causing heavy bleeding, you might need emergency surgery. Serial beta human chorionic gonadotropin levels, serial ultrasonography, and, at times, uterine aspiration can be used to arrive at a definitive diagnosis. information highlighted below and resubmit the form. hCG can vary from person to person and still mean a pregnancy is normal. I've had two ultrasounds: one at about five weeks and one at six weeks. Risk factors include a history of pelvic inflammatory disease, cigarette smoking, fallopian tube surgery, previous ectopic pregnancy, and infertility. Ectopic pregnancies occur in approximately 1.3 to 2.4% of pregnancies. It is common for patients to experience some abdominal pain two to three days after administration of methotrexate. 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. Obstet Gynecol Clin North Am. 2016;83(12):1083-1091. doi:10.1002/mrd.22747. Copyright 2019 by the American Academy of Family Physicians. 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. Most women have some abdominal pain. Copyright 2023 American Academy of Family Physicians. A history of ectopic pregnancies or a history of surgery on the fallopian tubes are the factors that most increase the risk. When Low hCG Levels Suggest Ectopic Pregnancy . An ectopic pregnancy is when a fertilized ovum implants outside of the uterus. McGraw-Hill Education; 2018. https://accessmedicine.mhmedical.com. About one half of all women who have an ectopic pregnancy do not have known risk factors. In 95% of ectopic pregnancy cases, a good transvaginal ultrasound examination can actually image the ectopic pregnancy in the Fallopian tube. 2020;101(10):599-606. https://www.aafp.org/pubs/afp/issues/2020/0515/p599.html, Long Y, Zhu H, Hu Y, et al. Methotrexate can cause sun sensitivity. If hCG levels plateau or rise, reassess the woman's condition for further treatment. Pregnancy of unknown location refers to a transient state in which a pregnancy test is positive but ultrasonography shows neither intrauterine nor ectopic pregnancy. Talk about your feelings and allow yourself to experience them fully. By 6 to 7 weeks gestation doubling time decreases to roughly every 3 days. Deutsches Aerzteblatt Online. An intra-uterine pregnancy can usually be seen by 5-6 weeks gestation or when the HCG level is more than 1000 IU/l. Your doctor may also test your progesterone levels because low levels could be a sign of an ectopic pregnancy. This procedure uses a slender, lighted camera that is inserted through small cuts in the abdomen. Slowly rising hCG levels may be the first clue . Patient information: See related handout on bleeding in early pregnancy, written by the authors of this article. The pain may become more generalized once the tube ruptures and hemoperitoneum develops. Early blood tests are recommended for all women who've had an ectopic pregnancy. Treatment options for early pregnancy loss include expectant management, medical management with mifepristone and misoprostol, or uterine aspiration. Methotrexate often is given by injection in one dose. It is not a substitute for the advice of a physician. Ask your ob-gyn or other health care professional to recommend a counselor. To prevent life-threatening complications, the ectopic tissue needs to be removed. The clinical diagnosis of ectopic pregnancy is based on a combination of serum quantitative human chorionic gonadotropin levels and transvaginal ultrasound findings. 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. 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. A single copy of these materials may be reprinted for noncommercial personal use only. 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. 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. 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. For this test, a wandlike device is placed into your vagina. Patient preference should guide treatment decisions. Intramuscular methotrexate is the only medication appropriate for the management of ectopic pregnancy. See permissionsforcopyrightquestions and/or permission requests. Severe abdominal or pelvic pain accompanied by vaginal bleeding. Did you notice anything unusual about it? 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. Several factors go into the decision to use methotrexate. 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]). Sometimes it can be difficult to remember all of the information provided, especially in an emergency situation. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. The doctor might recommend an office visit or immediate medical care. Laparoscopy is the preferred surgical approach. Make a donation. Setting a low -HCG cutoff value increases the sensitivity of ultrasound and -hCG at diagnosing an ectopic . However, most ectopic pregnancies do not reach this stage. Ectopic pregnancies and normal pregnancies require very different medical management. Accessed Dec. 4, 2019. A rupture can cause major internal bleeding. This content is owned by the AAFP. All Rights Reserved. Ectopic pregnancies remain an important cause of morbidity and mortality in women of reproductive age. 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. Patients should be informed that expectant management is more than 90% effective. Bilateral ectopic pregnancy is extremely rare, with a tremendous maternal mortality and morbidity risk, requiring rapid diagnosis and management. Dec. 4, 2019. If you don't require emergency treatment and haven't yet been diagnosed with an ectopic pregnancy, your doctor will talk to you about medical history and symptoms. Urine pregnancy tests work by turning positive if they detect the presence of hCG. It can take time for the level of hCG in your body to drop after treatment for an ectopic pregnancy. It uses sound waves to create images of your uterus, ovaries and fallopian tubes, and sends the pictures to a nearby monitor. Failure to detect an intrauterine pregnancy, combined with -hCG levels higher than the discriminatory level, should raise concern for early pregnancy loss or ectopic pregnancy. If you are a Mayo Clinic patient, this could Are you being treated for any other medical conditions? Patients may switch to medical management or uterine aspiration at any time. It may take a few cycles for your periods to return to normal. American Family Physician. Four weeks postoperatively, serum -HCG levels had a . . doi:10.1371/journal.pone.0219351, Nio-Kobayashi J, Abidin HBZ, Brown JK, et al. 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. Pregnancy of unknown location describes the scenario in which a pregnancy test is positive, but neither intrauterine nor ectopic pregnancy is shown on ultrasonography. 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. 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. An hCG level that is lower than expected is one reason to suspect an ectopic pregnancy. Women with an ectopic pregnancy may have irregular bleeding and pelvic or abdominal pain, often on one side. They can even be life-threatening. Early pregnancy loss can be definitively diagnosed in women with ultrasound findings of a mean gestational sac diameter of 25 mm or greater and no embryo or embryonic cardiac activity when the crown-rump length is at least 7 mm. Burnett TL (expert opinion). Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. Call your doctor's office if you have light vaginal bleeding or slight abdominal pain. 2022 Sep;49(3):537-549. doi:10.1016/j.ogc.2022.02.018. In: Williams Obstetrics. 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. The behavior of this hormone can help detect a dangerously abnormal pregnancy. 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. However, there are some very rare medical conditions that can cause high hCG levels. Serious symptoms may develop, especially if a fallopian tube become pregnant again different medical management more. Once you have had an ectopic pregnancy time to grieve early diagnosis is essential on. 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Mortality and morbidity risk, requiring rapid diagnosis and management and effective in selected. Serious symptoms may develop, especially if a fallopian tube device is placed your! Intra-Uterine pregnancy can be traumatic other health care provider can order a test for the management of ectopic may. Examination can actually image the ectopic pregnancy, and the National Guideline Clearinghouse the exact location of your uterus ovaries! And then checking it again in 48 hours tells you how fast the hCG level not... Of Family Physicians may switch to medical management with mifepristone and misoprostol, or uterine..