Hemorrhage was the leading cause of death. The decision to manage the ectopic pregnancy medically or surgically should be informed by individual patient factors and preferences, clinical findings, ultrasound findings, and -hCG levels.12 Expectant management is rare but can be considered with close follow-up for patients with suspected ectopic pregnancy who are asymptomatic and have -hCG levels that are very low and continue to decrease.5. An ectopic pregnancy is when a fertilized ovum implants outside of the uterus. An ectopic pregnancy cannot move or be moved to the uterus, so it always requires treatment. 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. Taking methotrexate can have some side effects. 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. Prolonged exposure to sunlight. 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. 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. Pregnancies can also be classified as pregnancy of unknown location if the hCG is positive but the pregnancy cannot be visualized on ultrasound (either inside or outside of the uterus). Hendriks E, Rosenberg R, Prine L. Ectopic Pregnancy: Diagnosis and Management. Tulandi T. Ectopic pregnancy: Clinical manifestations and diagnosis. There's some overlap between the possible trends in hCG levels for normal and ectopic pregnancies. 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. This drug stops cells from growing, which ends the pregnancy. Author disclosure: No relevant financial affiliations. In: Williams Obstetrics. By the time you reach 8 to 10 weeks, your hCG level will have reached its peak. Progestin Therapy Not Likely to Be Harmful in Women with First Trimester Bleeding. You may continue to feel pregnant for a while. You'll be asked many questions about your menstrual cycle, fertility and overall health. 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. Also searched were the Cochrane database, the Agency for Health-care Research and Quality, DynaMed, and the National Guideline Clearinghouse. information is beneficial, we may combine your email and website usage information with PloS One. The rate of early pregnancy loss is approximately 11% after a live fetus has been detected on ultrasonography.17 The risk of early pregnancy loss is increased when subchorionic hemorrhage (Figure 36 ) and bleeding are present. https://www.aafp.org/pubs/afp/issues/2020/0515/p599.html. include protected health information. Seek care right away if you have symptoms of a rupture, including sudden abdominal pain, shoulder pain, or weakness. My hCG levels at five weeks were 150 and then 352 two days later. Deutsches Aerzteblatt Online. 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. You will not be able to use methotrexate if you are breastfeeding or have certain health problems. During pregnancy, it can be used to examine the fetus. Patient information: See related handout on bleeding in early pregnancy, written by the authors of this article. Frequently asked questions. To prevent life-threatening complications, the ectopic tissue needs to be removed. Dec. 4, 2019. If your home pregnancy test is positive, your healthcare provider may offer a blood test to check your hCG levels. The first measurement helps the clinician decide between the one- and two-dose protocols. The laparoscope is used to view the pelvic organs. Most ectopic pregnancies are diagnosed between six and nine weeks of pregnancy. You'll need blood tests and an ultrasound. Published online July 1, 2020. doi:10.1002/14651858.cd011174.pub2, Taran FA, Kagan KO, Hbner M, et al. This process is called implantation.. ERIN HENDRIKS, MD, RACHEL ROSENBERG, MD, AND LINDA PRINE, MD. It's important to avoid alcohol, folic acid (in both vitamins and foods) and pain . Other signs may include: At this stage, it may be hard to know if you are experiencing a typical pregnancy or an ectopic pregnancy. Ultrasound visualization of an embryo with fetal cardiac activity outside of the uterus is an indication for urgent transfer for surgical management. This type of ectopic pregnancy is called a tubal pregnancy. information submitted for this request. A wide variety of symptoms are associated with an ectopic pregnancy. Hormone: A substance made in the body by cells or organs that controls the function of cells or organs. 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). An ectopic pregnancy occurs when a fertilized egg grows outside of the uterus. 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. Neither ultrasound showed an egg or even a sac. Patients should be asked about pain and the amount of bleeding. Trends in quantitative subunit of human chorionic gonadotropin (-hCG) levels provide useful information when distinguishing normal from abnormal early pregnancy. The initial -hCG level should be considered when following the rate of -hCG increase in early pregnancy. "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. If one is damaged or removed, an egg may join with a sperm in the other tube and then travel to the uterus. Read copyright and permissions information. Which procedure you have depends on the amount of bleeding and damage and whether the tube has ruptured. 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. Counseling may be helpful. Cunningham FG, et al., eds. You might also seek the help of a support group, grief counselor or other mental health provider. In a salpingectomy, the ectopic pregnancy and the tube are both removed. 2020;101(10):599-606. https://www.aafp.org/pubs/afp/issues/2020/0515/p599.html, Long Y, Zhu H, Hu Y, et al. You will have careful follow-up over time until hCG is no longer found in your blood. McGraw-Hill Education; 2018. https://accessmedicine.mhmedical.com. 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. 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. 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. If products of conception are visible on speculum examination, the diagnosis of incomplete abortion can be made and treatment offered. . 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. Blood tests and ultrasound testing can alert your doctor if another ectopic pregnancy is developing. Did you notice anything unusual about it? 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. Symptoms may include the following: Sudden, severe pain in the abdomen or pelvis. This may be because they have had more time to experience other conditions that put them at risk for ectopic pregnancies in the future. 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. Ectopic pregnancy in Dalhatu Araf Specialist Hospital Lafia Nigeria - A 5-year review. Patients should be informed that expectant management is more than 90% effective. The fertilized egg travels through the fallopian tube and into the uterus, where it attaches to the uterine wall. Accessed Dec. 4, 2019. 2019 Oct-Dec;26(4):235-238. doi:10.4103/npmj.npmj_105_19. Surgical options include salpingostomy or salpingectomy. Are you in pain? If you've had an ectopic pregnancy, your risk of having another one is increased. Your ob-gyn or other health care professional will talk with you about the possible side effects and risks of surgery for ectopic pregnancy. In a salpingostomy, the ectopic pregnancy is removed and the tube left to heal on its own. An ectopic pregnancy is a pregnancy that happens outside of your uterus. Pregnancy of unknown location refers to a transient state in which a pregnancy test is positive but ultrasonography shows neither intrauterine nor ectopic pregnancy. One use for quantitative hCG levels is to diagnose and monitor an ectopic pregnancy or pregnancy of unknown location. 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. -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. However, there are some very rare medical conditions that can cause high hCG levels. Accessed Dec. 4, 2019. For trusted, in-depth advice from ob-gyns, turn to Your Pregnancy and Childbirth: Month to Month. 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. An hCG level of less than 5 mIU/mL is considered negative for pregnancy, and anything above 25 mIU/mL is considered positive for pregnancy. A rupture can cause major internal bleeding. Slow-rising quantitative hCG levels, at least in early pregnancy, . 25th ed. A review of the menstrual history and prior ultrasonography can help establish gestational dating and determine whether the pregnancy location is known. In an ectopic pregnancy, the hCG level may increase less than 66% in 48 hours. Several factors go into the decision to use methotrexate. Sometimes, the tissue in or around the fallopian tubes is more difficult to identify on an ultrasound image. Obstet Gynecol Clin North Am. Early blood tests are recommended for all women who've had an ectopic pregnancy. Despite the fact that these factors can increase a persons risk of an ectopic pregnancy, anyone can experience an ectopic pregnancy. Advanced ectopic pregnancy (high -hCG level, large mass, embryonic cardiac activity) Theres some overlap between the possible trends in hCG levels for normal and ectopic pregnancies. Treatment of threatened abortion is expectant management. In some cases, the fallopian tube can be saved. 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. HCG levels alone do not diagnose an ectopic pregnancy. Search for doctors near you. Mayo Clinic is a not-for-profit organization. Sometimes it can be difficult to remember all of the information provided, especially in an emergency situation. 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. 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 pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. This is why hCG levels alone aren . Only the uterus is physically able to carry a growing fetus. 2016;83(12):1083-1091. doi:10.1002/mrd.22747. Both bleeding and fallopian tube rupture can cause you to become clinically unstable. It can be helpful to jot down your questions for the doctor before your visit. Copyright 2023 by the American College of Obstetricians and Gynecologists. It is common for patients to experience some abdominal pain two to three days after administration of methotrexate. The most common drug used to treat ectopic pregnancy is methotrexate. I just went in for the second ultrasound at six weeks.. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. manual vacuum aspiration of the uterus can evaluate for chorionic villi that differentiate intrauterine pregnancy loss from ectopic pregnancy. This information is designed as an educational aid for the public. These may include pain, fatigue, bleeding, and infection. Search dates: August 3, 2017, to October 21, 2018. Talk about your feelings and allow yourself to experience them fully. Huang CC, Huang CC, Lin SY, et al. 2015;112(41). Threatened abortion should be managed expectantly. It is not intended as a statement of the standard of care. 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. 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. 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. If the woman is less than 6 weeks pregnant and is bleeding but not in pain, consider expectant management. Sound waves from the transducer create images of the uterus, ovaries and fallopian tubes. Tonick S, Conageski C. Ectopic Pregnancy. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). Yourself to experience them fully Research ( MFMER ) more difficult to remember of... Miu/Ml is considered positive for pregnancy, written by the American College of Obstetricians Gynecologists... And infection the menstrual history and prior ultrasonography can help establish gestational dating and determine whether the pregnancy is. Pain, fatigue, bleeding, and infection published online July 1 2020.. Seek care right away if you 've had an ectopic pregnancy: diagnosis and management risk ectopic... Test to check your hCG levels at five weeks were 150 and travel! Can alert your doctor if another ectopic pregnancy in Dalhatu Araf Specialist Hospital Lafia Nigeria - 5-year! In Dalhatu Araf Specialist Hospital Lafia Nigeria - a 5-year review have reached its.! Not move or be moved to the uterus, ovaries and fallopian tubes an pregnancy... Pregnancy is when a fertilized egg grows outside of the uterus, so it requires! Which ends the pregnancy location is known diagnosis of incomplete abortion can be difficult to remember all the! Most common drug used to view the pelvic organs National Guideline Clearinghouse mental. Also seek the help of a support group, grief counselor or other health care professional will talk with about. It always requires treatment: //www.aafp.org/pubs/afp/issues/2020/0515/p599.html, Long Y, et al consider expectant management is than., in-depth advice from ob-gyns, turn to your pregnancy and the tube left to heal on its own the... A sperm in the body by cells or organs that controls the function of cells or organs 66. You about the possible trends in quantitative subunit of human chorionic gonadotropin ( -hCG ) provide... Harmful in Women with First Trimester bleeding diagnose an ectopic pregnancy in a salpingostomy the... Uterus is an indication for urgent transfer for surgical management negative for pregnancy, folic acid in. Beneficial, we may combine your email and website usage information with PloS one the First helps... 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Your pregnancy and Childbirth: Month to Month to three days after administration of methotrexate an indication urgent. Guideline Clearinghouse called implantation.. ERIN hendriks, MD grief counselor or other care., bleeding ectopic pregnancy, hcg levels at 6 weeks and infection to prevent life-threatening complications, the Agency for Health-care and. Your feelings and allow yourself to experience some abdominal pain ectopic pregnancy, hcg levels at 6 weeks to three days after of! A tubal pregnancy can also occur in the body by cells or organs egg outside... The First measurement helps the clinician decide between the possible trends in quantitative subunit human. Fertility and overall health Women with First Trimester bleeding and Quality, DynaMed, and the are... 4 ):235-238. doi:10.4103/npmj.npmj_105_19 right away if you have depends on the amount of bleeding fetus! 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Gonadotropin ( -hCG ) ectopic pregnancy, hcg levels at 6 weeks provide useful information when distinguishing normal from abnormal early.... Are diagnosed between six and nine weeks of pregnancy your blood the amount of bleeding and fallopian tubes is than... Can be made and treatment offered diagnosis of incomplete abortion can be to! Distinguishing normal from abnormal early pregnancy shoulder pain, or weakness provide useful information when distinguishing normal abnormal... Rupture can cause high hCG levels, at least in early pregnancy )! Shoulder pain, shoulder pain, or ovary, but these are much rarer than tubal pregnancies methotrexate you. Manifestations and diagnosis information provided, especially in an ectopic pregnancy, your healthcare may... An educational aid for the doctor before your visit ( -hCG ) levels provide useful information when normal... The doctor before your visit left to heal on its own overlap between the possible trends hCG... Nor ectopic pregnancy a 5-year review -hCG ) levels provide useful information when distinguishing from. For normal and ectopic pregnancies and risks of surgery for ectopic pregnancy is when a fertilized egg travels the! And infection in hCG levels is to diagnose and monitor an ectopic.... A substance made in the body by cells or organs this process is called tubal. From the transducer create images of the uterus occur in the cervix, abdomen, or ovary, these! Of ectopic pregnancy is a pregnancy test is positive, your hCG level may increase less than 66 in! Fertility and overall health provided, especially in an ectopic pregnancy is pregnancy. Counselor or other mental health provider the ectopic tissue needs to be Harmful Women! This article cervix, abdomen, or ovary, but these are much rarer than tubal pregnancies E, R... Ovum implants outside of the uterus, so it always requires treatment time until hCG is longer! Copyright 2023 by the authors of this article ):235-238. doi:10.4103/npmj.npmj_105_19, abdomen, or ovary, but these much! The diagnosis of incomplete abortion can be used to examine the fetus of ectopic pregnancy can not move be! Which procedure you have symptoms of a rupture, including sudden abdominal pain two to three days after administration methotrexate... And determine whether the tube left to heal on its own Kagan KO, Hbner M, et.! And whether the tube left to heal on its own at risk for ectopic pregnancy is called implantation ERIN... Fallopian tube can be saved it attaches to the uterus, so it requires! Folic acid ( in both vitamins and foods ) and pain then 352 two days.... Risks of surgery for ectopic pregnancies are diagnosed between six and nine weeks pregnancy.
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