Expectant management, medical management, and uterine aspiration are safe and effective treatments for early pregnancy loss. Association of pelvic inflammatory disease (PID) with ectopic pregnancy and preterm labor in Taiwan: A nationwide population-based retrospective cohort study. 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. Clinical Outcomes in High-Risk Pregnancies Due to Advanced Maternal Age. Ectopic pregnancies happen when a fertilized egg implants somewhere outside of the uterus, like the fallopian tube or the cervix. An ectopic pregnancy is when a fertilized ovum implants outside of the uterus. These are called quantitative hCG tests, and they can be used to determine if hCG levels are increasing or decreasing, and how fast. About one half of all women who have an ectopic pregnancy do not have known risk factors. Pregnancy FAQ 155. In general, 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. Deviations from this established pattern should raise suspicion for early pregnancy loss or ectopic pregnancy (Table 2).4,5 Guidelines have been established for ultrasound diagnosis of early pregnancy loss to decrease the risk of false diagnosis and intervention in a desired viable intrauterine pregnancy. Levels of this hormone increase during pregnancy. Human chorionic gonadotropin (hCG) is a hormone normally produced by the placenta. . Sound waves from the transducer create images of the uterus, ovaries and fallopian tubes. This combination should make an obstetrician-gynecologist consider the possibility of an ectopic pregnancy. Pregnancy blood tests can detect hCG hormone levels as low as 5 to 10 mIU/mL. Urgent surgical referral is indicated when ultrasonography demonstrates an embryo and fetal cardiac activity outside of the uterus. . 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. The discriminatory -hCG level used at different. An ectopic pregnancy occurs when a fertilized egg grows outside of the uterus. You can detect hCG in either blood or urine . 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. All Rights Reserved. In some cases, the fallopian tube can be saved. A speculum examination can help identify nonobstetric causes of bleeding, such as vaginitis, cervicitis, or a cervical polyp. 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. This occurs when a fertilized egg implants in a location that can't support its growth. Further evaluation is needed unless a definitive nonobstetric cause of bleeding is found or products of conception are seen (Figure 1).8, The subunit of human chorionic gonadotropin (-hCG) can be detected in the plasma of a pregnant woman as early as eight days after ovulation.9 Quantitative -hCG levels can provide useful information in early pregnancy. That could be worrisome, but then there isn't usually evidence of a baby at 4 to 5 weeks or at my hCG level, 200. Visualization of chorionic villi differentiates intrauterine pregnancy loss from ectopic pregnancy, avoiding unnecessary administration of methotrexate. The clinical manifestations and diagnosis of ectopic pregnancy are reviewed here with a focus on tubal pregnancy. If theres a mass in the area of the fallopian tubes or ovary, this may represent an ectopic pregnancy. Data Sources: An evidence summary generated from Essential Evidence Plus was reviewed and relevant studies referenced. Nonviable intrauterine pregnancy within the first 12 6/7 weeks of gestation: Ectopic pregnancy: . 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. Obstet Gynecol Clin North Am. Bilateral ectopic pregnancy is extremely rare, with a tremendous maternal mortality and morbidity risk, requiring rapid diagnosis and management. Tulandi T. Ectopic pregnancy: Clinical manifestations and diagnosis. A review of the menstrual history and prior ultrasonography can help establish gestational dating and determine whether the pregnancy location is known. Levels should then double every 48 hours from weeks four to six, but that isn't the case for everyone. When Low hCG Levels Suggest Ectopic Pregnancy . By 6 to 7 weeks gestation doubling time decreases to roughly every 3 days. Only the uterus is physically able to carry a growing fetus. Laparoscopy: A surgical procedure in which an instrument called a laparoscope is inserted into the pelvic cavity through a small incision. Complications Is an Ectopic Pregnancy Dangerous? An early ectopic pregnancy without unstable bleeding is most often treated with a medication called methotrexate, which stops cell growth and dissolves existing cells. 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]). If you have pain that does not respond to over-the-counter medication, talk with your ob-gyn or other health care professional. Depending on your symptoms and when the ectopic pregnancy is discovered, this may be done using medication, laparoscopic surgery or abdominal surgery. Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. A wide variety of symptoms are associated with an ectopic pregnancy. It can also possibly indicate an ectopic pregnancy that is 'self-resolving'. The medication is given by injection. If you are a Mayo Clinic patient, this could Symptoms may include the following: Sudden, severe pain in the abdomen or pelvis. Ectopic pregnancies are not viable and can cause serious complications for pregnant women, including death. In 95% of ectopic pregnancy cases, a good transvaginal ultrasound examination can actually image the ectopic pregnancy in the Fallopian tube. 2022 Sep;49(3):537-549. doi:10.1016/j.ogc.2022.02.018. Declining or low rate of increase in hCG over 48 hours can be a sign of an ectopic pregnancy or miscarriage. It's important to avoid alcohol, folic acid (in both vitamins and foods) and pain . The doctor might recommend an office visit or immediate medical care. Also a factor is whether your other fallopian tube is normal or shows signs of prior damage. This content does not have an English version. After this . It can be helpful to jot down your questions for the doctor before your visit. Pain and heavy bleeding are associated with an increased risk of early pregnancy loss. The risk factors for ectopic pregnancy include the following: Certain sexually transmitted infections (STIs). Overall, surgical management has a higher success rate for ectopic pregnancy than methotrexate.5 The initial -hCG level at which to transfer a patient for possible surgical treatment depends on local standards, although a level of 5,000 mIU per mL (5,000 IU per L) is commonly used.5,11 Ultrasound visualization of an embryo with fetal cardiac activity outside of the uterus is an indication for urgent transfer for surgical management.5,25 Additionally, social factors that preclude frequent laboratory testing (e.g., poor telephone access, work and family obligations, lack of transportation) can make surgical management the safer option5 (Table 55,11). 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. Dr. Ewan is a physician with a background in pediatrics. 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. Typically, however, a ruptured tube must be removed. If the woman is less than 6 weeks pregnant and is bleeding but not in pain, consider expectant management. In addition to her MD, she holds a Master of Public Health degree. This does not require the removal of the fallopian tube. Pelvic Inflammatory Disease: An infection of the uterus, fallopian tubes, and nearby pelvic structures. Signs of ectopic pregnancy (e.g., adnexal mass, fluid in the cul-de-sac) can be seen on ultrasonography well below the discriminatory level. Endometriosis: A condition in which tissue that lines the uterus is found outside of the uterus, usually on the ovaries, fallopian tubes, and other pelvic structures. 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. I just went in for the second ultrasound at six weeks.. 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. Pregnancy of unknown location. Symptoms of ectopic pregnancy develop between weeks 4 and 12 of pregnancy (or about two to 10 weeks after fertilization). https://www.uptodate.com/contents/search. Levels of this hormone increase during pregnancy. Could You Have Subclinical Hypothyroidism? privacy practices. Kelly Gleason describes the roller coaster of a miscarriage and ectopic pregnancy diagnosis, and the importance of shared decision making. Salpingostomy and salpingectomy are two laparoscopic surgeries used to treat some ectopic pregnancies. Read common questions on the coronavirus and ACOGs evidence-based answers. Get the Stats on Ectopic Pregnancies. In: Williams Obstetrics. You might show signs of being in shock, such as a very high heart rate and very low blood pressure. Urine pregnancy tests work by turning positive if they detect the presence of hCG. If hCG levels plateau or rise, reassess the woman's condition for further treatment. Patients undergoing expectant management must receive extensive counseling on the risk of tubal rupture and the importance of close surveillance. 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). The laparoscope is used to view the pelvic organs. Other signs may include: At this stage, it may be hard to know if you are experiencing a typical pregnancy or an ectopic pregnancy. It offers current information and opinions related to women's health. Copyright 2023 American College of Obstetricians and Gynecologists, Privacy Statement PMID: 36122984. 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. Levels of hCG should be increasing by at least 60% every 2-3 days, but ideally doubling every 48-72 hours. 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. Your doctor may also test your progesterone levels because low levels could be a sign of an ectopic pregnancy. 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. The pregnancy then is absorbed by the body over 4-6 weeks. Several factors go into the decision to use methotrexate. 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. https://www.acog.org/Patients/FAQs/Ectopic-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. 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. 25th ed. Copyright 2023 by the American College of Obstetricians and Gynecologists. The rate of -hCG increase is less rapid as the level increases. 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. Copyright 2020 by the American Academy of Family Physicians. Multidose protocols carry a higher risk of adverse effects and are not preferred.25, Before administering methotrexate, -hCG levels should be measured on days 1, 4, and 7 of treatment. Ectopic pregnancy. Established criteria should be used to determine treatment options for ectopic pregnancy, including expectant management, medical management with methotrexate, or surgical intervention. Author disclosure: No relevant financial affiliations. Ectopic precautions and serial -hCG levels should be continued until the level is undetectable. Your doctor will order the human chorionic gonadotropin (HCG) blood test to confirm that you're pregnant. It often begins as a colicky abdominal or pelvic pain that is localized to one side as the pregnancy distends the fallopian tube. A meta-analysis evaluating the accuracy of a single progesterone test to predict pregnancy outcomes for women with first trimester bleeding showed that a progesterone level less than 6 ng per mL (19.1 nmol per L) reliably excluded viable pregnancy, with a negative predictive value of 99%. 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. Pregnancy tests look for hCG (human chorionic gonadotropin) which is excreted in pregnancy. . Several weeks of follow-up are required with each treatment. . Patients with suspected or confirmed ectopic pregnancy who exhibit signs and symptoms of ruptured ectopic pregnancy should be emergently transferred for surgical intervention. Its not always possible to see an embryo either inside the uterus or in another location. Sexually active women should be alert to changes in their bodies, especially if they experience symptoms of an ectopic pregnancy. Mayo Clinic is a not-for-profit organization. As an ectopic pregnancy grows, more serious symptoms may develop, especially if a fallopian tube ruptures. All Rights Reserved. Progestin Therapy Not Likely to Be Harmful in Women with First Trimester Bleeding. The female body normally has two fallopian tubes. For this test, a wandlike device is placed into your vagina. An ectopic pregnancy cannot move or be moved to the uterus, so it always requires treatment. 5. Implantation and placental development. In this instance, a health care provider can order a test for the hCG level. 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 . The most common drug used to treat ectopic pregnancy is methotrexate. Uterus: A muscular organ located in the female pelvis that contains and nourishes the developing fetus during pregnancy. Despite the fact that these factors can increase a persons risk of an ectopic pregnancy, anyone can experience an ectopic pregnancy. Ultrasonography showing neither intrauterine nor ectopic pregnancy in a patient with a positive pregnancy test is referred to as a pregnancy of unknown location. One of the most important factors is your ability to follow up with blood tests that check your blood levels of hCG. Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. The discriminatory level varies with the type of ultrasound machine used, the sonographer, and the number of gestations. 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. A single copy of these materials may be reprinted for noncommercial personal use only. As the pregnancy grows, it can cause the tube to burst (rupture). In-vitro fertilization (IVF) also increases the chance of an ectopic pregnancy. There is a problem with 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. There are two methods used to treat an ectopic pregnancy: 1) medication and 2) surgery. Journal of Womens Health. Ectopic pregnancies remain an important cause of morbidity and mortality in women of reproductive age. They experience symptoms of ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity ruptured pregnancy... Location is known in pregnancy of early pregnancy loss from ectopic pregnancy: manifestations. The clinical manifestations and diagnosis is known is localized to one side the... 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