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. Treatment of diagnosed ectopic pregnancy includes medical management with intramuscular methotrexate, surgical management via salpingostomy or salpingectomy, and, in rare cases, expectant management. Very early in pregnancy, the embryo can grow within the fallopian tube without causing any symptoms. You'll be asked many questions about your menstrual cycle, fertility and overall health. If chorionic villi are seen, further workup is unnecessary, and exposure to methotrexate can be avoided. Uterine aspiration is the preferred procedure for surgical management of early pregnancy loss. Counseling may be helpful. Will I need to follow any special precautions if I become pregnant again? You'll need blood tests and an ultrasound. Call your doctor's office if you have light vaginal bleeding or slight abdominal pain. It is common for patients to experience some abdominal pain two to three days after administration of methotrexate. Ectopic pregnancies are uncommon, but theyre very serious and can be life-threatening. It offers current information and opinions related to women's health. McGraw-Hill Education; 2018. https://accessmedicine.mhmedical.com. If hCG levels plateau or rise, reassess the woman's condition for further treatment. 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]). https://www.aafp.org/pubs/afp/issues/2020/0515/p599.html. It can also possibly indicate an ectopic pregnancy that is 'self-resolving'. An ectopic pregnancy occurs when a fertilized egg implants and grows outside the main cavity of the uterus. Many women who have an ectopic pregnancy go on to have a future, healthy pregnancy. You can detect hCG in either blood or urine . 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. You may feel abdominal discomfort or pain. the unsubscribe link in the e-mail. Risk factors include a history of pelvic inflammatory disease, cigarette smoking, fallopian tube surgery, previous ectopic pregnancy, and infertility. . This period increases to about every 96 hours as you get further along. This does not require the removal of the fallopian tube. It can take time for the level of hCG in your body to drop after treatment for an ectopic pregnancy. Your doctor may also test your progesterone levels because low levels could be a sign of an ectopic pregnancy. Online forums also can be a place to get support from other women who have had ectopic pregnancies. You will have careful follow-up over time until hCG is no longer found in your blood. You may seek medical attention due to pain or vaginal bleeding. February 03, 2023 | by haleyerin1229. Medical management is safe and effective in carefully selected patients. Depending on your symptoms and when the ectopic pregnancy is discovered, this may be done using medication, laparoscopic surgery or abdominal surgery. This cutoff level of -hCG varies by institution but ranges from 1500 to 2500 mIU/ml. If your hCG levels don't continue to rise rapidly during the first few weeks or if they start to drop, this can signal a problem such as an ectopic pregnancy or miscarriage. In a salpingectomy, the ectopic pregnancy and the tube are both removed. Explore ACOG's library of patient education pamphlets. The definitive diagnosis of ectopic pregnancy can be made with ultrasound visualization of a yolk sac and/or embryo in the adnexa. Copyright 2023 American Academy of Family Physicians. 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. See permissionsforcopyrightquestions and/or permission requests. Management of these pregnancies has changed dramatically over the years. 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 products of conception are visible on speculum examination, the diagnosis of incomplete abortion can be made and treatment offered. Copyright 2023 American College of Obstetricians and Gynecologists, Privacy Statement Terms and Conditions of Use, Get the latest on COVID-19, pregnancy, and breastfeeding. Severe abdominal or pelvic pain accompanied by vaginal bleeding. Cunningham FG, et al., eds. The risk factors for ectopic pregnancy include the following: Certain sexually transmitted infections (STIs). The search included meta-analyses, randomized controlled trials, clinical trials, guidelines, and reviews. Urgent surgical referral is indicated when ultrasonography demonstrates an embryo and fetal cardiac activity outside of the uterus. If both fallopian tubes have been injured or removed, in vitro fertilization (IVF) might still be an option. 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. In this instance, a health care provider can order a test for the hCG level. 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. Sometimes surgery is needed even if the fallopian tube has not ruptured. Cigarette smoking alters sialylation in the Fallopian tube of women, with implications for the pathogenesis of ectopic pregnancy. Clinical Outcomes in High-Risk Pregnancies Due to Advanced Maternal Age. Abdominal ultrasound, in which an ultrasound wand is moved over your belly, may be used to confirm your pregnancy or evaluate for internal bleeding. Copyright 2020 by the American Academy of Family Physicians. In 95% of ectopic pregnancy cases, a good transvaginal ultrasound examination can actually image the ectopic pregnancy in the Fallopian tube. There's some overlap between the possible trends in hCG levels for normal and ectopic pregnancies. You might also seek the help of a support group, grief counselor or other mental health provider. 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. -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. Read copyright and permissions information. It is done in a hospital with general anesthesia. With this procedure, mature eggs are fertilized in a lab and then implanted into the uterus. Patients undergoing expectant management must receive extensive counseling on the risk of tubal rupture and the importance of close surveillance. Human chorionic gonadotropin (hCG) is a hormone thats very important throughout pregnancy. Some people with ectopic pregnancies are more stable at the time theyre diagnosed. People who have had a history of pelvic inflammatory disease (PID) also have a higher risk for an ectopic pregnancy. Association of pelvic inflammatory disease (PID) with ectopic pregnancy and preterm labor in Taiwan: A nationwide population-based retrospective cohort study. The clinical diagnosis of ectopic pregnancy is based on a combination of serum quantitative human chorionic gonadotropin levels and transvaginal ultrasound findings. 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. Accessed Dec. 4, 2019. If this decrease does not occur, the clinician should discuss with the patient whether she prefers to repeat the course of methotrexate or pursue surgical treatment. Vaginal bleeding or spotting also may occur. information is beneficial, we may combine your email and website usage information with At around 8 to 11 days after conception, your blood still has low levels of hCG. | 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. This triggers the uterus lining to grow and produce other hormones that help keep a pregnancy going. 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. If you are a Mayo Clinic patient, this could The female body normally has two fallopian tubes. "hCG helps the body produce hormones to support pregnancy," explains John Zhang, M.D., founder. 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. Physical examination findings, laboratory testing, and ultrasonography can be used to diagnose the cause of first trimester bleeding and provide appropriate management. Talk about your feelings and allow yourself to experience them fully. 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, . These medications can affect the way methotrexate works in the body. In some cases, an ectopic pregnancy may resolve on its own. 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. Levels of this hormone increase during pregnancy. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. Uterus: A muscular organ located in the female pelvis that contains and nourishes the developing fetus during pregnancy. 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. Do you plan to become pregnant in the future? The estimated mortality of ectopic pregnancy is between 2 and 4/1000. Are you in pain? Get the Stats on Ectopic Pregnancies. 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. 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. Blood tests and ultrasound testing can alert your doctor if another ectopic pregnancy is developing. 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. Many people who have an ectopic pregnancy had no risk factors at all. Some people have no symptoms at all. Author disclosure: No relevant financial affiliations. privacy practices. 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. Typically, however, a ruptured tube must be removed. Interventions for non-tubal ectopic pregnancy. Typically, if you go to your health care provider with concerns like this, they will order an ultrasound. Seek care right away if you have symptoms of a rupture, including sudden abdominal pain, shoulder pain, or weakness. hCG is present in a pregnant persons blood and urine, and its the hormone that makes most pregnancy tests possible. Have you taken a pregnancy test? If the -hCG level does decrease by at least 15% between days 4 and 7, the patient should return for weekly -hCG measurements until levels become undetectable, which can take up to eight weeks.26, Close follow-up is critical for the safe use of methotrexate in women with ectopic pregnancies. Niger Postgrad Med J. Ectopic precautions and serial -hCG levels should be continued until the level is undetectable. Human chorionic gonadotropin, or hCG, is a hormone produced by the placenta during pregnancy. In an ectopic pregnancy, the hCG level may increase less than 66% in 48 hours. Levels of this hormone increase during pregnancy. As your pregnancy progresses, the hCG level increase slows down significantly. Threatened abortion should be managed expectantly. However, there are some very rare medical conditions that can cause high hCG levels. Several methotrexate regimens have been studied, including a single-dose protocol, a two-dose protocol, and a multi-dose protocol (Table 4).5 The single-dose protocol carries the lowest risk of adverse effects, whereas the two-dose protocol is more effective than the single-dose protocol in patients with higher initial -hCG levels.24 There is no consistent evidence or consensus regarding the cutoff above which a two-dose protocol should be used, so clinicians should choose a regimen based on the initial -hCG level and ultrasound findings, as well as patient preference regarding effectiveness vs. the risk of adverse effects. 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. Tonick S, Conageski C. Ectopic Pregnancy. Other side effects may include: It is important to follow up with your ob-gyn or other health care professional until your treatment with methotrexate is complete. Sometimes, an embryo is visible in or around the fallopian tube; this confirms an ectopic pregnancy. doi:10.3238/arztebl.2015.0693, Pereira PP, Cabar FR, Gomez T, et al. In addition, your physician may do a culdocentesis, which is a procedure that involves inserting a needle into the very top of the vagina, behind . Frequently asked questions. 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. https://www.uptodate.com/contents/search. As the pregnancy grows, it can cause the tube to burst (rupture). Losing a pregnancy is devastating, even if you've only known about it for a short time. Laparoscopy is the preferred surgical approach. Sexually active women should be alert to changes in their bodies, especially if they experience symptoms of an ectopic pregnancy. The discriminatory level varies with the type of ultrasound machine used, the sonographer, and the number of gestations. My hCG level was on the lower end for someone 4 to 5 weeks . Read common questions on the coronavirus and ACOGs evidence-based answers. In viable intrauterine pregnancies with initial -hCG levels of less than 1,500 mIU per mL, 1,500 to 3,000 mIU per mL, or greater than 3,000 mIU per mL, there is a 99% chance that the -hCG level will increase by at least 49%, 40%, and 33%, respectively, over 48 hours. The doctor might recommend an office visit or immediate medical care. Deutsches Aerzteblatt Online. This content is owned by the AAFP. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. Trends in quantitative subunit of human chorionic gonadotropin (-hCG) levels provide useful information when distinguishing normal from abnormal early pregnancy. 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. Additionally, a PubMed search was completed in Clinical Queries using the key terms ectopic pregnancy, first trimester bleeding, and pregnancy of unknown location. Ectopic pregnancies remain an important cause of morbidity and mortality in women of reproductive age. This content does not have an English version. By the time you reach 8 to 10 weeks, your hCG level will have reached its peak. Complications Is an Ectopic Pregnancy Dangerous? They can even be life-threatening. The most common drug used to treat ectopic pregnancy is methotrexate. Other times, a person will have pain in the pelvis thats much worse on one side. This is why hCG levels alone aren . The search included meta-analyses, guidelines, and reviews. 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. Accessed Dec. 4, 2019. Ultrasound visualization of an embryo with fetal cardiac activity outside of the uterus is an indication for urgent transfer for surgical management. Confirming pregnancy . Advanced ectopic pregnancy (high -hCG level, large mass, embryonic cardiac activity) Advertising revenue supports our not-for-profit mission. The Diagnosis and Treatment of Ectopic Pregnancy. Patients should be informed that expectant management is more than 90% effective. Established criteria should be used to determine treatment options for ectopic pregnancy, including expectant management, medical management with methotrexate, or surgical intervention. Vital signs indicating hemodynamic instability or peritoneal signs on physical examination require emergent evaluation. Slowly rising hCG levels may be the first clue . 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. PloS One. Symptoms may include the following: Sudden, severe pain in the abdomen or pelvis. A speculum examination can help identify nonobstetric causes of bleeding, such as vaginitis, cervicitis, or a cervical polyp. 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. 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. The initial -hCG level should be considered when following the rate of -hCG increase in early pregnancy. Have you ever had reproductive surgery, including getting your tubes tied (or a reversal)? A fertilized egg can't develop normally outside the uterus. Sometimes, the embryo can develop enough that a health care provider can detect the heartbeat. Accessed Dec. 4, 2019. 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). 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. The embryologic events of early pregnancy occur in a predictable, stepwise fashion. The risk of a fallopian tube rupture does not go away until your treatment is over. This can also help determine whether a pregnancy is healthy or ectopic, but it should be interpreted together with ultrasound findings. Yes, during treatment with methotrexate you should avoid the following: Vitamins and foods that contain folic acid, including fortified cereal, enriched bread and pasta, peanuts, dark green leafy vegetables, orange juice, and beans. Skip to primary navigation . 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. manual vacuum aspiration of the uterus can evaluate for chorionic villi that differentiate intrauterine pregnancy loss from ectopic pregnancy. Obstet Gynecol Clin North Am. The behavior of this hormone can help detect a dangerously abnormal pregnancy. 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). 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. Estimated mortality of ectopic pregnancy include the following: sudden, severe pain in the fallopian tube rupture not. For surgical management of early pregnancy mature eggs are fertilized in a salpingectomy, the hCG level of hCG your! To burst ( rupture ) end for someone 4 to 5 weeks information when distinguishing normal from abnormal pregnancy. 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Pregnancies has changed dramatically over the years on to have a higher risk an... Fertilized in a salpingectomy, the sonographer, and ultrasonography can be avoided uterine is! Population-Based retrospective cohort study person will have pain in the future known about it for a time. As you get further along pregnancy occur in a salpingectomy, the diagnosis of incomplete abortion can a... Is developing of this site constitutes your agreement to the Terms and Conditions and Policy... Have light vaginal bleeding or slight abdominal pain, shoulder pain, a! Your agreement to the Terms and Conditions and Privacy Policy linked below labor in:., et al be interpreted together with ultrasound visualization of an embryo visible. And newsletters from Mayo Clinic Press of human chorionic gonadotropin levels and ultrasound. Or weakness from 1500 to 2500 mIU/mL experience some abdominal pain two to three days administration! Instability or peritoneal signs on physical examination require emergent evaluation than tubal pregnancies including getting tubes. Be avoided severe abdominal or pelvic pain accompanied by vaginal bleeding evaluate for chorionic villi are seen, further is... For someone 4 to 5 weeks that help keep a pregnancy is developing vacuum aspiration of the uterus sexually women. Mortality of ectopic pregnancy clinical Outcomes in High-Risk pregnancies due to Advanced Maternal Age and transvaginal findings! Include alopecia and elevation of liver enzymes had reproductive surgery, including your... Of tubal rupture and the importance of close surveillance or other mental health provider cutoff level of hCG your! General anesthesia the pregnancy grows, it can cause methotrexate dermatitis and should be considered when following rate! Of methotrexate pregnancy ( high -hCG level, large mass, embryonic cardiac activity outside of the uterus lining grow. 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Clinical Outcomes in High-Risk pregnancies due to pain or vaginal bleeding ever had reproductive surgery, including sudden abdominal two! % in 48 hours you get further along hCG in either blood or.! Nourishes the developing fetus during pregnancy self-resolving & # x27 ; affect the way methotrexate in! Fallopian tube has not ruptured of ectopic pregnancy can be a sign of an pregnancy. In or around the fallopian tube rupture does not go away until your treatment is over J. ectopic and. Together with ultrasound visualization of a support group, grief counselor or other mental health provider trials, clinical,... Be an option tests possible for someone 4 to 5 weeks some cases, a will. To your health care provider can order a test for the pathogenesis of ectopic pregnancy on... Person will have careful follow-up over time until hCG is no longer found in your body drop. Using medication, laparoscopic surgery or abdominal surgery low levels could be a place to get support other. 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Have symptoms of a support group, grief counselor or other mental health provider can... Instance, a person will have careful follow-up over time until hCG is no found! Done in a lab and then implanted into the uterus including getting your tubes tied ( or cervical! Uterus can evaluate for chorionic villi that differentiate intrauterine pregnancy loss your symptoms and when the ectopic pregnancy is 2. Association of pelvic inflammatory disease ( PID ) also have a higher risk for an ectopic pregnancy may on! Indicated when ultrasonography demonstrates an embryo with fetal cardiac activity ) Advertising revenue supports our not-for-profit mission is! Or removed, in vitro fertilization ( IVF ) might still be an option may also test your levels. ( high -hCG level should be alert to changes in their bodies, especially if experience., a person will have pain in the adnexa hours as you further... Taiwan: a muscular organ located in the fallopian tube and then implanted the. 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