An ectopic pregnancy is when a fertilized ovum implants outside of the uterus. Patients with suspected or confirmed ectopic pregnancy who exhibit signs and symptoms of ruptured ectopic pregnancy should be emergently transferred for surgical intervention. This triggers the uterus lining to grow and produce other hormones that help keep a pregnancy going. HCG levels alone do not diagnose an ectopic pregnancy. 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. All rights reserved. One of the most important factors is your ability to follow up with blood tests that check your blood levels of hCG. These medications can affect the way methotrexate works in the body. 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. 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. My hCG levels at five weeks were 150 and then 352 two days later. This content is owned by the AAFP. 2020;30(2). The most common gestational age of diagnosis is between 6 to 10 weeks. 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. 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. If you have pain that does not respond to over-the-counter medication, talk with your ob-gyn or other health care professional. Huang CC, Huang CC, Lin SY, et al. Treatment failure is assumed if the -hCG level plateaus or increases from days 4 to 7. In a salpingostomy, the ectopic pregnancy is removed and the tube left to heal on its own. Ultrasound Transvaginal ultrasound A transvaginal ultrasound allows your doctor to see the exact location of your pregnancy. Read common questions on the coronavirus and ACOGs evidence-based answers. If the ectopic pregnancy has ruptured a tube, emergency surgery is needed. . Review/update the The female body normally has two fallopian tubes. If so, was the test positive? It may take a few cycles for your periods to return to normal. Human chorionic gonadotropin (hCG) is a hormone normally produced by the placenta. Methotrexate can cause sun sensitivity. Almost all ectopic pregnanciesmore than 90%occur in a fallopian tube. 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. 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. Ask your ob-gyn or other health care professional to recommend a counselor. 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. In 95% of ectopic pregnancy cases, a good transvaginal ultrasound examination can actually image the ectopic pregnancy in the Fallopian tube. Will I need to follow any special precautions if I become pregnant again? Methotrexate often is given by injection in one dose. If your ectopic pregnancy isnt detected or treated early, you can experience severe health complications, including excessive bleeding, rupture of a fallopian tube, and death. It can take time for the level of hCG in your body to drop after treatment for an ectopic pregnancy. Are you being treated for any other medical conditions? On the other hand, it's also possible to have doubling hCG levels with an ectopic pregnancy. 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. 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. Dr. Ewan is a physician with a background in pediatrics. If an ultrasound doesnt show an embryo in your uterus, it could be that its too early in pregnancy to see the embryo, or it could be an ectopic pregnancy. Urgent surgical referral is indicated when ultrasonography demonstrates an embryo and fetal cardiac activity outside of the uterus. Cunningham FG, et al., eds. Treatment options for early pregnancy loss include expectant management, medical management with mifepristone and misoprostol, or uterine aspiration. "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. Data Sources: An evidence summary generated from Essential Evidence Plus was reviewed and relevant studies referenced. Other times, a person will have pain in the pelvis thats much worse on one side. It's important to avoid alcohol, folic acid (in both vitamins and foods) and pain . . The pregnancy then is absorbed by the body over 4-6 weeks. Very early in pregnancy, the embryo can grow within the fallopian tube without causing any symptoms. Slow-rising quantitative hCG levels, at least in early pregnancy, . Pain and heavy bleeding are associated with an increased risk of early pregnancy loss. The nature, location, and severity of pain in ectopic pregnancy vary. Interventions for non-tubal ectopic pregnancy. The incidence of ectopic pregnancy is 1% to 2% in the United States and accounts for 6% of all maternal deaths. In: Williams Obstetrics. Hendriks E, Rosenberg R, Prine L. Ectopic Pregnancy: Diagnosis and Management. Only the uterus is physically able to carry a growing fetus. Human chorionic gonadotropin, or hCG, is a hormone produced by the placenta during pregnancy. The differential diagnosis includes threatened abortion, early pregnancy loss, and ectopic pregnancy. This drug stops cells from growing, which ends the pregnancy. Ectopic pregnancies remain an important cause of morbidity and mortality in women of reproductive age. Depending on your symptoms and when the ectopic pregnancy is discovered, this may be done using medication, laparoscopic surgery or abdominal surgery. In some cases, an ectopic pregnancy may resolve on its own. Some people with ectopic pregnancies are more stable at the time theyre diagnosed. I've had two ultrasounds: one at about five weeks and one at six weeks. The initial -hCG level should be considered when following the rate of -hCG increase in early pregnancy. A speculum examination can help identify nonobstetric causes of bleeding, such as vaginitis, cervicitis, or a cervical polyp. A rupture can cause major internal bleeding. 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. Journal of Womens Health. Additionally, a PubMed search was completed in Clinical Queries using the key terms ectopic pregnancy, first trimester bleeding, and pregnancy of unknown location. . In a salpingectomy, the ectopic pregnancy and the tube are both removed. Ultrasound Exam: A test in which sound waves are used to examine internal structures. As your pregnancy progresses, the hCG level increase slows down significantly. 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. 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. Which procedure you have depends on the amount of bleeding and damage and whether the tube has ruptured. 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. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). What are the chances of dying from an ectopic pregnancy? Ectopic pregnancy should be considered in any pregnant patient with vaginal bleeding or lower abdominal pain when intrauterine pregnancy has not yet been established (Table 2).10 Vaginal bleeding in women with ectopic pregnancy is due to the sloughing of decidual endometrium and can range from spotting to menstruation-equivalent levels.10 This endometrial decidual reaction occurs even with ectopic implantation, and the passage of a decidual cast may mimic the passage of pregnancy tissue. Threatened abortion should be managed expectantly. Vital signs indicating hemodynamic instability or peritoneal signs on physical examination require emergent evaluation. If you've had an ectopic pregnancy, your risk of having another one is increased. Niger Postgrad Med J. Progesterone levels rise much differently than hCG levels, with an average of 1-3mg/ml every couple days until they reach their peak for that trimester. hCG levels at 6 weeks: 1,080-56,500 mIU/ml hCG levels at 7-8 weeks: 7,650-229,000 mIU/ml hCG levels at 9-12 weeks: 25,700-288,000 mIU/ml hCG levels at 13-16 weeks: 13,300-254,000 mIU/ml hCG levels at 17-24 weeks: 4,060-165,400 mIU/ml hCG levels at 25-40 weeks: 3,640-117,000 mIU/ml hCG levels if not pregnant: 0-5 mIU/ml However, if a persons hCG level is rising slowly or decreasing, this suggests that the pregnancy may be ectopic. This can be done laparoscopically or through an abdominal incision (laparotomy). It uses sound waves to create images of your uterus, ovaries and fallopian tubes, and sends the pictures to a nearby monitor. 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. This can also help determine whether a pregnancy is healthy or ectopic, but it should be interpreted together with ultrasound findings. Severe abdominal or pelvic pain accompanied by vaginal bleeding. Some people have no symptoms at all. Trends in quantitative subunit of human chorionic gonadotropin (-hCG) levels provide useful information when distinguishing normal from abnormal early pregnancy. ObstetricianGynecologist (Ob-Gyn): A physician with special skills, training, and education in womens health. A hCG level that is rising by less than 66% over 48 hours when the hCG is below 1,200 IU means it is likely, but not a certainty, that the pregnancy is ectopic. Patients who choose expectant management should have -hCG levels monitored every 48 hours, and medical or surgical management should be recommended if -hCG levels do not decrease sufficiently.5, This article updates a previous article on this topic by Barash, et al.12. The behavior of this hormone can help detect a dangerously abnormal pregnancy. 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. Have you taken a pregnancy test? When that happens, lower amounts of hCG are produced and the embryo can't develop normally. Copyright 2019 by the American Academy of Family Physicians. An ectopic pregnancy cannot move or be moved to the uterus, so it always requires treatment. See permissionsforcopyrightquestions and/or permission requests. Ononuju CN, Ogbe AE, Changkat LL, et al. 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. Treatment of threatened abortion is expectant management. hCG can vary from person to person and still mean a pregnancy is normal. It is done in a hospital with general anesthesia. An ectopic pregnancy most often happens in your fallopian tube (a structure that connects your ovaries and uterus). "hCG helps the body produce hormones to support pregnancy," explains John Zhang, M.D., founder. In cases where methotrexate is contraindicated or not preferred by the patient, surgical management can usually be performed laparoscopically if the patient is hemodynamically stable. Levels of hCG should be increasing by at least 60% every 2-3 days, but ideally doubling every 48-72 hours. Patients should be counseled to avoid taking folic acid supplements and nonsteroidal anti-inflammatory drugs, which can decrease the effectiveness of methotrexate, and to avoid anything that may mask the symptoms of ruptured ectopic pregnancy (e.g., narcotic analgesics, alcohol) and activities that increase the risk of rupture (e.g., vaginal intercourse, vigorous exercise). 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. . Get the Stats on Ectopic Pregnancies. Abdominal ultrasound, in which an ultrasound wand is moved over your belly, may be used to confirm your pregnancy or evaluate for internal bleeding. It is not a substitute for the advice of a physician. Abnormal bleeding and pelvic pain should be reported to your obstetriciangynecologist (ob-gyn) or other health care professional. 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. You might also seek the help of a support group, grief counselor or other mental health provider. Surgery typically is done with laparoscopy. . There's some overlap between the possible trends in hCG levels for normal and ectopic pregnancies. The diagnosis of threatened abortion should be made in patients with bleeding and an ultrasound-confirmed viable intrauterine pregnancy. A single copy of these materials may be reprinted for noncommercial personal use only. 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