Physical examination findings, laboratory testing, and ultrasonography can be used to diagnose the cause of first trimester bleeding and provide appropriate management. However, if a person's hCG level is rising slowly or decreasing, this suggests that the pregnancy may be ectopic. The combination of missing a menstrual period, pelvic pain, and vaginal spotting is often seen in ectopic pregnancies. Pain and heavy bleeding are associated with an increased risk of early pregnancy loss. An ectopic pregnancy is when the fertilized egg remains in the fallopian tube and continues to develop. The differential diagnosis includes threatened abortion, early pregnancy loss, and ectopic pregnancy. The doctor might recommend an office visit or immediate medical care. 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. McGraw-Hill Education; 2018. https://accessmedicine.mhmedical.com. Pregnancy blood tests can detect hCG hormone levels as low as 5 to 10 mIU/mL. 25th ed. Review/update the
Skip to primary navigation . However, if a persons hCG level is rising slowly or decreasing, this suggests that the pregnancy may be ectopic. This does not require the removal of the fallopian tube. Ectopic precautions and serial -hCG levels should be continued until the level is undetectable. 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. 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. Signs of ectopic pregnancy (e.g., adnexal mass, fluid in the cul-de-sac) can be seen on ultrasonography well below the discriminatory level. There's some overlap between the possible trends in hCG levels for normal and ectopic pregnancies. Yes, ectopic pregnancies are dangerous. Accessed Dec. 29, 2017. [2012] Whether you were treated with methotrexate or surgery, you may feel tired for several weeks while you recover. Treatment options for early pregnancy loss include expectant management, medical management with mifepristone and misoprostol, or uterine aspiration. This drug stops cells from growing, which ends the pregnancy. Patients with suspected or confirmed ectopic pregnancy who exhibit signs and symptoms of ruptured ectopic pregnancy should be emergently transferred for surgical intervention. Uterus: A muscular organ located in the female pelvis that contains and nourishes the developing fetus during pregnancy. health information, we will treat all of that information as protected health
It often begins as a colicky abdominal or pelvic pain that is localized to one side as the pregnancy distends the fallopian tube. Dec. 4, 2019. This occurs when a fertilized egg implants in a location that can't support its growth. If you are pregnant, you can detect it in your urine. It may take a few cycles for your periods to return to normal. Management of these pregnancies has changed dramatically over the years. Sound waves from the transducer create images of the uterus, ovaries and fallopian tubes. Clinics. Uterine aspiration should be considered to evaluate for intrauterine chorionic villi in patients with a pregnancy of unknown location. 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. This can be done laparoscopically or through an abdominal incision (laparotomy). In this case, the pregnancy is called a pregnancy of unknown location. There is no consensus about the next steps if a pregnancy is of unknown location. The rate of -hCG increase is less rapid as the level increases. 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. Despite the fact that these factors can increase a persons risk of an ectopic pregnancy, anyone can experience an ectopic pregnancy. Cunningham FG, et al., eds. 2016;83(12):1083-1091. doi:10.1002/mrd.22747. 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. Approximately one-fourth of pregnant women will experience bleeding in the first trimester. 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. Ectopic pregnancy should be considered in any patient presenting early in pregnancy with vaginal bleeding or lower abdominal pain in whom intrauterine pregnancy has not yet been established. An ectopic pregnancy occurs when a fertilized egg grows outside of the uterus. When an intrauterine pregnancy is detected on ultrasonography but viability is uncertain, repeat ultrasonography should be performed in seven to 10 days to confirm viability.3,5 In these cases, a normal increase in the -hCG level or a normal progesterone level can be reassuring. Online forums also can be a place to get support from other women who have had ectopic pregnancies. Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. In the vast majority of ectopic pregnancies, the fertilized egg implants somewhere in the fallopian tube. Surgical options include salpingostomy or salpingectomy. Methotrexate often is given by injection in one dose. It is not intended as a statement of the standard of care. Accessed Dec. 4, 2019. Laparoscopy: A surgical procedure in which an instrument called a laparoscope is inserted into the pelvic cavity through a small incision. Read ACOGs complete disclaimer. 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. manual vacuum aspiration of the uterus can evaluate for chorionic villi that differentiate intrauterine pregnancy loss from ectopic pregnancy. other information we have about you. Almost all ectopic pregnanciesmore than 90%occur in a fallopian tube. This type of ectopic pregnancy is called a tubal pregnancy. Next, your doctor uses a thin tube equipped with a camera lens and light (laparoscope) to view the tubal area. . Nonviable intrauterine pregnancy within the first 12 6/7 weeks of gestation: Ectopic pregnancy: . About one half of all women who have an ectopic pregnancy do not have known risk factors. 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. Urine pregnancy tests work by turning positive if they detect the presence of hCG. Sometimes it can be difficult to remember all of the information provided, especially in an emergency situation. All Rights Reserved. The embryologic events of early pregnancy occur in a predictable, stepwise fashion. This site complies with the HONcode standard for trustworthy health information: verify here. Frequently asked questions. Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. Author disclosure: No relevant financial affiliations. 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]). In stable patients, close monitoring of symptoms, serial quantitative -hCG testing, and ultrasonography are recommended4 (Figure 28,10,14,15 ). At around 8 to 11 days after conception, your blood still has low levels of hCG. https://www.acog.org/Patients/FAQs/Ectopic-Pregnancy. In the case of an ectopic pregnancy, the hCG level may just plateau or increase at a very slow rate, but . 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. If the woman is less than 6 weeks pregnant and is bleeding but not in pain, consider expectant management. However, most ectopic pregnancies do not reach this stage. Author disclosure: No relevant financial affiliations. Talk about your feelings and allow yourself to experience them fully. These medications can affect the way methotrexate works in the body. It typically takes from one to nine weeks for hCG levels to return to zero following a miscarriage (or delivery). Foods that produce gas, which can cause discomfort and mask the pain of a possible rupture of a fallopian tube. "hCG helps the body produce hormones to support pregnancy," explains John Zhang, M.D., founder. 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. Ononuju CN, Ogbe AE, Changkat LL, et al. Advanced ectopic pregnancy (high -hCG level, large mass, embryonic cardiac activity) For some women, ectopic pregnancy can be traumatic. What are the chances of dying from an ectopic pregnancy? Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. Surgery typically is done with laparoscopy. 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. 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. Burnett TL (expert opinion). 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. . "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. 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. Trends in quantitative subunit of human chorionic gonadotropin (-hCG) levels provide useful information when distinguishing normal from abnormal early pregnancy. If you are a Mayo Clinic patient, this could
Patient preference should guide treatment decisions. If theres a mass in the area of the fallopian tubes or ovary, this may represent an 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. 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. Clinicians should expect to see a gestational sac on transvaginal ultrasonography when -hCG levels reach 1,500 to 3,000 mIU per mL. Depending on your symptoms and when the ectopic pregnancy is discovered, this may be done using medication, laparoscopic surgery or abdominal surgery. See permissionsforcopyrightquestions and/or permission requests. https://www.aafp.org/pubs/afp/issues/2020/0515/p599.html. Read copyright and permissions information. privacy practices. In most normal pregnancies, at hCG levels below 1,200 mIU/ml, the hCG level usually doubles every 48-72 hours and normally increases by at least 60% every two days. Compared with sharp curettage, vacuum aspiration is associated with decreased pain, shorter procedure duration, and less blood loss.28 Office-based uterine aspiration is safe, less expensive, and often more convenient than treatment in the operating room.29,30 Choices about analgesia during the aspiration procedure should be made with the patient's input. 2020;30(2). Huang CC, Huang CC, Lin SY, et al. 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. Assisted Reproductive Technology: A group of infertility treatments in which an egg is fertilized with a sperm outside the body; the fertilized egg then is transferred to the uterus. Some people with ectopic pregnancies are more stable at the time theyre diagnosed. If products of conception are visible on speculum examination, the diagnosis of incomplete abortion can be made and treatment offered. 5. The fertilized egg travels through the fallopian tube and into the uterus, where it attaches to the uterine wall. 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. 2019;14(8):e0219351. In an ectopic pregnancy, the hCG level may increase less than 66% in 48 hours. 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. 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. February 03, 2023 | by haleyerin1229. In these cases, the ectopic pregnancy can be removed from the tube, or the entire tube with the pregnancy can be removed. It can take time for the level of hCG in your body to drop after treatment for an ectopic pregnancy. Because ectopic pregnancies can be life-threatening, early diagnosis is essential. People who are older at the time of pregnancy also have an increased risk of ectopic pregnancy. You'll need blood tests and an ultrasound. 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. Additionally, a PubMed search was completed in Clinical Queries using the key terms ectopic pregnancy, first trimester bleeding, and pregnancy of unknown location. ERIN HENDRIKS, MD, HONOR MACNAUGHTON, MD, AND MARICELA CASTILLO MACKENZIE, MD, Related letter: Progestin Therapy Not Likely to Be Harmful in Women with First Trimester Bleeding. In a normal pregnancy, the egg is fertilized by a sperm. For this test, a wandlike device is placed into your vagina. In these procedure, a small incision is made in the abdomen, near or in the navel. What are my chances of having a healthy pregnancy in the future? A transvaginal ultrasound allows your doctor to see the exact location of your pregnancy. . Some people have no symptoms at all. The behavior of this hormone can help detect a dangerously abnormal pregnancy. In a desired pregnancy, -hCG levels and serial ultrasonography combined with patient reports of pain or bleeding guide management.20 In an undesired pregnancy or when the possibility of a viable intrauterine pregnancy has been excluded, manual vacuum aspiration of the uterus can evaluate for chorionic villi that differentiate intrauterine pregnancy loss from ectopic pregnancy. Ask a loved one or friend to come with you, if possible. Other times, a person will have pain in the pelvis thats much worse on one side. In a typical pregnancy, your hCG levels double every 48 to 72 hours. Accessed Dec. 4, 2019. Complications Is an Ectopic Pregnancy Dangerous? Only the uterus is physically able to carry a growing fetus. 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. 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Especially in an emergency situation should guide treatment decisions a growing fetus be. Nine weeks for hCG levels for normal and ectopic pregnancies do not reach stage! Your periods to return to normal evaluate for chorionic villi in patients a... Ectopic pregnancies do not have known risk factors hCG levels double every 48 to 72.. A transvaginal ultrasound allows your doctor to see a gestational sac on transvaginal ultrasonography when -hCG levels should be to.