This content is owned by the AAFP. Clinicians should expect to see a gestational sac on transvaginal ultrasonography when -hCG levels reach 1,500 to 3,000 mIU per mL. doi:10.3238/arztebl.2015.0693, Pereira PP, Cabar FR, Gomez T, et al. 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). Additionally, a PubMed search was completed in Clinical Queries using the key terms ectopic pregnancy, first trimester bleeding, and pregnancy of unknown location. You may opt-out of email communications at any time by clicking on If theres a mass in the area of the fallopian tubes or ovary, this may represent an ectopic pregnancy. Intramuscular methotrexate is the only medication appropriate for the management of ectopic pregnancy. Additionally, a PubMed search was completed in Clinical Queries using the following key terms: first trimester bleeding, threatened abortion, miscarriage, ectopic pregnancy, and discriminatory zone. The pain may become more generalized once the tube ruptures and hemoperitoneum develops. All Rights Reserved. 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. 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. Ononuju CN, Ogbe AE, Changkat LL, et al. This occurs when a fertilized egg implants in a location that can't support its growth. Many people who have an ectopic pregnancy had no risk factors at all. This site complies with the HONcode standard for trustworthy health information: verify here. Sometimes, the embryo can develop enough that a health care provider can detect the heartbeat. Niger Postgrad Med J. Ultrasound Exam: A test in which sound waves are used to examine internal structures. An ectopic pregnancy occurs when a fertilized egg grows outside of the uterus. 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 Journal of Womens Health. It can also possibly indicate an ectopic pregnancy that is 'self-resolving'. To prevent life-threatening complications, the ectopic tissue needs to be removed. An intra-uterine pregnancy can usually be seen by 5-6 weeks gestation or when the HCG level is more than 1000 IU/l. Risk factors include a history of pelvic inflammatory disease, cigarette smoking, fallopian tube surgery, previous ectopic pregnancy, and infertility. An ectopic pregnancy occurs when a fertilized egg implants and grows outside the main cavity of the uterus. Methotrexate often is given by injection in one dose. A fertilized egg can't develop normally outside the uterus. 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. Human chorionic gonadotropin (hCG) is a hormone thats very important throughout pregnancy. Randomized trials have shown no difference in sequelae between methotrexate administration and fallopian tubesparing laparoscopic surgery, including rates of future intrauterine pregnancy and risk of future ectopic pregnancy.29 The decision whether to remove the fallopian tube or leave it in place depends on the extent of damage to the tube (evaluated intraoperatively) and the patient's desire for future fertility. This can be a life-threatening emergency that needs immediate surgery. "hCG helps the body produce hormones to support pregnancy," explains John Zhang, M.D., founder. 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. Copyright 2020 by the American Academy of Family Physicians. This blood test may be repeated every few days until ultrasound testing can confirm or rule out an ectopic pregnancy usually about five to six weeks after conception. McGraw-Hill Education; 2018. https://accessmedicine.mhmedical.com. There is no evidence that palpation during the pelvic examination leads to an increased risk of rupture.10, Beta human chorionic gonadotropin (-hCG) can be detected in pregnancy as early as eight days after ovulation.14 The rate of increase in -hCG levels, typically measured every 48 hours, can aid in distinguishing normal from abnormal early pregnancy. In 95% of ectopic pregnancy cases, a good transvaginal ultrasound examination can actually image the ectopic pregnancy in the Fallopian tube. Ectopic pregnancy. Also searched were the Cochrane database, the Agency for Health-care Research and Quality, DynaMed, and the National Guideline Clearinghouse. General Anesthesia: The use of drugs that produce a sleep-like state to prevent pain during surgery. This is why hCG levels alone aren . . The laparoscope is used to view the pelvic organs. It's very important that the diagnosis of ectopic pregnancy is certain before receiving this treatment. American College of Obstetricians and Gynecologists. In an ectopic pregnancy, the fertilized egg implants somewhere other than the lining of the uterus. 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. https://www.uptodate.com/contents/search. Counseling may be helpful. Tonick S, Conageski C. Ectopic Pregnancy. A single-dose methotrexate protocol is recommended for medical management of patients with ectopic pregnancy and low initial -hCG levels. 2022 Sep;49(3):537-549. doi:10.1016/j.ogc.2022.02.018. Call your doctor's office if you have light vaginal bleeding or slight abdominal pain. 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. Losing a pregnancy is devastating, even if you've only known about it for a short time. Slowly rising hCG levels may be the first clue . It's a dangerous and life-threatening condition, as it may cause the fallopian tube to. It is appropriate for family physicians to treat hemodynamically stable patients in conjunction with their primary obstetrician. Typically, if you go to your health care provider with concerns like this, they will order an ultrasound. Could You Have Subclinical Hypothyroidism? The most common drug used to treat ectopic pregnancy is methotrexate. 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. Cigarette smoking alters sialylation in the Fallopian tube of women, with implications for the pathogenesis of ectopic pregnancy. If hCG levels have not decreased enough after the first dose, another dose of methotrexate may be recommended. How long should I wait before trying to become pregnant again? Accessed Dec. 4, 2019. You'll be asked many questions about your menstrual cycle, fertility and overall health. 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. information highlighted below and resubmit the form. Kelly Gleason describes the roller coaster of a miscarriage and ectopic pregnancy diagnosis, and the importance of shared decision making. health information, we will treat all of that information as protected health If its high enough (most studies use a threshold of about 3,500 mIU/mL, or milli-international units per milliliter, but this can vary by practice), this indicates that the pregnancy is far enough along that a gestational sac should be able to be seen on an ultrasound. About one half of all women who have an ectopic pregnancy do not have known risk factors. Pregnancy that develops outside the uterus is called ectopic pregnancy. At around 8 to 11 days after conception, your blood still has low levels of hCG. The combination of missing a menstrual period, pelvic pain, and vaginal spotting is often seen in ectopic pregnancies. This combination should make an obstetrician-gynecologist consider the possibility of an ectopic pregnancy. Levels commonly increase between days 1 and 4, but should decrease by at least 15% between days 4 and 7. 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. In-vitro fertilization (IVF) also increases the chance of an ectopic pregnancy. Are you in pain? It can be helpful to jot down your questions for the doctor before your visit. Your hCG level can inform your doctor whether there is a risk of an ectopic pregnancy or whether a miscarriage has occurred. Patients with suspected or confirmed ectopic pregnancy who exhibit signs and symptoms of ruptured ectopic pregnancy should be emergently transferred for surgical intervention. In the case of an ectopic pregnancy, the hCG level may just plateau or increase at a very slow rate, but . A rupture can cause major internal bleeding. 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. This does not require the removal of the fallopian tube. Ultrasound visualization of an embryo with fetal cardiac activity outside of the uterus is an indication for urgent transfer for surgical management. Do you plan to become pregnant in the future? Frequently asked questions. -hCG levels should be obtained every 48 hours to confirm that they are decreasing, then weekly until they reach zero. Methotrexate can cause sun sensitivity. Ectopic pregnancies and normal pregnancies require very different medical management. 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. Copyright 2019 by the American Academy of Family Physicians. This can be done laparoscopically or through an abdominal incision (laparotomy). Dec. 4, 2019. This condition is usually diagnosed during surgery, as radiologists may not pay enough attention to the contralateral side of interest. Ultrasound findings diagnostic of early pregnancy loss include a mean gestational sac diameter of 25 mm or greater with no embryo and no fetal cardiac activity when the crown-rump length is 7 mm or more. 2019 Oct-Dec;26(4):235-238. doi:10.4103/npmj.npmj_105_19. An ectopic pregnancy is when the fertilized egg remains in the fallopian tube and continues to develop. It is done in a hospital with general anesthesia. Vaginal bleeding or spotting also may occur. Laparotomy is reserved for patients who are hemodynamically unstable. One use for quantitative hCG levels is to diagnose and monitor an ectopic pregnancy or pregnancy of unknown location. Expectant management can be considered for patients whose peak -hCG level is below the discriminatory zone and is decreasing, but has plateaued or is decreasing more slowly than expected for a failed intrauterine pregnancy.30 In cases where the initial -hCG level is 200 mIU per mL (200 IU per L) or less, 88% of patients will have successful spontaneous resolution of the pregnancy; however, rates of spontaneous resolution decrease with higher -hCG levels.31 Patient counseling must include the risks of spontaneous rupture, hemorrhage, and need for emergency surgery. However, your doctor can't diagnose an ectopic pregnancy by examining you. It may take a few cycles for your periods to return to normal. At first, an ectopic pregnancy may feel like a typical pregnancy with some of the same signs, such as a missed menstrual period, tender breasts, or an upset stomach. 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. In Vitro Fertilization (IVF): A procedure in which an egg is removed from a womans ovary, fertilized in a laboratory with the mans sperm, and then transferred to the womans uterus to achieve a pregnancy. During pregnancy, it can be used to examine the fetus. 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. Treatment failure is assumed if the -hCG level plateaus or increases from days 4 to 7. The estimated mortality of ectopic pregnancy is between 2 and 4/1000. Skip to primary navigation . Are you being treated for any other medical conditions? Data Sources: An evidence summary from Essential Evidence Plus was reviewed and relevant studies referenced. However, if a persons hCG level is rising slowly or decreasing, this suggests that the pregnancy may be ectopic. 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. Signs of ectopic pregnancy (e.g., adnexal mass, fluid in the cul-de-sac) can be seen on ultrasonography well below the discriminatory level. The doctor might recommend an office visit or immediate medical care. Molecular Reproduction and Development. A transvaginal ultrasound allows your doctor to see the exact location of your pregnancy. My hCG level was on the lower end for someone 4 to 5 weeks . When Low hCG Levels Suggest Ectopic Pregnancy . Pregnancy FAQ 155. Sometimes surgery is needed even if the fallopian tube has not ruptured. 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A life-threatening emergency that needs immediate surgery doi:10.3238/arztebl.2015.0693, Pereira PP, Cabar FR Gomez.
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