Advanced ectopic pregnancy (high -hCG level, large mass, embryonic cardiac activity) 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. Losing a pregnancy is devastating, even if you've only known about it for a short time. 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. PMID: 31621664. Treatment of diagnosed ectopic pregnancy includes medical management with intramuscular methotrexate, surgical management via salpingostomy or salpingectomy, and, in rare cases, expectant management. 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. The behavior of this hormone can help detect a dangerously abnormal pregnancy. After this . The prevalence of ectopic pregnancy in the United States is estimated to be 1% to 2%, but this may be an underestimate because this condition is often treated in the office setting where it is not tracked.1,2 The mortality rate for ruptured ectopic pregnancy has steadily declined over the past three decades, and from 2011 to 2013 accounted for 2.7% of pregnancy-related deaths.1,3 Risk factors for ectopic pregnancy are listed in Table 14,5; however, one-half of women with diagnosed ectopic pregnancy have no identified risk factors.46 The overall rate of pregnancy (including ectopic) is less than 1% when a patient has an intrauterine device (IUD). There is a problem with Copyright 2023 American College of Obstetricians and Gynecologists, Privacy Statement You can detect hCG in either blood or urine . What Are the Factors Contributing to Obesity. [2012] You'll need blood tests and an ultrasound. 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. the unsubscribe link in the e-mail. It is appropriate for family physicians to treat hemodynamically stable patients in conjunction with their primary obstetrician. An hCG level that is lower than expected is one reason to suspect an ectopic pregnancy. Many women who have an ectopic pregnancy go on to have a future, healthy pregnancy. This triggers the uterus lining to grow and produce other hormones that help keep a pregnancy going. 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. privacy practices. An ectopic pregnancy cannot move or be moved to the uterus, so it always requires treatment. 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. Pregnancy of unknown location can be diagnostically challenging because the increase in -hCG level can be similar among women with an early viable pregnancy, ectopic pregnancy, or early pregnancy loss.10 Because pregnancy of unknown location does not exclude ectopic pregnancy, and because rupture of ectopic pregnancy can occur at any -hCG level, serial measurements should be obtained until a definitive diagnosis is made or until the level is undetectable.16 Patients should be counseled about warning signs of ectopic pregnancy, including shoulder pain, pelvic pain, and dizziness. Don't have an ob-gyn? If the ectopic pregnancy has ruptured a tube, emergency surgery is needed. Seek care right away if you have symptoms of a rupture, including sudden abdominal pain, shoulder pain, or weakness. The search included meta-analyses, guidelines, and reviews. 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. . Cochrane Database of Systematic Reviews. Burnett TL (expert opinion). Levels peaks during the first eight to 11 weeks of pregnancy, then decline and plateau. During a transvaginal ultrasound, you lie on an exam table while a health care provider or a medical technician puts a wandlike device, known as a transducer, into the vagina. An ectopic pregnancy most often occurs in a fallopian tube, which carries eggs from the ovaries to the uterus. 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. The embryologic events of early pregnancy occur in a predictable, stepwise fashion. Sometimes, an embryo is visible in or around the fallopian tube; this confirms an ectopic pregnancy. other information we have about you. There are two methods used to treat an ectopic pregnancy: 1) medication and 2) surgery. Threatened abortion should be managed expectantly. 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. In-vitro fertilization (IVF) also increases the chance of an ectopic pregnancy. ERIN HENDRIKS, MD, RACHEL ROSENBERG, MD, AND LINDA PRINE, MD. Despite the fact that these factors can increase a persons risk of an ectopic pregnancy, anyone can experience an ectopic pregnancy. Skip to primary navigation . A speculum examination can help identify nonobstetric causes of bleeding, such as vaginitis, cervicitis, or a cervical polyp. Rho(D) immune globulin (Rhogam) is indicated within 72 hours for all Rh-negative patients with abdominal trauma or ectopic pregnancy, and in those who undergo uterine aspiration. For trusted, in-depth advice from ob-gyns, turn to Your Pregnancy and Childbirth: Month to Month. Because ectopic pregnancies can be life-threatening, early diagnosis is essential. 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%. Clinical Outcomes in High-Risk Pregnancies Due to Advanced Maternal Age. McGraw-Hill Education; 2018. https://accessmedicine.mhmedical.com. Yes, ectopic pregnancies are dangerous. Women with an ectopic pregnancy may have irregular bleeding and pelvic or abdominal pain, often on one side. 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. The combination of missing a menstrual period, pelvic pain, and vaginal spotting is often seen in ectopic pregnancies. Ectopic precautions and serial -hCG levels should be continued until the level is undetectable. Pregnancy FAQ 155. However, there are some very rare medical conditions that can cause high hCG levels. They can even be life-threatening. Read ACOGs complete disclaimer. 25th ed. For some women, ectopic pregnancy can be traumatic. At-home urine tests require higher levels of hCG to detect a pregnancy, typically at least 20 mIU/mL. If one is damaged or removed, an egg may join with a sperm in the other tube and then travel to the uterus. Most women have some abdominal pain. hCG can vary from person to person and still mean a pregnancy is normal. It's very important that the diagnosis of ectopic pregnancy is certain before receiving this treatment. doi:10.3238/arztebl.2015.0693, Pereira PP, Cabar FR, Gomez T, et al. Symptoms most often appear 6 to 8 weeks after the last normal menstrual period. 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 theres a mass in the area of the fallopian tubes or ovary, this may represent an ectopic pregnancy. Foods that produce gas, which can cause discomfort and mask the pain of a possible rupture of a fallopian tube. Some people with ectopic pregnancies are more stable at the time theyre diagnosed. Abdominal ultrasound, in which an ultrasound wand is moved over your belly, may be used to confirm your pregnancy or evaluate for internal bleeding. Hemorrhage was the leading cause of death. Human chorionic gonadotropin, or hCG, is a hormone produced by the placenta during pregnancy. All Rights Reserved. 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. Other factors that may increase a womans risk of ectopic pregnancy include: Use of assisted reproductive technology, such as in vitro fertilization (IVF). Levels of hCG should be increasing by at least 60% every 2-3 days, but ideally doubling every 48-72 hours. . 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. Pregnancy tests look for hCG (human chorionic gonadotropin) which is excreted in pregnancy. Pregnancy of unknown location refers to a transient state in which a pregnancy test is positive but ultrasonography shows neither intrauterine nor ectopic pregnancy. However, if a persons hCG level is rising slowly or decreasing, this suggests that the pregnancy may be ectopic. 2020;30(2). health information, we will treat all of that information as protected health 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. In: Williams Obstetrics. 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. If the ectopic pregnancy is causing heavy bleeding, you might need emergency surgery. hCG is present in a pregnant persons blood and urine, and its the hormone that makes most pregnancy tests possible. My hCG levels at five weeks were 150 and then 352 two days later. -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. Have you had a sexually transmitted infection? Checking the hCG level and then checking it again in 48 hours tells you how fast the hCG level is rising. See permissionsforcopyrightquestions and/or permission requests. Several weeks of follow-up are required with each treatment. Association of pelvic inflammatory disease (PID) with ectopic pregnancy and preterm labor in Taiwan: A nationwide population-based retrospective cohort study. Laparoscopy is the preferred surgical approach. This content is owned by the AAFP. Ultrasound visualization of an embryo with fetal cardiac activity outside of the uterus is an indication for urgent transfer for surgical management. 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. 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. Also searched were the Cochrane database, DynaMed, and the National Guideline Clearinghouse. Levels of this hormone increase during pregnancy. Search dates: August 3, 2017, to October 21, 2018. Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. 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. As an ectopic pregnancy grows, more serious symptoms may develop, especially if a fallopian tube ruptures. Mayo Clinic on Incontinence - Mayo Clinic Press, NEW The Essential Diabetes Book - Mayo Clinic Press, NEW Ending the Opioid Crisis - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Book: Mayo Clinic Guide to a Healthy Pregnancy, Book: Your Guide to Miscarriage and Pregnancy Loss. In a typical pregnancy, your hCG levels double every 48 to 72 hours. Fallopian Tube: Tube through which an egg travels from the ovary to the uterus. If so, was the test positive? Methotrexate can cause sun sensitivity. Methotrexate often is given by injection in one dose. Methotrexate may be used if the pregnancy has not ruptured a fallopian tube. It is not a substitute for the advice of a physician. Several factors go into the decision to use methotrexate. The incidence of ectopic pregnancy is 1% to 2% in the United States and accounts for 6% of all maternal deaths. Therefore, in a desired pregnancy, it is recommended that a discriminatory level as high as 3,500 mIU per mL (3,500 IU per L) be used to avoid misdiagnosis and interruption of a viable pregnancy, although most pregnancies will be visualized by the time the -hCG level reaches 1,500 mIU per mL.18,19. One use for quantitative hCG levels is to diagnose and monitor an ectopic pregnancy or pregnancy of unknown location. It does not explain all of the proper treatments or methods of care. Ononuju CN, Ogbe AE, Changkat LL, et al. Next, your doctor uses a thin tube equipped with a camera lens and light (laparoscope) to view the tubal area. If so, is it more or less than your typical period? 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. Taking methotrexate can have some side effects. doi:10.1089/jwh.2020.8860. Ask a loved one or friend to come with you, if possible. "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. Uterine aspiration should be considered to evaluate for intrauterine chorionic villi in patients with a pregnancy of unknown location. Make a donation. 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. | It typically takes from one to nine weeks for hCG levels to return to zero following a miscarriage (or delivery). . information submitted for this request. Interventions for non-tubal ectopic pregnancy. Blood tests and ultrasound testing can alert your doctor if another ectopic pregnancy is developing. After six weeks, the levels will double about every 96 hours. Severe abdominal or pelvic pain accompanied by vaginal bleeding. If hCG levels plateau or rise, reassess the woman's condition for further treatment. However, your doctor can't diagnose an ectopic pregnancy by examining you. If so, what was the outcome of each pregnancy? 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. Typically, however, a ruptured tube must be removed. Levels should then double every 48 hours from weeks four to six, but that isn't the case for everyone. You may feel abdominal discomfort or pain. 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. Mayo Clinic does not endorse companies or products. 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 period increases to about every 96 hours as you get further along. This does not require the removal of the fallopian tube. Recognize the loss, and give yourself time to grieve. Deutsches Aerzteblatt Online. An early ectopic pregnancy without unstable bleeding is most often treated with a medication called methotrexate, which stops cell growth and dissolves existing cells. Abnormal bleeding and pelvic pain should be reported to your obstetriciangynecologist (ob-gyn) or other health care professional. , is a hormone produced by the placenta during pregnancy produced by placenta... 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