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. To prevent life-threatening complications, the ectopic tissue needs to be removed. Whether you were treated with methotrexate or surgery, you may feel tired for several weeks while you recover. The nature, location, and severity of pain in ectopic pregnancy vary. A review of the menstrual history and prior ultrasonography can help establish gestational dating and determine whether the pregnancy location is known. This is why hCG levels alone aren . 1 Once levels zero out, this indicates that the body has readjusted to its pre-pregnancy stateand is likely primed for conception to occur again. The risk of a fallopian tube rupture does not go away until your treatment is over. I've had two ultrasounds: one at about five weeks and one at six weeks. An early ectopic pregnancy without unstable bleeding is most often treated with a medication called methotrexate, which stops cell growth and dissolves existing cells. Journal of Womens Health. In: Williams Obstetrics. As your pregnancy progresses, the hCG level increase slows down significantly. An ectopic pregnancy cannot move or be moved to the uterus, so it always requires treatment. 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. This procedure uses a slender, lighted camera that is inserted through small cuts in the abdomen. Do you plan to become pregnant in the future? Progestin Therapy Not Likely to Be Harmful in Women with First Trimester Bleeding. This can also help determine whether a pregnancy is healthy or ectopic, but it should be interpreted together with ultrasound findings. There are specific findings on an ultrasound that can show that the pregnancy is ectopic. 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 . Laparoscopy: A surgical procedure in which an instrument called a laparoscope is inserted into the pelvic cavity through a small incision. 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. Levels of hCG should be increasing by at least 60% every 2-3 days, but ideally doubling every 48-72 hours. Could You Have Subclinical Hypothyroidism? 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. 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. There's some overlap between the possible trends in hCG levels for normal and ectopic pregnancies. The discriminatory -hCG level used at different. Read common questions on the coronavirus and ACOGs evidence-based answers. You'll be asked many questions about your menstrual cycle, fertility and overall health. 2016;83(12):1083-1091. doi:10.1002/mrd.22747. Advanced ectopic pregnancy (high -hCG level, large mass, embryonic cardiac activity) You will have careful follow-up over time until hCG is no longer found in your blood. This content does not have an English version. It offers current information and opinions related to women's health. Early pregnancy loss can be definitively diagnosed in women with ultrasound findings of a mean gestational sac diameter of 25 mm or greater and no embryo or embryonic cardiac activity when the crown-rump length is at least 7 mm. 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. You may continue to feel pregnant for a while. Pregnancy of unknown location. Skip to primary navigation . information highlighted below and resubmit the form. This does not require the removal of the fallopian tube. You'll need blood tests and an ultrasound. 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. Urine tests. As an ectopic pregnancy grows, more serious symptoms may develop, especially if a fallopian tube ruptures. Surgery typically is done with laparoscopy. Terms and Conditions of Use, Get the latest on COVID-19, pregnancy, and breastfeeding. 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. There is a problem with These medications can affect the way methotrexate works in the body. Treatment for incomplete abortion should rely on shared decision making. This does not require the removal of the fallopian tube. 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. Prolonged exposure to sunlight. Have you been pregnant before? Data Sources: An evidence summary from Essential Evidence Plus was reviewed and relevant studies referenced. After six weeks, the levels will double about every 96 hours. Mayo Clinic is a not-for-profit organization. Clinical Outcomes in High-Risk Pregnancies Due to Advanced Maternal Age. Cigarette smoking and having more than one sexual partner also increase the risk for an ectopic pregnancy. Many women who have an ectopic pregnancy go on to have a future, healthy pregnancy. If so, is it more or less than your typical period? The rate of -hCG increase is less rapid as the level increases. In these procedure, a small incision is made in the abdomen, near or in the navel. Clinics. 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. Ectopic pregnancies remain an important cause of morbidity and mortality in women of reproductive age. A complete blood count will be done to check for anemia or other signs of blood loss. Other instruments can be used with it to perform surgery. 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. Established criteria should be used to determine treatment options for ectopic pregnancy, including expectant management, medical management with methotrexate, or surgical intervention. A pelvic exam can help your doctor identify areas of pain, tenderness, or a mass in the fallopian tube or ovary. 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. If you have pain that does not respond to over-the-counter medication, talk with your ob-gyn or other health care professional. 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. People who are older at the time of pregnancy also have an increased risk of ectopic pregnancy. Patients may switch to medical management or uterine aspiration at any time. Levels of this hormone increase during pregnancy. Approximately one-fourth of pregnant women will experience bleeding in the first trimester. All Rights Reserved. You may seek medical attention due to pain or vaginal bleeding. In these cases, the ectopic pregnancy can be removed from the tube, or the entire tube with the pregnancy can be removed. 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. Which procedure you have depends on the amount of bleeding and damage and whether the tube has ruptured. If so, was the test positive? Ectopic pregnancies occur in approximately 1.3 to 2.4% of pregnancies. 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). 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. Depending on your symptoms and when the ectopic pregnancy is discovered, this may be done using medication, laparoscopic surgery or abdominal surgery. It typically takes from one to nine weeks for hCG levels to return to zero following a miscarriage (or delivery). Molecular Reproduction and Development. Salpingostomy and salpingectomy are two laparoscopic surgeries used to treat some ectopic pregnancies. 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. Data Sources: An evidence summary generated from Essential Evidence Plus was reviewed and relevant studies referenced. Abdominal ultrasound, in which an ultrasound wand is moved over your belly, may be used to confirm your pregnancy or evaluate for internal bleeding. 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. It uses sound waves to create images of your uterus, ovaries and fallopian tubes, and sends the pictures to a nearby monitor. Ask your ob-gyn or other health care professional to recommend a counselor. In the vast majority of ectopic pregnancies, the fertilized egg implants somewhere in the fallopian tube. Pregnancy tests look for hCG (human chorionic gonadotropin) which is excreted in pregnancy. "hCG helps the body produce hormones to support pregnancy," explains John Zhang, M.D., founder. Copyright 2020 by the American Academy of Family Physicians. It's important to avoid alcohol, folic acid (in both vitamins and foods) and pain . 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. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. A single copy of these materials may be reprinted for noncommercial personal use only. Copyright 2023 American Academy of Family Physicians. Several factors go into the decision to use methotrexate. Deutsches Aerzteblatt Online. Accessed Dec. 4, 2019. On the other hand, it's also possible to have doubling hCG levels with an ectopic pregnancy. 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. 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. other information we have about you. This may be because they have had more time to experience other conditions that put them at risk for ectopic pregnancies in the future. If both fallopian tubes have been injured or removed, in vitro fertilization (IVF) might still be an option. Ectopic pregnancies are uncommon, but theyre very serious and can be life-threatening. You may opt-out of email communications at any time by clicking on 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. . Mayo Clinic. Patients should be informed that expectant management is more than 90% effective. PMID: 31621664. This drug stops cells from growing, which ends the pregnancy. Several weeks of follow-up are required with each treatment. The search included meta-analyses, guidelines, and reviews. Patients should be asked about pain and the amount of bleeding. Patients undergoing expectant management must receive extensive counseling on the risk of tubal rupture and the importance of close surveillance. An intra-uterine pregnancy can usually be seen by 5-6 weeks gestation or when the HCG level is more than 1000 IU/l. Medical management is safe and effective in carefully selected patients. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). During future pregnancies, be alert for signs and symptoms of ectopic pregnancy until your ob-gyn or other health care professional confirms the next pregnancy is growing in the right place. By 6 to 7 weeks gestation doubling time decreases to roughly every 3 days. Complications Is an Ectopic Pregnancy Dangerous? Very early in pregnancy, the embryo can grow within the fallopian tube without causing any symptoms. Ectopic pregnancies are not viable and can cause serious complications for pregnant women, including death. If theres a mass in the area of the fallopian tubes or ovary, this may represent an ectopic pregnancy. Patient satisfaction, mental health outcomes, infection rates, and future fertility are similar between these treatments.2022 Mental health outcomes are better when patients are included in the decision-making process, and shared decision making should guide management.23. Sometimes, the tissue in or around the fallopian tubes is more difficult to identify on an ultrasound image. 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. If you've had an ectopic pregnancy, your risk of having another one is increased. 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. Pregnancy FAQ 155. Abnormal bleeding and pelvic pain should be reported to your obstetriciangynecologist (ob-gyn) or other health care professional. Levels peaks during the first eight to 11 weeks of pregnancy, then decline and plateau. Uterine aspiration should be considered to evaluate for intrauterine chorionic villi in patients with a pregnancy of unknown location. 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. Four weeks postoperatively, serum -HCG levels had a . It can take time for the level of hCG in your body to drop after treatment for an ectopic pregnancy. Read copyright and permissions information. The Diagnosis and Treatment of Ectopic Pregnancy. Ultrasonography showing neither intrauterine nor ectopic pregnancy in a patient with a positive pregnancy test is referred to as a pregnancy of unknown location. Typical hCG Doubling Times. In some cases, the fallopian tube can be saved. This process is called implantation.. However, since they may go on to develop severe complications, they also require urgent medical attention.
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