Pregnancy that develops outside the uterus is called ectopic pregnancy. In 95% of ectopic pregnancy cases, a good transvaginal ultrasound examination can actually image the ectopic pregnancy in the Fallopian tube. 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 does not require the removal of the fallopian tube. If you don't require emergency treatment and haven't yet been diagnosed with an ectopic pregnancy, your doctor will talk to you about medical history and symptoms. Search for doctors near you. 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. 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. 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. Read common questions on the coronavirus and ACOGs evidence-based answers. Whether you were treated with methotrexate or surgery, you may feel tired for several weeks while you recover. Have you had a sexually transmitted infection? Slowly rising hCG levels may be the first clue . You may seek medical attention due to pain or vaginal bleeding. Blood tests and ultrasound testing can alert your doctor if another ectopic pregnancy is developing. The pregnancy then is absorbed by the body over 4-6 weeks. After six weeks, the levels will double about every 96 hours. People who are older at the time of pregnancy also have an increased risk of ectopic pregnancy. If hCG levels have not decreased enough after the . This process is called implantation.. In these cases, the ectopic pregnancy can be removed from the tube, or the entire tube with the pregnancy can be removed. Obstet Gynecol Clin North Am. 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. 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. About one half of all women who have an ectopic pregnancy do not have known risk factors. In an ectopic pregnancy, the hCG level may increase less than 66% in 48 hours. Copyright 2023 American College of Obstetricians and Gynecologists, Privacy Statement However, most ectopic pregnancies do not reach this stage. Human chorionic gonadotropin, or hCG, is a hormone produced by the placenta during pregnancy. Hyperthyroidism and Weight Gain: What to Know, Diabetes and Depression: How Telemedicine is Successfully Treating Both, COVID Long-Haulers Share Their Roads to Recovery, How Your Hunger Hormones Control Weight Loss, Thyroid Disorders and Infertility: A Doctors Personal Story. 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. Laparotomy is reserved for patients who are hemodynamically unstable. There are different treatment protocols, but the single-dose regimen is most common.15 This includes an intramuscular injection of 50 mg of methotrexate per m2, followed by close monitoring of symptoms and measurement of -hCG levels four and seven days after injection. Next, your doctor uses a thin tube equipped with a camera lens and light (laparoscope) to view the tubal area. [2012] The search included meta-analyses, randomized controlled trials, clinical trials, guidelines, and reviews. Other factors that may increase a womans risk of ectopic pregnancy include: Use of assisted reproductive technology, such as in vitro fertilization (IVF). It can also possibly indicate an ectopic pregnancy that is 'self-resolving'. This drug stops cells from growing, which ends the 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. Make a donation. American Family Physician. This does not require the removal of the fallopian tube. The definitive diagnosis of ectopic pregnancy can be made with ultrasound visualization of a yolk sac and/or embryo in the adnexa. Serial beta human chorionic gonadotropin levels, serial ultrasonography, and, at times, uterine aspiration can be used to arrive at a definitive diagnosis. 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. Guidelines for ultrasound diagnosis of early pregnancy loss have been established to decrease the likelihood of false diagnosis and of intervening in a desired viable pregnancy. The incidence of ectopic pregnancy is 1% to 2% in the United States and accounts for 6% of all maternal deaths. It's very important that the diagnosis of ectopic pregnancy is certain before receiving this treatment. To prevent life-threatening complications, the ectopic tissue needs to be removed. Typical hCG Doubling Times. Patient information: See related handout on bleeding in early pregnancy, written by the authors of this article. Levels should then double every 48 hours from weeks four to six, but that isn't the case for everyone. Abnormal bleeding and pelvic pain should be reported to your obstetriciangynecologist (ob-gyn) or other health care professional. Uterine aspiration is the preferred procedure for surgical management of early pregnancy loss. The female body normally has two fallopian tubes. PloS One. 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. Thus, a history of bleeding and passage of tissue cannot be relied on to differentiate ectopic pregnancy from early intrauterine pregnancy failure. You may continue to feel pregnant for a while. I've had two ultrasounds: one at about five weeks and one at six weeks. 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. Ectopic pregnancies happen when a fertilized egg implants somewhere outside of the uterus, like the fallopian tube or the cervix. As an ectopic pregnancy grows, more serious symptoms may develop, especially if a fallopian tube ruptures. Declining or low rate of increase in hCG over 48 hours can be a sign of an ectopic pregnancy or miscarriage. With this procedure, mature eggs are fertilized in a lab and then implanted into the uterus. Visualization of chorionic villi differentiates intrauterine pregnancy loss from ectopic pregnancy, avoiding unnecessary administration of methotrexate. In 95% of ectopic pregnancy cases, a good transvaginal ultrasound examination can actually image the ectopic pregnancy in the Fallopian tube. 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. 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. Cunningham FG, et al., eds. What are the chances of dying from an ectopic pregnancy? Do you have vaginal bleeding? 25th ed. The medication is given by injection. information highlighted below and resubmit the form. For symptomatic women with a viable intrauterine pregnancy, initial -hCG levels of less than 1,500 mIU per mL, 1,500 to 3,000 mIU per mL, or more than 3,000 mIU per mL will increase over 48 hours by at least 49%, 40%, or 33%, respectively.10 A slower rate of increase suggests early pregnancy loss or ectopic pregnancy. Treatment of diagnosed ectopic pregnancy includes medical management with intramuscular methotrexate, surgical management via salpingostomy or salpingectomy, and, in rare cases, expectant management. 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). The clinical manifestations and diagnosis of ectopic pregnancy are reviewed here with a focus on tubal pregnancy. Levels of this hormone increase during pregnancy. In addition to her MD, she holds a Master of Public Health degree. 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 . Tulandi T. Ectopic pregnancy: Clinical manifestations and diagnosis. In the case of an ectopic pregnancy, the hCG level may just plateau or increase at a very slow rate. If so, is it more or less than your typical period? Could You Have Subclinical Hypothyroidism? A meta-analysis evaluating the accuracy of a single progesterone test to predict pregnancy outcome in women with first trimester bleeding showed that a level less than 6 ng per mL (19.1 nmol per L) reliably excludes viable pregnancy, with a negative predictive value of 99%.13 A low progesterone level cannot distinguish intrauterine pregnancy from ectopic pregnancy.13, A baseline hemoglobin level should be documented for all women with bleeding during pregnancy. Copyright 2020 by the American Academy of Family Physicians. Several factors go into the decision to use methotrexate. Sometimes, an embryo is visible in or around the fallopian tube; this confirms an ectopic pregnancy. Other times, a person will have pain in the pelvis thats much worse on one side. However, vaginal spotting and pelvic painand, of course, missed periodscan also occur in normal pregnancies, so this combination doesnt guarantee that a pregnancy is ectopic. Ononuju CN, Ogbe AE, Changkat LL, et al. The combination of missing a menstrual period, pelvic pain, and vaginal spotting is often seen in ectopic pregnancies. 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. This type of ectopic pregnancy is called a tubal pregnancy. Ectopic pregnancies occur in approximately 1.3 to 2.4% of pregnancies. American College of Obstetricians and Gynecologists. If the ectopic pregnancy is causing heavy bleeding, you might need emergency 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. 25th ed. In some cases, an ectopic pregnancy may resolve on its own. 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. Some people have no symptoms at all. 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