include protected health information. Declining or low rate of increase in hCG over 48 hours can be a sign of an ectopic pregnancy or miscarriage. Patients should be asked about pain and the amount of bleeding. You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. Association of pelvic inflammatory disease (PID) with ectopic pregnancy and preterm labor in Taiwan: A nationwide population-based retrospective cohort study. You may be dealing with many emotions after an ectopic pregnancy, even if you were not planning to become pregnant. You will have careful follow-up over time until hCG is no longer found in your blood. 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. Recognize the loss, and give yourself time to grieve. . Ectopic pregnancies happen when a fertilized egg implants somewhere outside of the uterus, like the fallopian tube or the cervix. Niger Postgrad Med J. People who are older at the time of pregnancy also have an increased risk of ectopic pregnancy. Pregnancy of unknown location. https://www.uptodate.com/contents/search. Advertising revenue supports our not-for-profit mission. "hCG helps the body produce hormones to support pregnancy," explains John Zhang, M.D., founder. https://www.aafp.org/pubs/afp/issues/2020/0515/p599.html. A wide variety of symptoms are associated with an 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. If the -hCG level does decrease by at least 15% between days 4 and 7, the patient should return for weekly -hCG measurements until levels become undetectable, which can take up to eight weeks.26, Close follow-up is critical for the safe use of methotrexate in women with ectopic pregnancies. Expectant management, medical management, and uterine aspiration are safe methods for treating anembryonic gestations and fetal demise. Pregnancy FAQ 155. You may feel abdominal discomfort or pain. The search included meta-analyses, guidelines, and reviews. Patients may switch to medical management or uterine aspiration at any time. Ectopic pregnancies occur in approximately 1.3 to 2.4% of pregnancies. Ectopic pregnancy. Patients should be informed that expectant management is more than 90% effective. doi:10.3238/arztebl.2015.0693, Pereira PP, Cabar FR, Gomez T, et al. . 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. The incidence of ectopic pregnancy is 1% to 2% in the United States and accounts for 6% of all maternal deaths. A review of the menstrual history and prior ultrasonography can help establish gestational dating and determine whether the pregnancy location is known. Pregnancy blood tests can detect hCG hormone levels as low as 5 to 10 mIU/mL. Terms and Conditions of Use, Get the latest on COVID-19, pregnancy, and breastfeeding. 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 25th ed. Explore ACOG's library of patient education pamphlets. Pregnancy that develops outside the uterus is called ectopic pregnancy. If the hCG level is high and no gestational sac is seen in the uterus, this makes it highly likely that there is an ectopic pregnancy. People who have had a history of pelvic inflammatory disease (PID) also have a higher risk for an ectopic pregnancy. My hCG levels at five weeks were 150 and then 352 two days later. Several methotrexate regimens have been studied, including a single-dose protocol, a two-dose protocol, and a multi-dose protocol (Table 4).5 The single-dose protocol carries the lowest risk of adverse effects, whereas the two-dose protocol is more effective than the single-dose protocol in patients with higher initial -hCG levels.24 There is no consistent evidence or consensus regarding the cutoff above which a two-dose protocol should be used, so clinicians should choose a regimen based on the initial -hCG level and ultrasound findings, as well as patient preference regarding effectiveness vs. the risk of adverse effects. Search dates: October 26, 2018, through January 14, 2020. Accessed Dec. 29, 2017. This site complies with the HONcode standard for trustworthy health information: verify here. 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). Copyright 2019 by the American Academy of Family Physicians. -hCG levels should be obtained every 48 hours to confirm that they are decreasing, then weekly until they reach zero. 1. Treatment failure is assumed if the -hCG level plateaus or increases from days 4 to 7. If products of conception are visible on speculum examination, the diagnosis of incomplete abortion can be made and treatment offered. Are you in pain? These cases require medical attention immediately. Clinics. Approximately one-fourth of pregnant women will experience bleeding in the first trimester. Deviations from this established pattern should raise suspicion for early pregnancy loss or ectopic pregnancy (Table 2).4,5 Guidelines have been established for ultrasound diagnosis of early pregnancy loss to decrease the risk of false diagnosis and intervention in a desired viable intrauterine pregnancy. If your home pregnancy test is positive, your healthcare provider may offer a blood test to check your hCG levels. This is why hCG levels alone aren . 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. Accessed Dec. 4, 2019. Bed rest does not improve outcomes, and there is insufficient evidence supporting the use of progestins. The discriminatory level is the -hCG level above which an intrauterine pregnancy is expected to be seen on transvaginal ultrasonography.14 When combined with -hCG levels greater than the discriminatory level, ultrasonography that does not show an intrauterine pregnancy should raise concern for early pregnancy loss or ectopic pregnancy. This does not require the removal of the fallopian tube. This content does not have an Arabic version. The clinical diagnosis of ectopic pregnancy is based on a combination of serum quantitative human chorionic gonadotropin levels and transvaginal ultrasound findings. Author disclosure: No relevant financial affiliations. Progestin Therapy Not Likely to Be Harmful in Women with First Trimester Bleeding. It is common for patients to experience some abdominal pain two to three days after administration of methotrexate. For some women, ectopic pregnancy can be traumatic. Expectant management, medical management, and uterine aspiration are safe and effective treatments for early pregnancy loss. Data Sources: An evidence summary generated from Essential Evidence Plus was reviewed and relevant studies referenced. However, most ectopic pregnancies do not reach this stage. PloS One. Blood tests and ultrasound testing can alert your doctor if another ectopic pregnancy is developing. Thus, a history of bleeding and passage of tissue cannot be relied on to differentiate ectopic pregnancy from early intrauterine pregnancy failure. 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. 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. 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. Established criteria should be used to determine treatment options for ectopic pregnancy, including expectant management, medical management with methotrexate, or surgical intervention. Cochrane Database of Systematic Reviews. Some people have no symptoms at all. This does not require the removal of the fallopian tube. You might also seek the help of a support group, grief counselor or other mental health provider. Bilateral ectopic pregnancy is extremely rare, with a tremendous maternal mortality and morbidity risk, requiring rapid diagnosis and management. The pain may become more generalized once the tube ruptures and hemoperitoneum develops. Losing a pregnancy is devastating, even if you've only known about it for a short time. In a salpingostomy, the ectopic pregnancy is removed and the tube left to heal on its own. This content does not have an English version. Most often this occurs in one of the fallopian tubes (called a tubal pregnancy) but it can also happen on the cervix or elsewhere in the abdominal region. In early pregnancy, a 48-hour increase of hCG by 35% can still be considered normal. In this instance, a health care provider can order a test for the hCG level. Accessed Dec. 4, 2019. In a normal pregnancy, the egg is fertilized by a sperm. 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. 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. HCG levels alone do not diagnose an ectopic pregnancy. The first measurement helps the clinician decide between the one- and two-dose protocols. These are called quantitative hCG tests, and they can be used to determine if hCG levels are increasing or decreasing, and how fast. However, there are some very rare medical conditions that can cause high hCG levels. Frequently asked questions. Copyright 2020 by the American Academy of Family Physicians. General Anesthesia: The use of drugs that produce a sleep-like state to prevent pain during surgery. . Hemorrhage was the leading cause of death. Could You Have Subclinical Hypothyroidism? information is beneficial, we may combine your email and website usage information with By the time you reach 8 to 10 weeks, your hCG level will have reached its peak. An ectopic pregnancy most often happens in your fallopian tube (a structure that connects your ovaries and uterus). Have you ever had reproductive surgery, including getting your tubes tied (or a reversal)? Neither ultrasound showed an egg or even a sac. Checking the hCG level and then checking it again in 48 hours tells you how fast the hCG level is rising. 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. The female body normally has two fallopian tubes. Visualization of chorionic villi differentiates intrauterine pregnancy loss from ectopic pregnancy, avoiding unnecessary administration of methotrexate. Talk about your feelings and allow yourself to experience them fully. This cutoff level of -hCG varies by institution but ranges from 1500 to 2500 mIU/ml. 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. Some people with ectopic pregnancies are more stable at the time theyre diagnosed. 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. 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. Human chorionic gonadotropin, or hCG, is a hormone produced by the placenta during pregnancy. If the ectopic pregnancy is causing heavy bleeding, you might need emergency surgery. I just went in for the second ultrasound at six weeks.. The rate of early pregnancy loss is approximately 11% after a live fetus has been detected on ultrasonography.17 The risk of early pregnancy loss is increased when subchorionic hemorrhage (Figure 36 ) and bleeding are present. 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. A complete blood count will be done to check for anemia or other signs of blood loss. A choice of either methotrexate or surgical management is offered to women with an ectopic pregnancy who have a serum hCG level of at least 1500 IU/L and less than 5000 IU/L, . 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. Intramuscular methotrexate is the only medication appropriate for the management of ectopic pregnancy. 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. A history of ectopic pregnancies or a history of surgery on the fallopian tubes are the factors that most increase the risk. Other times, a person will have pain in the pelvis thats much worse on one side. With this procedure, mature eggs are fertilized in a lab and then implanted into the uterus. Levels peaks during the first eight to 11 weeks of pregnancy, then decline and plateau. This condition is usually diagnosed during surgery, as radiologists may not pay enough attention to the contralateral side of interest. Levels of hCG should be increasing by at least 60% every 2-3 days, but ideally doubling every 48-72 hours. 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. When Low hCG Levels Suggest Ectopic Pregnancy . Surgical options include salpingostomy or salpingectomy. Skip to primary navigation . By 6 to 7 weeks gestation doubling time decreases to roughly every 3 days. Urine pregnancy tests work by turning positive if they detect the presence of hCG. The risk factors for ectopic pregnancy include the following: Certain sexually transmitted infections (STIs). Salpingostomy is preferred for patients who wish to preserve fertility; however, it may result in inadequate evacuation of products of conception and a recurrence of symptoms. Burnett TL (expert opinion). These may include pain, fatigue, bleeding, and infection. Tulandi T. Ectopic pregnancy: Clinical manifestations and diagnosis. Trends in quantitative subunit of human chorionic gonadotropin (-hCG) levels provide useful information when distinguishing normal from abnormal early pregnancy. The typical hCG level around four weeks of pregnancy is around 140 mIU/ml 5, so a high hCG level can be generally considered to mean you are pregnant. [2012] Rho(D) immune globulin can also be administered within 72 hours of early pregnancy loss, especially later in the first trimester, although the risk of alloimmunization is estimated to be 1.5% to 2% in this setting.12 There is insufficient evidence for or against the use of Rho(D) immune globulin in Rh-negative patients who present with threatened abortion. 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. 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