privacy practices. doi:10.1089/jwh.2020.8860. If theres a mass in the area of the fallopian tubes or ovary, this may represent an ectopic pregnancy. It is appropriate for family physicians to treat hemodynamically stable patients in conjunction with their primary obstetrician. In-vitro fertilization (IVF) also increases the chance of an ectopic pregnancy. 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. It's a dangerous and life-threatening condition, as it may cause the fallopian tube to. A discriminatory -hCG level as high as 3,500 mIU per mL (3,500 IU per L) should be used when a woman wishes to avoid unnecessary intervention in a potentially viable intrauterine pregnancy. Patients with suspected or confirmed ectopic pregnancy who exhibit signs and symptoms of ruptured ectopic pregnancy should be emergently transferred for surgical intervention. For trusted, in-depth advice from ob-gyns, turn to Your Pregnancy and Childbirth: Month to Month. 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. The doctor might recommend an office visit or immediate medical care. An intra-uterine pregnancy can usually be seen by 5-6 weeks gestation or when the HCG level is more than 1000 IU/l. Tonick S, Conageski C. Ectopic Pregnancy. Your ob-gyn or other health care professional will talk with you about the possible side effects and risks of surgery for ectopic pregnancy. Pregnancy that develops outside the uterus is called ectopic pregnancy. All patients should be instructed to seek care if they have symptoms of anemia or heavy bleeding, quantified as soaking through more than two sanitary pads per hour for two consecutive hours.3. Seek care right away if you have symptoms of a rupture, including sudden abdominal pain, shoulder pain, or weakness. You may be dealing with many emotions after an ectopic pregnancy, even if you were not planning to become pregnant. The initial -hCG level should be considered when following the rate of -hCG increase in early pregnancy. The pregnancy then is absorbed by the body over 4-6 weeks. Did you notice anything unusual about it? Copyright 2023 American Academy of Family Physicians. 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. Early blood tests are recommended for all women who've had an ectopic pregnancy. Tulandi T. Ectopic pregnancy: Epidemiology, risk factors, and anatomic sites. Search dates: October 26, 2018, through January 14, 2020. The behavior of this hormone can help detect a dangerously abnormal pregnancy. Before you take methotrexate, blood tests will be done to measure the level of hCG and the functions of certain organs. A Cochrane review found no difference in success rates between laparoscopic salpingostomy and medical treatment with systemic methotrexate, as well as no differences in tubal patency or subsequent fertility rates.40. Ectopic pregnancy. There's some overlap between the possible trends in hCG levels for normal and ectopic pregnancies. 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. Rely on your partner, loved ones and friends for support. This site complies with the HONcode standard for trustworthy health information: verify here. 2020;30(2). This content is owned by the AAFP. In this case, a repeat dose of methotrexate may be given, although surgery may be required if the patient is symptomatic. PMID: 36122984. Treatment for incomplete abortion should rely on shared decision making. If so, where does it hurt? Fallopian Tube: Tube through which an egg travels from the ovary to the uterus. 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. Pregnancy of unknown location. After the injection, your doctor will order another HCG test to determine how well treatment is working, and if you need more medication. Signs of ectopic pregnancy (e.g., adnexal mass, fluid in the cul-de-sac) can be seen on ultrasonography well below the discriminatory level. See permissionsforcopyrightquestions and/or permission requests. Laparoscopy is the preferred surgical approach. Levels of this hormone increase during pregnancy. One of the most important factors is your ability to follow up with blood tests that check your blood levels of hCG. Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. 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. It uses sound waves to create images of your uterus, ovaries and fallopian tubes, and sends the pictures to a nearby monitor. 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 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. 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. -hCG levels should be obtained every 48 hours to confirm that they are decreasing, then weekly until they reach zero. Implantation and placental development. If your ectopic pregnancy isnt detected or treated early, you can experience severe health complications, including excessive bleeding, rupture of a fallopian tube, and death. If your home pregnancy test is positive, your healthcare provider may offer a blood test to check your hCG levels. You'll need blood tests and an ultrasound. Urgent surgical referral is indicated when ultrasonography demonstrates an embryo and fetal cardiac activity outside of the uterus. Interventions for non-tubal ectopic pregnancy. "hCG helps the body produce hormones to support pregnancy," explains John Zhang, M.D., founder. 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. Serial beta human chorionic gonadotropin levels, serial ultrasonography, and, at times, uterine aspiration can be used to arrive at a definitive diagnosis. information submitted for this request. 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. Deutsches Aerzteblatt Online. Don't have an ob-gyn? . Slowly rising hCG levels may be the first clue . However, there are some very rare medical conditions that can cause high hCG levels. 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. Accessed Dec. 4, 2019. Women with an ectopic pregnancy may have irregular bleeding and pelvic or abdominal pain, often on one side. Typically, if you go to your health care provider with concerns like this, they will order an ultrasound. 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. Many women who have an ectopic pregnancy go on to have a future, healthy pregnancy. Sometimes, the tissue in or around the fallopian tubes is more difficult to identify on an ultrasound image. Yes, ectopic pregnancies are dangerous. In the case of an ectopic pregnancy, the hCG level may just plateau or increase at a very slow rate, but . The clinical diagnosis of ectopic pregnancy is based on a combination of serum quantitative human chorionic gonadotropin levels and transvaginal ultrasound findings. 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. As the pregnancy grows, it can cause the tube to burst (rupture). Ultrasound Exam: A test in which sound waves are used to examine internal structures. Patient preference should guide treatment decisions. Once you have had an ectopic pregnancy, you are at higher risk of having another one. If you're diagnosed with an ectopic pregnancy, your doctor may also order tests to check your blood type in case you need a transfusion. Hormone: A substance made in the body by cells or organs that controls the function of cells or organs. You will have careful follow-up over time until hCG is no longer found in your blood. Overall, surgical management has a higher success rate for ectopic pregnancy than methotrexate.5 The initial -hCG level at which to transfer a patient for possible surgical treatment depends on local standards, although a level of 5,000 mIU per mL (5,000 IU per L) is commonly used.5,11 Ultrasound visualization of an embryo with fetal cardiac activity outside of the uterus is an indication for urgent transfer for surgical management.5,25 Additionally, social factors that preclude frequent laboratory testing (e.g., poor telephone access, work and family obligations, lack of transportation) can make surgical management the safer option5 (Table 55,11). One use for quantitative hCG levels is to diagnose and monitor an ectopic pregnancy or pregnancy of unknown location. Both bleeding and fallopian tube rupture can cause you to become clinically unstable. 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. Sunlight exposure during treatment can cause methotrexate dermatitis and should be avoided.5 Other adverse effects of methotrexate include alopecia and elevation of liver enzymes. This drug stops cells from growing, which ends the pregnancy. Sometimes it can be difficult to remember all of the information provided, especially in an emergency situation. As an ectopic pregnancy grows, more serious symptoms may develop, especially if a fallopian tube ruptures. Confirming pregnancy Surgical options include salpingostomy or salpingectomy. Vital signs indicating hemodynamic instability or peritoneal signs on physical examination require emergent evaluation. Clinicians should expect to see a gestational sac on transvaginal ultrasonography when -hCG levels reach 1,500 to 3,000 mIU per mL. Pregnancy of unknown location refers to a transient state in which a pregnancy test is positive but ultrasonography shows neither intrauterine nor ectopic pregnancy. Medical management is safe and effective in carefully selected patients. 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. Assisted Reproductive Technology: A group of infertility treatments in which an egg is fertilized with a sperm outside the body; the fertilized egg then is transferred to the uterus. An ectopic pregnancy is when a fertilized ovum implants outside of the uterus. Thus, a history of bleeding and passage of tissue cannot be relied on to differentiate ectopic pregnancy from early intrauterine pregnancy failure. As an ectopic pregnancy grows, more serious symptoms may develop, especially if a fallopian tube ruptures. 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. See permissionsforcopyrightquestions and/or permission requests. A complete blood count will be done to check for anemia or other signs of blood loss. Clinical Outcomes in High-Risk Pregnancies Due to Advanced Maternal Age. A speculum examination can help identify nonobstetric causes of bleeding, such as vaginitis, cervicitis, or a cervical polyp. 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. You may seek medical attention due to pain or vaginal bleeding. 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. Losing a pregnancy is devastating, even if you've only known about it for a short time. 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). In this case, the pregnancy is called a pregnancy of unknown location. There is no consensus about the next steps if a pregnancy is of unknown location. In addition to her MD, she holds a Master of Public Health degree. On the other hand, it's also possible to have doubling hCG levels with an ectopic pregnancy. Almost all ectopic pregnanciesmore than 90%occur in a fallopian tube. Urine tests. Pain and heavy bleeding are associated with an increased risk of early pregnancy loss. This can also help determine whether a pregnancy is healthy or ectopic, but it should be interpreted together with ultrasound findings. 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. Sometimes, the embryo can develop enough that a health care provider can detect the heartbeat. Make a donation. This does not require the removal of the fallopian tube. An ectopic pregnancy occurs when a fertilized egg implants and grows outside the main cavity of the uterus. Have you ever had reproductive surgery, including getting your tubes tied (or a reversal)? An ectopic pregnancy is a pregnancy that happens outside of your uterus. Levels of hCG should be increasing by at least 60% every 2-3 days, but ideally doubling every 48-72 hours. 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. . If you've had an ectopic pregnancy, your risk of having another one is increased. If both fallopian tubes have been injured or removed, in vitro fertilization (IVF) might still be an option. Search dates: August 3, 2017, to October 21, 2018. 1. You may continue to feel pregnant for a while. 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. Pregnancy of unknown location describes the scenario in which a pregnancy test is positive, but neither intrauterine nor ectopic pregnancy is shown on ultrasonography. 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. Cochrane Database of Systematic Reviews. In a salpingostomy, the ectopic pregnancy is removed and the tube left to heal on its own. manual vacuum aspiration of the uterus can evaluate for chorionic villi that differentiate intrauterine pregnancy loss from ectopic pregnancy. This condition is usually diagnosed during surgery, as radiologists may not pay enough attention to the contralateral side of interest. Ectopic pregnancies are uncommon, but theyre very serious and can be life-threatening. Methotrexate can cause sun sensitivity. Prescription pain medication and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. Dr. Ewan is a physician with a background in pediatrics. Get the Stats on Ectopic Pregnancies. A glossary of terms used in this article is available in Table 1.36. Published online July 1, 2020. doi:10.1002/14651858.cd011174.pub2, Taran FA, Kagan KO, Hbner M, et al. Medical conditions that can cause high hCG levels may be given, although surgery be! A mass in the cervix, abdomen, or weakness blood count will be done to measure the of. Ectopic pregnancy may have irregular bleeding and passage of tissue can not be relied on to have doubling hCG is... 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