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. Bilateral ectopic pregnancy is extremely rare, with a tremendous maternal mortality and morbidity risk, requiring rapid diagnosis and management. Women with an ectopic pregnancy may have irregular bleeding and pelvic or abdominal pain, often on one side. 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. 2022 Sep;49(3):537-549. doi:10.1016/j.ogc.2022.02.018. Data Sources: An evidence summary from Essential Evidence Plus was reviewed and relevant studies referenced. The clinical diagnosis of ectopic pregnancy is based on a combination of serum quantitative human chorionic gonadotropin levels and transvaginal ultrasound findings. 2019 Oct-Dec;26(4):235-238. doi:10.4103/npmj.npmj_105_19. The pregnancy then is absorbed by the body over 46 weeks. Severe abdominal or pelvic pain accompanied by vaginal bleeding. Clinics. In a salpingostomy, the ectopic pregnancy is removed and the tube left to heal on its own. Make a donation. Terms and Conditions of Use, Get the latest on COVID-19, pregnancy, and breastfeeding. An hCG level of less than 5 mIU/mL is considered negative for pregnancy, and anything above 25 mIU/mL is considered positive for pregnancy. If we combine this information with your protected
Patients may switch to medical management or uterine aspiration at any time. 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. My hCG level was on the lower end for someone 4 to 5 weeks . A pelvic exam can help your doctor identify areas of pain, tenderness, or a mass in the fallopian tube or ovary. In an ectopic pregnancy, the fertilized egg implants somewhere other than the lining of the uterus. Niger Postgrad Med J. When that happens, lower amounts of hCG are produced and the embryo can't develop normally. Bed rest does not improve outcomes, and there is insufficient evidence supporting the use of progestins. As your pregnancy progresses, the hCG level increase slows down significantly. 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. . 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, . Almost all ectopic pregnanciesmore than 90%occur in a fallopian tube. Abstract. 5. For some women, ectopic pregnancy can be traumatic. Advanced ectopic pregnancy (high -hCG level, large mass, embryonic cardiac activity) Mayo Clinic is a not-for-profit organization. Because ectopic pregnancies can be life-threatening, early diagnosis is essential. McGraw-Hill Education; 2018. https://accessmedicine.mhmedical.com. A ruptured fallopian tube can cause life-threatening internal bleeding. If ectopic pregnancy has been diagnosed, the patient is deemed clinically stable, and the affected fallopian tube has not ruptured, treatment options include medical management with intramuscular methotrexate or surgical management with salpingostomy (removal of the ectopic pregnancy while leaving the fallopian tube in place) or salpingectomy (removal of part or all of the affected fallopian tube). The diagnosis of threatened abortion should be made in patients with bleeding and an ultrasound-confirmed viable intrauterine pregnancy. In early pregnancy, a 48-hour increase of hCG by 35% can still be considered normal. Hormone: A substance made in the body by cells or organs that controls the function of cells or organs. As the pregnancy grows, it can cause the tube to burst (rupture). Fallopian Tube: Tube through which an egg travels from the ovary to the uterus. Ultrasound Transvaginal ultrasound A transvaginal ultrasound allows your doctor to see the exact location of your pregnancy. Additionally, a PubMed search was completed in Clinical Queries using the key terms ectopic pregnancy, first trimester bleeding, and pregnancy of unknown location. In 95% of ectopic pregnancy cases, a good transvaginal ultrasound examination can actually image the ectopic pregnancy in the Fallopian tube. February 03, 2023 | by haleyerin1229. People who have had a history of pelvic inflammatory disease (PID) also have a higher risk for an ectopic pregnancy. Vaginal bleeding or spotting also may occur. Sexually Transmitted Infections (STIs): Infections that are spread by sexual contact, including chlamydia, gonorrhea, human papillomavirus (HPV), herpes, syphilis, and human immunodeficiency virus (HIV, the cause of acquired immunodeficiency syndrome [AIDS]). Approximately 25% of pregnant women experience bleeding before 12 weeks' gestation.1,2 The differential diagnosis includes nonobstetric causes, bleeding in a viable intrauterine pregnancy, early pregnancy loss, and ectopic pregnancy. The clinical manifestations and diagnosis of ectopic pregnancy are reviewed here with a focus on tubal pregnancy. Many women who have an ectopic pregnancy go on to have a future, healthy pregnancy. Online forums also can be a place to get support from other women who have had ectopic pregnancies. Implantation and placental development. Data Sources: An evidence summary generated from Essential Evidence Plus was reviewed and relevant studies referenced. This content is owned by the AAFP. Do you plan to become pregnant in the future? The definitive diagnosis of ectopic pregnancy can be made with ultrasound visualization of a yolk sac and/or embryo in the adnexa. No specific range of decrease is considered normal as long as the patient is asymptomatic and the decrease continues.39 Surgical management is indicated if the patient experiences increased abdominal pain or if -hCG levels increase.38, Patients with previous ectopic pregnancy have higher rates of ectopic pregnancy and early pregnancy loss in subsequent pregnancies. 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. Some people with ectopic pregnancies are more stable at the time theyre diagnosed. | In: Williams Obstetrics. This can be a life-threatening emergency that needs immediate surgery. After the injection, your doctor will order another HCG test to determine how well treatment is working, and if you need more medication. Ultrasonography showing neither intrauterine nor ectopic pregnancy in a patient with a positive pregnancy test is referred to as a pregnancy of unknown location. Cigarette smoking and having more than one sexual partner also increase the risk for an ectopic pregnancy. It offers current information and opinions related to women's health. Pregnancy of unknown location. Accessed Dec. 4, 2019. Urgent surgical referral is indicated when ultrasonography demonstrates an embryo and fetal cardiac activity outside of the uterus. It is done in a hospital with general anesthesia. All women who may conceive should be counseled to take folic acid. Patients undergoing expectant management must receive extensive counseling on the risk of tubal rupture and the importance of close surveillance. Have you ever had reproductive surgery, including getting your tubes tied (or a reversal)? 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. If your home pregnancy test is positive, your healthcare provider may offer a blood test to check your hCG levels. After this . Patients should be informed that expectant management is more than 90% effective. There's some overlap between the possible trends in hCG levels for normal and ectopic pregnancies. Urine tests. https://www.aafp.org/pubs/afp/issues/2020/0515/p599.html. Further evaluation is needed unless a definitive nonobstetric cause of bleeding is found or products of conception are seen (Figure 1).8, The subunit of human chorionic gonadotropin (-hCG) can be detected in the plasma of a pregnant woman as early as eight days after ovulation.9 Quantitative -hCG levels can provide useful information in early pregnancy. -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. You may be dealing with many emotions after an ectopic pregnancy, even if you were not planning to become pregnant. The risk factors for ectopic pregnancy include the following: Certain sexually transmitted infections (STIs). If so, is it more or less than your typical period? This type of ectopic pregnancy is called a tubal pregnancy. Could You Have Subclinical Hypothyroidism? Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. 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. Advertising revenue supports our not-for-profit mission. Accessed Dec. 4, 2019. 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 should be obtained every 48 hours to confirm that they are decreasing, then weekly until they reach zero. In a typical pregnancy, your hCG levels double every 48 to 72 hours. Levels should then double every 48 hours from weeks four to six, but that isn't the case for everyone. Sound waves from the transducer create images of the uterus, ovaries and fallopian tubes. A single-dose methotrexate protocol is recommended for medical management of patients with ectopic pregnancy and low initial -hCG levels. Skip to primary navigation . Treatment options for early pregnancy loss include expectant management, medical management with mifepristone and misoprostol, or uterine aspiration. It may take a few cycles for your periods to return to normal. Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. In the United States, the estimated prevalence of ectopic pregnancy is 1% to 2%, and ruptured ectopic pregnancy accounts for 2.7% of pregnancy-related deaths. Hendriks E, Rosenberg R, Prine L. Ectopic Pregnancy: Diagnosis and Management. If your hCG level does not drop by at least 15 percent between the fourth to seventh day after treatment, a second dose is required. 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%. Signs of ectopic pregnancy (e.g., adnexal mass, fluid in the cul-de-sac) can be seen on ultrasonography well below the discriminatory level. These cases require medical attention immediately. Recognize the loss, and give yourself time to grieve. 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