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. Do you plan to become pregnant in the future? In a normal pregnancy, the egg is fertilized by a sperm. Urgent surgical referral is indicated when ultrasonography demonstrates an embryo and fetal cardiac activity outside of the uterus. A fertilized egg can't develop normally outside the uterus. The female body normally has two fallopian tubes. 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. This procedure uses a slender, lighted camera that is inserted through small cuts in the abdomen. You may seek medical attention due to pain or vaginal bleeding. information submitted for this request. Ectopic precautions and serial -hCG levels should be continued until the level is undetectable. However, most ectopic pregnancies do not reach this stage. Human chorionic gonadotropin (hCG) is a hormone thats very important throughout pregnancy. Pain and heavy bleeding are associated with an increased risk of early pregnancy loss. Several factors go into the decision to use methotrexate. The most common gestational age of diagnosis is between 6 to 10 weeks. 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. PID is usually caused by a sexually transmitted infection that spreads from the vagina to the uterus and fallopian tubes. 2020;101(10):599-606. https://www.aafp.org/pubs/afp/issues/2020/0515/p599.html, Long Y, Zhu H, Hu Y, et al. Whether you were treated with methotrexate or surgery, you may feel tired for several weeks while you recover. The risk factors for ectopic pregnancy include the following: Certain sexually transmitted infections (STIs). Burnett TL (expert opinion). Sound waves from the transducer create images of the uterus, ovaries and fallopian tubes. Rely on your partner, loved ones and friends for support. Molecular Reproduction and Development. Online forums also can be a place to get support from other women who have had ectopic pregnancies. Methotrexate may be used if the pregnancy has not ruptured a fallopian tube. 2019;14(8):e0219351. Interventions for non-tubal ectopic pregnancy. Most women have some abdominal pain. Human chorionic gonadotropin (hCG) is a glycoprotein hormone composed of 2 dissimilar subunits, alpha and beta, joined non-covalently. The clinical diagnosis of ectopic pregnancy is based on a combination of serum quantitative human chorionic gonadotropin levels and transvaginal ultrasound findings. 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. It's important to avoid alcohol, folic acid (in both vitamins and foods) and pain . information and will only use or disclose that information as set forth in our notice of Data Sources: An evidence summary generated from Essential Evidence Plus was reviewed and relevant studies referenced. American College of Obstetricians and Gynecologists. Prolonged exposure to sunlight. If you are a Mayo Clinic patient, this could If you have pain that does not respond to over-the-counter medication, talk with your ob-gyn or other health care professional. A single-dose methotrexate protocol is recommended for medical management of patients with ectopic pregnancy and low initial -hCG levels. Some experience a small amount of vaginal bleeding or spotting, but others dont. This does not require the removal of the fallopian tube. The estimated mortality of ectopic pregnancy is between 2 and 4/1000. Sometimes, there has been a positive pregnancy test, but no embryo can be seen in the uterus via ultrasound. An intra-uterine pregnancy can usually be seen by 5-6 weeks gestation or when the HCG level is more than 1000 IU/l. PMID: 36122984. It typically takes from one to nine weeks for hCG levels to return to zero following a miscarriage (or delivery). Ectopic pregnancies are not viable and can cause serious complications for pregnant women, including death. McGraw-Hill Education; 2018. https://accessmedicine.mhmedical.com. Recognize the loss, and give yourself time to grieve. It can take time for the level of hCG in your body to drop after treatment for an ectopic pregnancy. Patient preference should guide treatment decisions. It's very important that the diagnosis of ectopic pregnancy is certain before receiving this treatment. Patients should be informed that expectant management is more than 90% effective. An hCG level that is lower than expected is one reason to suspect an ectopic pregnancy. Mayo Clinic does not endorse companies or products. The incidence of ectopic pregnancy is 1% to 2% in the United States and accounts for 6% of all maternal deaths. This information is designed as an educational aid for the public. 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. People who are older at the time of pregnancy also have an increased risk of ectopic pregnancy. 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). It may take a few cycles for your periods to return to normal. Management of these pregnancies has changed dramatically over the years. In a viable intrauterine pregnancy with an initial -hCG level less than 1,500 mIU per mL (1,500 IU per L), there is a 99% chance that the -hCG level will increase by at least 49% over 48 hours.15 As the initial -hCG level increases, the rate of increase over 48 hours slows, with an increase of at least 40% expected for an initial -hCG level of 1,500 to 3,000 mIU per mL (1,500 to 3,000 IU per L) and 33% for an initial -hCG level greater than 3,000 mIU per mL.15 A slower-than-expected rate of increase or a decrease in -hCG levels suggests early pregnancy loss or ectopic pregnancy. 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. . If so, was the test positive? Very early in pregnancy, the embryo can grow within the fallopian tube without causing any symptoms. "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. Cunningham FG, et al., eds. Ectopic pregnancies remain an important cause of morbidity and mortality in women of reproductive age. Pelvic Inflammatory Disease: An infection of the uterus, fallopian tubes, and nearby pelvic structures. 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. In the case of an ectopic pregnancy, the hCG level may just plateau or increase at a very slow rate. Patients may switch to medical management or uterine aspiration at any time. Patients should be counseled that the risk of rupture persists until -hCG levels are undetectable, and that they should seek emergency care if signs of ectopic pregnancy occur. You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. Some people with ectopic pregnancies are more stable at the time theyre diagnosed. In an ectopic pregnancy, the hCG level may increase less than 66% in 48 hours. 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. Search dates: August 3, 2017, to October 21, 2018. The definitive diagnosis of ectopic pregnancy can be made with ultrasound visualization of a yolk sac and/or embryo in the adnexa. 2020;30(2). Typically, if you go to your health care provider with concerns like this, they will order an ultrasound. . The diagnosis of threatened abortion should be made in patients with bleeding and an ultrasound-confirmed viable intrauterine pregnancy. Author disclosure: No relevant financial affiliations. Additionally, a PubMed search was completed in Clinical Queries using the key terms ectopic pregnancy, first trimester bleeding, and pregnancy of unknown location. 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%. Patients should be asked about pain and the amount of bleeding. These medications can affect the way methotrexate works in the body. Certain factors place a person at a relatively higher risk of having an ectopic pregnancy. Ectopic pregnancy. This type of ectopic pregnancy is called a tubal pregnancy. Most ectopic pregnancies are diagnosed between six and nine weeks of pregnancy. 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. This process is called implantation.. It is not intended as a statement of the standard of care. Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. Its not always possible to see an embryo either inside the uterus or in another location. Hormone: A substance made in the body by cells or organs that controls the function of cells or organs. Treatment of threatened abortion is expectant management. Sign up for free, and stay up to date on research advancements, health tips and current health topics, like COVID-19, plus expertise on managing health. 1.6.11 For women with ectopic pregnancy who have had methotrexate, take 2 serum hCG measurements in the first week (days 4 and 7) after treatment and then 1 serum hCG measurement per week until a negative result is obtained. This period increases to about every 96 hours as you get further along. Treatment of diagnosed ectopic pregnancy includes medical management with intramuscular methotrexate, surgical management via salpingostomy or salpingectomy, and, in rare cases, expectant management. At-home urine tests require higher levels of hCG to detect a pregnancy, typically at least 20 mIU/mL. 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). 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. Mayo Clinic is a not-for-profit organization. If chorionic villi are seen, further workup is unnecessary, and exposure to methotrexate can be avoided. Early blood tests are recommended for all women who've had an ectopic pregnancy. Once you have had an ectopic pregnancy, you are at higher risk of having another one. Read copyright and permissions information. If your home pregnancy test is positive, your healthcare provider may offer a blood test to check your hCG levels. 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. 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. In this case, a repeat dose of methotrexate may be given, although surgery may be required if the patient is symptomatic. Have you ever had reproductive surgery, including getting your tubes tied (or a reversal)? 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. They can even be life-threatening. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. The doctor might recommend an office visit or immediate medical care. Established criteria should be used to determine treatment options for ectopic pregnancy, including expectant management, medical management with methotrexate, or surgical intervention. 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. Accessed Dec. 4, 2019. Surgical options include salpingostomy or salpingectomy. The differential diagnosis includes threatened abortion, early pregnancy loss, and ectopic pregnancy. Treatment for incomplete abortion should rely on shared decision making. Progesterone levels rise much differently than hCG levels, with an average of 1-3mg/ml every couple days until they reach their peak for that trimester. 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. ERIN HENDRIKS, MD, RACHEL ROSENBERG, MD, AND LINDA PRINE, MD. PloS One. 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. Do you have vaginal bleeding? The clinical manifestations and diagnosis of ectopic pregnancy are reviewed here with a focus on tubal pregnancy. It uses sound waves to create images of your uterus, ovaries and fallopian tubes, and sends the pictures to a nearby monitor. 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. Accessed Dec. 4, 2019. The fertilized egg travels through the fallopian tube and into the uterus, where it attaches to the uterine wall. 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. It is not a substitute for the advice of a physician. Pregnancy FAQ 155. Ectopic pregnancy in Dalhatu Araf Specialist Hospital Lafia Nigeria - A 5-year review. Oral mifepristone (Mifeprex), 200 mg, followed 24 hours later by misoprostol, 800 mcg vaginally, is the most effective regimen for medical management of early pregnancy loss and, when available, should be recommended over misoprostol alone. the unsubscribe link in the e-mail. Abdominal ultrasound, in which an ultrasound wand is moved over your belly, may be used to confirm your pregnancy or evaluate for internal bleeding. In this instance, a health care provider can order a test for the hCG level. Four weeks postoperatively, serum -HCG levels had a . Advanced ectopic pregnancy (high -hCG level, large mass, embryonic cardiac activity) An ectopic pregnancy is when the fertilized egg remains in the fallopian tube and continues to develop. This condition is usually diagnosed during surgery, as radiologists may not pay enough attention to the contralateral side of interest. Endometriosis: A condition in which tissue that lines the uterus is found outside of the uterus, usually on the ovaries, fallopian tubes, and other pelvic structures. Others may present in shock because their fallopian tube ruptured, causing internal bleeding. There are specific findings on an ultrasound that can show that the pregnancy is ectopic. Patients should be counseled to avoid repeat pregnancy until at least one ovulatory cycle after the serum -hCG level becomes undetectable, although some experts recommend waiting three months so that the methotrexate can be cleared completely.27 There is no evidence that methotrexate therapy affects future fertility.28. A wide variety of symptoms are associated with an ectopic pregnancy. Ultrasonography shows gestational sac with mean diameter 25 mm and no yolk sac or embryo, Complete passage of all products of conception, Nonviable intrauterine pregnancy within the first 12 6/7 weeks of gestation, A pregnancy outside the uterine cavity (most commonly in a fallopian tube), Ultrasonography shows embryo with crown-rump length 7 mm and no cardiac activity, Some, but not all, of the products of conception have passed, Intrauterine pregnancy of uncertain viability, Transvaginal ultrasonography shows intrauterine gestational sac with no embryonic cardiac activity (and no findings of definite pregnancy failure [, Pregnancy that cannot result in live birth (e.g., ectopic pregnancy, early pregnancy loss), Positive urine or serum pregnancy test with no intrauterine or ectopic pregnancy shown on transvaginal ultrasonography, More than two consecutive pregnancy losses, Spontaneous loss of pregnancy before 20 weeks' gestation, Bleeding before 20 weeks' gestation in the presence of an embryo with cardiac activity and a closed cervix, Pregnancy that can potentially result in a live birth, Gestational sac (measured by mean sac diameter), Appears four to five weeks after last menstrual period, Mean sac diameter of 16 to 24 mm and no embryo, Appears 5.5 weeks after last menstrual period, Absence of embryo with cardiac activity seven to 10 days after ultrasonography shows gestational sac and yolk sac, Absence of embryo withcardiac activity 11 days after ultrasonography shows gestational sac and yolk sac, Embryo (measured by crown-rump length and embryonic cardiac activity), Appears six weeks after last menstrual period; embryonic cardiac activity appears at 6.5 weeks, Crown-rump length < 7 mm and no embryonic cardiac activity, Crown-rump length 7 mm and no embryonic cardiac activity. Ectopic pregnancies occur in approximately 1.3 to 2.4% of pregnancies. You might show signs of being in shock, such as a very high heart rate and very low blood pressure. As an ectopic pregnancy grows, more serious symptoms may develop, especially if a fallopian tube ruptures. Pregnancy that develops outside the uterus is called ectopic pregnancy. Review/update the The nature, location, and severity of pain in ectopic pregnancy vary. Hemorrhage was the leading cause of death. You can detect hCG in either blood or urine . Ectopic pregnancy. These are called quantitative hCG tests, and they can be used to determine if hCG levels are increasing or decreasing, and how fast. Levels of hCG should be increasing by at least 60% every 2-3 days, but ideally doubling every 48-72 hours. Did you notice anything unusual about it? 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. Heres what to know. Bilateral ectopic pregnancy is extremely rare, with a tremendous maternal mortality and morbidity risk, requiring rapid diagnosis and management. How long should I wait before trying to become pregnant again? Get the Stats on Ectopic Pregnancies. Nonviable intrauterine pregnancy within the first 12 6/7 weeks of gestation: Ectopic pregnancy: . Obstet Gynecol Clin North Am. About one half of all women who have an ectopic pregnancy do not have known risk factors. Randomized trials have shown no difference in sequelae between methotrexate administration and fallopian tubesparing laparoscopic surgery, including rates of future intrauterine pregnancy and risk of future ectopic pregnancy.29 The decision whether to remove the fallopian tube or leave it in place depends on the extent of damage to the tube (evaluated intraoperatively) and the patient's desire for future fertility. . Levels of this hormone increase during pregnancy. Laparoscopy: A surgical procedure in which an instrument called a laparoscope is inserted into the pelvic cavity through a small incision. Pregnancy blood tests can detect hCG hormone levels as low as 5 to 10 mIU/mL. These cases require medical attention immediately. On the other hand, it's also possible to have doubling hCG levels with an ectopic pregnancy. Human chorionic gonadotropin (hCG) is a hormone normally produced by the placenta. After this . 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. In a patient with a -hCG value above this level, failure to visualize an intrauterine pregnancy strongly suggests ectopic pregnancy. A complete blood count will be done to check for anemia or other signs of blood loss. The search included meta-analyses, guidelines, and reviews. If hCG levels plateau or rise, reassess the woman's condition for further treatment. Counseling may be helpful. An ectopic pregnancy most often happens in your fallopian tube (a structure that connects your ovaries and uterus). This may be because they have had more time to experience other conditions that put them at risk for ectopic pregnancies in the future. Ultrasound findings diagnostic of early pregnancy loss include a mean gestational sac diameter of 25 mm or greater with no embryo and no fetal cardiac activity when the crown-rump length is 7 mm or more. Clinicians should expect to see a gestational sac on transvaginal ultrasonography when -hCG levels reach 1,500 to 3,000 mIU per mL. Higher-than-typical hCG levels can signal that you're carrying multiples or, in rare cases, have a molar pregnancy. It often begins as a colicky abdominal or pelvic pain that is localized to one side as the pregnancy distends the fallopian tube. Published online July 1, 2020. doi:10.1002/14651858.cd011174.pub2, Taran FA, Kagan KO, Hbner M, et al. An intra-uterine pregnancy can usually be seen by 5-6 weeks gestation or when the HCG level is more than 1000 IU/l. However, since they may go on to develop severe complications, they also require urgent medical attention. Uterine aspiration should be considered to evaluate for intrauterine chorionic villi in patients with a pregnancy of unknown location. 2019 Oct-Dec;26(4):235-238. doi:10.4103/npmj.npmj_105_19. Sometimes surgery is needed even if the fallopian tube has not ruptured. In viable intrauterine pregnancies with initial -hCG levels of less than 1,500 mIU per mL, 1,500 to 3,000 mIU per mL, or greater than 3,000 mIU per mL, there is a 99% chance that the -hCG level will increase by at least 49%, 40%, and 33%, respectively, over 48 hours. Checking the hCG level and then checking it again in 48 hours tells you how fast the hCG level is rising. If so, is it more or less than your typical period? All rights reserved. Data Sources: An evidence summary from Essential Evidence Plus was reviewed and relevant studies referenced. The laparoscope is used to view the pelvic organs. A rupture can cause major internal bleeding. | Several weeks of follow-up are required with each treatment. Vaginal bleeding in early pregnancy requires prompt attention. 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. Slow-rising quantitative hCG levels, at least in early pregnancy, .
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