Laparoscopy: A surgical procedure in which an instrument called a laparoscope is inserted into the pelvic cavity through a small incision. Cunningham FG, et al., eds. 2022 Sep;49(3):537-549. doi:10.1016/j.ogc.2022.02.018. If you wish to try to get pregnant again, it's very important to see your doctor regularly. This type of ectopic pregnancy is called a tubal pregnancy. Urine pregnancy tests work by turning positive if they detect the presence of hCG. If you have sudden, severe pain; shoulder pain; or weakness, you should go to an emergency room. 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. Pregnancy FAQ 155. Miscarriage. Obstet Gynecol Clin North Am. The discriminatory level (1,500 to 3,000 mIU per mL) is the -hCG level above which an intrauterine pregnancy should be visible on transvaginal ultrasonography. Get the Stats on Ectopic Pregnancies. 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%. Threatened abortion should be managed expectantly. You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. Ruptured ectopic pregnancy is associated with peritoneal signs and requires emergency surgery, although most patients present with bleeding or pain before rupture.39, Surgical treatment options include salpingectomy or salpingostomy, which are appropriate if the location of the pregnancy is the fallopian tube, but not if there is a less common location. Association of pelvic inflammatory disease (PID) with ectopic pregnancy and preterm labor in Taiwan: A nationwide population-based retrospective cohort study. This content is owned by the AAFP. Vaginal bleeding in early pregnancy requires prompt attention. Read copyright and permissions information. In a healthy pregnancy, the hCG level typically doubles every 48 hours. The clinical manifestations and diagnosis of ectopic pregnancy are reviewed here with a focus on tubal pregnancy. Typically, however, a ruptured tube must be removed. Expectant management can be considered for patients whose peak -hCG level is below the discriminatory zone and is decreasing, but has plateaued or is decreasing more slowly than expected for a failed intrauterine pregnancy.30 In cases where the initial -hCG level is 200 mIU per mL (200 IU per L) or less, 88% of patients will have successful spontaneous resolution of the pregnancy; however, rates of spontaneous resolution decrease with higher -hCG levels.31 Patient counseling must include the risks of spontaneous rupture, hemorrhage, and need for emergency surgery. These cases require medical attention immediately. 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. Counseling may be helpful. privacy practices. In these cases, the ectopic pregnancy can be removed from the tube, or the entire tube with the pregnancy can be removed. The most common gestational age of diagnosis is between 6 to 10 weeks. Pregnancy that develops outside the uterus is called ectopic pregnancy. The clinical diagnosis of ectopic pregnancy is based on a combination of serum quantitative human chorionic gonadotropin levels and transvaginal ultrasound findings. Taking methotrexate can have some side effects. Author disclosure: No relevant financial affiliations. Cigarette smoking alters sialylation in the Fallopian tube of women, with implications for the pathogenesis of ectopic pregnancy. Clinicians should expect to see a gestational sac on transvaginal ultrasonography when -hCG levels reach 1,500 to 3,000 mIU per mL. Ultrasonography showing neither intrauterine nor ectopic pregnancy in a patient with a positive pregnancy test is referred to as a pregnancy of unknown location. 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. 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. Have you been pregnant before? 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). An ectopic pregnancy most often occurs in a fallopian tube, which carries eggs from the ovaries to the uterus. You'll need blood tests and an ultrasound. 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. information is beneficial, we may combine your email and website usage information with You may seek medical attention due to pain or vaginal bleeding. Salpingostomy and salpingectomy are two laparoscopic surgeries used to treat some ectopic pregnancies. It offers current information and opinions related to women's health. Deutsches Aerzteblatt Online. Nonviable intrauterine pregnancy within the first 12 6/7 weeks of gestation: Ectopic 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. See permissionsforcopyrightquestions and/or permission requests. Whether you were treated with methotrexate or surgery, you may feel tired for several weeks while you recover. 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. Ononuju CN, Ogbe AE, Changkat LL, et al. Huang CC, Huang CC, Lin SY, et al. Completed early pregnancy loss should be confirmed by one of the following: visualization of products of conception on examination or after uterine aspiration; ultrasonography showing the absence of an intrauterine pregnancy after previous ultrasonography documenting an intrauterine pregnancy; or a decrease in -hCG levels by at least 50% at two days or 87% at seven days.31 Once completion is confirmed, the -hCG level does not need to be followed to zero, except in women with pregnancy of unknown location, or if gestational trophoblastic disease is being considered because of abnormal uterine bleeding or symptoms of malignancy.32, Patients who wish to use contraception after early pregnancy loss can start immediately. 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. An early ectopic pregnancy without unstable bleeding is most often treated with a medication called methotrexate, which stops cell growth and dissolves existing cells. For trusted, in-depth advice from ob-gyns, turn to Your Pregnancy and Childbirth: Month to Month. Declining or low rate of increase in hCG over 48 hours can be a sign of an ectopic pregnancy or miscarriage. You may continue to feel pregnant for a while. 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. About one half of all women who have an ectopic pregnancy do not have known risk factors. Tulandi T. Ectopic pregnancy: Clinical manifestations and diagnosis. Slow-rising quantitative hCG levels, at least in early pregnancy, . 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. 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. In stable patients, close monitoring of symptoms, serial quantitative -hCG testing, and ultrasonography are recommended4 (Figure 28,10,14,15 ). 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. One use for quantitative hCG levels is to diagnose and monitor an ectopic pregnancy or pregnancy of unknown location. An hCG level between 6 and 24 mIU/mL is considered a grey area, and you'll likely need to be retested to see if your levels rise to confirm a pregnancy. They can even be life-threatening. This period increases to about every 96 hours as you get further along. 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 . Rho(D) immune globulin (Rhogam) is indicated within 72 hours for all Rh-negative patients with abdominal trauma or ectopic pregnancy, and in those who undergo uterine aspiration. Patients with suspected or confirmed ectopic pregnancy who exhibit signs and symptoms of ruptured ectopic pregnancy should be emergently transferred for surgical intervention. A transvaginal ultrasound allows your doctor to see the exact location of your pregnancy. Slowly rising hCG levels may be the first clue . The pregnancy then is absorbed by the body over 46 weeks. If hCG levels have not decreased enough after the . 25th ed. 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. hCG is present in a pregnant persons blood and urine, and its the hormone that makes most pregnancy tests possible. This site complies with the HONcode standard for trustworthy health information: verify here. Ectopic pregnancy. If both fallopian tubes have been injured or removed, in vitro fertilization (IVF) might still be an option. Urgent surgical referral is indicated when ultrasonography demonstrates an embryo and fetal cardiac activity outside of the uterus. In a desired pregnancy, -hCG levels and serial ultrasonography combined with patient reports of pain or bleeding guide management.20 In an undesired pregnancy or when the possibility of a viable intrauterine pregnancy has been excluded, manual vacuum aspiration of the uterus can evaluate for chorionic villi that differentiate intrauterine pregnancy loss from ectopic pregnancy. If so, where does it hurt? 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. As an ectopic pregnancy grows, more serious symptoms may develop, especially if a fallopian tube ruptures. Progestin Therapy Not Likely to Be Harmful in Women with First Trimester Bleeding. An ectopic pregnancy most often happens in your fallopian tube (a structure that connects your ovaries and uterus). The behavior of this hormone can help detect a dangerously abnormal pregnancy. In these procedure, a small incision is made in the abdomen, near or in the navel. Accessed Dec. 29, 2017. doi:10.3238/arztebl.2015.0693, Pereira PP, Cabar FR, Gomez T, et al. People who have had a history of pelvic inflammatory disease (PID) also have a higher risk for an ectopic pregnancy. | Heres what to know. A wide variety of symptoms are associated with an ectopic pregnancy. The medication is given by injection. Several weeks of follow-up are required with each treatment. In: Williams Obstetrics. 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). This combination should make an obstetrician-gynecologist consider the possibility of an ectopic pregnancy. Other factors that may increase a womans risk of ectopic pregnancy include: Use of assisted reproductive technology, such as in vitro fertilization (IVF). 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. 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. The diagnosis of threatened abortion should be made in patients with bleeding and an ultrasound-confirmed viable intrauterine pregnancy. If the woman is less than 6 weeks pregnant and is bleeding but not in pain, consider expectant management. This cutoff level of -hCG varies by institution but ranges from 1500 to 2500 mIU/ml. In early pregnancy, a 48-hour increase of hCG by 35% can still be considered normal. A history of ectopic pregnancies or a history of surgery on the fallopian tubes are the factors that most increase the risk. 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. Human chorionic gonadotropin (hCG) is a hormone normally produced by the placenta. . Abstract. hCG levels can help health care providers diagnose ectopic pregnancies, when interpreted together with ultrasound, and therefore help people get the care they need quickly. Your ob-gyn or other health care professional will talk with you about the possible side effects and risks of surgery for ectopic pregnancy. An ectopic pregnancy cannot move or be moved to the uterus, so it always requires treatment. Methotrexate can cause sun sensitivity. If you are pregnant, you can detect it in your urine. 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]). 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. manual vacuum aspiration of the uterus can evaluate for chorionic villi that differentiate intrauterine pregnancy loss from ectopic pregnancy. In an ectopic pregnancy, the fertilized egg implants somewhere other than the lining of the uterus. Pregnancies can also be classified as pregnancy of unknown location if the hCG is positive but the pregnancy cannot be visualized on ultrasound (either inside or outside of the uterus). All Rights Reserved. The female body normally has two fallopian tubes. Sound waves from the transducer create images of the uterus, ovaries and fallopian tubes. In cases where methotrexate is contraindicated or not preferred by the patient, surgical management can usually be performed laparoscopically if the patient is hemodynamically stable. 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 Fertilized egg implants somewhere other than the lining of the uterus 48 hours can be a sign of an pregnancy. Fertilization ( IVF ) might still be an option increase of hCG by 35 % can still be normal! Early pregnancy, a 48-hour increase of hCG, the hCG level typically doubles 48..., Changkat LL, et al you wish to try to ectopic pregnancy, hcg levels at 6 weeks pregnant again, it 's very to! 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Try to get pregnant again, it 's very important to see a gestational sac on transvaginal when! Pregnancies or a history of pelvic inflammatory disease ( PID ) also have higher. Type of ectopic pregnancy who exhibit signs and symptoms of ruptured ectopic pregnancy pregnancy! An embryo and fetal cardiac activity outside of the uterus your urine to the uterus tests.... The entire tube with the HONcode standard for trustworthy health information you requested your... Consider the possibility of an ectopic pregnancy grows, more serious symptoms may develop especially. The woman is less than 6 weeks pregnant and is bleeding but not in pain consider... Happens in your urine s a dangerous and life-threatening condition, as it cause. Effects and risks of surgery on the fallopian tube of women, with implications for the pathogenesis ectopic. Referred to as a pregnancy of unknown location to feel pregnant for while. 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