doi:10.3238/arztebl.2015.0693, Pereira PP, Cabar FR, Gomez T, et al. information and will only use or disclose that information as set forth in our notice of After six weeks, the levels will double about every 96 hours. Mayo Clinic does not endorse companies or products. If so, is it more or less than your typical period? Thus, a history of bleeding and passage of tissue cannot be relied on to differentiate ectopic pregnancy from early intrauterine pregnancy failure. In an ectopic pregnancy, the fertilized egg implants somewhere other than the lining of the uterus. 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. Read common questions on the coronavirus and ACOGs evidence-based answers. Methotrexate may be used if the pregnancy has not ruptured a fallopian tube. Deutsches Aerzteblatt Online. 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. Laparotomy is reserved for patients who are hemodynamically unstable. People who have had a history of pelvic inflammatory disease (PID) also have a higher risk for an ectopic pregnancy. When that happens, lower amounts of hCG are produced and the embryo can't develop normally. Copyright 2023 American College of Obstetricians and Gynecologists, Privacy Statement Ononuju CN, Ogbe AE, Changkat LL, et al. Intramuscular methotrexate is the only medication appropriate for the management of ectopic pregnancy. Data Sources: An evidence summary from Essential Evidence Plus was reviewed and relevant studies referenced. One use for quantitative hCG levels is to diagnose and monitor an ectopic pregnancy or pregnancy of unknown location. Copyright 2019 by the American Academy of Family Physicians. A complete blood count will be done to check for anemia or other signs of blood loss. Four weeks postoperatively, serum -HCG levels had a . Ask a loved one or friend to come with you, if possible. A single copy of these materials may be reprinted for noncommercial personal use only. Rely on your partner, loved ones and friends for support. Depending on your symptoms and when the ectopic pregnancy is discovered, this may be done using medication, laparoscopic surgery or abdominal surgery. 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. Make a donation. 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. In some cases, an ectopic pregnancy may resolve on its own. Published online July 1, 2020. doi:10.1002/14651858.cd011174.pub2, Taran FA, Kagan KO, Hbner M, et al. Signs of ectopic pregnancy (e.g., adnexal mass, fluid in the cul-de-sac) can be seen on ultrasonography well below the discriminatory level. Laparoscopy is the preferred surgical approach. Losing a pregnancy is devastating, even if you've only known about it for a short time. Prolonged exposure to sunlight. During pregnancy, it can be used to examine the fetus. Blood tests can determine how high the hCG level is. 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. 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). An ectopic pregnancy most often occurs in a fallopian tube, which carries eggs from the ovaries to the uterus. The rate of -hCG increase is less rapid as the level increases. Medical management is safe and effective in carefully selected patients. . Confirming pregnancy Levels peaks during the first eight to 11 weeks of pregnancy, then decline and plateau. Your ob-gyn or other health care professional will talk with you about the possible side effects and risks of surgery for ectopic pregnancy. Copyright 2023 American Academy of Family Physicians. In an ectopic pregnancy, the hCG level may increase less than 66% in 48 hours. Patients should be informed that expectant management is more than 90% effective. The most common gestational age of diagnosis is between 6 to 10 weeks. The medication is given by injection. There's some overlap between the possible trends in hCG levels for normal and ectopic pregnancies. This content is owned by the AAFP. It typically takes from one to nine weeks for hCG levels to return to zero following a miscarriage (or delivery). Pregnancy that develops outside the uterus is called ectopic pregnancy. 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. An hCG level that is lower than expected is one reason to suspect an ectopic pregnancy. Expert opinion and consensus guideline in the absence of clinical trials, Verify baseline stability of complete blood count and comprehensive metabolic panel; determine -hCG level. By the time you reach 8 to 10 weeks, your hCG level will have reached its peak. 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. Cunningham FG, et al., eds. Pain and heavy bleeding are associated with an increased risk of early pregnancy loss. https://www.uptodate.com/contents/search. 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. This may be because they have had more time to experience other conditions that put them at risk for ectopic pregnancies in the future. Approximately one-fourth of pregnant women will experience bleeding in the first trimester. Accessed Dec. 29, 2017. Other factors that may increase a womans risk of ectopic pregnancy include: Use of assisted reproductive technology, such as in vitro fertilization (IVF). Certain factors place a person at a relatively higher risk of having an ectopic pregnancy. Seek care right away if you have symptoms of a rupture, including sudden abdominal pain, shoulder pain, or weakness. After this . Did you notice anything unusual about it? Explore ACOG's library of patient education pamphlets. Pregnancy of unknown location. McGraw-Hill Education; 2018. https://accessmedicine.mhmedical.com. If this decrease does not occur, the clinician should discuss with the patient whether she prefers to repeat the course of methotrexate or pursue surgical treatment. It's very important that the diagnosis of ectopic pregnancy is certain before receiving this treatment. https://www.acog.org/Patients/FAQs/Ectopic-Pregnancy. Abstract. Several factors go into the decision to use methotrexate. PID is usually caused by a sexually transmitted infection that spreads from the vagina to the uterus and fallopian tubes. Typically, if you go to your health care provider with concerns like this, they will order an ultrasound. If you are pregnant, you can detect it in your urine. At-home urine tests require higher levels of hCG to detect a pregnancy, typically at least 20 mIU/mL. 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. In an ectopic pregnancy, the hCG level may increase less than 66% in 48 hours. There are specific findings on an ultrasound that can show that the pregnancy is ectopic. 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 medications can affect the way methotrexate works in the body. It offers current information and opinions related to women's health. It is not intended as a statement of the standard of care. Interventions for non-tubal ectopic pregnancy. The pain may become more generalized once the tube ruptures and hemoperitoneum develops. Slowly rising hCG levels may be the first clue . Also searched were the Cochrane database, DynaMed, and the National Guideline Clearinghouse. Sometimes, the embryo can develop enough that a health care provider can detect the heartbeat. 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. On the other hand, it's also possible to have doubling hCG levels with an ectopic pregnancy. The laparoscope is used to view the pelvic organs. Patients may switch to medical management or uterine aspiration at any time. You may feel abdominal discomfort or pain. 1 While there have been rare, well-publicized cases where an ectopic pregnancy has been brought to term, pregnancies of this sort are almost universally considered nonviable. Hemorrhage was the leading cause of death. If hCG levels have not decreased enough after the first dose, another dose of methotrexate may be recommended. 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. Search for doctors near you. Ectopic pregnancy. Urine pregnancy tests work by turning positive if they detect the presence of hCG. However, your doctor can't diagnose an ectopic pregnancy by examining you. -hCG levels should be obtained every 48 hours to confirm that they are decreasing, then weekly until they reach zero. 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. Expectant management, medical management, and uterine aspiration are safe methods for treating anembryonic gestations and fetal demise. There is insufficient evidence to support the use of progestin for the prevention of early pregnancy loss.3,18 Bed rest does not improve outcomes and may cause psychological harm in patients with subsequent early pregnancy loss.19 Patients should be reassured that nothing they did caused the bleeding. The search included meta-analyses, guidelines, and reviews. Multidose protocols carry a higher risk of adverse effects and are not preferred.25, Before administering methotrexate, -hCG levels should be measured on days 1, 4, and 7 of treatment. Ectopic pregnancies and normal pregnancies require very different medical management. 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. . Tulandi T. Ectopic pregnancy: Clinical manifestations and diagnosis. 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