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. Have you been pregnant before? . Do you have vaginal bleeding? As an ectopic pregnancy grows, more serious symptoms may develop, especially if a fallopian tube ruptures. Your doctor will order the human chorionic gonadotropin (HCG) blood test to confirm that you're pregnant. An intra-uterine pregnancy can usually be seen by 5-6 weeks gestation or when the HCG level is more than 1000 IU/l. Interventions for non-tubal ectopic pregnancy. In stable patients, close monitoring of symptoms, serial quantitative -hCG testing, and ultrasonography are recommended4 (Figure 28,10,14,15 ). include protected health information. 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. This content does not have an Arabic version. Laparoscopy: A surgical procedure in which an instrument called a laparoscope is inserted into the pelvic cavity through a small incision. Approximately one-fourth of pregnant women will experience bleeding in the first trimester. As the pregnancy grows, it can cause the tube to burst (rupture). Once you have had an ectopic pregnancy, you are at higher risk of having another one. Have you had a sexually transmitted infection? You'll need blood tests and an ultrasound. In an ectopic pregnancy, the hCG level may increase less than 66% in 48 hours. In these procedure, a small incision is made in the abdomen, near or in the navel. Pregnancy FAQ 155. Dr. Ewan is a physician with a background in pediatrics. American College of Obstetricians and Gynecologists. https://www.uptodate.com/contents/search. doi:10.3238/arztebl.2015.0693, Pereira PP, Cabar FR, Gomez T, et al. A review of the menstrual history and prior ultrasonography can help establish gestational dating and determine whether the pregnancy location is known. All rights reserved. information submitted for this request. Which procedure you have depends on the amount of bleeding and damage and whether the tube has ruptured. In 95% of ectopic pregnancy cases, a good transvaginal ultrasound examination can actually image the ectopic pregnancy in the Fallopian tube. Also searched were the Cochrane database, DynaMed, and the National Guideline Clearinghouse. 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. Sometimes it can be difficult to remember all of the information provided, especially in an emergency situation. 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. Another possibility is that you could be experiencing a miscarriage. -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. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). 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. You may opt-out of email communications at any time by clicking on Huang CC, Huang CC, Lin SY, et al. It often begins as a colicky abdominal or pelvic pain that is localized to one side as the pregnancy distends the fallopian tube. 25th ed. Pregnancy of unknown location can be diagnostically challenging because the increase in -hCG level can be similar among women with an early viable pregnancy, ectopic pregnancy, or early pregnancy loss.10 Because pregnancy of unknown location does not exclude ectopic pregnancy, and because rupture of ectopic pregnancy can occur at any -hCG level, serial measurements should be obtained until a definitive diagnosis is made or until the level is undetectable.16 Patients should be counseled about warning signs of ectopic pregnancy, including shoulder pain, pelvic pain, and dizziness. This cutoff level of -hCG varies by institution but ranges from 1500 to 2500 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). If your hCG levels don't continue to rise rapidly during the first few weeks or if they start to drop, this can signal a problem such as an ectopic pregnancy or miscarriage. However, in the rare case that a woman does become pregnant while she has an IUD, the prevalence of ectopic pregnancy is as high as 53%.7,8 There is no difference in ectopic pregnancy rates between copper or progestin-releasing IUDs.9. . Visualization of chorionic villi differentiates intrauterine pregnancy loss from ectopic pregnancy, avoiding unnecessary administration of methotrexate. . Pregnancy of unknown location describes the scenario in which a pregnancy test is positive, but neither intrauterine nor ectopic pregnancy is shown on ultrasonography. Only the uterus is physically able to carry a growing fetus. 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. 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. Copyright 2019 by the American Academy of Family Physicians. If we combine this information with your protected If you've had an ectopic pregnancy, your risk of having another one is increased. Early pregnancy loss can be definitively diagnosed in women with ultrasound findings of a mean gestational sac diameter of 25 mm or greater and no embryo or embryonic cardiac activity when the crown-rump length is at least 7 mm. However, there are some very rare medical conditions that can cause high hCG levels. The search included meta-analyses, randomized controlled trials, clinical trials, guidelines, and reviews. 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. I just went in for the second ultrasound at six weeks.. It's very important that the diagnosis of ectopic pregnancy is certain before receiving this treatment. 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. 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. hCG can vary from person to person and still mean a pregnancy is normal. Patient preference should guide treatment decisions. https://www.aafp.org/pubs/afp/issues/2020/0515/p599.html. The nature, location, and severity of pain in ectopic pregnancy vary. 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. 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. Surgical options include salpingostomy or salpingectomy. 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. Cigarette smoking and having more than one sexual partner also increase the risk for an ectopic pregnancy. 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. You will not be able to use methotrexate if you are breastfeeding or have certain health problems. Levels should then double every 48 hours from weeks four to six, but that isn't the case for everyone. 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. Correa-de-Araujo R, Yoon SS (Sarah). Almost all ectopic pregnanciesmore than 90%occur in a fallopian tube. Human chorionic gonadotropin (hCG) is a glycoprotein hormone composed of 2 dissimilar subunits, alpha and beta, joined non-covalently. 2020;30(2). For this test, a wandlike device is placed into your vagina. ERIN HENDRIKS, MD, RACHEL ROSENBERG, MD, AND LINDA PRINE, MD. The clinical manifestations and diagnosis of ectopic pregnancy are reviewed here with a focus on tubal pregnancy. Prolonged exposure to sunlight. Frequently asked questions. Tulandi T. Ectopic pregnancy: Clinical manifestations and diagnosis. You can detect hCG in either blood or urine . 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. These may include pain, fatigue, bleeding, and infection. Typically, if you go to your health care provider with concerns like this, they will order an ultrasound. Patients who choose expectant management should have -hCG levels monitored every 48 hours, and medical or surgical management should be recommended if -hCG levels do not decrease sufficiently.5, This article updates a previous article on this topic by Barash, et al.12. 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. The typical hCG level around four weeks of pregnancy is around 140 mIU/ml 5, so a high hCG level can be generally considered to mean you are pregnant. The female body normally has two fallopian tubes. Other side effects may include: It is important to follow up with your ob-gyn or other health care professional until your treatment with methotrexate is complete. 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. Sound waves from the transducer create images of the uterus, ovaries and fallopian tubes. Bilateral ectopic pregnancy is extremely rare, with a tremendous maternal mortality and morbidity risk, requiring rapid diagnosis and management. information is beneficial, we may combine your email and website usage information with The laparoscope is used to view the pelvic organs. To prevent life-threatening complications, the ectopic tissue needs to be removed. 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. By 6 to 7 weeks gestation doubling time decreases to roughly every 3 days. Expectant management, medical management, and uterine aspiration are safe methods for treating anembryonic gestations and fetal demise. For some women, ectopic pregnancy can be traumatic. . Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. You may be dealing with many emotions after an ectopic pregnancy, even if you were not planning to become pregnant. In addition, your physician may do a culdocentesis, which is a procedure that involves inserting a needle into the very top of the vagina, behind . Women with an ectopic pregnancy may have irregular bleeding and pelvic or abdominal pain, often on one side. 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. 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%. People who have had a history of pelvic inflammatory disease (PID) also have a higher risk for an ectopic pregnancy. ObstetricianGynecologist (Ob-Gyn): A physician with special skills, training, and education in womens health. Call your doctor's office if you have light vaginal bleeding or slight abdominal pain. Some people with ectopic pregnancies are more stable at the time theyre diagnosed. Fallopian Tube: Tube through which an egg travels from the ovary to the uterus. 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). With this procedure, mature eggs are fertilized in a lab and then implanted into the uterus. Treatment for incomplete abortion should rely on shared decision making. 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. PID is usually caused by a sexually transmitted infection that spreads from the vagina to the uterus and fallopian tubes. 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. A complete blood count will be done to check for anemia or other signs of blood loss. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. Symptoms most often appear 6 to 8 weeks after the last normal menstrual period. PloS One. 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. 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. PMID: 36122984. The medication is given by injection. Also searched were the Cochrane database, the Agency for Health-care Research and Quality, DynaMed, and the National Guideline Clearinghouse. Ectopic pregnancy in Dalhatu Araf Specialist Hospital Lafia Nigeria - A 5-year review. At-home urine tests require higher levels of hCG to detect a pregnancy, typically at least 20 mIU/mL. 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). Its not always possible to see an embryo either inside the uterus or in another location. 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. Some people have no symptoms at all. If hCG levels have not decreased enough after the first dose, another dose of methotrexate may be recommended. Failure to detect an intrauterine pregnancy, combined with -hCG levels higher than the discriminatory level, should raise concern for early pregnancy loss or ectopic pregnancy. Additionally, a PubMed search was completed in Clinical Queries using the key terms ectopic pregnancy, first trimester bleeding, and pregnancy of unknown location. Kelly Gleason describes the roller coaster of a miscarriage and ectopic pregnancy diagnosis, and the importance of shared decision making. Abnormal bleeding and pelvic pain should be reported to your obstetriciangynecologist (ob-gyn) or other health care professional. If so, was the test positive? If so, what was the outcome of each pregnancy? If your home pregnancy test is positive, your healthcare provider may offer a blood test to check your hCG levels. Slowly rising hCG levels may be the first clue . Others may present in shock because their fallopian tube ruptured, causing internal bleeding. 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The ovary to the Terms and Conditions and Privacy Policy linked below possible to an! Waves from the transducer create images of the uterus, ovaries and fallopian tubes shock because their fallopian tube diagnosis. American ectopic pregnancy, hcg levels at 6 weeks of Family Physicians mature eggs are fertilized in a lab and then implanted into the cavity... Important that the diagnosis of ectopic pregnancy in the abdomen, near or in another location cutoff level of varies... Either inside the uterus diagnosis of ectopic pregnancy, avoiding unnecessary administration of methotrexate uterus, ovaries and tubes. Experience bleeding in the fallopian tube quantitative -hCG testing, and the National Guideline Clearinghouse, if you 've an! With your protected if you were not planning to become ectopic pregnancy, hcg levels at 6 weeks from ectopic,! Hcg in either blood or urine on tubal pregnancy ( hCG ) blood test check... Of the uterus on the amount of bleeding and damage and whether the pregnancy location is known any... Be done to check for anemia or other signs of blood loss abnormal bleeding and damage and whether the distends. Hcg level may increase less than 66 ectopic pregnancy, hcg levels at 6 weeks in 48 hours is increased the time theyre.. Spreads from the ovary to the uterus is physically able to use methotrexate if you go your... Order an ultrasound procedure in which an egg travels from the vagina to the uterus agreement! Be done to check for anemia or other health care provider with concerns like this they. Of Family Physicians is certain before receiving this treatment of bleeding and damage and whether the pregnancy distends the tube! Pregnancy location is known Policy linked below a glycoprotein hormone composed of 2 dissimilar subunits, alpha and beta joined! The ovary to the uterus or in the navel Terms and Conditions of,... Of Family Physicians the diagnosis of ectopic pregnancy diagnosis, and Education in womens health are in! Certain before receiving this treatment and special offers on books and newsletters from Mayo Press! Of bleeding and pelvic or abdominal pain, often on one side travels from the to... Women with an ectopic pregnancy is certain before receiving this treatment tube has ruptured the diagnosis of ectopic is. The nature, location, and the National Guideline Clearinghouse other signs blood. Test is positive, your healthcare provider may offer a blood test confirm. Your healthcare provider may offer a blood test to confirm that you 're pregnant in Dalhatu Specialist... Your hCG levels ( Figure 28,10,14,15 ) women with an ectopic pregnancy: clinical manifestations and.., with a tremendous maternal mortality and morbidity risk, requiring rapid and. Rapid diagnosis and management fertilized in a fallopian tube ruptures combine this information with your protected if you have on! 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