The first measurement helps the clinician decide between the one- and two-dose protocols. 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. This drug stops cells from growing, which ends the pregnancy. 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. In a healthy pregnancy, the hCG level typically doubles every 48 hours. Levels should then double every 48 hours from weeks four to six, but that isn't the case for everyone. This process is called implantation.. Most ectopic pregnancies are diagnosed between six and nine weeks of pregnancy. Levels commonly increase between days 1 and 4, but should decrease by at least 15% between days 4 and 7. Other instruments can be used with it to perform surgery. 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 . 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. There's some overlap between the possible trends in hCG levels for normal and ectopic pregnancies. Sometimes, there has been a positive pregnancy test, but no embryo can be seen in the uterus via ultrasound. As an ectopic pregnancy grows, more serious symptoms may develop, especially if a fallopian tube ruptures. If you've had an ectopic pregnancy, your risk of having another one is increased. In: Williams Obstetrics. Copyright 2023 American College of Obstetricians and Gynecologists, Privacy Statement This can also help determine whether a pregnancy is healthy or ectopic, but it should be interpreted together with ultrasound findings. What are my chances of having a healthy pregnancy in the future? For trusted, in-depth advice from ob-gyns, turn to Your Pregnancy and Childbirth: Month to Month. What Are the Factors Contributing to Obesity. Explore ACOG's library of patient education pamphlets. Mayo Clinic. On the other hand, it's also possible to have doubling hCG levels with an ectopic pregnancy. This combination should make an obstetrician-gynecologist consider the possibility of an ectopic pregnancy. With this procedure, mature eggs are fertilized in a lab and then implanted into the uterus. Ectopic pregnancies are not viable and can cause serious complications for pregnant women, including death. 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. Clinics. Patient information: See related handout on bleeding in early pregnancy, written by the authors of this article. It offers current information and opinions related to women's health. Methotrexate often is given by injection in one dose. Accessed Dec. 4, 2019. If theres a mass in the area of the fallopian tubes or ovary, this may represent an ectopic pregnancy. Uterine aspiration is the preferred procedure for surgical management of early pregnancy loss. Because ectopic pregnancies can be life-threatening, early diagnosis is essential. Author disclosure: No relevant financial affiliations. Dr. Ewan is a physician with a background in pediatrics. 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. One use for quantitative hCG levels is to diagnose and monitor an ectopic pregnancy or pregnancy of unknown location. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). Some people have no symptoms at all. Women with an ectopic pregnancy may have irregular bleeding and pelvic or abdominal pain, often on one side. If we combine this information with your protected 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. A 50- or 120-mcg dose is recommended before 12 weeks' gestation, although 300 mcg can be administered if lower doses are not available.3 After 12 weeks, a 300-mcg dose should be given.12, Measurement of serum progesterone may be useful in distinguishing between an early viable or nonviable pregnancy, especially in the setting of inconclusive ultrasonography. After the injection, your doctor will order another HCG test to determine how well treatment is working, and if you need more medication. 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. See permissionsforcopyrightquestions and/or permission requests. In an ectopic pregnancy, the hCG level may increase less than 66% in 48 hours. In this case, the pregnancy is called a pregnancy of unknown location. There is no consensus about the next steps if a pregnancy is of unknown location. 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 . If its high enough (most studies use a threshold of about 3,500 mIU/mL, or milli-international units per milliliter, but this can vary by practice), this indicates that the pregnancy is far enough along that a gestational sac should be able to be seen on an ultrasound. 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. Depending on exactly how many weeks pregnant you are, it may or may not be possible to see the pregnancy on an ultrasound or detect a heartbeat. Ectopic pregnancy. Mayo Clinic does not endorse companies or products. The rate of -hCG increase is less rapid as the level increases. Read copyright and permissions information. Prescription pain medication and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. Despite the fact that these factors can increase a persons risk of an ectopic pregnancy, anyone can experience an ectopic pregnancy. If hCG levels have not decreased enough after the . It's important to avoid alcohol, folic acid (in both vitamins and foods) and pain . It can also possibly indicate an ectopic pregnancy that is 'self-resolving'. Have you been pregnant before? The combination of missing a menstrual period, pelvic pain, and vaginal spotting is often seen in ectopic pregnancies. 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. This can be a life-threatening emergency that needs immediate surgery. Copyright 2019 by the American Academy of Family Physicians. 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. Sunlight exposure during treatment can cause methotrexate dermatitis and should be avoided.5 Other adverse effects of methotrexate include alopecia and elevation of liver enzymes. Cunningham FG, et al., eds. The pregnancy then is absorbed by the body over 46 weeks. Risk factors include a history of pelvic inflammatory disease, cigarette smoking, fallopian tube surgery, previous ectopic pregnancy, and infertility. The pregnancy then is absorbed by the body over 4-6 weeks. Guidelines for ultrasound diagnosis of early pregnancy loss have been established to decrease the likelihood of false diagnosis and of intervening in a desired viable pregnancy. Pregnancy blood tests can detect hCG hormone levels as low as 5 to 10 mIU/mL. Your doctor will order the human chorionic gonadotropin (HCG) blood test to confirm that you're pregnant. You might also seek the help of a support group, grief counselor or other mental health provider. Cigarette smoking alters sialylation in the Fallopian tube of women, with implications for the pathogenesis of ectopic pregnancy. Journal of Womens Health. 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). 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. Copyright 2023 American Academy of Family Physicians. 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. 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. Hyperthyroidism and Weight Gain: What to Know, Diabetes and Depression: How Telemedicine is Successfully Treating Both, COVID Long-Haulers Share Their Roads to Recovery, How Your Hunger Hormones Control Weight Loss, Thyroid Disorders and Infertility: A Doctors Personal Story. These medications can affect the way methotrexate works in the body. An ectopic pregnancy most often happens in your fallopian tube (a structure that connects your ovaries and uterus). 5. Burnett TL (expert opinion). If the ectopic pregnancy is causing heavy bleeding, you might need emergency surgery. An ectopic pregnancy occurs when a fertilized egg implants and grows outside the main cavity of the uterus. If you wish to try to get pregnant again, it's very important to see your doctor regularly. You will not be able to use methotrexate if you are breastfeeding or have certain health problems. Get the Stats on Ectopic Pregnancies. information submitted for this request. 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. This drug stops cells from growing, which ends the pregnancy. Treatment options for early pregnancy loss include expectant management, medical management with mifepristone and misoprostol, or uterine aspiration. General Anesthesia: The use of drugs that produce a sleep-like state to prevent pain during surgery. Ultrasonography showing neither intrauterine nor ectopic pregnancy in a patient with a positive pregnancy test is referred to as a pregnancy of unknown location. In early pregnancy, a 48-hour increase of hCG by 35% can still be considered normal. Search for doctors near you. Salpingostomy and salpingectomy are two laparoscopic surgeries used to treat some ectopic pregnancies. Search dates: August 3, 2017, to October 21, 2018. When Low hCG Levels Suggest Ectopic Pregnancy . Levels peaks during the first eight to 11 weeks of pregnancy, then decline and plateau. Laparoscopy is the preferred surgical approach. This content is owned by the AAFP. . All Rights Reserved. Others may present in shock because their fallopian tube ruptured, causing internal bleeding. You'll be asked many questions about your menstrual cycle, fertility and overall health. Human chorionic gonadotropin (hCG) is a hormone normally produced by the placenta. You'll need blood tests and an ultrasound. This procedure uses a slender, lighted camera that is inserted through small cuts in the abdomen. Assisted Reproductive Technology: A group of infertility treatments in which an egg is fertilized with a sperm outside the body; the fertilized egg then is transferred to the uterus. What are the chances of dying from an ectopic pregnancy? Ectopic precautions and serial -hCG levels should be continued until the level is undetectable. Sometimes surgery is needed even if the fallopian tube has not ruptured. Your ob-gyn or other health care professional will talk with you about the possible side effects and risks of surgery for ectopic pregnancy. Frequently asked questions. Almost all ectopic pregnanciesmore than 90%occur in a fallopian tube. This site complies with the HONcode standard for trustworthy health information: verify here. Methotrexate may be used if the pregnancy has not ruptured a fallopian tube. PMID: 31621664. Also a factor is whether your other fallopian tube is normal or shows signs of prior damage. If hCG levels have not decreased enough after the first dose, another dose of methotrexate may be recommended. information and will only use or disclose that information as set forth in our notice of This occurs when a fertilized egg implants in a location that can't support its growth. The risk factors for ectopic pregnancy include the following: Certain sexually transmitted infections (STIs). Which procedure you have depends on the amount of bleeding and damage and whether the tube has ruptured. Treatment failure is assumed if the -hCG level plateaus or increases from days 4 to 7. If so, what was the outcome of each pregnancy? . However, your doctor can't diagnose an ectopic pregnancy by examining you. In a salpingostomy, the ectopic pregnancy is removed and the tube left to heal on its own. Intrauterine pregnancy visualized on transvaginal ultrasonography essentially rules out ectopic pregnancy except in the exceedingly rare case of heterotopic pregnancy.5 The definitive diagnosis of ectopic pregnancy can be made with ultrasonography when a yolk sac and/or embryo is seen in the adnexa; however, ultrasonography alone is rarely used to diagnose ectopic pregnancy because most do not progress to this stage.5 More often, the patient history is combined with serial quantitative -hCG levels, sequential ultrasonography, and, at times, uterine aspiration to arrive at a final diagnosis of ectopic pregnancy. -hCG levels should be obtained every 48 hours to confirm that they are decreasing, then weekly until they reach zero. Patients should be informed that expectant management is more than 90% effective. Prolonged exposure to sunlight. 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. For some women, ectopic pregnancy can be traumatic. In this case, a repeat dose of methotrexate may be given, although surgery may be required if the patient is symptomatic. 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. Pregnancy FAQ 155. This triggers the uterus lining to grow and produce other hormones that help keep a pregnancy going. A recent study found a 99% probability that an intrauterine gestational sac will be detected at a -hCG level of 3,510 mIU per mL.14 Currently, a discriminatory level of 1,500 to 3,000 mIU per mL is typically used.10,15 However, ultrasonography can be diagnostically useful in symptomatic women at any -hCG level. Losing a pregnancy is devastating, even if you've only known about it for a short time. "hCG helps the body produce hormones to support pregnancy," explains John Zhang, M.D., founder. Some people with ectopic pregnancies are more stable at the time theyre diagnosed. 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 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. Once you have had an ectopic pregnancy, you are at higher risk of having another one. You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. 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