Additionally, a PubMed search was completed in Clinical Queries using the key terms ectopic pregnancy, first trimester bleeding, and pregnancy of unknown location. Human chorionic gonadotropin (hCG) is a hormone thats very important throughout pregnancy. It typically takes from one to nine weeks for hCG levels to return to zero following a miscarriage (or delivery). Author disclosure: No relevant financial affiliations. The differential diagnosis includes threatened abortion, early pregnancy loss, and ectopic pregnancy. Other signs may include: At this stage, it may be hard to know if you are experiencing a typical pregnancy or an ectopic pregnancy. 1. doi:10.3238/arztebl.2015.0693, Pereira PP, Cabar FR, Gomez T, et al. Have you been pregnant before? The first measurement helps the clinician decide between the one- and two-dose protocols. If you are a Mayo Clinic patient, this could Levels of hCG should be increasing by at least 60% every 2-3 days, but ideally doubling every 48-72 hours. 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. Confirming pregnancy Watchful waiting is recommended as first-line treatment for patients with incomplete abortion; more than 90% of these patients will complete the process spontaneously within four weeks.24 Watchful waiting is less effective in patients with an anembryonic gestation or embryonic demise, with completion rates at one month of 66% and 76%, respectively.24 Patients who choose expectant management over uterine aspiration experience more days of bleeding, longer time to completion, and higher rates of unplanned surgical intervention.20,21 Serious complications are rare, and patients who opt for expectant management should be informed that it is safe to wait as long as they wish as long as there are no signs of infection or hemorrhage. The definitive diagnosis of ectopic pregnancy can be made with ultrasound visualization of a yolk sac and/or embryo in the adnexa. 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. The search included meta-analyses, guidelines, and reviews. Search dates: August 3, 2017, to October 21, 2018. 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. Pain and heavy bleeding are associated with an increased risk of early pregnancy loss. This content does not have an English version. Tonick S, Conageski C. Ectopic Pregnancy. 5. Your doctor will order the human chorionic gonadotropin (HCG) blood test to confirm that you're pregnant. You may continue to feel pregnant for a while. Clinics. Laparotomy is reserved for patients who are hemodynamically unstable. This condition is usually diagnosed during surgery, as radiologists may not pay enough attention to the contralateral side of interest. For trusted, in-depth advice from ob-gyns, turn to Your Pregnancy and Childbirth: Month to Month. 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. 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. Clinicians should expect to see a gestational sac on transvaginal ultrasonography when -hCG levels reach 1,500 to 3,000 mIU per mL. Interventions for non-tubal ectopic pregnancy. Because ectopic pregnancies can be life-threatening, early diagnosis is essential. You may seek medical attention due to pain or vaginal bleeding. To provide you with the most relevant and helpful information, and understand which Patients may switch to medical management or uterine aspiration at any time. 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). 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. In a patient with a -hCG value above this level, failure to visualize an intrauterine pregnancy strongly suggests ectopic pregnancy. Pregnancy of unknown location. Some experience a small amount of vaginal bleeding or spotting, but others dont. An hCG level that is lower than expected is one reason to suspect an ectopic pregnancy. American College of Obstetricians and Gynecologists. The female body normally has two fallopian tubes. Next, your doctor uses a thin tube equipped with a camera lens and light (laparoscope) to view the tubal area. 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. In these cases, the ectopic pregnancy can be removed from the tube, or the entire tube with the pregnancy can be removed. Niger Postgrad Med J. It's important to avoid alcohol, folic acid (in both vitamins and foods) and pain . Nonviable intrauterine pregnancy within the first 12 6/7 weeks of gestation: Ectopic pregnancy: . Terms and Conditions of Use, Get the latest on COVID-19, pregnancy, and breastfeeding. Treatment options for early pregnancy loss include expectant management, medical management with mifepristone and misoprostol, or uterine aspiration. 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. 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. What are the chances of dying from an ectopic pregnancy? Theres some overlap between the possible trends in hCG levels for normal and ectopic pregnancies. 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. | Serial beta human chorionic gonadotropin levels, serial ultrasonography, and, at times, uterine aspiration can be used to arrive at a definitive diagnosis. 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. If so, was the test positive? Urine tests. Sometimes, the embryo can develop enough that a health care provider can detect the heartbeat. 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. Methotrexate can cause sun sensitivity. 2015;112(41). 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. It can take time for the level of hCG in your body to drop after treatment for an ectopic pregnancy. February 03, 2023 | by haleyerin1229. 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. In these procedure, a small incision is made in the abdomen, near or in the navel. Thus, a history of bleeding and passage of tissue cannot be relied on to differentiate ectopic pregnancy from early intrauterine pregnancy failure. In a normal pregnancy, the egg is fertilized by a sperm. It offers current information and opinions related to women's health. Severe abdominal or pelvic pain accompanied by vaginal bleeding. Also searched were the Cochrane database, DynaMed, and the National Guideline Clearinghouse. Prescription pain medication and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. Deviations from this established pattern should raise suspicion for early pregnancy loss or ectopic pregnancy (Table 2).4,5 Guidelines have been established for ultrasound diagnosis of early pregnancy loss to decrease the risk of false diagnosis and intervention in a desired viable intrauterine pregnancy. This content is owned by the AAFP. Make a donation. The pain may become more generalized once the tube ruptures and hemoperitoneum develops. 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. Signs of ectopic pregnancy (e.g., adnexal mass, fluid in the cul-de-sac) can be seen on ultrasonography well below the discriminatory level. This triggers the uterus lining to grow and produce other hormones that help keep a pregnancy going. Urgent surgical referral is indicated when ultrasonography demonstrates an embryo and fetal cardiac activity outside of the uterus. Hendriks E, Rosenberg R, Prine L. Ectopic Pregnancy: Diagnosis and Management. Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. In an ectopic pregnancy, the hCG level may increase less than 66% in 48 hours. -hCG levels should be obtained every 48 hours to confirm that they are decreasing, then weekly until they reach zero. 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 pregnancy.5 The discriminatory zone was previously defined as a -hCG level of 1,000 to 2,000 mIU per mL (1,000 to 2,000 IU per L); however, this cutoff can miss some intrauterine pregnancies that do not become apparent until a slightly higher -hCG level is achieved. Progestin Therapy Not Likely to Be Harmful in Women with First Trimester Bleeding. Blood tests and ultrasound testing can alert your doctor if another ectopic pregnancy is developing. This combination should make an obstetrician-gynecologist consider the possibility of an ectopic pregnancy. Patient preference should guide treatment decisions. The clinical diagnosis of ectopic pregnancy is based on a combination of serum quantitative human chorionic gonadotropin levels and transvaginal ultrasound findings. 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