In the case of an ectopic pregnancy, the hCG level may just plateau or increase at a very slow rate. On the other hand, it's also possible to have doubling hCG levels with an ectopic pregnancy. Mayo Clinic does not endorse companies or products. Sometimes, an embryo is visible in or around the fallopian tube; this confirms an ectopic pregnancy. This procedure uses a slender, lighted camera that is inserted through small cuts in the abdomen. Abdominal ultrasound, in which an ultrasound wand is moved over your belly, may be used to confirm your pregnancy or evaluate for internal bleeding. Levels of this hormone increase during pregnancy. Copyright 2023 American Academy of Family Physicians. . Search dates: August 3, 2017, to October 21, 2018. In a normal pregnancy, the egg is fertilized by a sperm. It may take a few cycles for your periods to return to normal. Only the uterus is physically able to carry a growing fetus. When Low hCG Levels Suggest Ectopic Pregnancy . Symptoms may include the following: Sudden, severe pain in the abdomen or pelvis. If hCG levels plateau or rise, reassess the woman's condition for further treatment. Urine pregnancy tests work by turning positive if they detect the presence of hCG. PID is usually caused by a sexually transmitted infection that spreads from the vagina to the uterus and fallopian tubes. https://www.aafp.org/pubs/afp/issues/2020/0515/p599.html. The nature, location, and severity of pain in ectopic pregnancy vary. If you've had an ectopic pregnancy, your risk of having another one is increased. The search included meta-analyses, randomized controlled trials, clinical trials, guidelines, and reviews. information is beneficial, we may combine your email and website usage information with After the injection, your doctor will order another HCG test to determine how well treatment is working, and if you need more medication. Vaginal bleeding or spotting also may occur. Multiple treatment options exist depending on the characteristics and gestational age of the pregnancy, which your health care provider can discuss with you. You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. Ectopic pregnancy in Dalhatu Araf Specialist Hospital Lafia Nigeria - A 5-year review. Several methotrexate regimens have been studied, including a single-dose protocol, a two-dose protocol, and a multi-dose protocol (Table 4).5 The single-dose protocol carries the lowest risk of adverse effects, whereas the two-dose protocol is more effective than the single-dose protocol in patients with higher initial -hCG levels.24 There is no consistent evidence or consensus regarding the cutoff above which a two-dose protocol should be used, so clinicians should choose a regimen based on the initial -hCG level and ultrasound findings, as well as patient preference regarding effectiveness vs. the risk of adverse effects. 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. You may feel abdominal discomfort or pain. Ectopic pregnancy. Methotrexate can cause sun sensitivity. Are you in pain? 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. Prolonged exposure to sunlight. Hormone: A substance made in the body by cells or organs that controls the function of cells or organs. There is no evidence that palpation during the pelvic examination leads to an increased risk of rupture.10, Beta human chorionic gonadotropin (-hCG) can be detected in pregnancy as early as eight days after ovulation.14 The rate of increase in -hCG levels, typically measured every 48 hours, can aid in distinguishing normal from abnormal early pregnancy. What Are the Factors Contributing to Obesity. General Anesthesia: The use of drugs that produce a sleep-like state to prevent pain during surgery. In a salpingostomy, the ectopic pregnancy is removed and the tube left to heal on its own. Burnett TL (expert opinion). The discriminatory level varies with the type of ultrasound machine used, the sonographer, and the number of gestations. Human chorionic gonadotropin (hCG) is a hormone normally produced by the placenta. Cigarette smoking alters sialylation in the Fallopian tube of women, with implications for the pathogenesis of ectopic pregnancy. 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. https://www.acog.org/Patients/FAQs/Ectopic-Pregnancy. Will I need to follow any special precautions if I become pregnant again? Tonick S, Conageski C. Ectopic Pregnancy. Ectopic pregnancies are uncommon, but theyre very serious and can be life-threatening. Patients should be informed that expectant management is more than 90% effective. Slowly rising hCG levels may be the first clue . Accessed Dec. 4, 2019. information and will only use or disclose that information as set forth in our notice of Treatment options for early pregnancy loss include expectant management, medical management with mifepristone and misoprostol, or uterine aspiration. An intra-uterine pregnancy can usually be seen by 5-6 weeks gestation or when the HCG level is more than 1000 IU/l. Data Sources: An evidence summary from Essential Evidence Plus was reviewed and relevant studies referenced. If you are a Mayo Clinic patient, this could 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. Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. This information is designed as an educational aid for the public. In some cases, the fallopian tube can be saved. The most common drug used to treat ectopic pregnancy is methotrexate. 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]). Declining or low rate of increase in hCG over 48 hours can be a sign of an ectopic pregnancy or miscarriage. Other times, a person will have pain in the pelvis thats much worse on one side. The estimated mortality of ectopic pregnancy is between 2 and 4/1000. 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. What are my chances of having a healthy pregnancy in the future? 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. 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. In: Williams Obstetrics. As an ectopic pregnancy grows, more serious symptoms may develop, especially if a fallopian tube ruptures. Treatment of threatened abortion is expectant management. Urine tests. 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. 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. Many regimens for using misoprostol alone have been studied, and none has been proven optimal.22 One common regimen is 800 mcg vaginally, with a repeat dose in 24 to 48 hours if the first dose is unsuccessful.27 Besides the expected cramping and vaginal bleeding, common adverse effects include nausea and diarrhea.22. 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. If your home pregnancy test is positive, your healthcare provider may offer a blood test to check your hCG levels. Cigarette smoking and having more than one sexual partner also increase the risk for an ectopic pregnancy. Your doctor may also test your progesterone levels because low levels could be a sign of an ectopic pregnancy. It is common for patients to experience some abdominal pain two to three days after administration of methotrexate. . 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. The discriminatory -hCG level used at different. If hCG levels have not decreased enough after the first dose, another dose of methotrexate may be recommended. If so, where does it hurt? Search dates: October 26, 2018, through January 14, 2020. Ultrasonography showing neither intrauterine nor ectopic pregnancy in a patient with a positive pregnancy test is referred to as a pregnancy of unknown location. Advertising revenue supports our not-for-profit mission. A patient with diagnosed ectopic pregnancy should be immediately transferred for surgery if she has peritoneal signs or hemodynamic instability, if the initial beta human chorionic gonadotropin level is high, if fetal cardiac activity is detected outside of the uterus on ultrasonography, or if there is a contraindication to medical management. Don't have an ob-gyn? After six weeks, the levels will double about every 96 hours. 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. One of the most important factors is your ability to follow up with blood tests that check your blood levels of hCG. 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. 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. People who are older at the time of pregnancy also have an increased risk of ectopic pregnancy. Have you been pregnant before? It typically takes from one to nine weeks for hCG levels to return to zero following a miscarriage (or delivery). Rely on your partner, loved ones and friends for support. Patients should be asked about pain and the amount of bleeding. 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. In these procedure, a small incision is made in the abdomen, near or in the navel. Ask a loved one or friend to come with you, if possible. Also a factor is whether your other fallopian tube is normal or shows signs of prior damage. Next, your doctor uses a thin tube equipped with a camera lens and light (laparoscope) to view the tubal area. Patient satisfaction, mental health outcomes, infection rates, and future fertility are similar between these treatments.2022 Mental health outcomes are better when patients are included in the decision-making process, and shared decision making should guide management.23. This type of ectopic pregnancy is called a tubal pregnancy. 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. An ectopic pregnancy is when a fertilized ovum implants outside of the uterus. 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. In a salpingectomy, the ectopic pregnancy and the tube are both removed. Call your doctor's office if you have light vaginal bleeding or slight abdominal pain. As the pregnancy grows, it can cause the tube to burst (rupture). Laparoscopy is the preferred surgical approach. 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. 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. include protected health information. In an ectopic pregnancy, the fertilized egg implants somewhere other than the lining of the uterus. 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. This site complies with the HONcode standard for trustworthy health information: verify here. 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. Treatment failure is assumed if the -hCG level plateaus or increases from days 4 to 7. Bed rest does not improve outcomes, and there is insufficient evidence supporting the use of progestins. 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. Bilateral ectopic pregnancy is extremely rare, with a tremendous maternal mortality and morbidity risk, requiring rapid diagnosis and management. There's some overlap between the possible trends in hCG levels for normal and ectopic pregnancies. You may seek medical attention due to pain or vaginal bleeding. This occurs when a fertilized egg implants in a location that can't support its growth. 2015;112(41). The search included meta-analyses, guidelines, and reviews. If the woman is less than 6 weeks pregnant and is bleeding but not in pain, consider expectant management. Human chorionic gonadotropin (hCG) is a hormone thats very important throughout pregnancy. 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). A wide variety of symptoms are associated with an ectopic pregnancy. 1. 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. It is not intended as a statement of the standard of care. 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. Expectant management, medical management, and uterine aspiration are safe methods for treating anembryonic gestations and fetal demise. The initial -hCG level should be considered when following the rate of -hCG increase in early pregnancy. Losing a pregnancy is devastating, even if you've only known about it for a short time. Hendriks E, Rosenberg R, Prine L. Ectopic Pregnancy: Diagnosis and Management. 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. The risk factors for ectopic pregnancy include the following: Certain sexually transmitted infections (STIs). 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. 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. 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. doi:10.1371/journal.pone.0219351, Nio-Kobayashi J, Abidin HBZ, Brown JK, et al. You'll be asked many questions about your menstrual cycle, fertility and overall health. Pregnancy blood tests can detect hCG hormone levels as low as 5 to 10 mIU/mL. In 95% of ectopic pregnancy cases, a good transvaginal ultrasound examination can actually image the ectopic pregnancy in the Fallopian tube. 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). hCG is present in a pregnant persons blood and urine, and its the hormone that makes most pregnancy tests possible. Ectopic precautions and serial -hCG levels should be continued until the level is undetectable. 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. Human chorionic gonadotropin, or hCG, is a hormone produced by the placenta during pregnancy. ERIN HENDRIKS, MD, RACHEL ROSENBERG, MD, AND LINDA PRINE, MD. You might also seek the help of a support group, grief counselor or other mental health provider. My hCG level was on the lower end for someone 4 to 5 weeks . In this instance, a health care provider can order a test for the hCG level. It is not a substitute for the advice of a physician. 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. Neither ultrasound showed an egg or even a sac. It can be helpful to jot down your questions for the doctor before your visit. Certain factors place a person at a relatively higher risk of having an ectopic pregnancy. the unsubscribe link in the e-mail. If you have pain that does not respond to over-the-counter medication, talk with your ob-gyn or other health care professional. 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. To prevent life-threatening complications, the ectopic tissue needs to be removed. 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. It for a short time is no consensus about the next steps if a pregnancy of location. Most important factors is your ability to follow up with blood tests that check your hCG levels return... 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