Methotrexate often is given by injection in one dose. Pregnancies can also be classified as pregnancy of unknown location if the hCG is positive but the pregnancy cannot be visualized on ultrasound (either inside or outside of the uterus). If so, what was the outcome of each pregnancy? Heres what to know. 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. If products of conception are visible on speculum examination, the diagnosis of incomplete abortion can be made and treatment offered. Signs of ectopic pregnancy (e.g., adnexal mass, fluid in the cul-de-sac) can be seen on ultrasonography well below the discriminatory level. Vaginal bleeding or spotting also may occur. Interventions for non-tubal ectopic pregnancy. Mayo Clinic. 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. 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. Its not always possible to see an embryo either inside the uterus or in another location. other information we have about you. It's important to avoid alcohol, folic acid (in both vitamins and foods) and pain . A complete blood count will be done to check for anemia or other signs of blood loss. 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. Surgical options include salpingostomy or salpingectomy. Search dates: October 26, 2018, through January 14, 2020. McGraw-Hill Education; 2018. https://accessmedicine.mhmedical.com. All rights reserved. Are you in pain? Sometimes surgery is needed even if the fallopian tube has not ruptured. Seek care right away if you have symptoms of a rupture, including sudden abdominal pain, shoulder pain, or weakness. 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. 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. Ectopic pregnancy. Confirming pregnancy Symptoms most often appear 6 to 8 weeks after the last normal menstrual period. The discriminatory -hCG level used at different. Certain factors place a person at a relatively higher risk of having an ectopic pregnancy. 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. Other signs may include: At this stage, it may be hard to know if you are experiencing a typical pregnancy or an ectopic pregnancy. The first measurement helps the clinician decide between the one- and two-dose protocols. An ectopic pregnancy most often occurs in a fallopian tube, which carries eggs from the ovaries to the uterus. Management of these pregnancies has changed dramatically over the years. 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 . If we combine this information with your protected
There's some overlap between the possible trends in hCG levels for normal and ectopic pregnancies. These medications can affect the way methotrexate works in the body. Sometimes it can be difficult to remember all of the information provided, especially in an emergency situation. Pregnancy of unknown location refers to a transient state in which a pregnancy test is positive but ultrasonography shows neither intrauterine nor ectopic pregnancy. Bleeding equal to or heavier than a menstrual period and bleeding accompanied by pain are associated with an increased risk of early pregnancy loss.2,7 Patients should be assessed for signs and symptoms of hypovolemia. Accessed Dec. 4, 2019. In an ectopic pregnancy, the fertilized egg implants somewhere other than the lining of the uterus. The search included meta-analyses, guidelines, and reviews. Methotrexate can cause sun sensitivity. Before you take methotrexate, blood tests will be done to measure the level of hCG and the functions of certain organs. A review of the menstrual history and prior ultrasonography can help establish gestational dating and determine whether the pregnancy location is known. If your hCG level does not drop by at least 15 percent between the fourth to seventh day after treatment, a second dose is required. Dr. Ewan is a physician with a background in pediatrics. This process is called implantation.. Randomized trials have shown no difference in sequelae between methotrexate administration and fallopian tubesparing laparoscopic surgery, including rates of future intrauterine pregnancy and risk of future ectopic pregnancy.29 The decision whether to remove the fallopian tube or leave it in place depends on the extent of damage to the tube (evaluated intraoperatively) and the patient's desire for future fertility. Nonviable intrauterine pregnancy within the first 12 6/7 weeks of gestation: Ectopic pregnancy: . PMID: 31621664. The most common gestational age of diagnosis is between 6 to 10 weeks. Vaginal bleeding in early pregnancy requires prompt attention. If you have sudden, severe pain; shoulder pain; or weakness, you should go to an emergency room. Uterine aspiration is the preferred procedure for surgical management of early pregnancy loss. Tonick S, Conageski C. Ectopic Pregnancy. Which procedure you have depends on the amount of bleeding and damage and whether the tube has ruptured. An ectopic pregnancy cannot move or be moved to the uterus, so it always requires treatment. The Diagnosis and Treatment of Ectopic Pregnancy. An hCG level that is lower than expected is one reason to suspect an ectopic pregnancy. An early ectopic pregnancy without unstable bleeding is most often treated with a medication called methotrexate, which stops cell growth and dissolves existing cells. 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. At-home urine tests require higher levels of hCG to detect a pregnancy, typically at least 20 mIU/mL. Checking the hCG level and then checking it again in 48 hours tells you how fast the hCG level is rising. If one is damaged or removed, an egg may join with a sperm in the other tube and then travel to the uterus. Take time to work through your feelings. Laparoscopy: A surgical procedure in which an instrument called a laparoscope is inserted into the pelvic cavity through a small incision. -hCG levels should be obtained every 48 hours to confirm that they are decreasing, then weekly until they reach zero. This combination should make an obstetrician-gynecologist consider the possibility of an ectopic pregnancy. It does not explain all of the proper treatments or methods of care. . Surgery typically is done with laparoscopy. By the time you reach 8 to 10 weeks, your hCG level will have reached its peak. Additionally, a PubMed search was completed in Clinical Queries using the key terms ectopic pregnancy, first trimester bleeding, and pregnancy of unknown location. Established criteria should be used to determine treatment options for ectopic pregnancy, including expectant management, medical management with methotrexate, or surgical intervention. 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. Clinicians should expect to see a gestational sac on transvaginal ultrasonography when -hCG levels reach 1,500 to 3,000 mIU per mL. 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. 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. Patients should be informed that expectant management is more than 90% effective. Visualization of chorionic villi differentiates intrauterine pregnancy loss from ectopic pregnancy, avoiding unnecessary administration of methotrexate. The risk of a fallopian tube rupture does not go away until your treatment is over. Urine tests. During a transvaginal ultrasound, you lie on an exam table while a health care provider or a medical technician puts a wandlike device, known as a transducer, into the vagina. It typically takes from one to nine weeks for hCG levels to return to zero following a miscarriage (or delivery). These cases require medical attention immediately. If you have pain that does not respond to over-the-counter medication, talk with your ob-gyn or other health care professional. 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. This triggers the uterus lining to grow and produce other hormones that help keep a pregnancy going. An intra-uterine pregnancy can usually be seen by 5-6 weeks gestation or when the HCG level is more than 1000 IU/l. Abdominal ultrasound, in which an ultrasound wand is moved over your belly, may be used to confirm your pregnancy or evaluate for internal bleeding. However, since they may go on to develop severe complications, they also require urgent medical attention. February 03, 2023 | by haleyerin1229. Severe abdominal or pelvic pain accompanied by vaginal bleeding. An intra-uterine pregnancy can usually be seen by 5-6 weeks gestation or when the HCG level is more than 1000 IU/l. Yes, during treatment with methotrexate you should avoid the following: Vitamins and foods that contain folic acid, including fortified cereal, enriched bread and pasta, peanuts, dark green leafy vegetables, orange juice, and beans. In a normal pregnancy, the egg is fertilized by a sperm. In addition to her MD, she holds a Master of Public Health degree. During pregnancy, it can be used to examine the fetus. In: Williams Obstetrics. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). It often begins as a colicky abdominal or pelvic pain that is localized to one side as the pregnancy distends the fallopian tube. In a typical pregnancy, your hCG levels double every 48 to 72 hours. Explore ACOG's library of patient education pamphlets. The clinical diagnosis of ectopic pregnancy is based on a combination of serum quantitative human chorionic gonadotropin levels and transvaginal ultrasound findings. 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. Copyright 2020 by the American Academy of Family Physicians. information highlighted below and resubmit the form. Abnormal bleeding and pelvic pain should be reported to your obstetriciangynecologist (ob-gyn) or other health care professional. An ectopic pregnancy occurs when a fertilized egg implants and grows outside the main cavity of the uterus. 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. Advanced ectopic pregnancy (high -hCG level, large mass, embryonic cardiac activity) 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. 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. Levels of hCG should be increasing by at least 60% every 2-3 days, but ideally doubling every 48-72 hours. It can also possibly indicate an ectopic pregnancy that is 'self-resolving'. 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. Burnett TL (expert opinion). Do you have vaginal bleeding? General Anesthesia: The use of drugs that produce a sleep-like state to prevent pain during surgery. If you're diagnosed with an ectopic pregnancy, your doctor may also order tests to check your blood type in case you need a transfusion. 2020;101(10):599-606. https://www.aafp.org/pubs/afp/issues/2020/0515/p599.html, Long Y, Zhu H, Hu Y, et al. In this case, a repeat dose of methotrexate may be given, although surgery may be required if the patient is symptomatic. Additionally, a PubMed search was completed in Clinical Queries using the following key terms: first trimester bleeding, threatened abortion, miscarriage, ectopic pregnancy, and discriminatory zone. HCG levels alone do not diagnose an ectopic pregnancy. This occurs when a fertilized egg implants in a location that can't support its growth. Treatment for incomplete abortion should rely on shared decision making. Counseling may be helpful. Have you taken a pregnancy test? 5. You may be dealing with many emotions after an ectopic pregnancy, even if you were not planning to become pregnant. Bed rest does not improve outcomes, and there is insufficient evidence supporting the use of progestins. Some people have no symptoms at all. If the woman is less than 6 weeks pregnant and is bleeding but not in pain, consider expectant management. You may feel abdominal discomfort or pain. doi:10.3238/arztebl.2015.0693, Pereira PP, Cabar FR, Gomez T, et al. Hemorrhage was the leading cause of death. For trusted, in-depth advice from ob-gyns, turn to Your Pregnancy and Childbirth: Month to Month. It is done in a hospital with general anesthesia. 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