In 95% of ectopic pregnancy cases, a good transvaginal ultrasound examination can actually image the ectopic pregnancy in the Fallopian tube. They can even be life-threatening. Typically, however, a ruptured tube must be removed. ERIN HENDRIKS, MD, RACHEL ROSENBERG, MD, AND LINDA PRINE, MD. Take time to work through your feelings. In some cases, the fallopian tube can be saved. The female body normally has two fallopian tubes. Symptoms most often appear 6 to 8 weeks after the last normal menstrual period. It often begins as a colicky abdominal or pelvic pain that is localized to one side as the pregnancy distends the fallopian tube. If you do not have the symptoms of a fallopian tube rupture but your ob-gyn or other health care professional suspects you may have ectopic pregnancy, he or she may: Perform an ultrasound exam to see where the pregnancy is developing, Test your blood for a pregnancy hormone called human chorionic gonadotropin (hCG). A review of the menstrual history and prior ultrasonography can help establish gestational dating and determine whether the pregnancy location is known. This type of ectopic pregnancy is called a tubal pregnancy. Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. Have you been pregnant before? An ectopic pregnancy occurs when a fertilized egg implants and grows outside the main cavity of the uterus. . 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 most common gestational age of diagnosis is between 6 to 10 weeks. These medications can affect the way methotrexate works in the body. Depending on your symptoms and when the ectopic pregnancy is discovered, this may be done using medication, laparoscopic surgery or abdominal surgery. Other times, a person will have pain in the pelvis thats much worse on one side. Risk factors include a history of pelvic inflammatory disease, cigarette smoking, fallopian tube surgery, previous ectopic pregnancy, and infertility. Almost all ectopic pregnanciesmore than 90%occur in a fallopian tube. Skip to primary navigation . Dec. 4, 2019. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. More often, patient symptoms combined with serial ultrasonography and trends in beta human chorionic gonadotropin levels are used to make the diagnosis. This drug stops cells from growing, which ends the pregnancy. include protected health information. For trusted, in-depth advice from ob-gyns, turn to Your Pregnancy and Childbirth: Month to Month. 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. Many people who have an ectopic pregnancy had no risk factors at all. A history of ectopic pregnancies or a history of surgery on the fallopian tubes are the factors that most increase the risk. Have you taken a pregnancy test? In-vitro fertilization (IVF) also increases the chance of an ectopic pregnancy. Mayo Clinic. Medical management is safe and effective in carefully selected patients. Yes, ectopic pregnancies are dangerous. 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. 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). All Rights Reserved. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. 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. Visualization of chorionic villi differentiates intrauterine pregnancy loss from ectopic pregnancy, avoiding unnecessary administration of methotrexate. Levels of this hormone increase during pregnancy. Data Sources: An evidence summary from Essential Evidence Plus was reviewed and relevant studies referenced. Setting a low -HCG cutoff value increases the sensitivity of ultrasound and -hCG at diagnosing an ectopic . The diagnosis of threatened abortion should be made in patients with bleeding and an ultrasound-confirmed viable intrauterine pregnancy. What are the chances of dying from an ectopic pregnancy? These may include pain, fatigue, bleeding, and infection. The risk of a fallopian tube rupture does not go away until your treatment is over. It is appropriate for family physicians to treat hemodynamically stable patients in conjunction with their primary obstetrician. Bed rest does not improve outcomes, and there is insufficient evidence supporting the use of progestins. Laparoscopy: A surgical procedure in which an instrument called a laparoscope is inserted into the pelvic cavity through a small incision. 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. If one is damaged or removed, an egg may join with a sperm in the other tube and then travel to the uterus. Symptoms may include the following: Sudden, severe pain in the abdomen or pelvis. Severe abdominal or pelvic pain accompanied by vaginal bleeding. Don't have an ob-gyn? After this . Search dates: August 3, 2017, to October 21, 2018. Pregnancy tests look for hCG (human chorionic gonadotropin) which is excreted in pregnancy. See permissionsforcopyrightquestions and/or permission requests. 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. PID is usually caused by a sexually transmitted infection that spreads from the vagina to the uterus and fallopian tubes. 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. Theres some overlap between the possible trends in hCG levels for normal and ectopic pregnancies. 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. Clinicians should expect to see a gestational sac on transvaginal ultrasonography when -hCG levels reach 1,500 to 3,000 mIU per mL. When that happens, lower amounts of hCG are produced and the embryo can't develop normally. Laparotomy is reserved for patients who are hemodynamically unstable. 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. Bilateral ectopic pregnancy is extremely rare, with a tremendous maternal mortality and morbidity risk, requiring rapid diagnosis and management. A wide variety of symptoms are associated with an ectopic pregnancy. The nature, location, and severity of pain in ectopic pregnancy vary. Higher-than-typical hCG levels can signal that you're carrying multiples or, in rare cases, have a molar pregnancy. Expectant management can be considered for patients whose peak -hCG level is below the discriminatory zone and is decreasing, but has plateaued or is decreasing more slowly than expected for a failed intrauterine pregnancy.30 In cases where the initial -hCG level is 200 mIU per mL (200 IU per L) or less, 88% of patients will have successful spontaneous resolution of the pregnancy; however, rates of spontaneous resolution decrease with higher -hCG levels.31 Patient counseling must include the risks of spontaneous rupture, hemorrhage, and need for emergency surgery. However, your doctor can't diagnose an ectopic pregnancy by examining you. In a typical pregnancy, your hCG levels double every 48 to 72 hours. Implantation and placental development. Very early in pregnancy, the embryo can grow within the fallopian tube without causing any symptoms. Surgical options include salpingostomy or salpingectomy. information and will only use or disclose that information as set forth in our notice of | . Ectopic pregnancy in Dalhatu Araf Specialist Hospital Lafia Nigeria - A 5-year review. Mayo Clinic is a not-for-profit organization. Sexually active women should be alert to changes in their bodies, especially if they experience symptoms of an ectopic pregnancy. You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. If you are a Mayo Clinic patient, this could . Patient information: See related handout on bleeding in early pregnancy, written by the authors of this article. Levels of hCG should be increasing by at least 60% every 2-3 days, but ideally doubling every 48-72 hours. This condition is usually diagnosed during surgery, as radiologists may not pay enough attention to the contralateral side of interest. My hCG levels at five weeks were 150 and then 352 two days later. In viable intrauterine pregnancies with initial -hCG levels of less than 1,500 mIU per mL, 1,500 to 3,000 mIU per mL, or greater than 3,000 mIU per mL, there is a 99% chance that the -hCG level will increase by at least 49%, 40%, and 33%, respectively, over 48 hours. With this procedure, mature eggs are fertilized in a lab and then implanted into the uterus. Miscarriage. This information is designed as an educational aid for the public. In the United States, the estimated prevalence of ectopic pregnancy is 1% to 2%, and ruptured ectopic pregnancy accounts for 2.7% of pregnancy-related deaths. 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. Ultrasound Exam: A test in which sound waves are used to examine internal structures. health information, we will treat all of that information as protected health General Anesthesia: The use of drugs that produce a sleep-like state to prevent pain during surgery. Losing a pregnancy is devastating, even if you've only known about it for a short time. PloS One. If you wish to try to get pregnant again, it's very important to see your doctor regularly. February 03, 2023 | by haleyerin1229. hCG is present in a pregnant persons blood and urine, and its the hormone that makes most pregnancy tests possible. Obstet Gynecol Clin North Am. If both fallopian tubes have been injured or removed, in vitro fertilization (IVF) might still be an option. Patients undergoing expectant management must receive extensive counseling on the risk of tubal rupture and the importance of close surveillance. Copyright 2023 American College of Obstetricians and Gynecologists, Privacy Statement 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). Search for doctors near you. 25th ed. Human chorionic gonadotropin (hCG) is a hormone thats very important throughout pregnancy. manual vacuum aspiration of the uterus can evaluate for chorionic villi that differentiate intrauterine pregnancy loss from 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. Ectopic pregnancy should be considered in any pregnant patient with vaginal bleeding or lower abdominal pain when intrauterine pregnancy has not yet been established (Table 2).10 Vaginal bleeding in women with ectopic pregnancy is due to the sloughing of decidual endometrium and can range from spotting to menstruation-equivalent levels.10 This endometrial decidual reaction occurs even with ectopic implantation, and the passage of a decidual cast may mimic the passage of pregnancy tissue. You may continue to feel pregnant for a while. 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. If you've had an ectopic pregnancy, your risk of having another one is increased. This site complies with the HONcode standard for trustworthy health information: verify here. Vaginal bleeding or spotting also may occur. 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. American College of Obstetricians and Gynecologists. Treatment for incomplete abortion should rely on shared decision making. In early pregnancy, a 48-hour increase of hCG by 35% can still be considered normal. An ectopic pregnancy cannot move or be moved to the uterus, so it always requires treatment. 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. 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%. The estimated mortality of ectopic pregnancy is between 2 and 4/1000. This does not require the removal of the fallopian tube. A choice of either methotrexate or surgical management is offered to women with an ectopic pregnancy who have a serum hCG level of at least 1500 IU/L and less than 5000 IU/L, . Sometimes, there has been a positive pregnancy test, but no embryo can be seen in the uterus via ultrasound. In this instance, a health care provider can order a test for the hCG level. Human chorionic gonadotropin, or hCG, is a hormone produced by the placenta during pregnancy. Neither ultrasound showed an egg or even a sac. Clinical Outcomes in High-Risk Pregnancies Due to Advanced Maternal Age. There are different treatment protocols, but the single-dose regimen is most common.15 This includes an intramuscular injection of 50 mg of methotrexate per m2, followed by close monitoring of symptoms and measurement of -hCG levels four and seven days after injection. It can take time for the level of hCG in your body to drop after treatment for an ectopic pregnancy. Thus, a history of bleeding and passage of tissue cannot be relied on to differentiate ectopic pregnancy from early intrauterine pregnancy failure. Sometimes it can be difficult to remember all of the information provided, especially in an emergency situation. Interventions for non-tubal ectopic pregnancy. The differential diagnosis includes threatened abortion, early pregnancy loss, and ectopic pregnancy. Also a factor is whether your other fallopian tube is normal or shows signs of prior damage. 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. One use for quantitative hCG levels is to diagnose and monitor an ectopic pregnancy or pregnancy of unknown location. All rights reserved. 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. Explore ACOG's library of patient education pamphlets. You might also seek the help of a support group, grief counselor or other mental health provider. Also searched were the Cochrane database, the Agency for Health-care Research and Quality, DynaMed, and the National Guideline Clearinghouse. For some women, ectopic pregnancy can be traumatic. However, if a persons hCG level is rising slowly or decreasing, this suggests that the pregnancy may be ectopic. Because ectopic pregnancies can be life-threatening, early diagnosis is essential. 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. Next, your doctor uses a thin tube equipped with a camera lens and light (laparoscope) to view the tubal area. Levels of this hormone increase during pregnancy. The rate of increase slows as pregnancy progresses and typically plateaus around 100,000 mIU per mL (100,000 IU per L) at 10 weeks' gestation.16 A decrease in -hCG of at least 21% over 48 hours suggests a likely failed intrauterine pregnancy, whereas a smaller decrease should raise concern for ectopic pregnancy.17, The discriminatory level is the -hCG level above which an intrauterine pregnancy is expected to be seen on transvaginal ultrasonography; it varies with the type of ultrasound machine used, the sonographer, and the number of gestations. These cases require medical attention immediately. If you are pregnant, you can detect it in your urine. In 95% of ectopic pregnancy cases, a good transvaginal ultrasound examination can actually image the ectopic pregnancy in the Fallopian tube. 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. A rupture can cause major internal bleeding. Human chorionic gonadotropin (hCG) is a glycoprotein hormone composed of 2 dissimilar subunits, alpha and beta, joined non-covalently. Huang CC, Huang CC, Lin SY, et al.
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