EVALUATION FOR ECTOPIC PREGNANCY AND EARLY PREGNANCY LOSS (EPL)
Patients presenting in early pregnancy with symptoms of bleeding and / or pain require evaluation for ectopic pregnancy according to local protocol—for example with US and / or serial hCGs, as well as exam. Referral for formal diagnostic ultrasound and/or emergency attention may be indicated.
Ultrasound
- A patient with a positive pregnancy test and no visible pregnancy on ultrasound is said to have a Pregnancy of Unknown Location (PUL).
Serial Serum hCG Levels
- The minimum rate of decline expected for EPL depends on the initial hCG at presentation, but it ranges from 35-50% at 2 days (Butts 2013).
- Rate of hCG rise with ectopic pregnancy is usually slower than expected for a viable IUP.
- Among patients diagnosed with ectopic pregnancies:
- The majority had serial hCG rise below the normal range for a viable IUP (i.e. level rose < 35-53% in 2 days).
- For those with declining hCG, the rate of decline is usually slower than that expected for EPL.
- However, 21% of ectopics have a hCG rise similar to viable IUP and 8% have a decrease that is normal for EPL (Silva 2006).
- Therefore, use caution when following patients in early pregnancy with possible symptoms of ectopic pregnancy, i.e. intermittent bleeding/spotting, pain.
- A “normal” rise or fall in levels is not sufficient to exclude ectopic – but should be used in conjunction with other clinical data including exam, ultrasound or diagnostic aspiration.
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Change in the hCG Level in Intrauterine Pregnancy, Ectopic Pregnancy, and Spontaneous Abortion (Note: Studies from ED not abortion care setting; therefore ectopic rate is higher.) An increase or decrease in the serial hCG level in a woman with an ectopic pregnancy is outside the range expected for that of a woman with a growing IUP or a EPL 71% of the time. However, the increase in the hCG level in a woman with an ectopic pregnancy can mimic that of a growing IUP, and the decrease in the hCG level can mimic that of an EPL. (Barnhart 2009) |