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.


  • 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.
image 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)



EARLY ABORTION TRAINING CURRICULUM Copyright © 2020 by UCSF Bixby Center for Global Reproductive Health. All Rights Reserved.