Pregnancy Testing Following and Patient Management in Early Pregnancy

A positive pregnancy test means that implantation of your embryo was successful (whether you conceived naturally, had IUI or IVF) and that you are in very early stages of pregnancy. In this case, the pregnancy hormone, human chorionic gonadotrophin (HCG), produced by the embryo’s placental tissue (chorionic villi), has entered your circulation and is now detectable in your bloodstream. The first 2 weeks after implantation (early pregnancy), is a period of time where the actual pregnancy tissue is invisible to ultrasound since it is too small to be visualized. The pattern of the rise of HCG is the only way to follow the progression and health of a pregnancy during that period. A good normally progressing pregnancy will witness almost doubling of the HCG value every 2-3 days or at least a 60% increase in 48 hours. The gestational sac and the embryo will become visible when the HCG level reaches the threshold of 2500 IU or more. This is usually achievable in most cases by 6 weeks gestation if not earlier(counting from the first day of last period or 4 weeks after ovulation or egg retrieval).

A pregnancy before transvaginal ultrasound evidence of pregnancy (5- 6) weeks is labelled as a “chemical pregnancy” since a chemical test is the only way to detect the pregnancy. A pregnancy is labelled a “clinical pregnancy” when a gestational sac is seen in the uterus by the ultrasound.

Ensure you are taking your medications as instructed by your doctor, including your folic acid supplements.
Once you had a positive pregnancy test, you will be booked for repeat blood work in 2 days and if the HCG doubles, an ultrasound will be booked in 2 weeks.

CONTINUE MAINTAINING A HEALTHY LIFESTYLE. Your usual physical activity does not harm the pregnancy!

The second blood test for pregnancy should show almost doubling of the HCG value. This would indicate a normally developing pregnancy and is very reassuring. An ultrasound will be booked 2 weeks later to confirm the proper location of the pregnancy in the uterus and to confirm the viability of the pregnancy (when fetal heart activity is observed on ultrasound). Continue all of your medications as directed by your doctor, including folic acid/prenatal vitamins.

Abnormal changes in serial HCG levels

BHCG increasing but not doubling or fluctuating

This indicates a failing pregnancy. This most likely represents a failing intrauterine pregnancy. However,an ectopic pregnancy must be ruled out. If your levels are above 2500 IU and no sac can be seen in the uterus, medical treatment for a suspected ectopic pregnancy will be recommended, especially if you have existing risk factors for an ectopic pregnancy. If your levels are below that threshold of 2500 and the pattern of HCG levels changes is suggesting a failing pregnancy and ultrasound is unable to detect any sign of pregnancy anywhere, your pregnancy will be labelled as “ Pregnancy of unknown location” or (PUL). With PUL, serial BHCG levels every 2-3 days will be requested. No action will be required if the value is constantly dropping; however, plateauing or fluctuating HCG levels would call for a decision to initiating medical treatment for a possible ectopic pregnancy especially if coupled with clinical symptoms or ultrasound findings raising the possibility of an ectopic pregnancy. Direct clinical assessment by your doctor at this point is mandatory to confidently aid the diagnosis and to make treatment decisions.

BHCG serially dropping

When the BHCG starts to drop before 6 weeks, it means the pregnancy is failing. Stop your progesterone supplementation if you are on progesterone. You will be instructed to repeat blood work in two days and then weekly afterwards until the BHCG is zero. No action will be needed if the value continues to fall, however, a plateauing or slow rise in the BHCG would call for possible initiation of medical treatment for a possible ectopic pregnancy. Clinical assessment by your doctor is mandatory to confidently aid the diagnosis.

Instructions depend on the findings at ultrasound:

Gestational sac seen in the uterus with “fetal heart activity seen”

Congratulations!

This confirms a clinical, viable pregnancy. A copy of the ultrasound result will be sent to your referring doctor to initiate prenatal care. We will continue to look after your urgent needs until 12 weeks, provided your transfer of care to your OB or the delivering family doctor has not effectively occurred!

Gestational sac seen in the uterus with  “no fetal heart activity seen”

This is not a reassuring finding; however, it may be due to performing the ultrasound a bit too soon. A repeat ultrasound a week later is usually indicated before reaching any conclusion or taking any action. Please report any bleeding or pain to your nurse immediately, if it happens.

If the same finding is encountered 7-10 days later, it means that you are unfortunately going to miscarry. Pregnancy failures typically occur due to a major chromosomal or structural error affecting the embryo, leading to rejection of the pregnancy tissue by your body. Miscarriages are not your fault. They are not due to something you did, or something that you should have done. Diagnosis of Missed abortion has now been made.

Please refer to instructions for Missed abortion.

No gestational sac seen in the uterus or “empty uterus”

If the dates are correct and the HCG is measurable, we are dealing with the pregnancy of unknown location (PUL) or possible ectopic pregnancy. This scenario likely indicates an abnormal and failing intrauterine pregnancy or ectopic pregnancy with neither being visible by ultrasound. Serial blood tests to check your HCG levels are mandatory to rule out an ectopic pregnancy. However, the most likely explanation is that we are dealing with a failing intrauterine pregnancy. Serial testing and clinical examination are necessary to guide the diagnosis and further treatment.

Call/email your nurse or after-hours Emergency Phone line to notify our clinic if you develop bleeding in early pregnancy.

You will be booked for blood work and potentially an ultrasound, depending on blood levels and how far are you in the gestation. Management decisions will depend on investigation results and clinical findings.

You may get a Rhogam injection if your blood type is Rh-negative and you are close to 6 weeks.

Please, DO NOT stop your medication on your own under the assumption that you are miscarrying!Bleeding in early pregnancy is common. A combination of bleeding and significant cramping, however, is more ominous. Rest and continuation of your meds is all that can be done while awaiting instructions from your team after your blood work and/or ultrasound results are available.

If you are having significant / severe bleeding or severe pain, please go to the nearest local hospital emergency department.

Bleeding

Bleeding is a common occurrence in early pregnancy. It does not necessarily mean that the pregnancy is going to end. Please call or e-mail your nurse to inform us. Stay calm and rest until we assess the situation. You will be asked to come in for blood work and an ultrasound to ensure the continued health of your pregnancy. You will need a Rhogam injection if your blood type is Rh-negative. If the bleeding is too heavy, or if bleeding is accompanied by significant cramping (this is certainly more alarming), you should go to the nearest hospital ER for assessment.

Pelvic Pain

Pelvic pain in early pregnancy is common. However, a viable intrauterine pregnancy should always be confirmed by ultrasound. Pain can be due to ovarian enlargement during early pregnancy if you were stimulated with fertility injections to conceive. Pain is also not uncommon in early pregnancy stages if you had a history of fibroids or endometriosis.

Other

For other symptoms in pregnancy like headaches, nausea, fatigue, etc., All these symptoms are common in early pregnancy. We will continue to assist you with advice and provide you with support until 12 weeks. Please consult with your primary care physician for further management.

A missed abortion means the pregnancy has failed, as evidenced by the arrest of growth of the fetal sac and the absence of a fetal heart activity detectable by ultrasound. Despite the pregnancy failure, the female body has not yet started the natural process of miscarriage or expulsion of the products of conception. The patient typically experiences no symptoms. Failure of the pregnancy is most likely caused by genetic/chromosomal errors in the developing embryo. This is totally beyond the patient’s control and is nature’s way of selecting the best by getting rid of an abnormal pregnancy. It is estimated that 15-20% of all early clinical pregnancies will end up with a miscarriage. That risk increases by up to 50% after age 40.

A repeat ultrasound may be needed a week later to confirm the findings before presenting the patient with her three management options:

A- Wait for the natural expulsion of the products of conception.

This can take some time. Expect cramping and bleeding on and off until the process is complete. If the bleeding is too heavy, going to the nearest ER is advisable. An ultrasound a week later is usually recommended to ensure completeness of the spontaneous abortion process.

B- Initiate the natural process of expulsion by electing medical termination of pregnancy.

This is accomplished using misoprostol (Cytotec) tablets vaginally every 4 hours, up to three doses. Success rates are almost 80%, with 20% of patients requiring a D&C or repeat administration of the medication to complete the expulsion. Side effects can include nausea, diarrhea or heavy vaginal bleeding and significant cramping requiring an ER visit.

C- The third option is booking an elective dilatation and curettage i.e. surgical termination of pregnancy.

Choosing this option, the products of conception will be vacuumed or suctioned out of the uterus. This will require deep, deep, sedation or a general anaesthetic. Cervical dilatation will be performed to allow a hollow plastic tube attached to a suction apparatus to enter the uterine cavity. This device will suction the contents of the uterus to ensure complete evacuation of the cavity. A Rhogam injection will be indicated if your blood type is Rh-negative.

Products of conception collected after a miscarriage will be sent for genetic testing if this is the second clinical pregnancy loss. The information gained from this testing can be valuable in managing future pregnancies.

Expect the resumption of your menstrual period 4-6 weeks after a miscarriage. Testing for recurrent pregnancy loss will be initiated if you meet the diagnostic criteria of this condition.

There is no reason to delay your fertility treatment or attempts to conceive after a miscarriage unless you are emotionally not ready to proceed.

It is not infrequent to have a suspected ectopic pregnancy following any type of fertility treatment, including IVF (1/200 chance).

An ectopic pregnancy is highly suspected when your BHCG is above the detection threshold to see a gestational sac by ultrasound, yet no sac can be seen in the uterus. An ectopic is also suspected when your levels of HCG are fluctuating up and down and not following the expected minimal pattern of increase (60% every 48 hours or doubling in 3 days). The presentation is more worrisome when accompanied by pelvic discomfort and spotting, especially if the ultrasound report comments on a possible mass in the adnexa (although this is not an unusual finding in patients with stimulated ovaries due to fertility drugs). The presence of significant free fluid in the pelvis increases the likelihood of a leaking ectopic pregnancy.

The only sure ultrasound diagnosis to confirm an ectopic is the visualization of a gestational sac with a yolk sac or fetal heartbeat outside the uterus.

If the diagnosis of ectopic pregnancy is made early with a clinically stable patient, surgery (laparoscopy) can be avoided by administering medical treatment in the form of Methotrexate injection.

Methotrexate is the drug used to terminate an ectopic pregnancy by stopping and preventing the growth of placental tissue. It stops the growth of rapidly dividing cells. Side effects are related to its negative effects on healthy tissue with fast-dividing cells somewhere else in the human body including the liver, bone marrow, and bowel lining tissues. With proper dosing and careful monitoring, side effects are minimized. Side effects include abdominal cramps, nausea, diarrhea, inflammation of lung tissue and possible mouth sores. Pain at the injection site is common. Changes in liver enzymes and blood counts can also occur.

Contraindications to medical treatment for an ectopic are: BHCG >10000, complex enlarging mass in the adnexa >4 cm, high clinical suspicion of an ectopic with impending rupture, or clinically unstable patient. There should also be no medical contraindication to receiving methotrexate.

The dose of methotrexate is based on body weight and height (total body surface area). The drug is administered via a deep intramuscular injection. A second injection is sometimes indicated if the levels of BHCG do not drop as expected.

Laparoscopic intervention is indicated in those situations where medical treatment is contraindicated, or when medical treatment fails, as evidenced by a continued rise of the BHCG or increasing abdominal pain and bleeding.

Instructions for patients on methotrexate:
Refrain from sexual activity for 2-3 weeks after the injection. Do not try to conceive until the HCG level has disappeared by the next period. Avoid alcoholic beverages. Stop any vitamin containing folic acid. Do not take Aspirin or anti-inflammatory drugs. Tylenol for pain control is safe within the recommended doses.

Follow up instructions after the methotrexate injection:
Return to the clinic for blood work and assessment in 4 days and then 7 days after the initial injection. A second injection will be sometimes indicated if HCG change is not satisfactory.Your blood sample will be hen taken weekly until HCG levels become undetectable.

Rhogam is needed if you are more than 5 weeks pregnant and your blood group is Rh-negative.

If you develop unexpected severe abdominal pain, or feel dizzy and unwell with faintness and palpitation, seek medical attention immediately or go to the nearest emergency room.