Ectopic Pregnancy of Unknown Location

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Thank you for creating this forum- very helpful.

I became pregnant for the first time at 44. Everything was always normal for me- no history of any pelvic inflammatory disease, no STDs, never used IUDs, and no smoking- very healthy. My AMH, LH, and FSH were excellent for my age- high above average. It took some time to fall pregnant (started at 41) with my partner due to his retrograde ejaculation. However he switched medication and we became pregnant soon after that. We always wanted kids since meeting in our late 30s.

At my seven-week sonogram, they could not see an embryo, just a small gestational sac so took my blood (HCG of 6526) and told me to come back in a week as it may still be too early. Before the next week’s appointment, my doctor called me worried about a possible ectopic pregnancy. At the next week’s appointment they saw the same small gestational sac and determined that it was a pseudo gestational sac. Also, my HCG rose to 8951.

They performed a second ultrasound and could not find an embryo anywhere- not in the tubes, ovaries, cervix, broad ligament and also did a trans abdominal ultrasound of my abdomen- no free fluid or mass anywhere.

So, they administered methotrexate (2 doses, 4 days apart). My HCG is slowly decreasing to around 8600. However, that is still high. They also performed a third transvaginal ultrasound and could not see any ruptures, masses, or free fluid in tubes, ovaries, cervix, or any part of the uterus. They reported that my tubes, uterus, cervix, and ovaries look very normal. Due to the methotrexate, I now have a medium period, which is expected. However, I’m super scared about the possibility of an embryo attaching to another organ and then rupturing due to the high HCG levels. Would there be anything else causing the high HCG levels? They are debating now whether or not I need an MRI.

Thank you,

Jessica

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Dear Jessica,

I am so sorry to hear of your loss.

Not knowing what is happening to our bodies can be extremely overwhelming and you have a friend here who understands. Whilst I was not diagnosed with a pregnancy of unknown location, I was admitted to hospital with a ? ectopic pregnancy on a Friday evening of a bank holiday weekend so I had to wait until the Tuesday to be informed that I was indeed having an ectopic pregnancy and it really was the most anxious wait.

It is important to understand that Pregnancy of unknown location - (PUL) is not a diagnosis; it is a label given until the final location of the pregnancy can be identified with certainty. In the event of a PUL, blood will be taken to measure serum progesterone and hCG and the hCG test repeated 48 hours later. The doctors would also want to repeat the scan.

Until the location of the pregnancy is known definitively or the serum hormone levels have decreased to below pregnancy levels, there is a risk of complications associated with an as yet undiagnosed ectopic pregnancy. Whilst I do not wish to alarm you, for every 100 pregnancies labelled as a PUL about 10 will subsequently be found to be ectopic; but not all of these will need treatment.

I am guessing from the words that you are using that you are not in the UK. We are a UK based charity and whilst we love supporting ladies, from all over the world, we often cannot comment on differing methods of treatment. The use of methotrexate injections four days apart is also not a method of administration in the UK, so it is difficult to comment on your levels. In the UK, a first dose is given and then bloods measured but the hCG level often rises on the day four blood test because the action of methotrexate is not instantaneous, so the cells will have continued to divide for two or three days after the injection was given, and some cells release more hCG when they start to disappear. Doctors look to see a drop in hCG value of at least 15% between days four and seven. If there has not been a 15% drop, this is when the doctors will consider a second dose of methotrexate or surgery. Although the way it has been administered maybe standard practice in your hospital, it makes it difficult for me to comment or suggest what may happen.

We would gently remind you to not undertake any strenuous exercise or lifting or housework while your hCG levels are dropping. While I do not want to alarm you, there remains the risk of rupture even with low or declining hCG levels. You should not resume exercise until your hCG levels are falling consistently and are in the low 100s.

I am sorry that I cannot provide you with more precise details but I hope all becomes much clearer over the forthcoming blood tests and scans.

We are here for you for as long as you need,

Sending much love,

Karen x

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Dear Karen,

Thank you for your thoughtful reply. Yes, I’m in the United States, but we don’t have a forum like this one. I went to university in London. My HCG level dropped to 5100 (from 8951) within a week, and my doctor told me my body is responding very well to the methotrexate (two doses). I’m still at risk for a rupture, but again they couldn’t find the embryo anywhere. Yes, the diagnosis is ectopic but it is very confusing as to why they can’t find the embryo on any scan given the high HCG levels. I will have weekly blood tests and hope nothing ruptures. It is all very scary though.

Thank you again.

Jessica