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• W1978988723 abstract "A 36-year-old, gravida 7 para 2, presented at 5 weeks of amenorrhea for vaginal bleeding and abdominal pain. She had two previous tubal ectopic pregnancies managed 11 and 12 years previously by medical therapy and laparoscopic salpingectomy, respectively, two cesarean deliveries and two surgical abortions. Abdominal and pelvic examination was unremarkable. Transvaginal sonography (TVS) showed no evidence of intrauterine or ectopic pregnancy. Serum human chorionic gonadotropin (hCG) level was 5841 IU/L. Diagnostic laparoscopy was considered in view of the absence of an intrauterine gestation sac on TVS above the hCG discriminatory level (1500 IU/L in our institution) 1. After counseling, the patient decided not to undergo laparoscopy, but preferred inpatient monitoring as she was asymptomatic. Serum hCG 48 h later showed normal doubling (19 655 IU/L). TVS repeated three days after the initial scan showed a live cervical pregnancy with a mean sac diameter of 1.1 cm and a 3-mm fetal pole (Figure 1). She was treated with intralesional methotrexate; the usual treatment method for cervical pregnancy in our institution 2. TVS four weeks after treatment showed a 2.0 × 1.4 × 1.5 cm heterogeneous lesion with irregularly shaped hypoechoic center and no fetal pole, compatible with residual cervical pregnancy. Her hCG level had normalized to <10 IU/L after seven weeks. We wish to draw attention to two important educational messages. First, despite the widespread use of an hCG discriminatory level in the management of pregnancy of unknown location, its value in diagnosing non-tubal ectopic pregnancies is still unclear. Laparoscopy, if performed in our patient based on the discriminatory level, would have been negative and unnecessary. Hence, we support the conclusion by Doubilet and Benson 3 in their recent publication that the hCG discriminatory level should not be used to determine the management of a hemodynamically stable patient with suspected ectopic pregnancy but for a different reason; that is, the potential risk of missing rare ectopics such as cervical pregnancies. Second, clinicians often use a suboptimal rise in hCG level or the so-called “doubling time”, to indicate an abnormal early pregnancy when TVS is not diagnostic. However, the doubling time for non-tubal ectopic pregnancies has never been adequately studied and is generally assumed to be the same as for tubal ectopic pregnancies. Although recently Barnhart et al. 4 suggested a minimal rise of 53% in two days in the hCG level in women with a potentially viable intrauterine pregnancy, the finding of a “normal” rise in serial hCG values does not always exclude the possibility of an ectopic pregnancy. Silva et al. 5 reported that 21% of women with an ectopic pregnancy could have a rise in hCG levels similar to women with an intrauterine pregnancy. Our case further illustrates that in patients with cervical ectopic pregnancy, a “normal” rise of hCG levels can be observed, and can be indistinguishable from that of a normal intrauterine pregnancy. With the understanding that experience from a single case cannot be generalized, we suggest that a combination of hCG value above the discriminatory level in the absence of an intrauterine gestation on TVS and with an “appropriate” rise in hCG values should alert the clinician to the likelihood of an alternative location, such as cervical ectopic pregnancy." @default.
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• W1978988723 date "2013-01-16" @default.
• W1978988723 modified "2023-10-18" @default.
• W1978988723 title "Value of human chorionic gonadotropin levels in diagnosing cervical ectopic pregnancy" @default.
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• W1978988723 doi "https://doi.org/10.1111/aogs.12057" @default.
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