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Laparoscopy
3%
3/89
Methotrexate
7%
6/89
Salpingectomy
6%
5/89
Salpingostomy
43%
38/89
Ultrasound and serum hCG in 48 hours
40%
36/89
Select Answer to see Preferred Response
This patient with a serum ß-hCG below the discriminatory zone has an ultrasound that does not identify an intrauterine pregnancy. Because the serum ß-hCG is below the discriminatory zone, the most appropriate next step in management is to repeat the serum ß-hCG and obtain an ultrasound in 48 hours.Ectopic pregnancy refers to implantation of the fetal sac outside of the uterine cavity and most commonly occurs in the fallopian tubes. It should be highly suspected in patients who present with severe abdominal pain, a positive pregnancy test, and no fetal sac in the uterine cavity on ultrasound. For patients with serum ß-hCG below the discriminatory zone, the pregnancy is likely not large enough to be visualized on ultrasound. The discriminatory zone varies by institution, but is generally around 3000 mIU/mL. Nearly all pregnancies are visualized as the ß-hCG approaches 3500. Under normal conditions, the serum level of ß-hCG produced by a healthy pregnancy should double approximately every 48 hours. For stable patients such as this one with a serum ß-hCG below the discriminatory zone and no intrauterine pregnancy visualized on ultrasound, the most appropriate next step in management is to repeat measurement of serum ß-hCG and obtain repeat ultrasound in 48 hours. By this time, the serum ß-hCG is likely to have doubled and the pregnancy will likely be visible on ultrasound.Mullany et. al review the diagnosis and management of ectopic pregnancy. They discuss the role of serum ß-hCG testing and the discriminatory zone in the diagnosis of ectopic pregnancy. They further discuss options for management of confirmed ectopic pregnancy based on level of serum ß-hCG, size of pregnancy, and hemodynamic stability.Incorrect Answers:Answer 1: Laparoscopy would be indicated for a ruptured ectopic pregnancy which may present with severe pain, peritoneal signs, hypotension, and tachycardia. This patient is hemodynamically stable and does not have imaging studies confirming the diagnosis, making laparoscopy inappropriate.Answer 2: Methotrexate is indicated for the medical management of an ectopic pregnancy that is small and not yet ruptured. However, the diagnosis of ectopic pregnancy must first be confirmed. It would be inappropriate without imaging confirmation of the diagnosis.Answer 3: Salpingectomy may be indicated in the management of some ectopic pregnancies with rupture or pending rupture. However, it would not be appropriate in this hemodynamically stable patient who does not have a confirmed diagnosis of ectopic pregnancy.Answer 4: Salpingostomy may be indicated in the management of some ectopic pregnancies that have not yet ruptured, and in patients who desire preservation of fertility. However, it would not be appropriate in this hemodynamically stable patient who does not have a confirmed diagnosis of ectopic pregnancy.Bullet Summary:For patients with serum ß-hCG below the discriminatory zone and no pregnancy visualized on ultrasound, the most appropriate next step in management is to repeat serum ß-hCG testing and ultrasound in 48 hours.
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