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Volume 99, Number 2 >
Pp. 90
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Department of Obstetrics and Gynaecology, Watford General Hospital, Watford WD18 0HB, UK
E-mail: lauriemontgomeryirvineresearch{at}yahoo.co.uk
The advent of automated assays for beta human chorionic gonadotropin (ß-hCG) has made expectant management a realistic option in selected cases of suspected ectopic pregnancy.
CASE HISTORY
A woman of 37, a multigravida, was referred because of continuous and increasingly heavy bleeding since her last menstrual period two weeks earlier and worsening left-sided pelvic pain for the past four days. She had been using a progesterone-only pill for contraception. A home urinary pregnancy test had been positive. On examination she was haemodynamically stable; she had lower abdominal tenderness on the left side without peritonism and a left adnexal mass was felt per vaginam. The diagnosis was in doubt but she was judged to have an intrauterine pregnancy. A transvaginal scan showed a thickened endometrium and the possibility of a right simple cyst, there was also some free fluid in the pouch of Douglas. Serum ß-hCG was 123 iu/mL. She was followed up as an outpatient, and two further ß-hCGs two days apart were 62 and 21 iu/mL; she was due to have a repeat scan at one week. Six days after her initial presentation severe lower abdominal pain developed and she was admitted to hospital. At diagnostic laparoscopy she was found to have a leaking left fimbrial ectopic pregnancy; she also had a right simple ovarian cyst. Partial salpingectomy was performed laparoscopically, and the ectopic pregnancy was confirmed histologically.
COMMENT
Ectopic pregnancy remains an important cause of maternal deaths in the UK; there were 11 fatal cases in the last triennial report.1 This is despite the advent of a rapid qualitative urine ß-hCG assay which if negative virtually excludes ectopic pregnancy. Other investigations include a quantitative serum ß-hCG assay which can be used with transvaginal scanning as part of an algorithm in suspected ectopic pregnancy. In the present case the low and falling ß-hCG suggested the pregnancy was unlikely to be ectopic.2 Even if a pregnancy is indeed ectopic, a falling ß-hCG points to a self-limiting form of pregnancy that requires no intervention.3
Review of the published work indicates a consensus that, whatever the site of pregnancy, a falling ß-hCG concentration justifies expectant management.4 Moreover, women whose ectopic pregnancy resolved spontaneously have been found to have lower initial ß-hCGs (mean 246 iu/L) than those who required surgery (mean 628 iu/L).5 Against this must be set rare cases in which a decline in ß-hCG was followed by tubal rupture.6 Possible mechanisms in these cases are blood-vessel erosion by a surviving clump of trophoblastic tissue (Padwick ML, personal communication) or pressure necrosis from an intraluminal clot.6
The special feature of the present case is the exceptionally low level at which symptoms of rupture developed (21 iu/L); the lowest previously reported was 97 iu/L. For clinicians the message is that, when expectant management is decided upon, the patient requires regular hospital review and the ß-hCG must be followed down to `non-pregnant' levels.7
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