A female has history of 6 weeks amenorrhoea, USG shows no sac, serum beta HCG-1000 IU/L. What would be next management?
Repeat HCG after 48 hrs Ectopic pregnancy Pregnancy is definitely diagnosed by demonstrating intrauterine sac. A normal intrauterine sac appears regular and well defined on ultrasound. So ectopic pregnancy can be diagnosed by demonstrating the absence of the intrauterine sac. In a woman in whom ectopic pregnancy is suspected because of pain, bleeding and positive pregnancy test, performance of vaginal sonography is the logical first step. If the sonography demonstrates live intrauterine fetus then ectopic pregnancy is extremely unlikely. Alternatively if the uterus is empty, an ectopic pregnancy can be diagnosed based on the visualization of an adnexal mass separate from the ovaries. 13-hCG hormones also play an impoant role in the dignosis of pregnancy. p HCG is a hormone secreted during pregnancy. A positive HCG confirms that patient is pregnant. It is positive in viually 100% of ectopic pregnancies. However, a positive test only confirms pregnancy and does not indicate whether it is intrauterine or extrauterine. In normal pregnancy 13 HCG should double up every 2 hCG is slow. 13 hCG titres and ultrasound complement one another detection. By correlating 13 hCG titres with ultrasound from intrauterine pregnancy. days hut in ectopic pregnancy the rate of increase of fl in detecting ectopic pregnancy and have led to earlier findings an ectopic pregnancy can often be differentiated The discriminatory zone of fl HCG levels is the level above which a normal intrauterine pregnancy is visualized. The threshold of discrimination of intrauterine pregnancy today is around 1500 IU/ml of R HCG. A high resolution, vaginal ultrasound scan showing no intrauterine pregnancy is presumptive evidence that an ectopic pregnancy is present but may also be consistent with an intrauterine pregnancy which is too small to be seen on ultrasound. If the diagnosis is unceain, it is necessary to wait for few days and repeal the bHCG after 48 hrs. If the flHCG falls on repeat examination. - This suggests an aboion or rupture. If the fl HCG is not increasing at a normal rate i.e., > 66% in two days. - Ectopic pregnancy is diagnosed. In the question the 13 HCG level is 1000. Absence of gestational sac at this 13 HCG level does not fully confirm ectopic pregnancy. 13 HCG level should be obtained after 48 hrs to confirm ectopic pregnancy (If the increase in 8 HCG is less compared to nonnal pregnancy the diagnosis is ectopic pregnancy). More on ectopic pregnancy Serum progesterone measurement A single measurement of serum progesterone may sometimes clarify the diagnosis when ectopic pregnancy is suspected, but Its accuracy is crude and the customary thresholds are < 5 nWm and > 25 ng/ml. i.e.a value exceeding 25 ng/ml excludes ectopic pregnancy with 97.5% sensitivity value below 5 ng/nil occur in only .3 percent normal regnancie.v. So normal pregnancies can be excluded if the progesterone level is below 5%. Surgical diagnosis of ectopic pregnancy :- Laparoscopy Direct visualization of the fallopian tubes and pelvis by diagnostic laparoscopy offers a reliable diagnosis in most cases of suspected ectopic pregnancy and a ready transition to definitive operative therapy. At times, identification of an early unruptured tubal pregnancy may be difficult even if the tube is fully visualized. Inspite of the low morbidity and quick recovery time, laparoscopy usually is performed when, on the basis of noninvasive test or curettage results, the diagnosis of ectopic pregnancy is fairly ceain and medical therapy is not planned. In these cases laporoscopy is used both for therapeutic and diagnostic purpose. Laparotomy Open abdominal surgery is preferred when the woman is hemodynamically unstable or when laparoscopy is not feasible. Laparotomy should not be delayed while laparoscopy is performed in a woman with obvious abdominal hemorrhage that required immediate definitive treatment. Culdocentesis Culdocentesis is the transvaginal passage of a needle into the posterior cul-de-sac in order to determine whether free blood is present in the abdomen. This procedure is useful in the diagnosis of intraperitoneal bleeding. This procedure will reveal nonclotting blood if intra- abdominal bleeding has occurred. If culdocentesis is positive, laparoscopy or laparotomy should be performed immediately. Indeed, some argue that the main purpose of culdocentesis is, not in diagnosis but to better prioritize patients so that those with positive culdocentensis are taken immediately to the operating room. More on imaging procedures used in the diagnosis of ectopic pregnancy Vaginal sonography There has been much improvement in the early diagnosis of ectopic pregnancy using vaginal sonography. Its use results in earlier and more specific diagnosis of uterine pregnancy than abdominal sonography and it has become the imaging method of choice in early pregnancy. Abdominal sonography Identification of pregnancy products in the fallopian tube.
Medical management
Repeat HCG after 48 hours
Repeat HCG after 1 weeks
None of the above