A 26-year-old female presents with lower abdominal pain and vaginal bleeding. Her last menstrual period was 7 weeks ago. A urine pregnancy test is positive, and a quantitative beta-hCG level is 2500 mIU/mL. Intravaginal ultrasonography shows no evidence of an intrauterine gestational sac. Baseline laboratory tests, including a CBC, liver function tests, and renal function tests, are all normal. She is treated with a single dose of intramuscular methotrexate at 50 mg/m² of body surface. Day 4 lab results show quantitative beta-hCG level of 2800 mIU/mL on day 4. Seven days later, the patient presents for reevaluation, and her quantitative beta-hCG is found to be 2640 mIU/mL
Which one of the following is the most appropriate next step?
Correct Answer A:
Management of ectopic pregnancy with methotrexate is appropriate in patients who have a beta-hCG level < 5,000 mIU/mL; who are without liver or renal disease, immune or platelet compromise, or significant pulmonary disease; and who are reliable and able to follow up daily if necessary.
If the beta-HCG level has not dropped at least 15% from the day-4 level, administer a second IM dose of methotrexate (50 mg/m2) on day 7, and observe the patient. If no drop has occurred by day 14, surgical therapy is indicated. Laparoscopy with salpingostomy is the preferred method. Expectant management is appropriate only if a patient has a beta-hCG level < 1000 mIU/mL that is declining.
A 16-year-old woman presents to the emergency department complaining of severe left-sided pelvic pain and vaginal spotting. Her last menstrual period was 6 weeks ago. A quantitative beta-hCG is 9000 mIU/ml. An endovaginal ultrasound notes a complex left adnexal mass, moderate free fluid, and no evidence of an intrauterine sac.
The most likely site of this pregnancy is:
Correct Answer D:
The most likely site of an ectopic pregnancy is the ampulla. Cervical, ovarian, and abdominal ectopics are very rare. Cornual ectopics often present later, and the rupture can be much more catastrophic due to the vascularity of this portion of the uterus.
→ Cervical pregnancies (choice A) can lead to massive bleeding. The cervix will often feel very large and can be tender. Methotrexate therapy may decrease the need for hysterectomy.
→ Ovarian pregnancies (choice B) are rare (0.5%).
→ Isthmus (choice C) and infundibulum of the fallopian tube (choice E) are less common sites of ectopics than ampulla of the fallopian tube.
A 23-year-old sexually active woman with a prior history of pelvic inflammatory disease presents with sudden onset of pelvic pain. On initial workup and exam, you note the following: Beta-hCG titer 5,400 mIU/ml; WBC 4.5 x 10^9/L; differential: 63 PMNs, 0 Bands, 37 lymphocytes; temperature 37.3°C (99.1°F). An endovaginal ultrasound shows nothing in the uterus, a 2-cm simple left ovarian cyst, and moderate free fluid in the cul-de-sac.
The most likely diagnosis is:
Correct Answer B:
With her prior history of PID, her chances of tubal damage are significantly elevated. Since she is pregnant with an HCG titer over 2000 mIU/ml, an intrauterine gestation sac should have been seen on the endovaginal ultrasound. With the moderate amount of free fluid in the cul-de-sac, along with the pelvic pain and normal white count and temperature, the index of suspicion for an ectopic must be high.
→ The white count is normal and her temperature is normal as well. With a positive HCG titer, an ectopic should be the first suspicion.
→ This can cause free fluid in the cul-de-sac as well as pelvic pain. With her history of PID in the past, the presence of tubal damage is high; so one should be much more suspicious of an ectopic. At an HCG titer of 5,400, an IUP should have been seen.
→ Although a source of pelvic pain, with the HCG titer, absence of an IUP on ultrasound, and free fluid in the cul-desac, ectopic pregnancy should be the primary diagnosis.
→ Can be a source of pelvic pain. See answer to D.
An obese woman who has poorly controlled diabetes on glyburide tells you that she wants to get pregnant. She has stopped taking her birth control pills.
What will you advise her?
Abundant data clearly show that uncontrolled maternal diabetes is teratogenic. It appears that in many cases, adverse fetal outcomes that have been attributed to oral glucose-lowering agents - including various anomalies, stillbirths, macrosomia, and neonatal hypoglycemia - were probably due to the diabetes itself.
In the best scenario, the woman should have optimization of glucose control and HbA1C before pregnancy. Diet and exercise are standard therapy. Insulin should be prescribed if glucose levels continue to be elevated.
If she has been taking oral agents, the dose should be adjusted to achieve optimal diabetes control while on adequate contraception, then switched to insulin once HbA1C is optimized and she's ready to become pregnant. (continuing glyburide or metformin is controversial).
The most important factor in improving perinatal outcome in diabetic pregnancies is:
Poor control of preexisting or gestational diabetes that occurs during organogenesis (up to about 10 weeks gestation) increases risk of major congenital malformations. Gestational diabetes can result in fetal macrosomia (fetal weight > 4500 g at birth) even if plasma glucose is kept nearly normal.
Preconception counseling and optimal control of diabetes before, during, and after pregnancy minimize maternal and fetal risks, including congenital malformations. Because malformations may develop before pregnancy is diagnosed, the need for constant, strict control of glucose levels is stressed to women who have diabetes and who are considering pregnancy (or not using contraception).
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