Obstetrics & Gynecology

Answer 2 Ectopic pregnancy. Distinguishing between early pregnancy complications is critical. Diagnosing ectopic pregnancy is particularly important, as it is the leading cause of pregnancy-related death in the first trimester. Critical pieces of information are the patient’s lack of bleeding and serum hCG level. First trimester bleeding is always a symptom with incomplete, complete, and threatened abortion, which are typically accompanied by abdominal cramps. In an incomplete abortion, products of conception are still in the uterus and the cervical os remains open. In complete and threatened abortions, the cervical os is closed; all products of conception are expelled in a complete abortion, whereas, the products of conception remain in the uterus in a threatened abortion. With a missed abortion, there is embryonic death or lack of development of an embryo (ie, anembryonic gestation). In this patient, the lack of an intrauterine gestational sac on ultrasound would be most consistent with either a complete abortion or an ectopic pregnancy. The patient has a serum hCG value of 4500 mIU/mL, and an intrauterine gestation, if present, should be visualized with TVUS. (1500 mIU/mL is the approximate hCG level when an intrauterine gestation can be visualized.) If the patient had bled heavily with cramping and symptoms had resolved, complete abortion would be a possible diagnosis. If this were the case, serum hCG levels would decline significantly.1,2 REFERENCE 1. Herbst AL, Mishell DR, Stenchever MA, Droegemueller W. Ectopic pregnancy. In: Comprehensive gynecology. 2nd ed. St. Louis: Mosby-Year Book; 1992:457-88. 2. Herbst AL, Mishell DR, Stenchever MA, Droegemueller W. Abortion. In: Comprehensive gynecology. 2nd ed. St. Louis: Mosby-Year Book; 1992:443-9. Click here to return to the questions

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