The purpose of this study is to assess whether serum beta-human chorionic gonadotropin (beta-hCG) levels on day 4 following methotrexate (MTX) treatment in patients with ectopic pregnancy predict successful single-dose therapy or the need for subsequent surgical intervention. Retrospective analysis of patients with ectopic pregnancies treated with MTX (50 mg/m (2)) was conducted. Inclusion criteria for MTX management were serum beta-hCG < 15,000 mU/mL, absent fetal cardiac activity, ultrasonographic gestational sac < 3.5 cm, normal liver function tests, hemodynamically stable patient with no evidence of hemoperitoneum, and informed consent. Day 1, 4, and 7 serum beta-hCG levels were obtained. Outcome parameters included successful single-dose MTX management, the requirement for multiple treatments, and whether subsequent surgery was required. Receiver operator characteristic (ROC) curves were used. P < 0.05 was considered significant throughout. Eighty-three patients were studied. Of these, 60 patients were treated successfully with single doses, 16 patients required two doses, and two patients required three doses of MTX, and five underwent surgical management. Mean day 1 serum beta-hCG levels of patients successfully treated with single-dose MTX was 3938.5 (+/- 589.2 [standard deviation]) versus 1767.65 (+/- 1237.8) mU/mL in patients requiring multiple doses of MTX therapy, ( P < 0.0001). ROC curves for serum beta-hCG levels on days 1, 4, and 7 were 0.449, 0.592, and 0.754, respectively, indicating that only day 7 serum beta-hCG levels were associated with successful single-dose MTX therapy. Serum beta-hCG levels on day 4 of MTX in patients with ectopic pregnancy do not predict successful single-dose therapy or the need for surgery.
CASE REPORTA 21-year-old woman, gravida 1 para 0, presented to the emergency room at State University of New York, Downstate Medical Center with right lower abdominal pain radiating to her back, and nausea and vomiting, 3 days after surgical termination of pregnancy at 14 weeks' gestation. Her medical history was unremarkable. The patient denied a history of sexually transmitted disease, and her recent cervical cytology was normal. Three days before presentation the patient had undergone an elective outpatient termination of pregnancy by dilatation and suction curettage. The presence of a 14-week intrauterine gestation had been confirmed by ultrasound scan before the procedure. The preoperative ultrasound examination did not reveal any abnormal uterine findings, including any evidence of uterine leiomyomata. The patient had been told that the procedure, which was not performed under real-time ultrasound guidance, was uneventful. She was given routine oral antibiotics (doxycycline 100 mg twice daily for 5 days and methergine 0.2 mg twice daily for 2 days). An immediate postprocedure ultrasound examination was not obtained following the termination of pregnancy.Physical examination on presentation revealed a healthy woman. She was afebrile, with blood pressure 103/66 mmHg, and pulse 82 beats per min. Her abdomen was soft, yet with marked tenderness of the lower abdomen but no signs of peritoneal irritation. Bimanual pelvic examination disclosed a soft tender uterus enlarged to 8 weeks' size. Both adnexa were normal. The cervix was long and closed yet motion tenderness was present. Laboratory results revealed a hemoglobin level of 10.3 g/dL, hematocrit 29.9%, a white blood cell count of 9.64 × 10 9 d/L and a platelet count of 227 × 10 9 d/L. Serum creatinine, blood urea nitrogen, electrolyte levels, prothrombin time and partial thromboplastin time were normal, and the serum betahuman chorionic gonadotropin (beta-hCG) level was 5651 mIU/mL. Transvaginal ultrasonography showed an acutely retroflexed uterus with a normal endometrial echo. Both adnexa were normal. No free fluid was noted in the cul-de-sac. A 5 × 5-cm, well circumscribed mass with a hypoechoic center was noted in the anterior aspect of the lower uterine segment (Figure 1). Color Doppler imaging
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