Ruptured Ectopic Pregnancy with Minimally Detectable Beta-HCG Level

Abstract

Background: Several studies have demonstrated that 25- 77% of ectopic pregnancies spontaneously resolve with expectant management. Expectant management has been recommended by some authors in order to increase possible future tubal patency. However, this is controversial and should only be considered in patients with small, unruptured gestational sacs, very low beta-HCG levels, and an absence of symptoms. There is no consensus how long to follow such patients. Objective: We report two patients with beta- HCG levels below 10 mIU/mL who presented with ruptured ectopic pregnancy and hemoperitoneum. Materials and Methods: Case report Result: A 31-year-old female infertility patient presented at 7 weeks estimated gestational age with inappropriately rising HCG level and no intrauterine pregnancy. No products of conception were identified on dilation and curettage; however, serial HCG levels revealed rapidly declining beta-HCG level. Three weeks later, she presented with sudden onset of severe abdominal pain, peritoneal signs and hemoperitoneum. Beta- HCG level was 6 mIU/mL. At laparotomy, right ruptured ectopic pregnancy was treated with salpingostomy. A 32-year-old female presented at 6 weeks estimated gestational age with HCG level below the discriminatory zone. Serial HCG levels revealed declining HCG level. Three weeks later she presented with abdominal pain, peritoneal signs and hemoperitoneum. Beta-HCG level was 5 mIU/mL. At laparoscopy, left ruptured ectopic pregnancy was treated with salpingostomy. Conclusion: While expectant management of suspected ectopic pregnancy may allow spontaneous resolution of ectopic pregnancy, rupture may occur at any time and even with extremely low beta-HCG levels. Patients need to be counseled about the risks of rupture and symptoms, immediate action should be taken if symptoms develop, and beta-HCG levels should be followed to zero.