High Serum β-hCG Levels Research Articles

Rare Case of Caesarean Scar Pregnancy with Soaring β-hCG Levels: A Therapeutic Challenge

Caesarean Scar Pregnancy (CSP) is a life-threatening form of ectopic pregnancy characterised by abnormal implantation of embryo within the myometrium and fibrous tissues of a previous scar on the uterus. This is the case report of a 24-year-old pregnant lady who underwent previous caesarean section presented at eight weeks gestation with bleeding per-vaginum. Ultrasound of pelvis revealed an intrauterine gestational sac with a live foetus at the site of previous caesarean scar with very high levels of serum beta-human Chorionic Gonadotropin (β-hCG) of 88789 mIU/mL. To prevent surgical complications, a conservative approach was employed, involving injection methotrexate and uterine artery embolisation. Serial measurements of serum β-hCG and transvaginal sonography were used for monitoring. Treatment was successful and the β-hCG levels returned to normal on day 48. This case report highlights that conservative management is successful even with extremely high serum β-hCG levels, and an early recognition and timely intervention is the key to prevent poor outcomes.

Cesarean scar pregnancy: Reproductive outcome after robotic laparoscopic removal with simultaneous repair of the uterine defect

ObjectiveTo describe perioperative adverse events, fertility and obstetric outcome, following a robot assisted laparoscopic approach for treating Cesarean scar pregnancies (CSP). Study DesignA retrospective case series of 14 consecutive women with a CSP and a wish for and attempts towards subsequent pregnancies, having undergone minimal invasive surgical treatment at two tertiary referral Swedish centers (Dep’s of Obstetrics and Gynecology Skåne University Hospital, Lund, and Södersjukhuset, Stockholm) between 2008 and 2019. The surgery was performed by temporary intraoperative occlusion of the uterine blood supply, removal of the CSP and repair of the niche, by the use of robot assisted laparoscopy (Da Vinci surgical robot, Intuitive Surgical, Sunnyvale, CA). ResultsAll surgeries were uneventful with a median bleeding of 75 mL. One woman had a postoperative Clavien-Dindo complication grade IIIa (hysteroscopic resection of an isthmic synechiae). During follow up nine women (64 %) conceived naturally; eight of these had an uneventful pregnancy and a full-term Cesarean delivery and one had recurrent CSP and Cesarean with simultaneous hysterectomy in gestational week 33. ConclusionA robotic removal of a CSP with simultaneous repair of the defect is a feasible option with acceptable reproductive outcome and should be considered when counseling women with a wish for future childbirth in cases of a live CSP and a thin, or absent, myometrium in the niche. A temporary intraoperative occlusion of the uterine blood supply may be useful in cases of live pregnancies and/or high serum β-hCG levels.

Risk factors for massive hemorrhage during the treatment of cesarean scar pregnancy: a systematic review and meta-analysis.

Cesarean scar pregnancy (CSP) is one of the serious complications associated with cesarean delivery (CD). This meta-analysis aims to identify risk factors associated with massive hemorrhage during the CSP treatment. Eight electronic databases were searched for case-control studies published before December 31th, 2018, which compared the possible factors causing massive bleeding during the CSP treatment. Quantitative synthesis was performed by RevMan 5.3. Sensitivity analysis and publication bias were performed by Stata 12.0. Total 20 case - control studies including 3101 CSP patients with previous CD met the inclusion criteria. Bleeding group had 573 patients and the control group had 2528 patients. The risk factors for massive bleeding during CSP treatment included multiple gravidities (MD = 0.15, 95% CI 0.03-0.28, P = 0.73), big maximum diameter of gestation sac (MD = 18.49mm, 95%CI 15.34-21.65, P < 0.01), high gestational days (MD = 8.98days, 95% CI 4.12-13.84, P < 0.01), high β-HCG level (MD = 21.39IU/ml, 95% CI 7.36-35.41, P = 0.03; MD = 3.02U/ml, 95% CI 0.21-5.84, P < 0.01) and rich blood flow around the lesion (OR = 6.73, 95% CI 3.93-11.51, P = 0.59). While, thick myometrium (MD = - 4.94mm, 95% CI - 6.12 to - 3.75, P < 0.01) may be protective factor. Multiple gravidities, big gestation sac, large gestational days, high serum β-HCG level, abundant blood supply to pregnancy sac and thin myometrium maybe the risk factors for massive bleeding during the CSP treatment.

Medical Treatment in Cesarean Scar Pregnancy with Fetal Heart Activity and High Level of Serum β-hCG: A Case Report

Background : Cesarean scar pregnancy (CSP) is the implantation of the gestational sac in the hysterotomy scar. The optimal treatment for a cesarean scar pregnancy is unclear and therapy should be selected according to the patients' clinical presentation. The aim of this study was reporting a successful medical treatment of a cesarean scar pregnancy with fetal heart activity and a very high level of beta human chorionic gonadotropin (β-hCG). Case Presentation: A 38-year-old woman referred for routine prenatal visit after 2 months of menstrual retard and positive pregnancy test. She had the history of 3 cesarean sections and a uterine curettage. Untrasonography revealed cesarean scar ectopic pregnancy. The serum level of β-hCG was 109063 mIU/ml. Two doses of systemic methotrexate therapy and intragestational sac injection of methotrexate and potassium chloride were administered. 8 weeks after the initial treatment, β-hCG level became undetectable. Conclusion: Combined medical treatment with local and systemic MTX administration may be a successful treatment with low complication even in the presence of high serum β-hCG level.

High-intensity focused ultrasound combined procedures treatment of retained placenta accreta with marked vascularity after abortion or delivery

Objective: To evaluate the safety and feasibility of combined procedures: HIFU combined with systemic MTX followed by ultrasound-guided curettage or hysteroscopic resection while treating placenta accreta (PA).Method: This study included 21 patients diagnosed with retained PA with marked vascularity after abortion or delivery from July 2015 to December 2017. Patients with high serum β-hCG level (≥100 mIU/mL) received systemic MTX + HIFU treatment for 3 days and the ones with low β-hCG level (<100 mIU/mL) only received USgHIFU treatment for 3 days before ultrasound-guided curettage or hysteroscopic resection. All patients had completed follow-up data. The safety and feasibility of the treatment were evaluated retrospectively.Result: Sixteen patients received systemic 100 mg MTX without myelosuppression. All patients received three days of HIFU ablation therapy; the median of HIFU treatment time was 60 minutes. Ultrasound-guided curettage and ovum forceps were used to extract planted placental tissue in 5 patients with one week after birth or after abortion. Sixteen patients received a hysteroscopic operation after the HIFU treatment. The median of intraoperative blood loss was 30 ml. Twenty patients had recovered normal menstruation on average 32 days (range 14–60) after the operation.Conclusion: Based on the results of this study, with a relatively small number of patients, it seems that three-days’ therapy of HIFU ± systemic MTX followed by ultrasound-guided curettage or hysteroscopic resection, is a safe and feasible treatment for retained PA with marked vascularity after abortion or delivery.

Conservative management of interstitial pregnancies: experience of a single centre

The aim of this study was to compare the effect of local intracavitary methotrexate (MTX) injection and laparoscopic (L/S) cornuostomy in the treatment of interstitial pregnancy (IP) in terms of clinical and reproductive outcome. The data of patients with IP (n:10) who were treated between September 2011 and December 2016 with either an intra-amniotic MTX injection (n:7) or L/S cornuostomy (n:3) were retrospectively evaluated. All cases (7/7) in the local injection group and two (2/3) in the L/S group were successfully treated with the initial treatment. One case (1/3, 33%) in L/S group needed systemic MTX due to an elevated β-hCG. No serious complication or secondary surgical intervention was observed in the study group. Five (71.4%) women in MTX group and two (66%) women in the L/S group had pregnancy after index case (p > .05). Post-treatment (hysterosalpingography) HSG results revealed that tubal patency was significantly higher in the MTX group (7/7 (100%) vs. 0/3 (0%) p < .05). Conservative treatment of IP with both methods was generally successful with regard to maternal morbidity and reproductive function. However, local MTX was superior for tubal patency compared to L/S cornuostomy. Since this is a retrospective study including a small study population, our results should be confirmed with larger prospective studies.Impact StatementWhat is already known on this subject? Earlier diagnosis of an interstitial pregnancy (IP) enables clinicians to pursue more conservative treatment modalities that can prevent morbidity (severe bleeding, rupture and massive transfusion, etc.) and loss of fertility. MTX treatment and conservative laparoscopic surgical procedures are gaining importance. High serum β-hCG levels and positive foetal cardiac activity are known as unfavourable pre-treatment prognostic predictors for systemic MTX treatment in patients with an ectopic pregnancy. Local MTX treatment is widely used for caeserean scar pregnancies or cervical pregnancies. L/S cornuostomy is an attractive alternative to L/S cornual resection, because it preserves the normal uterine myometrium.What the results of this study add? In the present study, we showed that the local MTX and laparoscopic cornuostomy were successful methods in IP patients and did not impair the fertility potential of the patients. We also demonstrated that local MTX application is superior to L/S cornuostomy in terms of the post-treatment tubal patency and this fact should be kept in mind when tailoring the treatment in patients desiring pregnancy.What the implications are of these findings for clinical practice and/or further research? The value of local MTX injection in cases with IP and high β-hCG levels should be further clarified.

Gestational ovarian choriocarcinoma: A case report

Ovarian choriocarcinoma is an extremely rare trophoblastic disease of either gestational or non-gestational origin. It can arise due to metastasis from uterine choriocarcinoma or from an ovarian ectopic pregnancy. Here we present a case of gestational ovarian choriocarcinoma in a 27-year-old female clinically diagnosed as ectopic ovarian pregnancy. Histopathologically, the tumor showed characteristic features of choriocarcinoma. The presence of corpus luteum adjacent to the tumor, high serum β-HCG levels and reproductive age of the patient favored the diagnosis of gestational choriocarcinoma.

An unexpected invasive hydatidiform mole in a rudimentary uterine horn: A case report.

Rudimentary horns of the uterus develop as a result of a partial non-development of one Müllerian duct, a type of congenital uterine anomaly. Pregnancy in a rudimentary horn is uncommon and the outcome tends to be poor, with the majority of cases resulting in rupture between 10 and 15 gestational weeks, with significant risk of morbidity and mortality. Regardless of the availability of imagiological procedures and the advances being made in this field, the diagnosis of this type of ectopic pregnancy often only occurs during laparotomy or laparoscopy subsequent to abdominal pain and collapse. The present study describes a rare case of a uterine rudimentary horn pregnancy. The case was diagnosed by the high serum β-HCG level, imageological results and dissection of the final pathological specimen, by combined hysteroscopy and laparoscopy. An ultrasound illustrated a suspicious gestational trophoblastic disease in the rudimentary uterine horn, with a rich blood flow signal at the right side of the uterus. A pelvic magnetic resonance image indicated that there was endometrial thickening and gestational trophoblastic disease in the rudimentary uterine horn. The patient was treated with surgery, including rudimentary horn dissection and diagnostic curettage; the ipsilateral adnexa was conserved as it appeared to be normal. Due to the apparent decline of the serum β-HCG level and the reluctance for chemotherapy, the patient chose to undergo no further treatment and closed follow-up. At the time of writing, the patient is in a good condition. Only a small number of reports of a horn pregnancy with invasive hydatidiform mole are described by other studies, thereby increasing the clinical significance of this case.

Safety and Efficacy of Uterine Artery Embolization in Ectopic Pregnancies Refractory to Systemic Methotrexate Treatment: A Single-Center Study.

To investigate the use of uterine artery embolization (UAE) to manage ectopic pregnancies that are refractory to systemic methotrexate (MTX) therapy and plagued by persistently high serum β-human chorionic gonadotrophin (hCG) levels and vaginal bleeding. The safety and efficacy of UAE were addressed. A retrospective review was conducted for thirteen patients (mean age 35.2years; range 28-41years), who were treated between December 2006 and June 2016. Each was subjected to UAE due to persistently high serum β-hCG levels and vaginal bleeding after systemic MTX therapy for ectopic pregnancy. Embolic agents used were non-spherical polyvinyl alcohol or gelatin sponge particles. Post-treatment follow-up was performed by monitoring for clinical signs of vaginal bleeding, serum β-hCG testing, and transvaginal US. Outcomes were technical success, clinical success, and complications. Median follow-up period was 172.5days (range 30-600days). Technical success was achieved in all 13 patients (100%). In 10 patients, vaginal bleeding resolved after one UAE attempt (clinical success 76.0%). Rebleeding in other three (23.1%) was controlled through repeat UAE. Seven patients (53.8%) had additional dilatation and curettage to remove gestational sac remnants. All ectopic pregnancies were successfully treated by UAE, with normalization of serum β-hCG levels during follow-up monitoring (P=0.01). Uterine preservation was achieved in all 13 patients, without major procedural complications. UAE appears safe and effective as treatment of ectopic pregnancies marked by persistently high serum β-hCG levels and vaginal bleeding after systemic MTX treatment.

Uterine artery embolization combined with curettage vs. methotrexate plus curettage for cesarean scar pregnancy.

To compare the efficacy and safety of uterine artery embolization (UAE) combined with curettage and methotrexate (MTX) plus curettage in the treatment of cesarean scar pregnancy (CSP). From January 2005 to December 2013, we treated 38 CSP patients with UAE combined with curettage, and another 26 patients with CSP were treated with methotrexate (MTX) plus curettage. The resulting data were analyzed statistically. The median volume of blood loss was 17.5ml in the UAE combined with curettage (UAE-C) group vs. 335ml in the MTX plus curettage (MTX-C) group (p<0.001). The time from the procedure till β-human chorionic gonadotropin (β-hCG) concentration returned to normal was 25.13±3.74days in the UAE-C group vs. 56.15±15.99days in the MTX-C group (p<0.001). The duration of hospitalization was 7.44±1.92 vs. 19.38±8.75days, respectively (p<0.001). The percentage of side effects in the UAE-C group was significantly lower than in the MTX-C group. UAE combined with curettage appears to be superior to MTX plus curettage for treatment of CSP with high serum β-hCG level, though prospective trials are needed.

Trichosanthin benefits the treatment of caesarean scar pregnancies

This retrospective study aimed to assess the efficacy of trichosanthin (TCS) in combination with or without uterine arteries embolisation (UAE), uterine curettage and sac aspiration for the treatment of caesarean scar pregnancies (CSPs). We enrolled 200 patients at 4–17 weeks’ postmenstrual age with suspected CSP. CSP was diagnosed based on serum β-human chorionic gonadotropin (β-hCG) level and transvaginal ultrasound. The patients were divided into TCS group and non-TCS group, who were treated with TCS and methotrexate, respectively, in combination with UAE and uterine curettage. TCS treatment had a success rate of 96.1% (50 of 52), similar to that in non-TCS group (98.6%, 146/148). Serum β-hCG levels on days 3, 5 and 7 in TCS group were significantly decreased. The complications were fever and pain, which were alleviated with symptomatic treatment. At follow-up, all 52 patients except one case with hysterectomy from TCS treatment group had resumed normal menstruation. In conclusion, TCS combined with bilateral UAE and uterine curettage is a safe and effective treatment for CSP, especially in patients with dangerously high serum β-hCG levels.

Endocrine dysfunction in Taiwanese children with human chorionic gonadotropin-secreting germ cell tumors

Human chorionic gonadotropin (HCG)-secreting germ cell tumors (GCTs) are rare childhood malignancies with unique clinical manifestations but delayed diagnosis is common. The purpose of this study is to investigate the clinical manifestations and endocrine dysfunction of Taiwanese children with HCG-secreting GCTs. From 1991 to 2011, 24 children (19 boys and five girls) with HCG-secreting GCTs were evaluated for their clinical findings and endocrine functions. The mean age at diagnosis of the study patients was 10.8±3.1 years. Of the 24 patients, 20 had central nervous system (CNS) GCTs and four had primary mediastinal GCTs (PMGCTs). The most common pathologic findings were germinomas and mixed type GCTs. The common initial symptoms and signs included polyuria, polydipsia, rapid growth, neurologic deficit,sexual precocity, and growth retardation. There was a delay in diagnosis in about 60% of patients. Diabetes insipidus and hypopituitarism were common endocrine dysfunctions in patients with CNSGCTs. Twelve boys had gonadotropin-independent puberty upon diagnosis, which were related to their high serum β-hCG levels. None of the five girls had this disorder despite their high serum β-hCG levels. Three of the four PMGCTs patients had the classic form of Klinefelter syndrome. Taiwanese children with HCG-secreting GCTs often have clinical manifestations related to endocrine dysfunction. High index of suspicion is important to avoid delayed diagnosis in these children.

Pregnancy of Unknown Location: A Case Report and Review of the Literature

We present a case of pregnancy of unknown location with high serum βhcg levels. This case posed a diagnostic difficulty in the management of pregnancy of unknown location. The patient underwent two laparoscopic procedures to establish the diagnosis. The case highlights the importance of close surveillance of patients who present with pregnancy of unknown location.