A 25 year old woman presents with vaginal spotting and right lower quadrant abdominal pain.There is minimal dark blood in the vaginal vault,and her cervix is closed and thick.Quantitative serum hCG is 4000 mIU/ml. A transvaginal ultrasound (TVUS) shows no evidence of pregnancy inside the uterus. What is the most likely diagnosis?
a. Hydatidiform mole
b. Ectopic pregnancy
c. Appendicitis
d. Endometriosis
Answer and explanation :
Correct answer : "b"(ectopic pregnancy)
Explanation : A gestational sac should be seen inside the uterus on a transvaginal ultrasound with a hCG level of 1500mIU/ml. If the pregnancy is not in the uterus investigation should be carried out for an ectopic pregnancy.
The pain in the appendicitis is severe with tenderness at the McBurney point, accompanied with fever and vomiting, hCG levels are not raised nor is there any associated vaginal bleeding.
In endometriosis, the pain is localised to the pelvis and radiates to the lower back and legs. Again hCG levels are not raised.
In hydatidiform mole the TVUS shows snowstorm appearance and vaginal bleeding is painless and there is a history of passing grape like vesicles. The beta hCG levels are markedly raised
In ectopic pregnancy, abdominal pain, dark vaginal bleeding and an empty uterus on TVUS is seen. The beta hCG levels reflect the duration of pregnancy. A level of 4000mIU/ml denotes 5-6 weeks from the LMP.
hCG overview :
1. hCG can be detected in maternal serum and urine.
2. It is a glycoprotein made by trophoblasts.
3. Composed of two subunits—α and β:
4. Function : Helps sustain the corpus luteum during the fi rst 7 weeks. After the first 7 weeks, the placenta makes its own hormones to sustain the pregnancy.
5. Can be detected in the maternal serum or urine 6–12 days after fertilization (3–3.5 weeks after the LMP).
a. Hydatidiform mole
b. Ectopic pregnancy
c. Appendicitis
d. Endometriosis
Answer and explanation :
Correct answer : "b"(ectopic pregnancy)
Explanation : A gestational sac should be seen inside the uterus on a transvaginal ultrasound with a hCG level of 1500mIU/ml. If the pregnancy is not in the uterus investigation should be carried out for an ectopic pregnancy.
The pain in the appendicitis is severe with tenderness at the McBurney point, accompanied with fever and vomiting, hCG levels are not raised nor is there any associated vaginal bleeding.
In endometriosis, the pain is localised to the pelvis and radiates to the lower back and legs. Again hCG levels are not raised.
In hydatidiform mole the TVUS shows snowstorm appearance and vaginal bleeding is painless and there is a history of passing grape like vesicles. The beta hCG levels are markedly raised
In ectopic pregnancy, abdominal pain, dark vaginal bleeding and an empty uterus on TVUS is seen. The beta hCG levels reflect the duration of pregnancy. A level of 4000mIU/ml denotes 5-6 weeks from the LMP.
hCG overview :
1. hCG can be detected in maternal serum and urine.
2. It is a glycoprotein made by trophoblasts.
3. Composed of two subunits—α and β:
- α subunit is similar in luteinizing hormone (LH), follicle-stimulating hormone (FSH), thyroid-stimulating hormone (TSH).
- β subunits are unique: Urine and serum tests are based on antibody specificity to β subunit of hCG.
4. Function : Helps sustain the corpus luteum during the fi rst 7 weeks. After the first 7 weeks, the placenta makes its own hormones to sustain the pregnancy.
5. Can be detected in the maternal serum or urine 6–12 days after fertilization (3–3.5 weeks after the LMP).
- ↑ by 66–100% every 48 hours prior to 10 weeks.
- In general, hCG should double every two days.
- Peaks at 10 weeks gestation.
- Nadirs at 14–16 weeks.
- Note : If β-hCG does not rise as expected, consider accidents of pregnancy: spontaneous abortion, missed abortion, ectopic pregnancy.
- Hydatidiform mole.
- Choriocarcinoma.
- Germ cell tumors.
- hCG produced by breast cancers and large cell carcinoma of the lung.
7. A gestational sac can be visualized with transvaginal ultrasound (TVUS) when hCG levels are >1500. If hCG is >1500 and no evidence of intrauterine pregnancy, think “ectopic pregnancy.”
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