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A 30-year old woman has irregular menses. She reports that her last menstrual period (LMP) was 8 weeks ago. She has been experiencing vaginal spotting and left lower quadrant pain. She is afebrile. She has a normal size uterus and mild tenderness in the right lower quadrant with no rebound tenderness. A human chorionic gonadotropin (hCG) beta-subunit level of 1400 mIU/ml is reported in her records from an obstetrics visit 2 days ago. Which of the following is the appropriate management?

A. Perform a pelvis ultrasound
B. Perform a culdocentesis
C. Repeat hCG measurement in 1 week
D. Repeat hCG measurement in 24 hours
E. Refer for diagnostic laparoscopy

A. Perform a pelvis ultrasound

A. Perform a pelvis ultrasound

The correct answer is D. This patient has irregular menses and an associated low hCG level. She may have a normal intrauterine gestation, with an associated corpus luteum cyst causing the left lower quadrant pain, a threatened abortion or an ectopic pregnancy. It is recommended to repeat the hCG assay in 24 hours to see if it is rising appropriately.

A pelvis ultrasound (choice A) would not be helpful in detecting the gestational sac since its sensitivity begins at 1500 mIU/ml for a vaginal ultrasound.

Culdocentesis (choice B) is an invasive procedure to be used after more information is obtained.

Repeating hCG in 1 week (choice C) may miss an ectopic pregnancy leading to tubal rupture and hemorrhage.

Diagnostic laparoscopy (choice E) would be too invasive an option at this time.

ahhh yes irregular menses

thx :-))