Vol. 56, No.4, October 1991

FERTILITY AND STERILITY

Printed on acid-free paper in U.S.A.

Copyright 1991 The American Fertility Society

Rupture of ectopic pregnancy in women with low and declining serum P-human chorionic gonadotropin concentrations

Togas Tulandi, M.D.* Robert Hemmings, M.D. Fahd Khalifa, M.D.t Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada

Early diagnosis of ectopic pregnancy has allowed conservative management of ectopic pregnancy (EP) without removing the tube. 1- 3 It appears that preserving the tube increased the chance of subsequent intrauterine pregnancies and live births. Recently, more conservative approaches have been advocated, including expectant management. 1- 3 It is usually assumed that resolution of EP is indicated by the decline in serum ,8-human chorionic gonadotropin (,8-hCG) levels. We hereby report rupture of tubal EP in two women whose ,8-hCG levels were low and declining. CASE REPORTS Case 1

A 30-year-old woman, with a last menstrual period (LMP) of November 2, 1990, was seen on December 7, 1990, with pregnancy symptoms (amenorrhea, breast tenderness, and fatigue). Serum ,8-hCG level was 380 miU/mL. Past history revealed a right tubal EP in 1989, which was treated conservatively by laparoscopy. Transvaginal ultrasound (US) examination on December 11, 1989, revealed an empty uterus and a recurrent EP with a 2.9 em gestational sac in the right fallopian tube. A dead embryo (crown-rump length: 1.2 em) was found inside the

Received February 25, 1991; revised and accepted June 20, 1991. * Reprint requests: Togas Tulandi, M.D., Department of Obstetrics and Gynecology, McGill University, Women's Pavilion, 687 Pine Avenue West, Montreal, Quebec, Canada H3A 1Al. t Fellow of Reproductive Surgery from The Embassy of The Kingdom of Saudi Arabia, Educational Mission, Jeddah, Saudi Arabia.

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sac. Serum ,8-hCG level was 212 miU/mL. Because of absence of abdominal pain and because of the decline in serum ,8- hCG levels, the patient was managed expectantly. Subsequent serum ,8-hCG levels were 203 miU /mL on December 14; 175 miU /mL on December 17; 109 miU/mL on December 20, 1990, and 41 miU/mL on January 2, 1991. Transvaginal US on January 2, 1991, revealed similar findings as previously. On January 4, 1991, the patient presented with severe abdominal pain, fainting episodes, vaginal bleeding, tachycardia, and hypotension. An emergency laparotomy was performed. A ruptured isthmic tubal pregnancy and 500 mL of hemoperitoneum were found. Partial salpingectomy was then performed. Histopathological examination revealed a ruptured isthmic EP. The largest diameter of the tube was 5 em, and it was filled mainly by blood clots with a fetus inside. Serum ,8-hCG level before surgery was 10 miU /mL. Case2

A 30-year-old woman with LMP of November 17, 1988, presented to the emergency room with acute abdomen on January 23, 1989. Ultrasound examination revealed an empty uterus and a complex, cystic adnexal mass of 5 em. Serum ,8-hCG level was 64 miU/mL. History of present illness revealed a positive pregnancy test and minimal vaginal bleeding on January 12, 1989. Serum ,8-hCG levels were 118 miU/mL on January 13,1989, and 103 miU/mL on January 16, 1989. Her past history was unremarkable. Emergency laparotomy was then performed. A ruptured left ampullary pregnancy and 800 mL of hemoperitoneum were found. A total salpingectomy was then performed. Histopathological Fertility and Sterility

examination of the removed tube confirmed the diagnosis of ruptured ampullary pregnancy. Serum concentrations of ,8-hCG were measured by a commercially available radioimmunoassay kit (Amerlex-M, Oakville, Ontario, Canada), and the results were expressed as international milliunits of Second International Standard of hCG/mL of serum. The interassay variation for ,8-hCG was 6.4%.

DISCUSSION

Rupture of tubal pregnancy in a patient whose serum ,8-hCG was declining from 5,620 miU/mL was previously reported. 4 Transvaginal US was not done, and the diagnosis of EP was not entertained until rupture occurred. A similar observation was found in case 2. However, serum ,8-hCG levels in this patient were much lower. Case 1 was diagnosed as an EP, but because of the absence of abdominal pain and because of the declining serum ,8-hCG levels, we decided to treat her expectantly. Serum ,8-hCG levels were also low. These findings suggest that despite low serum ,8-hCG levels, tubal distention and rupture can still occur. Indeed, in women with EP who were treated with transvaginal methotrexate administration, we also found that despite declining serum ,8-hCG levels, the tube in the majority of cases became distended before it gradually decreased in diameter. 5 In those cases, decrease of blood flow to the region of EP was observed by transvaginal Doppler US and no rupture was encountered. Doppler US was not done in these two patients. It is still not clear if one can predict rupture by this technique. Histopathological study of EP has demonstrated that hemorrhage into the wall and lumen of the tube causes more of the distortion of tubal anatomy than the products of conception.6 This might explain the tubal distention and rupture in spite of falling serum ,8-hCG levels. Previous reports of women with presumed diagnosis of EP whose serum ,8-hCG levels were declining suggest that in the absence of abdominal pain,

Vol. 56, No.4, October 1991

expectant management can be done without any complication. 1- 3 Fernandez et al. 2 found that the high probability of spontaneous resolution is high when serum ,8-hCG at diagnosis is

Rupture of ectopic pregnancy in women with low and declining serum beta-human chorionic gonadotropin concentrations.

Rupture of tubal EP in two women whose serum beta-hCG levels were low and declining was reported. It suggests that low and falling serum beta-hCG leve...
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