Question

A 30-year-old G3P2 woman, whose last normal menstrual period was eight weeks ago, began spotting three days ago and developed cramping this morning. She has a history of a chlamydia infection with a previous pregnancy. She smokes one pack of cigarettes per day and denies alcohol or drug use. On physical exam: blood pressure 120/70; pulse 82; respirations 20; and temperature 98.6°F (37.0°C). Abdominal examination is normal. Pelvic examination reveals old blood in the vaginal vault, closed cervix without lesions, slightly enlarged uterus and no adnexal tenderness. Pertinent labs: Quantitative Beta-hCG is 1000 mIU/ml; urinalysis normal; hematocrit = 32. What is the most appropriate next step in management?

1) Treat with methotrexate
2) Exploratory surgery
3) Repeat Beta-hCG in 48 hours
4) Repeat Beta-hCG in one week
5) Admit the patient to the hospital for observation

Answer 1

The most appropriate management is to repeat Beta-hCG in 48 hours to assess the viability of the pregnancy and rule out complications like an ectopic pregnancy.

Step-by-step explanation:

The most appropriate next step in the management of a 30-year-old woman presenting with spotting and cramping, who has a quantitative Beta-hCG of 1000 mIU/ml and no significant findings on physical examination, would be to repeat Beta-hCG in 48 hours. This approach helps to determine the viability of the pregnancy by assessing the rate of change of the hormone levels.

An increasing Beta-hCG level is typically associated with a viable intrauterine pregnancy, while decreasing levels may indicate a nonviable pregnancy, such as a miscarriage, or an ectopic pregnancy. Given her history, it is important to rule out an ectopic pregnancy, as her prior chlamydia infection could increase the risk of tubal scarring and ectopic implantation. Moreover, as this case lacks signs of acute abdomen, hemodynamic instability, or severe pain, there is no immediate indication for exploratory surgery, methotrexate treatment, or hospitalization at this time. Future management will depend on the outcome of the follow-up Beta-hCG test.