I wholeheartedly agree with Dr. Barbieri: There is virtually no role to administer methotrexate based on a single hCG determination in a hemodynamically stable patient.
Steven R. Goldstein, MD
New York, New York
References
1. Doubilet PM, Benson CB, Bourne T, Blaivas M; Society of Radiologists in Ultrasound Multispecialty Panel on Early First Trimester Diagnosis of Miscarriage and Exclusion of a Viable Intrauterine Pregnancy. Diagnostic criteria for nonviable pregnancy early in the first trimester. N Engl J Med. 2013;369(15):1443–1451.
2. Abaid LN, As-Sanie S, Wolfe HM. Relationship between crown-rump length and early detection of cardiac activity. J Reprod Med. 2007;52(5):375–378.
3. Frates MC, Doubilet PM, Peters HE, Benson CR. Adnexal sonographic findings in ectopic pregnancy and their correlation with tubal rupture and human chorionic gonadotropin levels. J Ultrasound Med. 2014;33(4):697–703.
4. Goldstein SR, Snyder JR, Watson C, Danon M. Very early pregnancy detection with endovaginal ultrasound. Obstet Gynecol. 1988;72(2):200–204.
Dr. Namaky, Dr. Hernandez, Dr. Hull, and Dr. Goldstein provide great clinical advice for readers. I agree with Dr. Namaky that the mainstays of managing a pregnancy of unknown location in a stable patient are clinical assessment and ultrasonography. Dr. Hernandez recommends using the serum progesterone measurement to help guide clinical decisions in a pregnancy of unknown location. I also use serum progesterone in my practice because a very low progesterone level helps the patient to understand that she has a failed pregnancy, and facilitates her acceptance of timely intervention. Many of my colleagues do not use progesterone measurement because they prefer to rely on clinical assessment, serial hCG measurement, and ultrasound results to guide their treatment. I agree with Dr. Hull that serial hCG measurements are most useful when the same laboratory performs all the tests. Dr. Goldstein, a world class expert in the evaluation and management of early pregnancy problems, provides great advice for all readers on how to best integrate ultrasonography in their practices to optimize patient care.
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