What are the next steps for a pregnancy with a low quantitative beta human chorionic gonadotropin (beta hCG) level of 13, drawn 22 days after ovulation?

From the Guidelines

For a pregnancy with a low beta hCG level of 13 at 22 days post-ovulation, the next steps should include repeat beta hCG testing in 48-72 hours to assess if levels are appropriately rising, as recommended by the most recent guidelines 1. A normal early pregnancy should show a significant increase in beta hCG every 48 hours.

• The patient's low beta hCG level is concerning, as typical levels at this stage range from 200-7,000 mIU/mL.
• The patient should be monitored for signs of ectopic pregnancy, including abdominal pain, vaginal bleeding, or shoulder pain, which would require immediate medical attention 1.
• Serial monitoring is essential to distinguish between the possibilities of very early pregnancy, impending miscarriage, ectopic pregnancy, or incorrect dating of ovulation, and to determine appropriate management 1. Some key points to consider:
• Ectopic pregnancy can present at almost any b-hCG level, high or low, and rupture has been documented at very low b-hCG levels 1.
• The b-hCG value should not be used to exclude the diagnosis of ectopic pregnancy in patients who have an indeterminate ultrasound 1.
• Progesterone supplementation is not routinely recommended at this point without additional clinical information.
• An early transvaginal ultrasound should be scheduled when beta hCG reaches 1,500-2,000 mIU/mL to confirm intrauterine pregnancy, as per the latest recommendations 1.

From the Research

Next Steps for Low Quantitative Beta hCG Level

• A quantitative beta hCG level of 13, drawn 22 days after ovulation, is considered low 2, 3.
• The next steps for a pregnancy with a low quantitative beta hCG level may include:
  • Serial ultrasonography to monitor the pregnancy and check for any signs of ectopic pregnancy 2, 4.
  • Serial beta hCG levels to monitor the trend of the hormone and determine if it is rising or falling 2, 5.
  • Uterine aspiration to check for any products of conception in the uterus 2.
• It is essential to consider the possibility of an ectopic pregnancy, especially if the patient presents with vaginal bleeding or lower abdominal pain 2, 3.
• The patient's medical history, including any previous ectopic pregnancies, pelvic inflammatory disease, or infertility, should be taken into account when determining the next steps 2, 3.

Ectopic Pregnancy Diagnosis and Management

• Ectopic pregnancy is a life-threatening condition that requires prompt diagnosis and treatment 2, 3.
• The definitive diagnosis of ectopic pregnancy can be made with ultrasound visualization of a yolk sac and/or embryo in the adnexa 2.
• Treatment options for ectopic pregnancy include medical management with intramuscular methotrexate, surgical management via salpingostomy or salpingectomy, and expectant management 2, 3, 6.
• The choice of treatment depends on various factors, including the patient's symptoms, beta hCG levels, and ultrasound findings 2, 3, 5.

Importance of Serial Beta hCG Levels

• Serial beta hCG levels are crucial in monitoring the trend of the hormone and determining if it is rising or falling 2, 5.
• A low beta hCG level, such as 13, may indicate a non-viable pregnancy or an ectopic pregnancy 2, 4.
• The trend of the beta hCG levels, rather than a single value, is more important in determining the next steps for a pregnancy with a low quantitative beta hCG level 2, 5.