What does a quantitative beta‑human chorionic gonadotropin level of 230 IU/L at 14 days past ovulation, one day before my expected period, indicate and how should I proceed?

β-hCG of 230 mIU/mL at 14 Days Post-Ovulation: Interpretation and Management

A β-hCG level of 230 mIU/mL at 14 days post-ovulation (DPO) is consistent with early viable intrauterine pregnancy, and you should obtain repeat quantitative β-hCG in exactly 48 hours to confirm appropriate doubling (≥53% rise), then schedule transvaginal ultrasound once levels reach 1,000–3,000 mIU/mL. 1

Understanding Your Current Result

Your β-hCG of 230 mIU/mL at 14 DPO falls within the expected range for early pregnancy, though individual variation is enormous at this stage. 1 At 14 DPO (equivalent to approximately 4 weeks gestational age by standard dating), β-hCG levels in viable pregnancies can range from as low as 50 mIU/mL to over 400 mIU/mL. 2, 3

• This level definitively confirms pregnancy, as any β-hCG >5 mIU/mL indicates pregnancy. 1
• A single measurement has extremely limited diagnostic value—it cannot distinguish between viable intrauterine pregnancy, early pregnancy loss, or ectopic pregnancy at this stage. 4
• The median β-hCG for viable intrauterine pregnancies at initial presentation is approximately 1,304 mIU/mL, for embryonic demise approximately 1,572 mIU/mL, and for ectopic pregnancy approximately 1,147 mIU/mL—demonstrating that single values overlap significantly. 4

Immediate Next Steps: Serial Monitoring Protocol

Obtain repeat quantitative serum β-hCG in exactly 48 hours (not 24 hours, not 72 hours, not one week). 4, 1 This 48-hour interval is the evidence-based standard for characterizing ectopic pregnancy risk and viable intrauterine pregnancy probability. 4

Interpreting the 48-Hour Result

β-hCG Change Over 48 Hours	Most Likely Diagnosis	Your Next Action
Increase ≥53% (to ≥352 mIU/mL)	Viable early intrauterine pregnancy	Schedule transvaginal ultrasound when β-hCG reaches 1,000–3,000 mIU/mL [1]
Increase 10–53%	Possible ectopic pregnancy or failing pregnancy	Obtain immediate gynecology consultation [1]
Plateau (<15% change)	Ectopic pregnancy or nonviable pregnancy	Obtain immediate gynecology consultation [1]
Decline	Failing pregnancy (spontaneous abortion or resolving ectopic)	Continue monitoring until β-hCG <5 mIU/mL [1]

• In viable intrauterine pregnancies, β-hCG should rise by at least 53% over 48 hours in early pregnancy. 5, 3
• Continue serial measurements every 48 hours until β-hCG rises to 1,000–1,500 mIU/mL, at which point ultrasound becomes diagnostically useful. 1

When to Perform Ultrasound

Do not perform transvaginal ultrasound at your current β-hCG level of 230 mIU/mL. 1 At levels below 1,500 mIU/mL, transvaginal ultrasound has only 33% sensitivity for detecting intrauterine pregnancy and 25% sensitivity for detecting ectopic pregnancy. 1

• Schedule transvaginal ultrasound when β-hCG reaches the discriminatory threshold of 1,000–3,000 mIU/mL. 1, 5
• At β-hCG ≥1,000 mIU/mL, a gestational sac should become visible on transvaginal ultrasound if an intrauterine pregnancy is present. 1
• The traditional threshold of 3,000 mIU/mL has virtually no diagnostic utility (positive likelihood ratio 0.8, negative likelihood ratio 1.1) for predicting ectopic pregnancy and should not delay imaging if clinical concern exists. 4

Critical Warning Signs Requiring Immediate Evaluation

Return immediately to the emergency department if you develop any of the following, regardless of your β-hCG level: 1

• Severe or worsening unilateral abdominal pain (suggests possible ectopic pregnancy)
• Shoulder pain (suggests hemoperitoneum from ruptured ectopic)
• Heavy vaginal bleeding (soaking one pad per hour)
• Dizziness, lightheadedness, or fainting (suggests hemodynamic instability)
• Any peritoneal signs (rebound tenderness, guarding)

Ectopic pregnancies can occur at any β-hCG level—approximately 22% of ectopic pregnancies present with β-hCG <1,000 mIU/mL. 4, 1 One documented case report describes a tubal ectopic pregnancy with an initially undetectable β-hCG level. 6

What to Expect in the Coming Days

If your β-hCG rises appropriately (≥53% over 48 hours), you likely have a viable early intrauterine pregnancy. 5, 3

• At 5 weeks gestational age (approximately 7 days from now), β-hCG typically reaches 1,000–3,000 mIU/mL, and a gestational sac becomes visible on transvaginal ultrasound. 1
• At 5½ weeks, a yolk sac should appear within the gestational sac—this is definitive evidence of intrauterine pregnancy. 1
• At 6 weeks, an embryo with cardiac activity should be visible. 1

Common Pitfalls to Avoid

• Do not rely on a single β-hCG value to exclude ectopic pregnancy—this is a Level B recommendation from the American College of Emergency Physicians. 4
• Do not defer ultrasound indefinitely based on "low" β-hCG—once levels reach 1,000–3,000 mIU/mL, imaging should be performed regardless of symptoms. 1
• Do not compare your β-hCG to population averages or online calculators—individual variation is enormous, and only the rate of rise over 48 hours matters. 4, 2
• Do not assume bleeding means pregnancy failure—approximately 36–69% of pregnancies of unknown location ultimately prove to be normal intrauterine pregnancies. 1

Special Considerations

If you conceived via assisted reproductive technology (donor insemination, IVF, etc.), the same monitoring principles apply. 5, 6 If you have risk factors for ectopic pregnancy (prior ectopic, pelvic inflammatory disease, IUD in place, prior tubal surgery), maintain heightened vigilance for warning signs even with reassuring β-hCG trends. 1