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Progesterone measurements increase the sensitivity of the algorithm by inexpensively screening large numbers of patients during the first trimester of pregnancy. The corpus luteum itself and hemoperitoneum secondary to it can lead to a false-positive diagnosis of ectopic pregnancy.

The definitive diagnosis is made by transvaginal ultrasound or uterine curettage and does not depend on the serum progesterone concentrations obtained during screening. 7) A large percentage of the time, identification of an ectopic adnexal mass is based on the findings of a tubal ring or complex adnexal mass (Fig. In addition, the clinician should be aware that very small ectopic pregnancies identified on ultrasound may be difficult to identify laparoscopically.

In fact, certification of residency programs requires documentation of adequate exposure to and training in the evaluation of first-trimester ultrasound.


The literature regarding the correlation between quantitative β-h CG titers and early intrauterine gestational sacs and embryonic structures has been made somewhat confusing by the array of reference standards used to quantify β-h CG.

Suffice it to say that the Third International Standard used by most companies marketing β-h CG kits corresponds roughly to the First International Reference Preparation.

Failure to check serial titers can result in improper administration of methotrexate to patients with healthy pregnancies.

Litigation has occurred in cases where methotrexate was inadvertently given to patients subsequently found to have an early intrauterine pregnancy.

With a transvaginal probe, a 3- to 4-mm gestational sac can usually be seen by 5 weeks from the last menstrual period (Fig. A yolk sac or small fetal pole is usually seen by 6 menstrual weeks, when the mean diameter of the sac has reached 10 mm.

As shown by Fossum and colleagues, the appearance of these structures can be correlated with β-human chorionic gonadotropin β-h CG) levels (Table 2).

The risk of a persistent adnexal mass during pregnancy subsequently diagnosed as malignant has probably been overestimated: it is significantly less than 1%. Their data suggested that the risk of spontaneous abortion increased in proportion to an increase in the size of the subchorionic bleeds; however, a larger sample size was needed to determine statistical significance.

found that a subchorionic bleed (identified on ultrasound) is associated with an increased risk of miscarriage, stillbirth, abruptio placentae, and preterm labor (Fig. Bradycardic fetal heart rates, small sac size, abnormal yolk sacs (Fig.

Consultation with specialists should be obtained if an adnexal mass persists into the second trimester.

The two most common benign neoplasms of the ovary during pregnancy are serous cystadenoma and benign cystic teratoma.

Any patient with a history of ectopic pregnancy, tubal ligation or tubal surgery, or pelvic inflammatory disease should undergo TVS by 6 weeks from the last menstrual period (LMP).

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