Low-serum bhCG EPs are common, and this is the weakness of the protocol described above. Simply assuming that a patient has a very early IUP because of a low serum bhCG level can be a major mistake. All patients need to have transvaginal sonography, even if they have a very low serum bhCG level. About 50 percent of symptomatic patients with an EP have a quantitative serum bhCG level below the discriminatory zone. In fact EPs with serum bhCG levels < 100 mIU/mL have been reported. EPs with low serum bhCG levels may rupture and cause bleeding just like other EPs.16 Patients with low serum bhCG and significant risk factors or findings suggestive of EP should be closely observed. (See Chapter100 for a detailed discussion of risk factors.) Those with low serum bhCG and no risk factors or evidence of EP may be sent home with close follow-up in 24 to 48 h. Pelvic sonography and quantitative serum bhCG are repeated on follow-up. During a normal early pregnancy, the serum bhCG will double about every 2 days. Abnormal pregnancies, ectopic or intrauterine, have a prolonged doubling time. 17
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