Re: Would love to have your medical opinions on this
From: Larry Glazerman (l.glazerman@rcn.com)
Wed Apr 16 22:04:53 2008
I've never routinely done an hCG after D&C/D&E for any pregnancy loss,
UNLESS there's some reason - persistent bleeding after the procedure,
concern for choriocarcinoma, etc, or if she had a mole.
--
Larry R. Glazerman, MD, FACOG
St. Luke's Center for Advanced Gynecologic Care
250 Cetronia Road
Suite 305
Allentown PA 18104
484-223-3279
484-223-2830 FAX
glazerl@slhn.org
On Apr 16, 2008, at 10:55 PM, GIN11153@aol.com wrote:
> it's a little long but I really would like to know the standards of
> care around the US and world for my learning experience:
>
> This was posted on a list for nurses in response to someone's
> question about a patient-my replies to an OB/GYN friend of mine are
> in parenthesis :
>
> "In the case you posted, the patient had a Missed Abortion. If a
> fetal heart beat was not detected on an ultrasound, and the fetus
> measured 6 weeks smaller than her dates, it sounds like it definitely
> was a missed abortion. The fetus has died and there is no need to do
> an ultrasound in the outpatient setting before the D & C. Even after
> a D & C, the Beta HCG levels can take up to 4 weeks to drop down to
> pre-pregnancy levels. Most women can expect their levels to return to
> a non-pregnant range about 4 weeks after the D & C. It also depends
> on how high the levels were when the loss occurred. At 13 weeks, the
> Beta HCG level could have been as high as 250,000 mlU/ml. The doctor
> should have had her levels checked after the D & C weekly or bi-
> weekly until the level returned to at or below 5."
>
> (I don't agree with her last sentence-I personally have had 2 D&Cs
> for a miscarriage and I have never heard in 34 years of working in
> OB of a doctor drawing weekly or biweekly HCG levels after a D&C for
> a missed AB. )
>
> My OB/GYN friend emailed this reply to me:
>
> It is not standard of care to check B-HCG levels after a
> miscarriage. Certainly not after an operative procedure.
>
> I sent that to this gal and she send this absurd reply, as if to say
> that this 'association' is 'authorative":
>
> Gail, Thanks for your email, but I respectfully disagree. I live in
> CT and I have worked in OB/GYN for 21 of my 24 years as a nurse. My
> most recent job was as Nursing Supervisor at a large 8 physician OB/
> GYN practice (one of the largest in the state). Our physicians
> always followed a miscarriage with at least one Beta HCG to be sure
> that the levels were back to 5 or below. We actually had a patient
> who had had a D &C and was found to still be pregnant.
>
> The paragraph below is from the American Pregnancy Association
>
> What can I expect of my hCG levels after a pregnancy loss?
> Most women can expect their levels to return to a non-pregnant range
> about 4 - 6 weeks after a pregnancy loss has occurred. This can
> differentiate by how the loss occurred (spontaneous miscarriage, D &
> C procedure, abortion, natural delivery) and how high the levels
> were at the time of the loss. Health care providers usually will
> continue to test hCG levels after a pregnancy loss to ensure they
> return back to <5.0
>
> I emailed her back to say that no blood test can differentiate an
> abortion at 8 weeks vs a spontaneous loss at 8 weeks, etc. I also
> asked my OB friend if it was possible and he said:
>
> The short answer is no.
>
> Typically, I will do an Ultrasound after the miscarriage to verify
> that the uterus is empty, but there is no need to draw a B-HCG
> unless you gave methotrexate, or the patient has persistent
> bleeding more than a month after the procedure.
> PS. I have never heard of the American Pregnancy Association
> Her final reply tonight that I am not planning to respond to was
> this where she's now totally contradicting her own statements:
>
> I was not going to reply until I realized that you misunderstood
> what the website said. The sentence that you quoted "this can
> differentiate by how the loss occurred...." is NOT stating that the
> blood test can determine how the loss occurred. If you read closely
> what it says, it is saying that the blood RESULTS can differentiate
> BY how the loss occurred. Obviously a blood test cannot tell how a
> pregnancy loss occurred. That's absurd. It is saying that the HCG
> levels can differentiate depending on how the loss occurred. I know
> that the doctors that I worked for order follow up HCG tests. I
> posted my answer according to my experience, not according to that
> website. I just happened to find that website so I attached a quote
> from it. I regret that part of my email to you. Can you show me
> where there is proof of the standard of care in this instance,
> except from your expert MD. I consider the 8 OB/GYN's that I worked
> for experts also.
> I am willing to admit if I am wrong. But please show me where to
> confirm the standard of care in this situation, other than one
> doctor that you know.
> *sigh* Advice please??? No names will be used but I know she's wrong
> and I don't see this on the ACOG website to send her.
>
> Gail.
>
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