Re: Ectopic questions (Long)
From: Harvey S. Marchbein, M.D. (anonymous@obgyn.net)
Sun, 30 Jul 2000 09:44:15 -0500 (CDT)
Long? Half of this would have been long. :-)
At Sat, 29 Jul 2000, geo_gal wrote:
>
>I am a 35 y.o. mother of one. I found out I was pregnant June 20th,
>after my expected period began with only light brown spotting (which
>lasted for almost 2 weeks). My BhCG levels were 379 on June 26 and 463
>on June 28. I went to the ER on June 26, because I was spotting, knew I
>was pregnant and awoke around 2 a.m. with strong pain just above my
>pubic bone. I was assessed by a triage nurse and shown into a room
>where I waited for 2 hours, alone. Not ONE person came to check in on
>me. The pain subsided somewhat and I felt that if no one at the
>hospital was concerned, perhaps I shouldn't be. So, I got dressed and
>went to tell a nurse I was leaving. It was a seemingly quiet night,
>only one patient visible in the ER, a sleeping elderly woman. I found
>the nurses chatting at the station. I didn't have to sign a release and
>I left to go home and get some sleep. I had an appointment at 7 a.m.
>with my doctor (a family practitioner). She felt I didn't have any
>predisposing factors for EP, and sent me for the 2 serial hCGs. I began
>to bleed (heavier than my normal mp) on July 6 and the bleeding ended
>July 13. It resumed on July 17th, and I went to the ER again. There, I
>had a repeat hCG (690) and an US and TV US. The ER doc told my husband
>and I that he suspected EP and called gyn for consult. Gyn came in
>short time later, and said something was detected in left fallopian tube
>(complex mass?). Gave option of D&C and laparoscopy that day (actually,
>as he was the ONLY ob/gyn in our community of 46,000, he said he could
>get to my surgery at around 2 a.m.). I asked what other options I might
>have. He said methotrexate was one. I asked him, based on the history
>of this situation, was there a hurry? He said no, I could get my hCG
>levels checked a couple more times and then see him with the results. My
>BhCG on July 19 was 586 and on July 21 was 405. Bleeding stopped on
>July 21. I have no symptoms of the pregnancy any more (no breast
>tenderness, no nausea, etc.). I saw the ob/gyn on July 24, where he did
>an internal to check for any tenderness. There was none. He said my
>pelvis was "clinically normal". I have not had any pelvic pain since
>June 26 episode (which seemed to be relieved after passing gas).
>However, he said that my hCG levels were still high, and that chorionic
>villi must still be producing hCG. I wondered how my levels could be
>dropping steadily, but I supposedly have villi that are still producing
>hCG?
To be honest, my spider senses are tingling (refer to Spiderman comics
if your'e not familiar withthe term). The HCG level was going up at an
inadequate rate and dropping at an equally inadequate rate. This is an
ectopic until proved otherwise. Especially witht he pain in June and
the sono with a complex tubal mass. If you were lucky, you may have had
a tubal abortion but this needs to be followed up seriously and find out
why the HCG is still present and not dropping like a rock.
> I asked him how this could be and he did not have an answer. He
>said he wanted to see my hCG levels declining by 50% every 48 hours. Why
>would he be comfortable with this, when any methotrexate protocol I have
>seen accepts a 15% decline weekly?
You'll have to ask him/
>When I asked him this, he said "Good
>question" and did not have an answer. Also, when I pressed him for a
>description of what was seen on US, he said the resolution is not that
>clear (ie. as to size and location of mass supposedly seen on July 17
>ER visit). He then went on to tell me that he had a patient who had an
>EP which ruptured with an hCG of 32.
I have a friend who had one at 34.
>Not to alarm me, he said, but just
>so that I know. I told him that I am not comfortable with the idea of
>the methotrexate therapy for a multitude of reasons. I would rather
>face surgery. I am still breastfeeding my son, and am not ready to stop
>that relationship (and neither is he). I know that "expectant
>management" of EP is rare. But, it seems to me that my body is taking
>care of this on its own. But, how does one know for sure?
Unless it's zero, one doesn't.
> It seems that
>they don't. I have been very stressed for the past 7.5 weeks, since the
>pregnancy began. With my first pregnancy, I had no such abnormalities
>or complications. No spotting, etc. So, we ended the appointment with
>him telling me that he will have my hCG tested once more (that happened
>July 28) and, if he is not comfortable with the level, he wants to do
>something. I asked him what value would he be comfortable with, and he
>evaded answering by saying, "We'll see on Monday". So, I have an
>appointment to see him July 31 and discuss the result. If he is not
>happy with it, he wants to do the D&C and laparoscopy/laparotomy. If I
>still want to wait, he will no longer see me, as I will be out of his
>"comfort zone". I am confused! I feel very unclear about how I should
>know what is the right decision.
This is frequently difficult, especially here on the internet. Since
ectopics are potentially life threatening, safety should alway be the
first consideration. That's how I decide.
>Wait some more, or opt for surgical
>management. How can I know if it is safe to wait? Is there no way of
>knowing?
Now you got it! Everyone accepts or rejects that which they feel
comfortabel or uncomfortable with. Just as you have the right to see
another doctor in another town, the doctor has the right to let you know
where his comfort level is as well., right or wrong.
>I have read that rupture can occur when hCG levels are below
>50. What I am wondering, in those women who had a rupture with an hCG
>below 50, did they have any other clinical indicators?
Some.
>Pelvic pain?
At some point, most do.
>Progesterone level?
Usually low.
>Creatine kinase level?
Not familiar with this for ectopics BWDIK?
>Adnexal mass resolved on TV
>US?
At 32, it frequently is resolved sonographically.
>Anything else to indicate that a rupture might be imminent? I wish I
>could talk to another doctor, but I don't know if I would hear anything
>different from him/her. I understand that the doctor would be much more
>comfortable doing something with me, because he would then have handled
>the potential problem. But, how do I know if "doing something" is
>necessary, or warranted? I am beginning to feel backed into a
>corner-with no way out but some intervention. Strangely, before the
>birth of my son, I probably wouldn't have asked so many questions. Now,
>I worry a lot more about things. I want to be around to watch him grow
>up. I am so bummed out by this whole thing and just wish it would be
>resolved-or, that I would have a definite answer. Right now, the best
>guess is that I have an EP. No one seems to know for sure. He also
>mentioned that there is a danger of the uterus involuting over retained
>placental materials and forming a pre-malignancy. Sure does scare me! I
>guess I am also wondering that will an hCG value of <5 be the value that
>means no intervention is necessary? Has anyone studied how hCG values
>decline in cases managed expectantly? I know that ultimately I will have
>to place my trust in this doctor, but, I need to be sure in my own mind
>that I am making the choice only after knowing all the facts. I am just
>concerned that this doc seems evasive at times, when I ask for details
>about the findings so far. Does anyone have any suggestions that might
>help ease my mind? He has also not suggested that it could be anything
>else but an EP, are there any other possibilities, based on the
>information I have shared with you? Thank you very much, in advance, for
>any thoughts/expertise shared.
>
>Sincerely,
>
>Lisa
Sounds like you need a flesh and blood second opinion. This is the
place for info to help with basic problems. You need a second opinion
to help you decide a potentially life threatening decision.
Good luck.
--
Harvey S. Marchbein, M.D. FACOG, FACS
Great Neck, New York
**Note: Opinions expressed here are for educational purposes only
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