Routine maternal ABO/Rhesus D blood typing can alert of massive foetomaternal haemorrhage.

BACKGROUND AND OBJECTIVES: Spontaneous massive foetomaternal haemorrhage (SM-FMH) is a rare yet critical condition that poses substantial risk to foetal health and survival. Existing data indicate that many cases may be undiagnosed. The current study aimed to investigate and validate the utility of identifying mixed field red blood cell (RBC) agglutination during maternal blood typing as a diagnostic aid for SM-FMH. MATERIALS AND METHODS: Retrospective analysis of medical records from neonates born at our tertiary, university-affiliated medical centre between 2016 and 2023 was performed. Diagnosis of SM-FMH was based on neonates born with severe anaemia (haematocrit [HCT] <15%) within the first 24 h post-delivery with positive maternal Kleihauer-Betke (KB) test. Maternal ABO/Rhesus D (RhD) blood typing results were scrutinized with the primary objective of assessing the ability to identify dual RBC populations in cases clinically diagnosed with SM-FMH. RESULTS: Among 29,192 neonates studied, a mere 0.02% (5 cases) exhibited severe SM-FMH. Notably, a mixed field RBC agglutination was discerned in 80% (4/5) of these cases. CONCLUSION: This study underscores the significance of detecting mixed field RBC agglutination during antepartum maternal ABO/RhD blood typing as a potential indicator for SM-FMH. Increased awareness among blood bank technology specialists and obstetricians regarding these laboratory findings could prove instrumental in saving foetal lives.

Mothers' Knowledge of Infants' Fever Management: A National Prospective Study.

OBJECTIVES: The aim of this study was to describe mothers' knowledge of infant fever management after birth and six months later and its association with sociodemographic characteristics, perceived support, sources of consultation and health education; and to assess determinants of change in mother's knowledge from birth to six months. METHODS: Mothers (n = 2804) answered a self-reporting questionnaire after giving birth in maternity wards in six hospitals in Israel; six months later follow- up interviews were conducted by telephone. RESULTS: The mothers' knowledge level of infant fever management was low after birth (mean = 50.5, range 0-100, SD = 16.1), and rose to a moderate level six months later (mean = 65.2, SD = 15.0). Mothers having their first born, with lower household income or education were less knowledgeable about infant fever management after birth. However, these mothers showed the largest improvement after six months. Mothers' perceived support or sources of consultation and health education (partner, family, friends, nurses, and physicians) were not associated with their knowledge at either time. Moreover, mothers stated self-learning from internet and other media as often as receiving health education by health professionals. CONCLUSIONS FOR PRACTICE: Public health policy for health professionals in hospitals and community clinics is essential to promote clinical interventions promoting mothers' knowledge of infant fever management. Efforts should focus at first time mothers, those with non-academic education, and those with a moderate or low household income. Public health policy enhancing communication with mothers regarding fever management in hospitals and community health settings, as well as accessible means of self-learning is warranted.

Intrapartum Atosiban Treatment During Tachysystole and Non-reassuring Fetal Monitoring: A Retrospective Cohort Study.

BACKGROUND: Uterine tachysystole during labor can lead to a decrease in fetal oxygen saturation and intracerebral oxygen saturation. Acute tocolysis using atosiban can inhibit uterine smooth muscle activity, potentially improving fetal status and facilitating vaginal delivery or allowing time to prepare for operative delivery. OBJECTIVES: To compare maternal and neonatal outcomes in cesarean and vaginal deliveries following atosiban administration during fetal prolonged deceleration and tachysystole at gestational age 37 0/7 to 43 0/7 weeks. METHODS: We conducted a single-center, descriptive retrospective cohort study at a large tertiary referral center. RESULTS: Of the 275 patients treated with atosiban, 186 (68%) delivered vaginally (either spontaneous delivery or instrumental delivery) and 89 (32%) underwent a cesarean delivery. In a univariate analysis, cesarean delivery was associated with higher body mass index (27.9 ± 4.3 vs. 30.2 ± 4.8, P = 0.003). Second stage atosiban administration was associated with vaginal delivery (89.3% vs. 10.7%, P = 0.01). Cesarean delivery was associated with lower Apgar at 1 and 5 minutes and a higher rate of neonatal intensive care unit admissions. The incidence of PPH among women treated with atosiban in our study (2.3-4.3%) was higher than the incidence reported in the literature (1-3%). CONCLUSIONS: Atosiban may be an effective acute intervention for non-reassuring fetal heart rate during tachysystole, increasing the rate of vaginal delivery and potentially reducing the need for cesarean delivery. However, the potential risk of postpartum hemorrhage should be taken into consideration.

[PHYSICAL ACTIVITY DURING PREGNANCY AND AFTER BIRTH].

INTRODUCTION: Physical activity (PA) decreases morbidity, improves quality of life and elongates life span. PA during pregnancy is safe and decreases complications. Physical inactivity during pregnancy is an independent risk factor for maternal weight gain and complications. Pregnancy is a golden opportunity to promote a healthy lifestyle. OBJECTIVES: This article aims to review the latest recommendations regarding PA in pregnancy. In this article we focused on the following: The joint guidelines of the Society of Obstetricians and Gynaecologists of Canada's (SOGC) and the Canadian Society for Exercise Physiology (CSEP), the American College of Obstetricians and Gynecologists (ACOG) committee opinion, and the ACSM's (American College of Sports Medicine) Guidelines for Exercise Testing and Prescription, the 11th Edition published in 2019, 2020 and 2022 respectively. CONCLUSIONS: PA during pregnancy is safe and essential. Every pregnant woman without contraindications should perform 150 weekly minutes of aerobic exercise and resistance training. DISCUSSION: A weekly goal of 150 medium intensity aerobic exercise minutes spread over at least 3 separate days combined with resistance training is recommended for every pregnant woman, including women who were inactive prior to the pregnancy, those diagnosed with gestational diabetes and overweight or obese women. Pregnant women with absolute contraindication can continue to perform their daily activities but avoid more intense activities, those with relative contraindications should discuss the advantages and risks of PA with their attending physician. After birth, women can return to PA gradually depending on the mode of delivery and complications encountered.

Prenatal exposure to heavy metal mixtures and anthropometric birth outcomes: a cross-sectional study.

BACKGROUND: Numerous studies have suggested significant associations between prenatal exposure to heavy metals and newborn anthropometric measures. However, little is known about the effect of various heavy metal mixtures at relatively low concentrations. Hence, this study aimed to investigate associations between prenatal exposures to a wide range of individual heavy metals and heavy metal mixtures with anthropometric measures of newborns. METHODS: We recruited 975 mother-term infant pairs from two major hospitals in Israel. Associations between eight heavy metals (arsenic, cadmium, chromium, mercury, nickel, lead, selenium, and thallium) detected in maternal urine samples on the day of delivery with weight, length, and head circumference at birth were estimated using linear and Bayesian kernel machine regression (BKMR) models. RESULTS: Most heavy metals examined in our study were observed in lower concentrations than in other studies, except for selenium. In the linear as well as the BKMR models, birth weight and length were negatively associated with levels of chromium. Birth weight was found to be negatively associated with thallium and positively associated with nickel. CONCLUSION: By using a large sample size and advanced statistical models, we could examine the association between prenatal exposure to metals in relatively low concentrations and anthropometric measures of newborns. Chromium was suggested to be the most influential metal in the mixture, and its associations with birth weight and length were found negative. Head circumference was neither associated with any of the metals, yet the levels of metals detected in our sample were relatively low. The suggested associations should be further investigated and could shed light on complex biochemical processes involved in intrauterine fetal development.

Antenatal betamethasone and the risk of neonatal hypoglycemia: it's all about timing.

INTRODUCTION: Our objective was to evaluate whether there is a relationship between the "time during the day" of maternal betamethasone administration between 24 and 34 weeks' gestation and the risk for neonatal hypoglycemia. MATERIAL AND METHODS: A retrospective study included cases between 2008 and 2018. Eligible cases were pregnant women with singleton pregnancies who received a single course of betamethasone between 24 and 34 weeks' gestation. Each woman was allocated into one of four pre-defined groups based on the time when intramuscular betamethasone was administered. Group 1 (23:00-04:59) represents the lowest daily natural corticosteroids' activity, group 2 (05:00-10:59) represents the peak daily natural corticosteroids' activity, whereas group 3 (11:00-16:59) and group 4 (17:00-22:59) present an intermediate natural state of steady corticosteroids' secretion and activity. The primary outcome of the study was the incidence of neonatal hypoglycemia (glucose level of less than 40 mg/dL). RESULTS: We have identified 868 women who received a single complete course of betamethasone, of which 353 women (40.7%) had a steroid treatment latency to delivery up to 14 days. The incidence of neonatal hypoglycemia was significantly higher in group 2 (39.5%, 30/76, p = 0.0063), compared to group 1, who had the lowest incidence of neonatal hypoglycemia (16.9%, 12/71), and to group 3 and group 4. CONCLUSIONS: The "time during the day" when betamethasone administered is important when considering the risk for neonatal hypoglycemia. The risk was significantly higher when betamethasone was administered during the peak time and significantly lower when administered at the nadir time of maternal endogenous corticosteroid activity.

Intrauterine bacterial growth in elective and non-elective caesarean sections.

We assessed intrauterine bacterial growth for elective and non-elective caesarean sections (CSs). Aerobic uterine cultures were obtained from the uterine cavity immediately following placental removal from 1376 patients who underwent CS in one center during one year. About 13.8% (115/832) of elective CS were positive vs. 55.9% (304/544) of non-elective CS (p < .001). Of non-elective CSs, 28.6% (56/196) of those without ruptured membranes (ROM) were positive vs. 71.3% (248/348) with ROM (p < .001). Mean birth weight and 1-minute Apgar scores were significantly lower in women with positive cultures, elective and non-elective, than negative cultures. A higher percentage of women with positive uterine cultures presented with postpartum endometritis (p < .05). Intrauterine bacteria in elective CSs demonstrate that the uterine cavity is not sterile. Non-elective CS, particularly after membrane rupture, is a significant risk factor for positive uterine culture. Positive uterine culture is associated with lower birth weight, lower one-minute Apgar score and postpartum endometritis.Impact statementWhat is already known on this subject? Postpartum endometritis is a leading cause of postpartum febrile morbidity. Caesarean sections, in particular non-elective cesareans, are an important risk factor for the development of postpartum endometritis. Controversy exists concerning the sterility of the placenta and uterus. The diagnosis of endometritis is based mainly on clinical findings and does not necessitate bacterial isolation from the uterine cavity. Positive culture at caesarean section has been associated with positive postoperative culture and yet, currently, professional organisations do not recommend the routine sampling of intrauterine cultures during caesarean section.What do the results of this study add? Since positive uterine culture rate was higher in non-elective CSs and associated with lower birth weight and 1-minute Apgar score and postoperative endometritis, obtaining uterine culture in those cases might be of clinical value.What are the implications of these findings for clinical practice and/or further research? Obtaining routine intrauterine cultures during non-elective caesarean sections might be useful for detecting significant pathogens and tailoring antibiotic treatment in postpartum endometritis. Further studies are necessary in order to determine the impact of obtaining intrauterine cultures during caesarean sections, particularly non-elective cesareans.

Incidence of congenital thoracic malformations detected by prenatal ultrasound.

BACKGROUND: The increased and earlier use of prenatal ultrasound has facilitated the detection of congenital thoracic malformations (CTMs). Our Pediatric Pulmonology Institute follows an increasing number of patients with CTMs. Thus, we aimed to evaluate and describe prenatal sonographic findings of CTM, and to estimate changes in detection rates of CTMs over a period of 16 years. METHODS: A retrospective, cross-section analysis of prenatal ultrasound (US) screening tests carried out in a large community-based clinic, comparing two periods: 2001-2007 and 2007-2017. RESULTS: A total of 34 716 prenatal US were performed at a median gestational age of 15.4 weeks (range, 11.6-23.9) and 15.7 weeks (range, 12-33.6) in 2001-2007 and 2007-2017, respectively. In 2001-2007, 12 016 prenatal US tests detected 19 CTMs, compared to 30 CTMs in 22 700 tests in 2007-2017. Detection rates did not change (1.58/1,000 in 2001-2007 versus 1.32/1,000 in 2007-2017, P = 0.64). The most common abnormality was congenital pleural effusion (CPE) (17 cases, 34.7%), followed by congenital pulmonary airway malformation) and congenital diaphragmatic hernia; 13 cases each, 26.5%. Twenty CTMs, mainly congenital diaphragmatic hernia and CPE, were associated with other fetal lesions. CONCLUSIONS: Congenital diaphragmatic hernia and CPE tend to appear with multiple lesions and warrant further attention. The incidence rates stayed stable when comparing the last decade to previous years. Thus, the increased referral of CTM can be attributed to an increase in the number of prenatal screening studies performed, rather than a true higher incidence.

Lockdown with a Price: The impact of the COVID-19 Pandemic on Prenatal Care and Perinatal Outcomes in a Tertiary Care Center.

BACKGROUND: The World Health Organization classified coronavirus disease-19 (COVID-19) as a pandemic and recommends strict restrictions regarding most aspects of daily activities. OBJECTIVES: To evaluate whether the pandemic has changed the prenatal care and pregnancy outcome in pregnant women without COVID-19. METHODS: The authors conducted a cross-sectional study to describe changes in outpatient clinic visits and to compare the rates of cesarean and instrumental deliveries between two periods of time: March-April 2020 (during the COVID-19 outbreak) with March-April of the preceding year, 2019. RESULTS: During the COVID-19 outbreak, visits to obstetric triage, gynecologic triage, high-risk clinic, and ultrasound units decreased by 36.4%, 34.7%, 32.8%, and 18.1%, respectively. The medical center experienced a 17.8% drop in the total number of births (610 births) compared with March and April 2019 (742 births). During the outbreak women were more likely to be nulliparous (33.3% vs. 27.6%, P = 0.02) and present with hypertensive disorders during pregnancy (7.5% vs. 4%, P = 0.005) or gestational diabetes (13% vs. 10%, P = 0.03). More epidural analgesia was used (83.1% vs. 77.1%, P = 0.006). There were more operative vaginal deliveries during the outbreak (16.7% vs. 6.8%, P = 0.01). All other maternal and neonatal outcomes were comparable between the two periods. CONCLUSIONS: The medical facility experienced a major decline in all aspects of the routine obstetrics activities during the time of the pandemic. The higher rate of operative vaginal deliveries among nulliparous may be associated with the pandemic effect on the rate of high-risk patients.

The Possibility of Transmitting Infections with Vaginal Ultrasound Probes: Why We Cannot Meet the Guidelines.

BACKGROUND: The use of ultrasound endovaginal probes is common practice in the fields of gynecology and obstetrics. The vagina serves as a host environment for many microorganisms, contributing greatly to its defensive mechanisms. It is not known whether the introduction of other microorganisms into the vaginal region are detrimental or require intensive preventative measures. Several national ultrasonography societies, as well as the Israel Ministry of Health, have addressed the proper and adequate handling of sonographic endovaginal probes, including the use of high-level disinfecting agents following cleansing and prior to using probe covers between patients. However, many obstetrics and gynecology ultrasound units in Israel find it difficult to adhere to these strict disinfecting requirements. While most of the guidelines are based on the theoretical risk of contaminations when ultrasound endovaginal probes are used, the rate of nosocomial infections linked to the use of these probes has yet to be verified. Based on the information available, there is an urgent need to find a solution that enables gynecological ultrasound users to properly disinfect endovaginal probes between patients. Currently, it is almost impossible to pragmatically adhere to the Israel Ministry of Health guidelines.

[IS IT APPROPRIATE TO CHANGE THE NAMES OF SURGICAL PROCEDURES AND EXAMINATIONS IN THE FIELD OF OBSTETRICS AND GYNECOLOGY WHICH GIVE EPONYMS DISTINCTION TO NAZI DOCTORS?]

INTRODUCTION: The majority of the German medical institutions and nearly half of the clinicians during the Nazi regime provided unwavering support to the distorted Nazi views on health and disability. Leading physicians were an integral part of the atrocities carried out during that era, with some of them having a vital role in executing the ideology of the "final solution". The names of Carl Clauberg and Walter Stoeckel, two notable doctors in the fields of obstetrics and gynecology, were also linked with the third Reich. Both of these physicians, collaborated, each in his own way, with the Nazi regime, which tainted their legacy indefinitely. The two received professional honor for their contribution to the fields of obstetrics and gynecology, which were unrelated to their Nazi past, after their names were linked in the form of eponyms to surgical procedures and examinations, which they developed. In recent years, as a consequence of their disturbing past, there are increasing arguments which call for erasing their eponyms from the medical lexicon. We, on the contrary, believe that the opposite is true and that maintaining these eponyms will actually enable teaching future generations and serve a dual educational role to both highlight professional and scientific achievements as well as serve as a mark of Cain and warning that professional achievements do not prevent ethical decline. Preserving the name will provide an educational opportunity to teach about the responsibilities that come with professional leadership, which these doctors abused carelessly, in order to prevent history from repeating itself.

Achieving the Recommended Gestational Weight Gain in High-Risk Versus Low-Risk Pregnancies.

BACKGROUND: Abnormal gestational weight gain (GWG) has been associated with adverse outcomes for mothers and their offspring. OBJECTIVES: To compare the achievement of recommended GWG and lifestyle factors in women with high-risk versus normal-risk pregnancies. METHODS: Pregnant women hospitalized in a gynecological and obstetrics department and pregnant women who arrived at a community clinic for a routine checkup were interviewed and completed questionnaires relating to weight gain and lifestyle factors (e.g., smoking, diet, exercise). Recommended GWG was defined by the American Congress of Obstetricians and Gynecologists (ACOG). RESULTS: GWG higher than ACOG recommendations was reported by 52/92 women (57%) with normal pregnancies and by 43/86 (50%) with high-risk pregnancies. On univariate analysis, characteristics associated with greater GWG were: current or past smoking, age > 40 years, pre-gestational body mass index (BMI) > 25 kg/m2, low fruit intake, and high snack intake. High-risk pregnancies were associated with pre-gestational BMI > 25 kg/m2 (48% vs. 27%, P = 0.012), consumption of vitamins (84% vs. 63%, P = 0.001), avoidance of certain foods (54% vs. 21%, P = 0.015), receiving professional nutritionist consultation (65% vs. 11%, P = 0.001), and less physical activity (9% vs. 24%, P = 0.01). CONCLUSIONS: A minority of pregnant women met the recommended GWG. No difference was noted between normal and high-risk pregnancies. High-risk population tended to have a less healthy lifestyle. Counseling to follow a healthy, balanced diet should be recommended, regardless of pregnancy risk, with particular attention to women at high risk of extra weight gain.

The History of the Low Transverse Cesarean Section: The Pivotal Role of Munro Kerr.

BACKGROUND: Cesarean section has undergone a transformation that has radically changed the prognosis of both the pregnant woman and her unborn child. The attributed mortality rate of Cesarean section during the 19th century was over 50% worldwide. Today, mortality from Cesarean delivery is rare. However, the technique of transversely incising the uterus in its lower uterine segment, although less than a century old, is passed on from instructor to apprentice, often without either of them being aware of its noble history. In this brief review, we discuss the reported history regarding this incision and the significant role played by John Munro Kerr.

[INTERVENTIONS FOR SUPPORTING WOMEN TO STOP SMOKING IN PREGNANCY].

INTRODUCTION: Smoking during pregnancy is a public health problem because of the many adverse effects associated with it. These include intrauterine growth restriction, placenta previa, abruptio placentae, decreased maternal thyroid function, preterm premature rupture of membranes, low birth weight, perinatal mortality, and ectopic pregnancy. An estimated 5-8% of pre-term deliveries, 13-19% of term deliveries of infants with low birth weight, 23-34% cases of sudden infant death syndrome (SIDS), and 5-7% of preterm-related infant deaths can be attributed to prenatal maternal smoking. The risks of smoking during pregnancy extend beyond pregnancy-related complications. Children born to mothers who smoke during pregnancy are at an increased risk of asthma, infantile colic, and childhood obesity. Cigarette smoking and tobacco use during pregnancy have been associated with adverse pregnancy outcomes, including spontaneous pregnancy loss, placental abruption, preterm delivery and low birth weight. In addition, smoking during pregnancy impacts fetal and neonatal development, increase infections rate and is associated with an increased risk for long term pediatric cardiovascular morbidity of the offspring. Identifying maternal tobacco product use allows for targeted interventions. Cessation of tobacco use and prevention of secondhand smoke exposure are key clinical intervention strategies during pregnancy and are recommended by obstetrical guidelines. Inquiry into tobacco use and smoke exposure should be a routine part of the prenatal visit and clinicians should provide pregnancy-tailored counseling for those who smoke. National guidelines from Australia, the UK, New Zealand and Canada recommend the use of nicotine replacement therapy (NRT) by pregnant women who have been unable to quit smoking without medication. According to the American College of Obstetrics and Gynecology, nicotine replacement therapy use in pregnancy has not been sufficiently evaluated to determine safety or efficacy and should only be used under supervision, after a risk benefit analysis. The aim of this review is to provide an overview of current guidelines regarding NRT use in pregnancy, considering the existing evidence base on safety, efficacy and effectiveness.

Gestational Weight Gain and Its Relationship with Maternal Characteristics.

BACKGROUND: Both high and insufficient weight gain during pregnancy have been associated with adverse outcomes for mothers and their offspring. OBJECTIVES: To describe self-reported weight gain during pregnancy, assess the concurrence of this weight gain with issued recommendations, and investigate associations between lifestyle factors and weight gain. METHODS: In this cross-sectional study, 109 pregnant women hospitalized in one gynecological and obstetrics department completed questionnaires related to weight gain and lifestyle factors such as smoking, diet and exercise. Recommended weight gain was defined by the American Congress of Obstetricians and Gynecologists and was compatible with the Ministry of Health guidelines in Israel. RESULTS: Fifty-three (49%) participants reported weight gain above the recommendation, 31 (28%) met the recommendations and 25 (23%) reported weight gain below the recommendations. Characteristics associated with high weight gain included past smoking and/or age above 36 years and/or body mass index (BMI) above 25 kg/m2. Only 34 women (31%) reported seeking professional nutritional counseling during pregnancy. An increased tendency to consult a nutritionist was reported among diabetic women. CONCLUSIONS: Only a minority of women gained the recommended weight during pregnancy. High BMI and/or a history of smoking and/or older age were associated with weight gain above recommendations. Particular effort should be directed toward counseling women at high risk of weight gain during pregnancy.

Detection Rate and Sonographic Signs of Trisomy 21 Fetuses at 14-17 Weeks of Gestation.

BACKGROUND: Early prenatal ultrasound is an important part of prenatal screening in Israel. No studies have described the rate of trisomy 21 [T21] identification at 14-17 weeks gestation. OBJECTIVES: To describe the rate of T21 identification by transvaginal sonograms (TVS) at 14-17 weeks gestation. METHODS: We conducted a historical prospective study. Since 1986, early TVS of 72,000 fetuses at 14-17 weeks gestation have been prospectively recorded together with prenatal screening data at a private ultrasound center (AL-KOL, Haifa). We calculated the fraction of T21 cases by dividing the total number of cases with abnormal sonographic findings by the total number of diagnosed T21 cases. We also examined the percentage of verified T21 cases that had completely normal prenatal screening tests prior to the early prenatal TVS, thus revealing the contribution of this examination to the existing prenatal screening. Fisher's exact test was used to calculate odds ratios for each sonographic marker. RESULTS: Of 137 T21 fetuses, 123 had sonographic markers on early TVS, yielding a prediction capability of at least 89.87%. Of all T21 cases, 14% had completely normal nuchal translucency/first-trimester screening prior to the abnormal 14-17 week TVS findings. Isolated abnormal sonographic findings, which were found to increase the risk for T21, were common atrioventricular septal canal (odds ratio 88.88), duodenal atresia (OR 88.23), nuchal edema (OR 39.14), and hydrocephalus (OR 15.78). Fetal hydronephrosis/pyelectasis was non-significant when isolated (OR 1), and cardiac echogenic focus was associated with a decreased risk (OR 0.13). CONCLUSIONS: Early prenatal TVS at 14-17 weeks may identify almost 90% of T21 and adds 14% to the identification rate at the first-trimester screening.

[FALSE POSITIVE Β-HCG MIGHT LEAD TO UNNECESSARY LIFE THREATENING INTERVENTIONS].

INTRODUCTION: False positive beta-human Chorionic Gonadotropin (hCG) results can lead to unnecessary life-threatening interventions. This article describes two clinical cases of false positive beta-hCG results that lead to unnecessary treatments. In one case the erroneous and unnecessary treatment caused a life-threatening complication. In cases where there is no correlation between the clinical manifestations, imaging and laboratory tests, and there is a suspicion of false positive beta-hCG result, there is a need to repeat the urine and blood beta-hCG analysis, if possible using a different assay method. These tests will raise the possibility of a correct indication for a false positive beta-hCG, thus avoiding unnecessary treatments and their complications.