Ectopic pregnancy until proven otherwise even with a negative serum hCG test: A case report.

Ectopic pregnancy is commonly considered in the differential diagnosis for first-trimester vaginal bleeding and acute abdominal pain in women of reproductive age. Negative human chorionic gonadotropin (hCG) tests have been considered the gold standard to rule out this life-threatening diagnosis and appropriately rising hCG levels are thought to exclude it as well. In the unique case reported here, pathology confirmed ectopic pregnancy is identified in the setting of a negative serum hCG test. The patient was a 23-year-old woman (with one living child and one earlier miscarriage) who presented to the emergency department (ED) with sudden onset of abdominal pain, vaginal bleeding and syncope. She was tachycardic but normotensive and had both a negative serum hCG test and a negative urine hCG test. Imaging demonstrated a hemoperitoneum and right adnexal mass. She was taken for emergency exploratory surgery. The right fallopian tube had a tubal mass consistent with an ectopic pregnancy as well as 500 mL of blood. Pathology confirmed the ectopic pregnancy. A literature review revealed only two prior documented cases of pathology-confirmed ectopic pregnancy in the setting of a negative serum hCG test. The patient had experienced an abortion two months earlier without a documented intrauterine pregnancy. Her hCG levels were followed to <5 mIU/mL and she had not yet had return of menses at the time of her presentation. Perhaps a chronic ectopic could explain this unusual case. This case highlights that an ectopic pregnancy should never be excluded from the differential diagnosis in a woman of reproductive age.

Postcesarean delivery adhesions associated with delayed delivery of infant.

OBJECTIVE: The purpose of this study was to estimate the incidence of adhesions after cesarean deliveries and to determine their impact on delivery and infant well-being. STUDY DESIGN: This was a retrospective cohort analysis with chart review. The charts of 542 women who had undergone primary (265 women) or repeat cesarean (277 women) deliveries were reviewed. The incidence, severity, and locations of adhesions; delivery time; cord blood pH, and Apgar scores were noted. RESULTS: After the first cesarean delivery, 100 of 217 women (46%) had pelvic adhesive disease; 48 of 64 women (75%) who underwent a third cesarean delivery and 5 of 6 women (83%) who underwent a fourth cesarean delivery had formed pelvic adhesive disease. Compared with primary cesarean section, delivery of the infant was delayed 5.6 minutes (52%) with 1 previous cesarean birth, 8.5 minutes (79%) after 2 cesarean birth, and 18.1 (169%) during the fourth cesarean birth (P < 0.001 for all comparisons). CONCLUSION: A high percentage of cesarean deliveries result in adhesive disease, which delays repeat cesarean delivery of the fetus. The potential for adhesive disease should be included in counseling regarding primary elective cesarean births.