A viable caesarean scar pregnancy in a woman using a levonorgestrel-releasing intrauterine device: a case report.

BACKGROUND: Although the levonorgestrel-releasing intrauterine device (LNG-IUD) is one of the most reliable methods of contraception, it is associated with an increased risk of ectopic pregnancy in case of unintended pregnancy. A rare form of ectopic pregnancy is the caesarean scar pregnancy (CSP), with a high risk of serious maternal morbidity, such as uterine rupture, massive haemorrhage and resulting infertility. This report describes the first case of a viable CSP at 13 weeks of gestation in association with the use of a LNG-IUD. Case-presentation: A 36-year-old Caucasian woman was referred to our outpatient clinic because of suspicion of a CSP. The pregnancy was unintended and was diagnosed during replacement of the LNG-IUD after five years. The patient had undergone two caesarean sections in the past. Ultrasound investigation showed an intact pregnancy of approximately 13 weeks of gestation located in the uterine scar. Because of the size of the gestational sac, a laparotomy was performed under general anaesthesia using a Joel-Cohen incision. The procedure was complicated by a total blood loss of 1500 mL, mostly caused by diffuse bleeding from the placental bed. CONCLUSION: Unintended pregnancies in women using a LNG-IUD are frequently ectopic pregnancies with a preponderance to nidate outside the fallopian tube. Therefore, early diagnosis and location of the pregnancy in women using a LNG-IUD is essential.

A case of consistent discrepancies between urine and blood human chorionic gonadotropin measurements.

BACKGROUND: Our laboratory was confronted with two successive urine samples from a single patient which tested positive for human chorionic gonadotropin (hCG) when tested with both qualitative and quantitative assays, combined with no detectable hCG in corresponding plasma samples. METHODS: Serial dilution and recovery experiments were performed in order to investigate the presence of interfering substances or a high-dose hook effect. The ovarian cysts that were removed from this patient were immunohistochemically stained using polyclonal anti-human hCG antibodies. Furthermore, a urine sample was sent to the USA hCG Reference Service for hCG variant analysis. RESULTS: Dilution and recovery experiments in urine and plasma samples were unremarkable. The biopsy stained negative for human hCG and free ß-subunit. hCG isoform analysis in the urine sample revealed that approximately 87.5% of the immunoreactive hCG lacked the ß-subunit C-terminal peptide (CTP). CONCLUSIONS: We report a rare case in which two successive urine samples test positive for hCG whereas in corresponding plasma samples hCG is undetectable. The majority of the total hCG contained a degraded form of ß-subunit that lacks the CTP. This hCG variant, possibly of pituitary origin, is thought to have an extreme fast clearance rate possibly explaining the discordance between the hCG results in urine and plasma samples.