Minimally invasive surgery is not always the best option … and more

The concept is misleading or misunderstood by some community providers, who commonly administer methotrexate when the hCG level is 2,000 mIU/mL or higher and no intrauterine pregnancy is visible on ultrasonography (US). This practice could interrupt a normal intrauterine pregnancy and should be discouraged.

In his response to other letters on the subject (see the April 2012 installment of “Comment & Controversy” at obgmanagement.com), Dr. Kaunitz mentioned Europe, where this practice is uncommon. I might add that most European countries have an early pregnancy unit that assesses the patient and follows her until the issue of a pregnancy “of unknown location” is resolved. We need to develop a similar approach in the United States and stop relying so heavily on the discriminatory zone.

Sebhat Afework, MD
Los Angeles, California

No more “medicine by the numbers”

As a mother as well as a clinician, I would agree that we should do away with “medicine by the numbers.”

I was informed that my third pregnancy was an incomplete abortion, based on the hCG level and a preliminary US showing a shadow “where the sac was attached—but now it’s gone” (or so I was told). I had been taking an oral contraceptive, so I had no idea of the correct date of my last menstrual period. After the US, my OB scheduled a dilatation and curettage for the next morning. However, because I was scheduled to work in a busy labor and delivery unit for the next 3 days, and because I was stable, with no pain and minimal bleeding (spotting), I asked to postpone the procedure until the following week. The next week, I requested another US, which revealed a gestational sac and fetal pole—a healthy pregnancy.

I understand the worry about women who could have an ectopic pregnancy or incomplete abortion and become unstable and trigger a lawsuit, but with good counseling, we could prevent the unwitting termination of a potentially normal pregnancy.

Traci Corder, MSN, RN, WHNP-BC
Dallas, Texas

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