First Trimester Bleeding

MARK DEUTCHMAN, MD, University of Colorado Denver School of Medicine, Aurora, Colorado
AMY TANNER TUBAY, MD, and DAVID K. TUROK, MD, MPH, University of Utah School of Medicine, Salt Lake City, Utah

Vaginal bleeding in the first trimester occurs in about one fourth of pregnancies. About one half of those who bleed
will miscarry. Guarded reassurance and watchful waiting are appropriate if fetal heart sounds are detected, if the
patient is medically stable, and if there is no adnexal mass or clinical sign of intraperitoneal bleeding. Discriminatory
criteria using transvaginal ultrasonography and beta subunit of human chorionic gonadotropin testing aid in dis-
tinguishing among the many conditions of first trimester bleeding. Possible causes of bleeding include subchorionic
hemorrhage, embryonic demise, anembryonic pregnancy, incomplete abortion, ectopic pregnancy, and gestational
trophoblastic disease. When beta subunit of human chorionic gonadotropin reaches levels of 1,500 to 2,000 mIU per
mL (1,500 to 2,000 IU per L), a normal pregnancy should exhibit a gestational sac by transvaginal ultrasonography.
When the gestational sac is greater than 10 mm in diameter, a yolk sac must be present. A live embryo must exhibit
cardiac activity when the crown-rump length is greater than 5 mm. In a normal pregnancy, beta subunit of human
chorionic gonadotropin levels increase by 80 percent every 48 hours. The absence of any normal discriminatory
findings is consistent with early pregnancy failure, but does not distinguish between ectopic pregnancy and failed
intrauterine pregnancy. The presence of an adnexal mass or free pelvic fluid represents ectopic pregnancy until
proven otherwise. Medical management with misoprostol is highly effective for early intrauterine pregnancy failure
with the exception of gestational trophoblastic disease, which must be surgically evacuated. Expectant treatment is
effective for many patients with incomplete abortion. Medical management with methotrexate is highly effective for
properly selected patients with ectopic pregnancy. Follow-up after early pregnancy loss should include attention to
future pregnancy planning, contraception, and psychological aspects of care. (Am Fam Physician. 2009;79(11):985-
992, 993-994. Copyright © 2009 American Academy of Family Physicians.)

A
Patient information: bout one fourth of all pregnant 10 to 11 weeks since last normal menses),
▲

A handout on first trimes- women experience spotting or and bimanual examination for masses and
ter bleeding, written by bleeding in the first several weeks tenderness. Guarded reassurance and watch-
the authors of this article,
is provided on page 993. of pregnancy, and one half of ful waiting are appropriate if fetal heart
those who bleed will miscarry.1 Family phy- sounds are detected with Doppler, if the
sicians who are familiar with the normal patient is stable, and if there is no adnexal
This clinical content progression of early pregnancy anatomy, mass, significant tenderness, or clinical sign
conforms to AAFP criteria sonographic findings, and beta subunit of of intraperitoneal bleeding.
for evidence-based con- human chorionic gonadotropin (β-hCG) Adnexal tenderness and the presence of
tinuing medical education
(EB CME). values can make a definitive diagnosis and a mass may indicate ectopic pregnancy.
proceed with appropriate treatment. Hypotension with other symptoms of hemo-
peritoneum (e.g., shoulder pain, absent
Managing First Trimester Bleeding bowel sounds, distended doughy abdomen)
By definition, bleeding before 20 weeks may point to ruptured ectopic pregnancy
of gestation constitutes threatened abor- and prompt immediate hospitalization for
tion (Table 12,3), but the majority of such evaluation.
pregnancies progress normally. The pace Examination with a vaginal speculum
of evaluation depends on the patient’s his- may reveal nonobstetric causes of bleeding,
tory, signs, and symptoms. If known, the such as cervicitis, vaginitis, cystitis, trauma,
time since the patient’s last normal menses cervical cancer, or polyps; or nonvaginal
may be used to estimate the gestational age. causes of bleeding, such as hemorrhoids.
In stable patients, the physical examination Significant cervical dilation or visible prod-
includes documentation of the size and posi- ucts of conception are indicative of an inevi-
tion of the uterus, auscultation of fetal heart table abortion. Tissue may be removed by
sounds by Doppler (if it has been at least gentle traction with ring forceps, and may be

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First Trimester Bleeding
SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References

Evidence does not support the routine use of antibiotics in all women with incomplete abortion. A 5
A normal pregnancy should exhibit a gestational sac when beta subunit of human chorionic C 1
gonadotropin levels reach 1,500 to 2,000 mIU per mL (1,500 to 2,000 IU per L), a yolk sac when
the gestational sac is greater than 10 mm in diameter, and cardiac activity when the embryonic
crown-rump length is greater than 5 mm.
Because expectant and surgical management of miscarriage are equally effective, the patient’s C 16
preference should play a dominant role in choosing a treatment.
When the patient has an incomplete abortion, nonsurgical treatments have a high likelihood of A 13-15
success; when the patient has an embryonic demise or anembryonic pregnancy, misoprostol
(Cytotec) or surgical treatment is more effective than expectant treatment.
Vaginal misoprostol is safer and more effective than oral misoprostol, with fewer gastrointestinal A 13, 15
side effects.
After a first trimester pregnancy loss, patients who are Rh negative should receive 50 mcg of anti D C 27
immune globulin.
Acknowledgment of grief, sympathy, and reassurance are useful techniques in counseling patients C 31
after miscarriage.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
org/afpsort.xml.

Table 1. Definition of Terms Applied to Early Pregnancy Loss

Term Definition

Anembryonic pregnancy Presence of a gestational sac larger than 18 mm without evidence of embryonic tissues (yolk sac or
embryo); this term is preferable to the older and less accurate term “blighted ovum”
Ectopic pregnancy Pregnancy outside the uterine cavity (most commonly in the fallopian tube) but may occur in the
broad ligament, ovary, cervix, or elsewhere in the abdomen
Embryonic demise An embryo larger than 5 mm without cardiac activity; this replaces the term “missed abortion”
Gestational trophoblastic Complete mole: placental proliferation in the absence of a fetus; most have a 46,XX chromosomal
disease or hydatidiform composition; all derived from paternal source
mole Partial mole: molar placenta occurring with a fetus; most are genetically triploid (69,XXY)
Heterotopic pregnancy Simultaneous intrauterine and ectopic pregnancy; risk factors include ovulation induction, in vitro
fertilization, and gamete intrafallopian transfer
Recurrent pregnancy loss More than two consecutive pregnancy losses; “habitual aborter” has also been used but is no
longer appropriate
Spontaneous abortion Spontaneous loss of a pregnancy before 20 weeks’ gestation
Complete abortion Complete passage of all products of conception
Incomplete abortion Occurs when some, but not all, of the products of conception have passed
Inevitable abortion Bleeding in the presence of a dilated cervix; indicates that passage of the conceptus is unavoidable
Septic abortion Incomplete abortion associated with ascending infection of the endometrium, parametrium,
adnexa, or peritoneum
Subchorionic Sonographic finding of blood between the chorion and uterine wall, usually in the setting of
hemorrhage vaginal bleeding
Threatened abortion Bleeding before 20 weeks’ gestation in the presence of an embryo with cardiac activity and
closed cervix
Vanishing twin A multifetal pregnancy is identified and one or more fetuses later disappear (occurs more often
now that early ultrasonography is common); if early in pregnancy, the embryo is
often reabsorbed; if later in pregnancy, it leads to a compressed or mummified fetus or
amorphous material

Information from references 2 and 3.

986 American Family Physician www.aafp.org/afp Volume 79, Number 11 ◆ June 1, 2009
 First Trimester Bleeding

examined for the presence of chorionic villi (Figure 1)

or sent for pathologic examination. Chorionic villi are
indicative of spontaneous abortion. Table 2 shows risk
factors of spontaneous abortion.2-4
Cervical testing for gonorrhea and chlamydia may
be performed. Fever and significant adnexal or perito-
neal symptoms are found in septic abortion. Treatment
of septic abortion is urgent, including prompt antibi-
otic administration and uterine evacuation. Infection,
retained products of conception, and uterine perfora-
tion are more common if the history includes attempted
abortion by someone who is untrained. Evidence does
not support the routine use of antibiotics in all women
with incomplete abortion.5 Figure 1. Passed tissue can be examined for chorionic villi.
If history and physical examination do not yield a If chorionic villi are present, the pregnancy was intrauter-
diagnosis, ultrasonography with or without β-hCG test- ine, except in the rare heterotopic pregnancy.
ing is required. Application and interpretation of this
testing will help determine the differential diagnosis of
early pregnancy failure. Table 2. Risk Factors for Spontaneous Abortion
and Ectopic Pregnancy
Normal First Trimester Pregnancy Markers
Human Chorionic Gonadotropin Spontaneous abortion
The first measurable finding in pregnancy is an elevated Endocrine (e.g., progesterone deficiency, thyroid disease,
uncontrolled diabetes)
β-hCG level, which is produced by the placenta after
Genetic aneuploidy (accounts for about one half of
implantation of the blastocyst. This occurs at approxi-
spontaneous abortions)
mately 23 menstrual days’ gestation, or as early as eight
Immunologic (e.g., antiphospholipid syndrome, lupus)
days after conception. Readily available home urine
Infection (e.g., chlamydia, gonorrhea, herpes, listeria,
pregnancy tests detect β-hCG levels as low as 25 mIU per mycoplasma, syphilis, toxoplasmosis, ureaplasma)
mL (25 IU per L) International Reference Preparation. Occupational chemical exposure
Therefore, it is possible to diagnose pregnancy before a Radiation exposure
missed period.6 Uterine (e.g., congenital anomalies)
Quantitative serum β-hCG levels rise in a predictable
Ectopic pregnancy
fashion during the first four to eight weeks of normal
Current intrauterine device
pregnancy, increasing by 80 percent every 48 hours.
History of ectopic pregnancy
This rate of increase in β-hCG levels is reassuring, but
History of in utero exposure to diethylstilbestrol
not indicative of normal pregnancy. Inadequately ris-
History of genital infection, including pelvic inflammatory
ing β-hCG levels do not distinguish between ectopic disease, chlamydia, or gonorrhea
and failing intrauterine pregnancy. Unexpectedly high History of tubal surgery, including tubal ligation or
β-hCG levels require consideration of gestational tro- reanastomosis of the tubes after tubal ligation
phoblastic disease. In vitro fertilization
Infertility
Ultrasonography
Smoking
Early detection of pregnancy depends on transvaginal
ultrasonography using transducer frequency of 5 MHz Information from references 2 through 4.
or greater.1 A 5-mm sonolucent gestational sac should be
visible in the endometrium at the fundus by five men-
strual weeks.1 The normal sac of an intrauterine preg- The yolk sac is visible using transvaginal scanning by
nancy consists of a central blastocyst surrounded by a six menstrual weeks. This confirms an intrauterine preg-
double ring of echogenic chorionic villi and decidua. nancy (Figure 2). By the end of the sixth week, a 2- to
This distinguishes it from a pseudogestational sac asso- 5-mm embryo or fetal pole becomes visible (Figure 3).
ciated with ectopic pregnancy. Measurement of the embryonic crown-rump length is

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First Trimester Bleeding

the most accurate way to date pregnancy (Figure 4). Car-

diac activity should be present when the embryo exceeds
5 mm in length.1 Transabdominal scanning is less sensi-
tive, and will show these landmarks about one week after
they are visible transvaginally.

Discriminatory Criteria

The predictable, linked progression of laboratory and

sonographic findings constitutes discriminatory criteria,
as shown in Table 3.1 A normal pregnancy should exhibit
Figure 2. Yolk sac (YS) within the gestational sac at five to a gestational sac when β-hCG levels reach 1,500 to 2,000
six menstrual weeks. This is the first sonographic finding mIU per mL (1,500 to 2,000 IU per L), a yolk sac when
that positively confirms intrauterine pregnancy.
the gestational sac is greater than 10 mm in diameter, and
cardiac activity when the crown-rump length is greater
than 5 mm.1 The absence of an expected discrimina-
tory finding is consistent with pregnancy failure; how-
ever, because of the emotional impact of pregnancy loss,
imaging may be repeated one week later to confirm the
diagnosis. After an embryo with a heartbeat is confirmed
using these criteria, continued follow-up by ultrasonog-
raphy provides more specific information about the state
of the pregnancy than serial measurements of β-hCG.

Making a Diagnosis
If the diagnosis is not clear from clinical examination alone,
knowledge of discriminatory criteria based on transvaginal
ultrasonography and β-hCG findings facilitates the differ-
ential diagnosis of first trimester bleeding (Table 3 1).

Ectopic Pregnancy

Ectopic pregnancy is responsible for 6 percent of all U.S.

Figure 3. The embryo is first visible as a fetal pole adjacent to maternal deaths.4 Intrauterine pregnancy with yolk sac
the yolk sac (YS). Cardiac activity is often visible at this time. or embryo rules out ectopic pregnancy, with the excep-
tion of a one in 4,000 chance of heterotopic pregnancy.
Transvaginal ultrasonography demonstrates an intra-
uterine gestational sac with nearly 100 percent sensitiv-
ity at β-hCG levels of 1,500 to 2,000 mIU per mL.1 If the
β-hCG level is above this discriminatory cutoff and a
gestational sac is not visible, then there is a high likeli-
hood of ectopic pregnancy.
An embryo with cardiac activity outside the uterus
proves ectopic pregnancy. Conditions that impede the
tubal transport of a fertilized ovum are associated with
ectopic pregnancy7 (Table 2 2-4), although many ectopic
pregnancies occur in women without risk factors. Early
diagnosis is the key to preventing morbidity and mortal-
ity, and preserving fertility.
An adnexal mass or free pelvic fluid (Figure 5) signifies
Figure 4. Measurement of the embryonic crown-rump a high probability of ectopic pregnancy, even if the gesta-
length is the most accurate way to date pregnancy. This tional sac or embryo is not visible. The presence of a cor-
10.5-week pregnancy measures 38 mm. pus luteum cyst of pregnancy may confuse the picture.

988 American Family Physician www.aafp.org/afp Volume 79, Number 11 ◆ June 1, 2009
 First Trimester Bleeding
Table 3. Discriminatory Findings in Early Pregnancy

Menstrual Embryologic Laboratory and transvaginal sonographic

age event discriminatory findings
Spontaneous Abortion
and Embryonic Demise Three to Implantation Decidual thickening
four weeks site
Products of conception in the cervix or an Four weeks Trophoblast Peritrophoblastic flow on color flow Doppler
intrauterine embryo without cardiac activ- Four to five Gestational Present when beta subunit of human
ity proves incomplete abortion, inevitable weeks sac chorionic gonadotropin level is greater
abortion, or embryonic demise. Their pres- than 1,500 to 2,000 mIU per mL (1,500
ence rules out ectopic pregnancy, although to 2,000 IU per L; varies with sonographer
there is a one in 4,000 chance of hetero- experience and quality of ultrasonography)
topic pregnancy. Anembryonic pregnancy Five to six Yolk sac Present when diameter of gestational sac
weeks is greater than 10 mm
is often suspected when the patient reports
Five to six Embryo Present when diameter of gestational sac
regression of pregnancy symptoms or when weeks is greater than 18 mm
Doppler fails to detect fetal heart sounds Five to six Cardiac Present when embryonic crown-rump
by 10 to 11 weeks after the last normal weeks activity length is greater than 5 mm
menses.
Adapted with permission from Paspulati RM, Bhatt S, Nour SG. Sonographic evalua-
Gestational Trophoblastic Disease tion of first-trimester bleeding [published correction appears in Radiol Clin North Am.
2008;46(2):437]. Radiol Clin North Am. 2004;42(2):299. http://www.sciencedirect.
Gestational trophoblastic disease is char- com/science/journal/00338389.
acterized by a “snowstorm” of amorphous
material filling the uterus in patients pre-
senting in the first trimester.8,9 Prompt surgical evacua-
tion is required with close follow-up because of the risk
of metastatic disease.9

Subchorionic Hemorrhage

Subchorionic hemorrhage (Figure 6) is a common find-

ing with first trimester bleeding and may also be an
incidental finding in uncomplicated pregnancies. It is
important to note whether embryonic cardiac activity is
present. Subchorionic hemorrhage may be mistaken for
a twin gestational sac.

The Difficult Diagnosis

It is common for β-hCG levels to be less than 1,500 mIU Figure 5. The presence of free pelvic fluid in the cul-de-sac
is highly suggestive of ectopic pregnancy.
per mL with sonographic findings that are nondiagnos-
tic. It is reasonable to perform repeat ultrasonography
after one week in a stable patient. This interval allows
significant growth of the gestational sac or embryo, both
of which should grow at the rate of 1 mm per day. In
this situation, serial quantitative β-hCG levels in com-
bination with follow-up imaging are also useful. Based
on a prospective study, the minimum β-hCG increase
necessary for a living pregnancy over a 48-hour interval
is 53 percent.10 When β-hCG rises more slowly than this,
plateaus, or falls, the differential diagnosis is limited to
failing intrauterine pregnancy or ectopic pregnancy.
When β-hCG levels are not rising normally and ultra-
sonography cannot confirm pregnancy location, a dilata-
tion and curettage or manual vacuum aspiration may be
helpful. Manual vacuum aspiration requires a specially- Figure 6. Subchorionic hemorrhage (SCH) appears as a
designed 60-mL syringe with attached cannula to apply sonolucent area adjacent to the gestational sac, which
suction to the uterine cavity. If evacuation of the uterus contains an embryo (E) and yolk sac (YS).

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First Trimester Bleeding

yields chorionic villi, then a failed intrauterine pregnancy treatment.14,16 Misoprostol has fewer gastrointestinal side
is diagnosed and treatment for an ectopic pregnancy effects when given vaginally than when given orally.13,15
may be avoided. When ectopic pregnancy is suspected Based on these findings, increased use of medical man-
but cannot be confirmed with noninvasive testing, con- agement has benefits for patients, although misoprostol
sultation for diagnostic laparoscopy or treatment with is not approved by the U.S. Food and Drug Administra-
methotrexate is appropriate. tion for use in treating miscarriage.17 The doses used
in published studies are 800 mcg vaginally or 600 mcg
Management orally.13-15 If a single vaginal dose of 800 mcg does not
Threatened Abortion result in complete expulsion by day 3, the dose should
The presence of an intrauterine embryo with cardiac activ- be repeated. If complete expulsion has not occurred by
ity on ultrasonography should be reassuring because it day 8, manual vacuum aspiration should be offered.18
essentially rules out ectopic pregnancy. It is also associ- Additional published protocols are available.19
ated with a pregnancy loss rate of only 2 percent in women Confirming a negative urine β-hCG four to six weeks
35 years and younger and 16 percent in women older than after early pregnancy loss excludes the presence of
35 years.11 If subchorionic hemorrhage (Figure 6) is present persistent gestational trophoblastic disease.20 Although
in an intrauterine pregnancy with fetal heart
sounds, the likelihood of spontaneous abor-
tion is 9 percent and may be even higher if the Table 4. Criteria for Managing Ectopic Pregnancy
patient is older than 35 years or if the hema-
toma is large.12 In this situation, the physician Expectant management
should caution patients to expect continued No evidence of tubal rupture
bleeding and possible impending miscarriage. Minimal pain or bleeding
Patient reliable for follow-up
Spontaneous Abortion, Embryonic Starting β-hCG level less than 1,000 mIU per mL (1,000 IU per L) and falling
Demise, and Anembryonic Pregnancy
Ectopic or adnexal mass less than 3 cm or not detected
Most first trimester miscarriages occur com- No embryonic heartbeat
pletely and spontaneously without interven- Medical management with methotrexate
tion. Although dilatation and curettage has Stable vital signs and few symptoms
historically been the treatment of choice, No medical contraindication for methotrexate therapy (e.g., normal liver
several recent trials confirm that expectant enzymes, complete blood count and platelet count)
management or medical management with Unruptured ectopic pregnancy
misoprostol (Cytotec) can be as effective and Absence of embryonic cardiac activity
safer while offering the patient more control Ectopic mass of 3.5 cm or less
over her care.13-16 Starting β-hCG levels less than 5,000 mIU per mL (5,000 IU per L)
Clinical trials comparing expectant, medi- Dosage: single intramuscular dose of 1 mg per kg, or 50 mg per m2
cal, and surgical management reach several Follow-up: β-hCG on the fourth and seventh posttreatment days, then
weekly until undetectable, which usually takes several weeks
conclusions. In incomplete abortion, high
Expected β-hCG changes: initial slight increase, then 15 percent decrease
success rates have been demonstrated for
between days 4 and 7; if not, repeat dosage or move to surgery
expectant management (86 percent) and med-
Special consideration: prompt availability of surgery if patient does not
ical management (100 percent).13 However, respond to treatment
expectant management is more likely to fail Surgical management
in embryonic demise or anembryonic preg- Unstable vital signs or signs of hemoperitoneum
nancy; in these patients, the success of expect- Uncertain diagnosis
ant management by day 7 drops to 29 percent, Advanced ectopic pregnancy (e.g., high β-hCG levels, large mass, cardiac
compared with 87 percent for medical man- activity)
agement.13 Women treated expectantly have Patient unreliable for follow-up
more outpatient visits than those treated med- Contraindications to observation or methotrexate
ically.13 Women treated medically have more
bleeding but less pain than those treated surgi- β-hCG = beta subunit of human chorionic gonadotropin.

cally.14 Surgery is associated with more trauma Information from references 23 through 26.
and infectious complications than medical

990 American Family Physician www.aafp.org/afp Volume 79, Number 11 ◆ June 1, 2009
 First Trimester Bleeding

substantially reduces the risk of neural tube defects.29

Table 5. Approaches to Grief Counseling After The psychological impact of pregnancy loss can be dev-
Miscarriage astating to the patient and her partner.30 Approaches to
managing patient grief are shown in Table 5.31
Acknowledge and attempt to dispel guilt
This article is one in a series on “Advanced Life Support in Obstetrics
Acknowledge and legitimize grief
(ALSO),” initially established by Mark Deutchman, MD, Denver, Colo. The
Provide comfort, sympathy, and ongoing support series is now coordinated by Patricia Fontaine, MD, MS, ALSO Managing
Reassure the patient about the future Editor, Minneapolis, Minn., and Larry Leeman, MD, MPH, ALSO Associate
Counsel the patient on how to tell family and friends about Editor, Albuquerque, N.M.
the miscarriage: Figure 5 provided by Matthew F. Reeves, MD, MPH, Magee-Womens
Speak simply and honestly Hospital of the University of Pittsburgh (Pa.) Medical Center.
Avoid medical details
Recognize that others may react emotionally The Authors
Explain how others can help, if known
MARK DEUTCHMAN, MD, is a professor in the Department of Family Medi-
Warn patients of the anniversary phenomenon cine at the University of Colorado Denver School of Medicine in Aurora,
Include the patient’s partner in your psychological care Colorado. He received his medical degree from The Ohio State University
Assess level of grief and adjust counseling accordingly in Columbus, and completed a family medicine residency at Sacred Heart
Medical Center in Spokane, Wash.
Information from reference 31. AMY TANNER TUBAY, MD, is an adjunct instructor in the Department of
Family and Preventive Medicine at the University of Utah School of Medi-
cine in Salt Lake City. She received her medical degree from Emory Univer-
sity School of Medicine in Atlanta, Ga., and completed a family medicine
there is solid evidence to support the use of prophylac- residency and an obstetrics fellowship at the University of Utah.
tic antibiotics for induced abortion, there is no evidence DAVID K. TUROK, MD, MPH, is an assistant professor in the Department
supporting this practice in early pregnancy failure.21 of Obstetrics and Gynecology and the Department of Family and Preven-
tive Medicine at the University of Utah School of Medicine. He received
his medical and master of public health degrees from Tufts University in
Ectopic Pregnancy
Boston, Mass., and completed a family medicine residency at Brown Uni-
Early diagnosis of ectopic pregnancy brings management versity in Pawtucket, R.I., and a residency in obstetrics and gynecology at
into the outpatient setting. Current treatment options the University of Utah School of Medicine.
favor medical and laparoscopic management,22 with Address correspondence to Mark Deutchman, MD, University of Colorado
expectant management reserved for patients with a declin- Denver School of Medicine, Mail Stop F-496, Academic Office 1, 12631
East 17th Ave., Room 3617, Aurora, CO 80045 (e-mail: mark.deutchman@
ing quantitative β-hCG of less than 1,000 mIU per mL ucdenver.edu). Reprints are not available from the authors.
(1,000 IU per L) and open surgical management reserved
Author disclosure: Nothing to disclose.
for patients with tubal rupture and hemoperitoneum.
Medical management with methotrexate is appropriate for
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992 American Family Physician www.aafp.org/afp Volume 79, Number 11 ◆ June 1, 2009