Virginia Via Research Day Book 2026

Medical Student Research Case Reports

Madi Bautista, MPH, OMS III; Alexandra Reagan, MS, OMS III; Anita Register, DO Corresponding author: areagan@vcom.edu 48 MANAGEMENT OF PREGNANCY IN AN UNKNOWN LOCATION AND COMPLICATIONS FROM INCONSISTENT Β -HCG TRENDS

Carilion Clinic VCOM-Virginia, Blacksburg, Virginia A 25-year-old Hispanic G2P1 presented with an irregular β-hCG pattern over the course of one month. She underwent eight serial β-hCG measurements demonstrating the following trend: 33.6 → 23.1 → 37.7 → 52.9 → 76.7 → 25.2 → 38.6 → 25.2 mIU/ mL. Initially, the patient presented to the emergency department (ED) with abdominal pain and vaginal bleeding. Transvaginal ultrasound (TVUS) showed no intrauterine pregnancy and no adnexal masses. Her initial β-hCG was 33.6 mIU/mL, and gestational age was estimated at 8 weeks 5 days by last menstrual period. Ectopic pregnancy could not be definitively excluded, but the patient was discharged with close follow-up. Two days later, β-hCG decreased to 23.1 mIU/mL, so she elected expectant management with continued serial β-hCG monitoring for a pregnancy of unknown location(PUL). Three days later, her level rose to 37.7 mIU/mL, and methotrexate was recommended for the inconsistent trend, but liver function tests returned elevated (AST 44 U/L, ALT 121 U/L), making her ineligible for methotrexate. β-hCG rose to 52.9 mIU/mL, and manual vacuum aspiration (MVA) was recommended. Subsequent β-hCG increased to 76.7 mIU/mL. Pathology revealed weak secretory endometrial tissue

without products of conception. Given the absence of products of conception and continued β-hCG elevation, concern for ectopic pregnancy increased, and diagnostic laparoscopy was recommended. The procedure was scheduled for the following week, but was cancelled the day of, since her β-hCG decreased to 25.2 mIU/mL and she remained clinically stable with improving liver enzymes and hemoglobin of 14.6 g/dL. Nine days later, repeat β-hCG testing showed an increase to 38.6 mIU/ mL and sent to the ED. At this time, she denied vaginal bleeding but reported two days of vomiting and new onset, exquisitely tender left lower quadrant pain. In the emergency department, she was hemodynamically stable with hemoglobin 13.6 g/dL. Diagnostic laparoscopy was recommended given her persistent β-hCG elevation, new focal pain, and planned international travel back to her home country with no plan for return. Evaluation revealed a left ectopic pregnancy,and left salpingectomy was performed, with surgical pathology positive for products of conception. This case illustrates the diagnostic and management challenges of a pregnancy of unknown location with low yet fluctuating β-hCG levels. Expectant management was initially appropriate given the nondiagnostic ultrasound and transient early decline in β-hCG, which

aligns with literature reporting spontaneous resolution rates of approximately 47.7–69.2% in carefully selected patients. However, intermittent rises in β-hCG, a negative manual vacuum aspiration specimen, and later development of new focal adnexal pain increased concern for an evolving ectopic pregnancy. Although methotrexate is recommended for clinically stable, unruptured ectopic pregnancies that meet standard criteria—and has reported success rates up to 90%—it was contraindicated in this patient due to elevated liver transaminases. Per ACOG guidance, serum β-hCG values alone should not be used to diagnose an ectopic pregnancy and must be interpreted alongside symptoms, history, and imaging; in this case, the combination of rising β-hCG, localized pain, and the patient’s inability to ensure reliable follow-up due to imminent international travel appropriately shifted management toward surgical intervention.

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86 Edward Via College of Osteopathic Medicine (VCOM)