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I Found Out I Was Pregnant In March. Started Spotting

Posted on Sun, 19 May 2019

Question: I found out I was pregnant in March. Started spotting brown for 3 days at the end of March. Then exactly 1 day later I had what I thought was a miscarriage the pain was not as intense as I’ve had 2 miscarriages in the past. The bleeding lasted 5 days. Made my first appointment with clinic to confirm miscarriage blood was drawn on April 10 and again on April 12th labs showed an increase in bhcg. Started to bleed April 16-26th, doctor assumed it was a miscarriage of twins. Levels were continuously being checked and increasing but not significantly. I was referred to ER for methotrexate IM due to speculation of ectopic pregnancy. First ER visit doctor stated levels were not high enough for an ultrasound to detect anything. 2nd ER labs were taken abdominal and transvaginal ultrasound given. Hcg was 441 and ultrasounds came back clear doctors did not find any pregnancy and I was discharged. Follow up labs with clinic came back with an hcg level of 523. Doctor from clinic wants me to return to ER for methotrexate injection. I wan to get a second opinion. These are the dates and levels of my bhcg. 4/10-302 4/12-314 4/15-389 4/18-488 4/22-441(ER) 4/24-523. I have no other symptoms other than the bleeding I had which has since stopped.

Answered by Dr. Dr. Antoneta Zotaj (2 hours later)

Brief Answer:
Ectopic pregnancy is a possibility, further explanations below

Detailed Answer:
Hello and welcome to "Ask a Doctor" service,

I carefully read you and here is my advice:

In a normal pregnancy BHCG should raise at least 60% in 2 days, this is why your doctors are worried about ectopic pregnancy. In ectopic pregnancy BHCG raises slowly and if treated early with methotrexate you may not need surgery.

On the other hand there are other very rare causes for BHCG to be high and ectopic pregnancy is diagnosed if BHCG reaches 1500 and no intrauterine sac is found in transvaginal ultrasound so technically it is not possible to diagnose it unless levels reach 1500.

To conclude:
- increasing BHCG but not at least 60% in 2 days is a concern for ectopic pregnancy
- if BHCG does not reach 1500 ectopic pregnancy can not be diagnosed so repeat tests every 2 days might be recommended. If it reaches 1500 and no intrauterine sac is noticed in transvaginal ultrasound then ectopic pregnancy is diagnosed and treatment for it should be started (methotrexate in early cases).
- If BHCG continues to grow so slow and is not reaching 1500 then probably other rare causes might be considered like antibodies that simulate a positive BHCG test, etc
- finally, you will need to discuss these with your doctor and decide together on further steps.

I hope this answers your query. Let me know if I can assist you further.

Regards,
Dr. Antoneta Zotaj
General and Family Physician

Above answer was peer-reviewed by : Dr. Raju A.T

Follow up: Dr. Dr. Antoneta Zotaj (12 hours later)

Can vitamins with folic acid affect the bhcg levels. I read somewhere that I should refrain from taking vitamins with folic acid as it may increase bhcg levels after miscarriage. Is this accurate. I’m just trying to make sure before I’m injected with a cancer treatment medication.

Answered by Dr. Dr. Antoneta Zotaj (2 hours later)

Brief Answer:
High dose folic acid supplements might reduce methotrexate effectiveness.

Detailed Answer:
Hello and welcome back,

Folic acid does not particularly increase BHCG levels but may be a possible contraindication for treatment with methotrexate. This is because methotrexate works by reducing folic acid which is vital for cell division of the cells that grow fast, so the lack of folic acid results in abortion. If you have high level of folic acid in blood then this effect of methotrexate might be compromised.

You may need to discuss this with your doctor because methotrexate single dose might not be effective if a patient has been receiving high dose of folic acid.

If you have not been taking high dose of folic acid but the standard 400-800 mcg a day very likely there is nothing to worry about the effect of methotrexate but please discuss it with your doctor anyway.

I hope this answers your query. Let me know if I can assist you further.

Regards,
Dr. Antoneta Zotaj
General and Family Physician

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Above answer was peer-reviewed by : Dr. Yogesh D