I was rushed into surgery eight months ago to remove a 16-week ectopic pregnancy in the abdomen. At my first prenatal visit, I had reported spotting, lost appetite, nausea and breast tenderness. I also told the doctor I'd had an ectopic a few years earlier in which the tube was removed, along with a cyst and my appendix. He did the usual urine test and an abdominal ultrasound and said everything appeared to be in the right place. Later my HCG levels started dropping, and he prescribed vaginal progesterone, which did raise the levels. Still, I remained extremely ill. He did another ultrasound and said there appeared to be some debris in the uterus, but my pregnancy was progressing. I'm having a hard time understanding why he couldn't see there no embryo in the uterus, and how he missed all the red flags of an ectopic pregnancy. Is it that difficult to discover an abdominal ectopic? What is the likelihood of this occurring?

R.S.

Nausea, breast tenderness and lost appetite are not signs of ectopic pregnancy, and not enough to raise suspicion in themselves. What is more important is your history of a previous ectopic. When I have a patient who has had an ectopic pregnancy in the past, I ALWAYS put her on special precautions until we know the exact location of the pregnancy, and I tell her to notify the office immediately if she experiences spotting or abdominal pain locating on either side.

I also monitor blood hCG levels 48 hours apart. If the rise in hCG is not 60 percent or greater between tests, I recommend repeat evaluations to monitor more closely. The hCG levels also enable me to determine when a transvaginal ultrasound examination will show whether the pregnancy is in the uterus. You mentioned that your physician chose to use an abdominal ultrasound rather than the more appropriate transvaginal approach. Abdominal ultrasound has limited ability to pick up an ectopic pregnancy.

If I cannot confirm that the pregnancy is in the uterus, the use of methotrexate injections may avoid the complications of surgery for ectopic pregnancy.