Letters to the Editor
Level of hCG for Considering an Ectopic Pregnancy
TO THE EDITOR: I would like some clarification on a discrepancy I found between two articles in American Family Physician (AFP), "Management of Spontaneous Abortion"1 in the October 1, 2005, issue and "Diagnosis and Management of Ectopic Pregnancy"2 in the November 1, 2005, issue.
The authors of the article on spontaneous abortion1 use the Advanced Life Support in Obstetrics syllabus3 to substantiate the statement that, "When transvaginal ultrasonography reveals an empty uterus and the quantitative serum hCG [human chorionic gonadotropin] level is greater than 1,800 mIU per mL (1,800 IU per L), an ectopic pregnancy should be considered."1
However, the article on ectopic pregnancy2 refers to a previous AFP article4 on ectopic pregnancy to support the statement that, "ectopic pregnancy is suspected…if transvaginal ultrasonography does not show an intrauterine gestational sac and the patient's beta-hCG level is 1,500 mIU per mL (1,500 IU per L) or greater."2
Thank you for any clarification you can provide on the current standard for this critical management issue.
REFERENCES
1. Griebel CP, Halvorsen J, Golemon TB, Day AA. Management of spontaneous abortion. Am Fam Physician 2005;72:1243-50.
2. Lozeau A, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician 2005;72:1707-14.
3. Deutchman M, Eisinger S, Kelber M. First trimester pregnancy complications. In: ALSO: Advanced Life Support in Obstetrics course syllabus. 4th ed. Leawood, Kan.: American Academy of Family Physicians, 2000:1-27.
4. Tenore JL. Ectopic pregnancy. Am Fam Physician 2000;61:1080-8.
in reply: We appreciate the opportunity to clarify the issue regarding the beta-human chorionic gonadotropin (beta-hCG) level above which a gestational sac can be visualized consistently with transvaginal ultrasound. The beta-hCG level at which we can visualize a gestational sac has decreased over time with advances in ultrasound technology. The article by the Advanced Life Support in Obstetrics (ALSO) syllabus refers to an article published in 1986.1 The recent literature regarding evaluation for possible ectopic pregnancy is consistent in recommending that, at a beta-hCG level of 1,500 mIU per mL (1,500 IU per L) or greater, the gestational sac should be visualized with transvaginal ultrasound.2-6 Our diagnostic strategy reflects this recommendation.
REFERENCES
1. Nyberg DA, Filly RA, Filho DL, Laing FC, Mahony BS. Abnormal pregnancy: early diagnosis by US and serum chorionic gonadotropin levels. Radiology 1986;158:393-6.
2. Tenore JL. Ectopic pregnancy. Am Fam Physician 2000;61:1080-8.
3. Della-Giustina D, Denny M. Ectopic pregnancy. Emerg Med Clin North Am 2003;21:565-84.
4. ACEP Clinical Policies Committee and Clinical Policies Subcommittee on Early Pregnancy. American College of Emergency Physicians. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med 2003;41:123-33.
5. Barnhart K, Mennuti MT, Benjamin I, Jacobson S, Goodman D, Coutifaris C. Prompt diagnosis of ectopic pregnancy in an emergency department setting. Obstet Gynecol 1994;84:1010-5.
6. Borrelli PT, Butler SA, Docherty SM, Staite EM, Borrelli AL, Iles RK. Human chorionic gonadotropin isoforms in the diagnosis of ectopic pregnancy. Clin Chem 2003;49:2045-9.
Pain Management Is Part of Advance Directives Discussion
TO THE EDITOR: The authors of "Respecting End-of-Life Treatment Preferences"1 in American Family Physician provide a good synopsis of how family physicians can assist patients in developing their care plans before a terminal illness is diagnosed; however, a discussion of pain management should be included when deciding on advance directives. Patients generally understand the concept of withholding or withdrawing treatment when it is futile, but physicians and patients may not think to include pain relief options when discussing an advance directive because these documents traditionally address removal of treatment, not active treatment.
Palliative sedation, an aggressive intervention that may hasten death, evokes ethical dilemmas that will be difficult to sort through once the patient is suffering intractable pain despite other interventions.2 Educating patients about choices for treatment of pain should be done early, and these should be added to an advanced directive to aid in avoiding confusion about the patient's wishes once the disease has progressed. Also, providing information early will allow patients to discuss their desires with family members. Treatment of pain may lead to a prolonged unconscious state or may even result in death, and patients have the right to have these possibilities presented to them before they develop pain.
The intent of palliative sedation is to relieve suffering, not to hasten death, and thereby differs from euthanasia and physician-assisted suicide. This is the doctrine of "double effect."2,3 The U.S. Supreme Court has agreed with this opinion.4 Exploration of the ethics of palliative sedation is beyond the scope of this letter, but the topic provides an example of the difficulties that arise with pain management decisions at the end of life. Admittedly, written documents may sometimes fail, and although specific interventions may not need to be included, an advance directive should provide an expression of the patient's general preferences.5 Perhaps, if nothing else, the scenario of palliative sedation should lead to a discussion during the preparation of their advance directives of the patient's desires for pain management.
Family physicians are well suited for addressing the spectrum of issues surrounding end-of-life care and pain because of their unique relationship with entire families. This relationship can enhance communication, which is essential during end-of-life care.5
Pain is not an inevitable experience. Courts in the United States have not overlooked the treatment of pain in dying individuals. In two cases, Estate of Henry James v. Hillhaven Corp., 89 CVS and Bergman v. Wing Chin, M.D. and Eden Medical Center,6 the courts have awarded the plaintiffs large sums because of neglect to relieve suffering and pain at the time of death.4 Physicians should neither neglect treatment of pain nor neglect to discuss pain management options while helping patients prepare an advance directive.
REFERENCES
1. Crane MK, Wittink M, Doukas DJ. Respecting end-of-life treatment preferences. Am Fam Physician 2005;72:1263-8.
2. Lo B, Rubenfeld G. Palliative sedation in dying patients: we turn to it when everything else hasn't worked. JAMA 2005;294:1810-6.
3. Snyder L, Leffler C; Ethics and Human Rights Committee, American College of Physicians. Ethics manual: fifth edition. Ann Intern Med 2005;142:560-82.
4. Rich BA. The process of dying. In: Sanbar SS. Legal medicine. 6th ed. Philadelphia, Pa.: Mosby, 2004:308-14.
5. Tulsky JA. Beyond advance directives: importance of communication skills at the end of life. JAMA 2005; 294:359-65.
6. Estate of Henry James v. Hillhaven Corp, 89 CVS 64 (NC Super Ct 1991); and Bergman v. Wing Chin, MD and Eden Medical Center, No. H205732-1 (Cal App Dept Super Ct 1999).
The article "Foreign Body Ingestion in Children" (July 15, 2005, page 287) contained an error in the abstract. The following sentence contained a typographic error and was missing a phrase: "Foreign bodies lodged in the esophagus should be removed endoscopically, but some small, blunt objects may be pulled out using a Foley catheter or bougie." The sentence should have been: "Foreign bodies lodged in the esophagus should be removed endoscopically, but some small, blunt objects may be pulled out using a Foley catheter or pushed into the stomach using bougienage." The online version of this article has been corrected.
Send letters to Kenny Lin, M.D., assistant editor, American Family Physician, e-mail: afplet@aafp.org. Letters submitted via regular mail should be sent (on disk) to: 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-6272.
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Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the American Academy of Family Physicians permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.
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