Ectopic pregnancy Quiz: Ace Your Exams

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A 36-year-old woman, gravida 4, para 2, aborta 1, at 6 weeks gestational age by last menstrual period, presents to the emergency department with left lower quadrant pain and vaginal bleeding. She and her partner have been trying to conceive and had a positive home pregnancy test last week. Her initial antenatal appointment is scheduled for next week. Past medical history is notable for two uncomplicated spontaneous vaginal deliveries and one ruptured ectopic pregnancy treated with a right salpingectomy 6 years ago. She also has a history of endometriosis and mild intermittent asthma requiring the use of albuterol 2 to 3 times per month. Temperature is 37.1 °C (98.7 °F), heart rate is 86 bpm, respirations are 18/min, and blood pressure is 128/76 mmHg. Weight is 125 pounds. The exam is notable for left adnexal tenderness and a small amount of bright red blood in the vaginal vault. Labs are obtained, with results shown below. A transvaginal ultrasound shows an empty uterine cavity and a 3.2 cm complex left adnexal mass. Neither a gestational sac, yolk sac, nor embryo are visible. Which of the following clinical factors indicates the need for surgical management in this patient? 
 
 Lab values      Results   
 Hemoglobin      12.1  g/dL    
 Total leukocyte count     7500/mm³    
 Platelet count     87,000/mm³    
 Blood urea nitrogen (BUN)     23 mg/dL    
 Creatinine     1.3  mg/dL    
 Aspartate aminotransferase      20 U/L    
 Human Chorionic gonadotropin     4200 mIU/ml    

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