Repeat b-hCG in 2 days.
When the quantitative hCG level is below the discriminatory zone (usually 2,000 mIU/mL, depending on the ultrasound machine) and no pregnancy is visualized by transvaginal ultrasound, no conclusive diagnosis can be made, and the patient should return in 2 days for repeat hCG level, and if it is then above the discriminatory zone, repeat ultrasound can be performed to aid in diagnosis of intrauterine or ectopic pregnancy.
Determining the location of the pregnancy is important not only to establish the correct treatment, but also to counsel the patient regarding her risk of having an ectopic in a subsequent pregnancy. Methotrexate would not be ideal at this point because it is not clear that the patient has an ectopic pregnancy since there is no pregnancy identifi ed in the uterus and there is no sign of a pregnancy in the tubes by ultrasound.
If diagnosis of an ectopic pregnancy has been confi rmed by finding no chorionic villi at D&C, then methotrexate would be an option.
Neither a laparoscopy nor a laparotomy is necessary yet because no mass has been visualized on ultrasound.