CASE REPORT

Persistent Low Levels of Beta-hCG: A Pitfall in Diagnosis of Retained Product

of Conception
Leila Pourali1, Sedigheh Ayati1, Parvaneh Layegh2, Atieh Vatanchi1, Zahra Rastin1, Azadeh Shourvi1
1
Department of Obstetrics and Gynecology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
2
Department of Radiology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

Received: 09 Jul. 2017; Accepted: 18 Dec. 2017

Abstract- Persistent low level of beta-hCG (PLL) is defined as rising hCG level no more than two-fold over
a three months period. Almost many types of PLL can lead to the wrong diagnosis. Here, we presented two
cases of the retained product of conception (RPOC) with persistent low levels of beta-hCG. Both cases were
presented with persistent low levels of beta-hCG and abnormal uterine bleeding since first-trimester
pregnancy termination. Ultrasonography revealed a vascular mass with extension from the endometrial cavity
to myometrium imitating gestational trophoblastic disease (GTD) or arteriovenous malformation (AVM). The
final pathologies of both cases were retained product of conception. Imaging features of RPOC can closely
imitate those of an AVM or GTN; so, hysteroscopy is one of the best non-invasive procedures which may be
helpful in diagnosis and selection of appropriate treatment especially in young patients who desire to preserve
their fertility.
© 2018 Tehran University of Medical Sciences. All rights reserved.
Acta Med Iran 2018;56(7):478-481.

Keywords: Beta-hCG; Conception; Curettage

Introduction condition may be considered when a patient has had

prior uterine surgery like cesarean section or uterine
Persistent low level of beta-hCG (PLL) is defined as evacuation (9,10).
rising hCG level no more than two-fold over a three Hysteroscopic evaluation has both advantages of
months period. Some causes of this situation are early simultaneous diagnosis and treatment and is most
pregnancy, pituitary hCG secretion, false positive β- appropriate for women without heavy uterine bleeding.
hCG, quiescent gestational trophoblastic disease (GTD), It may be best used for cases with persistent signs of
placental site trophoblastic tumor (PSTT), and hCG RPOC on imaging. This procedure has the advantages of
consumption (1-3). Retained products of conception visualizing complete tissue and its removal (11,12).
(ROPC) refer to a portion of placental tissue which Almost many types of PLL can lead to the wrong
retained in the uterine cavity after abortion or full-term diagnosis of gestational trophoblastic disease, so
delivery. These retained pieces of placental tissue are overtreatment like chemotherapy or aggressive surgery
common causes of abnormal uterine bleeding (AUB) in like hysterectomy may be performed in this situation.
women of reproductive age (4). The incidence of PROC Here, we presented two cases of RPOC with persistent
varies widely and depends on the initial treatment of low levels of beta-hCG and uterine mass.
miscarriage (surgical or non-surgical), diagnostic criteria
(symptoms and signs), and duration of follow-up (5). Case Report
The combination of echogenic endometrial mass and
AUB is a sensitive indicator of ROPC (6,7). Radiologic Case 1
findings of RPOC may be similar to what is seen in A 29-year-old woman, P2 L2 ab1 referred to the
GTD or arteriovenous malformations (AVM) (8). gynecology clinic of our academic hospital because of
Another important issue is abnormal adherent placenta AUB since three months ago. She had an abortion at
which can lead to massive hemorrhage and eight weeks of gestation three months ago, and curettage
hysterectomy at the time of uterine curettage. This was done. At that time, pathologist reported the product

Corresponding Author: A. Vatanchi

Department of Obstetrics and Gynecology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
Tel: +98 915 3106837, Fax: +98 51 38430569, E-mail address: VatanchiA@mums.ac.ir
 L. Pourali, et al.

of normal conception. Serum β-hCG was 3909 IU/L medical treatment (misoprostol) because of missed
before surgery. Three months after curettage, she abortion one month ago. The patient was pale; vital
referred because of AUB. Physical examination and signs showed blood pressure 90/60 mm/Hg; pulse rate
laboratory assessment were normal except β-hCG to 110/min and normal temperature. Vaginal examination
titrate which was 63 IU/L. Vaginal ultrasonography showed bleeding not more than menstrual bleeding and
showed normal size uterus and ovaries, but a 20×29×34 cervix was normal. Complete blood count showed
mm Prominent vascular mass with slow flow in anemia (HCT: 24%). Beta-hCG was 13 IU/L. Other
grayscale and marked vascularity in color Doppler is laboratory data were normal. The vaginal
seen near the fundal part which extending focally in full ultrasonography revealed an irregular hypoechoic area
thickness of myometrium. These sonographic findings with 27×19 mm diameter and marked vascularity
were highly suspicious to GTD or PSTT (Figure 1). isolated from myometrium near the uterine fundus
Because of the persistent low level of β-hCG, we (Figure 2).
suspected to PSTT. Unfortunately, we didn’t have any
access to check human placental lactogen (HPL) for
more confirmation of our diagnosis. Patient’s vaginal
bleeding was continued, so the second vaginal
ultrasound was done two weeks later. Serum β-hCG was
rechecked, and it was 48 IU/L (declined), and urine β-
hCG was positive. Abdominal ultrasound and chest X-
ray was also normal. The second vaginal ultrasound
showed the same result. With regard to this evidence,
our diagnosis was PSTT and hysterectomy was planned.
The final pathological assessment showed no malignant
tumor in the uterus, and the diagnosis was retained
product of conception. Figure 2. Axial color Doppler vaginal US image shows marked
Serum β-hCG become zero 10 days after surgery, vascularity isolated to the myometrium (red arrow)
and then, the patient didn’t have any symptoms.
Also, MR imaging showed vascular mass with
obvious enhancement in the uterine cavity and
prominent vessels near the myometrium (Figure 3).

Figure 1. Longitudinal color Doppler and grayscale vaginal US

image shows prominent vascular space with marked vascularity
isolated to the full thickness of myometrium (arrows)
Figure 3. Axial contrast-enhanced fat-saturated T1-weighted MR

Case 2 image shows vascularized mass lesion with obvious enhancement in

A 22-year-old woman P1L1ab1 referred to our the uterine cavity and prominent vessels in myometrium (arrows)
academic hospital because of persistent AUB and
persistent low-level beta-hCG (12 IU/L) after first- Transfusion was done by 2 units of packed red blood
trimester abortion. Pregnancy termination was done by cells. With regard to the experience from the first case,

Acta Medica Iranica, Vol. 56, No. 7 (2018) 479

Persistent low levels of beta-hCG

we decided to evaluate uterine cavity by hysteroscopy prudent in this situation, since this procedure has the
which again the retained product of conception was advantages of diagnosis and treatment, especially in
observed, and uterine curettage was done successfully. RPOC cases.
Beta-hCG becomes zero 2 days after curettage and Imaging feature of RPOC can closely imitate those
patient discharged without any symptoms. of an AVM or GTN; so, hysteroscopy is one of the best
non-invasive procedures which may be helpful in
Discussion diagnosis and selecting appropriate treatment especially
in young patients who desire to preserve their fertility.
This report presented a pitfall in diagnosis and
management of patients with AUB and positive Beta- References
hCG after first-trimester pregnancy termination.
In the first case, she presented with AUB after first- 1. Cole LA, Khanlian SA, Muller CY. Detection of
trimester pregnancy termination by uterine curettage. In perimenopause or postmenopause human chorionic
one similar article, patients presented with heavy uterine gonadotropin: an unnecessary source of alarm. Am J
bleeding after the first-trimester termination of Obstet Gynecol 2008;198:275.e1.
pregnancy (13). This difference could be due to the main 2. Khanlian SA, Cole LA. Management of gestational
pathology; since the arteriovenous malformation could trophoblastic disease and other cases with low serum
be the cause of heavy uterine bleeding. However, in our levels of human chorionic gonadotropin. J Reprod Med
second case, she presented with heavy uterine bleeding 2006;51:812-8.
which complicated her condition with anemia. So, 3. Cole LA, Butler SA, Khanlian SA, Giddings A, Muller
ROPC can cause both light and heavy uterine bleeding. CY, Seckl MJ, et al. Gestational trophoblastic diseases: 2.
Our patients had persistent low level of beta-hCG (<100 Hyperglycosylated hCG as a reliable marker of active
IU/L) several weeks after pregnancy termination. In neoplasia. Gynecol Oncol 2006;102:151-9.
similar reports, patients were assessed because of 4. Cunningham FG, Leveno KJ, Bloom SL, Spong CY,
persistent low-level serum beta-hCG after first-trimester Dashe JS, Hoffman BL, et al. Williams Obstetrics. 24th
miscarriage. Like our patient, almost many of them had ed. New York: McGraw-Hill Education, 2014:671.
serum beta-hCG level less than 100 IU/L (13-15). 5. Trinder J, Brocklehurst P, Porter R, Read M, Vyas S,
Our cases were young women (22 and 29-year-old) Smith L. Management of miscarriage: expectant, medical,
with low parity, so fertility preservation was an or surgical? Results of randomised controlled trial
important issue for them. In similar reports also many (miscarriage treatment (MIST) trial). BMJ
cases were young women with low parity (13-15). 2006;332:1235-40.
Vaginal ultrasonography and color Doppler 6. Abbasi S, Jamal A, Eslamian L, Marsousi V. Role of
assessment in both cases showed normal size uterus and clinical and ultrasound findings in the diagnosis of
adenex, but prominent vascular mass with slow flow in retained products of conception. Ultrasound Obstet
grayscale ultrasonography and marked vascularity in Gynecol 2008;32:704-7.
color Doppler is seen near the fundal part extending 7. van den Bosch T, Daemen A, Van Schoubroeck D,
focally in full thickness of myometrium. These Pochet N, De Moor B, Timmerman D. Occurrence and
characteristics raised suspicion of malignant lesions like outcome of residual trophoblastic tissue: a prospective
PSTT or invasive molar pregnancy. One study reported study. J Ultrasound Med 2008;27:357-61.
hypervascular lesion with even some extension to 8. Jain K, Fogata M. Retained products of conception
myometrium after first-trimester pregnancy termination mimicking a large endometrial AVM: complete resolution
which their final diagnosis was arteriovenous following spontaneous abortion. J Clin Ultrasound
malformations (AVM) (13). In another case report, a 2007;35:42-7.
woman with heavy menstrual bleeding was admitted, 9. Takeda A, Koyama K, Imoto S, Mori M, Nakano T,
and both color Doppler ultrasonography and MRI Nakamura H. Conservative management of placenta
revealed diffuse hypervascular intramural lesion is increta after first trimester abortion by transcatheter
imitating AVM, but after hysterectomy, the final arterial chemoembolization: a case report and review of
pathology report was RPOC (16). Despite using multi- the literature. Arch Gynecol Obstet 2010;281:381-6.
diagnostic modalities for diagnosis of such patients, it 10. Wang YL, Su TH, Huang WC, Weng SS. Laparoscopic
could be challenging especially in young cases, so management of placenta increta after late first-trimester
conservative approach like hysterectomy may be more dilation and evacuation manifesting as an unusual uterine

480 Acta Medica Iranica, Vol. 56, No. 7 (2018)

 L. Pourali, et al.

mass. J Minim Invasive Gynecol 2011;18:250-3.

11. Rein DT, Schmidt T, Hess AP, Volkmer A, Schöndorf T,
Breidenbach M. Hysteroscopic management of residual
trophoblastic tissue is superior to ultrasound-guided
curettage. J Minim Invasive Gynecol 2011;18:774-8.
12. Hamerlynck TW, Blikkendaal MD, Schoot BC, Hanstede
MM, Jansen FW. An alternative approach for removal of
placental remnants: hysteroscopic morcellation. J Minim
Invasive Gynecol 2013;20:796-802.
13. Darlow KL, Horne AW, Critchley HO, Walker J, Duncan
WC. Management of vascular uterine lesions associated
with persistent low-level human chorionic gonadotrophin.
J Fam Plann Reprod Health Care 2008;34:118-20.
14. Cole LA. Phantom hCG and phantom choriocarcinoma.
Gynecol Oncol 1998;71:325-9.
15. González Aguilera B, Syrios P, Gadisseur R, Luyckx F,
Cavalier E, Beckers A, et al. Persistent low levels of
serum hCG due to heterophilic mouse antibodies: an
unrecognized pitfall in the diagnosis of trophoblastic
disease. Gynecol Endocrinol 2016;32:439-41.
16. Kido A, Togashi K, Koyama T, Ito H, Tatsumi K, Fujii S,
et al. Retained products of conception masquerading as
acquired arteriovenous malformation. J Comput Assist
Tomogr 2003;27:88-92.

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