Reevaluation of Discriminatory and
Threshold Levels for Serum b-hCG in
Early Pregnancy
AnnaMarie Connolly, MD, David H. Ryan, MD,
OBJECTIVES: To reevaluate both discriminatory and
threshold levels associated with visualization of gesta-
tional sacs, yolk sacs, and fetal poles in patients present-
ing with vaginal bleeding, pain, or vaginal bleeding and
pain in the first trimester of pregnancy using current
ultrasonographic technology.
METHODS: We reviewed the records of patients with
first-trimester vaginal bleeding, pelvic pain, or both
who were evaluated with a serum b-hCG level and
a transvaginal ultrasonogram within 6 hours of each
other and had a known pregnancy outcome. Discrimi-
natory and threshold b-hCG levels for visualization of
a gestational sac, yolk sac, and fetal pole were identi-
fied for all ultimately viable pregnancies. Logistic
regression was used to model the predicted probability
of visualizing these structures as a function of b-hCG
values using fractional polynomials.
RESULTS: Six hundred fifty-one pregnancies met inclu-
sion criteria; 366 were viable. Discriminatory b-hCG lev-
els at which structures would be predicted to be seen
99% of the time were 3,510 milli-international units/mL,
17,716 milli-international units/mL, and 47,685 milli-
international units/mL for gestational sac, yolk sac, and
fetal pole, respectively. In our population, threshold val-
ues for b-hCG levels at which these structures could be
From the Divisions of Maternal-Fetal Medicine and Female Pelvic Medicine
and Reconstructive Surgery, Department of Obstetrics and Gynecology,
University of North Carolina School of Medicine, Chapel Hill, North
Carolina; and the Department of Obstetrics and Gynecology, MacDonald
Women’s Hospital, and Department of Reproductive Biology, Case School of
Medicine, Cleveland, Ohio.
Corresponding author: AnnaMarie Connolly, MD, University of North Carolina
School of Medicine, Obstetrics and Gynecology, 4036 Old Clinic Building,
Division of Urogynecology/Reconstructive Pelvic Surgery, CB #7570, Chapel
Hill, NC 27599-7570; e-mail: amc004@med.unc.edu.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2012 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/13
VOL. 121, NO. 1, JANUARY 2013
Alison M. Stuebe, MD, and Honor M. Wolfe, MD
seen were 390 milli-international units/mL, 1,094 milli-
international units/mL, and 1,394 milli-international
units/mL, respectively.
CONCLUSIONS: Improvements in ultrasonographic
technology have led to lower threshold b-hCG values
for ultrasonographic visualization of early intrauterine
gestational structures. However, discriminatory levels
for serum b-hCG levels were higher than values currently
used in practice.
(Obstet Gynecol 2013;121:65–70)
DOI: http://10.1097/AOG.0b013e318278f421
LEVEL OF EVIDENCE: II
M any women experience vaginal bleeding and
pain in the first trimester of pregnancy. Esti-
mates for first-trimester bleeding range from 15% to
25%, with roughly half of these pregnancies ending in
miscarriage by 20 weeks of gestation.1,2 A woman
presenting with these symptoms may have a normal
intrauterine pregnancy, embryonic death, or ectopic
pregnancy. The increased availability of diagnostic
technology has led to evaluation of pregnancies at
early gestational ages to better assess these symp-
toms.3–13 This technology includes the measurement
of b-hCG and the use of ultrasonography.
Although the discriminatory level describes the
serum b-hCG level at which ultrasonographic findings
should be detected, the threshold level for b-hCG
refers to the lowest serum b-hCG level at which an
ultrasonographic finding such as a gestational sac or
fetal pole can be detected. The concept of the discrim-
inatory “zone” was first described by Kadar and col-
leagues3 in relation to visualization of a gestational sac
with the use of transabdominal ultrasonography at a b-
hCG level of 6,500 milli-international units/mL. With
the development of transvaginal ultrasonography, pro-
gressively lower discriminatory levels of b-hCG were
found to be associated with normally developing intra-
uterine pregnancies. These levels ranged from 1,000
OBSTETRICS & GYNECOLOGY 65
milli-international units/mL to 2,000 milli-international
units/mL.4–14 A discriminatory b-hCG zone commonly
used in clinical practice, 1,500–2,000 milli-international
units/mL, is derived from the work of Barnhart et al.8
These authors followed 68 consecutive pregnancies in
women with reliable menstrual histories who ovulated
spontaneously. Repeat ultrasonographic studies and
serum b-hCG levels were performed serially until a ges-
tational sac was visualized. The phase of this study dur-
ing which this discriminatory zone was established
(“Phase I”) did not evaluate women presenting with pain
or bleeding, and thus may not be generalizable to the
clinical settings where ultrasonography is commonly
used.8 Of note, serum b-hCG levels have been mea-
sured over the years using the First International Refer-
ence Preparation, the Second International Standard, the
Third International Standard, and the Fourth Interna-
tional Standard. The Second International Standard pro-
duces values that measure approximately half the value
of the First International Reference Preparation, the
Third International Standard, and Fourth International
Standard. All b-hCG levels reported in this article are
referenced against the First International Reference
Preparation, the Third International Standard, or
the Fourth International Standard. Changes in ultraso-
nography technology over the past 15 years have
resulted in improved diagnostic capabilities. We hypoth-
esized that these improvements would result in both
lower discriminatory and threshold b-hCG values in
the first trimester of pregnancy. We performed a retro-
spective cohort study to evaluate the effect of these
changes on discriminatory and threshold b-hCG levels
in the first trimester of pregnancy.
MATERIALS AND METHODS
After receiving approval by the Office of Human
Research Ethics at the University of North Carolina,
we performed a retrospective cohort study of all
women presenting to the Emergency Department at
the University of North Carolina with vaginal bleed-
ing, pelvic pain, or both in the first trimester of
pregnancy from August 1, 2007, through July 31
2009. Women in whom transvaginal ultrasonography
and serum b-hCG levels (Third International Stan-
dard) were performed within 6 hours of each other
were included in the analysis. Those with an ectopic
pregnancy, multiple gestation, suboptimal scanning
conditions (eg, uterine leiomyomas), or unknown
pregnancy outcome were excluded from further anal-
ysis. For women for whom data from multiple visits
were available, only the earliest visit was used in the
analysis.
66 Connolly et al Discriminatory b-hCG Levels
Viable intrauterine gestations were defined by the
presence of fetal cardiac activity at the time of the
initial or follow-up ultrasonograms or the delivery of
a live neonate or stillbirth whose gestational age
corresponded with that predicted by the original
ultrasonogram. Nonviable intrauterine pregnancies
were defined by any of the following: 1) the presence
of a gestational sac with a mean sac diameter 20 mm
or greater without ultrasonographic visualization of
a fetal pole; 2) a crown rump length of greater than or
equal to 5 mm without ultrasonographic documenta-
tion of cardiac activity; 2) a falling serum b-hCG level
within 1 week of the initial b-hCG; 4) a negative
serum bhCGb-hCG or urine pregnancy test within
3 months; or 5) documentation of a “failed preg-
nancy” in an operative report. Operative reports,
rather than pathology reports, were used because
these were uniformly available for chart review, which
was not the case for pathology reports. All surgical
procedures were performed within the University of
North Carolina health care system.
Transvaginal ultrasonography examinations were
performed by registered diagnostic medical ultra-
sonographers from the department of radiology or
the prenatal diagnostic ultrasound unit in the depart-
ment of obstetrics and gynecology at the University of
North Carolina. All studies were reviewed by a board-
certified maternal-fetal medicine physician with expe-
rience in the interpretation of first-trimester obstetric
ultrasonograms who made the determination of the
presence of a gestational sac, yolk sac, and fetal pole.
Ultrasonographic examinations were performed using
a 8- to 9-MHz vaginal transducer on a GE Logic E8,
Acuson Sequoia, Siemens S2000, or Phillips IU22
ultrasonography machine.
Serum b-hCG levels were reported according to
the Third International Reference Preparation and all
samples were analyzed in the same laboratory.
To determine the threshold for detection of
a gestational sac, yolk sac, and fetal pole, we analyzed
all viable pregnancies and identified the lowest serum
b-hCG level at which these structures were identified.
To determine discriminatory levels, we used logistic
regression to model the association between b-hCG
value and visualization of a gestational sac, yolk sac,
and fetal pole using fractional polynomials.15 Frac-
tional polynomials allow for a nonlinear association
between a continuous parameter and an outcome of
interest. We selected the parameterization with the
best fit based on the log likelihood test. We used the
resulting models to identify the b-hCG value at which
there would be a 50%, 90%, 95%, and 99% probability
of visualizing each structure in a viable pregnancy.
OBSTETRICS & GYNECOLOGY
We defined confidence intervals (CIs) as the b-hCG
value at which the lower and upper 95% CIs for visu-
alizing each structure was 50%, 90%, 95%, or 99%.
SAS 9.2 was used for all analyses.
RESULTS
During the study period, 1,015 women presenting with
vaginal bleeding, pain, or both in the first trimester of
pregnancy had an ultrasonogram and serum b-hCG
level performed within 6 hours of each other. In this
series, 295 cases were excluded (160 pregnancies with
unknown outcomes, 92 ectopic pregnancies, and 43
pregnancies excluded for other reasons such as multi-
ple gestation and suboptimal scanning conditions). For
women for whom data from multiple visits were avail-
able (n569), only the earliest visit was used in the
analysis. As such, a total of 651 pregnancies (366 via-
ble, 285 nonviable) were analyzed.
The majority of nonviable pregnancies had low
levels of b-hCG. However, there were nonviable
pregnancies seen with b-hCG levels as high as
122,000 milli-international units/mL. As expected,
higher b-hCG levels were associated with a greater
proportion of ultimately viable pregnancies.
Prior work has defined the discriminatory level as
the highest b-hCG value where a given structure
Fig. 1. Predicted probability and
95% confidence interval (CI) of
detecting gestational sac (A), yolk
sac (B), and fetal pole (C) from
a logistic regression model among
viable pregnancies. Open circles
represent individual observations
for which the structure was seen
(probability51) or not seen (prob-
ability50). Serum b-human cho-
rionic gonadotropin (b-hCG) values
in milli-international units/mL.
Connolly. Discriminatory b-hCG
Levels. Obstet Gynecol 2013.
VOL. 121, NO. 1, JANUARY 2013
should be visualized on ultrasonography. In our pop-
ulation, the highest observed values at which struc-
tures were not visualized in ultimately viable
pregnancies were 2,317 milli-international units/mL,
9,975 milli-international units/mL, and 35,486 milli-
international units/mL for gestational sac, yolk sac,
and fetal pole, respectively.
We further used logistic regression with frac-
tional polynomials to model the association between
serum b-hCG level and visualization of a gestational
sac, yolk sac, and fetal pole. Using these models, we
identified the b-hCG level for which the predicted
probability of visualizing each structure was 50%,
90%, 95%, and 99% (Fig. 1; Table 1). We defined
the modeled discriminatory b-hCG value as the
value at which there was a 99% probability of visu-
alizing these structures in a viable pregnancy. In our
sample, the modeled discriminatory b-hCG values
were 3,510 milli-international units/mL, 17,716
milli-international units/mL, and 47,685 milli-
international units/mL for gestational sac, yolk sac,
and fetal pole.
Using a serum b-hCG level of 1,500 milli-
international units/mL, the predicted probability of
seeing a gestational sac in a viable pregnancy was
80.4% (95% CI 56.5–92.8%). Using the previously
Connolly et al Discriminatory b-hCG Levels 67
Table 1. Serum b-Human Chorionic Gonadotropin Levels and Predicted Probability of Detection in Viable
Intrauterine Gestations (n5366)
b-hCG Level for Given Predicted Probability (95% CI) of Visualizing Structure*
Highest
b-hCG
Where
Structure
50% 90% 95% 99% Not Seen

Gestational 879 (553–1,310) 1,918 (1,368–3,970) 2,363 (1,641–5,201) 3,510 (2,294–8,910) 2,317
sac
Yolk sac 1,826 (1,211–2,516) 5,412 (3,843–9,037) 7,832 (5,293–15,007) 17,716 (10,264–48,132) 9,975
Fetal pole 10,091 (7,753–12,619) 24,599 (20,120–31,982) 30,982 (25,021–41,374) 47,685 (37,346–66,919) 35,486
b-hCG, b-human chorionic gonadotropin; CI, confidence interval.
* Logistic regression model using fractional polynomials to quantify the association between serum b-hCG level and probability of
visualizing each structure through transvaginal ultrasonography. Gestational sac and fetal pole modeled using b-hCG0.5.

reported b-hCG threshold of 2,000 milli-international
units/mL, the predicted probability reached 91.2%
(95% CI 77.6–99.4%). All discriminatory values were
higher than those previously reported (Table 2).
The lowest b-hCG value at which a gestational
sac was visualized in a viable pregnancy, the threshold
value, was 390 milli-international units/mL. The
threshold values for yolk sac and fetal pole visualiza-
tion were 1,094 milli-international units/mL and
1,394 milli-international units/mL, respectively, in
viable pregnancies (Table 2).
DISCUSSION
This is the first study of which we are aware using
cross-sectional data to specifically establish discrimi-
natory and threshold serum b-hCG levels in a large
population of patients presenting with pain, bleeding,
or both using current ultrasonographic technology.
Lower threshold values than previously reported were
found for visualization of a gestational sac, yolk sac,
and fetal pole, reflecting the use of higher frequency
ultrasonographic probes. However, the discrimina-
tory levels were higher than previously reported for
all three structures, reflecting the limitations of ultra-
sonography in clinical practice rather than a controlled
research environment. In addition, we reported 50%,
90%, 95%, and 99% probabilities for visualization of
three early first-trimester ultrasonographic findings.
These values may allow clinicians to better counsel
patients about the likelihood of an ultimately viable
gestation, which could affect clinical care positively.
Although previous work by Doubilet and Benson
examined 202 patients over an 11-year period and
found that all nine of the women with b-hCG levels
2,000 milli-international units/mL or higher had ultra-
sonographically confirmed intrauterine pregnancies,
this work did not examine threshold and discrimina-
tory levels for each of the three early gestational struc-
tures seen ultrasonographically.16
As expected, improvements in ultrasonography
technology over the past 10–15 years, including the
routine use of 8- to 12-MHz probes, have resulted in
lower threshold values for the detection of early intra-
uterine pregnancy findings. The threshold value of 390
milli-international units/mL for gestational sac, the ear-
liest ultrasonographically visible pregnancy structure,

Table 2. Discriminatory and Threshold Values: Serum b-Human Chorionic Gonadotropin Levels
Prior Studies4–14 (Milli-International
Current Study (99% Predicted Probability of Units/mL Reported as First International
Detection, Milli-International Units/mL, Reference Preparation or Third
Reported as Third International Standard) International Standard)

Discriminatory values
Gestational sac 3,510 1,000–2,000
Yolk sac 17,716 7,200
Fetal pole 47,685 5,100–10,800
Threshold values
Gestational sac 390 500–1,000
Yolk sac 1,094 5,600
Fetal pole 1,394 24,000

68 Connolly et al Discriminatory b-hCG Levels OBSTETRICS & GYNECOLOGY

was lower than previously reported. Values for yolk sac
(1,094 milli-international units/mL) and fetal pole
(1,394 milli-international units/mL) were markedly
lower than in previous studies (Table 2).4–13 Unexpect-
edly, however, we found that the discriminatory b-hCG
levels for visualization of early gestational structures
were higher than previously reported.4–14 Particularly,
our cross-sectional study found that, in our population,
the b-hCG level associated with a 99% predicted prob-
ability of detecting an intrauterine gestational sac was
3,510 milli-international units/mL. Previously reported
original evidence, much of which was obtained through
longitudinally conducted work, had placed the b-hCG
discriminatory zone at a lower level of 1,000–2,000
milli-international units/mL.4–6,8–14 Potential explana-
tions for these findings include the limitations of actual,
cross-sectional, clinical practice; patient discomfort;
patient anatomy; duration of the examination; and
delayed rather than real-time visualization of ultrasono-
graphic images by physicians.
Previous reports that established currently used
discriminatory b-hCG values4–6,8–12,14 were character-
ized by small sample size (10–74 pregnancies) and
were performed in the late 1980s and early 1990s
using 3.5- to 7.5-MHz probes.4–6,8–12,14 This prior
work was often longitudinal in study design.5,6,8,12,14
Patients were followed serially with transvaginal ultra-
sonographic examinations and serum b-hCG levels in
controlled research settings until the ultrasonographic
findings under study were detected. Previous work by
Barnhart et al13 examining 333 consecutive pregnant
women who presented to the emergency department
investigated the diagnostic accuracy of a discrimina-
tory level commonly used in clinical practice, 1,500
milli-international units/mL; however, they did not
seek to report on individual discriminatory levels for
early gestational structures.
The serum b-hCG level is widely used in clinical
practice to inform medical decision-making regarding
the location or viability of a pregnancy on the basis of
a single clinical encounter. Many have reported the
limitations of such use of a single b-hCG level and
ultrasonographic examination.13,16–19 This underlines
the importance of discriminatory b-hCG levels that
are associated with high probabilities of detecting
early gestational structures. We found that the serum
b-hCG level associated with 99% probability of detec-
tion of a gestational sac was 3,510 milli-international
units/mL, higher than the current discriminatory
level. Use of the previously reported b-hCG level of
1,500 milli-international units/mL as the discrimina-
tory value for patients in this study would have
detected only 80% of the ultimately viable pregnan-
VOL. 121, NO. 1, JANUARY 2013
cies with the potential mismanagement of up to 20%
of viable pregnancies as nonviable gestations. Even at
the higher b-hCG value of 2,000 milli-international
units/mL, the predicted probability reached only
91.2%. Serum b-hCG levels associated with 99%
probability of detection of a yolk sac and a fetal pole
were 17,716 milli-international units/mL and 47,685
milli-international units/mL, respectively.
This study has several limitations, including
variation in ultrasonographer ability and ultrasono-
graphic equipment, although all ultrasonographers
were registered diagnostic medical ultrasonographers
and all ultrasonographic studies were performed
with a minimum of an 8-mHz transvaginal probe.
Although patients with suboptimal scanning condi-
tions were not included in this study, there were
variations in image quality based on maternal factors
such as body habitus and discomfort. All of these
limitations are inherent to clinical practice. Given
strict imaging criteria and the high level of training of
ultrasonographers and physicians, the discriminatory
levels described in this work are likely the lowest that
should be used in general clinical practice.
In conclusion, improvements in ultrasonographic
technology have lowered threshold values for ultra-
sonographic visualization of a gestational sac, yolk
sac, and fetal pole in the first trimester. However,
currently used discriminatory serum b-hCG levels are
too low for use in clinical practice and may result in
the underdiagnosis of ultimately viable gestations.
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