Pregnancy of unknown location

Question 1

How is a PUL diagnosed?

Answer 1

Working diagnosis

Empty uterus with no evidence of an adnexal mass on TVUSS (in a patient with a postive pregnancy test)

Question 2

How common is PUL diagnosis?

Answer 2

Studies report that 5–42% of women attending for an ultrasound assessment in early pregnancy will be classified as having a PUL.

However reports from specialized early pregnancy units describe lower PUL rates of 8–10%.

Question 3

How does PUL present?

Answer 3

• pelvic pain
• vaginal bleeding

+ positive pregnancy test

Question 4

What are the 3 possibilities with PUL?

Answer 4

1. Very early intrauterine pregnancy – this means the pregnancy is in the correct place but too small to see on scan
2. Miscarriage – this means the pregnancy has ended and the developing tissue has already passed out of the body
3. Ectopic pregnancy – this means the pregnancy is developing outside the uterus.

Question 5

How is PUL diagnosed?

Answer 5

Initial US will be “normal” with no intrauterine pregnancy and normal adnexa.

Question 6

What is the management of PUL?

Answer 6

Methotrexate/surgical intervention are not recommended in a hemodynamically-stable patient.

• Serial measurement of hCG every 48hrs
• Serum progesterone
• Repeat US at appropriate intervals

If hCG levels are static an endometrial biopsy should be done. MUST be iinvestigated to determine the location of the pregnancy

Question 7

What change in bHC is significant?

Answer 7

Change in concentration between 50% decline and 63% rise inclusive over 48 hours

= should be referred for clinical review in an EPAU within 24 hours

Question 8

What progesterone is significant in PUL?

Answer 8

<5 ng/mL is a good indicator of non-viability

however, larger values cannot exclude an ectopic pregnancy