Pregnancy of unknown location

Question 1

Definition

Answer 1

Positive pregnancy test/serum hCG >5 with no sign of intrauterine or ectopic pregnancy or retained products of conception

Question 2

Outcomes of PUL

Answer 2

Early intrauterine pregnancy (too small for visualisation on scan)
Complete miscarriage
Failing PUL that will resolve on own without appearance on scan
Ectopic pregnancy
Persistent PUL
hCG-secreting tumour (very rare)

Question 3

Management (general)

Answer 3

Dependent on symptoms

Question 4

Management of suspected PUL with pain and haemoperitoneum

Answer 4

Laparoscopy

Question 5

Management of suspected PUL without red flag symptoms

Answer 5

Test hCG and progesterone levels on day of first scan, repeat 48hrs later and follow up at later stage

Question 6

What does progesterone <20nmol/L suggest?

Answer 6

Failing pregnancy

Question 7

What does hCG rise >66% in 48hrs suggest?

Answer 7

Normal pregnancy; arrange rescan when likely >1500 or 10-14 days later

Question 8

What does hCG rise <66% - or plateau - in 48hrs suggest?

Answer 8

Monitor until <15 or consider rescan with senior team

Question 9

What if hCG is plateauing/fluctuating?

Answer 9

Senior advice after 2-3 serial hCGs; if asymptomatic continue expectant management or offer methotrexate