Pregnancy of Unknown Location

Question 1

What is pregnancy of unknown location (PUL)?

Answer 1

When there is no sign of intrauterine pregnancy, ectopic pregnancy of retained products in the presence of a positive pregnancy test

Question 2

What are the possible explanations for PUL?

Answer 2

Early intrauterine pregnancy 
Failing PUL (early intrauterine or ectopic pregnancies which will fail)
Early ectopic pregnancy
Complete miscarriage 
hCG secreting tumour

Question 3

In which scenarios are you more lily to have higher hCG levels?

Answer 3

Multiple pregnancies (high hCG even before pregnancy can be visualised)

Molar pregnancies (very high hCG levels)

Question 4

At what rate do hCG levels usually increase in weeks 4-8 in pregnancy?

Answer 4

Levels will usually double every 72 hours.
OR
66% rise over 48h

Question 5

What could be the cause if hCG is not increasing at the rate it should be?

Answer 5

Suggestive of ectopic pregnancy

Question 6

Which markers are suggestive of a failing PUL?

Answer 6

If hCG levels are not increasing at the correct rate/ are falling.

If progesterone is less than 20nmol/L

Question 7

Define ectopic pregnancy?

Answer 7

When the embryo implants outside the uterine cavity

Question 8

What is the most common implantation sites in ectopic pregnancies?

Answer 8

Tubes (95%)

Question 9

What is the classical presentation of an ectopic pregnancy?

Answer 9

8 week amenorrhoea followed by mild lower abdominal pain.

Vaginal bleeding.

Referred shoulder tip pain (diaphragmatic irritation form haemoperitoneum)

Collapse

Question 10

How should you initially manage a stable patient with a suspected ectopic pregnancy?

Answer 10

Initial management:

• IV access
• X match
• Anti D to be given if patient is rhesus negative and not already sensitised
• Nil by mouth

Question 11

What are the treatment options in a stable patient with suspected ectopic pregnancy?

Answer 11

Medical:
Only if ectopic is enruptured has no cardiac activity and has hCG levels less than 1500IU/ml.

Single dose of methotrexate. Requires follow up hCG levels. 15% of women will need a 2nd dose and 10% will require surgery.

Surgical:
-Laparoscopic salpingostomy (remove ectopic but not tube)
OR
-Laparoscopic salpingectomy (remove whole tube)
If other tube is normal fertility rates are similar.

Question 12

What is the management of an unstable patient with a suspected ectopic pregnancy?

Answer 12

ABC resus

Surgery:
Laparoscopic salpingectomy (if operator is experienced)
OR
Laparotomy with salpingectomy