PUL

Question 1

You receive a consult on a 21 y/o G1 presents with a missed period x 2 weeks, vaginal bleeding, and cramping. What is the probability that she may have an ectopic pregnancy?

Answer 1

7-20% symptomatic PUL will have an ectopic

Question 2

By her irregular LMP, she is 6 w 3d. You order a pelvic ultrasound. What should you expect to see by this gestational age?

Answer 2

If LMP correlates with a GA 5w5d, then a GS should be seen regardless of singleton or multiple gestation or beta value.

On the flip side, don’t scan an asymptomatic pregnant women prior to 5w5d to avoid confusion of PUL.

Question 3

The ED team orders an initial sets of labs, including a progesterone. How will the progesterone assist with diagnoses?

Answer 3

Progesterone level <6ng/mL indicates an abnormal gestation (EP or SAB) w/ 99% certainty.

Question 4

Her BHCG returns 734 with no GS or adnexal masses. What would be your recommendation at this time?

Answer 4

Schedule 48 hour BHCG

Question 5

For a normal IUP, what is the average versus minimal rise of BHCG in 48 hrs?

Answer 5

The 1st %ile will increase by 35% in 48hrs

99th %ile will increase by 53% in 48 hrs

Question 6

Give the absolute minimum expected rise (1st %ile) depending on the initial BHCG:
<1500 = ___
1500-3000 = ___
>3000 = ___

Answer 6

<1500 = 49%
1500-3000 = 40%
>3000 = 33%

General rule: Lower betas will rise at a higher rate. Higher betas will rise at a lower rate.

Question 7

Her 48 hr beta returns 1,027. What is your next step?

Answer 7

How to calculate % increase:
New - original / original x 100%

Increase of 39%. Likely normal IUP. Can plan for repeat US in 1-2 weeks to look for GS. Give return precautions.

Of note: EP 21% have a similar rise to IUP/ 8% have a similar decline to SAB.
Using three betas instead of two correctly classicifed IUPs below discriminatory zone

Question 8

You see her back in 1.5 weeks. Her BHCG is 4200. What would you expect to see on US?

Answer 8

Discriminatory zone for desired pregnancies should be >3500 (GS visualized, 99%ile)

Of note: Prior use of 1500 cut off would identify only 80% of viable pregnancies and lead to a 20% misdx.

Question 9

You see an IUP with GS, + yolk sac. She is no longer symptomatic. What would be your next step?

Answer 9

Repeat US in 11 days to look for CRL and FHM

Of note: If no yolk sac was seen, repeat US in 14 days to look for CRL and FHM

Question 10

You receive a consult on a 28 y/o G2P1001 with IUP at 5w1d by LMP presenting with bleeding and cramping. Os closed with blood in the vault. + No IUP or adnexal masses. Her BHCG today is 1200. This is highly desired.

If this was a SAB, what would you expect your BHCG decline to look like?

Answer 10

· Avg 35-50% after 48hrs / 66-87% at D7

· No dx of EP were made if beta declined >85% in 4 days or >95% in 1 week

In general, SAB’s drop FAST compared to ectopics. The drop is depending on initial BHCG. Higher BHCG’s will drop faster.

Question 11

In 48 hours, her BHCG dropped by 40%.

How often would you check her BHCG’s?

Answer 11

Beta fall 15-30% over 48hr suggests nonviable pregnancy, regardless of location.

oPUL downtrending beta can check q week with >15% fall as adequate

o Days to beta <5 ranged from 12-16d (about 2 weeks)

Question 12

Let’s say in 48 hours, her BHCG dropped by 10%.
Your suspicion of ectopic is increased.

How can you change your followup BHCG pattern to increase EP prediction?

Answer 12

EP dx prediction increased by 7-13% if a third beta is added whether on D4 or D7

Slowest (95th %ile) decline for SABs · 21-35% red in 2 days · 60-84% red in 7 days

o <1% risk of rupture while trending, none occurred in the studies

o EP 23% can mimic decline rate of SABs and EP trends are unpredictable.

Question 13

How accurate is not seeing CV on endometrial sample in confirming ectopic pregnancy?

Answer 13

D&C confirmed- 73% had EP/ 27% confirmed IUP

However, No CV on endometrial sample does not confirm ectopic location. 15-40% can be missed with histopath analysis.

Question 14

For persistent PUL, BHCG’s are plateauing up or plateauing down.

What is the risk of EP? What is the risk of SAB?

Answer 14

> 50% risk of EP/ rest SAB

Question 15

For persistent PUL, what are your management options?

Answer 15

· Tx preference/style depends on geographic location and training

· Tx usually D&C - If +CV, SAB is your diagnosis. If no CV, can consider MTX or expectant.

Of note: If + SAB, you should anticipate BHCG at least 15% q week.