PREGNANCY OF UNKNOWN LOCATION DR. SHARDA JAIN DR. JYOTI AGARWAL DR. JYOTI BHASKAR WHY THIS PPT ?? One of our of patient’s was discharged home with presumed COMPLETE miscarriage. Subsequently returned with pain abdomen , bleeding & ruptured EP …We thought of reviewing PRENANCY OF UNKNOWN LOCATION

1. PREGNANCY OF
UNKNOWN LOCATION
DR. SHARDA JAIN
DR. JYOTI AGARWAL
DR. JYOTI BHASKAR
…Caring hearts, healing hands

2. WHY THIS PPT ??
One of our of patient’s was
discharged home with presumed
COMPLETE miscarriage.
Subsequently returned with pain
abdomen , bleeding & ruptured EP
…We thought of reviewing
PRENANCY OF UNKNOWN LOCATION
…Caring hearts, healing hands

3. DEFINITION
of PRENANCY of UNKNOWN LOCATION
When the human chorionic gonadotropin (HCG)
test or URINE PREGNANCY TEST is Positive
BUT
ULTRASOUND fails to confirm an intrauterine nor
ectopic pregnancy.
…The women is said to have a
Pregnancy of Unknown Location(PUL)
…Caring hearts, healing hands

4. NOT TO FORGET…..
The incidence of PULs is dependent not
only upon the expertise of the examiners
& the adequacy of the ULTRASOUND
evaluation but also upon gestational age .
As women presenting earlier in
pregnancy , more PULs are reported.
…Caring hearts, healing hands

5. PREGNANCY OF UNKNOWN
LOCATION
The diagnostic possibilities in this setting are:
• A normal intrauterine pregnancy that is too
early to be visualized.
• A failed intrauterine pregnancy (miscarriage)
• An ectopic pregnancy.
…Caring hearts, healing hands

6. IT IS A FACT…..
Some ECTOPIC PREGNANCY are too small to be
visualized on UTRASOUND in very early
pregnancy.
But on follow up…..
In good 6% to 20 % cases of apparent
miscarriage on ultrasound,
may actually be diagnosed as ECTOPIC
PREGNANCY on follow up
…Caring hearts, healing hands

7. STUDIES OF PULs
In 1999 Banerjee & colleagues
Reported an 8% incidence (135 cases) of PULs in
their series of first trimester ULTRASOUNDS.
On follow – up
14% of these turned out to be ECTOPIC
PREGNANCY;
9% resulted in MISCARRIAGE;
Sited ultrasound obstet gynecol 14:231-236,1999.

8. ANOTHER STUDY OF PULs
• Kirk & Bourne reported
• that in 8% to 31% cases of early pregnancies ,
the gestation sac will not be visualized on the
initial TVS .
• The vast majority of PULs are eventually found
to be IUPs or failed IUPs & only approximately
7% to 20% are Ectopic pregnancies
…Caring hearts, healing hands

9. P U L s
Follow – up is very very important .
There is no reliable method by which to predict.
which PULs are Intra Uterine Pregnancy & will
either progress normally or miscarry
&
which PULs are Ectopic Pregnancy & of these ,
which Ectopic pregnancy will spontaneously
resolve & which are likely to rupture.
…Caring hearts, healing hands

10. CAUTION & TIP
It is therefore incorrect to assume that
because the B- hCG level is low , an
ECTOPIC PREGNANCY is unlikely or stable
or to assume that an EP is too small to
visualize & thus not perform an
ULTRASOUND.
…Caring hearts, healing hands

11. GREAT TIP FOR DIAGNOSIS OF PUL
Care must be taken not to rely on
a “single HCG level” to distinguish
intrauterine pregnancy from failed
intrauterine pregnancy
or
an ectopic pregnancy
…Caring hearts, healing hands

12. Do not use serum hCG measurement ONLY
to determine the location of the pregnancy.
It should be interpreted
along with the
ULTRASOUND findings
…Caring hearts, healing hands

13. IMPORTANT OBSERVATION
In TRANS ABDOMINAL SONOGRAPHY….
i/u sac suggestive of normal pregnancy is seen
at B HCG levels of 6500 IU
In TRANS VAGINAL SONOGRAPHY
i/u sac is seen when B HCG levels are > 1500 IU
TVS IS NOW THE MODALITY OF CHOICE
…Caring hearts, healing hands

14. *Please Remember
The progression of trans-vaginal sonography
findings in normal early first trimester
pregnancies follows a highly predictable
pattern,
• with a gestational age variability of
approximately ±.5 week:
• gestational sac at 5.0 weeks,
• yolk sac at 5.5 weeks,
• embryo with heartbeat at 6.0 weeks &
• amnion at 7.0 weeks
…Caring hearts, healing hands

15. ANOTHER TIP
Consider an earlier TRANS VAGINAL
scan for women with a
serum HCG level > 1500 IU
…Caring hearts, healing hands

16. Caution& Tip – which pays in the
long run
Please involve Senior Gynaecologists
in patient’s care as two minds are
better than one
…Caring hearts, healing hands

17. DECIDING FACTOR
Take 2 serum HCG measurements
48 hours apart (and not earlier)
to determine subsequent management.
**Three options**
*DOUBLE or > 66 %---NORMAL PREG is possibility
** >50 % BUT <66 %---Failing pregnancy..but
ectopic pregnancy can be equal possibility.
*** <50 %--Failing pregnancy or ectopic pregnancy

18. Can Serum Progesterone
levels help ??
For women with a PUL , when using
serial serum hCG measurements , do
not use serum progesterone as an
adjunct to diagnose either viable
intrauterine pregnancy or ectopic
pregnancy .

19. Progesterone
mmol/L
>60
Viable IUP
>20
Probable
failing PUL
Repeat HCG in
1W

20. MANAGEMENT TIPS
Management is based on BHCG and TVS findings
There are 4 possible clinical outcomes. They are:
1.FAILING PREGNANCY .
B-HCG levels increase is less than 63 %..
No treatment is required..except close follow up to R/O ECTOPIC
PREGNANCY
2.AN INTRAUTERINE PREGNANCY
if B-HCG levels are over 63 %....
A normal pregnancy is most likely…Normal antenatal care is offered unless
a woman opts for termination.
RCOG Guideline No .25,10-2006

21. MANAGEMENT TIPS
3.AN ECTOPIC PREGNANCY
PROMPT MANAGEMENT in setting of classical symptoms & signs
4.Persisting PUL….
Expectant management by repeating weekly scans & repeated
serum HCG levels 2-3 days is helpful.
This avoids unnecessary intervention.
A worsening clinical situation or excessive bleeding may require
surgical treatment
…Caring hearts, healing hands

22. EXPERTS feel Interpretation 0f 2-HCG
levels 48Hrs apart helps a lot…
For a women with an increase in serum B-HCG
concentration greater than 66% or double.... after 48
hrs….
 Inform her that she is very likely to have a developing
Intrauterine pregnancy (although the possibility of an
ectopic pregnancy cannot be excluded with 100%
surety)
 Offer her TVS [trans vaginal sonography) to determine
the location of the pregnancy 7 and 14 days later.

23. FAILING PREGNANCY
Failing pregnancy if a viable
Intra Uterine pregnancy is not
confirmed on ULTRASOUND
RCOG Guideline 2006 …Caring hearts, healing hands

24. ECTOPIC PREGNANCY (EP)
In a patient suspected of having an EP, quantitative
serum hCG levels & TVS are used in conjunction for
diagnosis.
It is reasonable to proceed with TVS while the
quantitative serum Hcg is being measured .
EXPERTS report that up to 50% of ruptured ECTOPIC
Pregnancy have extremely low hCG levels (<1000
miu/ml) & that B- hCG level do not necessarily
correlate with risk of rupture in EP
…Caring hearts, healing hands

25. Access Emergency Care 24 x7
is very very important
 Please advise women to report immediately if
there are new symptoms or if existing symptoms
worsen.
 Please give her the phone number and the name of
the hospital she needs to contact in emergency in
writing
 This can help avert a life threatening condition…
RCOG Guideline No .25,10-2006

26. COUNSELLING is Must
for 24 hours EMERGENCY CARE
Provide her with oral and written
information about 24 hours emergency care
where she can access medical Treatment
and counselling services.
Ask her to take a urine pregnancy test 14
days after the second serum HCG test
…Caring hearts, healing hands

27. COUNSELLING
For a women with a serum HCG concentration just
greater than 50% after 48 hours but not exceeding
63%......
If live I/U pregnancy is not confirmed
Inform her that the pregnancy is unlikely to
continue.
Let her do URINE PREGNANCY TEST after 2 weeks
&Repeat TVS TOO
…Caring hearts, healing hands

28. INNTERPRETATION OF
URINE PREGNANCY TEST AFTER 2 WEEKS
*If the test is negative no further
action is necessary
**If the test is positive ,she should
be evaluated for normal early
pregnancy assessment
…Caring hearts, healing hands

29. Interpretation of 2 HCG levels & NO
INTRAUTERINE Pregnancy on ULTRSOUND
<1500
<35%
Probable EP
Laparoscopy
<63%
Possible E
Serial HCG / TVS until
diagnosis made or HCG
reach <15 IU/L
>63% more
Possible
IUP
US in
2W
>1500
Probable E
Laparoscopy
…Caring hearts, healing hands

30. WORD OF WISDOM
• PUL should be considered and treated as an ectopic
pregnancy until the location is determined.
• Place more importance on clinical symptoms than on
serum HCG results & review the women’s condition.
• If any of her symptoms change or her condition
worsens, Consider Ectopic pregnancy, regardless of
previous results & assessments.
…Caring hearts, healing hands

31. SUMMARY
• In 8-20% of patients on their First Ultrasound
in Early pregnancy , Pregnancy may not be
identified….They are called PUL
• Follow up of these patients is essential as
15-20% of them may be Ectopic Pregnancy
• Serial BHCG and TVS are the main stay for
their follow up
SUMMARY
…Caring hearts, healing hands

32. ONLY IF YOU ARE ALERT TO THE
POSSIBILITY OF ECTOPIC
PREGNANCY…….
LOOK FOR AND DIAGNOSE IT EARLY
&
BE THE ONE TO SAVE A LIFE
…Caring hearts, healing hands

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Karkari Morh Flyover,
Delhi - 51
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9650588339
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9599044257
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