Pregnancy of Un-Known Location: Need for Evolving New Protocols for DGH Units

Research Article

Austin J Obstet Gynecol. 2017; 4(5): 1088.

Pregnancy of Un-Known Location: Need for Evolving New Protocols for DGH Units

Rafi J* and Khalil H

Department of Obstetrics and Gynecology, Ipswich Hospital NHS Trust, UK

*Corresponding author: Junaid Rafi, Department of Obstetrics and Gynecology, Ipswich Hospital NHS Trust, Heath Road, UK

Received: November 20, 2017; Accepted: December 12, 2017; Published: December 19, 2017

Abstract

Aims: To find out the timeline for diagnosis and outcome of pregnancy of unknown location PUL cases. To find out the approach for accuracy of diagnosis and to prevent doing unnecessary scan follow ups and βHCG tests.

Methods: Prospective observational study over one year period between January 2015 and January 2016

Results: In this study 50 patients were included and six patients were excluded as they didn’t meet the criteria. The Intra-Uterine Pregnancy (IUP) was diagnosed in 28% (n=14). The suboptimal βHCG was seen in 11% (n=5) patients, who later were diagnosed with ectopic pregnancy. The remaining 56% (n=25/44) patients unfortunately had failing IUP, and none of them were labelled as persistent PUL.

The number of βHCG tests undertaken in Ectopic group ranged from 3-8, compared to 2-6 times in failing IUP group whereas in IUP cohort it remained one to two tests. Similarly, we found that number of pelvic scan required for making diagnosis in three above-mentioned groups varied. Our study data revealed that each patient had 2-4 scans in Ectopic group, and 1-3 scans needed in Failing IUP.

Conclusion: To reach the final definite diagnosis / outcome in PUL cases in set time limit may not be possible in some atypical presentation of early pregnancy problems especially when the aim is to avoid un-necessary scans, follow ups and blood test without compromising the safety. Therefore we suggested a new local protocol for diagnosing and managing atypical presentations outcome will be possible from and in our study, it took 5 to 9 days durations.

Keywords: Pregnancy Un-known Location (PUL); Ectopic pregnancy

Background

Ascertaining pregnancy location is the key determinant for streamlining management for patients presenting with abdominal pain or bleeding in early pregnancy. However sometimes in spite of all efforts finding the location of gestation sac is difficult and such cases have been classified categorised as Pregnancy of Unknown Location (PUL).

As locating early pregnancy is dependent on many factors therefore incidence of PUL varies in different setup. According to recent reports the Specialist unit reported that to around 8-10% vs. 8-31% in non-specialist Unit [1].

The lack of well accepted consensus for diagnostic criteria for PUL is reflected by differences in the management strategies of PUL.

The possibility of missing an ectopic pregnancy in the course of PUL management may lead to higher rate of maternal mortality and morbidity, likelihood of requiring a surgical intervention.

It can adversely affect patients’ and health professionals’ confidence for any management of PUL.

The main concern remains the potential interventions of a PUL case which may be a viable intrauterine pregnancy.

PUL case reports in UK makes it evident that most hospitals are lacking a clear and predictable PUL managing tool. However the PUL outcome data is very encouraging from hospitals that have developed clear PUL care pathways incorporating reliable diagnostic criteria.

Only few UK units have opted their PUL management based on a clear predictive tool including widely accepted hormone tests.

We conducted a prospective study to review PUL managed cases and aimed to propose a PUL management pathway and thereby reducing variation.

Aim

The aim was to find out the timeline for diagnosis and outcome of PUL cases and to propose the prompt and effective approach for PUL diagnosis. Also wanted to find out the pattern and frequency of scans and BHCG in PUL cases.

Criteria

PUL cases were identified if there was no evidence of intrauterine or extra uterine pregnancy on first transvaginal ultrasound scan (5-6 week gestation) in women with a positive pregnancy test.

Methods

This was a prospective observational study, including all patients attending EGAU (Early Gynaecology Assessment Unit) who were diagnosed as PUL between January 2015 and January 2016 at District General Hospital, and cases were followed up for object analysis of outcome.

Results

Fifty patients who attended EGAU were included in this PUL study. Six patients were excluded as they didn’t meet the criteria of PUL study protocol. The 28% (n=14) found to have Intra-Uterine Pregnancy (IUP).

The suboptimal βHCG rise was seen in 11% (n=5) patients, who later were diagnosed with ectopic pregnancy. The remaining 56% (n=25/44) patients failing IUP and none of them were labelled as persistent PUL (Figure 1).