{"id":3297,"date":"2021-01-08T12:52:36","date_gmt":"2021-01-08T17:52:36","guid":{"rendered":"https:\/\/obgconnect.com\/library\/?p=3297"},"modified":"2024-12-30T20:40:26","modified_gmt":"2024-12-31T01:40:26","slug":"pregnancy-of-unknown-location","status":"publish","type":"post","link":"https:\/\/obgconnect.com\/library\/2021\/01\/08\/pregnancy-of-unknown-location\/","title":{"rendered":"Pregnancy of Unknown Location"},"content":{"rendered":"\n<ul class=\"wp-block-list\">\n<li><a href=\"#key-points\">Key Points<\/a><\/li>\n\n\n\n<li><a href=\"#background\">Background<\/a>\n<ul class=\"wp-block-list\">\n<li><a href=\"#diagnosis\">Diagnosis<\/a><\/li>\n\n\n\n<li><a href=\"#treatment\">Treatment<\/a><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><a href=\"#primary-sources\">Primary Sources<\/a>\n<ul class=\"wp-block-list\">\n<li><a href=\"#gracia-barnhart\">Gracia and Barnhart<\/a><\/li>\n\n\n\n<li><a href=\"#seeber\">Seeber et al.<\/a><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><a href=\"#recommendations\">Professional Recommendations<\/a><\/li>\n\n\n\n<li><a href=\"#references\">References<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/obgconnect.com\/library\/2020\/03\/29\/labor-and-delivery-table-of-contents\/\"><strong>ObG L&amp;D<\/strong> Table of Contents<\/a><\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"key-points\">KEY POINTS: <\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Have a high index of suspicion for ectopic pregnancy in any premenopausal woman with abnormal uterine bleeding and pain<\/li>\n\n\n\n<li>Pregnancy of unknown location requires follow up and a diagnosis<\/li>\n\n\n\n<li>If patient is clinically stable and pregnancy is desired\n<ul class=\"wp-block-list\">\n<li>Repeat transvaginal ultrasound and\/or serial measurement of quantitative hCG (qHCG)<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>If patient is clinically unstable, surgical management is warranted (uterine aspiration, laparoscopy, and \/or laparotomy)<\/li>\n\n\n\n<li>The goal of diagnosing an ectopic pregnancy is to make the determination before rupture, allowing conservative, medical treatment\n<ul class=\"wp-block-list\">\n<li>Obtain blood type and Rh status on all women suspected of ectopic pregnancy and all Rh-negative women with bleeding should receive anti-D immune globulin (RhoGam), regardless of the final outcome of the pregnancy<\/li>\n\n\n\n<li>Choice of uterine aspiration for diagnosis should be based on <a href=\"https:\/\/www.contemporaryobgyn.net\/view\/why-shared-decision-making-matters-more-than-ever?utm_source=sfmc&amp;utm_medium=email&amp;utm_campaign=11_18_20_COG_SYN-19-COD0196_%20HOL-20-COP0108_COG_eNL_US_Only&amp;eKey=anZhbmRpc0BnbWFpbC5jb20=\" target=\"_blank\" rel=\"noreferrer noopener\">shared decision making<\/a><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"background\">BACKGROUND:<\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Pregnancy of unknown location is defined as a pregnancy where intrauterine or ectopic location cannot be confirmed<\/li>\n\n\n\n<li>Over 90% of ectopic pregnancies are in the fallopian tube; the remainder can occur in the cervix, ovary, uterine cornua, or abdomen.<\/li>\n\n\n\n<li>Risk factors for ectopic pregnancy include (ACOG PB 193)\n<ul class=\"wp-block-list\">\n<li>Tubal surgery<\/li>\n\n\n\n<li>PID<\/li>\n\n\n\n<li>Previous ectopic pregnancy (10% with one previous ectopic rising to 25% with \u22652)<\/li>\n\n\n\n<li>Infertility<\/li>\n\n\n\n<li>Assisted reproductive technologies with multiple embryo transfer<\/li>\n\n\n\n<li>Previous pelvic\/abdominal surgery<\/li>\n\n\n\n<li>Age &gt;35 years<\/li>\n\n\n\n<li>Smoking<\/li>\n\n\n\n<li>Current IUD use<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p><strong>Note: <\/strong>IUDs are associated with fewer ectopics compared to women not using contraception because IUDs are such an effective method of birth control | However, if a woman does become pregnant with an IUD, the risk of an ectopic is approximately 50%<\/p>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"diagnosis\">Diagnosis<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Diagnosis of ectopic pregnancy versus failed intrauterine pregnancy depends on the following factors\n<ul class=\"wp-block-list\">\n<li>qHCG (beta-hCG) \u2018Discriminatory Level\u2019 \u2013 the level at which an intrauterine gestation can be seen via transvaginal ultrasound with a skilled sonographer<\/li>\n\n\n\n<li>Levels are specific to sonographers and equipment but generally are set between qHCG of 1500-3500<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p><em>qHCG Discriminatory Level<\/em><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Absence of gestational sac in the uterus above \u2018discriminatory level\u2019 has a PPV of 50 to 70% (based on a higher range qHCG level of 3500)<\/li>\n\n\n\n<li>Multiple gestation may have higher qHCG levels (&gt;2,000 mIU\/mL) before ultrasound evidence of pregnancy is visible<\/li>\n\n\n\n<li>Large fibroids can obscure an intrauterine gestation<\/li>\n\n\n\n<li>Even with a value of 4000 mIU\/mL, 5.6% of women had an early IUP that wasn\u2019t detected on ultrasound (Barnhart et al. Fertil Steril, 2015)<\/li>\n<\/ul>\n\n\n\n<p><em>Trending qHCG Levels<\/em><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Gestational sac with yolk sac in the uterus is normally visible between 5 to 6 weeks<\/li>\n\n\n\n<li>Nondiagnostic transvaginal ultrasound: Fails to show a gestational sac with yolk sac in the uterus or the adnexa\n<ul class=\"wp-block-list\">\n<li>Measure qHCG and then repeat it in 48 hours<\/li>\n\n\n\n<li>Repeat again every 2 to 7 days based on level\/pattern of qHCG results<\/li>\n\n\n\n<li>Higher the initial level, slower the expected rate of increase<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Expected qHCG rate increase (based on 99%ile rates, 99% of women with normal IUP will have a rise at this rate or faster [Barnhart et al. Obstet Gynecol, 2016])\n<ul class=\"wp-block-list\">\n<li>&lt;1,500 mIU\/mL: 49% increase rate<\/li>\n\n\n\n<li>1,500 to 3,000 mIU\/mL: 40% increase rate<\/li>\n\n\n\n<li>&gt;3,000 mIU\/mL: 33% increase rate<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>An increase in qHCG&nbsp; &lt;50% in 48 hours in an early pregnancy is very concerning but cannot determine location, i.e., ectopic vs intrauterine\n<ul class=\"wp-block-list\">\n<li>1% of patients with early viable pregnancies may not meet minimal increase thresholds in 48 hours<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p><em>Transvaginal Ultrasound (TVUS)<\/em><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>With ectopic pregnancy, fluid in the uterus mimicking a gestational sac, called a \u201cpseudosac\u201d\n<ul class=\"wp-block-list\">\n<li>For diagnosis of intrauterine pregnancy need to see double decidual sign or yolk sac on ultrasound<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Mass or hypoechoic area separate from the ovary is \u2018suspicious\u2019 but not diagnostic\n<ul class=\"wp-block-list\">\n<li>PPV is only 80%<\/li>\n\n\n\n<li>May be confused with paratubal cyst, corpus luteum, hydrosalpinx, endometrioma or bowel<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Once IUP is confirmed on TVUS, trending qHCG is no longer useful or diagnostic for success or failure of IUP<\/li>\n\n\n\n<li>Some IUP milestones\n<ul class=\"wp-block-list\">\n<li>Yolk sac should be visualized by a gestational sac of 1.5cm<\/li>\n\n\n\n<li>Fetal pole should be visualized by gestational sac of 2 cm | However, cannot be sure it is a blighted ovum until approximately 4 cm empty sac.<\/li>\n\n\n\n<li>Cardiac activity when embryo 1 to 2mm in length<\/li>\n\n\n\n<li>Absence of FCA when embryo measures &gt;7mm is diagnostic of pregnancy failure<\/li>\n\n\n\n<li>Absent embryo when mean sac diameter \u226525mm is diagnostic of pregnancy failure<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"treatment\">Treatment<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>If TVUS or qHCG is not available, or if clinical picture remains unclear\n<ul class=\"wp-block-list\">\n<li>Diagnostic endometrial aspiration to confirm chorionic villi may be necessary<\/li>\n\n\n\n<li>Patients should be counseled in advance that this will terminate the pregnancy if intrauterine<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p><em>Chorionic Villi Absent<\/em><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Monitor hCG levels 12 to 24 hours after aspiration<\/li>\n\n\n\n<li>hCG plateau (decrease &lt;10% to 15%) indicates the following possible scenarios\n<ul class=\"wp-block-list\">\n<li>Uterine evacuation incomplete<\/li>\n\n\n\n<li>Ectopic pregnancy, but not seen on ultrasound<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>hCG decrease \u226550%\n<ul class=\"wp-block-list\">\n<li>Monitor with serial hCG measurements<\/li>\n\n\n\n<li>Treat if patient becomes symptomatic or levels plateau or increase<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>hCG decrease between 15% and 50%\n<ul class=\"wp-block-list\">\n<li>Individualize treatment<\/li>\n\n\n\n<li>Follow-up with serial hCG measurements<\/li>\n\n\n\n<li>Treat if (1) patient becomes symptomatic, (2) levels plateau or increase, (3) there is clinical suspicion or (4) strong risk factors for ectopic pregnancy are present<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p><strong>Note: <\/strong>See Ectopic pregnancy management chapter (find link in \u2018Related Topics\u2019 below) for MTX and surgical management options<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"priamry-sources\">PRIMARY SOURCES:<\/h2>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"gracia-barnhart\">Gracia and Barnhart. Obstet Gynecol, 2001<\/h3>\n\n\n\n<p>A decision analysis compared multiple algorithms to determine the best approach for diagnosing ectopic pregnancy<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Data derived from women presenting with abdominal pain or bleeding in their first trimester<\/li>\n\n\n\n<li>Results\n<ul class=\"wp-block-list\">\n<li>Ideal strategy for diagnosing ectopic pregnancy while minimizing interruption of early IUP was TVUS followed by serial qHCG in those cases where the ultrasound was non-diagnostic<\/li>\n\n\n\n<li>Only 1% of IUPs were interrupted and average time to diagnosis was 1.46 days&nbsp;<\/li>\n\n\n\n<li>Progesterone did not prove to be a useful marker in this analysis as it was not specific for pregnancy location<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"seeber\">Seeber et al. Fertil Steril, 2006<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Publication that provides qHCG curves derived from a large cohort of patients to determine the validity of the curves and time to diagnosis<\/li>\n\n\n\n<li>Results\n<ul class=\"wp-block-list\">\n<li>By using the rate of change between 2 consecutive qHCG values vs a minimal rise of 35% (IUP curve) or minimal drop of 21 to 35% (SAB curve) the researchers were able to diagnose an ectopic pregnancy on average 2.5 days earlier than by standard clinical practice at the time&nbsp;<\/li>\n\n\n\n<li>12% of ectopic cases were diagnosed later, as the initial rise mimicked a normal pregnancy<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"recommendations\">PROFESSIONAL RECOMMENDATIONS:<\/h2>\n\n\n\n<h3 class=\"wp-block-heading\">ACOG PB 193<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>ACOG recommends that<\/li>\n<\/ul>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\">\n<p>A pregnancy of unknown location should not be considered a diagnosis, rather it should be treated as a transient state and efforts should be made to establish a definitive diagnosis when possible<\/p>\n\n\n\n<p>A woman with a pregnancy of unknown location who is clinically stable and has a desire to continue the pregnancy, if intrauterine, should have a repeat transvaginal ultrasound examination, or serial measurement of hCG concentration, or both, to confirm the diagnosis and guide management&nbsp; <\/p>\n<\/blockquote>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"references\">REFERENCES:&nbsp;<\/h2>\n\n\n\n<p><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/?term=24101604\" target=\"_blank\" rel=\"noreferrer noopener\">Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location (Kirk et al. Hum Reprod Update, 2014)<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/?term=24101604\" target=\"_blank\" rel=\"noreferrer noopener\">Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/m\/pubmed\/29470343\/\" target=\"_blank\" rel=\"noreferrer noopener\">ACOG Practice Bulletin 193: Tubal Ectopic Pregnancy\u202f<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/www.fertstert.org\/article\/S0015-0282(15)00608-1\/fulltext\" target=\"_blank\" rel=\"noreferrer noopener\">Don\u2019t discriminate: even a discriminatory zone as high as 4000 can result in interruption of an IUP (Barnhart et al. Fertil Steril, 2015)<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/27500326\/\" target=\"_blank\" rel=\"noreferrer noopener\">Differences in Serum Human Chorionic Gonadotropin Rise in Early Pregnancy by Race and Value at Presentation (Barnhart et al. Obstet Gynecol, 2016)<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/obgyn.onlinelibrary.wiley.com\/doi\/10.1111\/1471-0528.15468\" target=\"_blank\" rel=\"noreferrer noopener\">RCOG Scientific Impact Paper 58:&nbsp;Diagnostic Biomarkers for Predicting Adverse Early Pregnancy Outcomes<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK544906\/\" target=\"_blank\" rel=\"noreferrer noopener\">Nice guideline 126: Ectopic pregnancy and miscarriage: diagnosis and initial management<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/23849842\/\" target=\"_blank\" rel=\"noreferrer noopener\">ASRM: Medical treatment of ectopic pregnancy: a committee opinion<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/32044011\/\" target=\"_blank\" rel=\"noreferrer noopener\">Imaging of Acute Pelvic Pain: Pregnant (Ectopic and First-trimester Viability Updated)<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/11239658\/\" target=\"_blank\" rel=\"noreferrer noopener\">Diagnosing Ectopic Pregnancy: Decision Analysis Comparing Six Strategies (Gracia and Barnhart. Obstet Gynecol, 2001)<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/16753158\/\" target=\"_blank\" rel=\"noreferrer noopener\">Application of redefined human chorionic gonadotropin curves for the diagnosis of women at risk for ectopic pregnancy (Seeber et al. Fertil Steril, 2006)<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Pregnancy of unknown location is defined as a pregnancy where intrauterine or ectopic location cannot be confirmed<br \/>\nOver 90% of ectopic pregnancies are in the fallopian tube; the remainder can occur in the cervix, ovary, uterine cornua, or abdomen<\/p>\n","protected":false},"author":6,"featured_media":3368,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[91],"tags":[88,89,85,90],"class_list":["post-3297","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-gyn","tag-early-pregnancy","tag-ectopic","tag-methotrexate","tag-unknown-location"],"acf":[],"featured_image_urls_v2":{"full":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2021\/01\/leon-biss-FjAD28N8-IQ-unsplash-featured.jpg",400,265,false],"thumbnail":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2021\/01\/leon-biss-FjAD28N8-IQ-unsplash-featured-150x150.jpg",150,150,true],"medium":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2021\/01\/leon-biss-FjAD28N8-IQ-unsplash-featured-300x199.jpg",300,199,true],"medium_large":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2021\/01\/leon-biss-FjAD28N8-IQ-unsplash-featured.jpg",400,265,false],"large":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2021\/01\/leon-biss-FjAD28N8-IQ-unsplash-featured.jpg",400,265,false],"1536x1536":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2021\/01\/leon-biss-FjAD28N8-IQ-unsplash-featured.jpg",400,265,false],"2048x2048":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2021\/01\/leon-biss-FjAD28N8-IQ-unsplash-featured.jpg",400,265,false],"ultp_layout_landscape_large":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2021\/01\/leon-biss-FjAD28N8-IQ-unsplash-featured.jpg",400,265,false],"ultp_layout_landscape":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2021\/01\/leon-biss-FjAD28N8-IQ-unsplash-featured.jpg",400,265,false],"ultp_layout_portrait":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2021\/01\/leon-biss-FjAD28N8-IQ-unsplash-featured.jpg",400,265,false],"ultp_layout_square":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2021\/01\/leon-biss-FjAD28N8-IQ-unsplash-featured.jpg",400,265,false],"woocommerce_thumbnail":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2021\/01\/leon-biss-FjAD28N8-IQ-unsplash-featured-300x265.jpg",300,265,true],"woocommerce_single":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2021\/01\/leon-biss-FjAD28N8-IQ-unsplash-featured.jpg",400,265,false],"woocommerce_gallery_thumbnail":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2021\/01\/leon-biss-FjAD28N8-IQ-unsplash-featured-100x100.jpg",100,100,true]},"post_excerpt_stackable_v2":"<p>Pregnancy of unknown location is defined as a pregnancy where intrauterine or ectopic location cannot be confirmed<br \/>\nOver 90% of ectopic pregnancies are in the fallopian tube; the remainder can occur in the cervix, ovary, uterine cornua, or abdomen<\/p>\n","category_list_v2":"<a href=\"https:\/\/obgconnect.com\/library\/category\/labor-and-delivery\/gyn\/\" rel=\"category tag\">GYN Emergencies<\/a>","author_info_v2":{"name":"mharris","url":"https:\/\/obgconnect.com\/library\/author\/mharris\/"},"comments_num_v2":"0 comments","yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - 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