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Pregnancy of unknown location (PUL) (Pathophysiology (B-hCG is secreted…
Pregnancy of
unknown location (PUL)
Definition
No sign of an interuterine pregnancy,
ectopic pregnancy, or retained products of
conception in presence of +ve B-hCG
Epidemiology
10% EPAU
Aetiology
Neoplastic
hCG-secreting tumour (RARE)
Developmental
Early IUP
Failing/persisting PUL
Ectopic pregnancy (10%)
Complete miscarriage
Clinical
presentation
Abdominal pain
PV bleeding
Asymptomatic
Diagnosis
Examination
Abdominal
Tenderness, guarding, bloating
Pelvic/bimanual
Adnexal tenderness, cervical excitation,
bleeding, discharge
Speculum
Cervix open/closed, cervicitis/vaginitis,
blood in vagina
Investigation
Bedside
Obs (BP, HR, RR, sats, temp)
Urine
Pregnancy tests (-ve/+ve)
Urine (dipstick, MCS)
Bloods
FBC, U+E, LFTs, clotting,
crossmatch, group and save
Hormones: PG (low=failing; high=success);
B-hCG (low=failing, plateau=ectopic; doubling 48h=viable)
Imaging
TV USS: empty uterus, unclear location
Laparoscopy:
History
PGH
Menses, bleeding, contraception,
STIs/PID, smears
POH
Gravity/parity, previous ectopics/miscarriages,
conception, delivery, gestation, complications
Current pregnancy
Gestation, scans/bloods,
problems, health in preg
PMH
Known conditions, abdo/pelvic surgery
PC/HPC
Abdo pain, bleeding,
N+V, fever, syncope
DH
Current medications
Allergies
FH
Miscarriages, ectopics
Uterine abnormalities
Cancers
SH
Occupation, social support,
smoking, alcohol, drugs
Pathophysiology
B-hCG is secreted by trophoblast, very similar to LH;
acts to sustain the corpus luteum
B-hCG detectable early in pregnancy
Normal pregnancy
Rises quickly, especially at 4-8w (doubles every 48h)
Less predictable >8w, should be raised but can fluctuate
Relative change important rather than absolute level
Discriminatory zone - level at which should be visible on USS is not absolute, requires expert sonographers
Management
Investigate and
manage cause