Evaluation of PUL in a hemodynamically stable patient with a desired pregnancy

PUL is a term used to describe the clinical scenario in which a patient with a positive pregnancy test has a TVUS that shows neither an IUP nor an ectopic pregnancy. PUL may be asymptomatic or present with vaginal bleeding and/or abdominal pain. This algorithm does not apply to hemodynamically unstable patients or those with uncommon or rare etiologies including, but not limited to, the following: malignancy (eg, invasive mole, choriocarcinoma), pituitary hCG production, heterophilic antibodies. These are described in related UpToDate content. Patients with PUL and an undesired pregnancy are also managed differently.

PUL: pregnancy of unknown location; hCG: human chorionic gonadotropin; TVUS: transvaginal ultrasound; IUP: intrauterine pregnancy; MTX: methotrexate; IVF: in vitro fertilization.

* TVUS may be repeated sooner in patients with new or worsening symptoms or when the discriminatory zone is reached. The discriminatory zone is the serum hCG level above which a gestational sac should be visualized when an IUP is present. It varies by laboratory and institution and can range from 2000 to >3500 milli-international units/mL. Approximately 1% of IUPs will not be visualized on TVUS when the discriminatory zone is set at 3510 mIU/mL.

¶ Laparoscopy may also be performed in patients with an adnexal mass.

Δ Risk factors for ectopic pregnancy include, but are not limited to, prior ectopic pregnancy, prior tubal pathology or surgery (eg, pelvic inflammatory disease or tubal ligation), current use of an intrauterine device, and IVF.

Reference:

Barnhart KT, Guo W, Cary MS, et al. Differences in Serum Human Chorionic Gonadotropin Rise in Early Pregnancy by Race and Value at Presentation. Obstet Gynecol 2016; 128:504.

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Evaluation of PUL in a hemodynamically stable patient with a desired pregnancy