2Specialist, Department of Obstetrics &Gynecology, RIPAS, Bandar Seri Begawan, Brunei Darussalam
3Specialist, Oasis Hospital Al Ain Abu Dhabi, United Arab Emirates
4Medical officer, Department O&G, RIPAS, Bandar Seri Begawan, Brunei Darussalam
53rd Year Medical Student, Father Muller Medical College, Mangalore, India
6Specialists, O&G, Oasis Hospital, Al Ain, Abu Shabi, UAE
7MSC Statistics, University of Karachi Pakistan
8Senior Director Medical and Regulatory and Business Development, Hilton Pharma Pvt Ltd. Pakistan
9Medical Officer, JSMU. Pakistan
10Senior Lecturer Department of Physiology, Altibri Medical College, Pakistan
Objective: To determine the prevalence of pregnancy of unknown location (PUL) and its outcome.
Method: A prospective case series study of pregnant women with suspected early pregnancy complication was carried out. Cases were classified as having a pregnancy of unknown location (PUL) by transvaginal ultrasound. Blood sample was taken on presentation to measure the serum beta human chorionic gonadotropins. Expectant management was done until the pregnancy resulted in predefined outcomes. All collected data were analyzed by employing chi square test using SPSS version 20.
Result: Among 2038 women who were referred for suspected early pregnancy complication, 124(6%) women with a PUL were recruited into this study. The mean age of the study participants was29.98±5.79 years whereas the mean serum b HCG level was 1446±1079.63iu/l. Out of total 2038 patients, 124 (6%) were diagnosed with pregnancy of unknown location (PUL). 13 (10.48%) of them had a previous history of ectopic pregnancy, 32 (26%) had previous history of miscarriage whereas 16(13%) had previous history of Caesarean section. After stratifying with respect to symptoms, significant differences were observed between the occurrences of various pregnancy outcomes (p=0.001).
Conclusion: The study findings revealed that only 6%of the patients were diagnosed with pregnancy of unknown location (PUL). Furthermore, after stratifying with respect to medical history, duration of disease, symptoms, parity and age, significant differences was observed between the occurrences of various pregnancy outcomes for symptoms only.
Keywords: Pregnancy of unknown location; Ectopic Pregnancy; Ultrasonography; Intrauterine Pregnancy and Miscarriage
This study was intended to determine the prevalence of pregnancy of unknown location (PUL) and its outcome. Furthermore it was aimed to identify its association with age and clinical features.
The exclusion criteria were visualization of any Intrauterine pregnancy(IUP), Identification of an adnexal mass that was thought to be ectopic, blood in pouch of Douglas on the initial scan, visualization of retained product of conception through the speculum and clinically unstable patient and patients with an acute abdomen. In our study the serum beta HCG levels of 25U/L represented positive pregnancy test. Level of beta HCG was measured again after 48 hours as per study protocol. The follow up consisted of monitoring of the clinical features; measurement of serum beta HCG levels every 48 hours and valuation of TVS findings. These women were followed until the final diagnosis was established as a failing PUL, an intrauterine pregnancy (IUP) or an ectopic pregnancy. Data were collected prospectively only from women classified as having a PUL.
Management of pregnancies of unknown location led to four possible outcomes i.e. spontaneous resolution, ectopic pregnancy, IUP and persisting PUL. Normal pregnancy was diagnosed when gestational sac was visualized on TVS within endometrial cavity. These women were re-scanned 7-10 days later to confirm viability. Miscarriage was diagnosed either histological following surgical evacuation of the uterine content or on ultrasound examination in pregnancies that progressed to develop a demonstrable intrauterine gestational sac that subsequently failed in the first trimester. Ectopic Pregnancies were diagnosed on follow up when TVS revealed a heterogeneous mass seen in the adnexal region adjacent to the ovary, a mass with a hyper echogenic ring around the gestational sac or the presence of embryo with or without a heartbeat in the adnexal accompanied by raised serum level of beta human chorionic gonadotropins. Spontaneous resolution was defined by a reduction in serum b HCG levels to < 25 iu/l with a complete resolution of symptoms without the need for any therapeutic intervention so the location of pregnancies therefore remained unknown.
Data were cleaned and then analyzed through the SPSS version 20.Meansand standard deviations were calculated for continuous variables such as age, duration of disease and beta HCG level. Frequencies and percentages were calculated for categorical variables like the outcome of the PUL and medical history of ectopic pregnancy, miscarriage, Caesarean Section, symptoms and parity. Stratification with respect to age, parity, duration of disease and symptoms was done. Post stratification Chi-square test was applied for univariate analysis of all the parameters. P < 0.05 was taken as significant.
At follow up the observed outcome of these124 patients revealed that 44 (35%) cases had spontaneous resolution, 40 cases (32%) were diagnosed to have ectopic pregnancy, 22 (18%) cases were diagnosed with normal intrauterine true pregnancies with positive pregnancy test, 13 cases (10%) had miscarriage of an IUP and 5 cases (4%) remained as cases of persisting PUL. Surgical interventions were required only in 20(16.1%) cases; 2(1.61%) uterine curettages in the miscarriage group, 12(9.6%) laparoscopy and 6(4.8%) laparotomies for treatment of ectopic pregnancies, whereas 10(8.1%) patients received MXT. The mean follow up period was 6 weeks (ranged from 4 to 14 weeks).
After stratifying with respect to medical history, duration of disease, parity and age, no significant differences was observed between the occurrences of various pregnancy outcomes whereas after stratifying with respect to symptoms, significant differences were observed between the occurrences of various pregnancy outcomes (p=0.001) (Figure 1) (Table 1).
Variables |
Failing Pregnancy (n=44) |
Ectopic Pregnancy (n=40) |
Intrauterine Pregnancy (n=22) |
Miscarriage(n=13) |
Persisting Pregnancy of Unknown Location((n=05)) |
Overall((n=124)) |
P-values |
Age |
30.62±6.04 |
30±5.63 |
27.90±5.43 |
32.18±6.91 |
30.5±3.01 |
29.98±5.79 |
--------- |
b HCG level |
869.18±105.74 |
1925.08±1184.04 |
1399.1±1115.28 |
1596.14±1293.98 |
1468±988 |
1446±1079.63 |
--------- |
Medical history |
|||||||
Ectopic |
5(11.36%) |
8(20%) |
- |
- |
- |
13(10.48%) |
0.125 |
Miscarriage |
9(20.45%)) |
10(25%) |
4(18.18%) |
6(46.15%) |
3(60%) |
32(25.80%) |
|
Caesarean section |
5(11.36%) |
8(20%) |
1(4.54%) |
2(15.38%) |
- |
16(12.90%) |
|
Duration of disease |
|||||||
≤ 6 weeks |
25 |
24 |
18 |
3 |
4 |
6.29±2.24 |
0.069 |
7―8 weeks |
14 |
12 |
2 |
6 |
1 |
(4―12) |
|
>8 weeks |
5 |
4 |
2 |
4 |
0 |
||
Symptoms |
|||||||
GA |
10 |
8 |
5 |
- |
2 |
25(20.16%) |
0.001 |
Bleed |
29 |
17 |
5 |
10 |
2 |
63(50.80%) |
|
LAP |
5 |
10 |
12 |
3 |
1 |
31(25%) |
|
Triad |
- |
5 |
- |
- |
- |
5(4%) |
|
Parity |
|||||||
Nullipara |
12 |
15 |
12 |
4 |
4 |
47(37.90%) |
0.068 |
Multipara |
18 |
18 |
9 |
4 |
1 |
50(40.32%) |
|
Grandpara |
14 |
7 |
1 |
5 |
0 |
27(21.77%) |
|
Age |
|||||||
Less than 26 years |
11 |
12 |
9 |
3 |
- |
35(28.23%) |
0.324 |
26―35 years |
24 |
19 |
12 |
7 |
5 |
67(54.03%) |
|
Above 35 years |
9 |
9 |
1 |
3 |
- |
22(17.74%) |
Literature suggests that only some cases require diagnostic laparoscopy or uterine curettage to determine the location of pregnancy but there is no consensus on what is an acceptable intervention rate in this group. In this study, only 20(16.1%) women required surgical intervention; 12(9.6%) laparoscopies were performed and 6(4.8%) laparotomies to treat ectopic pregnancies while only 2(1.61%) cases required uterine evacuation in the miscarriage group. However, an expectant management is appropriate for patients who are hemodynamically stable.
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