Pregnancy of unknown location

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What is a pregnancy of unknown location (PUL)?

You have had an ultrasound, based on your positive pregnancy test and any symptoms that brought you to the clinic. This was to check that your pregnancy was developing normally.

Following this scan we have not been able to localise your pregnancy. We will perform blood tests today and then blood tests in 48 hours to determine a trend.

Please ensure that you give us your correct contact number so that we can telephone you with the results and next steps with regards to your plan of care.

What are the causes of a PUL?

There are three possible reasons for a PUL. We will discuss each of these with you and support you through the process.

Very early pregnancy

The pregnancy may be normal but too small to be seen because we are scanning you too early into your pregnancy. This is not unusual especially in patients that are unsure of their dates or those with irregular or long cycles.

Miscarriage

The pregnancy loss may have occurred prior to the ultrasound scan. This will usually be associated with vaginal bleeding which may not be heavy if the pregnancy loss occurred very early. The pregnancy hormones will however remain in your body for a while after a miscarriage and gradually disappear. Your urinary pregnancy test can remain positive for up to 10 days after a pregnancy loss, and you can continue to ‘feel’ pregnant.

Ectopic pregnancy

This is when the pregnancy forms outside the womb, usually in the fallopian tube. This is a potentially dangerous situation and may be difficult to diagnose on ultrasound scan in the early stages. It is very important for this reason that you are carefully monitored to allow the early diagnosis of an ectopic pregnancy before internal bleeding occurs or to rule it out.

How will I be monitored?

We will request that you give us a blood sample to measure your pregnancy hormone levels. We will then compare both results and explain the potential implications of these results.

If the initial blood sample is high we may counsel you and consent you for a diagnostic laparoscopy (looking into the tummy with a telescope). This is more likely to be the case if you are experiencing abdominal pains or at increased risk of a ectopic pregnancy as established from your past medical history.

If at subsequent scans we see that the pregnancy is within the womb and looks to be developing normally then we need do nothing further and you should not experience any further problems. Sadly we may also see that your pregnancy hormone levels start to fall and this will show that the pregnancy is failing. In the majority of women (over 97%) the pregnancy will then be reabsorbed naturally and there will be no need for any more treatment. You may have some further bleeding during this time.

What should I do if I have pain or bleeding?

Please attend the emergency department if you develop pain, abdominal bloating, faintness, pain or pressure with opening your bowels or shoulder tip pain.

Please bring the documentation given to you by us and the specialist doctor will assess you and decide on the most appropriate management. We advise that you contact us through the telephone numbers given below.

Until the diagnosis of the location of the pregnancy is confirmed, we advise that you avoid any strenuous activity and long distance travel. We also advise that you do not have sexual intercourse.

NHS Choices 111 when you need medical help fast but it’s not a 999 emergency. The service is available 24 hours a day, 365 days a year. Calls are free from landlines and mobile phones.

Contact numbers

If you have bleeding and /or pain you can get medical help and advice from:
• Your GP or midwife who may advise you to go to hospital
• Your nearest EPU
• Referral into the Early pregnancy unit is based on assessment by a health professional

References:

• BSUH NHS TRUST(2011) GP001 Early Pregnancy Unit Clinical Guidelines.
• Patient UK Information leaflets Women’s Health Category
• Royal College of Obstetricians and Gynaecologists 
• National institute for Heath and Clinical Excellence