The expectant management of women with early pregnancy of unknown location

Background: Pregnancy of unknown location (PUL) is defined as the absence of intrauterine or extrauterine sac and Beta Human Chorionic Gonadotropin levels (β-HCG) above the discriminatory zone of 1500 mIU/ml. It should be noted that PUL is not always an ectopic; however, by measuring the trends of serum β-HCG, we can determine the outcome of a PUL. Objective: This study aims to identify the various trends β-HCG levels in early pregnancy and evaluate the role of β-HCG in the management strategy. Methods: We conducted a prospective observational study of pregnant women suspected with early pregnancy. Cases were classified as having a pregnancy of unknown location (PUL) by transvaginal ultrasound and ß-HCG greater than 1000 mIU/ml. Expectant management was done until there was a definite outcome. All the collected data were analyzed by employing the chi-square test using SPSS version 20. Results: Among 1200 women who had early first trimester scans, 70 women who fulfilled our criteria of PUL and ß-HCG > 1000 mIU/ml were recruited in this study. In our study, the mean age of the participants was 30±5.6yrs, and the overall mean serum ß-HCG was 3030±522 mIU/ml. The most common outcome observed was an ectopic pregnancy, 47% in our study. We also found the rate of failing pregnancy was 27%, and that of intrauterine pregnancy (IUP) was 25%. Overall, in PUL patients diagnosed with ectopic pregnancy, 9% behaved like IUP, and 4% had an atypical trend in their ß-HCG. Those who had an IUP, 11% had a suboptimal increase in ß-HCG. Conclusion: PUL rate in our unit was 6%. Majority of the outcome of PUL was ectopic in our study. Every case of PUL should be managed based on the initial ß-HCG values, clinical assessments and upon the consent of the patient.

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Pregnancy of unknown location: outcome in a tertiary care teaching hospital

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20172532 ◽

2017 ◽

Vol 6 (7) ◽

pp. 2787

Author(s):

A. Shanti Sri ◽

P. Kalpana

Keyword(s):

Ectopic Pregnancy ◽

Early Pregnancy ◽

Tertiary Care ◽

Expectant Management ◽

Transvaginal Sonography ◽

Intrauterine Pregnancy ◽

Care Teaching ◽

Asymptomatic Patients ◽

Pain Outcome ◽

Pregnancy Of Unknown Location

Background: A pregnancy of unknown location (PUL) is a descriptive term used to classify a woman when she has a positive pregnancy test but no intra- or extra-uterine pregnancy is visualized on transvaginal sonography. The objective of present study was to find out the outcome of women with pregnancy of unknown location presenting to a tertiary care teaching hospital.Methods: The prospective study was conducted from from 1st October 2015 to 31st September 2016, to antenatal out-patient department, at Princess Esra Hospital, Deccan College of medical sciences, Hyderabad. Data was collected for women with early pregnancy or with history of amenorrhea, bleeding or pain. These women were investigated with serum beta-human chorionic gonadotrophin levels at interval of 48 hrs and transvaginal ultrasonography. Expectant management was done for failing pregnancy of unknown location while medical or surgical management was considered for persistent pregnancy of unknown location and ectopic pregnancy.Results: During study period, 9210 patients were admitted, and, of them, 960 (10.42%) were patients with early pregnancy. Meeting the inclusion criteria were 112 (11.6%) patients who formed the study sample. There were 104 (92.85%) patients presenting with amenorrhea, 98 (87.5%) had bleeding and 78 (69.64%) presented with pain. Outcome of 42 (48.83%) patients was failing pregnancy, 31 (36.04%) had intrauterine pregnancy, 8 (9.3%) converted to ectopic pregnancy, while 5 (5.81%) had persistent pregnancy of unknown location. All patients with persistent pregnancy of unknown location and 3 patients with ectopic pregnancy were medically treated. Three patients having an ectopic pregnancy were managed surgically.Conclusions: Management of choice for asymptomatic patients having pregnancy of unknown location is expectant management. Most of the patients suspected to have PUL resolved either into F-PUL or IUP with expectant management.

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Perspectives on self-managed abortion among providers in hospitals along the Texas–Mexico border

BMC Women s Health ◽

10.1186/s12905-021-01281-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Sarah Raifman ◽

Sarah E. Baum ◽

Kari White ◽

Kristine Hopkins ◽

Tony Ogburn ◽

...

Keyword(s):

Early Pregnancy ◽

Pregnancy Termination ◽

Expectant Management ◽

Clinical Intervention ◽

Structured Interviews ◽

Local Resources ◽

Provider Experiences ◽

Study Team ◽

Mexico Border ◽

Provider Knowledge

Abstract Background Following self-managed abortion (SMA), or a pregnancy termination attempt outside of the formal health system, some patients may seek care in an emergency department. Information about provider experiences treating these patients in hospital settings on the Texas-Mexico border is lacking. Methods The study team conducted semi-structured interviews with physicians, advanced practice clinicians, and nurses who had experience with patients presenting with early pregnancy complications in emergency and/or labor and delivery departments in five hospitals near the Texas-Mexico border. Interview questions focused on respondents’ roles at the hospital, knowledge of abortion services and laws, perspectives on SMA trends, experiences treating patients presenting after SMA, and potential gaps in training related to abortion. Researchers conducted interviews in person between October 2017 and January 2018, and analyzed transcripts using a thematic analysis approach. Results Most of the 54 participants interviewed said that the care provided to SMA patients was, and should be, the same as for patients presenting after miscarriage. The majority had treated a patient they suspected or confirmed had attempted SMA; typically, these cases required only expectant management and confirmation of pregnancy termination, or treatment for incomplete abortion. In rare cases, further clinical intervention was required. Many providers lacked clinical and legal knowledge about abortion, including local resources available. Conclusions Treatment provided to SMA patients is similar to that provided to patients presenting after early pregnancy loss. Lack of provider knowledge about abortion and SMA, despite their involvement with SMA patients, highlights a need for improved training.

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Expectant management of incomplete miscarriage, anembryonic pregnancy and early fetal demise: a comparative study

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20203100 ◽

2020 ◽

Vol 9 (8) ◽

pp. 3144

Author(s):

Reshma Sajan K. K. ◽

Mumtaz P. ◽

Chandrika C. V. ◽

Abdul Vahab ◽

Hassan Sheikh Imrana

Keyword(s):

Success Rate ◽

Early Pregnancy ◽

Tertiary Care ◽

Expectant Management ◽

First Line ◽

Proper Selection ◽

Fetal Demise ◽

Incomplete Miscarriage ◽

Selection Of ◽

Anembryonic Pregnancy

Background: Expectant management as first line management of early pregnancy miscarriages is less accepted due to failure and increased complications reported in few studies. Proper selection of cases improves outcome of expectant management. Aim of this study was to compare success rate and complications in expectant management in three groups of early pregnancy miscarriages- Incomplete miscarriage, anembryonic pregnancy and early fetal demise.Methods: Prospective observational study conducted in tertiary care centre for 3 years, including 107 patients with USG confirmed pregnancy miscarriage <13 weeks. Patients preferring expectant management were managed as outpatient without intervention for 2 weeks after which repeat USG was done to ascertain complete miscarriage. Failed expectant management patients underwent planned surgical uterine evacuation. Emergency admission and evacuation was done, if symptomatic during waiting period. Success rate and complications like emergency evacuation, vaginal bleeding, abdominal pain, limitation of physical activity and patient satisfaction were assessed and compared in subgroups of anembryonic pregnancy, early fetal demise and incomplete miscarriage. Statistical analysis was done by chi-square test.Results: Incomplete miscarriage group had highest success rate of 88.46%. followed by anembryonic pregnancy (72.5%) and EFD (47.83%) p value = 0.007. Complication rate was highest in EFD, followed by anembryonic and the least in incomplete miscarriage all of which was statistically significant except vaginal bleeding.Conclusions: Expectant management should be offered as first line choice for all types of early pregnancy miscarriages. Proper selection of case as to type of miscarriage especially incomplete miscarriage and selected cases of anembryonic pregnancy and EFD ensures higher success rate with lesser complications. Reserving medical and surgical management for unsuitable/failed cases.

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Pregnancy of Unknown Location and Ectopic Pregnancy

10.2310/obg.19004 ◽

2018 ◽

Author(s):

Bri Anne McKeon ◽

Sarah Lambeth

Keyword(s):

Early Pregnancy ◽

Treatment Strategies ◽

Current Treatment ◽

Reproductive Age ◽

Women Of Reproductive Age ◽

Early Evaluation ◽

Diagnostic Strategies ◽

Ectopic Pregnancies ◽

Review Current ◽

Pregnancy Of Unknown Location

The ability to diagnose early pregnancy and manage normal and abnormal findings associated with early pregnancy is important and commonly used in the medical care of women of reproductive age. The purpose of this review is to describe the evaluation of early pregnancy, discuss indications for early evaluation of pregnancy location, delineate diagnostic strategies to further evaluate pregnancy of unknown location, and review current treatment strategies for ectopic pregnancies, both tubal and nontubal in location. This review contains 11 figures, 4 tables and 39 references Key words: early pregnancy, ectopic, human chorionic gonadotropin, methotrexate, pregnancy of unknown location, salpingectomy, salpingostomy, ultrasound criteria, vaginal bleeding

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Neutrophil/Lymphocyte Ratio: Predictive Biomarker for Outcomes of Early Pregnancy of Unknown Location [7L]

Obstetrics and Gynecology ◽

10.1097/01.aog/01.aog.0000559241.24126.c6 ◽

2019 ◽

Vol 133 (1) ◽

pp. 130S-130S

Author(s):

Anubha Arora ◽

Sharifa Menon ◽

Ayodeji Sanusi ◽

Kolawale Felix Akinnawonu ◽

Abhishek Kumar ◽

...

Keyword(s):

Early Pregnancy ◽

Predictive Biomarker ◽

Neutrophil Lymphocyte Ratio ◽

Lymphocyte Ratio ◽

Pregnancy Of Unknown Location

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Predictors of complete miscarriage after expectant management or misoprostol treatment of non-viable early pregnancy in women with vaginal bleeding

Archives of Gynecology and Obstetrics ◽

10.1007/s00404-020-05672-6 ◽

2020 ◽

Vol 302 (5) ◽

pp. 1279-1296

Author(s):

Anna Fernlund ◽

Ligita Jokubkiene ◽

Povilas Sladkevicius ◽

Lil Valentin

Keyword(s):

Logistic Regression ◽

Early Pregnancy ◽

Gestational Age ◽

Vaginal Bleeding ◽

Treatment Success ◽

Expectant Management ◽

Crown Rump Length ◽

Multivariable Logistic Regression ◽

Vaginal Deliveries ◽

Gestational Sac

Abstract Purpose To identify predictors of complete miscarriage after expectant management or misoprostol treatment of non-viable early pregnancy in women with vaginal bleeding. Methods This was a planned secondary analysis of data from a published randomized controlled trial comparing expectant management with vaginal single dose of 800 µg misoprostol treatment of women with embryonic or anembryonic miscarriage. Predefined variables—serum-progesterone, serum-β-human chorionic gonadotropin, parity, previous vaginal deliveries, gestational age, clinical symptoms (bleeding and pain), mean diameter and shape of the gestational sac, crown-rump-length, type of miscarriage, and presence of blood flow in the intervillous space—were tested as predictors of treatment success (no gestational sac in the uterine cavity and maximum anterior–posterior intracavitary diameter was ≤ 15 mm as measured with transvaginal ultrasound on a sagittal view) in univariable and multivariable logistic regression. Results Variables from 174 women (83 expectant management versus 91 misoprostol) were analyzed for prediction of complete miscarriage at ≤ 17 days. In patients managed expectantly, the rate of complete miscarriage was 62.7% (32/51) in embryonic miscarriages versus 37.5% (12/32) in anembryonic miscarriages (P = 0.02). In multivariable logistic regression, the likelihood of success increased with increasing gestational age, increasing crown-rump-length and decreasing gestational sac diameter. Misoprostol treatment was successful in 80.0% (73/91). No variable predicted success of misoprostol treatment. Conclusions Complete miscarriage after expectant management is significantly more likely in embryonic miscarriage than in anembryonic miscarriage. Gestational age, crown-rump-length, and gestational sac diameter are independent predictors of success of expectant management. Predictors of treatment success may help counselling women with early miscarriage.

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