pregnancy of unkown location
TRANSCRIPT
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PREGNANCY OF UNKOWN LOCATION(PUL)
Dr. Omneya Nagy Elmakhzangy
Special Fetal Care unit
Ain Shams Univeristy
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What is PUL?
The term PUL is used whenever there is no sign of either intra or extrauterine pregnancy or retained products of conception on transvaginal ultrasound.
Up to 31% of women attending early pregnancy assessment centres have a PUL though the experience of the sonographer can reduce this to 10%.
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Positive Urine Pregnancy Test
Transvaginal ultrasound scan
PUL / Inconclusive scan
Haemodynamically stable Pain free
Haemodynamically stable in pain
Haemodynamically unstable in pain
Expectant management Admit and Serum hCG
Consider laparotomy
>66% increase in SerumhCG 0‐48 hours
<66% increase or <15%decrease in Serum hCG 0‐48 hrs
>15% decrease in SerumhCG 0‐48 hrs
? Intra Uterine Pregnancy ? Ectopic pregnancy
? Failing PUL
Serum hCG in 48 hrs.Rescan if hCG >1000 IU/L
Repeat serum hCG in 1week to confirm failing pregnancy
Early IUPEctopic
pregnancyPUL
Rescan 2 weeks toconfirm viability
Management asclinically indicated
Repeat hCG nowand 48 hrs later
Consider weekly hCG monitoring until < 25IU/L
If no pregnancy seen on repeat scan and suboptimal rise in hCG, consider methotrexate
Serum hCG at 0 & 48 hrs
Rescan in 1 week toconfirm pregnancy location
Consider laparoscopy or medical management
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Discriminatory zone of hCG The discriminatory zone of β-HCG is the
level above which an imaging scan should reliably visualize a gestational sac within the uterus in a normal intrauterine pregnancy is as follows:
1- 1500-1800 mIU/mL with transvaginal ultrasonography, but up to 2300 mIU/mL with multiple gestations .
2- 6000-6500 mIU/mL with abdominal ultrasonography.
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Serum progesterone levels Progesterone level < 25 nmol/l,
associated with nonviable pregnancy (viable in 0.3%).
Progesterone < 20 nmol/l predicts failing pregnancy.
Levels > 25 nmol/l are associated with pregnancies.
Levels > 60 nmol/l are strongly associated with intrauterine pregnancy (2.6% ectopic).
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Scanning Modalities
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Gestational sac TAUS
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Gestational sac TVUS
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3 D Scanning
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3D of interstitial Pregancy
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Doppler & 3D
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MRI in Ectopic pregnancy
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Abdominal pregnancy
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Endometrial Findings Suggestive of intrauterine Pregnancy
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Double decidual sac sign (DDSS) Is a useful feature on early pregnancy ultrasound
in distinguishing between an early intrauterine pregnancy (IUP) and a pseudogestational sac. It consists of the decidua parietalis (that lining the uterine cavity) and decidua capsularis (lining the gestational sac).
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Gestational Sac and pseudogestational sac
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Decidual Cyst
Decidual cysts appearing at the junction of endometrium and myometrium are associated with both intrauterine and ectopic pregnancy.
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Endometrial FINDINGS DIAGNOSTIC OF INTRAUTERINE PREGNANCY
Diamond ring appearance of FP and YS
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Adenexal Findings
Ovaries Fallopian tubes
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Corpus luteum
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Tubal Ectopic pregnancy
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Adenxal mass
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Adenxal ectopic pregnancy with positive cardiac pulsation
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Rare Ectopic Sites
Interstitial pregnancy
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Ovarian Ectopic
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Cervical Ectopic
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Heterotropic Pregnancy
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Peritoneal Free Fluid
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Ring of fire Sign The ring of fire sign also known as ring of
vascularity signifies a hypervascular lesion with peripheral vascularity on colour or pulsed Doppler examination of pelvis due to low impedance high diastolic flow .
This sign can be seen in highly vascular pelvic lesions like:
1-corpus luteum cyst (more commonly)
2-ectopic pregnancy
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Failed Early Pregnancy
failed early pregnancypregnancy of uncertain viability (PUV)
Abortionthreatened abortionmissed abortioninevitable abortionIncomplete abortioncomplete abortion
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Missed Abortion Major criteria A pregnancy is considered non-viable on transvaginal ultrasound if: no fetal heart beat where:
CRL ≥ 7 mm no fetal pole where:
G.S > 25 mm with no embryo If a fetal pole is present, fetal pole measurements override MSD
measurement. Both fetus and gestational sac are expected to grow 1mm/day. Hence,
absence or inadequate growth on serial scans at least 7-10 days apart is suggestive of non-viability.
Other poor prognostic indicators include: no yolk sac, where:
G.S > 8 mm embryo seen
irregular gestational sac low position of the gestational sac
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Pregnancy of uncertain viability Pregnancy of uncertain viability (PUV) is a term given to an
intrauterine pregnancy in a situation where there are not enough criteria (usually on ultrasound grounds) to confidently categorise a pregnancy as a miscarriage.
On transvaginal ultrasound: an empty intrauterine gestational sac measuring less than 20mm
in mean sac diameter 1. an intrauterine gestational sac containing a fetal pole with a
crown-rump length(CRL) of less than 6mm with no fetal cardiac activity .
gestational sac < 25mm in mean diameter and containing yolk sac only .
In these situations a follow up ultrasound scan in 7-14 days with serial beta HCG correlation is recommended as some of these pregnancies may progress to be a viable pregnancy.
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Inevitable abortion An inevitable abortion refers to the
presence of an open internal os in the presence of bleeding in the first trimester of pregnancy. Most often intra cervical contents are present at the time of examination.
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Incomplete abortion with retained Products of conception
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Complete Abortion