1. Purpose
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To standardise the ongoing management of women who have attended the Women's EPAS, and have a diagnosis of Pregnancy of Unknown Location.
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2. Definition of Terms
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EPAS – Early Pregnancy Assessment Service. This service runs Monday – Friday mornings in the Well Women’s Clinic.
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Early pregnancy – all gestations up to 16 completed weeks. (Note: Women with pregnancy of gestation >16 completed weeks should be referred to the obstetric unit).
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Pregnancy of unknown location / P.U.L – When ßhCG levels are 5-1000 IU/L and there is no intrauterine or extrauterine pregnancy visible on transvaginal ultrasound. Approximately 3% of all PUL are ectopic pregnancies. The remainder are failing intrauterine pregnancies or intrauterine pregnancies too early to visualise using TVS.
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3. Management
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- Check for signs of ectopic pregnancy.
- Obtain blood for ßhCG and blood group (if not known or confirmed by clinician).
- Advise woman of the following:
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 | - What is happening, and the differential diagnoses
- What to expect (in terms of pain, bleeding etc.)
- She may take simple analgesia for pain.
- To contact EPAS / ED after hours if concerns regarding pain or bleeding.
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- Discharge woman home and arrange repeat ßhCG in 48 hours, and manage as follows:
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| | | | | | No intrauterine sac
No adnexal mass
No fluid in POD
No symptoms
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| | | If ßhCG > 1500 repeat ultrasound
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| If ßhCG < 1500 repeat ßhCG 48 hours later
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| | No intrauterine sac
No adnexal mass
No fluid in POD
No symptoms
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| First repeat ßhCG in 48hrs.
Then continue to monitor as clinically indicated
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| | Continue to monitor ßhCG until <5 IU/L
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- Where the ßhCG is rising, also refer to the CPG: Ectopic Pregnancy: Management
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4. Refer also to the following Women's resources:
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Clinical Practice Guidelines (CPGs)
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5. References
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The content of this CPG is based on:
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- Royal College of Obstetricians and Gynaecologists - RCOG (2006) Greentop Guideline number 25: The Management of Early Pregnancy Loss, http://www.rcog.org.uk/index.asp?PageID=515
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- Royal College of Obstetricians and Gynaecologists - RCOG (2004) Greentop Guideline number 21: The Management of Tubal Pregnancy, http://www.rcog.org.uk/index.asp?PageID=537
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- The Association of Early Pregnancy Units – AEPU (2004) Organisational, Clinical and Supportive Guidelines, http://www.earlypregnancy.org.uk/guidelines.asp
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Additional information has been drawn from:
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- Sheffield NHS Foundation Trust: Management of early pregnancy problems.
- Cambridge University NHS Foundation Trust: Guidelines for the management of women presenting with bleeding and or pain in early pregnancy.
- Cambridge University NHS Foundation Trust: Algorithm for management of patients with ultrasound scan findings showing an empty uterus.
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Evidence Table
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1 August 2007
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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