Pregnancy of unknown location

Last revised by Dr Jeremy Jones on 20 Sep 2021

The term pregnancy of unknown location (PUL) is assigned when neither an intrauterine pregnancy (IUP) or an ectopic pregnancy is identified on transvaginal ultrasound in the context of a positive pregnancy test.

  • pelvic pain
  • vaginal bleeding
  • positive pregnancy test
  • serial beta-hCG: has an adjunct role in the diagnosis of ectopic pregnancy, and is useful in the follow-up of clinically-stable patients 
  • serum progesterone: lack of progesterone has been considered an indication of non-viability 3
    • <5 ng/mL is a good indicator of non-viability, however, larger values cannot exclude an ectopic pregnancy 4

These patients will present with a "normal" pelvic ultrasound, with no signs of an intrauterine pregnancy and a normal adnexa 5.

Since the most likely underlying diagnosis is non-viable intrauterine pregnancy 6, methotrexate and/or surgical intervention are not recommended in a hemodynamically-stable patient 6.

Thus, for the hemodynamically-stable patient, a short interval repeat ultrasound examination and quantitative beta-hCG level are generally appropriate 5,6.

While patients and referring doctors may want conclusive answers, we must strive to safeguard both mother and child by delivering accurate and appropriate conclusions that lead to intervention mostly in instances of absolutely failed IUP or visible ectopic pregnancy8.

Intervening in women with a "pregnancy of unknown location" (since only a small fraction of these may be hidden ectopic pregnancies) can be far more detrimental than getting serial beta-hCG levels and repeating Ultrasound scans at suitable intervals8.

A pregnancy of unknown location reflects four possibilities:

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Cases and figures

  • Case 1
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