Diagnostic accuracy validation study of the M6 model without initial serum progesterone (M6NP) in triage of pregnancy of unknown location

OBJECTIVES

The M6 prediction model stratifies the risk of development of ectopic pregnancy (EP) for women with pregnancy of unknown location (PUL) into low risk or high risk, using human chorionic gonadotrophin (hCG) and progesterone levels at the initial visit to a gynaecological emergency room and hCG level at 48 h. This study evaluated a second model, the M6NP model, which does not include the progesterone level at the initial visit. The main aim of this study was to validate the diagnostic accuracy of the M6NP model in a population of French women.

STUDY DESIGN

Between January and December 2021, all women with an hCG measurement from the gynaecological emergency department of a teaching hospital were screened for inclusion in this study. Women with a pregnancy location determined before or at the second visit were excluded. The diagnostic test was based on logistic regression of the M6NP model, with classification into two groups: high risk of EP (≥5%) and low risk of EP (<5%). The reference test was the final outcome based on clinical, biological and sonographic results: failed PUL (FPUL), intrauterine pregnancy (IUP) or EP. Diagnostic performance for risk prediction of EP, and also IUP and FPUL, was calculated.

RESULTS

In total, 759 women with possible PUL were identified. After screening, 341 women with PUL were included in the main analysis. Of these, 186 (54.5%) were classified as low risk, including three (1.6%) with a final outcome of EP. The remaining 155 women with PUL were classified as high risk, of whom 60 (38.7%), 66 (42.8%) and 29 (18.7%) had a final outcome of FPUL, IUP and EP, respectively. Of the 32 women with PUL with a final outcome of EP, 29 (90.6%) were classified as high risk and three (9.4%) were classified as low risk. Therefore, the performance of the M6NP model to predict EP had a negative predictive value of 98.4%, a positive predictive value of 18.7%, sensitivity of 90.6% and specificity of 59.2%. If the prediction model had been used, it is estimated that 4.5 visits per patient could have been prevented.

CONCLUSION

The M6NP model could be used safely in the French population for risk stratification of PUL. Its use in clinical practice should result in a substantial reduction in the number of visits to a gynaecological emergency room.

hCG trends after mifepristone and misoprostol for undesired pregnancy of unknown location

OBJECTIVES

To describe human chorionic gonadotropin (hCG) trends for patients with a pregnancy of unknown location (PUL) presenting for medication abortion by management strategy and outcome.

STUDY DESIGN

This retrospective cohort study included patients presenting for medication abortion with a PUL at ≤42 days gestation managed with either (1) immediate mifepristone with serial hCG follow-up (same-day-start) or (2) hCG testing every 48 to 72 hours ± ultrasonography to confirm pregnancy location followed by treatment (delay-for-diagnosis). The primary outcome was percent hCG change over time between presentation and diagnosis, summarized using a multivariate regression model.

RESULTS

Of the 55 same-day-start patients, none were treated for ectopic. The eight who eventually required suction curettage had median hCG percent changes (interquartile range) on days 3, 4, and 5 of +57% (-14 to 127; n = 2), +292% (226-353; n = 4), and +392% (n = 1), while the 41 successful medication abortions had declines of -64% (n = 1), -65% (-75 to -27; n = 17), and -77% (-85 to -68; n = 13). Of the 380 delay-for-diagnosis patients, the 30 ectopic pregnancies had day 3, 4, and 5 changes of +38% (-17 to 56; n = 14), +50% (17-71; n = 7), and +115% (87-177; n = 4). None of the ectopic pregnancies declined ≥50% by days 3 to 5. The hCG trend for ectopic pregnancies differed from successful medication abortions (p < 0.01), but not medication abortions with retained intrauterine pregnancies (p = 0.41).

CONCLUSIONS

Serum hCG trends can help differentiate ectopic pregnancy from successful medication abortion, but cannot distinguish between ectopic and retained intrauterine pregnancy.

IMPLICATIONS

Serial serum hCG testing is effective for confirming successful medication abortion and identifying patients requiring further follow-up among patients undergoing medication abortion for an undesired PUL.

Expectant management versus systemic methotrexate in the management of persistent pregnancy of unknown location, a seven-year retrospective analysis

PURPOSE

To compare Expectant management to systemic methotrexate in the management of persistent pregnancy of unknown location with beta-hCG levels below the discrimination zone.

METHODS

A retrospective cohort study was conducted on 71 women with persistent pregnancy of unknown location. They were divided into two groups according to the applied management; Group 1, (n = 40) who were managed expectantly and Group 2 (n = 31) who were given a single dose of methotrexate. Data variables were collected and analyzed to evaluate whether expectant management was as effective as methotrexate.

RESULTS

There was no significant difference between the two groups regarding age, parity, gestational age, body mass index and day seven beta-hCG. Success rates were (32 patients (80%) and 28 patients (90.3%) in expectant management and methotrexate groups, respectively (P > 0.05). The mean values for day zero and day four beta-hCG were significantly higher and the mean duration for complete recovery was statistically shorter in the methotrexate group (P < 0.05). There were no significant differences between the two groups regarding prior ectopic, percentage of beta-hCG level drop on day four and day seven, success rate, occurrence of sequelae and patient satisfaction that area under the curve (AUC) for group 1 (expectant management) is 0.566 at 95% Confidence Interval of (0.388: 0.745).

CONCLUSION

Expectant management is an effective and safe alternative to single-dose methotrexate for persistent PUL with beta-hCG levels below the discrimination zone.

Beta-human chorionic gonadotrophin point of care testing for the management of pregnancy of unknown location

RESEARCH QUESTION

Does a commercially available quantitative beta-human chorionic gonadotrophin (BHCG) point of care testing (POCT) device improve workflow management in early pregnancy by performing comparably to gold standard laboratory methods, and is the performance of a validated pregnancy of unknown location (PUL) triage strategy maintained using POCT BHCG results?

DESIGN

Women classified with a PUL between 2018 and 2021 at three early pregnancy units were included. The linear relationship of untreated whole-blood POCT and serum laboratory BHCG values was defined using coefficients and regression. Paired serial BHCG values were then incorporated into the validated M6 multinomial logistic regression model to stratify the PUL as at high risk or at low risk of clinical complications. The sensitivity and negative predictive value were assessed. The timings required for equivocal POCT and laboratory care pathways were compared.

RESULTS

A total of 462 PUL were included. The discrepancy between 571 laboratory and POCT BHCG values was -5.2% (-6.2 IU/l), with a correlation coefficient of 0.96. The 133 PUL with paired 0 and 48 h BHCG values were compared using the M6 model. The sensitivity for high-risk outcomes (96.2%) and negative predictive values (98.5%) was excellent for both. Sample receipt and laboratory processing took 135 min (421 timings), compared with 12 min (91 timings) when using POCT (P < 0.0001).

CONCLUSIONS

POCT BHCG values correlated well with laboratory testing measurements. The M6 model retained its performance when using POCT BHCG values. Using the model with POCT may improve workflow and patient care without compromising on effective PUL triage.

Safety of methotrexate administration in women with pregnancy of unknown location deemed to have high risk of ectopic pregnancy

OBJECTIVES

This study evaluates the safety of current guidelines on methotrexate (MTX) administration in women with pregnancy of unknown location (PUL) who are considered to have high risk of underlying ectopic pregnancy (EP) and to investigate whether this would result in inadvertent exposure of MTX to viable intra-uterine pregnancy (IUP).

METHODS

A retrospective observational study was conducted on clinically stable women who were classified PUL at Early Pregnancy Unit, Nepean Hospital, between 2007 and 2021. PUL is defined as when a woman presents with a positive pregnancy test but has no signs of IUP or EP on the transvaginal ultrasound (TVS). If patients with a PUL behave biochemically like an EP but the location is not confirmed on ultrasound, these women are eligible for MTX to minimize the risk of subsequent tubal rupture. Criteria discussed in the guidelines of American College of Obstetricians and Gynaecologists (ACOG), American Society for Reproductive Medicine (ASRM), Royal College of Obstetricians & Gynaecologists (RCOG) and National Institute for Health Care Excellence (NICE) were applied to the collected PUL database. The number of patients eligible to receive MTX and the number of women with underlying viable IUP who would be inadvertently given MTX were calculated.

RESULTS

A total of 816 consecutive women with PUL were reviewed, and 724 had complete data and were included in the final analysis. 6 patients were persistent PULs, and 718 fell among outcomes of 4 subgroups: viable IUP, non-viable IUP, EP, failed PUL. According to the ACOG, ASRM, RCOG and NICE, the rate of possible MTX administration among patients with a PUL is 2.76%, 4.56%, 0.41% and 35.36%, respectively. However, no single persistent-PUL would have received MTX according to the above protocols, and majority of the MTX treatment were unnecessary because those patients were classified as NVIUP or FPUL later. More importantly, ACOG and ASRM could theoretically result in inadvertent MTX administration to women with an underlying IVUP at rates of 4.1/1000 (3/724).

CONCLUSIONS

Current guidelines used to predict high risk of EP among PUL population are not safe enough to avoid inadvertent MTX administration to women with an underlying viable IUP. These guidelines need to be wisely used to ensure that no wanted pregnancy is exposed to MTX. Women with PULs should be carefully monitored and MTX should be used with judicious care when the location of pregnancy is yet to be confirmed. This article is protected by copyright. All rights reserved.

Follow-up and outcomes of patients with a pregnancy of unknown location: A comparison of two prediction models

BACKGROUND

The time period while delineating the final diagnosis following presentation with a pregnancy of unknown location (PUL) can be an anxious time, as well as being time and resource intensive. Prediction models have been utilised in order to tailor counselling, frame expectations and plan care.

OBJECTIVES

We aimed to review diagnoses of PUL in our population and assess the value of two prediction models.

STUDY DESIGN

We reviewed all 394 PUL diagnoses over a three year period in a tertiary level maternity hospital. We then retrospectively applied the M1 and M6NP models to assess their accuracy when compared to the final diagnosis.

RESULTS

PUL comprises of 2.9% (394/13401) of attendances in our unit, requiring 752 scans and 1613 separate blood tests. Just under one in ten women (9.9%, n = 39) presenting with a PUL had a viable pregnancy at discharge, however of the remainder, only 18.0% (n = 83) required medical or surgical treatment for a PUL. The M1 model was more successful at predicting an ectopic pregnancy than the M6NP, with the latter over-predicting viable pregnancies (33.4%, n = 77).

CONCLUSIONS

We demonstrate that the management of women with a PUL could be stratified through the application of outcome prediction models, having positive results for framing expectations and potentially reducing this resource-intensive diagnosis.

At-home urine pregnancy test assessment after mifepristone and misoprostol for undesired pregnancy of unknown location

OBJECTIVES

The ideal assessment after mifepristone and misoprostol for undesired pregnancy of unknown location (PUL) is unknown.

STUDY DESIGN

We prospectively followed patients at Planned Parenthood League of Massachusetts (2019-2021) with PUL who received immediate mifepristone and misoprostol with serial at-home urine pregnancy tests (UPT) and in-office serum HCGs.

RESULTS

Of 13 patients, 10 had a successful medication abortion. For those who completed UPTs (N = 9), all were negative by Day 14. Two abnormal pregnancies had positive UPTs on Day 14.

CONCLUSION

A negative UPT on Day 14 may help determine complete abortion after medication abortion for undesired PUL. A positive UPT on Day 14 warrants further evaluation.

IMPLICATION

Patients taking mifepristone and misoprostol in the setting of undesired PUL who cannot access serum testing may consider an at-home UPT to confirm complete abortion.

Medication abortion and uterine aspiration for undesired pregnancy of unknown location: A retrospective cohort study

OBJECTIVE

To compare days to diagnosis of pregnancy location for same-day medication abortion and same-day uterine aspiration with delayed treatment (expectant management) in patients with undesired pregnancy of unknown location (PUL).

STUDY DESIGN

We conducted a retrospective cohort study at a single Planned Parenthood health center in Minnesota. We reviewed electronic health records and included patients presenting for induced abortion diagnosed with PUL (positive high-sensitivity urine pregnancy test and no evidence of intrauterine or extrauterine pregnancy on transvaginal ultrasonography) without symptoms or ultrasonographic imaging concerning for ectopic pregnancy (low risk). The primary outcome was days to pregnancy location clinical diagnosis.

RESULTS

Of 19,151 abortion encounters in 2016-2019, 501 (2.6%) had a low-risk PUL. Participants chose delay-for-diagnosis before treatment (148, 29.5%), immediate treatment medication abortion (244, 48.7%), or immediate treatment uterine aspiration (109, 21.8%). Median days to diagnosis were significantly lower in the immediate treatment uterine aspiration group (2 days, IQR 1-3 days, p < 0.001) and similar for immediate treatment medication abortion (4 days, IQR 3-9 days, p = 0.304) compared with delay-for-diagnosis (3 days, IQR 2-10 days). Thirty-three low-risk participants (6.6%) were treated for ectopic pregnancy, but no difference in ectopic rate was detected among groups (p = 0.725). Participants in the delay-for-diagnosis group were more likely to be nonadherent with follow-up (p < 0.001). For participants who completed follow-up, abortion completion rate was lower for immediate treatment medication abortion (85.2%) compared with immediate treatment uterine aspiration (97.6%, p = 0.003).

CONCLUSIONS

For patients with undesired PUL, diagnosis of pregnancy location was fastest with immediate treatment uterine aspiration and similar for expectant management and immediate treatment medication abortion. Medication abortion efficacy may be reduced in treatment of undesired PUL.

IMPLICATIONS

For PUL patients desiring induced abortion, the option of proceeding at initial encounter may help improve access and patient satisfaction. Uterine aspiration for PUL may help diagnose pregnancy location more quickly.

Ectopic Pregnancy

Ectopic pregnancy occurs in 2% of all pregnancies and is a potentially life-threatening emergency. A high level of clinical suspicion is required for any pregnant patient who presents with vaginal bleeding and/or pelvic pain. Workup should begin with immediate triage based on vital signs, a pregnancy test, and transvaginal ultrasound. Ectopic pregnancy can be treated either medically with methotrexate or surgically with either salpingectomy or salpingostomy. Carefully counseled, asymptomatic patients may be candidates for expectant management.

[Retrospective validation of a model to predict the outcome of pregnancies of unknown location]

OBJECTIVE

The prediction model M6 classifies pregnancy of unknown location (PUL) into a low-risk or a high-risk group in developing ectopic pregnancy (EP). The aim of this study was to validate the two-step M6 model's ability to classify PUL in French women.

MATERIAL AND METHODS

All women with a diagnosis of PUL over a year were included in this single center retrospective study. Patients with a diagnosis of EP at the first consultation of with incomplete data were excluded. For each patient, the M6 model calculator was used to classified them into "high risk of EP" and "low risk of EP" group. The reference standard was the final diagnostic: failed PUL (FPUL), intrauterine pregnancy (IUP) of EP. The statistical measures of the test's performance were calculated.

RESULTS

Over the period, 255 women's consulted for a PUL, 197 has been included in the study. Final diagnosis were: 94 FPUL (94/197; 47.7%), 74 IUP (74/197; 37.6%) et 29 EP (29/197; 14.7%). The first step of the M6 model classified 16 women in the FPUL group of which 15 (15/16; 93.7%) correctly. The second step of the M6 model classified 181 women: 90 (90/181; 49.7%) in the "high risk of EP" group of which 63 (63/90; 70%) were FPUL/IUP and 27 (27/90; 30%) were EP. 91 (91/181; 50.3%) was classified in the "low risk of EP" group of which 90 (90/91; 98.9%) were FPUL/IUP and 1 (1/91; 1.1%) were EP. EP were correctly classified with sensitivity of 96.4%, negative predictive value of 98.9%, specificity of 58.8% and positive predictive value of 30.0%.

CONCLUSIONS

The prediction model of PUL M6 classified EP in "high risk of EP group" with a sensitivity of 96.4%. It classified 50.3% of PUL in a "low risk of EP" group with a negative predictive value of 98.9%.

Pregnancies lost and found: a quality improvement project to increase follow-up for early pregnancy complications

Pregnancy of unknown location (PUL) and medically managed ectopic pregnancy (EP) require longitudinal surveillance to avoid adverse outcomes; however, patients with PUL/EP in the United States (U.S.) are often unable to adhere to recommended treatment plans. This quality improvement (QI) project sought to improve PUL/EP follow-up using a three-pronged intervention: standardised recall procedures, direct patient-provider communication and electronic medical record (EMR) documentation templates and tracking. We compared patients with PUL/EP managed before and after the QI project. Our primary outcome was completion of PUL/EP clinical care. Demographics, initial diagnoses and adverse outcomes were similar between 87 pre-QI and 81 post-QI patients. Significantly more patients completed PUL/EP clinical care post-QI (80.2 vs. 65.5% p = .03). Post-QI, more providers contacted patients at standard intervals (100 vs. 57.1%, p < .0001), and EMR documentation was improved (100 vs. 69.0%, p < .001). Simple changes to PUL/EP management improved completion of clinical care and compliance with standardised recall and documentation.IMPACT STATEMENTWhat is already known on this subject? Pregnancy of unknown location (PUL) and medically managed ectopic pregnancy (EP) require longitudinal surveillance to avoid adverse outcomes; however, patients with PUL/EP in the United States (U.S.) are often unable to adhere to recommended treatment plans.What do the results of this study add? By standardising recall procedures, ensuring direct communication between patients and providers using a dedicated cell phone, and integrating case tracking and documentation into the electronic medical record (EMR), this quality improvement (QI) project improved completion of clinical follow-up for patients with PUL/EP (overall, 80.2 vs. 65.5% pre-QI, p=.03) and for the subgroup with medically managed EP not requiring surgery (76.5 vs. 36.4% pre-QI, p= .05). We also improved providers' compliance with standardised recall procedures and EMR documentation post-QI (p < .0001). There was no difference in the number of attempts to contact patients, or in the number of surveillance blood draws actually performed. Post-QI, survey responses indicated that patients were easily able to contact their provider and understood the importance of follow-up processes.What are the implications of these findings for clinical practice and/or research? Early pregnancy care providers can utilise simple strategies to improve follow-up of patients with PUL and medically managed EP, without increasing burdens to their health systems. Patients' favourable experiences with this management support its implementation.

The many faces of ectopic pregnancies: demystifying the common and less common entities

Ectopic pregnancy is a major cause of 1st trimester pregnancy deaths. It occurs in various locations in the abdominopelvic cavity. Ultrasonography is a first-line, rapid, and noninvasive modality for ectopic pregnancy evaluation. MRI can help clarify equivocal cases. When in doubt about the location, one should give an intrauterine pregnancy the benefit of the doubt with close ultrasound and hCG follow-up. Here, we will review the imaging findings and mimickers of ectopic pregnancies.

Tubal Ectopic Pregnancy with Undetectable Initial Serum β-Human Chorionic Gonadotropin Level

We present a case of a tubal ectopic pregnancy (EP) in a patient with an initially undetectable serum β-human chorionic gonadotropin (β-hCG) level. A 33-year-old woman in a same-sex relationship underwent timed donor intrauterine insemination. Her serum β-hCG level was <5 mIU/mL 14 days after the intrauterine insemination. She reported menstrual bleeding 3 days after her negative pregnancy test and returned to the office 10 days later to begin a new treatment cycle. Her serum levels of estradiol, progesterone, and β-hCG were 119 pg/mL, 6.1 ng/mL and 1157 mIU/mL, respectively. Transvaginal ultrasonography did not show an intrauterine pregnancy. Her β-hCG level increased to 1420 mIU/mL the next day. She was diagnosed with a pregnancy of unknown location and treated with methotrexate. Her β-hCG levels continued to increase despite 3 methotrexate doses, necessitating laparoscopy. The diagnostic laparoscopy demonstrated approximately 100 mL of hemoperitoneum in the posterior cul-de-sac with an intact right fallopian tube that was dilated at its distal end by the EP. A total right salpingectomy was performed. Her β-hCG level was <5 mIU/mL 3 weeks later. The current case supports that although rare, an undetectable serum β-hCG level does not completely rule out the diagnosis of an EP.

Complications in Early Pregnancy

Early in pregnancy women frequently experience nausea, vomiting, and vaginal bleeding. Nausea and vomiting can be mild, managed by dietary modifications and medications, or severe, requiring intravenous fluids and medications. Care should be used when selecting medications for nausea to avoid additional side effects or potential harm to the developing fetus. When evaluating vaginal bleeding in early pregnancy, ectopic pregnancy must be ruled out. If an intrauterine pregnancy is seen, threatened miscarriage should be considered and the patient appropriately counseled. If neither intrauterine pregnancy nor ectopic pregnancy can be established, a management algorithm for pregnancy of unknown location is presented.

Perception and knowledge of early pregnancy assessment units among perinatal practitioners in Europe

OBJECTIVE

To investigate perceptions of early pregnancy assessment units (EPAUs) among perinatal practitioners working in Belgium, France, and Switzerland.

METHODS

A prospective multinational survey was conducted between September 1, 2015, and May 21, 2016. Obstetricians, gynecologists, medical doctors, radiologists, and midwives were recruited during meetings, via e-mail invitations, or through the websites of regional obstetrics and gynecology scientific societies. The survey comprised 17 questions that assessed the participants' knowledge, interest, and management of early pregnancy.

RESULTS

Of the 871 individuals invited to participate in the survey, 306 (35.1%) responded. Most of the participants were gynecologists and/or obstetricians (225 [73.5%]). A total of 258 (84.3%) participants had no or limited knowledge about EPAUs. Furthermore, 211 (69.0%) participants reported incorrect management when they visualized a gestational sac without embryo and 265 (86.6%) misinterpreted changes in serum levels of chorionic gonadotropin during early pregnancy. In all, 201 (65.7%) participants were interested in collaboration with an EPAU; however, only 125 (40.8%) had sufficient time and resources available to support a patient's psychological distress after early pregnancy loss or salpingectomy.

CONCLUSION

Knowledge about early management of pregnancy was limited among the perinatal practitioners surveyed; however, the concept of EPAUs was welcomed by many.

Trends in the Management of Nonviable Pregnancies of Unknown Location in the United States

BACKGROUND

When managing a nonviable pregnancy of unknown location (PUL), a debate has emerged in the literature whether to perform uterine curettage for definitive diagnosis of pregnancy location or administer methotrexate for a presumed ectopic pregnancy. The purpose of this study is to describe the treatment patterns when managing a PUL.

METHODS

A prospective, anonymous Internet based-electronic survey of PUL case scenarios was administered to a random sample of physicians across the United States.

RESULTS

A total of 214 physicians responded. When presented with a PUL by ultrasound and a βhCG measurement of 3,270 mIU/mL, which is above the discriminatory level, 88.3% (188) would choose an additional βhCG measurement before recommending any intervention. When presented with a PUL by ultrasound and serial βhCG measurements demonstrating an inappropriate trend for a viable gestation, 36.5% would offer uterine curettage and 31.3% would offer methotrexate. Resident and private clinicians had a fourfold lower adjusted odds of choosing uterine curettage compared to academic physicians.

CONCLUSIONS

Based on our findings, there does not appear to be a consensus regarding the management of a PUL.

Metastatic gestational choriocarcinoma: a masquerader in obstetrics

We describe a case of a 36-year-old woman presenting with vaginal bleeding and suboptimally rising serum human chorionic gonadotropin levels, who was investigated for a pregnancy of unknown location. Ultrasonography, laparoscopy and dilatation and curettage failed to reveal signs of an intra-uterine or intra-abdominal pregnancy. Following computed tomography imaging, a mediastinal mass was histologically determined to be a gestational choriocarcinoma. Following surgical resection and chemotherapy, the patient recovered and proceeded to have a successful intra-uterine pregnancy. We describe this exceptionally rare case and emphasise the importance of follow-up of hCG levels in pregnancy of unknown location.

Pitfalls and tips in the diagnosis of ectopic pregnancy

Women of reproductive age with pelvic pain, vaginal bleeding, and a positive pregnancy test often require evaluation with pelvic ultrasound. In these situations, the primary role of pelvic ultrasound is to differentiate an ectopic pregnancy from either a normal or abnormal intrauterine pregnancy. While an accurately performed and interpreted pelvic ultrasound results in rapid diagnosis and management, numerous diagnostic pitfalls can lead to negative outcomes. Therefore, familiarity with the appropriate laboratory tests, sonographic technique, and imaging features of ectopic pregnancy is essential for all radiologists. We present a review of ectopic pregnancy cases from our institution with attention to common pitfalls and troubleshooting tips for physicians who perform and interpret pelvic ultrasounds. We also present recently published literature to aid in the management of first trimester pregnancy.

Pregnancy of Unknown Location: A Survey-Based Evaluation of When and Why Physicians Intervene?

INTRODUCTION

Management of pregnancies of unknown location (PUL) is a complex challenging clinical situation with possibilities for pitfalls. Obstetricians and gynaecologists of varied levels of training and experience from Canada and the Nordic countries were questioned about their approach when faced with PUL.

METHOD

A 13-item web-based questionnaire was used to evaluate physicians' behaviors by surveying their management of a PUL encountered at different levels of human chorionic gonadotropin (hCG). They were queried regarding the level of hCG at which they would take management action in an asymptomatic PUL, in a given scenario.

RESULTS

Three hundred fifty three questionnaires were completed resulting in a response rate, representing completeness of the survey, of 78.6%. Three distinct hCG thresholds, at which intervention to interrupt a PUL would be considered, dominated the responses. Thirty seven percent of physicians would intervene at hCG levels between 1000-3000 IU, 22% selected the 4000-6000 IU range, and 13% would only intervene if the hCG level exceeded 10 000 IU. These ranges were similar across different levels of clinical experience. In addition to hCG values, a patient's desire to keep the pregnancy, the development of new symptoms, and the expected gestational age were the other principal factors influencing the decision to intervene.

CONCLUSION

There appears to be little consensus regarding the hCG threshold at which medical intervention should be initiated in an asymptomatic pregnancy of unknown location and further studies to justify earlier or later intervention are needed to determine the appropriate time for intervention.

Primary renal artery choriocarcinoma causing secondary renovascular hypertension

INTRODUCTION

Choriocarcinoma is a rare primary germ cell tumour of the ovary composed of cyto- and syncytotrophoblast cells. Most of the choriocarcinomas are normally arising in the gestational trophoblast, gonads and, less frequently, mediastinum, pineal gland and retroperitoneum.

PRESENTATION OF CASE

We report a case of primary choriocarcinoma of renal artery causing secondary renovascular hypertension in a 28 years old woman of reproductive age, presenting with abdominal pain, minimal vaginal bleeding and a delayed menstrual period.

DISCUSSION

Non-gestational choriocarcinomas, are histologically related to the pregnancy related gestational choriocarcinomas. These two subtypes may have to be differentiated according the clinical and radiological findings and DNA analysis may be used for this purpose as well. In many studies, authors have stated that nongestational choriocarcinoma diagnosis could be implemented in situations where the presence of a pregnancy could not be considered like the prepubertal period.

CONCLUSION

Choriocarcinoma should as well be considered among the possibilities in the differential diagnosis of the causes for secondary hypertension, especially within a picture of pregnancy of unknown location, albeit being one of the rarest.

Pregnancy of unknown location

Pregnancy of unknown location (PUL) is defined as the situation when the pregnancy test is positive but there are no signs of intrauterine pregnancy or an extrauterine pregnancy via transvaginal ultra-sonography. It is not always possible to determine the location of the pregnancy in cases of PUL. The reported rate of PUL among women attending early pregnancy units varies between 5 and 42% in the literature and the frequency of PUL incidents has increased with the increase in the number of early pregnancy units. The management of PUL seems to be highly crucial in obstetrics clinics. Therefore, in the current review, issues identified from the literature related to pregnancy of unknown location, potential tools for prediction and algorithms will be discussed.