Pregnancies of unknown location: update on nomenclature and final outcomes
نویسنده
چکیده
Ectopic pregnancy occurs in 1–2% of pregnancies and is the leading cause of maternal mortality in the first trimester; accounting for up to 15% first trimester deaths. There is a worldwide consensus regarding the use of transvaginal ultrasound (TVS) and (serial) quantitative serum human chorionic gonadotrophin (hCG) levels in the diagnosis of ectopic pregnancy. Diagnosis can be straightforward when TVS definitively identifies an intra-uterine pregnancy (IUP) or an ectopic pregnancy. Both TVS diagnoses are made based upon either the positive visualisation of either an intra-uterine gestational sac or an adnexal mass separate to the ovary. However, in a substantial number of women, the location of a gestation after TVS can be inconclusive. This situation is termed a pregnancy of unknown location (PUL), necessitating further diagnostic tests and followup to achieve a final diagnosis. Approximately 10% of women who present to an Early Pregnancy Unit (EPU) for a first trimester TVS will be classified with a PUL. This is not a pathological entity but rather an ultrasound classification defined on TVS when there is no intraor extra-uterine pregnancy visualised and the absence of retained products of conception. According to many published data, on follow up, ectopic pregnancies account for 8–14% of women classified with a PUL. Therefore it is of great importance that clinicians follow up women with a PUL until either the pregnancy is located or found to have failed spontaneously. There are four final pregnancy outcomes in women initially classified with a PUL and these include: failed PUL, intrauterine pregnancy (IUP), ectopic pregnancy, or persisting PUL. In a recent consensus statement in Fertility Sterility, by Barnhart, et al. 2011, on PUL nomenclature, definitions and outcome, the expert panel agreed that “differences in the criteria used to describe women with a PUL can result in potentially meaningful differences in populations reported in the literature”. There was consensus that the PUL final outcomes of a woman in the current literature were not clearly and consistently used. It was therefore decided that careful definition of populations and classification of final outcomes were essential so that both past and future research could be interpreted correctly. The panel proposed the following categorisation for first trimester ultrasound diagnosis (see Figure 1): 1 Definite ectopic pregnancy: extra-uterine gestational sac with yolk sac and/or embryo (with or without cardiac activity) on TVS. 2 Probable ectopic pregnancy: inhomogeneous adnexal mass (“bagel” sign) or extra-uterine sac-like structure on TVS. 3 PUL: no signs of either ectopic pregnancy or IUP on TVS. 4 Probable IUP: intra-uterine echogenic sac-like structure eccentrically placed within the endometrial cavity on TVS. 5 Definite IUP: intra-uterine gestational sac with yolk sac and/ or embryo (with or without cardiac activity) eccentrically placed within the endometrial cavity on TVS. Therefore at presentation, women who present to an EPU for an early pregnancy ultrasound, can be classified with one of the five aforementioned categories based upon their TVS findings. There was also consensus that final PUL outcomes reported in the literature should be as definitive as possible. Active or present tense terms such as “failing” or “resolving” PULs should also be avoided in presented manuscripts. It was also the panel’s opinion that the audience be able to understand the criteria used to diagnose ectopic pregnancy or IUP as well as have an appreciation of the certainty of the diagnosis. In other words, the ultrasound criteria used to diagnose an EP or IUP should be clearly documented as too should the criteria used to classify the various categories of a non-viable IUP. The panel also proposed the following categorisation of PUL final outcome based upon pregnancy location (see Figure 2):
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