Ectopic Pregnancy

What does "pregnancy of unknown location" mean?

When the pregnancy test is positive but where the pregnancy is cannot yet be seen on ultrasound, this is called a pregnancy of unknown location. The guideline's warning is clear: until the location is established it must be accepted that it could be an ectopic pregnancy.

Why are blood tests requested 48 hours apart?

The pregnancy hormone measured in the blood (hCG) does not show where the pregnancy is. The guideline states this plainly: hCG measurement is used not to establish the location but to see how the process is progressing and to decide the next step.

For this reason two measurements are made as close as possible to exactly 48 hours apart (not earlier). Depending on the result:

• A rise of more than 63%: it is likely that a pregnancy inside the womb is developing — but an ectopic pregnancy is still not ruled out. An ultrasound is done 7–14 days later; if the hCG level is above a certain threshold it may be done earlier.
• A fall of more than 50%: it is likely that the pregnancy is not continuing. A urine pregnancy test is done 14 days after the second blood test; if it is negative no further action is needed, and if it is positive you should be seen within 24 hours.
• Results in between (a fall of less than 50% or a rise of less than 63%): assessment is needed within 24 hours.

Measuring progesterone is not used as an additional test to distinguish the location of the pregnancy.

What is looked at on ultrasound?

• Whether there is a moderate or large amount of free fluid in the abdomen or in the space behind the womb — this may suggest internal bleeding.
• The womb and the area around the ovaries are scanned together, with regard to the possibility of a pregnancy inside the womb and an ectopic pregnancy at the same time.
• Findings are interpreted not on their own but by assessing the other ultrasound findings, your complaints and your hCG level together.

The guideline also states that all ultrasound examinations should be carried out by health professionals trained and experienced in the diagnosis of ectopic pregnancy, or conducted and reviewed under their direct supervision.

Treatment options

Everyone diagnosed with an ectopic pregnancy should be given verbal and written information about the treatment options, what to expect during and after treatment, whom to contact and how after treatment, and where to go in an emergency.

1. Expectant management (watching and waiting)

Expectant management is offered as an option if all the following apply:

• The condition is medically stable and there is no pain
• The pregnancy in the tube is smaller than 35 mm and no heartbeat is seen on ultrasound
• The hCG level is below the defined threshold
• You are able to attend for follow-up

Under expectant management, hCG is repeated on days 2, 4 and 7 after the first test. If the value is falling by 15% or more at each measurement compared with the previous one, weekly follow-up continues until a negative result is reached. If it is not falling, stays the same or rises, the situation is reassessed and a senior opinion is obtained.

2. Medical treatment

Drug treatment that acts on the whole body (systemic) is recommended if all the following apply: no significant pain; an unruptured tubal pregnancy smaller than 35 mm with no heartbeat seen; an hCG level below the defined threshold; no pregnancy inside the womb on ultrasound; and being able to attend for follow-up.

This treatment is recommended at the first visit only if the diagnosis of ectopic pregnancy has been confirmed and a viable pregnancy inside the womb has been ruled out. If drug treatment is not acceptable to you, surgery is recommended.

3. Surgery

Surgery is recommended as the first option in those who would not be able to attend for follow-up after methotrexate treatment. Surgery also comes up in the other situations in which drug treatment is not suitable.

Is there a difference between expectant and medical management?

The guideline reports the following, stating that it rests on limited evidence — no difference appears between expectant and medical management in terms of:

• The rate at which the ectopic pregnancy resolves on its own
• The risk of the tube rupturing
• The need for further treatment — but it should be known that emergency admission may be needed if the situation worsens
• General health, and depression and anxiety scores

The two methods are also expected to be similar in terms of the time the ectopic pregnancy takes to resolve and future fertility outcomes.

Afterwards

People who have had an ectopic pregnancy should be told that in a future pregnancy, if they have any concern in the early stage, they can refer themselves directly to the early pregnancy assessment unit.