Pregnancy of Unknown Location – Next Steps

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Define ‘a pregnancy of unknown location’
2. Discuss the use of uterine aspiration in the setting of a pregnancy of unknown location

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Genoox, Inc., and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from March 12 2018 through March 11 2020, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:

ACOG has updated guidance on pregnancy of unknown location, defined as a pregnancy where intrauterine or ectopic location cannot be confirmed. If the location cannot be definitively determined

Pregnancy of unknown location requires follow up and a diagnosis
If patient is clinically stable and pregnancy is desired
- Repeat transvaginal ultrasound and/or serial measurement of hCG

Uterine Aspiration to Determine Pregnancy Location

Perform uterine aspiration if pregnancy is not progressing normally (see ‘Related ObG Topics’ below)

Chorionic villi present
- Indicates failed uterine pregnancy
- No further follow-up needed
Chorionic villi absent
- Monitor hCG levels 12–24 hours after aspiration
- hCG plateau (decrease <10-15%) indicates the following possible scenarios
  - Uterine evacuation incomplete
  - Ectopic pregnancy, but not seen on ultrasound
- hCG decrease ≥50%
  - Monitor with serial hCG measurements
  - Treat if patient becomes symptomatic or levels plateau or increase
- hCG decrease between 15% and 50%
  - Individualize treatment
  - Follow-up with serial hCG measurements
  - Treat if (1) patient becomes symptomatic, (2) levels plateau or increase, (3) there is clinical suspicion or (4) strong risk factors for ectopic pregnancy are present

Determination of Pregnancy Location Prior to Methotrexate (MTX) Use

Arguments against determining location prior to MTX
- Delay in MTX treatment may result in a potentially preventable tubal rupture
Arguments for determining location prior to MTX
- Limits MTX exposure to those patients who actually need it
- Confirmation/knowledge of true location may impact management of current and future pregnancies
- Risk of rupture appears to be low if patient is closely monitored

KEY POINTS:

Choice of uterine aspiration should be based on shared decision making
- Discuss risk of MTX and birth defects if location not confirmed and intrauterine pregnancy continues
Consider MTX if following met
- Confirmed or high clinical suspicion of ectopic pregnancy
- Hemodynamically stable
- Unruptured mass
- No absolute contraindications to MTX
Absolute MTX Contraindications include
- Intrauterine Pregnancy | Breastfeeding | Immunodeficiency | Blood Dyscrasias | Clinically Important Hepatic Dusfunction | Active Pulmonary Disease | Active Peptic Ulcer Disease | Clinically Important Renal Dysfunction | Patient sensitive to MTX | Inability to Participate in Follow-up
Relative MTX Contraindications
- Gestational Sac > 4 cm (TV ultrasound) | High Quantitative HCG (qHCG) | Positive FH | Refusal to Accept Blood Transfusion