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Grand Rounds

What Model is Best for Managing a Pregnancy of Unknown Location?

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BACKGROUND AND PURPOSE: 

  • Pregnancy of unknown location (PUL) 
    • Positive urine pregnancy test  and
    • Location of pregnancy not seen on transvaginal ultrasonography (TVS) 
  • Bobdiwala et al. (BJOG, 2018) compared different methods for the management of PUL 

METHODS: 

  • Systematic review and meta-analysis  
  • Inclusion 
    • PUL at initial ultrasound 
    • RCTs, case–control studies, cohort studies and observational studies 
    • Retrospective and prospective  
  • 4 models 
    • Single hCG cut-off level 
    • hCG ratio (48 hours/initial hCG) 
    • Single progesterone cut-off level 
    • ‘M4 model’: Logistic regression model based on hCG average and hCG ratio (see ‘Learn More – Primary Sources’ for previous M4 publication)  
  • Primary outcome  
    • High risk: Accurate risk prediction of women initially diagnosed with a PUL having an ectopic pregnancy compared to  
    • Low risk: Failed PUL or intrauterine pregnancy (IUP)  
  • Sensitivity and specificity were calculated for each diagnostic model

RESULTS: 

  • 43 studies were included  
  • High level of heterogeneity among papers for definitions of   
    • PUL  
    • Final outcomes 
  • Areas under the curves (ROC) and 95% CIs for these four management protocols for the prediction of high risk (ectopic pregnancy) was  
    • Single hCG: 0.42 (0.00–0.99) 
    • hCG ratio: 0.69 (0.57–0.78) 
    • Single progesterone cut-off: 0.69 (0.54–0.81) 
    • M4 protocol: 0.87 (0.83– 0.91) 

CONCLUSION: 

  • The M4 model that uses logistic regression analysis and incorporates both hCG levels and ratios was the best available approach for detecting ectopic pregnancy

Learn More – Primary Sources: 

Diagnostic protocols for the management of pregnancy of unknown location: a systematic review and meta-analysis  

The clinical performance of the M4 decision support model to triage women with a pregnancy of unknown location as at low or high risk of complications 

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Related ObG Topics:

Pregnancy of Unknown Location – Next Steps
Diagnosing the Extrauterine Pregnancy-What You Need to Know
You’ve Diagnosed the Ectopic Pregnancy – When and How to Use the Medical Option

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