EPU Leaflet: Pregnancy of Unknown Location (PoUL)

Leaflet Details

Patient Information

Introduction

We performed an ultrasound scan today because of bleeding and or pain or a history of problems in your previous pregnancy. Despite a positive pregnancy test, we were not able to see a pregnancy on your scan today. When this happens, we say you have a Pregnancy of Unknown Location (POUL).

This leaflet will give you information about what this could mean and the next steps.

Why were you unable to see my pregnancy on the scan?

There are 3 possible reasons this may happen:

The pregnancy is developing normally in the womb but is too early to be seen on scan

This is most likely to be the reason if you have not had any vaginal bleeding, you are not sure of the date of your last period, your periods are irregular, your menstrual cycle is longer than four weeks or the USS is performed too early in the pregnancy.

There can be a delay of approximately 1 week between a positive pregnancy test and a very early pregnancy sac being seen on internal (vaginal) scan. A pregnancy sac is usually visible on internal scan a week after you miss a period, and we see a baby a week after the pregnancy sac is seen on scan. This pattern is more commonly if you have regular 28-day menstrual cycle and if the pregnancy developing as expected.

It is an early miscarriage

The pregnancy may have been growing in your womb but unfortunately it wasn’t developing normally, and you may have already miscarried and passed the pregnancy through the vagina. This is the most likely reason if you have had heavy vaginal bleeding.

The pregnancy test can still be positive after a miscarriage because the pregnancy hormones (which are detected by the urine or blood test) take some time to gradually disappear. A urine pregnancy test can remain positive for up to 3 weeks after a pregnancy loss and you might continue to feel pregnant during this time.

It is an Ectopic Pregnancy

This is where the pregnancy grows outside of your womb, most commonly in the fallopian tube. An ectopic pregnancy isn’t normal and doesn’t grow at the same rate as a normal pregnancy and this may explain why it was not seen on the initial scan or the ectopic pregnancy may have been too small to be seen on the initial scan. Unfortunately, an ectopic pregnancy can’t grow to become a healthy baby because it is located outside the womb.

Of the three conditions that may account for a POUL, an ectopic pregnancy is more likely to affect your health because there is a small chance this may rupture resulting in internal bleeding which could be life threatening.

It is important you read the rest of this leaflet, so you are aware of what the next steps are, the signs that are abnormal and what to do if you are concerned.

What happens now?

The next step will be a blood test. For most women, it is safe to go home once this is done and we will contact you with the result of the blood test by phone. Please ensure you confirm your telephone number before you leave the unit. When we call you, our number will be WITHHELD. Please ensure you pick your phone up, thank you. Sometimes we will recommend you are admitted to hospital while waiting for your blood result if we think you are at a high risk of an ectopic pregnancy or there are concerning features seen on scan.

The blood tests look at two pregnancy hormones: hCG and Progesterone.

• hCG tells us the level of pregnancy hormone in your body
   
• Progesterone tells us how quickly the pregnancy is progressing

These tests do not tell us where the pregnancy is, but it can provide additional information to help us determine what the next plan should be.

We will call you today if we receive your result before the close of work or on the next working day if results are not back by close of work. We may give you a courtesy call if the results are not available by the close of work.

What do the blood results mean?

These are the possible outcomes of the blood test results:

Low hCG and high progesterone.

This indicates a very early pregnancy that is developing but not yet big enough to be seen on a scan. We will arrange a re-scan when we think we should be able to see the pregnancy on ultrasound scan.

Borderline hcg and progesterone

If the progesterone is borderline, we cannot tell if it is a miscarriage, an early pregnancy, or an ectopic pregnancy from one blood test. We will repeat your blood test in 2 days to gather more information.

If on the second blood test your hCG level is increasing like a healthy pregnancy, we will advise you on when you can come for another scan.

If on the second blood test your hCG level is going down significantly, it is likely you are having an early miscarriage, and we will continue to monitor your blood tests to ensure it goes back to non-pregnancy level or recommend a home pregnancy test.

If the hCG level is the same or increases slightly or falls slightly, we will either invite you for a further blood test or advise you to come back for another scan to check if we may be able to see the pregnancy.

If your second blood test falls on a weekend or a bank holiday we will arrange a scan on the next working day or occasionally arrange for a repeat blood test on the next working day. The decision will vary between different patients depending on the clinical situation and your symptoms.

Very low progesterone

If your progesterone is very low, it is likely the pregnancy will fail. These types of pregnancies may be within the womb or may be a very small ectopic pregnancy. We call this type of pregnancy a resolving pregnancy. We usually monitor your hormone blood results until it returns to the nonpregnancy range. We may also recommend a repeat scan depending on how quickly your hormone results are reducing or if you develop any concerning symptoms. If the pregnancy was in the womb, you may experience vaginal bleeding. If the pregnancy was in the tube, the body’s normal healing process will gradually absorb the pregnancy and you may experience some abdominal discomfort plus/minus some vaginal bleeding.

What will happen once the result is available?

We will contact you and arrange follow-up which usually involves one of the following:

• A repeat blood test, usually after two days or in one week.
   
• A repeat ultrasound scan.
   
• A repeat home pregnancy test.
   
• Telephone follow up with our nursing or medical team.

If we think this is an early pregnancy and it is too early to see on scan, we will arrange another scan when the pregnancy is likely to be seen on scan.

If we think this is a miscarriage, we will discuss your options with you and support the verbal information with written patient information leaflets. We will recommend a home pregnancy test in three weeks, and you should contact us if this is still positive.

If an ectopic pregnancy is eventually identified, we will discuss what this means and what the options for treatment are. We will support the verbal information with written patient information leaflet on ectopic pregnancy and treatment options.

What to look out for during follow up:

We have not been able determine the location of your pregnancy on scan. Please be aware an ectopic pregnancy may be present, but this has not yet been seen on scan. Ectopic pregnancies can be harmful to your health because if it ruptures, this can result in internal bleeding.

We advise you to remain in the local area and within easy access of an Emergency Department and avoid any strenuous activity and sexual intercourse. Please go to the Emergency Department with your letter/scan report if you develop the symptoms below.

1. Significant pain in your abdomen, pelvis or shoulders (which is not controllable with Paracetamol or Ibuprofen)
    
2. Unmanageable bleeding (for example having to change your sanitary pad every half an hour or more)
    
3. If you feel dizzy, lightheaded or you collapse
    
4. If you become unwell with a fever, shivers and shakes as this may be due to an infection.

Support

We hope that this leaflet has answered any questions or concerns that you might have. Please do not hesitate to speak to the doctors or nurses if there is anything you are unsure of.

You or your partner may experience anxiety or other emotions while we are looking after you. Our nursing team will be happy to support you or refer you for counselling if necessary. Please let us know how we can best support you. Your local GP can also refer you to local mental health services.

You can call the Early Pregnancy Unit on 01932 722662.

Early Pregnancy Unit opening hours

If the line is engaged, please leave a message and we will call you back.

Trying for another pregnancy

If you wish to try to conceive again after a miscarriage, a resolving pregnancy or an ectopic, we advise waiting until after your next period before trying to get pregnant. If you get pregnant before your next period, this is not harmful. We recommend pre-conceptual folic acid, ensure any medical condition is well managed, stop smoking, be active and maintain a healthy diet and weight. This will ensure you are in good health before getting pregnant.

Further Information and contact details

Early Pregnancy Unit website:
https://www.ashfordstpeters.nhs.uk/early-pregnancy-unit

Early Pregnancy Unit email:
This email address is being protected from spambots. You need JavaScript enabled to view it.

Miscarriage UK
Helpline: 01924 200799
https://www.miscarriageuk.org

The Ectopic Pregnancy Trust:
https://ectopic.org.uk

Royal College of Obstetrics and Gynaecology (RCOG):
https://www.rcog.org.uk/for-the-public/browse-our-patient-information/

Useful Early pregnancy Unit leaflets:

• Ectopic Pregnancy
• Expectant, surgical and outpatient management of miscarriage
• Treating Ectopic pregnancy with methotrexate