Leaflet: Pregnancy of Unknown Location

We are sorry that your doctor has informed you that you have a Pregnancy of Unknown Location or PUL.

It is an emotionally difficult time and you will probably have some questions about your Pregnancy of Unknown Location. In this handout, we will try to cover some of those that are most frequently asked.

What is a Pregnancy of Unknown Location?

You may be classified as having a Pregnancy of Unknown Location when you undergo a transvaginal ultrasound examination (where a probe is placed inside the vagina) and it is not possible to see the pregnancy on the scan.

A Pregnancy of Unknown Location is a medical label and not a diagnosis in itself. The label is given until the final location of the pregnancy can be identified with certainty.

What are the reasons for a Pregnancy of Unknown Location?

There are four main reasons why you may be classified as having a Pregnancy of Unknown Location:

  1. It might be too early to see your pregnancy on a scan
    Urinary pregnancy tests are now very sensitive and some even allow a pregnancy to be detected before a period has been missed. However, a pregnancy cannot reliably be seen on a scan until around six weeks after having a missed period so it may be too early to see anything.
  2. You may have already miscarried the pregnancy
    If you have experienced heavy bleeding, similar to a period or heavier, you may have already had a miscarriage and the womb is now empty.
  3. You may have an ectopic pregnancy, which may be too early to be seen on a scan
    An ectopic pregnancy is where an egg implants (gets stuck somewhere) outside of the womb. As with an early pregnancy in the womb, it may be too early for an ectopic pregnancy to be seen on a scan.
  4. You may have an ectopic pregnancy that has not been seen on the scan due to fibroids and poor views

How will my doctors reach a final diagnosis?

This will depend on the local policy of your Early Pregnancy Unit (EPU), ultrasound clinic or hospital.

In general, it will involve blood tests and a possible repeat ultrasound examination (scan).

The doctors will use the blood tests to measure either one or two hormones: the pregnancy hormone known as human chorionic gonadotrophin (hCG) and also sometimes progesterone. Some units will measure these two hormone levels on one occasion and others will take two levels of hCG 48 hours apart.

It is very important that if you develop pain, abdominal (stomach) bloating, faintness, pain with opening your bowels or shoulder tip pain, you must attend the hospital/accident and emergency unit as soon as possible. You should be seen by a specialist doctor (gynaecologist).

Depending on the results, you will be advised on appropriate management.

  • Your hormone levels may be increasing consistent with a normally growing pregnancy which is too early to be seen on the scan. If this happens, a scan should be repeated once your hormone level has exceeded 1000iu/l or 1500iu/l. The pregnancy may be located inside or outside the womb, which is why it is important to have a follow-up scan when the hormone level is at the appropriate level.
  • Your hormone levels may have reduced by half, which suggests a failed pregnancy and likely miscarriage.
  • Your hormone levels may be slowly decreasing, staying the same or increasing which may indicate an ectopic pregnancy.

If you are suspected as having a normally growing pregnancy or an ectopic pregnancy, you will usually be asked to return to hospital for a repeat ultrasound scan to try to locate the pregnancy. The timing of the ultrasound scan will depend on the level of hCG in your blood, as shown by your blood test results.

If, unfortunately, your hCG levels are decreasing, rather than repeating an ultrasound scan, you may be asked to attend for further blood tests or to repeat a urinary pregnancy test to check the pregnancy hormone levels have decreased to non-pregnant levels.

What are my chances of having an ectopic pregnancy?

Fortunately, the majority of women who are initially classified as having a Pregnancy of Unknown Location do not have an ectopic pregnancy. About 10% of women will subsequently be diagnosed with an ectopic pregnancy.

If my pregnancy has failed, does it mean I have not had an ectopic pregnancy?

In most cases of failed Pregnancies of Unknown Location, the true location of the pregnancy is never known. The majority will be failed intrauterine (in the womb) pregnancies – also called miscarriages. It would only be possible to diagnose a failed ectopic pregnancy if a repeat ultrasound examination is performed, but this is not usually needed from a medical care point of view.

Your emotions

Undergoing diagnosis can be a worrying time for any woman. As well as the physical strain of repeated hospital visits and tests, you may also find it challenging to come to terms emotionally with what is happening to you. It can be difficult to process and for your emotions to surface properly. Women often feel a complex mix of emotions and this is very understandable. Being worried about whether the pregnancy is ectopic or not is very normal.

If you are diagnosed with an ectopic pregnancy or miscarriage, it is important to remember that there was nothing you could have done to prevent it from happening and it was not your fault.

Your partner’s emotions

Partners can sometimes find it difficult to understand your feelings and you may feel that your partner is not supporting you in the way in which you would like. Partners can feel confused, scared and isolated too but typically express their emotions in a different way and often do not share how they feel. Your partner’s focus may be on you and your wellbeing rather than on the pregnancy and this can be difficult to accept. It is important to keep communication open and to speak to your partner about your feelings and theirs.

How The Ectopic Pregnancy Trust can provide support

The Ectopic Pregnancy Trust provides information and support to women and their families experiencing early pregnancy complications and loss, such as ectopic pregnancy and miscarriage. Our website has medically-overseen content and includes moderated message boards where you can share your experiences and ask questions. The message boards provide an arena for mutual support in a safe, supportive environment: ectopic.org.uk/talk. If you think we can help you, please visit our website, email or call.

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