Persistent Pregnancy of Unknown Location: Landmark Evidence to Guide Management

This transcript has been edited for clarity.

Today I'd like to discuss treatment of persistent pregnancies of unknown location (PUL). When women present with a positive pregnancy test, ultrasound may not identify the site of the gestation. In one third of PULs, serial serum hCG levels clarify that although the pregnancy is not viable, the rate of hCG decline does not indicate a resolving pregnancy loss. Such pregnancies are considered persistent PULs. What constitutes optimum management in this clinical setting has been unclear.

Researchers conducted an NIH-funded trial at 12 US academic centers comparing uterine aspiration followed by methotrexate (if indicated), primary methotrexate treatment, and expectant management. This study was recently published in JAMA.

Therapy was considered successful when the initial treatment, whether active (meaning uterine aspiration or primary methotrexate) or expectant, resulted in pregnancy resolution without deviating from the initial approach. Among women randomized to active treatment, almost half declined the therapy they were assigned to. Among those randomized to expectant management, approximately one quarter declined. Ultimately, 62 patients underwent uterine aspiration, 84 received primary methotrexate, and 107 received expectant management.

After analysis based on treatment as received, active treatments were almost 95% successful, whereas expectant management was only 56% successful.