Other Types of Pregnancy Loss
Pregnancy of Unknown Location
Pregnancy of Unknown location (PUL) is a medical term used when a woman has a positive pregnancy test but no intra or extra uterine pregnancy is visualised on ultrasound scan.
There could be three reasons for a scan result to be classified as a PUL:
a very early intrauterine pregnancy
an early ectopic pregnancy.
The hCG blood test is performed to aid medical assessment and management in PUL. This blood test is done at intervals of 48 hours. Therefore ongoing monitoring is necessary and may be carried out as an inpatient or outpatient until further information is known. However it is important to note that an ultrasound scan is rarely beneficial at a gestational age of less than six weeks. A study of PULs in CUMH found that only 7% of this population group experienced an ectopic pregnancy.
Pain and bleeding in early pregnancy can signify an ectopic pregnancy. An ectopic pregnancy occurs when implantation takes place outside the womb. 95% of the time implantation occurs in the fallopian tube but it is possible to have an ectopic pregnancy in the ovaries, cervix, abdomen or within a previous caesarean section scar.
An ectopic pregnancy is a life-threatening condition that affects approximately 1 in 70 pregnancies.
Symptoms of ectopic pregnancy that you should look out for:
Lower abdominal pain
Shoulder tip pain
Gastrointestinal symptoms – diarrhoea or pain on passing a bowel motion
Amenorrhoea (missed period).
Confirmation of an ectopic pregnancy is performed using an ultrasound scan and serial blood hCG tests. It can take a number of blood tests and ultrasounds before a diagnosis of ectopic pregnancy becomes clear. By determining the rate of change of the hCG level the appropriate treatment for women can be discussed.
Once the diagnosis of an ectopic pregnancy is made, a medical review is required and conservative, medical or surgical management is decided based on clinical history, physical exam and the ultrasound scan findings.
There is good evidence that ectopic pregnancies with a hCG level greater than 1500 have a 60% chance of resolution with conservative management alone. If an ectopic pregnancy is at an early gestation medical management may also be an option. A drug called methotrexate is given and hCG blood levels are monitored until normal pre pregnant levels are reached.
Surgical treatment is another option in the management of ectopic pregnancy; this will involve laparoscopic surgery, or keyhole surgery, and removal of the affected fallopian tube.
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A molar pregnancy is also known as a hydatidiform mole. It occurs when the pregnancy does not develop properly and there is abnormal placental growth in the womb.
There are two types of molar pregnancy, complete and partial. Complete molar pregnancy occurs when an egg with no genetic information and a sperm form a pregnancy and there is overgrowth of placental tissue and no fetus present. In a partial molar pregnancy an egg and two sperm cells form a pregnancy and there can be some fetal development. All molar pregnancies will result in miscarriage, but women can have a normal pregnancy following a molar pregnancy.
Women with molar pregnancy experience the same symptoms as that of a normal pregnancy, i.e. missed period, morning sickness, etc.
The symptoms of molar pregnancy may also include:
severe nausea and vomiting
signs of hyperthyroidism (overactive thyroid)
an enlarged uterus (womb).
Molar pregnancy is often suspected on ultrasound but only confirmed following removal of the molar tissue by surgical intervention (e.g. D&C/ERPC). Women have follow-up monitoring of the pregnancy hormone (hCG) to ensure it returns to pre-pregnancy levels. This surveillance period is necessary to ensure early detection of a rare cancer which can develop after molar pregnancy. The risk of this cancer developing is low and is associated with the type of molar pregnancy. This cancer has excellent cure rates (approaching 100%) when treatment is received in an expert centre.
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