Proposed Updated Guidelines for Diagnosis of Pregnancy of Unknown Location (PUL)
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International Journal of Science and Healthcare Research
Vol.5; Issue: 2; April-June 2020
Website: ijshr.com
Short Communication ISSN: 2455-7587
Proposed Updated Guidelines for Diagnosis of
Pregnancy of Unknown Location (PUL)
Maged MN1, Mohamed MN2, Lamia H. Shehata3
1
Mazahmiya Hospital, Ministry of Health, Kingdom of Saudi Arabia,
2
Department of Obs/Gyn, King Fahd Hospital, Ministry of Health, Kingdom of Saudi Arabia,
3
Department of Surgery, Consultant Endoscopic Surgery, Department of Radiology,
Care National Hospital, KSA
Corresponding Author: Maged MN
ABSTRACT combination of the two is between 6% and
16%.
Early diagnosis of an extra-uterine pregnancy is
important for safe and effective management. Epidemiology of Ectopic Pregnancy
However, a pregnancy's location often cannot be Usually the oocyte and the sperm
easily determined with abnormal implantations
meet in the ampullary part of the fallopian
or prior to 5-6 weeks’ gestation. Multiple testing
strategies exist to diagnose an abnormal tube, and impregnation takes place. The
pregnancy when location is unknown, but growing morula moves slowly toward the
caution needs to be used to avoid a false uterus cavity while differentiating into the
diagnosis. Medical treatment is optimal when an embryoblast and trophoblast. Implantation
abnormal pregnancy is diagnosed early. Because in the uterine cavity usually takes place after
most of these pregnancies are intrauterine, 6 or 7 days.
additional testing to localize the pregnancy will
allow the correct choice of therapy and avoids Etiology and Risk Factors
unnecessary exposure to a toxic therapy should Theoretically, anything that impedes
be reserved for patients with significant concern migration of the conceptus to the uterine
for ectopic pregnancy, based on either risk
cavity may predispose a woman to develop
factors or clinical findings.
Updating guidelines, to include MRI and new an ectopic gestation. These may be intrinsic
biomarkers, is required to define early location anatomic defects in the tubal epithelium,
of pregnancy (intrauterine or extra uterine) and hormonal factors that interfere with normal
condition (healthy and unhealthy) pregnancy. transport of the conceptus, or pathologic
conditions that affect normal tubal function.
Keywords: (Ectopic pregnancy; MRI, The hormonal interference effects that
Ultrasonography; Biomarkers; B-hCG; estrogen and progesterone show on the
Progesterone). growth and the motility of the epithelial
ciliae, and estrogen stimulates the growth
INTRODUCTION and differentiation of the fallopian tube
Implantation of the zygote outside including the generation of the epithelial
the uterine cavity occurs in 2% of all ciliae. (1)
pregnancies. The rate of ectopic pregnancies
has increased from 0.5% in 1970 to 2% Diagnosis
today. The prevalence of ectopic pregnancy Usually the earliest appearance of
(EP) in all women presenting to an symptoms occurs in the sixth week after the
emergency department with first-trimester last period. Patients with ectopic pregnancy
bleeding, lower abdominal pain, or a can show all symptoms of a normal early
International Journal of Science and Healthcare Research (www.ijshr.com) 447
Vol.5; Issue: 2; April-June 2020Maged MN et.al. Proposed updated guidelines for diagnosis of pregnancy of unknown location (PUL)
pregnancy, such as interruption of the almost all cases of suspected ectopic
normal menstrual period, nausea, vomiting, pregnancy, ultrasound in combination with
breast fullness, and fatigue. Typical clinical data and laboratory tests is sufficient
symptoms of ectopic pregnancies are lower for making a correct diagnosis. Advantages
abdominal pain and abnormal uterine include the ability of ultrasound to assess
bleeding, ranging from spotting to severe for fetal heart activity to confirm the
bleeding, Involuntary guarding and presence of an embryo and the ability to
peritoneal signs are indicative of differentiate ectopic pregnancy from a
intraperitoneal blood collection; there may corpus luteum by pressing down on the
be tenderness on cervical motion. (2) ectopic pregnancy to separate it from an
ovary. The most specific sonographic
Serial Serum Human Chorionic feature of ectopic pregnancy is the presence
Gonadotropin of an extra-uterine gestational sac (5)
In a normally developing pregnancy, B-hCG
starts secretion on days 5 to 8. A serum Role of MRI in ectopic pregnancy
array detects levels as low as 5 mIU/mL, As previously described, ultrasound
whereas the detection limit in urine is 20 to is the first-line imaging modality for
50 mIU/mL. obstetric imaging and diagnosis of ectopic
The B-hCG levels double every 1.5 days in pregnancy.
the first 5 weeks of a regular gestation. In addition to the aforementioned
After 7 weeks, the sequence for double titers limitation of operator dependence,
is 3.5 days. ultrasound is also limited by bowel gas
In comparison, only 30% of ectopic interference, obesity or large body habitus,
pregnancies show a normal B-hCG course, and small field of view. Another important
In 70% of ectopic pregnancies, the B-hCG limitation relative to diagnosis of ectopic
levels rise more slowly and reach a plateau pregnancy is ultrasound’s inability to
or show a decrease in serum levels. An differentiate hemorrhage from other fluids.
abnormal B-hCG pattern is highly As such, MRI plays an important
suggestive of an ectopic gestation or a no role in the early diagnosis and management
longer intact gestation. (3) of ectopic pregnancy. MRI is now
increasingly being used in complicated
Progesterone cases, in cases with unusually located
Single serum P doses have been used ectopic pregnancy, and as a supplementary
together with serum B-hCG doses in the problem-solving imaging modality, MRI
follow-up of ectopic pregnancy. requires no specific patient preparation or
Serum P levels are a satisfactory marker of premedication. Other advantages of MRI
pregnancy viability, but they are unable to include no ionizing radiation, multi-planar
predict the location of a pregnancy. P levels imaging, and excellent soft tissue contrast (6)
below 5 ng/mL are associated with The major roles of MRI are to
nonviable gestations, whereas levels above identify fresh hemorrhage, to accurately
20 ng/mL are correlated with viable localize the abnormal implantation site with
intrauterine pregnancy, however, a superb spatial resolution, and to identify
considerable proportion of EPs present with associated congenital uterine anomalies or
P doses between 5 and 20 ng/mL, which Mullerian abnormalities. The fallopian
limits its use in clinical practice to exclude tubes, round ligaments, and other adnexal
the possibility of EPs (4) structures are easier to identify in the
Role of ultrasound in ectopic pregnancy presence of pelvic fluid or hemorrhage.
Ultrasound remains the first-line imaging Other important roles of MRI include
modality for the evaluation of pregnant planning of the surgical approach in
patients with abdominal or pelvic pain. In abdominal pregnancy, differentiation of
International Journal of Science and Healthcare Research (www.ijshr.com) 448
Vol.5; Issue: 2; April-June 2020Maged MN et.al. Proposed updated guidelines for diagnosis of pregnancy of unknown location (PUL)
some forms of ectopic pregnancy from serum B-hCG level is 1800-2000 mIU/ml.
incomplete abortion, and differentiation of In normal healthy pregnancies, the B-hCG
ectopic pregnancy from other acute level should double about every two days, if
conditions, such as ovarian torsion, pelvic no intrauterine pregnancy is detected,
inflammatory disease, and acute knowledge of the B-hCG level is crucial. A
appendicitis. (7) B-hCG level of 2000
long) non-protein coding genes able to mIU/ml (IRP), the intrauterine gestational
recognize complementary messenger RNAs sac should be identified. (16)
(mRNAs), acting as master gene regulators
by repressing mRNA translation or by The discriminatory zone indicates the value
mRNA degradation. (10) of serum B-hCG above which an
Previous studies demonstrated dysregulation intrauterine gestational sac should be visible
of miRNA expressions in early embryonic on ultrasound.
tissues and in the fallopian tube of women Most services consider a
with EP, including Lin28b, let-7, miR-132, discriminatory zone between 1,500 and
miR-145, miR-149, miR-182, miR-196, 2,000/2,500 mIU/mL of B-hCG while using
miR-223, miR-424, and miR-451 (11,12,13) TVUS. (17) When the B-hCG value is above
Circulating miR-323-3p has a high the discriminatory zone and no intrauterine
sensitivity for ectopic pregnancy diagnosis, gestation is visible on TVUS, an EP should
when used as a single marker (14) miR-873 be suspected; however, it is possible to have
could be a valuable noninvasive and stable a viable intrauterine pregnancy, even if the
biomarker for the early detection of EP (15) ultrasound does not show an IUP, and the
B-hCG value is above the discriminatory
DISCUSSION zone.
Early diagnosis of ectopic pregnancy Several studies have documented the
is essential, because ruptured ectopic appearance of embryos with cardiac activity
pregnancy in a hemodynamically unstable in the follow-up of pregnancies where the
patient requires urgent or emergent surgical gestational sac was not visible on TVUS
intervention. with B-hCG values above 2,000 mIU/Ml.
(18)
Laboratory investigations in ectopic
pregnancy with negative serum B-hCG level Serum P doses are useful in cases of
virtually exclude the possibility of live PUL (pregnancy of unknown location) to
pregnancy. identify patients with PULF (pregnancy of
Serum B-hCG is secreted by the unknown location failure) and thereby
placenta and can be detected in the blood minimize the examinations and days of
stream about 9 days after conception or follow-up because they are considered low
approximately 3 weeks after last menstrual risk, regardless of the location of the
period (LMP). A gestational sac should be pregnancy. PMaged MN et.al. Proposed updated guidelines for diagnosis of pregnancy of unknown location (PUL)
positive predictive value for Pregnancy As such, MRI plays an important
failure of 98.2%. (19) role in the early diagnosis and management
Concentration of serum miR-323-3p of ectopic pregnancy.
was higher, in women with EP. Among MRI is now increasingly being used in
these miRNAs, circulating miR-323-3p has complicated cases, in cases with unusually
the highest sensitivity when used as a single located ectopic pregnancy,
marker. Furthermore, the combined B-hCG, On MR imaging, the features of tubal
progesterone, and miR-323-3p show even pregnancy include:
higher sensitivity and specificity when Sac-like cystic tubal lesion with a thick
compared to each use alone, suggesting that wall (24) that is located within the
miR-323-3p might be a useful biomarker to fallopian tube. The wall shows high
improve the diagnosis of EP. (20) signal intensity on T2-weighted MR
As a single marker, miR-873 has a high images, and hemorrhage adjacent to the
sensitivity at 61.76 % (at a fixed specificity wall is frequently observed
of 90%), suggesting its potential as a Hemato-salpinx with tubal dilatation
biomarker for the early detection of EP. (15) occurs after implantation of the embryo
Ultrasonography is the best into the epithelium of the fallopian tube.
examination method for identifying the This process can lead to bleeding and
location of an early pregnancy. TVUS subsequent hemato-salpinx. (25) It
identified the location of the pregnancy in typically demonstrates as dilated
91.3% of pregnant women. Of these fallopian tube with high signal intensity
women, 89.6% were diagnosed with fluid on T1-weighted MR images.
intrauterine pregnancies (IUPs), 1.7% were Hemorrhagic complex adnexal mass that
diagnosed with ectopic pregnancies (EPs), is separate from the ovary when non-
and 8.7% were diagnosed with PUL. (21) contrast images are equivocal, post-
One great concern of PULs is that contrast images may be helpful.
they are cases of ectopic pregnancy whose Findings on post-gadolinium
diagnosis might be postponed. TVUS is able administration images include tree-like solid
to identify an EP with a sensitivity ranging enhancement that represents feto-placental
from 87% to 94% and a specificity ranging tissue within complex adnexal mass,
from 94% to 99% when multiple exams are peripheral enhancement of gestational cystic
performed. mass that corresponds with the sonographic
With a single examination, TVUS identifies tubal ring sign, and tubal wall enhancement
EPs with 73.9% sensitivity and 98.3% that is thought to reflect increased
specificity. (22) vascularity in the tubal wall. Post-
Regarding PULs, a common mistake gadolinium images may facilitate more
is to perform TVUS alone. The adnexa accurate detection of ruptured tubal
might be located in a higher region, and pregnancy.
only a pelvic abdominal ultrasound enables Although no specific MRI findings
visualization and identification via a relating to tubal rupture have been fully
suggestive image to diagnose EP. (23) described, disruption of tubal wall
In addition to the aforementioned enhancement may be seen in ruptured tubal
limitation of operator dependence, pregnancy, and the demonstration of acute
ultrasound is also limited by bowel gas or recent hematoma showing distinct low
interference, obesity or large body habitus, signal intensity on T2 weighted images
and small field of view. Another important located outside the enhancing implantation
limitation relative to diagnosis of ectopic site may suggest tubal rupture in
pregnancy is ultrasound’s inability to symptomatic patients. (26)
differentiate hemorrhage from other fluids. Interstitial pregnancy occurs when
the embryonic tissue implants in the
International Journal of Science and Healthcare Research (www.ijshr.com) 450
Vol.5; Issue: 2; April-June 2020Maged MN et.al. Proposed updated guidelines for diagnosis of pregnancy of unknown location (PUL)
intramural or interstitial portion of the fundus at one end and the cervical canal at
fallopian tube, which is eccentrically located the other. (29)
in the fundal region of the uterus. This Ovarian pregnancy is a rare form of
location allows for painless growth, and the ectopic pregnancy, being found in only 3%
increased distensibility of this region of all ectopic pregnancies. A gestational
facilitates a gestation period that can last as sac-like structure within the ovary that
long as 16 weeks. frequently contains acute hemorrhage with
Given the proximity of this type of obvious low signal intensity on T2-weighted
pregnancy to the uterine artery, rupture can image and normal fallopian tubes are the
cause life-threatening uncontrolled massive suggestive imaging features of ovarian
intraperitoneal bleeding. Early diagnosis of pregnancy on MRI (8)
interstitial pregnancy is sometimes difficult Cesarean scar pregnancy, MRI,
to make on ultrasound since it can be however, is able to demonstrate gestational
misinterpreted as normal intrauterine sac localization and its relationship with
pregnancy with eccentric location. (27) adjacent organs, and it can assess for
Angular pregnancy refers to myometrial invasion and bladder
implantation of the embryo in the involvement.
endometrium of the lateral edge of the A key MRI finding is the absence or
uterus, medial to the utero-tubal junction. thinning of myometrium between the
Angular pregnancy can be confused with bladder wall and the gestational sac on T2-
both normal pregnancy and interstitial weighted imaging. Other imaging findings
pregnancy. to support a diagnosis of cesarean scar
Distinction between angular pregnancy are an empty uterus and cervical
pregnancy and interstitial pregnancy can be canal, and gestational sac formation in the
difficult, but it is important because angular anterior part of the lower uterine segment.
(30)
pregnancy can be carried to term. Angular
and interstitial pregnancies may both appear Abdominal pregnancy is categorized
as a heterogeneous mass of gestational sac into primary and secondary types. Primary
with intermediate to high signal intensity on abdominal pregnancy is defined as
T2-weighted imaging and surrounded by pregnancy in which the embryo is directly
myometrium. implanted in the peritoneal cavity, and this
However, if there is an intact type is extremely rare. Secondary abdominal
junctional zone between the mass and pregnancy, the more common type of
endometrium, and the mass is lateral to the abdominal pregnancy, is defined as tubal
round ligament, then these findings are pregnancy that ruptured and that then re-
suggestive of an interstitial pregnancy. (28) implanted in the abdomen. Blood supply
Incidence of cervical pregnancy is can be recruited from the omentum and
less than 1% of all ectopic pregnancies. abdominal organs. Early abdominal
Diagnosis can be made when the gestational pregnancy may mimic tubal pregnancy if
sac is discovered within the cervix. MRI is located in the pelvic cavity. MRI may be
helpful for making a diagnosis. MRI helpful to establish diagnosis.
findings include, a heterogeneous mixed On MR imaging, a gestational sac
signal intensity lobulated mass that associated with hematoma may be detected
represents the gestational sac occupying the in the pouch of Douglas. There is an
cervix, enlarged cervical canal, and normal observable lack of myometrium surrounding
endometrial stripe. the gestational sac.
A cervical pregnancy may result in MRI is better than sonography for
an hourglass-shaped or figure eight-shaped clarifying anatomic relationship with
uterus that is formed by a distended uterine surrounding structures, vascular supply,
oligohydramnios, placental site, and unusual
International Journal of Science and Healthcare Research (www.ijshr.com) 451
Vol.5; Issue: 2; April-June 2020Maged MN et.al. Proposed updated guidelines for diagnosis of pregnancy of unknown location (PUL)
fetal lie, and this can assist in preoperative Advise women to return if there are new
planning and prediction of possible symptoms or if existing symptoms worsen,
complications during surgical treatment. (31) and for a woman with an increase in serum
The benefits of MRI in abdominal B-hCG levels greater than 63% after 48
pregnancy also include detection of unusual hours, inform her that she is likely to have a
shape of gestational sac, location of developing intrauterine pregnancy (although
implantation site, and presence of flattened the possibility of an ectopic pregnancy
placenta. MRI also provides details about cannot be excluded) and offer her a
potential vascular connections and placental transvaginal ultrasound scan to determine
adherence to surrounding structures. A the location of the pregnancy between 7 and
rounded gestational sac and crescentic 14 days later. Consider an earlier scan for
placenta are more likely to be observed in women with a serum B-hCG level greater
intrauterine and tubal pregnancy. than or equal to 1500 IU/litre. (33)
Abdominal pregnancy can present at
advanced gestational age, up to and ACOG recommendations
including full term. Associated Here may be a role for expectant
complications include massive hemorrhage, management of ectopic pregnancy in T
disseminated intravascular coagulation, gut specific circumstances. Candidates for
obstruction, and fistula formation caused by successful expectant management of ectopic
fetal bones protruding through the thin pregnancy should be asymptomatic; should
amniotic sac. (32) have objective evidence of resolution
All guidelines for pregnancy of (generally, manifested by a plateau or
unknown origin recommended conservative decrease in hCG levels); and must be
period 7-14 days, with repeated B-hCG counseled and willing to accept the potential
levels and TVS examinations. risks, which include tubal rupture,
hemorrhage, and emergency surgery. If the
RCOG GUIDELINES initial hCG level is less than 200 mIU/mL,
Women with a pregnancy of 88% of patients will experience spontaneous
unknown location could have an ectopic resolution; lower spontaneous resolution
pregnancy until the location is determined. rates can be anticipated with higher hCG
Do not use serum B-hCG measurements to levels (34)
determine the location of the pregnancy, and Irish guidelines recommendations
place more importance on clinical Extended observation of women
symptoms than on serum B-hCG results, who have an uncertain prognosis in early
and review the woman's condition if any of pregnancy has shown that many EPs resolve
her symptoms change, regardless of spontaneously. Expectant management is an
previous results and assessments. Use serum option in selected women with probable EP
B-hCG measurements only for assessing provided they have minimal symptoms and
trophoblastic proliferation to help to are compliant with follow-up. In the
determine subsequent management, and presence of a non homogenous adnexal
take 2 serum B-hCG measurements as near mass, it has been shown that expectant
as possible to 48 hours apart (but no earlier) management may have a success rate of
to determine subsequent management of a over 80% provided that the initial B-hCG is
pregnancy of unknown location. less than 1,000 IU/L and falling by at least
Regardless of serum B-hCG levels, 13% over 48 hours.
give women with a pregnancy of unknown Continuing outpatient observation is
location written information about what to appropriate if the woman is clinically stable.
do if they experience any new or worsening She should be given written information
symptoms, including details about how to explaining her condition and the possible
access emergency care 24 hours a day. complications of EP. She should understand
International Journal of Science and Healthcare Research (www.ijshr.com) 452
Vol.5; Issue: 2; April-June 2020Maged MN et.al. Proposed updated guidelines for diagnosis of pregnancy of unknown location (PUL)
the importance of compliance with follow- 3. Brennan D. Ectopic pregnancy Vpart I:
up and have easy 24 hour access to clinical and laboratory diagnosis. Acad
emergency hospital gynecological care. Emerg Med. 1995; 2: 1081Y1089.
Women managed expectantly should be 4. American College of Obstetricians and
followed at least weekly with serial B-hCG Gynecologists. ACOG Practice Bulletin No.
94: Medical management of ectopic
measurements and TVS Considering the pregnancy. Obstet Gynecol. 2008;
potentially serious risks of tubal rupture and 111(6):147985.
hemorrhage and the established safety and 5. Brown D, Doubilet P. Transvaginal
effectiveness of medical and surgical sonography for diagnosing ectopic
treatment of EP, it seems prudent that pregnancy: positivity criteria and
expectant management should be reserved performance characteristics. J Ultrasound
for asymptomatic patients with very low and Med. 1994; 13: 259–266.
falling B-hCG levels. Any plateau or rise in 6. Masselli G, Brunelli R, Casciani E, Polettini
the B-hCG measurements should prompt E, Bertini L, Laghi F, et al. Acute
medical or surgical treatment. (35) Abdominal and Pelvic Pain in Pregnancy:
MR Imaging as a Valuable Adjunct to
Ultrasound? Abdominal Imaging 2011;
CONCLUSION 36:596-603.
As a supplementary imaging 7. Jung S, Byun J, Lee J, Rha S, Kim H, Choi
modality to ultrasound, MRI can provide B, et al. MR imaging of maternal diseases in
information that improves physician ability pregnancy. AJR Am J Roentgenol. 2001;
to diagnose ectopic pregnancy. MRI also 177: 1293-300.
plays an important role in identifying the 8. Tamai K, Koyama T, Togashi K. MR
implantation site in tubal and non-tubal features of ectopic pregnancy. Eur
ectopic pregnancy (with or without rupture) Radiol.2007; 17(12):3236–3246.
and in differentiating ectopic pregnancy 9. Dechaud M, LFilhastreesnik A, Taourel P.
from other diseases. miR-323-3p and miR- Interstitial pregnancy: role of MRI.
873 are potential markers for early ectopic EuropRadiol. 2005; 15: 93–95y.
10. Steinkraus B, Toegel M, Fulga T, “Tiny
pregnancy diagnosis, adding MRI, miR-
giants of gene regulation: experimental
323-3p and miR-873 to early ectopic strategies for microRNA functional
pregnancy diagnosis guidelines will studies,” Wiley Interdisciplinary Reviews:
decrease maternal morbidity and mortality. Developmental Biology, 2016; vol. 5, no. 3,
It is time to update guidelines, pp. 311–362.
changing our practice, using combined 11. Feng Y, Zou S, Weijdegard B, et al., “The
diagnostic modalities, including MRI and onset of human ectopic pregnancy
new biomarkers, improving our demonstrates a differential expression of
management and prognosis. miRNAs and their cognate targets in the
Fallopian tube,” International Journal of
Conflict of interest Clinical and Experimental Pathology, 2014;
All authors declare no conflicts of interest. vol. 7, no. 1, pp. 64–79.
12. Dominguez F, Moreno-Moya J, Lozoya J, et
Authors’ contribution al., “Embryonic miRNA profiles of normal
Authors have equally participated and shared and ectopic pregnancies,” PLoS ONE, 2014;
every item of the work. vol. 9, no. 7, Article ID e102185.
13. Lozoya T, Dom´ınguez F, Romero-Ruiz A,
REFERENCES et al., “The Lin28/Let-7 system in early
1. Murray H, Baakdah H, Bardell T, et al. human embryonic tissue and ectopic
Diagnosis and treatment of ectopic pregnancy,” PLoS ONE, 2014; vol. 9, no. 1,
pregnancy. CMAJ. 2005; 173: 905Y912. Article ID e87698.
2. Hucke J, Fu¨ llers U. Extrauterine 14. Zhao Z, Moley K, Gronowski A.
Schwangerschaft. Der Gyna¨ kologe. 2005; “Diagnostic potential for miRNAs as
6: 535Y552. biomarkers for pregnancy-specific
International Journal of Science and Healthcare Research (www.ijshr.com) 453
Vol.5; Issue: 2; April-June 2020Maged MN et.al. Proposed updated guidelines for diagnosis of pregnancy of unknown location (PUL)
diseases,” Clinical Biochemistry, 2013; vol. 26. Nishino M, Hayakawa K, Kawamata K,
46, no. 10-11, pp. 953–960. Iwasaku K, Takasu K. MRI of early
15. Qi L, Qi Y, Fengying X, Yuhong L, Wenxia unruptured ectopic pregnancy: detection of
Z, Chunzhu W, Yudong W, Xiao L. Cell gestational sac. J Comput Assist Tomogr.
Physiology Biochem. 2017; 41: 2513-2522. 2002; 26 (1):134-137.
16. Tamai K, Koyama T, Saga T, Kido A, 27. Lin E, Bhatt S, Dogra V. "Diagnostic clues
Kataoka M, Umeoka S, et al MR features of to Ectopic Pregnancy." Radio graphics.
physiologic and benign conditions of the 2008; 28: 1661-1671.
ovary. EurRadiol. 2006; 16 (12): 2700– 28. Filhastre M, Dechaud H, Lesnik A, Taourel
2711. P. Interstitial pregnancy: role of MRI. Euro
17. American College of Obstetricians and Radiol. 2005; 15: 93–95.
Gynecologists. ACOG Practice Bulletin No. 29. Kung F, Lin H, Hsu T, Chang C, Huang H,
94: Medical management of ectopic Huang L, Chou Y, Huang K. Differential
pregnancy. Obstet Gynecol. 2008; diagnosis of suspected cervical pregnancy
111(6):147985. and conservative treatment with the
18. Doubilet P, Benson C. Further evidence combination of laparoscopy-assisted uterine
against the reliability of the human artery ligation and hysteroscopic
chorionic gonadotropin discriminatory level. endocervical resection. FertilSteril. 2004
J Ultrasound Med. 2011; 30 (12):1637- Jun; 81(6):1642-1649.
1642. 30. Li S, Wang W, Tang X, Wang Y. Cesarean
19. Cordina M, Schramm-Gajraj K, Ross J, scar pregnancy: a case report. Chin Med J.
Lautman K, Jurkovic D. Introduction of a 2004; 20:105-117.
single visit protocol in the management of 31. Lockhat F, Corr P, Ramphal S, Moodley J.
selected patients with pregnancy of The value of magnetic resonance imaging in
unknown location: a prospective study. the diagnosis and management of extra-
BJOG. 2011; 118(6):693-697 uterine abdominal pregnancy. ClinRadiol.
20. Zhao Z, Zhao Q, Warrick J, et al., 2006; 61:264-269.
“Circulating microRNA miR-323-p as a 32. Allibone G, Fagan C, Porter S. The
biomarker of ectopic pregnancy,” Clinical sonographic features of intra-abdominal
Chemistry, 2012; vol. 58, no. 5, pp 3896– pregnancy. Clin Ultrasound J. 1981; 9: 383–
905. 7.
21. Kirk E, Papageorghiou A, Condous G, Tan 33. Elson CJ, Salim R, Potdar N, Chetty M,
L, Bora S, Bourne T. The diagnostic Ross JA, Kirk EJ on behalf of the Royal
effectiveness of an initial transvaginal scan College of Obstetricians and Gynecologists.
in detecting ectopic pregnancy. Hum Diagnosis and management of ectopic
Reprod. 2007; 22 (11): 2824-2828. pregnancy. BJOG 2016;.123:e15–e55.
22. Kirk E, Bourne T. Diagnosis of ectopic 34. Korhonen J, Stenman UH, Ylostalo P.
pregnancy with ultrasound. Best Pract Res Serum human chorionic gonadotropin
ClinObstetGynaecol. 2009; 23(4):501-508. dynamics during spontaneous resolution of
23. Mausner G, Slywotzky C, Bennett G. ectopic pregnancy. FertilSteril 1994;61:
Pitfalls and tips in the diagnosis of ectopic 632–6. (Level II-3)
pregnancy. Abdomen Radiol. 2017; 42 (5): 35. Jurkovic D and Wilkinson H (2011).
1524-1542. Diagnosis and management of ectopic
24. Kataoka M, Togashi K, Kobayashi H, Inoue pregnancy. British Medical Journal, 342,
T, Fujii S, Konishi J. Evaluation of ectopic d3397.
pregnancy by magnetic resonance imaging.
Hum Repro’d. 1999; 14(10): 2644-2650. How to cite this article: Maged MN, Mohamed
25. Tamai K, Koyama T, Togashi K. MR MN, Shehata LH. Proposed updated guidelines
features of ectopic pregnancy. EurRadiol. for diagnosis of pregnancy of unknown location
2007; 17(12):3236–3246. (PUL). International Journal of Science &
Healthcare Research. 2020; 5(2): 447-454.
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