Pregnancy of unknown location (PUL): a case report and review of literature

Setu Rathod, Sunil Kumar Samal, Seetesh Ghose


While most pregnancies are obviously within the uterus, Pregnancy of Unknown Location (PUL) is used to describe cases where, there is a positive pregnancy test but no sign of a pregnancy inside or outside the uterus, on transvaginal ultrasound or even at laparoscopy. We report a case of multigravida with history of disturbed tubal ectopic pregnancy in previous pregnancy presented with lower abdominal pain and spotting per vaginum following 6 weeks amenorrhoea. The patient was clinically stable with no evidence of intrauterine or extrauterine pregnancy in transvaginal sonography with serum beta human chorionic gonadotropin (beta-hCG) above descriminatory levels. Provisional diagnosis of Pregnancy of Unknown Location (PUL) was made and serial beta-hCG levels shows increasing levels. Endometrial curettage done with histopathology report showed product of conception following which there was a fall in serum beta-hCG. She was finally diagnosed as a case of silent miscarriage. Expectant management has been shown to be safe and effective in reducing the need for surgical intervention but does require close surveillance of patients who present with PUL.


Pregnancy of unknown location, Serum beta-hCG, Discriminatory zone

Full Text:



Rajan DC, Matts SJF. Pregnancy of unknown location: a case report and review of the literature. J Clin Case Rep. 2012;2:207.

Banerjee S, Aslam N, Woelfer B, Lawrence A, Elson J, Jurkovic D. Expectant management of early pregnancies of unknown location: a prospective evaluation of methods to predict spontaneous resolution of pregnancy. BJOG. 2001;108:158-63.

Kirk E, Papageorghiou AT, Condous G, Tan L, Bora S, Bourne T. The diagnostic effectiveness of an initial transvaginal scans in detecting ectopic pregnancy. Hum Reprod. 2007;22:2824.

Seeber BE, Barnhart KT. Suspected ectopic pregnancy. Obstet Gynaecol. 2006;107:399.

Mol BW, Hajenius PJ, Engelsbel S, Ankum WM, Van der Veen F, Hemrika DJ, et al. Serum human chorionic gonadotropin measurement in the diagnosis of ectopic pregnancy when transvaginal sonography is inconclusive. Fertil Steril. 1998;70:972.

Cacciatore B, Stenman UH, Ylostalo P. Diagnosis of ectopic pregnancy by vaginal ultrasonography in combination with a discriminatory serum hCG level of 1000 IU/l (IRP). Br J Obstet Gynaecol 1990;97:904.

Fritz MA, Speroff L. Ectopic pregnancy. In: Fritz MA, eds. Clinical Gynaecological Endocrinology and Infertility. 8th ed. New Delhi: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011: 1391-1395.

Kadar N, Romero R. Further observations on serial human chorionic gonadotropin patterns in ectopic pregnancies and spontaneous abortions. Fertil Steril. 1988;50:367.

Barnhart KT, Katz I, Hummel A, Gracia CR. Presumed diagnosis of ectopic pregnancy. Obstet Gynaecol. 2002;100:505.

Lipscomb GH, Stovall TG, Ling FW. Nonsurgical treatment of ectopic pregnancy. New Engl J Med. 2000;343:1325.

Stovall TG, Ling FW, Andersen RN, Buster JE. Improved sensitivity and specificity of a single measurement of serum progesterone over serial quantitative beta-human chorionic gonadotrophin in screening for ectopic pregnancy. Hum Reprod. 1992;7:723.