Navigating Uncertainty: Expectant or Active Management for Persisting Pregnancy of Unknown Location?

Wu, Jessica K; Montoya, Melissa; Peipert, Benjamin J; Barnhart, Kurt

doi:10.21608/jrme.2025.356363.1026

Navigating Uncertainty: Expectant or Active Management for Persisting Pregnancy of Unknown Location?

Document Type : Debate

Authors

¹ Obstetrics and Gynecology Department, Hospital of the University of Pennsylvania, Philadelphia.

² Division of Family Planning, Obstetrics and Gynecology Department, Hospital of the University of Pennsylvania, Philadelphia.

³ Division of Reproductive Endocrinology and Infertility, Obstetrics and Gynecology Department, Hospital of the University of Pennsylvania, Philadelphia.

10.21608/jrme.2025.356363.1026

Abstract

INTRODUCTION
Up to 40% of patients presenting for evaluation of early pregnancy are diagnosed with a transient state called a pregnancy of unknown location (PUL). Management of PUL is dynamic and variable, with the ultimate goal of avoiding risks of ectopic pregnancy while balancing other factors, such as patient priorities. We compare active versus expectant management of persisting PUL to guide clinician counseling for PUL management.

ACTIVE MANAGEMENT
Active management involves either uterine evacuation or empiric methotrexate and has the clinical benefit of preventing ruptured ectopic pregnancy if clinical suspicion is high; it has been shown in prior studies to increase likelihood of successful pregnancy resolution compared to expectant management. Patient-specific factors are important to consider when thinking about active management, such as prior abdominal surgical history that may make emergent surgery for a downstream ectopic pregnancy more challenging and morbid, or challenges with follow-up required for expectant management. Patient priorities, such as pregnancy desiredness, are also important to center in these decisions.

EXPECTANT MANAGEMENT
Expectant management involves serial HCG monitoring to use HCG trends to risk-stratify likelihood of ectopic pregnancy. Benefits include avoiding unnecessary interventions or disrupting a viable pregnancy, as well as avoiding risks of uterine evacuation or methotrexate. Patient preferences should similarly be prioritized in decision-making, such as desire for diagnostic certainty or concerns about future fertility.

CONCLUSION
Shared decision-making is critical in determining optimal management of persisting PUL, which is dynamic and individualized. Several patient-specific factors should be used to guide patient counseling and clinical practice.

Keywords

Main Subjects