Combined use of cell phone technology, serum Progesterone and ß-HCG can reduce the extra visits in the management of pregnancy of unknown location in law resource settings

Abstract

Introduction: With the modern ultrasound machines, there is advance in the field of diagnosis of early pregnancy complications. In many cases a location of pregnancy cannot be determined on initial scan. These women are diagnosed with pregnancies of unknown location (PUL), and they are often treated as being at high risk of having an ectopic pregnancy which consequently lead to either admission to the hospital or asking to attend for multiple visits for repeated blood testes and scans which presents a major burden for health services, despite their usually benign clinical course especially in law resource settings. The outcome of such a PUL can be continuation of normal pregnancy, failing pregnancy, ectopic pregnancy and persistent PUL. While pregnancy continuation is a favorable outcome, and failing pregnancy is not life threatening, the outcome of ectopic pregnancy and persistent PUL were the point of focus in terms of development of effective prediction and practical management guidelines. Many agree with the philosophy of reducing intervention in the PUL population. This, however, must not be at the expense of maternal safety. The aim of this study was to evaluate efficacy and safety of the combined use of mobile phone and serum progesterone in the management of patients with pregnancy of unknown location. Material and Methods: A prospective interventional study was introduced to the emergency ward for managing all patients attended to emergency gynecological ward in El Minya maternity university hospital between the period of 1st of August 2010 and 31st of October 2011 whereby clinically stable patients with PUL and serum progesterone level less than 10 nmol/l were discharged after initial visit. Patients were advised to contact emergency mobile number to two dedicated persons (author & co-author) who follow a chart of symptoms & reading of serum levels of progesterone and incorporate the human chorionic gonadotropin (HCG) 48 h/0 h ratio if necessary. Surgical or medical intervention was offered to all women with persistent or worsening symptoms and non-declining serum beta-hCG. Results: 590 pregnant women had an ultrasound diagnosis of PUL, 204 of them (34.5%) had progesterone level less than 10 nmol/l. In this group, the patients asked to phone the emergency numbers with the serum BHCG after 48 h and follow-up continued with the symptoms follow chart till 4 weeks later. 190 (93%) patient completed their follow -up as the pregnancy resolved without any complications.14 patients (7%) re-attended because of worrying or persistent pain or bleeding, 11 of them reevaluated and reassured and discharged soon without any intervention and 3 of them required surgical intervention. There was significant reduction in the number of visits (P < 0.001). Conclusions: The introduced protocol based upon combined use of mobile phone technology, serum progesterone less than 10 nmol/l at law risk of developing complications and if combined with HCG 48 h/0 h ratio notification will be effective in reducing the extra visits & costs and help in triaging women with PULs without significant maternal harm especially in law resource settings.