Miscarriage, Pregnancy

Pregnant…but where? A pregnancy of unknown location

My second miscarriage was completely different to my first and third for a number of reasons, not least because nobody knew where the pregnancy actually was. Pregnancy of unknown location (PUL) is a term used to describe pregnancies when hcg levels are raised but an ultrasound scan doesn’t show anything in your uterus or Fallopian tubes (or anywhere else for that matter). 

I thought the month of my PUL was just an unsuccessful cycle of trying. I was staying in London overnight for a training course and had taken copious amounts of pregnancy tests with me for ‘entertainment’. It was the second cycle after my first miscarriage and I was convinced by sheer desperation that this must be it. 

After (too) many are-they aren’t-they tests, I went to my training course hopeful that I may still have time to get a positive result before my period arrived. But by lunchtime the telltale cramps had arrived and by mid-afternoon, my usual period flow had begun. I stopped testing through my ‘period’, knowing that I definitely wasn’t pregnant this cycle. 

A shock

Seven days into my next cycle, I started testing using ovulation predictor kit (OPK) sticks and got a dark enough result to make me wonder what was happening. I certainly wouldn’t expect to be this close to ovulation only a week after starting my period. 

So I used a spare pregnancy test just to confirm I wasn’t pregnant. Except, as I watched the second line appear almost immediately, I realised I was. Two tests later, I was undeniably pregnant.

I didn’t have any of the joy of my first positive test result. All I could focus on was the fact I’d just had a period and my temperature had dropped back to pre-ovulation levels (they usually sit around 36.3 celsius pre-ovulation and 36.7 after). 

So how could this be viable? 

Back to hospital

I contacted the Emergency Gynae Unit at my local hospital and they asked me to come in. During the first visit, I explained that I was having cramps and that these were generalised in my right-hand side, but at this early stage, the nurse could give no indication of what might be happening. A blood sample was taken and sent away to determine my hcg level – I found out the next day it was 78, so I was definitely pregnant. 

I was invited back for a second blood test 48 hours later to see how quickly the hcg level was rising. The ideal would be a doubling every 48-72 hours. This second test came back at 159, perfectly on target for a viable pregnancy. 

Another blood test two days later came back at 303, almost doubling again. 

By this stage, I had known I was pregnant for almost a week and despite my best efforts, I had begun to get excited. Maybe this was just a strange beginning to what was going to be a successful pregnancy. After all, we’d been unlucky the first time, but there was no reason why it should happen again, was there?

My fourth trip to the hospital arrived with me expecting another doubling of my hcg, I was already working out how long it would take to get to the numbers required to see something on a scan. Only a few days. Come on baby!

Dropping levels, dropping heart

Except this time the hcg result came back at 190, a drop of around a third. The pregnancy definitely wasn’t viable. I was told I had to come back in a week for another blood test to make sure the levels were dropping.

I was more downhearted than expected. I’d let myself believe that this was just a slow starter, but now I was faced with another failed pregnancy. And I still didn’t know what was wrong. 

Monitoring symptoms

I started to experience stronger cramping on my right hand side, sometimes it made the whole side of my body ache, at other times, it was a localised stabbing pain.  

Due to the pain, the fact I’d experienced something period-like and was still bleeding, the possibility of the pregnancy being ectopic was being mentioned. I was told that I needed to be aware of any shoulder tip pain, any rectal pain, any intense pain in my sides that could indicate ruptured Fallopian tubes. And if I felt any of this, I had to go back to the EGU straight away. 

When you are already experiencing unusual pains, it is very difficult to monitor yourself accurately. I was scared of the pain, and worried about what it could mean and what might happen. I didn’t want to go in to hospital unnecessarily only to be told to go home. But I also didn’t want to not go in to hospital if and when something bad started to happen. 

The sense of limbo in the PUL situation is emotionally so difficult. It consumed me. All day every day I was rating my pain, comparing it against the days and hours before, to evaluate if it was getting worse. But still not knowing what was actually happening. And not knowing when it would all be over. 

A week later, I went back in for my next blood test, this time the levels had dropped to 118, less than the 50% drop in a week that I had been told to expect. 

At this stage, the EGU booked me in for a scan. I was still experiencing intense – but not excruciating – pain in my side and my levels were only dropping slowly, so they wanted to err on the side of caution. 

And I was so grateful for this open-minded and proactive attitude. After two weeks of incessant reading about the potential problems associated with PUL and ectopic pregnancy, I was terrified my tubes were going to rupture and I would be left completely infertile. That my worries were actually being taken seriously was invaluable during this whole experience.

Watching and waiting

I came in for the ultrasound scan and, as expected, it showed nothing – an empty uterus and nothing growing in my tubes. Another blood test showed my levels had dropped again to 73, a better drop in 48 hours. 

Two days later and my test result came back at 73 again. No drop. The nurse suggested that as my levels had stayed the same, and because the longer I had raised levels, the longer I ran the risk of something going wrong, maybe I should take methotrexate – a drug used to treat cancer – to ‘dissolve’ whatever was left inside me.

This was something I really didn’t want to do. I knew that we’d have to stop trying to conceive for at least 3 months after taking methotrexate, as it would remove the folate from my body and then would take 3 months or more to build back sufficiently to support a pregnancy. Knowing I was turning 40 in less than 6 months, I asked if I could have one more blood test the following day to see if my levels dropped. 

Thankfully, they agreed and my levels dropped from 73 to 64 overnight. I was back on expectant management. 

The waiting and watching continued for another three weeks. Three weeks where I wasn’t allowed to travel far from the hospital in case I needed emergency treatment, where I was still second guessing every pain in my side, where I was still wondering how long this interminable situation was going to last. 

Until finally – finally! – my hcg levels dropped back to non-pregnant levels, in my case, less than 1. 

The ordeal was finally over. 

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