Southend University
Hospital
NHS
INHS Foundation Trust
OBJECTIVES
1. To improve Pregnancy of Unknown
Location (PUL) rate
2. To engage stakeholders to optimise each step of PUL protocol.
3. To
educate
sonographers
recognising
intrauterine
structures
and
diagnosing
on cystic
PUL
appropriately.
ONGOING QUALITY IMPROVEMENT PROJECT ON PREGNANCY OF UNKNOWN LOCATION RATES
IN AN EARLY PREGNANCY ASSESSMENT UNIT
Author & Affiliations: RAISHAM SALEEM '(Clinical Fellow Obstetrics and Gynaecology)|SAROJINI BURUGAPALLI (Consultant Obstetrics and Gynaecology)
METHODS
1. Initial audit identified a PUL rate of 30%.
Updated PUL guideline: empty gestational sacs were no longer classified as PUL.
3. Initiated a Plan-Do-Study-Act (PDSA) cycle as part of the Quality Improvement Project (QIP).
Re-audit after guideline
Re-audit after guideline update showed PUL rate reduced to 15%.
5. Delivered sonographer training through regular educational sessions.
Training resident doctors on the PUL protocol.
7. Re-audit post-intervention revealed further reduction to 11.8%.
8. Ongoing monthly multidisciplinary review of PUL cases.
9. Plan re-audit after further refinements.
RESULTS
PUL Rate Reduction Over Time
30.0%
30
25
20
Beis
10
5
15.2%
11.8%
10.4%
Initial Audit
Post-Guideline Update
Post-Retraining Audit
Adjusted Rate
Initial audit revealed PUL rate of 30%.
Re-audit following updated guideline identified PUL rate of 15.2%.
Retraining of unit sonographers and doctors on updated guideline.
Re-audit revealed the PUL rate further reduced to 11.8% (61% improvement from baseline). 17/85 (20%) reported "intrauterine cystic structure present."
Independent Review of 17 cases with "intrauterine cystic structure present":
• 10/17 (58.8%) of PUL cases has reported as intrauterine
•104%o- -adiusted unit PUL rate after reclassification.
Case Review (Re-audit, 85 cases):
1. Ultrasound and blood tests: 85/85 (100%) compliance at initial review (target: 100%)
2. Sequence compliance: 74/85 (87.1%) had ultrasound before blood test (target: 100%)
3. Blood test compliance:
a. First tests: 100% had b-hCG; 83.5% had progesterone checked (target: 100%)
b. Repeat tests: 67.1% had second b-hCG (target: 100%);
15.3% had second progesterone (target: 0%)
CONCLUSION
Reducing the PUL rate is vital for alleviating
alleyiaising he tenancial burden od
repeated
investigations.
Educational
interventions
multidisciplinary
and collaboration
significantly improved PUL rates, with further refinements
protocol adherence and ultrasound reporting
identified for ongoing
improvement.
FUTURE GOALS
• Continue monthly review of
PUL
cases
with specialist
doctors and sonographers.
• Regular teaching sessions with resident doctors.
• Re-audit
in
one year
to
evaluate sustained improvement