Background: When managing a nonviable pregnancy of unknown location (PUL), a debate has emerged in the literature whether to perform uterine curettage for definitive diagnosis of pregnancy location or administer methotrexate for a presumed ectopic pregnancy. The purpose of this study is to describe the treatment patterns when managing a PUL. Methods: A prospective, anonymous Internet based-electronic survey of PUL case scenarios was administered to a random sample of physicians across the United States. Results: A total of 214 physicians responded. When presented with a PUL by ultrasound and a βhCG measurement of 3,270 mIU/mL, which is above the discriminatory level, 88.3% (188) would choose an additional βhCG measurement before recommending any intervention. When presented with a PUL by ultrasound and serial βhCG measurements demonstrating an inappropriate trend for a viable gestation, 36.5% would offer uterine curettage and 31.3% would offer methotrexate. Resident and private clinicians had a fourfold lower adjusted odds of choosing uterine curettage compared to academic physicians. Conclusions: Based on our findings, there does not appear to be a consensus regarding the management of a PUL.

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INTRODUCTION: When managing a non-viable pregnancy of unknown location (PUL), it is unknown which factors influence the decision to perform a uterine curettage versus presumptive administration of methotrexate. METHODS: A prospective, anonymous electronic survey of PUL case scenarios was administered to physicians registered with the American Medical Association Physician Masterfile and to all Obstetrics and Gynecology residents and academic faculty located in the United States. RESULTS: A total of 214 physicians responded. When presented with a patient diagnosed with a PUL by transvaginal ultrasound and serial βhCG measurements demonstrating an inappropriate trend for a viable pregnancy, 78 (37.0%) would offer uterine curettage before administrating methotrexate while 67 (31.7%) would offer methotrexate presumptively. The odds of choosing uterine curettage was more than four-fold higher among academic physicians compared to resident physicians (adjusted OR 4.05, 95% CI 1.62-10.10). There was no difference between private practice physicians and resident physicians. Compared to physicians in the Northeast, physicians in the South were much more likely to select uterine curettage as their initial management strategy (adjusted OR 2.48, 95% CI 0.99-6.20). CONCLUSION: Resident physicians appear to be significantly more likely to presumptively administer methotrexate compared to academic physicians in the context of a non-viable PUL. If confirmed by larger studies, this finding has direct implications for future resident education.