As the HIV epidemic continues to grow worldwide, women are increasingly and disproportionally affected. With the introduction of anti-retroviral medications that have been found to effectively prevent perinatal transmission of HIV, the approach to HIV testing in pregnant women has grown increasingly more controversial. In recent years, the model of voluntary counseling and testing (VCT) has come into question with opt-out testing now advocated for by the Centers for Disease Control and occurring widely in pregnancy. The benefits of opt-out testing are numerous and may justify its use in replacing the VCT that many have come to see as insufficient. An ethical analysis of opt-out testing suggests it may be at odds with true informed consent and involve a degree of coercion that would not be allowed outside the prenatal setting. If opt-out testing is going to remain the standard of care then the ethical issues it raises must be made transparent. Strategies need to be designed for ensuring that HIV counseling and testing in pregnancy is done in accordance with ethical and reproductive rights principles.

Pregnancy of unknown location (PUL) is a descriptive term for when a woman with a positive pregnancy test has a transvaginal ultrasound that cannot determine the site of the pregnancy. While the majority of women with PUL are subsequently diagnosed with a spontaneous abortion or viable intrauterine pregnancy, 7% to 20% of these women have an ectopic pregnancy. The potential for morbidity and mortality related to an ectopic pregnancy means that considerable care is necessary in the evaluation and management of women with PUL. In some cases, the location of the pregnancy is never determined and the PUL is categorized as resolving or persisting. Evidence suggests expectant management is a safe and effective approach for most women with PUL and should be the mainstay of care. However, in the case of persisting PUL, continued concern for ectopic pregnancy remains. Strategies for deciding when to intervene when a woman has a PUL are reviewed. A variety of clinical tools, including serum beta human chorionic gonadotropin (β-hCG), repeat ultrasonography, dilation and curettage (D&C), and empiric methotrexate therapy are discussed. Finally, a proposal is made that women with persisting PUL can be presented with the option of choosing expectant management, diagnostic D&C, or empiric methotrexate treatment.

No abstract