Psychological Impact of Pregnancy of Unknown Location
Conditions: Pregnancy of Unknown Location, Ectopic Pregnancy, Anxiety
Sponsor: Imperial College London

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Psychological Impact of Pregnancy of Unknown Location (SOUL) 
 
12th September 2021 
 
Main Sponsor 
Imperial College London 
Study coordination centre 
IRDB Hammersmith Hospitals 
REC/NRES Reference 
20/LO/0477 
Version Number 
V5  
 
Effective Date 
September 2021 
Author 
Dr Christopher Kyriacou  
Dr Margaret Pikovsky 
Protocol authorised by: 
Date: 
 
 
 

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Study Management Group 
Chief Investigator: 
Professor Tom Bourne PhD, FRCOG 
Consultant Gynaecologist 
Early Pregnancy Assessment Unit 
Imperial College London, Hammersmith Campus  
Queen Charlotte’s and Chelsea Hospital, Du Cane Road, London W12 0HS 
Tel: 0207 636 6765 Mobile:  07768076797 
E-mail: t.bourne@ic.ac.uk 
 
Study Management 
Dr Christopher Kyriacou BSc MBBS 
Clinical Research Fellow (CRF) 
Early Pregnancy and Acute Gynaecology Unit 
Queen Charlotte’s & Chelsea Hospital 
Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0TR 
Tel: 0208 383 5131 
Email: Christopher.kyriacou@nhs.net 
 
Dr Margaret Pikovsky BSc MBBS 
Clinical Fellow 
Queen Charlotte’s & Chelsea Hospital 
Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0TR 
Tel: 0208 383 5131 
Email:  m.pikovsky@nhs.net 
 
Study Coordination Centre 
All clinical queries should be directed to Dr Margaret Pikovsky (contact details as above). 
 
Sponsor 
Imperial College London is the main research sponsor for this study. For further information 
regarding the sponsorship conditions, please contact the Research Governance and 
Integrity Team: 
Room 215, Level 2,  
Medical School Building 
Norfolk Place 
London 

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W2 1PG 
+44 02075941862 
r.nicholson@imperial.ac.uk 
Research Governance and Integrity Team (RGIT) 
 
Funding 
The fellows are funded by the Imperial College NHS Healthcare Trust. The research is 
performed and funded within the Tommy’s National Centre for Miscarriage Research at 
Imperial. 
 
This protocol describes the study and provides information about procedures for entry. 
Problems relating to this study should be referred, in the first instance, to the Chief 
Investigator. 
 
This study will adhere to the principles outlined in the UK Policy Frame Work for Health and 
Social Care Research. It will be conducted in compliance with the protocol, the Data 
Protection Act and other regulatory requirements as appropriate. 
 
 

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Table of contents 
 
1. Study summary  
2. Introduction 
2.1 Background 
2.2 Study rationale and hypothesis 
3. Study Objectives 
4. Methodology and Design 
4.1 Study centre 
4.2 Design and links to previous studies 
4.3 Duration 
4.4 Inclusion criteria 
4.5 Exclusion criteria 
4.6 Withdrawal criteria 
4.7 Consent and information leaflet 
4.8 Method of study 
4.9 Study closure 
4.10 
Documentation and communication 
5. Study Outcome Measures 
5.1 Primary outcome measures 
5.2 Secondary outcome measures 
6. Study Population and Sample size 
6.1 Statistics and data analysis 
7. Study supervision and monitoring 
8. Regulatory issues 
8.1 Ethics approval 
8.2 Consent 
8.3 Confidentiality 
8.4 Indemnity 
8.5 Sponsor 
8.6 Adverse events 
8.7 Audits and inspections 
9. Study management 
10. Publication policy 
11. References  
 
 

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12. Appendix 
12.1 
Flow chart outlining patient pathway and summary of investigations 
12.2 
Consent forms 
12.3 
Patient information sheets 
 
 

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1. Study Summary 
Title 
Psychology of pregnancy of unknown location (SOUL) 
 
Design 
Prospective cohort observational study  
 
Primary aim 
To assess the psychological impact of pregnancy of unknown location (PUL) classification 
pending a final diagnosis. 
 
Secondary aims 
To assess psychological burden of PUL on patients and their partners. 
To assess if shortening time to providing patients classified with PUL with results and advice 
using point-of-care beta human chorionic gonadotrophin (BhCG) testing reduces 
psychological burden. 
 
Hypothesis 
1) PUL causes significant psychological distress to patients and their partners which 
can be assessed using a validated psychological tool.  
2) Increasing the efficiency of PUL management will reduce anxiety and depression 
symptoms in patients and their partners. 
 
Outcome measures 
Psychological morbidity will be assessed using the HADS on time of PUL classification, 48 
hours from PUL classification and following final diagnosis and management.  
 
Eligibility 
Pregnant women attending the Early Pregnancy Unit in the first trimester (up to 14 weeks 
gestation) with a pregnancy of unknown who are over 18 years old and are able to give 
consent. 
 
Duration 
The study will be conducted over a minimum period of two years. 
 
Keywords 
Pregnancy of unknown location, beta-human chorionic gonadotrophin, depression, anxiety. 

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2. Introduction 
  
2.1 Background and study rationale 
a. Pregnancy of unknown location and Ectopic pregnancy 
Pregnancy of unknown location (PUL) is a syndrome of early pregnancy composed of a 
positive urine pregnancy test without the visualisation of a pregnancy on trans-vaginal 
ultrasound (TVUS). There are four possible final diagnoses from PUL: intrauterine 
pregnancy (IUP); failing pregnancy of unknown location (FPUL); persistent pregnancy of 
unknown location (PPUL); and ectopic pregnancy (EP) [1]. 
 
The initial investigation that is currently performed with TVUS is serum beta human chorionic 
gonadotrophin (BhCG) testing. Previous studies however have highlighted that the traditional 
single serum hCG testing following TVUS is a poor predictor of outcome, viability and 
location of PUL [3]. 
 
b. BhCG monitoring and modelling 
hCG (a glycoprotein produced by syncytiotrophoblast cells responsible for maintaining the 
corpus luteum in early pregnancy). hCG is hetrodimeric and consists of an alpha and beta 
subunit. The beta subunit is unique to hCG and is therefore clinically useful in pregnancy. 
The use of beta hCG (BhCG) and progesterone levels in the management of PUL is 
commonplace [4-5]. However, interpretation of the results can be subjective [6-7]. 
 
A statistical logistical regression model which utilised initial BhCG levels and BhCG ratio (48-
hour BhCG divided by 0 hour BhCG) was created by a research group with the aim of 
allowing PUL to be safely risk stratified [8-14]. This has been validated and found to be 
superior to isolated progesterone and BhCG protocols, although unclear how applicable this 
may be to populations such as the United States [14-15]. A modified and validated model 
has since been trialled and used in a multi-centre study across North West London in order 
to optimise PUL risk stratification into ‘low risk’ (encompassing IUP and FPUL) and ‘high risk’ 
(encompassing PPUL and EP) [2]. This was part of the Assessment of Biomarkers and 
Ultrasound in Pregnancy of Unknown Location and Ectopic Pregnancy study (ABPEP) which 
utilised serial BhCG observation (at 0 hours and 48 hours from diagnosis of PUL), BhCG 
ratio along with progesterone testing [2]. 
 
This model has come to be known as the ‘M6 model’ and was developed from a cohort of 
2753 cases of PUL. It classified 62.1% PUL as ‘low risk’ with a negative predictive value of 
98.6% [2]. This the model which we currently adopt in our unit. 

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c. Point of care BhCG testing 
BhCG measurements require serum samples sent to hospital laboratories in order to assess 
levels in a standardised manner. However, point of care (POC) BhCG testing is now 
available that uses whole blood to provide lab-quality, quantitative results in minutes. This 
could lead to a reduction in time waiting for results as well as a reduction in the associated 
psychological distress to patients and their partners [16]. The only food and drug agency 
approved quantitative test is the i-STAT BhCG (Abbott POC) test that could play a role in 
providing quick results that are comparable to hospital laboratory analysis. This could 
therefore be used to risk stratify within a risk prediction model [17]. The Abbott POC test is 
CE marked, confirm its conformity with European standards for health and safety of products 
sold within the European Economic area. 
 
d. Anxiety and Depression related to Early Pregnancy Loss 
Anxiety, depression and post-traumatic stress disorder (PTSD) are recognised complications 
following early pregnancy loss. A systematic review of 27 papers exploring the psychological 
impact of early pregnancy loss identified significant depression and anxiety within the first 
month, with 8-20% moderate depression and 18-32% anxiety reported at 4-6 weeks [18]. A 
Cochrane review of six studies involving 1001 women demonstrated no single beneficial 
method of managing the psychological impact of early pregnancy loss, but that counselling 
may be beneficial [19] 
 
A UK study of 160 women demonstrated that uncertainty in diagnosis, rather than the 
negative or positive connotations of the diagnosis itself, was a greater contributing factor in 
women’s feelings of anxiety and depression in relation to PUL [20]. Furthermore, a local pilot 
study demonstrated women experiencing both miscarriage and ectopic pregnancy fulfilled 
criteria for PTSD, with many suffering from moderate-to-severe anxiety and depression, with 
psychological morbidity persisting at least 3 months following pregnancy loss [21]. 
 
e. The Hospital and Anxiety Depression Scale 
The Hospital Anxiety and Depression Scale is a 14-part questionnaire with 7 questions 
exploring symptoms of anxiety and depression respectively. Each question is answered with 
a scale of 0-3 to represent severity of symptoms, with an independent maximum score of 21 
for depression or anxiety. A score >11 is deemed moderate, whilst >16 represents severe 
symptoms [22]. 
  
No single validated psychological tool is recommended for evaluation of these symptoms in 
the context of early pregnancy loss, and existing literature has relied on existing scoring 

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systems, self-reported symptoms or structured interview [18, 19]. The HADS tool has been 
previously utilised in our unit for the psychological impact of early pregnancy loss in women 
experiencing miscarriage or ectopic pregnancy [21].  
 
A 2002 review of 747 papers identified HADS has a Cronbach’s alpha coefficient of 0.83 
(0.68-0.93) for internal consistency of anxiety symptoms and 0.82 (0.67-0.90) for depression. 
It was found to perform well in symptom assessment in a range of clinical settings including 
in primary care, the general population and in somatic and psychiatric forms of depression 
and anxiety [23].  
 
2.2 Study rationale and study hypothesis 
a. Study rationale 
PUL is a syndrome of early pregnancy composed of a positive urine pregnancy test without 
the visualisation of a pregnancy on trans-vaginal ultrasound (TVUS). The current method for 
risk stratifying a PUL is via serum BhCG levels at the time of identification of PUL and after 
48 hours, in order to ascertain the viability of the pregnancy. Patients and their partners need 
to wait for this result before a management plan can be adopted, taking at least 2-3 hours. 
 
There is a clear need for the patient care pathway to evolve in order to aid and improve the 
management of women classified with a PUL. By using point-of-care BhCG testing, we 
would shorten the time to management. We propose that shortening the time interval would 
reduce psychological morbidity.  
 
b. Study hypothesis 
1) PUL causes significant psychological distress to patients and their partners which 
can be assessed using a validated psychological tool.  
2) Increasing the efficiency of PUL management will reduce anxiety and depression 
symptoms in patients and their partners. 
 
 
3. Study Objectives 
 
This study aims to improve the pathway of care to this cohort of women by: 
• 
Assessing the psychological impact of pregnancy of unknown location (PUL) 
classification pending a final diagnosis. 
• 
Assessing psychological burden of PUL on patients and their partners. 

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• 
Assessing if shortening time to providing patients classified with PUL with results and 
advice using point-of-care beta human chorionic gonadotrophin (BhCG) testing 
reduces psychological burden. 
 
 
4. Methodology and Design 
 
4.1 Study centre 
The primary centre for the study will be Queen Charlotte’s and Chelsea Hospital, part of 
Imperial Healthcare NHS Trust). 
Secondary centres will include St Mary’s Hospital (part of Imperial College Healthcare NHS 
Trust). 
 
There will be: 
- 
A named individual (clinical research fellow - CRF) in the primary study centre who 
will be responsible for co-ordinating the project, reporting to the chief investigator and 
co-ordinating the study at the secondary study centres; 
- 
Regular inspection by the named individual under the supervision of the chief 
investigator in order to ensure both the service (literature, communication, 
documentation, supervision and logistics) and facilities (ultrasound, equipment, 
space) are of a high standard; 
- 
Assurances that those who contribute to the study are experienced and trained in the 
management of patients presenting to an Early Pregnancy Unit (e.g. specialist nurse, 
research nurse, sonographer, gynaecologist); 
- 
A PhD thesis documenting the outcome. 
 
4.2 Design and links to previous studies 
a. Design 
SOUL is prospective cohort observational study focussing on psychological assessment of 
patients and their partners with PUL. 
 
b. Links to previous studies 
Pilot study undertaken in the unit in 2016 by Farren J et al [21], led by Chief Investigator 
Professor Bourne, explored the severity and type of emotional distress in women after early 
pregnancy loss compared with women with ongoing pregnancies (REC 11/SW/0052). This 
group implemented HADS.  
 

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4.3 Duration 
The study will be conducted over a minimum of one year to ensure adequate recruitment 
and follow up. 
 
4.4 Inclusion criteria 
Pregnant women attending the Early Pregnancy Unit in the first trimester (up to 14 weeks 
gestation) with a pregnancy of unknown who are over 18 years old and are able to give 
consent. 
 
4.5 Exclusion criteria 
Presence diagnosed with cancer, the presence of an acute medical condition, 
patients/partners aged less than 18 years, patients or partners who cannot give fully 
informed study consent (language or learning impairment), presence of a viable intrauterine 
pregnancy, ectopic pregnancy and miscarriage. 
 
4.6 Withdrawal criteria 
Patients and/or their partners may withdraw from the study at any stage and all data 
captured in relation to their participation may be destroyed at their request. 
 
4.7 Consent and information leaflet 
Regarding written consent, participants will be given sufficient time to consider recruitment 
and consent to participate so long as they are clinically stable and that the time taken does 
not compromise safety and management. 
 
Patients who wish to participate in the study will be provided with a patient information sheet  
and they will be given a minimum of 15 minutes without the research team present to 
consider whether they wish to participate. There will be separate patient information sheets 
for women and their partners. They will be made aware that participation is voluntary and 
that they can withdraw from the study at any point without affecting their usual care. They 
will have then have time to formulate and ask questions and time to discuss the study with a 
relative or personal doctor. If the patient or partner wishes to enter the study, this will be 
documented on the ultrasound scan notes and the consent form will be completed. 
 
Three copies will be taken, one to the participant, one with health records, one kept by the 
Chief Investigator within the study file. Good Clinical Practice (GCP) training is mandatory for 
training in consent for research purposes. 
 

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4.8 Recruitment Process 
The recruitment process will be undertaken within EPU. The participants could potentially be 
any woman who is referred or who presents to the early pregnancy assessment 
unit (EPAU) and requires a trans-vaginal ultrasound scan and will be identified by a member 
of the clinical care team on EPAU who is scanning, who has signed the delegation log and 
who is certified with Good Clinical Practice (GCP). 
 
Those that will be invited to participate in the study will include patients and their partners 
attending the Early Pregnancy Unit in the first trimester (up to 14 weeks gestation) classified 
with a PUL on trans-vaginal ultrasound scan over the age of 18. 
 
All patients and partners will first be approached by members of the direct care team before 
being invited to the study once a PUL has been classified using TVUS. Members of the 
direct care team (if not part of the research team) will ask patients if they can them refer 
them to a member of the research team.  
 
Advertising using posters in the EPU will be used in order for patients and partners to view 
the research being offered in the unit and any interest will be referred to the research team 
where they can ask questions and discuss the study further. The poster that will be on the 
walls of the early pregnancy unit (EPU) located on the second floor of Hammersmith 
Hospital, part of Imperial College Healthcare NHS Trust, Block D, Du Cane Road, W12 0HS. 
Contact details on the poster will allow participants to contact the team through email or over 
the phone in order to ask questions. There will be separate posters for phases one and two 
of the study. 
 
Written consent will be required for all aspects of the study. Participants will be made aware 
that participation is voluntary and that they can withdraw from the study at any point without 
giving any reason and without affecting their usual care.  
 
Patients and partners will first be approached by members of the direct care team. If they are 
not part of the research team, they will refer the patient and partner to a member of the 
research team if the patient and partner give them verbal consent to do so. Patients and 
partners will then be seen by a member of the research team.  
 
Patients and partners that approach through advertising will be referred to a member of the 
research team. This may be face to face, or via the contact details available on the poster. If 

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the patient meets the inclusion criteria, they will be invited to the EPU if not present in the 
unit already. 
 
4.9 Method of study 
This is a cohort study and will recruit patients in the first trimester (less than 14 weeks 
gestation) and their partners who meet the inclusion criteria attending the Early Pregnancy 
Unit. There will be two phases of the study, each with a minimum duration of 4 months. 
Phase 1 aims to establish the psychological burden of PUL under the existing care pathway, 
whilst phase 2 introduces point of care BhCG testing in clinical practice. The phases of the 
study are described in more detail below. 
  
 An information leaflet detailing the purpose of the study will be provided, and separate 
patient information sheets will be used for each phase of the study. A minimum of 15 
minutes will be provided for patients to read the study information with the research team not 
present. Patients will then have opportunity to elicit further information or clarification from 
the research team. There are no significant ethical, legal or management issues. Women 
who both verbally consent and consent in writing will follow a well-defined pathway (see 
flowchart appendix). 
 
The phases of the study are 
• 
Group 1: Assessing the psychological impact of pregnancy of unknown location 
(PUL) classification pending a final diagnosis. Confirming the reliability of point of 
care testing in correlation with laboratory BhCG levels (gold standard).   
• 
Group 2: To assess if shortening time to providing patients classified with PUL with 
results and advice using point-of-care beta human chorionic gonadotrophin (BhCG) 
testing reduces psychological burden. 
 
Women with symptoms in the first trimester are routinely seen in the Early Pregnancy Unit 
(EPU). A clerking proforma is completed, urine is tested and a transvaginal ultrasound scan 
is performed. Blood testing and follow up arrangements are made if required with blood 
results inputted into a validated statistical model if a patient is classified with a PUL. 
 
Participants in phase one of the study will not be provided with the POC BhCG result. They 
will await the laboratory result. Simultaneously we will ascertain reliability of POC in clinical 
practice during this time.  
 

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Patients in phase two will be provided with the POC test result, which will reduce the time to 
which they receive the result. Prior to transfer from phase 1 to phase 2 of research, 
correlation between POC and laboratory BhCG levels will be calculated in order to confirm 
its reliability by creating a correlation curve using the data. 
 
Patients and partners will be asked to complete the questionnaire at three time points: 1) On 
classification of PUL at time zero once blood is taken, 2) at the 48-hour time point after blood 
is taken (if 48-hour bloods are required for the patient); and 3) after definitive diagnosis and 
management.  
 
The maximum number of questionnaires that will be completed will be 6: 1 for each time 
point for the patient and 1 for each time point for the partner. 
 
The questionnaires for the first two time points will be offered electronically whilst the patient 
is having their blood sample taken via use of a quick response matrix barcode (QR code). 
The third time point HADS will be texted through the encrypted system Accurx. We will 
contact the patient a maximum of 3 times to complete the questionnaire at the third time 
point to reduce loss of follow up.  
 
The results will be submitted electronically each time. The results will be reviewed on a 
weekly-biweekly basis by the research team.  
If patients score for moderate to severe anxiety or depression at any time point, we will call 
the patient. If they are struggling with their PUL classification or diagnosis, we will advise 
them to make an appointment to see their GP as soon as possible to arrange appropriate 
follow up, whilst clarifying any ongoing follow up at the early pregnancy unit.  
If patients score for moderate to severe anxiety or depression at any time point where no 
further follow up at the unit is indicated, we will also ask permission to send a text over 
Accurx that will list information relating to local miscarriage support groups, Tommy’s 
Miscarriage charity, Petals Baby Loss Counselling Charity, the Ectopic Pregnancy Trust, the 
Miscarriage Association and Improving Access to Psychological Therapists (IAPT). If further 
support is required, they will be advised to contact their GP as soon as possible. 
 
a. Symptoms  
Patients will be asked to complete the standard clerking proforma used within the unit, 
including demographic data and information regarding previous obstetric, medical and 
gynaecological history and questions regarding symptoms. 
 

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b. Ultrasound 
Trans-vaginal ultrasound is then performed as part of standard practice. Women with a PUL 
will be identified as eligible for the study 
 
Any ultrasound abnormality detected will be managed in accordance with local and national 
guidance. Follow up trans-vaginal ultrasound for all will be arranged as per routine clinical 
practice if required. 
 
c. Assessment of psychological symptoms 
Patients diagnosed with PUL and their partners will be offered to take part in the study. 
Participants will be asked for written consent prior to point-of-care BhCG testing and 
completion of the HADS tool.  The HADS tool takes 2-5 minutes to complete [22].  
 
d. Clinical intervention 
Performed in EPU as part of PUL classification: 
- 
Transvaginal ultrasound 
- 
20ml venous blood sample 
 
Performed in EPU or on the gynaecology ward following consent to participate in study: 
- 
HADS tool 
- 
1ml sample of blood for point-of-care BhCG testing 
 
e. Cataloguing 
All data collection will be compliant with the Data Protection Act. The pseudonymised details 
will be logged onto a protected database with access restricted to only those personnel 
involved in the study. The data will be archived for secondary analysis. 
 
Patients will be followed up for the duration of their care in the Early Pregnancy Unit. There 
will be no additional visits planned for research purposes. 
 
Patients would remain in the study for a maximum of 2 months allowing time for final 
diagnosis and relevant follow up following intervention. 
 
4.9 Study closure 
We aimed to recruit approximately 250 participants in total (at least 62 patients and 47 
partners per phase) with a minimum study duration of  two years. The end of the study will 
be following the analysis of the patients’ questionnaires.  

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However, in light of the SARS-CoV-2 pandemic, partners cannot attend early pregnancy 
units. It is likely that data from patients only will be possible to be collected as we will not be 
able to make up the difference regarding partners as patient recruitment is already under 
way. The total we will be able to recruit will therefore be at least 124 (at least 62 patients per 
phase). Although this reduces the scope of the study, we will still be able to meet the vast 
majority of our objectives. 
 
4.10 Documentation and communication 
Clinical data, patient demographics and ultrasound findings will be recorded on the standard 
clerking proforma filled in by each patient and on a computer software programme (Astraia). 
This data will be prospectively collated into a master database with raw data relevant to the 
study. All potential identifiable patient data that requires electronic storage will be stored 
electronically on NHS approved computers, accessible by members of the research team or 
the patients direct care team via secure password in the Early Pregnancy Unit, Queen 
Charlotte’s & Chelsea Hospital, Imperial College Healthcare NHS Trust, Hammersmith 
Hospital. No patient identifiable information will leave the hospital premises nor be subject to 
access or viewing by anyone other than those directly involved with this research study. Data 
will be stored for a minimum of 10 years after completion of the study. 
 
 
5. Study Outcome measures 
 
Psychological morbidity will be assessed using the HADS on time of PUL classification, 48 
hours from PUL classification and following final diagnosis and management.  
 
 
6. Study population and sample size 
 
6.1 Statistics and data analysis 
Recruitment will commence upon ethical approval of the study. The infrastructure, research 
fellow and nurses, questionnaires, BhCG machines and database are already in place, which 
ensure that the study can start promptly upon approval, without affecting or compromising 
routine clinical service provision. We aim to recruit 250 participants. As the early pregnancy 
unit assesses approximately 4200 women per annum, this aim is achievable over the course 
of two years. We will also be recruiting in two centres within Imperial College Healthcare NHS 
Trust to ensure there is generalizability in the results. 

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The calculated sample size follows from the pilot study performed by Farren et al [21] as well 
as the associated study focussing on partners [24]. Data from the pilot study suggests that 
32% of those suffering early pregnancy complications had moderate to severe anxiety 
compared with 10% in the control group [21]. As this will initially be performed as a pilot 
study, at least 62 women will be required in both phase 1 and phase 2 where recruitment 
ratio is 1:1 with type 1 error of 0.05 and power of 80% [25]. Data from the partner study 
highlighted that the 30% of women reported moderate to severe anxiety compared with 6% 
of partners [24]. Again, as this will be performed as a pilot study, at least 47 partners will be 
required in both phase 1 and phase 2 where recruitment ratio is 1:1, with type 1 error of 0.05 
and power of 80% [25]. However, due to the SARS-CoV-2 pandemic, it is likely we will only 
be able to assess patients and not partners. 
 
 
7. Study Supervision and Monitoring 
 
a. Risk assessment 
In summary, there is no significant increase in time spent within the unit or of risk of 
complications to the patient: 
- 
Trans-vaginal ultrasound is performed routinely in EPU and so does not add to the 
burden or risk of the patient; 
- 
All research blood samples will be taken/arranged for patients who attend routine 
EPU appointments only or following admission to the gynaecology ward. All blood 
samples will therefore be taken at the same time as blood taken as part of routine 
clinical care, preventing risk and burden as no further venepuncture will be required. 
These will be taken by highly skilled and trained clinical fellows and research 
midwives who are medically trained in phlebotomy, reducing potential for discomfort; 
 
Taking part in the study will allow the assessment of the psychological impact of pregnancy 
of unknown location (PUL) classification pending a final diagnosis. It will also allow the 
assessment of psychological burden of PUL on their partners. Finally, we hope to establish if 
shortening time to providing patients classified with PUL with results and advice using point-
of-care BhCG testing reduces psychological burden. 
 

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The results will not impact patient care negatively, and we in fact hope patients in the future 
will benefit from the information gained in this study.  
 
b. Central and local supervision 
The chief investigator at Imperial College London will be responsible for the protocol, quality 
control, interim analyses of the data, advice on progress and final analysis and reporting of 
the study. 
 
 
8. Regulatory Issues 
 
8.1 Ethical approval 
The Chief Investigator has obtained approval from the Health Research Authority and 
Research Ethics Committee. The study must also receive confirmation of capacity and 
capability from Imperial College Healthcare NHS Trust before accepting participants into the 
study. The study will be conducted in accordance with the recommendations for physicians 
involved in research on human subjects adopted by the 18th World Medical Assembly, Helsinki 
1964 and later revisions. 
 
No human samples will be stored after they are taken for this study.  
 
8.2 Consent 
Consent to enter the study will be sought from each participant only after a full explanation 
has been given, an information leaflet offered, and time allowed for consideration. Sufficient 
time will be given to ask any questions about the study. Signed participant consent will be 
obtained for the collection of research blood samples and completion of a validated 
psychological tool. The right of the participant to refuse to participate without giving reasons 
will be respected.  
 
After the participant has entered the study, the clinician remains free to deviate from the 
outlined pathway at any stage if he/she feels it is in the participants’ best interest, but the 
reasons for doing so will be recorded. In these cases, the participants remain within the study 
for the purposes of follow-up and data analysis. All participants are free to withdraw at any 
time from the protocol treatment without giving a reason and without prejudicing further 
treatment. 
 
8.3 Confidentiality 

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All patient derived data will be collected onto a paper proforma - primarily consent forms with 
a case report form (CRF). Patient identifiable data will at no point leave the hospital 
premises or be subject to access or viewing by anyone not involved with research being 
carried out. Code in the form of a three-digit number (e.g. 001) will be assigned to 
participants.  
The study number will then be attached to the sheet as well as to the samples taken.  The 
Clinical Research Fellow, Dr Christopher Kyriacou, will keep a log which enables the 
matching of sample numbers to patient details. This log and all copies of all versions of the 
consent forms and the CRF will be stored within the study file. This is kept safely within the 
locked research filing area in the Early Pregnancy Unit, second floor, block D, Queen 
Charlotte’s & Chelsea Hospital, Imperial College London, Hammersmith Campus, Du Cane 
Road, London W12 0TR and will only accessed when required by researchers directly 
involved in this study. 
All potential identifiable participant data that requires electronic storage will be stored 
electronically on NHS approved computers, accessible only by a member of the study team 
or patients direct care team involved in the study via secure password.  
All hard copies of data to be stored long term after the study has ended will remain filed 
securely within the Early Pregnancy Unit at Queen Charlotte’s and Chelsea Hospital. All data 
stored electronically will be kept on an NHS approved computer's hard drive accessible only 
by responsible personnel involved in the study and will be password protected. This will be in 
the Early Pregnancy Unit, Queen Charlotte’s & Chelsea Hospital, Imperial College Healthcare 
NHS Trust, Hammersmith Campus. At the end of the study, data will be archived at an Imperial 
College London archiving facility. 
The Chief Investigator will preserve the confidentiality of participants taking part in the study 
and is registered under the Data Protection Act. 
 
8.4 Indemnity 
Imperial College London holds negligent harm and non-negligent harm insurance policies 
which apply to this study. 
 
8.5 Sponsor 
Imperial College London and Tommy’s National Centre for Miscarriage Research at Imperial 
act as the main sponsors for this study. Funding for the fellows is provided by Imperial College 
Healthcare NHS Trust.  
 
8.6 Adverse events 
a. Definitions: 

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Adverse Event (AE): Any untoward medical occurrence in a patient or clinical study subject.  
Serious Adverse Event (SAE): Any untoward and unexpected medical occurrence or effect 
that:  
- 
Results in death  
- 
Is life-threatening – refers to an event in which the subject was at risk of death at the 
time of the event; it does not refer to an event which hypothetically might have caused 
death if it were more severe 
- 
Requires hospitalisation, or prolongation of existing inpatients’ hospitalisation  
- 
Results in persistent or significant disability or incapacity  
- 
Is a congenital anomaly or birth defect  
Medical judgement will be exercised in deciding whether an AE is serious in other situations. 
Important AEs that are not immediately life-threatening or do not result in death or 
hospitalisation but may jeopardise the subject or may require intervention to prevent one of 
the other outcomes listed in the definition above, will also be considered serious.  
 
There are no additional risks to the patients participating in this study.  
 
b. Reporting Procedures 
All adverse events will be reported. Depending on the nature of the event the reporting 
procedures below will be followed. Any questions concerning adverse event reporting will be 
directed to the Chief Investigator in the first instance.  
 
c. Non-serious AEs  
All such events, whether expected or not, will be recorded.  
 
d. Serious AEs  
A SAE form will be completed and faxed to the Chief Investigator within 24 hours. However, 
relapse, death and hospitalisations for elective treatment of a pre-existing condition do not 
need reporting as SAEs.  
All SAEs will be reported to the Chief Investigator who will determine if the event was:  
- 
Related- resulted from the administration of any of the research procedures 
- 
Unexpected- an event that is not listed in the protocol as an expected occurrence  
 
Reports of related and unexpected SAEs will be submitted within 15 days of the Chief 
Investigator becoming aware of the event, using the NRES SAE form for non-IMP studies. 
The Chief Investigator will also notify the Sponsor of all SAEs. 
Local investigators will report any SAEs as required by their Local Research Ethics 

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Committee, Sponsor and/or Research & Development Office.  
 
Contact details for reporting adverse events: 
Professor Tom Bourne Ph.D., FRCOG 
Consultant Gynaecologist 
Early Pregnancy Assessment Unit 
Imperial College London, Hammersmith Campus  
Queen Charlotte’s and Chelsea Hospital 
London UK 
Tel: 0203 313 5131 
E-mail: t.bourne@ic.ac.uk  
 
Women’s Health Research Centre, 
c/o Imperial College London, IRDB, Ground Floor, 
Du Cane Road, London W12 0NN 
Office: 0203 313-5281   Fax: 020 3313 5284 
Email: whrcenquiries@imperial.ac.uk 
 
8.7 Audits and Inspections 
The study may be subject to inspection and audit by the Joint Research Compliance Office 
under their remit as sponsor and other regulatory bodies to ensure adherence to GCP and 
the UK Policy Frame Work for Health and Social Care Research. Direct access to source 
data/documents as requested will be permitted. 
 
 
9. Study Management 
 
The day-to-day management of the trial will be co-ordinated through the Early Pregnancy Unit 
at Queen Charlotte’s and Chelsea Hospital by Dr Margaret Pikovsky. 
 
 
10. Publication Policy 
 
All publications and presentations relating to the study will be authorised by the Study 
Management Group. The investigators will therefore be responsible for publication of the 
data. As such they are co-authors in all resulting clinically relevant papers to which they 
made significant contributions. Co-authors will be included according to their contribution in 
the study and depending on the journals’ publication guidelines. 
 

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11. References 
 
 [1] Kirk E, Bottomley C, Bourne T. Diagnosing ectopic pregnancy and current concepts in 
the management of pregnancy of unknown location. Hum Reprod Update 2014;20(2):250-61  
 [2] Bobdiwala S, Al-Memar M, Farren J, Bourne T. Factors to consider in pregnancy of 
unknown location. Womens Health (Lond) 2017:13(2):27-33 
 [3] Van Mello N, Mol F, Opmeer BC, AnkumWM, Barnhart K, Coomarasamy A, Mol BW, van 
der Veen F, Hajenius PJ. Diagnostic value of serum hCG on the outcome of pregnancy of 
unknown location: a systematic review and meta-analysis. Hum Reprod Update 
2012;18:603–17 
 [4] Condous G, Lu C, Van Huffel SV, Timmerman D, Bourne T. Human chorionic 
gonadotrophin and progesterone levels in pregnancies of unknown location. Int J Gynaecol 
Obstet 2004 Sep;86(3):351-7 
 [5] Condous G, Kirk E, Van Calster B, Van Huffel S, Timmerman D, Bourne T. Failing 
pregnancies of unknown location: a prospective evaluation of the human chorionic 
gonadotrophin ratio. BJOG 2006;113:521–27 
 [6] Condous G, Kirk E, Lu C, Van Huffel S, Gevaert O, De Moor B, et al. Diagnostic 
accuracy of varying discriminatory zones for the prediction of ectopic pregnancy in women 
with a pregnancy of unknown location. Ultrasound Obstet Gynecol 2005;26:770–5 
 [7] Silva C, Sammel MD, Zhou L, Gracia C, Hummel AC, Barnhart K. Human chorionic 
gonadotrophin profile for women with ectopic pregnancy. Obstet Gynecol 2006;107:605–10 
 [8] Condous G, Kirk E, Van Calster B, Van Huffel S, Timmerman D, Bourne T. Failing 
pregnancies of unknown location: a prospective evaluation of the human chorionic 
gonadotrophin ratio. BJOG 2006;113:521–27. 
 [9] Van Calster B, Condous G, Kirk E, Bourne T, Timmerman D, Van Huffel S. An 
application of methods for the probabilistic three-class classification of pregnancies of 
unknown location. Artif Intell Med. 2009 Jun;46(2):139-54 
 [10] Condous G, Okaro E, Khalid A, Timmerman D, Lu C, Zhou Y, Van Huffel S, Bourne T. 
The use of a new logistic regression model for predicting the outcome of pregnancies of 
unknown location. Hum Reprod. 2004;19(8):1900-10 
 [11] Kirk E, Condous G, Haider Z, Lu C, Van Huffel S, Timmerman D, Bourne T. The 
practical application of a mathematical model to predict the outcome of pregnancies of 
unknown location. Ultrasound Obstet Gynecol. 2006;27(3):311-5 
 [12] CondousG, Van Calster B,  Kirk E, Haider Z, Timmerman D, Van Huffel S, Bourne T. 
Clinical information does not improve the performance of mathematical models in predicting 
the outcome of pregnancies of unknown location. Fertil Steril 2007;88:572–80 
 [13] Van Calster B, Abdallah Y, Guha S, Kirk E, Van Hoorde K, Condous G, Preisler J, Hoo 
W, Stalder C, Bottomley C, Timmerman D, Bourne T. Rationalizing the management of 
pregnancies of unknown location: temporal and external validation of a risk prediction model 
on 1962 pregnancies. Hum Reprod. 2013;28(3):609-16 
 [14] Guha S, Ayim F, Ludlow J, Sayasneh A, Condous G, Kirk E, Stalder C, Timmerman D, 
Bourne T, Van Calster B. Triaging pregnancies of unknown location: the performance of 
protocols based on single serum progesterone or repeated serum hCG levels. Hum Reprod. 

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2014;29(5):938-45 
 [15] Barnhart KT, Sammel MD, Appleby D, Rausch M, Molinaro T, Van Calster B, Kirk E, 
Condous G, Van Huffel S, Timmerman D, Bourne T. Does a prediction model for pregnancy 
of unknown location developed in the UK validate on a US population? Hum Reprod. 
2010;25(10):2434-40 
[16] Reid S, Casikar I, Barnhart K, Condous G. Serum biomarkers for ectopic pregnancy 
diagnosis. Expert Opin Med Diagn. 2012;6(2):153-65 
[17] Sowder AM, Yarbrough ML, Nerenz RD, Mitsios JV, Mortensen R, Gronowski AM, 
Grenache DG. Analytical performance evaluation of the i-STAT Total b-human chorionic 
gonadotropin immunoassay. Clin Chim Acta 2015;446:165-70 
 [18] Farren J, Mitchell-Jones N, Verbakel JY, Timmerman D, Jalmbrant M, Bourne T. The 
psychological impact of early pregnancy loss. Human reproduction update. 2018 Sep 
11;24(6):731-49. 
[19] Murphy FA, Lipp A, Powles DL. Follow‐up for improving psychological well being for 
women after a miscarriage. Cochrane Database of Systematic Reviews. 2012(3). 
[20] Richardson A, Raine‐Fenning N, Deb S, Campbell B, Vedhara K. Anxiety associated 
with diagnostic uncertainty in early pregnancy. Ultrasound in Obstetrics & Gynecology. 2017 
Aug;50(2):247-54. 
[21] Farren J, Jalmbrant M, Ameye L, Joash K, Mitchell-Jones N, Tapp S, Timmerman D, 
Bourne T. Post-traumatic stress, anxiety and depression following miscarriage or ectopic 
pregnancy: a prospective cohort study. BMJ open. 2016 Nov 1;6(11):e011864. 
[22] Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta psychiatrica 
scandinavica. 1983 Jun;67(6):361-70. 
[23] Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety and 
Depression Scale: an updated literature review. Journal of psychosomatic research. 2002 
Feb 1;52(2):69-77. 
[24] Farren J, Jalmbrant M, Falconieri N, Mitchell-Jones N, Bobdiwala S, Al-Memar M, Tapp 
S, Van Calster B, Wynants L, Timmerman D, Bourne T. Differences in post-traumatic stress, 
anxiety and depression following miscarriage or ectopic pregnancy between women and 
their partners: multicenter, prospective, cohort study. Ultrasound in Obstetrics and 
Gynecology. 2020 57;1: 141-148. 
[25] MedCalc. Software version 19.6.4 available from https://www.medcalc.org 
 
 
 

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12. Appendix 
12.1 Flow chart outlining patient pathway and summary of investigations 
12.2 Consent forms 
12.3 Patient information sheet 
12.4 QR code shown to patients