Role of institutional and state policies in management of pregnancies of unknown location: A 2024 online survey of Ryan Programs in the United States

Objective: This study aimed to assess the perceived impact of state and institutional policies on managing pregnancies of unknown location (PULs) at US Ryan residency programs. Study design: We conducted a cross-sectional electronic survey of US Ryan residency programs (n = 113) from March to April 2024. We compared the perceived influence of institutional and state policies on PUL management among Ryan Programs in restrictive vs nonrestrictive abortion climates. Provision of diagnostic uterine aspiration in the workup of PUL was a secondary outcome. We compared proportion of responses between restrictive and nonrestrictive climates with Fisher exact tests. Results: We obtained responses from 75 Ryan Programs in 32 states (66.4% response rate). 29 (38.7%) were from states with restrictive abortion policies. Eight programs (10.7%) changed PUL management after the Dobbs decision. Compared to programs in nonrestrictive states, programs in restrictive states were more likely to report that state policy inhibits their ability to care for patients with PUL (34.5% vs 2.17%, p < 0.001), rarely or never offer diagnostic uterine aspiration (34.5% vs 8.7%, p = 0.01), and identify institutional leadership as a barrier to offering diagnostic uterine aspirations (20.7% vs 2.2 %, p = 0.01). The most common institutional barriers to providing diagnostic uterine aspiration were staffing and faculty comfort/willingness, which did not differ by state abortion climate. Conclusions: State abortion policy and institutional policy may impact the options available to patients with PULs. Implications: Programs in all legislative climates should address institutional barriers to providing diagnostic uterine aspiration. Legislative advocacy in restrictive states is needed to ensure access to expedient PUL management.