0:00

All right, so we're gonna wrap this all up.

0:03

Let's get back to our flow chart here.

0:07

We've talked about diagnosing and treatment in

0:09

pregnancy, in which case we can proceed

0:11

normally. A definitive pregnancy failure —

0:14

it's safe to evacuate.

0:16

Pregnancy of uncertain viability,

0:17

we're going to get follow-ups. Definitive ectopic,

0:21

it's safe to treat. And pregnancy of unknown

0:23

location, whether the hCG is high or low,

0:27

we're going to get a follow-up.

0:29

So I'm going to, uh, just recap our guidelines here, just

0:33

so they're all in a nice bow. Definitive pregnancy

0:37

failure — only two criteria on an initial scan:

0:42

an embryo greater than seven millimeters without

0:45

a heartbeat, or an empty sac — and a completely

0:49

empty sac greater than 25 millimeters.

0:51

That's it.

0:52

Simple enough.

0:54

So what is our follow-up for

0:56

pregnancy of uncertain viability?

0:58

These are using the slightly more

1:00

simpler guidelines that I like.

1:02

If we see an embryo less than seven millimeters

1:04

without a heartbeat, we're gonna follow up in

1:07

seven days, and we should see a live embryo at that

1:10

time — or it will be a definitive pregnancy failure.

1:14

If we see any gestational sac less than 12

1:17

millimeters, we're gonna do a 14-day follow-up.

1:20

If we see a gestational sac greater

1:23

than or equal to 12 millimeters, then

1:25

we're gonna follow it up in seven days.

1:28

And then how about our pregnancy of unknown location?

1:32

So again, in the setting of a

1:33

near normal adnexa, single hCG —

1:38

again, these are all single — does not

1:41

distinguish between ectopic and IUP.

1:44

We should not presumptively treat for ectopic

1:46

with a single hCG greater than 3000. And if

1:50

it's greater than 3000 on a single measurement,

1:53

a viable IUP is possible but unlikely.

1:57

It's more likely a non-viable IUP.

2:00

And as they say, it is reasonable to

2:02

get a follow-up hCG and ultrasound. So,

2:06

again, I almost don't even look at

2:09

the hCG on the vast majority of cases.

2:12

I just want to know whether it's positive or negative.

2:16

And then the final rule we talked about: a round

2:20

or oval fluid collection is most likely to be a

2:23

gestational sac and not a pseudo-sac of ectopic.

2:26

So get a follow-up and don't initially

2:29

treat with methotrexate. That can — I've seen

2:33

a medical malpractice case where

2:34

that literal exact thing happened.

2:36

There was a sac, they gave methotrexate.

2:39

Patient came back three weeks

2:40

later to see what was going on.

2:42

There's a live baby in there now

2:44

that was exposed to methotrexate.

2:46

So not a good look, and not good practice.

2:50

So finally, we're gonna change this last

2:54

little section to: assuming near normal adnexa,

2:58

it is not safe to treat for ectopic.

2:59

We'll get a follow-up to bring us back here, and

3:02

these two will get follow-ups to bring us back here.

3:05

So hopefully that's kind of given

3:07

you a way to approach this topic in

3:09

a framework that makes sense.

3:12

And follow the rules that I've laid out

3:15

from the guidelines to make sure we're

3:18

practicing not only good, but safe medicine,

3:21

and not sending patients down the wrong path.