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0:49

Today, we are honored to welcome Dr. Alka

0:51

Singhal for a lecture on ectopic pregnancy

0:54

challenges and ultrasound diagnosis.

0:57

Dr. Singhal, a radiology postgraduate from S.M.S. Medical College,

1:01

Jaipur, India, has over 28 years of global radiology experience

1:06

and has worked and trained in Australia and the U.S.

1:10

She's currently Associate Director of Radiology at

1:13

Medanta Hospital, Delhi, India, and beyond radiology.

1:16

She's also a quality champion working on

1:19

constant improvement of services and training.

1:22

Dr. Singhal is also Associate Editor of

1:24

Indian Journal of Radiology and Imaging.

1:27

At the end of the lecture, join Dr. Singhal

1:29

in a Q&A session where she will address

1:31

questions you may have on today's topic.

1:34

Please remember to use the Q&A feature

1:36

to submit your questions so we can get to

1:38

as many as we can before our time is up.

1:40

And with that, we are ready to begin today's lecture.

1:43

Dr. Singhal, please take it from here.

1:46

Okay, so my screen sharing is paused, so

1:49

we'll have to resume the screen share.

1:53

My screen sharing is still paused.

1:59

Should I just stop and reshare?

2:03

Yeah, try that.

2:04

We can see your screen, though.

2:05

Uh, one second.

2:07

Uh, because I just, uh, went to the

2:11

minimize to lower the increase of volume.

2:14

Okay.

2:15

We all good now?

2:16

Yes.

2:18

Thank you so much.

2:19

Good evening, everyone.

2:20

Good afternoon, and uh, good morning as you're

2:24

all joining from different parts of the world.

2:26

Thank you, MRI online, for giving me an

2:28

opportunity to share this, uh, beautiful topic

2:33

of ectopic pregnancy, which we deal with.

2:36

Every now and then, and it's often a nightmare,

2:39

even now, up till after so many years,

2:42

it's often a very challenging diagnosis.

2:45

Believe me, it is.

2:46

Sometimes it's really engrossing, time and devotion and

2:50

dedication to actually get to the core of the diagnosis.

2:54

So let's try and simplify it.

2:57

So, of course, uh, ultrasound, I mean basic

3:00

is general abdomen and obstetric rights,

3:03

and ectopic pregnancy is a part and parcel.

3:06

It's a very basic round work that we do.

3:09

So basically, whenever we are doing an early pregnancy

3:12

ultrasound, what are our aims and objectives?

3:14

So we start with that, and then whatever difference

3:17

in the opinion that we encounter, then we are

3:20

challenged to think beyond the normal appearances.

3:24

So our core objectives are, where is the

3:27

pregnancy located in a patient with LMP?

3:30

So we have the LMP done, missed figure.

3:32

We have a positive pregnancy test.

3:34

I, uh, we serum hCG level above a discriminatory

3:39

value that we will come to in the short five.

3:42

We are looking at the location, we

3:44

are looking at the structure height.

3:45

That's like, whether it's a molar pregnancy or whether it's

3:48

normal pregnancy, whether there's a viability, whether, and

3:52

then if there is a viability, we are going to do the dating.

3:56

Uh, even if there's not a viability, even it's

3:58

beyond a certain size, we will do the dating.

4:00

And, of course, we will also establish whether

4:03

it's a singleton pregnancy or multiple gestation.

4:06

And, and of course, the honesty.

4:09

Of course, in every pregnancy.

4:11

Beyond that, we look for that you try and shape

4:14

and abnormalities and pelvic masses and any other

4:18

pathologies and anything else in the abdomen

4:20

that just po forms of art and parcel, even though

4:23

it's not being requested, it's actually included

4:26

in your assessment, and the kidneys as well.

4:29

Okay.

4:30

So with that, moving on.

4:31

So we've been all being used to doing these scans.

4:34

We've been getting these lovely

4:36

images of the uterus edge transverse.

4:38

We do the endometrial lining, and we know

4:42

that the endometrial lining changes over a

4:45

various, um, uh, period of the menstrual cycle.

4:52

So we know it thickens towards

4:54

the, uh, towards the third week.

4:56

And then, of course, if we have an any ill-defined

5:00

hyperechoic area there and we see vascularity,

5:04

we might be looking at an early implantation.

5:08

So this just to form the groundwork that we

5:10

have assumed that we have a, a diagnostic

5:14

ability to diagnose, uh, the adnexal region

5:18

and, uh, maneuver to look at them very well.

5:22

And now we are going to look at the, our

5:25

Doppler settings that will support us in the

5:27

diagnosis along with our 3D capabilities.

5:32

So with this background, let's understand before we want

5:35

to diagnose an abnormal pregnancy, what do we understand

5:40

by a normal pregnancy, an intrauterine normal pregnancy?

5:45

Of course, we know we've been used to

5:47

looking at, uh, hyperechoic ring, a gestational sac, and

5:50

implantation, inside that is a yolk sac.

5:54

This is an echogenic ring with a central area.

5:57

And then we see some eccentric fetal pole there.

6:01

And then we measure the CRL, and we may see a little

6:05

bit of CRL and a little bit of a cardiac focus

6:09

that we can demonstrate well in color Doppler.

6:12

And then when we do the spectral, we can record the

6:14

fetal heart tracing, and that's how we establish it.

6:17

And, of course, we finish each and every scan with

6:19

the scanning of the adnexal region, looking at the, uh,

6:23

ovaries, uh, for the corpus luteum cyst, and, uh,

6:27

that also suggests which side ovulation happened.

6:29

And also heterotopic pregnancy is a

6:33

real possibility in each and every case.

6:37

Okay, so then, of course, we will follow up.

6:41

The first trimester to see if there's any

6:43

twinning or absorption of any twinning

6:45

and any hemorrhage and other things.

6:48

Right?

6:48

So we'll be looking at the gestational sac, the yolk sac, the

6:53

embryo presence, and the presence or absence of cardiac

6:56

activity and measurement and demonstration of it.

7:00

When we are doing all these parameters, we

7:04

have to first establish the, uh, the gestational sac.

7:09

The gestational sac.

7:10

Now, when do we begin to see the gestational sac?

7:13

Visible at four to five weeks with the

7:16

transvaginal ultrasound, and at six weeks on

7:20

transabdominal ultrasound.

7:23

How does it appear?

7:24

It appears as an echogenic ring, as you saw, with

7:26

an anechoic center, and it's just measured by the

7:29

mean sac diameter, which is very well integrated

7:33

in the software in most ultrasound equipment.

7:36

Increases by a millimeter a day in early pregnancy, and

7:40

often can be used to monitor the normal growth or not.

7:44

So normal growth, that discriminatory zone is a very

7:48

important factor that allows you to correlate values.

7:53

When you look at this discriminatory, uh, you

7:57

have the company in serum beta hCG level.

7:59

So when the beta hCG is more than 2,000 milli

8:02

units by milliunits by TVUS, you should

8:06

be able to see the gestational sac. And if it's more than

8:09

6,000, you should be able to see a gestational sac, right,

8:12

transabdominal ultrasound.

8:14

So this is very, very important, and it

8:17

supports you in evaluation, like we discussed.

8:20

Yolk sac is a bright ring, echogenic center, and it's seen at

8:26

around five weeks, transabdominal, and persists 11 to 12 weeks.

8:30

The embryo is seen by TVUS as a thickening of the yolk

8:33

sac, and there is presence or absence of cardiac activity

8:36

that we see after, um, uh, uh, five to six weeks, right?

8:44

So, um,

8:47

cardiac

8:48

activity seen, and we measure it by the spectral Doppler.

8:52

Now coming to this, so we will have the discriminatory

8:57

zone of the weak hCG values, and we are going to compare

9:00

it, and we should be able to see the gestational sac and correlate it.

9:04

Now, what are the key signs when we are in that gray zone?

9:10

When we are in the doubtful zone, when

9:12

we are in that overlapping feature zone?

9:15

What features help you really separate our findings?

9:19

Let's look at those.

9:20

The three key signs that we must remember

9:23

are, one is the double decidual sac sign.

9:27

Second is the intradecidual sign,

9:29

and the help is the double blood sign.

9:31

So let's look at that.

9:32

So first let's look at the double decidual sac sign.

9:36

So what it says is it's a useful feature

9:39

to confirm the intrauterine pregnancy when

9:42

the yolk sac or embryo is not yet seen.

9:44

In the very early scenarios, how we see it, the decidua

9:49

parietalis, which is the lining of the cavity, and the

9:52

decidua capsularis, which is lining the gestational sac,

9:55

we are seen as two concentric rings

9:58

surrounding an anechoic gestational sac.

10:02

So when these two adhere, and it, uh, it's the decidua basalis,

10:06

and that's the site of the future placental formation.

10:09

And we can normally see that

10:11

in about 53% of uterine pregnancies.

10:14

So that's a supportive sign in imaging.

10:18

So that's the decidua, uh, and that's the

10:21

other layer of the decidua, and that's the

10:25

anechoic area that we are seeing in the middle.

10:29

Now with the TVUS, we can see this accurately in

10:33

majority cases, and however, the absence of this

10:38

does not preclude an intrauterine pregnancy.

10:42

Okay.

10:44

Right, now let's look at the second sign.

10:47

What's the second sign?

10:48

The second sign is the

10:52

sign.

10:53

So what we have is, as per the implantation, uh, one second.

11:02

Uh,

11:02

yeah.

11:03

As per the sign, the site of the implantation

11:05

is seen as an early gestational sac, an

11:09

intrauterine fluid collection, or an, which is an

11:12

echogenic area and thick decidua on the side of it.

11:16

So when you look at it, what happens is you

11:19

will be able to see, you have to distinguish it

11:23

from the other, uh, differential diagnosis of

11:27

pseudogestational sac and other shape findings.

11:30

So this is useful in identifying an early uterine

11:33

pregnancy as early as 25 days of gestation.

11:36

And the threshold level, the earliest one

11:39

can see the sign is at 24 days of gestation.

11:42

And the discriminatory level, one should

11:45

always see the sign in four to seven days.

11:49

So although useful, if seen, its presence has

11:53

been reported in fewer cases of intrauterine

11:55

pregnancy than originally thought, and its absence

11:59

does not exclude an intrauterine pregnancy.

12:02

So coming to the next, the double bleb sign, so this is

12:06

visualization of a gestational sac containing a yolk sac and

12:10

an amniotic sac, giving an appearance of two small bubbles.

12:14

So this kind of an appearance, which

12:15

you can very well see on a 3D as well.

12:18

And the embryonic disc is in between the two bubbles.

12:22

So this kind of an appearance, when you

12:23

see the double bleb sign, it's quite

12:26

statistical and an intrauterine pregnancy.

12:29

So this is very easy.

12:31

We are often seeing it very well.

12:33

So that's the double bleb sign here.

12:35

We can see that. Now, you've seen these

12:39

typical features, we are very happy.

12:41

But however, if you have not seen these typical features.

12:45

Then what do we do?

12:46

What are we looking at?

12:47

Pregnancy of unknown location.

12:50

That's what we are looking at.

12:51

So what do we do for that?

12:55

I just want to, okay, so what are the possibilities

13:01

that you're looking at in that case?

13:02

Now, is it an early, very early intrauterine

13:06

pregnancy that it hasn't had the time to

13:08

actually be developed enough for us to be seen?

13:11

Or is it an early extrauterine pregnancy that has not

13:16

been, uh, grown enough for us to be seen, or it has

13:21

been obscured due to various technical factors, or

13:26

factors obscured by bowel gases or any other factors,

13:29

or, uh, expertise challenge could also be a factor for it?

13:33

Or is it an early failed pregnancy?

13:36

There was a pregnancy, but there's, uh,

13:38

it's a failed pregnancy, so it's already

13:41

uh, going into abortion in progress.

13:44

Let's, uh, separate the possibilities.

13:47

So pregnancy of unknown location, and you have a

13:51

positive pregnancy test, and you don't see any

13:53

intrauterine, and you don't see an extrauterine pregnancy.

13:56

What are the possibilities?

13:59

First and foremost is to ask the patient to

14:01

uh, check the LMP, the last menstrual period date.

14:05

Most likely, we have to look at the early, very

14:07

early pregnancy not detected on early ultrasound, or

14:12

there could be a possibility of a complete miscarriage

14:14

or an unidentified ectopic pregnancy, which is

14:17

our major point of concern discussion today.

14:20

So let's look at that.

14:21

So, as we all know, ectopic pregnancy is when the

14:25

gestational sac is implanted anywhere

14:29

else but the fundal endometrium of a normal uterus.

14:33

And by definition, it's called ectopic pregnancy.

14:36

And these locations can be, so mainly the

14:40

tubal area, almost 90 to 95%, the tubes and the ovary.

14:45

So ranging from the interstitial area

14:49

to the fallopian tube and to the ovary.

14:53

And then the other location possibilities

14:56

are the intramural part of the uterus or

14:58

the C-section scar, the cervical, or the abdominal.

15:02

This chunk contributes to 90 to 95% of ectopic

15:06

cases. Right. Now, why is the diagnosis important?

15:11

Obviously, we know that's the significant cause of

15:14

morbidity, mortality, abnormal pregnancy outcome,

15:20

pregnancy complications, and risk to the mother.

15:22

So it's very, very important to have an early diagnosis

15:25

that can significantly reduce all these, right?

15:30

So now what do we do?

15:33

Do we, we need to suspect, right?

15:36

First, more so, when do I suspect an ectopic pregnancy?

15:39

In anybody?

15:40

In any patient.

15:41

I mean, how will the patient clinically present?

15:44

That's the first thing.

15:45

When you look at the prescription or you

15:46

look at the patient, two things, that's when

15:49

you think, oh my God, could it be that?

15:52

So let's look at that.

15:53

So first, of course, there would be a period of

15:55

amenorrhea, or the patient may not remember, or

15:58

the patient may be incorrect about the dates.

16:01

So keep that possibility also in mind.

16:04

So the period of amenorrhea always, always may

16:07

not be declared and be apparent to you.

16:11

Of course.

16:11

Positive serum hCG, again, depends upon the duration

16:16

of the, uh, since the last menstrual period.

16:20

Spotting and irregular bleeding, that is often, uh,

16:24

there could be a history, and there could be pain.

16:26

There could be, uh, of course, if there has already been

16:30

a significant amount of bleeding or due to

16:32

pain, it could be vomiting, shock, and fainting as well.

16:37

Now, what do we see on physical examination?

16:39

Of course, if there's a vasovagal shock, you

16:41

will have hypotension, tachycardia, abdominal

16:44

distension due to fluid, tenderness, shifting dullness.

16:48

If there's a ruptured, uh, ectopic gestation, and, of

16:52

course, bloodstream discharge would be seen right now.

16:58

Of course, differential diagnosis of various other

17:01

pathologies is always, always running in our minds.

17:06

We always, we are always thinking if it's a

17:09

right-sided appendicitis or any renal colic or any

17:12

tubal inflammation or any ovarian torsion or any ovarian

17:17

rupture or any pelvic inflammatory disease, starting

17:20

from endometritis or any spontaneous abortion.

17:25

So these findings of these

17:29

um, yeah,

17:30

clinical entities are often overlapping,

17:33

and they give a lot of challenge.

17:35

Of course, salpingitis, we know, is inflammation.

17:38

We know we have enlarged bulky ovary with peripherally

17:41

displaced follicles, adnexal obvious rupture.

17:46

We have the ring of fire and characteristic location.

17:49

Endometritis and inflammation can have other associated features.

17:53

Spontaneous abortion may have significant blood clots

17:56

and bleeding and other features that you could see.

17:58

Appendicitis, we could see typically with a

18:01

high-frequency transducer, we may be able to

18:04

identify an inflamed, uh, bowel, uh, dilated

18:08

appendix with a blind end and tenderness.

18:12

We could have diverticulitis and inflammation that could

18:15

be diagnosed on ultrasound or may need further imaging for

18:18

the same, or you could have non-specific mesenteritis.

18:22

And of course, renal colic is one of the commonest of.

18:26

Um, overlapping, uh, clinical feature entities, right?

18:32

Right.

18:32

So, in a patient with a missed period or a

18:35

positive beta hCG, when will you suspect an ectopic?

18:39

So these are the scenario clinical scenarios.

18:42

You have low beta hCG values than expected according

18:45

to the duration of amenorrhea, right, and slow rise

18:49

in beta hCG levels when the normal rise is 1.7

18:53

times per day, or at least 53% in 48 hours.

18:57

Or then when the discriminatory zone serum beta hCG

19:00

level is more than 1,500 milliunits with no

19:04

gestational sac on TVS, five to 8% of ectopics will still

19:08

have a,

19:11

will still have a living, will still have a living

19:16

embryo with normal levels of serum beta hCG. Right.

19:20

So, one second.

19:21

Okay.

19:22

So, but will you always wait till

19:24

the beta hCG level reaches 1,500?

19:28

No, waiting until the discriminatory zone of beta

19:33

hCG is reached before performing a TVS could

19:37

miss a very early extrauterine implantation,

19:41

especially in the distal part of the fallopian tube.

19:43

Right.

19:45

Will you get any other hormonal investigation done?

19:48

Of course, you would get the progesterone. In viable

19:50

intrauterine pregnancies, more than 15 nanograms

19:52

per mL. And, of course, no definitive values

19:55

certain in the market in ectopic pregnancy from an

19:57

intrauterine pregnancy, but the progesterone is low.

20:02

Okay.

20:07

Some extra,

20:08

um, uh, some groups use a low progesterone to differentiate

20:13

between low-risk patients when a pregnancy of unknown

20:16

location may be suitable for conservative management

20:19

and at-risk patients who require definitive management.

20:23

So this is how you go about it.

20:26

Of course, we all know that TVS is the modality of

20:29

choice, but what, what are the sensitivity and specificity

20:34

data as per literature? Sensitivity is very high,

20:37

96%. Specificity has a challenge of 88%, of course,

20:43

because the features of other, um, uh, findings as

20:49

variant lesions or cysts or bowel lesions overlap.

20:53

PPV, positive predictive value, of 89%,

20:57

and negative predictive value of 95%.

20:59

So actually is one of the preferred first

21:03

choice imaging.

21:04

So combination of clinical examination

21:06

and history, serum beta hCG, and TVS.

21:10

It's possible to diagnose ectopic pregnancy with

21:14

hundred percent sensitivity and 99% specificity.

21:19

So when you are really, really thorough in

21:21

a nutshell, you can say for sure whether the

21:24

patient has an ectopic pregnancy or whether

21:27

the patient does not have an ectopic pregnancy.

21:30

It's quite, quite in all your control

21:33

and in your hands to diagnose that.

21:35

Okay, so here we have, uh, uh, just a scan just to.

21:41

We just explore the images as we go along.

21:44

That's a transabdominal scan.

21:45

We can very well see the uterus, which

21:47

is showing a thickened endometrium.

21:49

Looks like a symmetrical, homogeneous.

21:52

And that's a, and it's a region that

21:55

we can see that's a transverse image.

21:56

Looks nice and good and clear, thickened endometrium.

22:00

That's again, thickened endometrium.

22:01

So we do not see any asymmetry in

22:04

the endometrial lip thickening.

22:07

And we see the endometrial lining thicken,

22:09

and that's the ovary that we can see there.

22:13

Uh, and that's the ovary again, and that's,

22:16

we see something there's kind of ring of

22:19

fire and a heterogeneous, uh, area there.

22:22

And yes, of course, we have an ectopic gestation

22:26

in the right region and which has got a

22:29

echogenic ring of the sac and a yolk sac as well.

22:34

Right.

22:34

So, and uh, this, this image is just to show

22:39

if there's any fluid in the POD, which there isn't.

22:42

And that's the corpus luteum cyst on side.

22:46

And that's, uh, the ectopic pregnancy, right?

22:51

So that's the commonest, uh, tubal

22:54

site. So, so what are the early signs?

22:58

So how do we really see it?

23:00

When do we suspect it?

23:01

You can see, uh, an echogenic, uh, sac in the adnexal region.

23:06

You can see the CRL, you can see the fetal

23:10

pole, and you can see the cardiac pulsations

23:13

as well, depending upon the duration of the, or

23:18

gestation of the pregnancy, right?

23:21

So

23:24

second.

23:28

So uterine signs for the early pregnancy are, uh,

23:32

there's an empty endometrial cavity, which may

23:35

or may show increased endometrial thickness due to

23:38

decidual reaction and the symmetrical endometrial lips.

23:44

So this lining is central because if there is

23:47

an intrauterine implantation, you may often find

23:51

that once one of the lips may be a little bit more

23:55

thickened as compared to the contralateral one.

23:59

An empty endometrial cavity may or may not show increased

24:02

endometrial thickness that we discussed. Pseudogestational sac

24:05

seen in 10 to 20% of cases with ectopic pregnancy,

24:09

which is basically a fluid trapped in the cavity, right?

24:15

So.

24:18

Asymmetrical.

24:19

So what are the vice versa?

24:21

What are the subjective signs

24:23

of an intrauterine implantation?

24:26

Of course, the endometrium is echogenic.

24:28

There is asymmetric thickening of the endometrium.

24:31

So here there's a difference in the thickening of the

24:35

endometrial lining on the, uh, anterior, posterior wall.

24:39

And of course there is a focal localized area of

24:42

increased vascularity in the endometrium, which

24:45

is a response to the site of implantation, right?

24:49

So you see that, and then of course later

24:52

you will see a gestational sac that has developed.

24:56

And to begin with, you just see a focal area

24:59

of increased vascularity in the endometrium.

25:03

So that corresponds to the possible site of

25:07

implantation in the endometrial lining, right?

25:11

So later there you can see the gestational sac development.

25:15

We talked about pseudogestational sac, which is often seen in ectopic.

25:19

Now, let's understand, what do we mean by the pseudogestational sac?

25:24

Pseudogestational sac can be identified by one.

25:27

It's located in the center, so why?

25:29

Why?

25:30

Because basically it's a fluid-filled bag, which

25:33

is given the appearance of a gestational sac, but it's not

25:36

actually a gestational sac. So in between the two lips of the

25:39

endometrial lining, it's just a fluid trap there.

25:42

So it's seen in the center of the uterine cavity.

25:45

There's, of course, an absence of the double decidual sign.

25:48

Double sign.

25:50

And the changing shape with uterine contractions

25:52

happens because you'll see it's going to, when

25:55

you are doing the real-time scan, you'll see with the

25:57

uterine contractions there's a change in the shape.

26:00

And of course there's no, uh, peripheral flow or

26:03

the trophoblastic flow as compared, uh, in case,

26:08

as in case of the normal intrauterine pregnancy.

26:12

Right?

26:13

So a true gestational sac would be like that with a flow.

26:17

Pseudo gestational sac is like a fluid trapped in the endometrial

26:20

cavity, which will have a kind of a shape.

26:22

And with the uterine contraction,

26:24

this will, of course, be dynamic.

26:27

Right.

26:29

Coming to the next, specifically tubal

26:32

pregnancy, what are the adnexal signs that you see?

26:36

So, like you said, that's probably

26:39

the ovary, that's the adnexal region.

26:41

Here's the uterus, and that's what you

26:42

see, a typical hyperechoic rim and, uh,

26:47

uh, with an anechoic or a hypoechoic area.

26:54

So when you see an adnexal mass, point number one,

26:57

you see often maybe a thick echogenic rim.

27:01

Number two, you see a central anechoic area.

27:05

And the gestational sac in the adnexa with the yolk sac and uterine heart

27:09

activity is only in 15 to 28% of ectopic pregnancies.

27:16

And, of course, you can see the free fluid in the pelvis.

27:21

You can see, uh, like a sign with a, with

27:24

a vascularity that you call ring sign.

27:28

So that is suggestive of tubal pregnancy.

27:31

So again, that's the ovary and that's the ectopic pregnancy.

27:36

That's again the corpus luteum, and that's

27:38

the ectopic pregnancy there.

27:42

Now, is there any role of color Doppler in

27:45

this diagnosis of, uh, of ectopic pregnancy?

27:50

Color and power

27:51

Doppler do show the vascular rim

27:53

around the adnexal mass and RI of 0.45.

27:56

Honestly speaking, I really don't need this.

27:59

I think the grayscale really helps given the diagnosis.

28:03

The extent of vascularity reflects the

28:06

trophoblastic vitality and the invasiveness.

28:09

And the 3D ultrasound can show extended fallopian

28:12

tube with a thin hypoechoic border, and, uh, effective

28:17

for the diagnosis of earlier ectopic before the

28:19

site rupture of amenorrhea and asymptomatic patients.

28:22

So this is for, we see the ectopic.

28:26

That's another case of ectopic.

28:28

That's again there.

28:30

So you have this kind of an appearance.

28:32

You can see very classically there's

28:34

an ovary, and that's the next ectopic.

28:38

Of course, we all know there are factors that lead to this.

28:42

Uh, STDs, ART, abnormal conductors, hormonal changes,

28:46

surgical procedures and pelvis, uterine malformations.

28:49

Previous history of pregnancy, IUD against

28:53

ectopic pregnancy and progesterone.

28:55

Endocrine contraceptive, whether that's again,

28:57

another 3D, and that's the ectopic pregnancy.

29:03

We can have pregnancy growing even up to

29:05

nine, 10 weeks and being, uh, having still

29:09

the viability and heart rate that can be seen.

29:14

You can have the free fluid seen in the POD,

29:16

which can appear as clear hyperechoic, or which

29:19

can appear as heterogeneous with echoes.

29:22

And we, every attempt is made to measure the volume.

29:26

So, uh, one, one way is to get the

29:29

perpendicular depth of the fluid behind in POD.

29:34

And one way is, of course, when it's crossing the fundus,

29:37

then, you know, definitely it's, uh, it's a large amount,

29:40

and, of course, it could be heterogeneous as well.

29:46

Now, the risk of ectopic pregnancy

29:48

increases sevenfold after acute salpingitis.

29:52

And history of PID reported in 20 to

29:54

50% of patients with salpingitis, right?

29:58

There's a diagnostic, uh, dilemma between angular

30:01

pregnancy, interstitial pregnancy, and cornual pregnancy.

30:05

Three very, very important points in

30:07

angular, interstitial, and cornual pregnancy.

30:11

So these often are used, and they're assumed that they

30:16

mean similar and the same, however, they mean different.

30:20

Their management is different,

30:22

the diagnostic points are different.

30:23

So let's understand them, this overlapping picture.

30:28

Let's just try and separate and get

30:30

it very clearly into our minds today.

30:33

Let's clarify.

30:34

So coming to the first one, the angular pregnancy.

30:41

An angular pregnancy is an eccentric intrauterine

30:44

pregnancy with an implantation of the embryo in the

30:47

lateral superior angle of the uterine cavity, right here.

30:51

So on laparoscopy, it shows asymmetric

30:54

enlargement of the uterus and the lateral part.

30:57

So what you see is like that.

30:58

So it's basically this eccentric implantation of the, um,

31:06

uh, of the.

31:09

I'm just gonna put up, so

31:13

Right.

31:14

Okay.

31:14

So, and the 3D image will show, one second.

31:19

Right.

31:20

You can see that.

31:21

So it's located at the lateral angle of the

31:23

endometrial cavity, and there is a broad-based

31:27

connection with the endometrium, and there is

31:29

a normal myometrium noted on the lateral edge.

31:34

So it's, so that presence is frankly helps

31:38

differentiate from other tubal ectopic that

31:41

we will, uh, we will try and just understand.

31:44

So angular pregnancy is a normal intrauterine gestational sac, which

31:49

is, so, it's technically not really an ectopic, though it's

31:54

a normal intrauterine gestational sac, which is implanted in the

31:57

very lateral part of the upper angle of the uterine cavity.

32:01

Right.

32:01

So the location of the sac is still medial

32:04

to the interstitial part of the fallopian tube.

32:07

And of course there's a wide range of the, uh, uh, there's a

32:12

wide angle of the communication with the uterine cavity.

32:17

So we'll just understand with an ultrasound

32:18

image, so the sac is seen about.

32:25

And, uh,

32:29

Okay.

32:32

So coming to

32:33

the next, the interstitial pregnancy.

32:35

So as we all know, this is the

32:36

interstitial part of the fallopian tube.

32:39

So this is the endometrial lining, and that's

32:41

the interstitial part of the fallopian tube.

32:45

So when the sac is implanted here in between this

32:48

part, so sac is seen one centimeter lateral from

32:53

the edge, lateral edge, of the uterine cavity.

32:56

It is, if it is here within this part, and it's the

33:00

angular pregnancy, but if it's beyond the lateral

33:04

edge of the uterine cavity, then here, right?

33:08

Just after that, then it is in the interstitial part of

33:12

the fallopian tube, and that is the interstitial pregnancy.

33:16

So an interstitial pregnancy is when the

33:18

implantation is within the interstitial portion

33:24

interstitial.

33:25

Okay?

33:28

Right.

33:30

So what do we see on ultrasound?

33:36

We see, of course, like in all ectopics,

33:38

we see an empty endometrial cavity.

33:40

We see the interstitial line sign, we look at the ultrasound

33:43

images to follow, which is an echogenic line that is

33:47

extending from the endometrium to the interstitial gestational sac.

33:51

And we see the myometrial mantle sign, which

33:53

is a gestational sac surrounded by the myometrium.

33:56

And we see the bulging sign, the gestational

33:58

sac in the fundus, resulting in, uh, uh,

34:02

abnormal bulging of the uterine contour.

34:04

Now let's look at that.

34:06

The first one, the interstitial line sign, is an

34:10

echogenic line that is connecting the, uh, endometrial

34:15

stripe to the gestational sac. And if you see this line, this is

34:22

a hundred percent specific and with 80% sensitivity again.

34:29

The gestational sac is seen here in the interstitial

34:32

portion of the fallopian tube.

34:35

So with the fetal pole here.

34:37

So, and the echogenic line, which is abutting the

34:41

gestational sac, represents the interstitial line sign, right?

34:47

So coming to the interstitial, um, ectopic pregnancy.

34:53

Um, so you can see the peripheral flow also around

34:59

when you turn the color Doppler on, right?

35:03

So again, that's about the interstitial line sign.

35:06

So it's in the interstitial part of the fallopian tube.

35:09

That's the central endometrial cavity.

35:11

A thin, thin line that connects

35:13

the

35:17

tube and a myometrial mantle of

35:21

3 mm.

35:23

When you, what, what is it that the

35:26

clinician or the gynecologist wants to know?

35:29

That the sac, is it, is it intrauterine or extrauterine?

35:32

So if it's towards the edge, if it's angular or if

35:36

it's just a bit towards the edge of the, uh, area,

35:39

what you want to know is how much of the endometrium is

35:42

there and how much is it away from the serosa.

35:45

So those are the kind of measurements you must always see.

35:48

See, this is all the uterus that we have here,

35:51

and we see a gestational sac, which is just at the edge.

35:54

Of course, it's very close.

35:55

It can rupture, right?

35:57

So this endometrial mantle, whatever, you can see this.

36:00

If you see it's very thin, it's just

36:02

right next to the serosa or something.

36:05

You must take the nice, well-perpendicular

36:08

measurement and, and image it and document

36:12

this measurement in all your reports.

36:15

That is very, very vital.

36:17

So like we discussed, angular pregnancy was here.

36:20

Now interstitial pregnancy is in the interstitial

36:24

part of the fallopian tube, where the gestational sac is embedded

36:28

in the interstitial segment of the fallopian tube.

36:31

So the thick surrounding margins

36:33

are echogenic on ultrasound.

36:34

And, of course, there is particular trophoblastic flow because

36:38

it's an intrauterine pregnancy, right?

36:43

So, of course, there's abundant vascularity

36:45

at the gestational sac, and its close proximity

36:48

is there to the arterial vessels and the artery.

36:51

Yeah.

36:52

Okay, coming to the third word, which is

36:55

called cornual pregnancy, which could also

36:58

sometimes be overlapped with both of these,

37:01

the angular, the interstitial, and the cornual.

37:03

So we've separated them all.

37:06

From now on, we are going to be very clear when we

37:08

are talking and referring, what do we mean by angular?

37:12

What do we mean by interstitial and what

37:14

do we mean by cornual pregnancy?

37:16

So a cornual pregnancy historically is described as the

37:20

intrauterine fundal implantation within the anomalous

37:24

bicornuate or the septate uterus, for example.

37:27

That appears to be probably a septate uterus.

37:32

And we have two implantations into two.

37:36

Uh, two of the.

37:38

Divisions of the endometrial cavity, right?

37:40

So cornual pregnancy historically describes an

37:43

intrauterine implant, a fundal implantation within

37:48

the anomalous bicornuate or the septate uterus.

37:53

So that's what is labeled as cornual pregnancy.

37:56

So bicornuate or septate uterus, simply.

38:01

And that's about it.

38:02

So you, these are just more

38:04

illustrations of a cornual pregnancy.

38:06

So we have two cornua.

38:08

So this pregnancy in front of the cornua again here.

38:11

Similar story, similar here too.

38:14

Right now.

38:15

Why is it important to differentiate between

38:19

the interstitial and the angular pregnancy?

38:22

So we have to give the prognosis and the management. Why?

38:25

Because interstitial pregnancy, though

38:29

it accounts for two to 4% of ectopic,

38:31

it has 2.5% mortality. Twenty percent of deaths that occur with

38:36

ectopic pregnancy occur due to interstitial pregnancy.

38:41

Of course, it occurs before the 12 weeks, and

38:44

uh, it's treated with systemic or local methotrexate,

38:48

or you can have a cornual resection and then

38:52

laparoscopic-assisted transcervical vacuum aspiration

38:56

can also be offered to the patient as a management.

39:00

Of course, things do happen.

39:02

You do get pregnancy with IUCD.

39:05

So always in your pregnancy, in your IUCD cases,

39:09

do ask for last menstrual history to ask whether

39:13

you've, um, taken care of your, uh, teeth as well.

39:19

Right.

39:19

So again, so this is again an interstitial,

39:23

so see it's just, uh, uh, reaching almost up to

39:27

the serosa, so there's not, uh, because this is a 3D

39:30

image, again, we would need 2D to confirm that.

39:34

How much is the endometrial and the

39:36

serosal effective thickness of the width.

39:39

So, so 3D is powerful and, uh, the gestational sac will

39:43

start filling the endometrial cavity as we go,

39:48

progress along.

39:49

Right.

39:49

Okay.

39:50

So potentially now coming to the next,

39:55

coming to the angular pregnancy, like we discussed,

39:58

how do we manage, because angular pregnancy

40:01

is potentially an intrauterine viable pregnancy.

40:04

It's just close to the angle of the uterus, right?

40:07

Of course, because it's just eccentric and it's just close

40:11

to the angle, there is a higher risk of uterine rupture.

40:14

There is a risk of spontaneous abortion,

40:16

and there is a risk of placenta accreta.

40:19

So with expectant management in different series,

40:23

25 to 70% of these pregnancies resulted in live births.

40:28

That's about the management of angular pregnancy.

40:31

So, uh, um, interstitial, how do we, how are they managed?

40:36

You can have a D&C, local methotrexate, or systemic

40:39

methotrexate, and of course after things are settled

40:43

down, this because it's very close to the angle.

40:46

And then, of course, if the patient is not

40:48

desiring to continue, then you can go for

40:51

hysteroscopic removal of the pregnancy.

40:55

Now you could have an acute abdomen

40:57

even before the period is missed.

40:59

Do you think somebody could be pregnant?

41:01

That's a very intelligent question.

41:03

So yes, it can be ectopic and where in

41:07

the isthmic part of the fallopian tube.

41:10

So in the isthmic part of the fallopian tube,

41:13

you could be, um, that could, uh, be the

41:18

site of the ectopic implantation in such cases.

41:20

So pregnancy, even before the missed period.

41:25

Of course, heterotopic, as you all know, is

41:28

when you have a coexisting, uh, gestational sac along

41:33

with, uh, an extrauterine and an intrauterine, both

41:37

together, and viable interstitial pregnancies are

41:40

unseen with cardiac activity in both the fetuses.

41:44

And 3D will show the eccentric sac

41:47

separate from the endometrium.

41:50

So, of course, there would be intervening myometrium.

41:53

Now.

41:54

So anything special about heterotopic pregnancy?

41:57

Not really.

41:57

Right?

41:58

So let's look at it.

42:00

So on, how do we manage heterotopic pregnancy?

42:05

So what's the aim when you want to manage pregnancy?

42:08

The aim is to do what?

42:10

To protect, to protect, to save the intrauterine

42:16

pregnancy and to avoid complications of the ectopic.

42:20

So because ectopic would run in the various

42:24

clinical scenarios of maybe, uh, ruptures or any

42:28

other factors, they would have a different approach.

42:33

Our aim here in heterotopic pregnancy is first, and

42:36

the foremost motto is to aim to save intrauterine

42:41

pregnancy and avoid the complications of the ectopic.

42:44

Right, coming to the next, cervical pregnancy.

42:49

Cervical pregnancy is basically, it's in the cervix.

42:53

So cervix, what are the anatomical boundaries of the cervix

42:57

begins from the external os to the internal os.

43:01

Now, when do you suspect cervical pregnancy?

43:05

When and what are the criteria to diagnose it on ultrasound?

43:10

That's the two key things we need to know.

43:13

So we don't have any more, um, our life is smooth.

43:17

Right?

43:18

So when will you suspect cervical pregnancy, and

43:21

what are the diagnostic criteria on ultrasound?

43:25

So here, somebody has been very kind to write that.

43:28

Missed periods, positive beta hCG, history of

43:30

spotting or more than frank bleeding, right?

43:33

Anyways, so here you see this anechoic

43:36

area between the two echogenic lines.

43:38

The gestational sac is low in the endometrial cavity in cases

43:42

of cervical pregnancy because the days are less.

43:46

This is all the fundus.

43:48

The sac could have been anywhere

43:49

here, here, here; however, the sac

43:53

appears to be really, really low.

43:55

Like at this moment, right now, coming to the next

43:58

cervical pregnancy, of course, where is LSCS scar?

44:02

It's somewhere here and down.

44:05

This is where she liked, and she has marked it up.

44:09

So again, in cervical pregnancy, you will

44:11

have the fundus, of course, empty, ballooned.

44:14

Cervical canal is there, an hourglass uterus is there, and

44:17

there's, of course, lots of vascularity in the uterus, right?

44:20

So closed internal os is there.

44:22

And, of course, peripheral flow is seen right now.

44:27

Cervical pregnancy, again, we have two, uh, um, uh,

44:34

bottles, uh, that hourglass kind of an appearance.

44:40

Now, hourglass, how does it appear?

44:44

Because that's the area that's holding

44:47

onto any clot, any bleeding, or anything.

44:51

The upper areas, they both look pretty similar.

44:54

That is why now.

44:58

So this is a spotter class six cervical pregnancy.

45:01

So that is probably the external os, that's probably

45:05

the internal os, or maybe this is the internal os.

45:08

And here we have a very nice, uh, uh, ectopic

45:12

gestational sac, which is towards the inferior part, meaning

45:15

hopefully it will go towards the urinary bladder.

45:19

That is the LSCS. Okay, so that's

45:22

the gestational sac, and that's what the scenario is.

45:26

So in cases of cervical pregnancy, you can see

45:28

the, uh, I guess you can see the, the embryo and

45:33

measure it and get the parameters that you can.

45:36

So get and support yourself.

45:39

Coming to the heterotopic pregnancy, that's another big one.

45:43

How, how do these, um, uh.

45:48

Throat gets dry in this, be it the weather or

45:50

any other challenges that you're having.

45:53

So when you have concurrent cervical ectopic and cervical

45:57

intrauterine, that's a boom that will really, really help.

46:03

Right?

46:04

So again, you have a lot of echogenic

46:06

endometrium, lots of, uh, shadowing over there.

46:10

And, uh, things now coming to the differential diagnosis

46:15

of cervical pregnancy, that is very, very important.

46:19

Why?

46:20

Because the management is different.

46:22

So most common is the abortion in progress.

46:26

The sac is there in the cervical canal, in the

46:28

center, and there's no vascularity around.

46:31

And the sac may be irregular.

46:33

Internal os may always be open, right?

46:38

So, yeah.

46:39

And, uh, coming to the next, so.

46:44

Okay.

46:45

Yeah.

46:46

One second.

46:47

Um, okay, so differential diagnosis: abortion in progress, it's

46:51

heterogeneous, it's as if it's going on.

46:53

The internal os is open.

46:54

Internal os also could be open or could not be open, could

46:59

have subchorionic hemorrhage, but remember that's outside the sac.

47:03

It's not, per se, inside the sac.

47:06

Do not take it inside the gestational sac.

47:08

You will be feeling a lot better with your own self.

47:12

So again, this is a very thick endometrium.

47:15

Would probably be about, um, uh, wait, let me see.

47:21

About 25 mm. That's what it looks

47:23

like if each of this is one.

47:26

So you have about 20, 20 to 25 mm, right?

47:29

So coming on to the next, misdiagnosis of cervical pregnancy

47:34

as an abortion in progress can have serious consequences.

47:39

Dilatation and curettage in a cervical pregnancy can cause massive,

47:45

life-threatening hemorrhage, secondary to trophoblastic invasion of

47:48

the cervix and lack of musculature in cervical hemostasis.

47:52

Right. Now, of course, we have a long list

47:56

of, excuse me, um,

48:02

a long list of differential diagnoses that we

48:04

must, um, we can use to figure out.

48:09

So, of course, how do we manage a

48:11

cervical ectopic, and what is the risk?

48:13

We do conservative management by KCl or potassium

48:17

chloride, or to try uterine artery embolization.

48:20

And, of course, you can go through

48:21

surgical management as well.

48:24

To the another very important

48:26

cesarean scar pregnancy.

48:28

So with the rising incidence of cesarean deliveries,

48:31

the incidence of scar pregnancy is also increasing. There's

48:34

a high index of suspicion for cesarean scar pregnancy.

48:38

And, uh, let's look at that.

48:41

So basically what we have is the implantation

48:44

at the cesarean scar, and then it can,

48:49

uh, appear as a well-defined hyperechoic ring.

48:52

And you can see the yolk sac there.

48:54

So again, the uterus is empty.

48:56

There's an empty cervical canal.

48:57

There could be a pseudogestational sac, some fluid there.

49:01

Sac is seen inferiorly.

49:03

Now this gestational sac would grow inside the uterus or outside.

49:08

And depending upon the, uh, growth, we

49:12

can have it growing outside or inside.

49:16

We have the terminologies, uh, which is, uh,

49:22

called, uh,

49:24

type one cervicoisthmic or type two, which is exogenic.

49:30

So exogenic has more chances of

49:32

rupture, and endogenic is growing inside.

49:36

So it's still a little bit covered up.

49:39

So type one, the endogenic, is when the

49:41

implantation occurs at the scar site.

49:43

In this case, it goes towards the cervix to make

49:46

all the uterine cavity, and type two grows outside, right?

49:51

So that's, uh, the full classification of the same.

49:55

And, uh, so that's again another

49:58

case where you have a cesarean scar

50:00

pregnancy very well demonstrated, and

50:04

implications, of course, are quite, uh, sinister.

50:09

So the management is based on, of course, the gestational

50:12

age, beta hCG level, size of gestational sac, endogenic or exogenic growth.

50:17

And there is dual myometrial thickness

50:19

around and the viability of pregnancy.

50:23

So accordingly, we have grading of that and, uh, management.

50:30

And the last part is the intramyometrial ectopic

50:34

pregnancy, when it's implanted within the myometrium.

50:37

So again, it's not connected with the endo

50:40

cervical canal, so it is rare, and it's completely

50:44

surrounded by the myometrium, and it's separate from

50:47

the endometrial cavity and the fallopian tubes.

50:50

And this is how you would see an intramyometrial ectopic

50:54

pregnancy, where it's not connected with the endo

50:58

cervical canal at all, coming to an abdominal pregnancy.

51:02

So it is, uh, it's a commonly overdiagnosed entity

51:06

when you have an adnexal or a tubal pathology.

51:09

So there are definite criteria

51:11

for ovarian pregnancy, which must be

51:14

fulfilled before it's labeled as an ectopic pregnancy.

51:19

So, of course, for it to be called,

51:21

it's located within the ovary.

51:24

So how, so like you have within the ovary, you

51:28

have a sac, and, uh, uh, it's diagnosed that way.

51:35

So how do we diagnose when the embryo is retained in the

51:40

ovary, and they constitute 3% of ectopic pregnancy?

51:45

So Spiegelberg criteria: the fallopian tube on the

51:48

affected side must be intact, fetal sac must be

51:52

involved, and the ovary must be connected to the uterus

51:55

by the ovarian ligament.

51:57

Right.

51:58

So,

52:02

and, uh,

52:06

yeah, so it's within the ovary that is

52:10

the one.

52:10

And, um, second.

52:14

So we have to differentiate, of course, we can

52:17

differentiate with the ring of fire sign, and we do

52:20

the differential diagnosis and follow up with the

52:22

serum hCG. I think, uh, we have covered all of them.

52:27

And ovarian is, we come into the

52:30

last part, abdominal pregnancy.

52:33

How and when it could happen.

52:35

It could be a primary or it could be a secondary

52:37

ectopic, and where can it implant? Anywhere.

52:41

Anything that can support vascularity.

52:45

It could be the peritoneum, liver, or the spleen.

52:48

And what are the ultrasound criteria?

52:50

Of course, you can just, uh, see a sac, and it could

52:54

be surrounded by bowel or any tissue, which,

52:56

wherever it can get the nutrition to grow, right?

53:00

So often asymptomatic, usually diagnosed late.

53:03

Now.

53:04

You try and see a plane between the sac

53:06

and the abdominal wall, and very clearly see

53:08

fetal parts and an abnormal lie that you

53:12

can see if you see it in advanced pregnancy.

53:15

And what do we need to do?

53:16

Of course, you will need an MRI. I think so.

53:19

That's the only thing that will give

53:21

you the complete outline of the condition.

53:24

And, um, you will see an absence of gestational sac.

53:28

And how do we manage? Surgery, of course, is the mainstay.

53:33

Differential diagnoses from others are also there.

53:36

So there’s a lot of challenge, appendicitis, renal, and you

53:40

have, I did have slides for ovarian in detail, but we’ll leave

53:46

that for another time and we’ll move on to the Q and A.

53:49

So I really thank you everyone for, uh, for the

53:55

interaction on the ovarian, on the ectopic pregnancy.

54:00

I did put in those slides, but

54:03

we’ll just keep up to our topic.

54:05

That brings me to this

54:07

last slide of the working algorithm.

54:11

So, of course, so whenever you have, um,

54:15

a patient, uh, with pain and vaginal

54:18

bleeding, you will do the pregnancy test.

54:20

If it’s negative, it will solve the pregnancy.

54:23

If it’s positive, you do the ultrasound, and if you find

54:26

a normal intrauterine pregnancy and you find a normal

54:30

looking adnexa, then it means you are looking at a normal

54:33

pregnancy; however, the possibility of heterotopic exists.

54:36

So you have a normal intrauterine and an abnormal adnexa.

54:41

So, of course, you could be looking at heterotopic pregnancy.

54:44

And, of course, when you don’t see any intrauterine

54:47

pregnancy and you have a positive, uh, pregnancy test,

54:51

you could, uh, be looking at a normal adnexa or an extrauterine,

54:55

empty uterus with a yolk sac or

54:59

an adnexal mass. Accordingly, that will help

55:02

you in the diagnosis and in the workup of the case.

55:06

Right?

55:07

So thank you everyone for, uh,

55:10

all your patient listening, and I hope

55:13

this has been of value to all of you.

55:16

Thank you so much at this hour to attend the

55:19

seminar, and I’m happy to take the Q and As.

55:22

And we do have Q and As in the chat.

55:26

So,

55:29

Uh, so the question asked, the first question is,

55:34

does the angular pregnancy successfully reach term?

55:38

So again, it would depend upon a case-to-case basis,

55:41

depending upon the amount of thickness.

55:44

But yes, technically it can.

55:47

And thank you for the compliment and excellent lecture.

55:50

Thank you, Scott Moss, that’s, uh, very kind of you.

55:54

Thank you so much.

55:55

And, uh,

55:57

and this is done.

55:58

So, uh, and how do you differentiate an

56:01

ovarian ectopic and a corpus luteum?

56:04

So ovarian corpus luteum is just the ring of fire.

56:07

There wouldn’t be a yolk sac, there wouldn’t be

56:09

a fetal pole, there wouldn’t be an embryo, and

56:12

an ovarian ectopic would have a ring of fire,

56:15

would have a yolk sac and fetal parameters.

56:18

And, of course, you can have, uh, POD fluid and

56:22

other parameters as well to support the diagnosis

56:26

and repeat the Doppler significance in ectopic.

56:29

So again, you Doppler would apply to the areas

56:32

where you can see the blood flow to this.

56:36

However, it's, uh, the ring of fire is the

56:39

main thing that helps you, the chorionic membrane.

56:44

Chorionic tissue, which, uh, has dense vascularity.

56:48

So when you have a pseudosac, you

56:50

wouldn't have that much vascularity.

56:52

So, but, uh, on the Doppler, if you have good vascularity,

56:56

it supports that you're looking at chorionic tissue.

57:00

How do you differentiate corpus luteum from tubal ectopic?

57:04

Again, the same way, tubal ectopic would have, uh,

57:07

associated yolk sac or an associated, uh, embryo.

57:12

And, uh, it can have, uh, other fluid and other

57:17

features, and we wouldn't have that for a corpus luteum.

57:21

Can we call ectopic pregnancy, is applied to ectopic?

57:25

If no, uh, embryo is seen, I mean ectopic pregnancy.

57:30

Blighted.

57:31

Blighted ectopic is not a word that I've ever used in my

57:34

terminology, nor that I have read it in literature anywhere.

57:37

So I simply would choose to call it an ectopic

57:40

pregnancy and label as to the findings I'm seeing.

57:45

Okay.

57:46

So next is how to measure the volume

57:48

of the blood in ruptured ectopic.

57:50

So for the quantification of the hemoperitoneum, uh, one,

57:55

uh, like we do the quantification of the fluid in the

57:58

pelvis, so when we have the sagittal image, so one is if you

58:02

have the perpendicular width, the depth of the fluid just in

58:06

the POD, and if you see the fluid is reaching up to the

58:10

fundus region, then, of course, it is definitely significant

58:13

in its amount. So you can see fluid is seen in the POD up to

58:18

the depth of, say, three centimeters, five centimeters, whatever.

58:24

And you say the fluid is seen extending up to the fundus.

58:28

Brim, and you can also see the fluid is

58:32

seen extending up to the Morrison pouch or

58:36

peri, uh, or below the domes of the diaphragm.

58:39

So that will give more indication to actually

58:43

measure the three-dimensional volume would be

58:45

a challenge, but I, I use these parameters to

58:48

communicate my findings to the physician.

58:51

You can attempt to measure it in length and breadth, that

58:55

whatever you are able to measure, probably the fluid

58:58

would usually be way more than what you have measured.

59:02

So how to differentiate between

59:04

endogenic and exogenic scar ectopic?

59:09

Uh, I mean it, the way it's growing, the way

59:12

it's growing, where is the vascularity.

59:15

So it’s going more towards the os, more inside.

59:19

So how the prognosis is, it’s a follow-up.

59:21

It’s a follow-up thing.

59:23

So which way it’s going, on a static one-time scan,

59:27

you cannot say which way it’s going to be headed.

59:31

And, uh, thank you for your compliment,

59:34

uh, yes, for a nice presentation.

59:37

I’m really, really grateful to all

59:39

of you for your patient listening.

59:41

Thank you so much, and it will be possible to follow on

59:44

from tomorrow the recording of this webinar.

59:46

I’m sure the team would advise you. You would have

59:48

registered with your email, and you would get the information.

59:51

Thank you so much.

59:53

Thank you, Dr. Singhal.

59:55

Thank you so much for your lecture today, and

59:58

thanks for participating in our noon conference.

60:01

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60:03

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60:09

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60:12

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60:15

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60:19

The FIGO Classification System for Uterine Fibroids:

60:22

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60:26

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60:28

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60:31

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60:38

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