0:01

So the first column on our chart was

0:05

diagnosing an intrauterine pregnancy.

0:07

In which case we obviously said we wouldn't wanna evacuate

0:10

the uterus and we are not gonna treat for ectopic.

0:12

So really what we're saying is that we have a green light

0:15

to continue with a normal pregnancy.

0:20

So we usually think about diagnosing sort

0:24

of abnormal things

0:25

and pregnancy isn't necessarily an abnormal thing,

0:28

but it's not the normal physiology of a woman.

0:31

So we do have to actually diagnose an intruder pregnancy.

0:36

And we have specific criteria to call

0:39

an intruder in pregnancy.

0:42

And essentially what we have is these four findings

0:46

that are increasing in diagnostic confidence

0:49

as we go from top to bottom on this list.

0:51

But the first one is the intertidal sign.

0:54

And we'll get into what these look like,

0:56

the double decidual sac.

0:59

We could see a gestational sack with a yolk sack

1:03

and we can see what I'll term the G globular embryo

1:07

or basically we can see an embryo.

1:11

So before we dive into that a little bit, just

1:14

so we understand why these things look the way they do,

1:19

we want to cover a little bit of the anatomy here.

1:23

So when the conceptus, the fertilized egg implants,

1:28

it actually burrows into the endometrial lining.

1:33

And so here's the the endometrium.

1:37

It is not technically in the endometrial canal.

1:40

The canal itself is actually a potential space.

1:44

But the endometrial tissue with this,

1:46

which is this echogenic area, is

1:49

where the embryo actually lives.

1:53

So when the embryo does burrow into the

1:58

endometrium, we can actually see a little

2:01

echogenic ring develop.

2:03

And I like this cine clip

2:05

because we actually see this fluid here.

2:09

There's fluid, this is actually in the endometrial canal,

2:13

that potential space.

2:15

But as I roll through it, you can actually see here

2:19

a little echogenic ring

2:20

that is in the endometrium itself, not the canal.

2:25

Um, this one shows it even better.

2:28

So we have this little echogenic ring

2:30

and right here you can actually see a little fluid within

2:34

the potential space of the canal itself.

2:37

So we call this the intra decidual sign.

2:41

The next thing we look at in our list is called the double

2:46

decidual sac sign.

2:47

And this is very similar to the intertidal sign,

2:51

except in this case we've got two echogenic rings,

2:55

if you want to call it them.

2:57

So we have this first

2:58

Echogenic ring and then this outer part is actually the

3:03

second echogenic ring and that is the endometrial lining.

3:07

Now, I honestly sort

3:11

of despise pathologic names

3:13

and going over stuff like this,

3:16

so I'm gonna talk about them here a little bit

3:19

'cause it really does explain the devil decidua sac sign.

3:22

Well, and it's not that hard.

3:24

But honestly feel free to forget these names,

3:26

just not the concept as we go forward.

3:30

So the first thing is the term decidua, you know,

3:34

is a Latin word and it's a little bit esoteric to us.

3:37

But basically it means grave endometrium.

3:40

So if you have the endometrium, which we all know what

3:43

that is, as soon as the patient becomes pregnant,

3:45

the endometrium is now called the decidua.

3:49

And this is the endometrium

3:53

and that is the decidua.

3:55

So the part that actually interacts with the

4:00

embryo and the trophoblastic tissue is called the

4:02

decidua basalis.

4:04

And the rest of it is called the decidua vera.

4:07

And this part here is the decidua cap salus,

4:11

which is basically the sac.

4:14

So again, the names aren't important,

4:18

but as we look at the double decidual sac sign, we can see

4:22

what this represents.

4:23

This sac number one of the double is this

4:28

decidua capsularis or this gestational sac.

4:32

And the second is the endometrium.

4:36

And the reality is the rest

4:37

of this stuff is a potential space inside of there.

4:40

You can actually see some, some fluid inside of it.

4:44

So that's the double desig sac.

4:46

The next thing we can move on to would be, uh,

4:49

seeing a gestational sac with the yolk sack.

4:52

And in this case, we actually again

4:54

see basically a double decidual sack here.

4:58

And I'm showing this one

5:00

because I don't see a yolk sack in here as it goes by.

5:04

And so sometimes when you, you really have

5:07

to actually zoom in and pay close attention.

5:11

And here we actually see a yolk sac.

5:13

Here's that double decidual sac,

5:15

here's the outer ring, the inner ring.

5:18

But we don't even need to worry about that anymore

5:20

because we actually see a yolk sac inside

5:23

of this gestational sac.

5:25

So we are very confident

5:27

that this is in fact an intru in pregnancy.

5:30

And again, we are trying

5:32

to be confident in diagnosing an intru in pregnancy.

5:36

And the reason being is in the setting of ectopic,

5:39

which will come up later.

5:40

But we wanna know how

5:42

and why we are saying that

5:44

what we are looking at is in fact an intrauterine pregnancy.

5:49

So obviously the last thing that we would see would be

5:51

to find an embryo inside the uterus.

5:54

And if we find an embryo inside the

5:56

Uterus, then we know we are dealing

5:58

with an intrauterine pregnancy.

6:01

And in theory you would think this is pretty easy,

6:03

but it might not always be as easy as you think.

6:07

And the reason is that these little embryos don't look like

6:11

a tiny baby early on.

6:12

They don't have arm buds or a face,

6:14

and they honestly look like a little glob of echoes.

6:19

I mean, this is just a small little bump

6:23

of echogenic tissue.

6:26

And sometimes as in this case, we can see a heartbeat.

6:30

Here you can see some little motion,

6:33

E breon heart motion right there.

6:35

But if you don't see a heartbeat, then how do you know that

6:40

that little glob of echoes is in fact an embryo

6:44

and not maybe a tiny blood clot?

6:48

So here's a glob

6:50

of echoes it pretty amorphous.

6:53

We don't see any heartbeat in it.

6:55

So how do we know if this is an embryo or not?

7:00

Well, there's a couple rules

7:01

or a couple criteria we can use

7:03

to know whether this little glob

7:06

of echoes is in fact an embryo.

7:09

And the first one is that it needs to lie in direct contact

7:14

with that yolk sack that we saw.

7:16

So in this case, this actually shows an embryo

7:19

with a yolk sack, and there's a structure called the yolk

7:24

stalk in embryology.

7:25

But in embryos, less than seven millimeters in

7:29

that number will become important.

7:31

A little later become later.

7:32

The yolk stuck has actually not yet developed yet.

7:36

So as this picture shows, the embryo

7:39

actually must lie in immediate continuity

7:43

with the yolk sack.

7:45

So this little glob of echoes here is immediately in contact

7:50

with this yolk sack.

7:52

So despite the fact that we don't see any heartbeat here,

7:56

we do know at least that this glob

8:00

of echoes is definitively an embryo.

8:04

The second criteria

8:06

or rule is

8:07

that sometimes we see an embryo without an amnion,

8:11

but if we see an amnion,

8:13

the embryo should be completely surrounded by it.

8:17

So in this case, we see a yolk sac as well,

8:19

but we see an amnion

8:22

and we see an embryo completely surrounded by it.

8:26

So we know in this case that this is in fact an embryo.

8:31

So we know we will be diagnosing an intru in pregnancy.

8:36

No, this is a just a case from our practice.

8:39

And we've got this echogenic glob of echoes here,

8:45

and there's this kind

8:49

of a rounded structure here.

8:51

Maybe that's an amnion. Is this thing inside it?

8:55

I can't be sure it's inside there.

8:57

There's a yolk sack right there,

9:00

and part of it is touching it,

9:02

but you know,

9:03

this thing's pretty big in relation to that yolk sack.

9:06

So is it really the whole thing in immediate

9:08

continuity with the yolk sack?

9:10

I would say not. So is this an embryo?

9:15

Maybe? It could be.

9:17

It's probably not a living embryo,

9:19

but it could be an embryo.

9:20

However, this isn't satisfying our criteria.

9:25

So this could be a blood clot or something else.

9:29

So I would not diagnose this

9:34

as a definite embryo.

9:37

Um, I do think it's an intru in pregnancy as evidenced

9:40

by the yolk sac, but I would not start measuring this embryo

9:45

and start making decisions based on those measurements.

9:48

Those measurements are what we'll talk about coming up next.