0:01

So let's look at the embryo with regards

0:04

to the criteria for pregnancy failure

0:08

and the term we sort of introduced earlier,

0:10

which is the pregnancy of uncertain viability.

0:14

And that's gonna be when we see a pregnancy in the uterus,

0:17

but we're not sure if it's really alive or not.

0:21

So we talked about first trimester bleeding and pain.

0:24

We can diagnose an injury in pregnancy,

0:27

in which case we will continue with a normal pregnancy.

0:31

Uh, we can define a definitive pregnancy failure,

0:35

in which case it's safe to evacuate.

0:38

And then pregnancy of uncertain viability,

0:42

in which case we decided it's not safe to evacuate.

0:45

So how do we get from this red stop sign back to,

0:50

you know, the green light to either continue

0:53

with normal pregnancy or know whether it's safe to evacuate?

0:56

And we do that by getting a follow up.

1:01

So let's dive into this a little bit.

1:03

So first off, what is viability?

1:07

So how do we diagnose pregnancy failure?

1:10

We need to understand what the term viability means.

1:13

And it might sound really simple,

1:15

but just to clarify that, that definition actually changed

1:19

with the publishing of this paper that we're talking about.

1:23

So it used to be that the viability meant

1:28

that a baby was able to live outside the uterus,

1:31

and that was fairly well established being about 24 weeks.

1:35

As technology improves, you know,

1:38

these numbers can get better and better,

1:40

but that's what we meant by viability.

1:43

However, a lot of people were misusing the term for so long,

1:47

meaning just a living embryo that we ended up just

1:53

changing the definition of viability

1:55

to now mean just a living embryo.

1:58

So now when we say it's viable, we mean it's alive.

2:02

So we know what viability is. But what about non viability?

2:05

If you remember that the title

2:07

of this paper was something like, you know,

2:09

diagnosing Non Viability in first

2:11

trimester or something like that.

2:13

And there are several ways to diagnose non viability

2:16

that we will go over, but I just don't like

2:19

that term non viability because it gets confusing.

2:22

'cause you start talking about ruling out non viability

2:26

or a false positive of a diagnosis of non viability,

2:29

and you get all these double negatives

2:31

and it gets confusing what you're even talking about.

2:35

And since most people don't like

2:36

to use the word dead when they're talking about an embryo

2:40

or a fetus, we tend

2:42

to use the terms either early pregnancy failure

2:45

or embryonic demise.

2:48

And how do we diagnose these?

2:51

We diagnose them by seeing an embryo

2:54

of a certain size without a heartbeat

2:57

or an empty gestational sack also

3:00

of a certain size without an embryo.

3:03

So after this paper came out in 2013, in my opinion,

3:08

this whole thing got very dumbed down.

3:12

It's almost idiot proof at this point.

3:14

It left us with two very conservative ways to

3:19

diagnose non viability.

3:20

And at the time there were some other, I would argue,

3:23

very well established criteria for demise that were

3:26

not utilized by the consensus panel.

3:29

And, and we'll get into what some of those were,

3:31

but at this point, we have what we have

3:34

and we need to use these, these guidelines.

3:38

So for embryonic demise, again, we're documenting an embryo

3:42

of a certain size without a heartbeat.

3:44

And what is that size?

3:47

Well, I showed this c clip earlier

3:49

and we saw an embryo that was less than three

3:51

millimeters without a heartbeat.

3:53

So if you perform ultrasound

3:54

or you look at ultrasounds, which I'm sure most of you do,

3:58

a lot of times we see this tiny embryo

4:00

that is just barely anything.

4:03

It looks like almost essentially just a beating

4:05

heart and nothing else.

4:07

And in my experience, to be totally honest,

4:08

if you see any embryo, without a heartbeat, it's

4:12

probably going to be a demise.

4:14

However, we cannot practice in that way and,

4:16

and nor should we.

4:18

So what we previously used was an embryo without a heartbeat

4:23

greater than five millimeters.

4:25

And that's when I started this training.

4:26

That was the cutoff.

4:28

But the large British study we talked about found out

4:31

that there were some embryos, albeit a very smaller amount,

4:35

that were measured at greater than five millimeters

4:37

that did come back and have a heartbeat later.

4:40

So the much more conservative measurement

4:42

of seven millimeters was established by the panel.

4:46

Now we can disagree

4:47

or agree whether this is the right, you know, decision

4:51

or why it might have occurred.

4:53

You know, including the wide variability

4:56

of personnel performing ultrasounds, um,

4:59

particularly in Britain where I think, you know,

5:01

it's not all physicians.

5:03

There's a, there's a big variety

5:04

and that's, that's okay, that's, you know, quality

5:07

of machines, whether they're using those

5:09

true criteria for embryos.

5:11

But nonetheless, the point is it essentially doesn't matter

5:14

whether this was right or wrong.

5:17

The number seven is frankly here to stay.

5:20

It's what I use and what we all need to use.

5:23

So in this case, we've got an an embryo.

5:28

It measures 15 millimeters.

5:31

Cine clip doesn't show a heartbeat.

5:33

So this is in fact a demise.

5:36

It's an embryo greater than seven millimeters.

5:38

Doesn't have a heartbeat, embryonic demise, definitive.

5:42

In this case, we see an embryo.

5:44

We know it's an embryo

5:45

because, well, first off, it's in the uterus

5:47

and it's immediately adjacent to the yolk sax.

5:50

So we know it's an embryo, it measures 6.1 millimeters.

5:54

It doesn't have a heartbeat.

5:57

So here it is an asinine clip.

5:58

Again, we see the yolk sac, the embryo,

6:00

there's no heartbeat.

6:02

So we will not call this a demise.

6:06

And this leads us to the term pregnancy

6:09

of uncertain viability.

6:11

So to recap, we see an embryo.

6:15

There's no heartbeat.

6:18

It measures less than seven millimeters.

6:22

That is a pregnancy of uncertain viability.

6:24

And with regard to the embryo, this is the only criteria

6:28

for pregnancy failure or pregnancy of uncertain viability.

6:31

It's that simple.

6:34

So we're gonna go back to this case we talked about.

6:38

We definitely have an IUP as we talked about.

6:41

We have a glob of echoes without a heartbeat

6:44

and there's no measurement on it.

6:46

But trust me, it's more than seven millimeters.

6:48

But remember, we could not reliably say

6:51

that this was an embryo.

6:54

So you can see I the report of this here,

6:57

it says irregular appearing fetal pole without evidence

7:01

of cardiac activity.

7:03

This is consistent with pregnancy failure.

7:07

Do I think this is a pregnancy failure?

7:10

Yes, it probably is,

7:12

but I would disagree with dictating it this way.

7:14

And, and part of this lecture is about staying safe.

7:17

So while it is a glob of echoes without a heartbeat,

7:21

and it does measures more than seven millimeters,

7:24

we were not confident that it satisfied our criteria

7:28

for a globular echo.

7:30

So I would not call this a demise,

7:32

and I would stay with using the term of pregnancy

7:35

of uncertain viability.

7:37

In this instance.