0:01

Okay, so the next arm of our decision tree here was

0:05

diagnosing a definitive ectopic.

0:08

And then obviously if we have a definitive ectopic,

0:13

we're gonna feel pretty confident about saying it's safe

0:16

to treat for the ectopic.

0:19

So why are these bad? We've always heard how

0:22

patients can crash quickly

0:23

and bleed to death from an ectopic,

0:25

but this video was sent to me by one

0:27

of my OB colleagues on a case that we diagnosed

0:30

and went to the OR

0:31

and this really drove home how bad these things can be.

0:35

I mean, this thing is just squirting out blood.

0:39

So you could see how fast a patient could bleed

0:43

to death from an ectopic pregnancy.

0:46

So as an aside, as we're mostly talking about our framework

0:49

for approaching the entire topic of first trimester,

0:54

you know, uh, bleeding

0:56

and pain, I'm not going to go into an exhaustive discussion

0:59

of ectopic and how to look for them and,

1:03

and all the different things,

1:05

but I am gonna go through a few types of ectopic

1:08

and what we would determine as a definitive ectopic to sort

1:12

of frame our discussion about when we are not sure if

1:15

there's an ectopic or not, which we'll call a pregnancy

1:18

of unknown location.

1:20

So definitive ectopic, we have an empty uterus,

1:23

we have a cul-de-sac filled with quote echogenic free fluid.

1:27

In this case it's actually just a giant blood clot.

1:30

And then we have an echogenic extra ovarian, a NAL ring.

1:34

This is our classic triad for ectopic.

1:38

And in this cine clip is nice

1:39

because you can see the echogenic ring,

1:43

we can see the ovary,

1:46

and it does appear that it's separate from it.

1:49

One thing I like the text A do if the patient's not in too

1:52

much pain, this is the head of the endo vaginal transducer

1:57

and you can press right between this structure

2:00

and the ovary to sort of push it away

2:03

and separate them to show that it truly is extra ovarian.

2:08

Um, and again, I'm not gonna go into corpus lutia

2:12

and how we kind of distinguish between

2:16

ectopics can do an entire lecture on just ectopic.

2:20

But let's talk about a couple of the other types.

2:23

There's the corneal

2:24

or interstitial ectopic,

2:26

in which case we have an eccentric gestational sac.

2:30

And all intrauterine gestational sacs should be surrounded

2:34

by myometrium, uh,

2:36

360 degrees in orthogonal plains.

2:40

So in this case we've got the gestational sac,

2:43

but we see the myometrium coming up to one side of it

2:46

and the other side of it, but it's not surrounding it.

2:48

So we know that this is not a true intrauterine pregnancy

2:53

and is actually a corneal or interstitial ectopic.

2:57

The next SI type that we might run into is a

2:59

cervical ectopic.

3:01

This one can be hard

3:02

to distinguish sometimes from an abortion in progress

3:06

because obviously the gestational psych will travel

3:09

through the cervix at some point.

3:11

You can see that this cervix looks a little bit odd.

3:14

There's some cystic change within it.

3:17

Also, interestingly, the external OSS is not open,

3:21

but the best way to determine whether something is a

3:24

cervical ectopic versus a demise pregnancy passing

3:28

through the cervix is to actually zoom in

3:32

and look in real time.

3:34

This is a cine clip

3:35

where you can actually see trophoblastic flow circling

3:40

around this gestational sac

3:43

that is actually implanted within the cervix itself.

3:47

And then similar to a cervical ectopic

3:50

is a C-section scar ectopic

3:52

and has cesarean sections have gotten more

3:56

popular over time.

3:58

There are a lot more cesarean section scars than there used

4:02

to be and the embryo can actually implant in there.

4:05

So if you see a low lying pregnancy within the uterus,

4:10

so here's the fundus, here's the endometrium,

4:14

and this is implanted within

4:17

the C-section scar right here.

4:20

And you see just a very small amount of myometrium there.

4:26

So when we have a definitive ectopic, we know it's safe

4:29

to treat for ectopic.

4:31

The question that does come up from time to time is

4:34

what about a heterotopic pregnancy?

4:38

In general, we teach

4:40

that if there is an intrauterine pregnancy,

4:42

then we have essentially excluded an ectopic pregnancy

4:46

or we have taken the patient out of the risk pool

4:49

for ectopic pregnancy.

4:52

And is this perfectly or precisely true?

4:56

No, there is the possibility

4:58

of a concomitant intrigue in pregnancy

5:01

and an ectopic pregnancy.

5:03

Um, and as many of you I'm sure know,

5:05

we call this a heterotopic pregnancy

5:08

and these are rare for sure,

5:09

but remember, rare does not mean that it doesn't happen.

5:13

The rate of these have varied by study.

5:15

I think when I was a resident I was told they were like one

5:18

in 30,000 to one in 15,000.

5:21

The real numbers probably closer to one in 5,000.

5:26

However, with the increasing prevalence

5:29

of in vitro fertilization, these are actually

5:34

becoming more common and actually about one

5:36

to two per thousand in that patient population.

5:40

We can't practice

5:42

by always worrying about whether there could be a

5:44

heterotopic pregnancy, but we don't wanna

5:46

shut our brains off.

5:48

So let's talk about why is this rare?

5:51

Well, the female has to dual ovulate, then

5:57

both of those eggs have to get fertilized.

6:00

Both of those fertilized eggs have to implant one

6:03

of them ectopically,

6:05

and then they both must survive long

6:06

enough to cause symptoms.

6:08

So you know, that's why it's rare.

6:12

But with IVF, we are basically jumping right to step three.

6:16

We're inserting multiple two

6:19

or more fertilized eggs in.

6:23

So while the finding of an entry

6:26

to pregnancy is very powerful, it does not end the exam.

6:29

And we do need to at least keep in mind looking

6:34

for those other signs of ectopics that we talked about.

6:37

You know, a large amount of echogenic free fluid,

6:39

an extra ovarian adnexal mass.

6:42

And we're not talking about simple cyst,

6:43

but an extra ovarian echogenic mass or ring.

6:47

So when you see one of those,

6:49

that's the time you might wanna consider thinking

6:51

about a heterotopic.

6:53

And here's a case that it was relatively recent in our own

6:57

practice and I could show you kind

6:58

of like cool cases of heterotopic.

7:00

But this one I want go through

7:02

because this, this was a real thing

7:05

that just happened not that long ago.

7:08

So we have in intruding pregnancy here,

7:12

we know it's an echogenic ring.

7:14

Uh, I don't know that we saw a yolks sec,

7:16

but we could, you know, dive into that.

7:19

But we also have a ton of echogenic free fluid right here.

7:22

This is not simple fluid.

7:24

And then as we had in that other case

7:26

of ectopic I showed you, we've got a huge

7:28

blood clot here in the cul-de-sac.

7:32

And then in the adnexa

7:37

we've got an echogenic ring.

7:41

I don't really see the ovary separate from here

7:43

and I don't see the ovary at all to be totally honest.

7:46

But we do have an echogenic adnexal mass.

7:50

So this patient was obviously bleeding, uh, profusely.

7:55

But here was the interpretation.

7:57

So we have an intru in pregnancy.

7:59

They said size was consistent with dates. Okay, that's fine.

8:03

But in addition, there's a large amount

8:04

of hemoperitoneum true.

8:07

There's a more focal hyper coic clot measuring 2.7

8:11

by 2.7 centimeters,

8:12

which could theoretically be a hemorrhagic ovarian cyst.

8:16

However, while rare would consider the possibility

8:19

of heterotopic pregnancy,

8:21

I may have dictated this, I don't remember.

8:23

So it may have showed it to me.

8:24

But this is basically exactly what I would say.

8:27

And since this patient was bleeding so much, they did go

8:30

to the OR and it turned out to be a hemorrhagic cyst.

8:34

And so they needed to go to the or either way.

8:37

But despite the fact that it's not a heterotopic

8:39

or if it turned out to be a heterotopic,

8:41

I think this interpretation is the way I

8:44

would approach that.

8:46

So I am gonna talk a little bit,

8:48

even though it's not something we do about the treatment

8:51

of ectopic pregnancy, because the fact that

8:55

One of the treatments is surgical

8:57

and the other is medical using methotrexate,

9:00

which is a medicine that is teratogenic to fetuses, we need

9:05

to be very careful about diagnosing an ectopic pregnancy

9:09

because the treatment could significantly harm

9:15

a viable intrauterine pregnancy.

9:19

And that is a situation that is fraught with, you know,

9:23

medical malpractice.

9:24

So this is one of the things we need to be very serious

9:28

about, which is why we use the very strict criteria

9:32

for diagnosing an injury in pregnancy

9:35

and why we follow the rules for

9:40

definite ectopic versus pregnancy of unknown location.

9:44

So when are they gonna treat with methotrexate?

9:47

Again, this isn't something we do, um, or we need to know,

9:51

but it's always good to have an idea of

9:52

what the clinician is looking for with regard

9:55

to making their treatment decision.

9:56

So obviously if the patient's hemodynamically unstable,

9:59

they're gonna go to surgery,

10:02

but methotrexate doesn't tend to work quite

10:05

as well if the beta HCG is less than or equal to 5,000.

10:09

And if there's fetal

10:11

or embryonic, I should say cardiac activity,

10:14

it also doesn't tend to work that well,

10:17

less well established.

10:19

But something they will use is that ectopic mass size

10:22

of less than three to four centimeters.

10:25

So if it's less than three to four centimeters,

10:27

there's no cardiac activity.

10:29

The HG is less than a thousand.

10:31

Methotrexate is certainly gonna be on the table.