0:01

So what did the panel recommend in the setting

0:04

of pregnancy of unknown location?

0:07

And there were three main statements

0:11

from them that I'm gonna cover.

0:13

Um, and again, remember this is in the setting of

0:16

no intrigue and fluid collection.

0:17

So that small round fluid collection statements, different

0:21

and normal or near normal adnexa meaning

0:25

no echogenic free fluid,

0:26

or at least not a large amount,

0:28

no extra ovarian adnexal ring or mass.

0:31

If you see a simple cyst

0:33

or something in that adnexa like appar ovarian cyst, that

0:36

that still keeps us in the setting of pregnancy,

0:40

of uncertain locations.

0:41

So again, number one,

0:46

and these are very important to really dig into,

0:50

so I'm gonna go through them section by section again.

0:52

So a single measurement of HCG,

0:58

regardless of its value, so it doesn't matter what it is,

1:01

does not reliably distinguish between ectopic

1:05

and intru in pregnancy.

1:07

Whether it's viable or non-viable, the single measurement

1:10

of HCG, whatever it is, does not distinguish between ectopic

1:14

and intru pregnancy.

1:17

Number two, a single HCG over 3000.

1:22

So we're above this discriminatory level at that level.

1:27

Presumptive treatment of ectopic with the use

1:29

of methotrexate

1:31

or surgery should not be undertaken in order

1:36

to avoid the risk of interrupting a viable IUP.

1:41

So this is very important.

1:43

A single HCG greater than 3000,

1:46

we should not be treating again, single measurement.

1:51

Number three, if a single HCG measurement is greater than

1:55

3000 a viable intru in pregnancy is possible,

2:01

however unlikely it is possible, the most likely

2:06

diagnosis is a non-viable IUP.

2:11

So it's generally appropriate to obtain at least one

2:14

follow-up HCG measurement and follow up ultrasound

2:18

before undertaking treatment for a topic.

2:22

Again, honestly, I can sit here

2:24

and talk about how at 48 hours it slightly went up

2:26

or it doubled not getting into how they change over time,

2:31

because that's really becomes more in the setting

2:34

of the clinical decision.

2:38

And I didn't talk about this earlier,

2:39

but I'll talk about it for a second.

2:41

Now, I actually was an internal medicine doctor

2:44

before I went into radiology.

2:46

And when I transitioned from being a clinician over

2:49

to a radiologist, I had to really do a mindset change of

2:54

focusing on the clinical picture versus what the imaging

2:58

Findings were. And

2:59

when you're a radiologist,

3:01

you should really be focusing on interpreting

3:04

the imaging findings.

3:05

And I'm not saying you wanna interpret things in a vacuum,

3:08

you, you definitely don't wanna interpret in a vacuum,

3:10

but you have to be careful about what do the images show

3:15

and what should I say about that versus taking that

3:18

to the next level and taking the beta HG into account

3:22

and making recommendations.

3:24

I try and stay away from that.

3:26

I'm happy to have a discussion in person with the clinician

3:30

and, and talk about what's going on.

3:32

And, and we do that all the time.

3:33

I just did it the other day.

3:35

But I do want you to just focus on, again, our job is

3:40

to interpret the sonographic findings.

3:42

This is not a lecture on management of ectopic pregnancy,

3:45

um, or pregnancy of unknown location.

3:47

So we can know that the beta will tend to double ish

3:52

in normal pregnancies or tend to stay stable

3:56

or slightly rise in ectopic or go down in demise.

4:00

But these can really vary.

4:03

And unless you're an expert in that field,

4:05

I wouldn't really get into worrying about that.

4:08

I would just know, kind of stick in our lane

4:11

and interpret the sonographic findings.

4:15

So again,

4:16

we are gonna make this a red box as we talked about.

4:19

We don't wanna lead people down the wrong path

4:22

and we don't wanna hinder clinical judgment.

4:25

So I don't give recommendations.

4:28

And to be totally honest,

4:30

I almost never look at the HCG, uh,

4:34

in the vast majority of cases.

4:37

Similarly, like you wouldn't say the HCG is this,

4:40

you know, recommend this or that.

4:43

I don't dictate there's diverticulitis.

4:45

I'd recommend treatment with ci, Cipro

4:47

and Flagyl for 14 days.

4:48

I just say there's diverticulitis.

4:51

And then, you know, we can have, uh, a,

4:53

a nuanced conversation with clinicians as necessary.

4:56

So does the HCG matter to me? Yes, it matters.

5:01

It matters whether it's positive or negative.

5:03

There is no value that is too low to warrant an ultrasound.

5:08

The, the only value that's too low is zero.

5:12

But again, using a single HCG

5:14

to make decisions is bad medicine.

5:17

And we know that now and we need to understand

5:20

what the guidelines are.

5:22

'cause it is not our decision to make,

5:24

I routinely have no idea what the beta HCG is.

5:29

So I urge you to know

5:31

that we're interpreting it in the setting of

5:34

positive pregnancy tests and a positive HCG

5:37

and what the implications of certain numbers are.

5:40

But your practice should be based on the

5:43

sonographic, um, findings.

5:46

So basically that number is almost irrelevant.

5:51

And, and the reason is, you know, there are twins,

5:54

there's normal variation of singleton pregnancies, you know,

5:58

weird stuff I'm not gonna go into.

5:59

But there are reasons that, that these numbers can

6:03

fluctuate and be different.

6:05

And again, that's a clinical decision

6:08

and something they should be focused on.