0:01

Okay, so we've mentioned this term pregnancy

0:04

of unknown location and we're gonna talk about

0:06

what the diagnostic criteria for that are.

0:09

So we used to just say something like,

0:12

there is no intra in pregnancy.

0:14

Ectopic pregnancy cannot be excluded.

0:16

I mean, I can't count the number of times I dictated that,

0:19

but the consensus conference came out with uh, a term

0:23

for this and they called this pregnancy of unknown location

0:26

to kind of go along with the pregnancy

0:28

of uncertain viability we discussed earlier.

0:31

And what is that exactly?

0:33

We can't diagnose a definitive IUP

0:35

and there's no definitive ectopic.

0:38

So we have an empty uterus here.

0:40

We have no secondary signs of ectopic,

0:45

echogenic free fluid blood, extra ovarian,

0:48

a nyl, mass, et cetera.

0:50

So back to our chart here, pregnancy of on the location.

0:56

We talked about looking at the beta HCG level

0:59

and whether it would be safe to treat for ectopic

1:02

or not safe.

1:03

And again, when it's elevated,

1:06

we're putting a yellow light here

1:07

and we're gonna caveat that a little bit.

1:10

As I mentioned before, except for the rare

1:14

heterotopic pregnancy, when you call an intru in pregnancy

1:19

or diagnose an intru pregnancy, as I mentioned,

1:22

you are taking the patient out

1:24

of the wrist pool essentially for an ectopic.

1:27

So when you do this, basically

1:28

what you're saying is they are safe to go home.

1:32

IE they're not gonna go home

1:33

and bleed to death from a ruptured topic.

1:36

So we used to harp very much on the fact that you had

1:41

to be very convinced that

1:42

what you were calling an IUP really was an IUP

1:46

and anything else would basically be dictated

1:50

as can't rule out a topic.

1:52

So what were those things?

1:53

The intertidal sign, which was the least diagnostic,

1:58

followed by the double sid sac, a gestational sac

2:01

with a yolk sac and an embryo.

2:04

And that's why I harped on these earlier

2:06

'cause we wanna make sure we are confidently diagnosing an

2:09

entry in pregnancy because you were now taking the patient

2:13

out of that arm or that risk pool of ectopic.

2:17

So let's go back to this case. How would we interpret this?

2:22

Is this a normal injury to pregnancy?

2:24

Well, I would say no,

2:27

this is not an residual sign.

2:30

Could it be? Maybe,

2:31

but it, it doesn't satisfy their criteria.

2:34

Um, so we used to have a lot of discussion about

2:38

something called the pseudo gestational sac

2:40

of ectopic pregnancy.

2:41

So when an ectopic pregnancy forms the

2:45

endometrium becomes

2:47

desexualized and we learn what that meant.

2:49

That's just a pregnant endometrium.

2:52

And when that happens, you can get kind of little cavities

2:55

and spaces and fluids.

2:57

So you can sometimes

2:58

Get these little, what we called pseudo gestational sacks

3:03

and it could be a fake out.

3:05

And we used to think a lot about that.

3:07

We would decide whether or not to call it

3:09

that or not call it that.

3:11

However, the consensus conference brought in a statement,

3:16

and I'm gonna read the statement

3:18

because it's very important.

3:20

And that is any round

3:24

or oval intrauterine fluid collection

3:28

most likely represents an intrauterine gestational sac

3:32

and should be treated as such.

3:36

It is much less likely

3:37

to represent a pseudo gestational sac of ectopic.

3:42

That's a very, very important statement and very crucial

3:46

because is there a chance of a viable IUP?

3:51

Yes, there's a chance.

3:53

So it is not safe to evacuate the uterus

3:56

and not safe to treat with methotrexate in the setting

4:00

of near normal AED nexa, you know, corpus sodium,

4:03

small amount of free fluid, no, no extra ovarian mass.

4:06

This is how we need to treat a small round fluid collection.

4:10

So again, is this an in injury intrauterine pregnancy?

4:15

It doesn't satisfy our criteria

4:17

and we need to focus on this small round fluid collection.

4:23

So this is the verbiage I actually use to kind of be,

4:27

be safe both from an ectopic standpoint

4:29

and a pregnancy of uncertain viability standpoint.

4:32

So there's an intrauterine sac like structure in the setting

4:35

of a positive pregnancy test.

4:36

Statistically this most likely represents a gestational sac,

4:40

however, it does not satisfy strict criteria

4:44

for an intrauterine pregnancy.

4:45

So we're saying that it's not definitely an IEP.

4:49

So the patient's still at risk for ectopic

4:53

recommend follow up with ultrasound

4:54

and Beta H CG to exclude ectopic.

4:58

This is not the, it's an empty sac follow-up in 14 days case

5:02

of a pregnancy of uncertain viability.

5:06

It we're basically have not diagnosed during pregnancy.

5:10

So we're still keeping ectopic pregnancy on the table.