Ultrasound –Guided Minimally Invasive Therapy of Pregnancies in Abnormal Locations - HD

Introduction

Hi, I'm Dr. Peter Dubay, a radiologist at the Brigham and Women's Hospital and Harvard Medical School in Boston.

I'll be speaking about ultrasound guided, minimally invasive, treatments of unusual ectopic pregnancies.

As you'll see in the talk, these are excellent alternatives to surgical treatment of these ectopic pregnancies.

They're treatments that preserve the uterus and preserve the woman's ability to get pregnant in the future.

I'll be addressing in this talk ultrasound guided minimally invasive therapy of pregnancies in abnormal locations.

In particular, some unusual ectopic pregnancies, as well as pregnancies in cesarean section scars, as you can see on the title slide, back in 1986, this is you can see the surgical specimen that resulted after the first time that I ever made the ultrasound diagnosis of a cervical ectopic pregnancy, one implanted in the cervix.

And as you can see, at that time, the standard treatment of cervical ectopic pregnancy was to do a hysterectomy.

And the reason that hysterectomy had to be done, you can see on that specimen how much blood there is surrounding the pregnancy.

These the mother is danger for bleeding to death with a cervical ectopic pregnancy, and that's why they did a hysterectomy, of course, that treated the cervical ectopic pregnancy, but involved fairly major surgery and also eliminated the woman's chance of ever getting pregnant again.

Now days, we treat these by minimally invasive technique, as you can see on the right, inserting a needle through transvaginal guide on a ultrasound transducer and injecting the pregnancy, as you'll see in much greater detail as I get into the talk.

Unusual Ectopic Pregnancies and Abnormal Locations

So what do I mean by abnormal locations or usual, or unusual ectopics and so on?

So usual ectopic pregnancies, more than 90% of all ectopic pregnancies appear occur in the fallopian tube outside the cornew of the uterus.

So those are usual ectopic pregnancies, and those are not the topic of this presentation.

The, there are good treatments for tubal ectopic pregnancies that usually involve giving the woman a shot of intramuscular methotrexate very simply, or occasionally lapa laparoscopy.

So those are treatments work well for the usual ectopic pregnancies, unusual ectopic pregnancies, or really any other ectopic pregnancies, a pregnancy implanted in the cervix or a cervical ectopic pregnancy, pregnancy that's implanted in the tube as it passes through the cornew.

That's the interstitial part of the tube.

So those are corneal or interstitial ectopic pregnancies.

I use the words interchangeably.

Another kind of unusual ectopic pregnancy is what I call a tubal heterotopic pregnancy, one that's in the tube and one that's in the uterus.

And these unusual ectopic pregnancies are pretty rare, but they are they do occur with a higher than average incidence in pregnancies achieved via assisted reproductive techniques, such as in vitro fertilization, and then another kind of pregnancy in an abnormal location that isn't exactly a an ectopic pregnancy, but it's in an abnormal location, is a since pregnancy implanted in the uterus, but in a cesarean scar instead of in the normal place.

Why Treat Unusual Ectopics and Cesarean Scar Implantations Differently

So why treat unusual ectopics and cesarean scar implantations differently than tubal ectopics?

The treatment options, as I mentioned, for tubal ectopics include systemic intramuscular methotrexate or laparoscopic surgery.

Why are these less suitable for the unusual ectopics and cesarean scar implantations?

Well, one reason is that with these unusual ectopics or C-section scar pregnancies, systemic methotrexate, if given, well very often just fail to work.

And surgery is more difficult in these kinds of pregnancies than for tubal pregnancies.

If you have a heterotopic pregnancy, one in the tube and one in the uterus, you wouldn't wanna treat the patient with systemic methotrexate because that may damage the intrauterine fetus.

So for these unusual ectopics and cesarean section scar pregnancies, the we have to look for different treatments.

And the treatments that we use include transvaginal injection into the gestational sac or embryo, as you'll see, and you can inject either potassium chloride, that's KCL or methotrexate listed here as MTX.

Another treatment is transabdominal injection into the sac.

And a final kind of therapy in one case is transabdominal ultrasound guided dilatation and extraction, basically scraping out the pregnancy.

So if you look across the top for cervical pregnancies, we treat those all with transvaginal intra sac injection for corneal pregnancies, we treat them either with transvaginal or transabdominal intra sac injection, and we choose whether to go transvaginally or transabdominally, depending on which we think will be the safest given.

The what we're seeing on our ultrasound, which, whether transabdominal or transvaginal, looks like it's safer to and easier to get a needle into the sac with tubal heterotopic, one in the tube and one in the uterus.

We also treat those either transvaginally or abdominally injecting into the sac.

And finally, with a c-section or cesarean section scar pregnancy, we can treat them with any of the methods listed on the left, transvaginal or transabdominal intra sac injection, or occasionally, not very often by transabdominal ultrasound guided dilatation and scraping out of the pregnancy in the cesarean scar.

Experience with Ultrasound-Guided Minimally Invasive Therapy

In we have been doing these for since 1992.

I'll show you soon.

The first case that we ever did back in 1992, we've been doing that there for for about 20 years.

And over the years, 1992 to 2011, we did we treated a total of 65 patients by ultrasound guided minimally invasive therapy.

About half of those, or 28 of them were cervical pregnancies.

Cornual and cesarean scar pregnancies are the next most common, and we've treated a few tubal heterotopic.

You can see that on the middle and right hand columns of the slide, about two thirds of the patients that we've treated are pregnancies that were achieved naturally.

And about one third, our pregnancies achieved via assisted reproductive techniques, like in vitro fertilization.

I will show you some more numbers and data at the very end of the talk.

So now what I'm gonna do is take you through each one of the different pregnancies, abnormal pregnancies that we treat.

And the first thing that I'm gonna do for each one is to tell you how we make the diagnosis.

Because before you can even consider treating a pregnancy in an abnormal location, you have to make sure you have the right diagnosis.

Cervical Ectopic Pregnancy

Diagnosis

For cerv ectopic pregnancy.

The main differential diagnosis when you see a gestational sac situated in the cervix is to differentiate a cervical ectopic pregnancy from a miscarriage in progress.

Cervical ectopic pregnancy, as you can see from the schematic diagram on the left, is one that is actually implanted in the cervix while a miscarriage in progress.

The pregnancy happens to be in the cervix right now, but it's not implanted there.

It started up in the uterus and is now sliding out through the cervix at, and happens to be there at the time you're doing the ultrasound.

As you can see from this diagram, some of the ways that you make the distinction is that with a cervical ectopic pregnancy, you tend to have a pretty well-formed sac with a nice, bright thick rim around it, that represents the so-called trophoblastic tissue around the gestational sack.

The sack looks like a good sac.

You may see an embryo with a heartbeat.

The only problem with it, it's a it's a good looking sack, but it's in the wrong place.

With a miscarriage in progress, you will typically have a as you can see from the schematic diagram, a flattened sack, a thin rim around it, and generally no embryo in it, and certainly no embryo with a heartbeat if you put these diagnostic criteria into words.

If the ultrasound finding in these cervix is a well-formed sac with a prominent echogenic rim, especially if you see a live embryo, you're dealing with a cervical ectopic pregnancy.

If you have a flattened irregular sac with a thin or absent genic rim around it, and no live embryo, you're dealing with a miscarriage in progress.

If the ultrasound findings are equivocal, and the patient is stable, the best thing to do then is to wait one or two days and see what happens.

So if it's une, if it's equivocal, you're you see a pregnancy sac, a gestational sac in the cervix, you're not sure if it's really implanted there or just passing through the cervix.

If you wait, usually a day in these cases, and there's absolutely no change, you're seeing the diagnosis then is pretty clearly a cervical ectopic pregnancy.

If it has changed or has is completely gone, then you know that you had a miscarriage in progress.

So that's in words how you do it.

Just some examples.

This is a cervical ectopic pregnancy.

You can see on the here's a transvaginal view.

There's the body of the uterus. Here's the cervix.

In the cervix is a gestational sac.

You can see a yolk sac with an, it's pretty well-formed sac.

This is looking transversely through the cervix.

Also looks like a good sac, except that it's in the wrong place.

This is a 3D coronal reconstruction of the uterus.

And you can also see the gestational sac sitting in the in the cervix.

Here you can see side by side, cervical ectopic pregnancy, these two images and a miscarriage in progress.

These two images with the cervical ectopic pregnancy, we see a well-formed gestational sac seen right here, nice prominent rim around it.

You can see on the transverse view through the cervix, you can see the embryo or fetus with a heartbeat.

So it's a a normal appearing gestational sac.

The only thing that's abnormal about it is that it's in the cervix.

So this is a cervical ectopic or cervical implantation.

On the other hand, this case on the right, you can see a very flattened gestational sac in the cervix.

There happens to be a a yolk sac within it, but no live embryo.

This is a miscarriage in progress when you're not sure.

In here was a case where we weren't completely sure.

There's a gestational sac in the cervix, there's an embryo, but there's no heartbeat.

There's not much of an echogenic rim around it.

We thought it was probably, but not definitely a miscarriage in progress.

So we waited. And here on follow up, if the sac is gone, there's just some blood sitting in the in the cervix.

So in retrospect, this the follow up confirmed that the original case was miscarriage in progress and not something that needs our treatment.

Treatment

But when we do confirm the diagnosis of a cervical ectopic pregnancy, then treatment is needed.

And the treatment that we use, as I showed in the earlier slide, is a transvaginally guided needle injection into the gestational sac.

So we use what we do is we put a 20 gauge needle through a guide on a transvaginal transducer.

We advance the needle into the gestational sac.

We try and get it into the fetus, if it measures more than one centimeter in diameter, in in length, but if not, we just put it into the gestational sac.

And then we, once we're in there, we inject three to five milliliters of potassium chloride.

We do it if there's a heartbeat, we inject until we're sure the heartbeat has stopped.

We do this right in the ultrasound suite.

No general anesthesia is needed, no hospitalization is needed.

The woman can go home.

Right after we finished the procedure.

Cases

This is the first case that we ever treated with cervical ectopic pregnancy that we ever treated in this way, a woman.

So this is from 1992, which is why the images look a little older than some of the others that I'll show woman.

Got pregnant at another institution, at another hospital in our city via an assisted reproductive technique.

And she went to check after her infertility treatment.

And they told her that she had two pregnancies at the same time.

One on this trans on this transabdominal scan.

You can see one within the body of the uterus and one in the cervix.

Same thing on this transvaginal scan, one in the body of the uterus and one in the cervix.

And they recommended to her, they said to her that she should have a hysterectomy because of her cervical ectopic pregnancy.

That was the usual treatment back in 1992 for cervical ectopic pregnancies.

She didn't like that too much because even though that would treat her cervical ectopic pregnancy, it would eliminate her intrauterine pregnancy and would also eliminate any possibility that she could get pregnant in the future.

So she came to us for a second opinion, and we said, well, you know, one other option would be to see if we can inject potassium chloride into the cervical ectopic pregnancy.

And maybe then what it'll do is to shrivel up into a small remnant in the cervix.

But the other one can go on to become a normal baby through the end, and that you can have at the end of the pregnancy.

And she said, that sounds much better than a hysterectomy.

Let's try it. So here we are on that same woman back in 1992.

This is a closeup of her cervical ectopic pregnancy.

There's the yolk sac, there's the embryo.

Here we are putting a needle through the transvaginal guide right into the embryo.

We injected potassium chloride.

The heartbeat stopped on the cervical one, but it continued on the intrauterine one, one week after potassium chloride injection, you can see the intrauterine pregnancy is here, and there's just some heterogeneous epigenic material in the cervix a week later.

And at term, this was the head of the normal intrauterine pregnancy.

The cervix was highly vascular at that time, but that was okay.

She actually had a cesarean section and delivered a normal baby.

And three years later, because she still had her uterus in place, she was able to get pregnant again, and she had a second baby three years later, and a third baby, five years later, she now has three babies.

Whereas if she had undergone a hysterectomy, of course, she'd have no babies today.

So this kind of treatment, this good example of how ultrasound guided minimally invasive treatments preserve the the uterus, if there happens to be another one in it, lets them get that one continue and if there's no other one in it, lets them have future pregnancies.

So we've gone on to do many of these treatments.

Here's another example.

This is a seven week cervical ectopic pregnancy. Here.

Here you can see this is a transvaginal view through the full bladder, which is here.

This is the body of the uterus. Pregnancy is not there.

The pregnancy is sitting right in the cervix seen here.

And on this transvaginal view, video, you can actually see right above my pointer, a little heartbeat.

So this is a pregnancy with a heartbeat sitting in the cervix.

Actually, this patient had been treated at another hospital with intramuscular methotrexate one week earlier, but it had no effect on the pregnancy.

So she came to us for our treatment. And here we are.

You can see we have a transvaginal scan.

These guide marks are related to the guide on the transvaginal transducer.

A needle is approaching, as you can see right here, right about here, the needle is approaching the gestational sac.

Here, the needle is entering the gestational sac.

Again, we do try to put it into the embryo if possible.

Here we are injecting, you can see the blast of potass as we inject the potassium chloride.

And 10 days later, there's just a little remnant of that gestational sac.

I'll talk towards the end of the talk about how long it takes for resolution after these procedures.

This was an eight and a half week, or 8.6 week, eight week and four day cervical ectopic pregnancy that we treated with potassium chloride.

Again, you can see the heartbeat in this pregnancy in the cervix.

You can also see that the with the color doppler, that it's very, very vascular around the gestational sac.

That's why you can't just scrape these out.

If you try and just scrape them out, the mother can have life-threatening bleeding.

Here we are injecting, putting a needle in and injecting potassium chloride.

In fact, as we inject, you can see that it pushes the fetus off the needle, but you get enough into the fetus to stop the heartbeat.

When you do it later, and again, we'll look at some data at the end of the talk, but this is pretty far along to do it at eight and a half weeks.

You can see six weeks later, this is the same pregnancy we treated on the prior slide.

Six weeks later, you can see still a very large mass.

There's no embryo. There's just some debris inside the sack, but a very large mass.

It's actually grown in size at six weeks, even at four, at four months, the cervix still has debris within it, and even at six months, a little bit of debris.

So when you treat them late, it can take quite a long time to for things to resolve.

Cornual Ectopic Pregnancy

Diagnosis

The next kind of unusual ectopic pregnancy that we treat by a minimally invasive approach are corneal ectopic pregnancies.

And as you can see on the schematic diagram here, that's a pregnancy that's implanted in the tube just as it passes through the cornew or horn of the of the uterus, not way, not out here in the free tube, but in the interstitial part of the tube.

So this is a corneal ectopic pregnancy.

Again, you have to make the correct diagnosis here, and the things you have to be careful about.

You'll notice that with a corneal ectopic pregnancy, the pregnancy is situated way off to one side.

If this is the middle, the this is situated way off to the side, but you can have other pregnancies where the gestational sac is off to to the side.

Sometimes you just have a completely normal pregnancy, but I mean, uterus.

But early on, the pregnancy is implanted off on the edge of the of the endometrium or decidua.

So it's off to the side of midline.

In other cases, you can have a bicornuate uterus with a pregnancy on one side.

So it's once, it's not in the midline, which would be here, it's one side or a septate uterus.

So how do you distinguish corneal ectopics?

Well, you'll notice, and I'll show on the next slide.

The thing that I the feature that I find most useful is that with a corneal ectopic pregnancy, not only is the gestational sac off of midline, but you see virtually no myometrium.

The myometrium appears dark on ultrasound, and you see virtually no myometrium around part of it on the side or the top of it.

So, to put it in words, if the ultrasound finding is an eccentric gestational sac, one that's off of midline, that bulges the uterine contour and has little or no visible myometrium around the superior or lateral aspect, then you have a corneal ectopic pregnancy.

If you see an eccentric gestational sac, but you do see myometrium around the entire sac, you are dealing with an intrauterine pregnancy.

It may be in a duplicated uterus like a bi corne or septate uterus, but it's intrauterine.

What if you're not sure?

Well, if it's equivocal, you're not sure.

3D ultrasound can be very helpful in making the distinction, or you can follow it up.

So here are two side by side cases.

One, the one on the left represents a corneal ectopic pregnancy.

This is it's transverse view.

The middle of the uterus would be here.

Pregnancy sac is way off to the side here.

It is in closeup, but you can see there's the heartbeat, the embryo, you can see the bright tissue around it, the trophoblastic tissue.

But basically no myometrium, no hypoechoic or dark tissue around the edge.

This, and you can see how it bulges out, this is a corneal ectopic pregnancy.

On the other hand, here's another view where this whole thing is the uterus.

That's the left side, the right side.

You can see the pregnancy is way off towards the right side.

However, you can see good myometrium all the way around it.

And it's not bulging out.

This is an eccentric, but pregnancy.

But it's an intrauterine pregnancy.

And in fact, two weeks later, this at six weeks, this was at eight and a half weeks, it's moved into the center, and it's just a completely normal uterus.

The pregnancy happened to be eccentric at the beginning.

Here is another corneal ectopic pregnancy.

There's it's way off to the right side of the uterus.

There's the left side, there's the middle.

It's way off to the right.

And you can see as in the last case, there is no myometrium around the edge of this of this pregnancy sac gestational s sex.

So it's corneal ectopic.

Here are some examples of eccentric pregnancies off, all off on the right side, but that are different.

The first one on the upper right is a ecto is an intrauterine pregnancy in a septate uterus.

This is an an intrauterine pregnancy.

On one side of a bco uterus, you can actually see some fluid on the other side.

And this is a intrauterine pregnancy in a delphic uterus, which is an extreme form of a bco uterus pregnancy in the right horn, just some fluid in the left horn.

But you can see myometrium around this gestational sex.

So it's not a corneal ectopic pregnancy.

What if you're not sure? Well, here are two different cases, and in both cases, I wasn't completely sure.

In fact, I thought there's a good chance that they were both corneal ectopic pregnancies.

In both cases, the gestational sac is way off on the side.

In this case, on the left side, not much.

If any myometrium around this one or this one wasn't completely sure.

So what do I do? Well, I can wait, but there's if you use 3D ultrasound and get a true coronal reconstructed view of the of the uterus, you can often tell.

So that's what we did here.

So when we took this case and we did 3D ultrasound with coronal view, you can see this is here's the uterus.

This is the fundus of the uterus.

This is actually the right cornea.

And here, right in the left cornea or left horn of the uterus is the pregnancy separate from the endometrium or the also called the deci during pregnancy, this corneal ectopic preg pregnancy.

So this one is a corneal.

This one, which looks very much the same on the regular 2D view, when we do our 3D ultrasound with reconstruction, you can actually see that it is here it is, it is contin.

It's part of the decidua. There's myometrium around it.

This is an intrauterine pregnancy.

So these two cases were equivocal on 2D.

So we got the 3D, and that gave us the answer, and she ended up having a nice intrauterine pregnancy on later ultrasounds.

Treatment

When we've diagnosed a corneal ectopic pregnancy, we treat these by potassium chloride injection.

And as I mentioned near the beginning of the talk, we get a needle into the the goal is to put a needle into the gestational sac.

But unlike the cervical pregnancies, which we always treat by trend, those we always treat by transvaal guidance.

These we treat by either transvaginal or transabdominal guidance.

We'll put a 20 gauge needle through a guide on either a transabdominal or transvaginal probe.

And then everything else is the same as for a cervical pregnancy.

We advance the needle into the gestational sac, into the fetus, if possible, we inject potassium chloride, wait till the heart stops.

If there is a heartbeat, we do it in the ultrasound suite, and the patient goes home at the end of the procedure.

Cases

And here's an example of such a treatment.

There is a corneal ectopic pregnancy in the left in the left cornea of the uterus.

Here we have the guide.

You can see the heartbeat actually.

And these guide marks are there, meaning that we've put a guide on the transducer.

Here you can see moving up and down is it was a needle that goes into the sac.

And then here we are injecting potassium chloride, which you can see right there.

In this same case, 16 days later, about two and a half weeks later, you can see that this corneal pregnancy, there's no longer an embryo visible in there or fetus, but it's actually grown a bit and gotten quite vascular.

These can take quite a while to go away, but they do go away.

This is an example of a six week corneal ectopic pregnancy that we treated via transabdominal guidance, because on this transabdominal scan, there's the main part of the uterus, the body of the uterus.

Here in the right cornea is a corneal ectopic pregnancy.

We felt that it would be very easy to get a needle in through this path, directly trans by transabdominal guidance right into the sac.

And here we are guiding transabdominally.

There's the needle approaching, and there we're injecting potassium chloride.

You can see all the movement as we inject.

This too gets pretty big within the first days to few weeks after the injection, but ultimately goes away.

Tubal Heterotopic Pregnancy

Diagnosis

The third type of unusual pregnancy that we treat by ultrasound guided injection is what I've called the tubal heterotopic.

One intrauterine and one in the tube.

The main distinction here you have to make is between an intrauterine pregnancy and an an ad adnexal mass that is not an ectopic, such as a most often a corpus luteum.

Here's an example of a tubal heterotopic pregnancy.

There's one in the body of the uterus and or in the uterus.

And this one is close by, but it's actually in the in the tube.

Treatment

So when we di diagnose a tubal heterotopic pregnancy, one in the uterus, one in the tube, the we treat these similar to the way that we treat corneal ectopic pregnancies.

Namely, we get a needle in via either transabdominal or transvaginal probe, whichever one looks easier, and then we proceed in the same way that we did with the cervical or corneal pregnancies.

Here's an example of a tubal heterotopic pregnancy.

One in the uterus, one in the tube.

There's a heartbeat in each, if you look closely at this video clip.

And here we are treating it via guided injection into the into the tubal pregnancy.

Cesarean Scar Implantation

Diagnosis

The final kind of abnormal implanted pregnancy that we treat by ultrasound guided injection are cesarean scar implantations.

These are not technically ectopic pregnancies, but they are pregnancies in abnormal location that can lead to some pretty serious complications if you don't treat them.

So, first of all, we have to make the correct diagnosis.

Cesarean scar implantation.

You can see here on the left hand diagram, it's not in the main body of the uterus.

It's up in a scar from a prior cesarean section.

They can sometimes be confused with a low lying gestational sac, one that's not in the cervix, that would be a cervical ectopic, but just above it, that may be miscarriage in progress or just a normal pregnancy that's implanted low.

So the way that you can tell the difference is that the cesarean scar implantations are above the midline, and they extend up to the edge or ci rusal surface of the uterus.

They sometimes even bulge it.

So the diagnostic criteria for to cesarean scar implantation, the woman, of course, has to have had a prior cesarean section.

The gestational sac is located low and anteriorly in the uterus just above the cervix, and the sac and the surrounding genic tissue of the the trophoblastic tissue should extend to the serosal surface of the uterus.

And here's an example. This is a pregnancy that's very low.

That's the main body of the uterus. There's the cervix.

So it's just above the cervix. Here it is.

If you look closely at it, you can see there's an embryo with a heartbeat.

There's a yolk sac. But look at the trophoblastic tissue.

It extends all the way up to the cisso edge of the uterus, even seems to bulge that surface a little bit.

Outcomes and Risks

Pregnancies implanted in cesarean section.

Scars can have different kinds of outcomes, but when they're all the way up into the scar, even at the earliest time in pregnancy, have the potential to cause serious and potentially life-threatening problems as her occurred.

In this case, here is a five and a half week pregnancy that's in the cesarean section.

Scar already all the way up into it. You can see these.

So echogenic or trophoblastic tissue extending up just about to the serosal edge of the uterus.

We were quite concerned, but the woman didn't want to have any treatment.

So we watched, and two weeks later, at about seven and a half weeks, now, you can see that this is growing.

There was a embryo with a heartbeat, but that the edge of the uterus is bulging out.

And at that point, we said, because it's so big, so far out and bulging the edge, we're very concerned that if you don't undertake treatment for this, your uterus may rupture, which could be potentially very dangerous to you.

And she said, no, I don't wanna do anything.

So we continue to watch her.

At 11 and a half weeks, the uterus, there's now a huge bulge.

She was having very severe pain.

She had blood in her abdomen.

She was had clearly a very an impending uterine rupture.

And she ended up having a hysterectomy because she didn't undertake treatment earlier.

And I'll show you the treatments that can be done earlier.

If she had undertaken treatment earlier, she'd have a uterus today, which she doesn't.

And therefore she would have the possibility of future pregnancies, which she doesn't.

Treatment

The main the the treatment option here are ultrasound-guided dilatation and extraction, which we've done in one or two cases.

Mostly we use ultrasound-guided injection of potassium chloride into the gestational sac or the fetus.

In the case that I showed you a few slides ago, we treated her via ultrasound guided dilatation and extraction.

So the I actually was doing the ultrasound in the operating room while the gynecologist was scraping out the gestational sac from the C-section scar.

The gynecologist wanted me to be doing ultrasound watching by ultrasound while she scraped it out, because she was concerned that if I wasn't, if I wasn't watching carefully telling her exactly where to go, that she might on her own rupture the uterus as she was scraping.

So I'm watching here she is scraping that part of the that lower uterine part of the lower uterus where the sac was in the C-section scar.

She's scraping it and then applying suction here.

And at the end of the procedure, you can see that the gestational sac, which had been right over here, is gone.

Maybe a teeny little bit of fluid, but the sack has been scraped out.

The more common treatment that we do is an ultrasound guided injection.

In this case, there's actually two pregnancies, one in the C-section scar right here, one in the uterus.

Here we are injecting, putting a needle into this one, the cesarean scar pregnancy, and then we inject, you can see the movement of fluid as we inject.

And at the end of the procedure, there's no longer any heartbeat in this.

The c-section pregnancy, this one in the uterus did fine.

And here's yet another case of a cesarean implantation seen here and here with the heartbeat where we are putting a needle in and injecting into the cesarean scar pregnancy.

And here it is, 10 weeks later, these can take quite a while to go away.

Data and Outcomes

So let me finish up with some data.

I've shown you how we make the diagnoses, and then once we make the diagnoses, how we treat them, and I'll show you some data related to them.

So the data, I'll come from our 20 year experience.

As I showed you on an earlier slide, we'd done 65 cases.

So the first thing that we looked at in terms of data are how often was our ultrasound guided treatment, the only treatment that was needed?

Nothing needed in follow-up.

Things just got better on their own.

Well, the answer was that in 50, one of the 65 cases, or about 80% of the time, that treatment was all that was needed in about 10% each.

Either intramuscular methotrexate was needed in follow up because usually because the HCG was continuing to rise, or the mass was continuing to get to enlarge for longer than expected, or in eight cases or 12% of our cases, a follow-up interventional procedure was needed after in the days or couple of weeks after our ultrasound guided procedure.

And these eight procedures included two hysterectomies out of the 65 patients, four salpingectomy or corneal rece resections, and two patients who required uterine artery embolization in the days to weeks after our treatment.

So is there a way that we can predict how likely it is to need a follow-up interventional procedure like those eight that needed it?

Well, the answer is yes.

The higher the HCG at the time of our initial treatment, the greater the need for a follow-up procedure.

In particular, if the HCG was below 30,000 only, and that only one of 28 patients when the HCG was below 30,000, required a follow-up interventional procedure, or about three or 4%.

On the other hand, if the HCG was high above 30,000, above 30,000, a third of those patients, seven outta 21 required a follow-up interventional procedure.

So clearly, the HCG under 30,000, the procedure is much more likely to work on its own.

And as you can see from the so-called P values, the difference, the these differences between high and low HCG were statistically significant.

Another thing that we looked at in our 65 cases was the time that it took to resolve.

And for resolution, we meant we measured or determined the number of weeks until the HCG became negative, excluding any treatment.

Any cases that had a a concomitant intrauterine pregnancy are ones who needed follow-up treatments.

So the ones that were just a singleton pregnancy in an abnormal location that we injected and the injected and the injection was all that was needed.

In those cases, if you look down at the at the bottom, 7.8 weeks was how long it took on average for our cases to to resolve for the HCG to go to negative.

And there were slight differences among the different kinds of ectopics, but there weren't statistically significant.

So it's about eight weeks or about two months until the HCG becomes negative.

Can we predict when, how long it's gonna take?

Well, again, we can have some prediction.

First is the HCG.

Again, the higher the HCG at the time that we do our treatment, the longer the time to resolution.

If we look at HCGs above and below 30,000, you can see again a big difference.

When the HCG was below 30,000 at the time of treatment, it took about five and a half weeks to for the HCG to drop to zero.

But it took more than twice as long.

When the HCG was above 30,000, the other factor that determined how long it took to resolve was the gestational age at the time of treatment.

The further along or the larger the gestational age at the time of treatment, the longer the time to resolution.

There, the main cutoff that we looked at was seven weeks.

When the when we treated these pregnancies below seven weeks, it took about six weeks after that, for the mean time to resolution.

When the gestational age was seven weeks or higher, it took more than twice that about 13 weeks to resolve.

What about the our experience when there was a pregnancy in an abnormal location, but there was also an intrauterine pregnancy?

I showed you two or three of those during the talk.

We actually had 10 of our 65 cases where there was one pregnancy in the uterus and one in an abnormal location.

Two cervical pregnancies with an intrauterine, three corneal with an intrauterine and so on.

Total of 10 patients.

What was the outcome of the intrauterine pregnancy in those 10 cases?

In six of them, more than half, the woman ended up with a live born term baby.

Three of them miscarried and one was lost to follow.

Conclusion

So to conclude, ultrasound guided therapy treats or ablates the ectopic pregnancy or the pregnancy in the c-section scar and preserves the uterus, which permits delivery of an concomitant intrauterine pregnancy, if it's present, and the opportunity for subsequent pregnancy.

So it's a really excellent treatment.

Early diagnosis and treatment improves the outcome, the treat, the the treatment works best if it's done before a gestational age of seven weeks or with an HCG level below 30,000.

So that's the end of the talk.

I hope it's been useful to you both in terms of how to diagnose these unusual pregnancies, unusual ectopic pregnancies, and cesarean scar pregnancies, and how to treat them once you've made the diagnosis.

Thank you.