Ultrasound Evaluation of Ectopic Pregnancy: 2013 - HD

Introduction

Hello, my name is Faye Lang.

I'm a radiologist who has practiced for many, many years

and for the past three years

I've been enjoying my life in Washington DC

where I work at the Georgetown University Hospital.

Today I'm going to be discussing the use

of ultrasound in the diagnosis of ectopic pregnancy.

I don't know how many of you have ever had the opportunity

to visit the United States

and in particular our capital, Washington DC,

but if you do plan a trip, I would suggest you try

to come in the spring when we have our very famous cherry

blossoms in bloom

and just showing you some of our highlights

to visit our memorials.

This is the Jefferson Memorial,

this is the Lincoln Memorial,

this is the Washington Monument and this is our capital.

I hope you'll someday be able to see these as I do.

It's a lovely city

and I extend an invitation to visit it.

Use of Ultrasound in Ectopic Pregnancy

Today we're gonna talk about the use

of ultrasound in the evaluation of patients suspected

of having ectopic pregnancy.

The primary role remains to make the diagnosis,

but other roles are expanding.

And these include to screen women who are at risk

to be involved with therapies,

to determine appropriate therapy to guide therapy,

whether it is with methotrexate

or potassium chloride, to monitor women

who have received therapy

and then to evaluate a group of women

who are clinically stable

and who perhaps will handle their ectopic on their own.

If it no longer is alive, it may be resorbed

and we can monitor those women as well.

There are many things to consider.

Three-Pronged Approach

When we think about the possibility

of an ectopic pregnancy, I think there is sort

of a three-pronged approach.

One, it would be nice to know

what is the pregnancy test level, the HCG level,

and then how to look, where to look

and how to look for an ectopic pregnancy.

Pregnancy Test Levels

Beginning with the idea

of knowing a pregnancy test, what is its level?

The reason we do that is if the test is negative

for the purposes of our discussion here,

the patient is not pregnant.

If the test is positive, then we have

to consider three possibilities.

She could have an early intrauterine pregnancy,

normal or abnormal.

And the other possibility is an ectopic pregnancy.

When we look at what is the pregnancy test level,

we might think of it in terms of a discriminatory number.

Some people think of it in terms of a threshold number.

Now until recently, the discriminatory number that was

touted as important is 2000 million international

units per ml.

As I'll discuss in a minute, we don't believe

that this number is an effective one to use anymore.

But just to mention what the difference is

between discriminatory versus threshold.

Threshold number is the lowest number at which

a certain finding may be present.

In this case a gestational sac, a discriminatory number

as the word suggests discriminates.

In other words, until recently we would say

that if your HCG was 2000

or above, you would expect to see

a sac in the uterus if you were pregnant

and failing to see that would put you at risk

for an ectopic pregnancy saying that a different way.

If the pregnancy test is above a certain number

and there I was showing you 2000, you lack an intra

and sac, you would have to think very strongly of it.

For an ectopic pregnancy,

we can see big bold capital letters in yellow,

but there is that little asterisk there

and that asterisk reminds me to

have you think about is the patient bleeding.

Many of these women who come in at risk

for an ectopic pregnancy present

with a clinical constellation of threatened abortion,

that's pain and typically some bleeding

and often a closed cervix that's part of the constellation

of a threatened abortion.

If they're bleeding,

the patient may have miscarried.

And when you talk about bleeding,

you wanna know did she pass a large amount of clot?

And if she did, you might think that the HCG is positive

above a certain number and she's miscarried.

But the HCG is still relatively high.

Another thing to consider is to know

that it was technically a good exam if the uterus is

retroverted, if she's got fibroids, if she's a heavy woman,

all of these things limit the ability to have

a perfectly ideal exam.

And you might have a relatively high HCG

and still not see a sac.

So what I'm trying to say is we have to be wary.

And from the Brigham

and Women's Hospital where I used to work

until just a few years ago, Peter Dubay put together

and reported a retrospective study,

over an 11 year period where four

and a half percent of women had their pregnancy test level

above that supposed magic number of 2000,

no intrauterine fluid,

and yet six of nine of those women, nine of

202 or four and a half percent delivered a term baby.

That's pretty scary.

So the take home message there was not to act in haste

and get a follow-up ultrasound or serial H CG levels

unless clinically contraindicated.

So that number of 2000 is going by the wayside.

As a matter of fact, just about a year ago, the Society

of Radiologists and ultrasound had a consensus meeting

to look at this amongst other things.

When we had, we were looking at first trimester issues

and the conclusion based on that consensus,

discussion, which was by the way,

just published in the New England Journal of Medicine,

this is actually in October, 2013, stating

that a single HCG determination should not be used

as a criteria if the location of the pregnancy is unknown.

So A PUL is a pregnancy of unknown location

and that if you have an HCG above that 2000 level,

let's say between two and 3000,

although a normal intrauterine pregnancy is unlikely,

perhaps 2%,

most likely those people will have an ectopic versus

an abnormal IUP.

But we have not completely excluded an intra in pregnancy.

If the HCG is greater than 3000, it's even less likely

to have a normal intrauterine pregnancy.

Perhaps it approaches about 0.5%,

but that's still not zero.

So a single HCG is not effective any longer

to use

to determine could a patient have an ectopic pregnancy.

In other words, if you're above that level,

you should not conclude definitively that,

that it cannot be a normal early IUP.

So we would recommend you follow the HCG providing the woman

as clinically stable.

And of course you've looked in the ADIA

and you do not see an ectopic pregnancy.

If the HCG is followed, you should do it every two days

and to see if it doubles, let's say if it was fairly low,

you might wait until it gets to be about two, two to 3000

to see if you could determine there was an

intrauterine pregnancy.

If it is rising plateauing

or decreasing, that is not consistent with the normal

HCG increase.

Again, that should be every two days. It should double.

And you would have to think of the possibility

of an abnormal intrauterine pregnancy

or an ectopic pregnancy in any of these three situations.

Ultrasound Examination of the Uterus

Now if you have looked at the HCG

and let's say it's really high

and there's no intrauterine pregnancy,

we wanna use ultrasound.

And the place to start looking is by looking in the uterus,

not looking for the ectopic,

but look in the uterus first

to see is there an intrauterine sac?

Yes or no?

Why do we start by looking for an intra and sac?

Because the incidence of if you see an intra

and sac, the likelihood of having an ectopic pregnancy

is perhaps one in 7,000.

So statistically, if you're confident there is an intra

and sac, it's gonna be very unlikely

to have an ectopic pregnancy as well.

And 90% of patients who come in with a slip of paper

that says rule at ectopic are going to be shown

to have an intrauterine pregnancy.

So how do we look at the uterus?

We're gonna ideally use a vaginal probe, much more sensitive

to pick up early pregnancies.

What do we look for when we wanna determine if an

intrauterine pregnancy is present?

What you wanna look for is the so-called

intradecidual sac sign.

What do we mean by that? When you get pregnant,

you have thickening of your endometrium.

And the endometrium at

that point is no longer called an endometrium.

When you're pregnant, it's called decidua.

So you're gonna thicken the decidua.

And what you wanna look for is if you can find it

a line running down the thickened endometrium

or decidua, which is the central cavity echo,

where the two walls of endometrium come together.

We can see that on a scan here as a white line.

And just immediately next to it, you wanna look

to see if you can see a small sack like structure, which is

rounded and surrounded by bright echoes.

That would be the product of conception or an early sac.

So if you can see that,

you can conclude this is a positive intradecidual sac sign

and you should think of an intrauterine pregnancy.

Now, I didn't say normal, it could be normal or abnormal,

but you think of an intrauterine pregnancy.

What happens if you have a different appearance?

What does it mean? Here,

I think if you look at the schematic,

you can see there's fluid, but that is in line

or continuous with the opposing walls

of the central cavity echo that places this fluid,

not in the thickened decidua but in the uterine cavity itself.

So that's fluid in the cavity.

And you can see it here on this, on this image,

this ultrasound image

that is a negative intradecidual sac sign.

And at that point you should not be thinking about a normal

early IUP, but it could be an abnormal IUP

or an ectopic pregnancy.

And we have a clip here that I think will hopefully

convince you that that fluid is in line

with the opposing walls of the thickened endometrium

or decidua and therefore that fluid is in the uterine cavity.

Notice that the fluid is not rounded. It has a pointed edge.

It is not surrounded by bright echoes.

And most important it is again within the cavity in line

with the opposing walls of the thickened endometrium,

a negative intradecidual sac sign.

The problem that I often will face is I see a fluid

collection and I cannot see the lines

where the thickened endometrial walls

or decidua come together.

And when I see that I, it's difficult

and I would call that an indeterminate intradecidual sac sign.

Now most of those, especially when they're rounded like this

and are surrounded by bright echoes of the

chorionic reaction, will turn out

to be an intrauterine pregnancy.

But it could be a little more tricky in this situation.

And at that point, when I call it indeterminate,

although I realize most

of these will be an intrauterine pregnancy,

there will be a few that can mimic this finding

with an ectopic.

And here's a larger collection again where I cannot see the

opposing lines, the central cavity echo

and I will conclude that's indeterminate.

Here's an example of how difficult this really can be.

This woman had a ectopic a year earlier.

She was now pregnant, she underwent in vitro fertilization.

She's five and a half weeks pregnant

with a normal intrauterine pregnancy.

At five and a half weeks, we typically expect

to see a yolk sac.

We didn't see a yolk sac here.

And in this woman looking at the clip,

I think you can agree there's no visible yolk sac.

I went and looked at her adnexa

to see if I could see any evidence for an ectopic.

I did not see that. But then I came back

to her uterus again 11 minutes later

and this clearly has become flattened.

This doesn't look like a normal early IUP.

So what am I supposed to conclude here?

This is really a pregnancy of unknown location

because I do not definitely see that yolk sac.

The shape of the sac is very suspicious for being abnormal.

What do you do in a situation like this?

I did not see an ectopic,

but this lady is clinically stable.

She desperately wants to be pregnant.

She underwent IVF and she's five

and a half weeks, which is sort of a cutoff

for seeing the yolk sac.

So what did I do? I actually brought this lady back.

I wasn't willing to call this a definitively abnormal

situation and I brought her back since I was on call.

This is a Friday afternoon.

I brought her back on Saturday

'cause I knew I'd be in the hospital normally I would wait a

couple of days, but under these circumstances knowing I

would be in the hospital anyway,

I brought her back 24 hours later

and sure enough, now there is a yolk sac,

clearly an intrauterine pregnancy.

So I'm showing you this case to stress.

This can be a very difficult situation.

Here's another example

where you might fall into a trap just looking at

this rounded structure.

Clearly this is in the thickened endometrium.

In this case we can see the central stripe.

You might conclude that this is an early IUP.

You might even look at this

and say, that looks like it could be

an early yolk sac.

Okay, so I think there are a lot of features here

that would be very suspicious

for an early intrauterine pregnancy

with a positive intradecidual sac sign.

The situation here that's a problem

however is this lady's not even pregnant.

This lady has a negative pregnancy test

and just has this little fluid collection

in the thickened endometrium.

I do not know why she has this,

but it is not a pregnancy when the

pregnancy test is negative.

So we have some problems with these

intradecidual sac signs.

And I actually wrote about it quite a while ago now

and I had people look

for the intradecidual sac sign, four different people.

And our statistics, as you can see, the sensitivity,

specificity, accuracy varied amongst the individuals

who looked, but they're not terribly good.

And this led me to conclude

that this finding is not particularly sensitive

or specific to diagnose an early intrauterine pregnancy.

And when you see a small fluid collection without an embryo

or a yolk sac within the uterus,

ideally you wanna get a follow-up ultrasound

unless clinically contraindicated.

I mean if there's a large hemoperitoneum

or you see an ectopic that will change what you do here.

But it is very similar to what we just discussed

with the HCG level about how an HCG level, single one,

especially if it's in the range of two to 3000,

can be very problematic.

And ideally you do not wanna depend upon either a single

intra, a single HCG determination

or a single ultrasound examination

unless you see that yolk sac because you can get faked out

and it can be very problematic.

So follow up scans are very, very good things to do and

or follow up HCGs

and a two day interval I think is a good way

to look at these people again.

Diagnosing Ectopic Pregnancy

Now let's say you have a really high HCG.

The woman has not been bleeding,

she does not have anything in the uterus.

You did a follow-up HCG and it has not doubled.

We are getting very suspicious here

that she could have an ectopic pregnancy.

How do you go about finding it? Where do you look?

We can see that well over 95% of ectopics

live in the fallopian tube.

And I'm not talking about women here

who have undergone in vitro fertilization

or assisted reproduction therapies

because those women have a greater variety as to

where the ectopic can implant.

We'll talk about that more in a little bit.

But I'm talking about the average woman who comes in

and we wanna look for an ectopic.

The tube is the place to go.

And actually the ampullary portion of the tube right here,

right here toward the end of the tube

by the fimbriated end, is the place to look.

So as we are looking in the tube, I will stress

that the tube bears a fixed anatomic

relationship to the ovary.

So even though it may be hard to find the tube,

it's much simpler to find the ovary.

So what I do when I wanna look

for an ectopic is I seek out the ovary.

And once I find that ovary, I look carefully in the vicinity

of the ovary to see if I can find an ectopic pregnancy.

What am I going to look for?

I have a variety of things I can look for.

I can look for a living embryo if I see that, I would call

that my strictest criteria.

And I can go all the way down to look for free fluid.

My most liberal criteria with a variety of criteria seen

between the strictest to the most liberal, including looking

for an ectopic gestational sac with a fetal pole

and yolk sac, but perhaps no heartbeat.

Something called a tubal ring in the adnexa a

complex adnexal mass.

I might look at doppler. What am I looking at for flow?

Developing placental

or trophoblastic tissue in an ectopic location.

So let's look at these different criteria.

While this is ideal, if we could see it all the time,

I think this lecture would be a lot simpler.

But life isn't always so simple.

Here's the ovary and then we see a ectopic with a yolk sac

and a little embryonic disc.

Perhaps there was no heartbeat,

but I'll concentrate very carefully here

to see if I can find a heartbeat.

And sure enough here we can see an embryo with a heartbeat.

Very important to make sure you label your scans correctly.

Failure to label when you do a scan like this,

it's very blown up.

I'm very concentrated on a large image, hard to put,

see the relationship of exactly where I am.

I mean this could even be in the uterus.

So I urge you

to make sure you label your scans appropriately.

This is in the right adnexa, a living ectopic pregnancy.

Now in a scan like this, I see the ovary,

I see something right at the edge of the ovary.

Is that an ectopic?

Well, it could be, but could it be a corpus luteal cyst

or corpus luteum that every ectopic pregnancy has?

Well work hard when you see something like this.

By what do I mean by work hard?

Well, if you can increase your megahertz, go

to a higher frequency, better resolution,

make your image larger,

make sure you focus at the appropriate level

with your focal zone.

And in this case, doing this, I can now see a yolk sac.

Once I see a yolk sac.

I am definite that this is an ectopic

and as I said, most ectopic live in the tube.

So in all likelihood this will be in the tube.

But I will show you in just a minute

how I can confirm when I see something like this

that it's in the tube as opposed to let's say the rare case

of an ovarian ectopic.

We will get back to that.

Here again, I'm looking and I see a round structure

and if I looked at it in all from different planes

and different obliquities, I would confirm that this is

round spherical, surrounded by bright echoes.

And I don't really see the ovary here,

but what I see is this structure which would be consistent

with a tubal ring.

What we mean here is it's an early sac surrounded by

developing trophoblastic

or placental tissue, which is echogenic

and that's called the tubal ring.

But in this case, I don't see a tube per se,

I don't even see the ovary,

but look very carefully

for this white echogenic material which is consistent

with blood clot.

And very often when you have an ectopic,

especially if there's leaking from the tube

or even a rupture of the tube, you will get blood clot often

around the sac itself.

And that is known as this would be a hemoperitoneum

with clot surrounding a tubal ring

clot can be very difficult to see

and a lot of people don't really look hard for it,

they just may assume you're dealing with bowel.

But here is another example of an ectopic tubal ring

surrounded by a large blood clot.

Look for the blood clot.

It is really your friend

and it helps you to find ectopic pregnancies.

So getting back to the case where we see

what looks like a sac and it's right next to the ovary.

Let's say I couldn't find a yolk sac in here

and I wanted to know is this a corpus luteum at the edge

of the ovary or is this an ectopic in the tube

next to the ovary?

What can I do? Well, you can take your probe here,

there's a vaginal scan.

Take your probe and see if you can push

and separate these two structures

because if you can do that then you're clearly going to say

that this being separate from the ovary

would be in the tube.

So when you have these cases,

and this is not uncommon, you wanna push with the probe

to see if you can separate

the ovary from the questionable area using ultrasound

almost as you would do a bi-manual clinical exam.

So you're applying a physical exam using the

ultrasound probe.

And as we do that here, you just push down rather firmly

to see if you can show independent motion

of the ovary from the area in question.

And if you can, as in this case you would conclude

that this is an ectopic pregnancy.

Here's another example where we had the same question

and when we pushed here, we were not able to separate

the ovary from the area in question.

We looked hard to see if there was any other evidence

of a corpus luteum elsewhere.

There was not.

And we concluded therefore that this is just at the edge

of the ovary being a corpus luteum associated

with a pregnancy.

Sometimes you see something

and it's not exactly,

doesn't really look like a gestational sac,

but it's right at the edge of the ovary again

and there's a little bit of free fluid surrounding this.

And when we pushed in this case,

'cause you might question could that be bowel,

but when we pushed in this case,

you can see again independent motion

of this structure from the ovary

and bowel if you pushed against bowel would collapse

because of the pressure.

This is not collapsing here is bowel,

you can see some air in bowel surrounding this structure.

And furthermore, if I turned on this 90 degrees,

you would see it was more or less a tubular shape.

So what this represents is an ectopic pregnancy

separate from the ovary, it's the tube

containing all this echogenic material, which most likely is due

to a blood clot within the tube.

If you put color on here

and you see that some of the area has flow in it,

that could be developing tissue

or trophoblastic material within the tube.

But this maneuver is a very, very effective one

to help you decide if you're dealing

with an ectopic pregnancy as we were able

to conclude in this case.

Now here again looking around carefully,

we see some free fluid,

but look very carefully to see if you have heterogeneous

or homogeneous echogenic material

that doesn't look like bowel.

Because again, in this case this is a large blood clot.

It's very easy to miss an overlook.

But if you see a large amount of blood,

always look carefully to see if you can suggest this is clot

and also always look above the uterus

and even up into the flanks.

I have a rule in our lab that

whenever the question is to rule out ectopic

and I don't see an intrauterine pregnancy, make sure you look

by the kidneys in the flanks, you can end up

with a large hemoperitoneum.

And if you don't look up high, you may miss the fact

that the whole abdomen is filled

with a large amount of blood.

Every time there is a blood clot, you are going

to see free fluid above the blood clot.

And a clue that you're dealing with blood of course is

to see if the fluid is echogenic.

Now if I turn my settings up on my machine,

I can put echoes artifact into any fluid collection.

And you might think if you are dealing with echogenic fluid

that you're dealing with blood but it may be artifactual.

So what do you do to prove if this is really echogenic fluid

as opposed to artifact, you can take the probe

and push against it.

And when you do, as in this case,

I hope you can appreciate these echoes are spinning

and if these echoes are spinning, then you're dealing

with actual echogenic fluid, not artifact

echogenic fluid, but true echogenic fluid, proteinaceous fluid

with the appropriate history as in this case would be blood.

So with respect to fluid

and blood in people query ectopics, most women

who have an ectopic will have some blood in their pelvis.

It's important to realize this does not imply tubal rupture.

I don't believe there's any way you can use ultrasound

to suggest tubal rupture per se.

You can have a large hemoperitoneum due to leaking fluid for

or leaking blood from the end of the tube.

And it's also important to realize that

20% of women who have early

IUPs have fluid in their pelvis a small amount.

What you wanna look for is echogenic fluid

because that implies blood.

And this was just a study published a number

of years ago showing

that if you looked at any fluid versus echogenic fluid in women

with ectopic pregnancy, you can increase the specificity

and positive predictive value from the

sixties to the nineties.

So I urge you to look specifically for clot

and also echogenic fluid above the clot

and make sure it's real

and not artifactual by pushing against it to see the echo

to spinning.

And I'll urge you again to look carefully for clot

because it's very easy to overlook.

Here is a woman who was at risk for an ectopic,

an intrauterine pregnancy is not seen.

This was done by one of our residents

and he missed the fact that there is a large amount

of blood clot in the pelvis

because he didn't have a whole lot of experience

and it's very easy to overlook this kind of clot.

But he knew enough to look up higher.

And when he looked up high in this woman in the flanks,

clearly he would not have missed that echogenic fluid.

But just looking in the pelvis per se,

he could overlook a large hemoperitoneum

and this was a ruptured ectopic.

So if we look at the criteria

that we have been discussing from the strictest

to the more liberal, as we go from strict to liberal,

we are increasing our sensitivity

and our negative predictive value as we go

from our strictest to more liberal criteria.

We're not really changing our specificity

and positive predictive value.

And this is all very good

because what this tells me is

that I can use all the criteria starting with the most,

the strictest going down to the more liberal criteria

and still be able to make the diagnosis of ectopic pregnancy

with assuredness.

Even though I don't always see an ectopic sac,

I don't always see a heartbeat

and so forth, just seeing an extra ovarian mass that's not a

paraovarian cyst

or paratubal cyst in the appropriate patient allows me

to make the diagnosis.

Doppler Use in Diagnosis

Now what about using doppler flow?

The idea and the rationale is to look for flow in developing

trophoblastic or ectopic tissue developing placental tissue

outside the ovary.

Now people have talked about this by suggesting we look

for the ring of fire, meaning you turn on your color doppler

and you see a ring-like structure

and it is surrounded by bright echoes of flow.

And you can see two examples here of

what looks like a ring of fire.

The problem is that if you look at this one, the location

of this was clearly in the ovary,

in the left ovary in this case,

in this patient it was not in the ovary,

it was next to the ovary.

It a an ectopic pregnancy.

So I honestly am not a fan of just turning on doppler

and looking for a ring of fire.

To me it is, where is that flow located?

Because all corpus luteal cysts should have blood flow in

the periphery of them.

And therefore just looking

for flow is not gonna tell you that that's an ectopic,

it's the location where that structure is located.

That helps me. So I'm not a big believer in just

turning on doppler.

Furthermore, as an example here we see

a ring-like structure.

It is in a tubular structure filled

with heterogeneous echogenic material

that would be in a dilated fallopian tube with blood.

Here is some free fluid around that tube

and yet there is no flow around this structure.

Does that make me conclude?

This is not an ectopic pregnancy.

Clearly this is an ectopic pregnancy,

but it may not be alive and

therefore I may not be seeing flow within the wall of the

ectopic pregnancy.

So it may not be developing trophoblastic tissue,

but clearly there is an ectopic in this case.

So lack of flow does not exclude an ectopic.

Some people suggest

that we look in the uterus at the flow patterns.

Sometimes there are small amounts of fluid,

so-called pseudogestational sacs associated

with an ectopic pregnancy.

Perhaps 10 or 15%

of the time when there's an ectopic there may be a little

fluid, as we've already mentioned in the uterine cavity.

Well, if you put flow in that uterus

and you see flow around that fluid collection,

you might suggest that this is a patient

who has an early intrauterine pregnancy, normal

or abnormal with developing tissue around it.

And lack of flow around that fluid collection would suggest

that this would be a pseudosac with an ectopic pregnancy.

So that might be something to consider.

Lack of flow, as in this case this was an ectopic

with fluid in the uterine cavity.

But the problem here is that absent flow

might occur with an abnormal intrauterine pregnancy.

So the lack of flow doesn't exclude that.

And you might have a pregnancy in the

uterus with lack of flow.

Another problem is the doppler energy that we use

is higher than using grayscale technology.

And if there's any time when you wanna avoid using energy,

it's at a very, very early stage ing gestation.

And unless you have a good reason to turn color and doppler

and power doppler on, I would suggest you

consider omitting it altogether.

And in our lab, our suggestion is in the first trimester not

to use doppler to evaluate for whether

or not there is a sac present.

Unusual Ectopic Locations

Now we've talked about pregnancies, in the typical

location, the ampullary portion of the tube,

and that's what most women have.

But I think we need to consider some other locations,

the isthmic, ovarian pregnancy, the interstitial cervical

and even abdominal pregnancies.

And these unusual pregnancies go up in patients

who have had assisted reproduction.

The technology, the IVF patients in other forms of

assisted reproduction to get pregnant.

Ovarian

and abdominal pregnancies go up from about 0.15

to maybe almost 5% interstitial pregnancies

that occur in the portion of the tube that's traversing.

The upper myometrium go up from maybe 2%

to about 7%.

Cervical ectopics clearly under 1% go up tenfold

to perhaps one and a half percent.

And heterotopic, that's a con

current intra

and extrauterine pregnancy, we said one in 7,000

In the typical patient who gets,

who is pregnant is basically one in 7,000.

So that's 0% goes up to 3%.

So in a woman who is undergoing assisted reproduction

therapy, we have to look harder and further afield.

So let's now look at some of these pregnancies.

The interstitial

or some people call this cornual ectopic is one

that occurs in the portion of the tube

that is traversing the upper myometrium.

So that pregnancy is not developing in the endometrial,

in the central portion of the endometrium.

And this kind of pregnancy is a real problem

because it is surrounded by a certain amount

of muscular tissue.

Therefore it can grow larger than a typical,

tubal pregnancy.

And there is a branch of the uterine artery

that traverses this portion of the myometrium.

It comes in with the tube.

And since this is larger, that vessel gets bigger.

And when these pregnancies rupture, it is a catastrophe

because they take that large branch

of the uterine artery with it.

This is by far the number one cause of maternal

mortality in the first trimester of pregnancy,

rupturing a cornual or interstitial ectopic pregnancy.

So how do we make the diagnosis?

Well, one thing we can do is look

to see if we have a little bit of the endometrial cavity

as we can see coming up to the edge of that sac

that's been called the interstitial line sign.

You can see it nicely in the scan.

Another thing we can look for is the location of the sac.

Notice this is high up in the uterus.

It's toward the fundus. That's where the tube comes in.

So we can clearly see on this 3D image.

And this is a very nice use for 3D

that it is located in the fundus.

Even if you do not have 3D, you can pan through the uterus

and realize these sac

implantations are high up in the fundus

and surrounded by a small amount of tissue

as we can see here.

So very important to make that diagnosis,

of the interstitial ectopic pregnancy

because of the associated maternal morbidity and mortality.

And they will present later often when,

because they don't rupture that early as a tubal ectopic

So be aware of these pregnancies.

Now here we have a case where there's a pregnancy both in

an extrauterine, a heterotopic pregnancy.

And in this case you can see a heartbeat in each

of the embryos.

And we will talk about

how we address this in just a few minutes.

Here. We have a fluid collection in the cervix

and if you look carefully,

there is a small yolk sac down here.

What would the diagnosis be?

The differential would lie between could this be a patient

who is miscarrying

and has the pregnancy at this point in time in the cervix

or is this a cervical ectopic?

So partly it depends upon the clinical situation.

Patients who present with cervical ectopic,

at least in our experience, are usually not symptomatic.

Patients who are miscarrying certainly are symptomatic.

And of course if you have an earlier scan showing the

implantation was within the uterus

and is now at the cervical level, it's easy

to make the diagnosis.

But you have to look at the clinical picture.

In this case, this patient had a cervical ectopic.

She was not symptomatic at this point I just also wanna

alert you to the fact be aware.

If you don't see a yolk sac

and you just see what looks like a large

structure here surrounded by echoes, you could be dealing

with a large nabothian cyst.

Again, old scans are very helpful.

If you're uncertain if it's a nabothian cyst versus a cervical

ectopic, I suggest you again get serial HCG re-scan

the patient couple of days

to see if you can see a developing yolk sac.

So here we have a challenge case.

This is unusual again, a fluid collection at the cervix.

There is a yolk sac here,

you can see it in the coronal scan better.

And there is actually a heartbeat,

although it is a slow heartbeat.

So the differential again is an abortion in progress versus

a cervical ectopic.

Well, we actually thought

that this was gonna be a cervical ectopic.

This patient was scanned up in the emergency room.

We brought her down to look at her,

and we were going to inject this with potassium chloride.

By the time we got around to looking at her,

she came to ultrasound.

And this was maybe an hour or so later it was gone.

And this was a patient who had a spontaneous abortion.

And even though this is uncommon to having a living

pregnancy at the level of the cervix during the process

of miscarrying, it can actually occur.

You can have a heartbeat that is no in this pregnancy,

which clearly no longer has a blood supply.

But the heartbeat can clearly go on for,

I don't know exactly what the period of time is.

And you may in a rare situation be dealing with

a heart beating in the cervix, which would lead you to think

that this is a cervical ectopic when you're actually dealing

with a spontaneous abortion.

Here's a case where we can look at the ovary

and if you look carefully within this ovary,

there is clearly an embryo with a living heartbeat.

But that is an unusual situation,

an ovarian ectopic pregnancy.

Management of Ectopic Pregnancies

So now we've looked at a variety of ectopic pregnancies.

How do we manage pregnancies that are ectopic?

Well, in the United States it used to be laparotomy,

but today laparoscopy is still the most common way

to treat ectopic pregnancies.

But we also have a variety

of other therapies including non

laparoscopic medical therapy.

By that I mean potassium chloride injected into the sac,

methotrexate injected into the sac

or injected intramuscularly

or even to observe women who are clinically stable,

whose HCG is not going up, who doesn't have a lot of

color flow within the ectopic pregnancy, all suggesting

that it is a non-viable ectopic pregnancy.

So we have guidelines and these are only guidelines

and you have to look at of course, the patient as well.

What is the number of h the HCG level?

If it's fairly low, the tubal mass is fairly small,

although I think these numbers from literature are rather

high and rather large.

Of course, if you're not going to operate on a patient,

you have to have a clinically stable patient.

The literature debates whether

or not cardiac activity should yes or no be present.

When I was at the Brigham where we did see a lot

of these patients and we treated them medically, many

of them had heartbeats.

You have to have a secure diagnosis without having

laparoscopic, having to deal with,

a laparoscopic confirmation.

And if you treat the patient with methotrexate, you have

to have no contraindication to administering it.

That means a patient whose liver is functioning well.

As I said, methotrexate can be given intramuscularly

or into the sac.

Potassium chloride can also be used directly into the sac.

One of the differences between these therapies

injecting potassium chloride,

particularly if you can inject it directly into the embryo,

ideally into the heart, will stop the development of

that pregnancy instantaneously.

Methotrexate takes time.

It has to get into the developing cascade of DNA,

it acts like an anti folate

and so it has to be used when it,

in a developing embryo and it will take days for it to work.

It's not instantaneous,

but it does stop the development of trophoblastic tissue

or placental tissue around a sac.

So sometimes we use potassium chloride into the sac

and methotrexate as well to try

to prevent the development of the continuous growth

of trophoblastic tissue.

So let's look at some examples.

Here is an unfortunate woman. She's IVF.

So she desperately wants to be pregnant.

She has an intrauterine as well

as an extrauterine pregnancy.

And the extrauterine, it's not really extrauterine.

This pregnancy is an interstitial ectopic pregnancy.

How are you gonna handle this situation?

Because if this continued to grow

and rupture, this woman is at high risk to lose her life.

Notice we are high up in the uterus here

because that's where this is in the fundus.

This is more or less an oblique scan

to show you this is actually in the lower part

of the uterus, higher part where we're dealing

with the cornua.

So since we're high up, it's attractive to think

that we could inject this transabdominally would be hard

to reach from a vaginal approach.

And this is Dr. Dubay

who actually did this injecting this cornual ectopic

and terminating the cornual ectopic without affecting the

intrauterine pregnancy

because he's using potassium chloride here.

If he used methotrexate here,

he would affect both pregnancies.

So you never want to use methotrexate in a situation

where you're dealing with a heterotopic ectopic pregnancy.

Here's another situation, two pregnancies, vaginal scan,

and both of these have a heartbeat.

Now let's address this pregnancy in the lower

aspect of the uterus.

Where is it located?

Well, it's in the upper cervix

and actually it's in the tissue of the cervix.

It's in the anterior portion of the tissue of the cervix.

If you ask the patient's history, I'm sure many

of you are already suspicious, the location

of this would suggest it's in a cesarean section scar.

So how do you handle this?

She's got a pregnancy in a c-section scar

and she's got an intrauterine pregnancy, both

of which are alive.

So what was done in this case was using the vaginal probes

since it's right in front of

where the vaginal probe is located.

Mary Frates actually injected this pregnancy

with potassium chloride

and you can see the administration here

of the potassium chloride into this sac

that's located in the C-section scar.

And the pregnancy was terminated,

as a result of

that procedure, whereas the pregnancy in the uterus here

continues to have a heartbeat and continued to grow.

Looking at the lower uterine segment,

that pregnancy slowly resorbed

and this resulted in a very, very good outcome

where the intrauterine pregnancy was delivered.

Not only that, this woman

experienced a subsequent pregnancy as well.

So this is a win-win situation.

Whereas without that administration of the,

potassium chloride to terminate the cervical ectopic,

the pregnancy at the level of the cervix

and the c-section scar, she likely would've lost her uterus.

Here's just a third example where we can see, again,

this is a C-section scar pregnancy,

and I'm showing you this show a variety of ways

to treat this here.

There is a living pregnancy again in a c-section.

And the clinician at this point, instead of,

injecting this with, potassium chloride, elected

to do a careful DNC using ultrasound guidance

through a fluid-filled distended bladder.

And we were able to guide the clinician

as she did a gentle DNC to remove

the sac in this manner.

So that was successfully accomplished within 15 minutes.

So there are a variety of approaches we can use

using ultrasound to help us

to terminate these unusual pregnancies.

Conclusion

Now, just to end, if you look at the ectopic rate,

and this is in the United States,

the ectopic rate slowly has increased.

This chart shows you to about 1990, the number

of hospital admissions was continuing

to increase to that point.

And fortunately, the maternal death rate,

and this is thanks to good pregnancy tests

and good ultrasound,

has gone way down over the period from about 1970

to 1990.

Now, you might ask yourself,

why am I terminating this graph at 1990?

Well, the reason is it's harder to get statistics

because the number of hospital admissions has gone down.

Well, why is that?

Well, because the number

of ectopics we believe has gone way up

and continues to go up.

But since these patients are now being treated

as outpatients, it's much harder to get good statistics.

We don't think the number of ectopics have gone down.

We know the number has gone up,

but it's a real win-win situation

where now we know we can deal with ectopics as an outpatient

and actually treat these women as outpatients.

And that is an economically very,

rewarding experience.

So I think,

and I hope that the past few minutes has allowed you

to look at a number of ectopic pregnancies.

Not only how we go about making the diagnosis,

especially using the physical exam, using that probe to push

and to confidently show that

that suspicious tubal structure is separate from the ovary.

And in addition to making the diagnosis

to understand the variety of therapies we have

and how we go about using those therapies, often

with ultrasound assistance.