Ectopic Pregnancy - HD

Introduction

I am Dr. Marcella Les, a woman's immature, from Pittsburgh, Pennsylvania, and I will be speaking about ectopic pregnancy.

Incidence and Statistics

The incidence of ectopic pregnancy has been increasing, even though mortality has been declining.

Point nine to 2.6% of all pregnancies are ectopic.

11.5 to 18% of maternal deaths are due to ectopic pregnancy.

15% ectopic pregnancies are patients who have had previous ectopic pregnancies.

Definition of Ectopic Pregnancy

An ectopic pregnancy is an abnormal implantation and growth of products of conception outside of the endometrial cavity.

Locations of Ectopic Pregnancies

The majority of ectopic pregnancies, approximately 98% arise in the fallopian tube and in the order of frequency, the ula, isthmus, fia, and interstitium.

Other ectopic pregnancies include an abdominal uterine, cervical and less common in the ovary.

And here's a diagram from netter showing the different locations of an ectopic pregnancy, FIA of the fallopian tube, the ula isma, and the interti tissue, which is the portion of the fallopian tube that goes inside of the uterus.

Also ovarian ectopics are rare and cervical ectopics can be seen, but are rare.

Risk Factors

The risk factors for ectopic pregnancies include a previous ectopic pregnancy, which increases your risk 10 times.

Pelvic adhesions due to pelvic inflammatory disease.

Endometriosis or tubal surgeries will increase the risk of a pelvic of a ectopic pregnancy by 30 to 40%.

Infertility or assisted fertilization increases the risk of ectopic pregnancy in addition to intrauterine device.

Think ectopic in all reproductive females, since 50% of patients with ectopic pregnancy have no risk factors, early diagnosis is crucial to initiate treatment before rupture hemoperitoneum, and result in hypovolemic shock.

Clinical Presentation

The clinical triad for ectopic pregnancies is seen in less than 50% of the patients, which includes abdominal pain, abdominal va, abnormal vaginal bleeding, and a palpable adexo mass.

Usually these symptoms present approximately 7.5 weeks from the last menstrual period.

Diagnosis of Ectopic Pregnancy

How do we make the diagnosis of atopic pregnancy?

The two tools we have are the quantitative beta H-C-G-S-A and ultrasound, which allows us to evaluate the uterus for interuterine pregnancy, a yac cardiac activity or embryo, and evaluate the adex for masses.

Quantitative Beta-hCG

The human choon atropin, or HCG is a glycoprotein produced by trophoblast.

It contains an alpha and beta subunit.

It's specific marker for pregnancy, and it supports the corpus lutin in first trimester.

It's usually detected in the third menstrual week in the urinal serum, and it sends an a cur lineal fashion until it reaches a plateau at nine to 11 weeks, and it starts to decline after 20 weeks.

The radio immuno assays can be detected as low as one to 2 million international immuno per milliliter of beta HCG.

It's usually positive approximately 23 days after the last menstrual period or nine days after conception.

Initially, in the initial studies or research projects that were done, the radio immuno essay of HCG was calculated with a second international standard.

However, most more recently, the first or third international reference preparation is used, which is equal to two times the second international standard and negative serum beta.

A TG excludes pregnancy and normal pregnancy.

The H-C-H-C-G doubles or increases 66% every 48 hours.

In ectopic pregnancy, the rise is much slower.

However, 15 to 21% of ectopic pregnancy will have a rise, very similar to that seen in a normal in Ute pregnancy.

The human choon atropin is important to have before level.

It's important to have before you do perform an ultrasound, because if the beta a TG is negative, there is no pregnancy, no intrauterine or extrauterine pregnancy.

You still wanna do the ultrasound because you want to look for reasons for the signs and symptoms of the patient.

50% of cases, the positive beta HCT is due to an intrauterine pregnancy, therefore, the identification of an intrauterine pregnancy will exclude an ectopic pregnancy.

If you have any doubts, zero beta HT should be done

Discriminatory zone that was described many years ago and it means, or the definition of this discriminatory zone is the beta HCG level at which an intrauterine gestational sac should be visualized by ultrasound up to now 2000 million international unit per milliliters of first international reference preparation using transvaginal ultrasound was the level at which if no interal sac was seen, an ectopic pregnancy was highly suspicious.

33% of patients with a beta actg of 2000 milli international renal per milliliters and no treatment had an intrauterine pregnancy as a follow-up, and here you can see a transvaginal ultrasound, and within it is a tiny little interuterine fluid collection, which was a gestational sac, a patient who had a beta a CG of 2000, however, recently published cases of beta, a CGS of 6,000 million international unit per milliliters with an empty sacs that have gone to a normal pregnancy.

And since many patients have been treated in the past 10 years for beta ATGs with methotrexate, which is not a benign medication, a drug, the new recommendations are that an empty sac, even with a beta a CG of 6,000 milliliters per milliliters.

You should repeat the ultrasound in a few days or repeat the beta ACGs, but do not call it an incomplete ab abortion.

Do not call it a miscarriage or do not call it a pregnancy.

We want to avoid treating incorrectly patients with methotrexate.

Ultrasound Evaluation

Well, ultrasound that's been very controversial.

Should you do transabdominal, should you do a transvaginal study?

We know that the transabdominal study gives a more global view.

It's very helpful in the presence of a ruptured ectopic pregnancy to be able to identify the extent of the blood within the pelvis and abdomen.

However, the transvaal probe is higher frequency, closer to the pelvic because it's closer to the pelvic organs and gives better resolution.

It allows us to identify an intrauterine and or an extrauterine pregnancy yac embryo cardiac activity much earlier than with the transabdominal probe.

And here's an old study, but a very nice study showing a retroverted uterus in this transabdominal study on your left, and nothing is seen within the uterus.

However, when you do that transvaal study, you can see very nicely that within the uterus there's a live intrauterine pregnancy.

So in this case, you were able to identify that the why the patient had a beta a CGA positive beta beta a CG was due to a normal intrauterine pregnancy.

We did a study many years ago comparing transabdominal transvaal ultrasound, and we found that transvaal ultrasound identified the intrauterine yolk sac cardiac activity in embryo at least seven to 11 days earlier than the transabdominal study, increasing our diagnostic accuracy from 60% using only transabdominal study to 83% using the transvaginal probe.

As you can see here in this diagram, that there was a significant improvement when we did the trans using the transvaginal probe.

An exclusion of an ectopic pregnancy can be done with certainly if there's identification in intu identification of an intu pregnancy, except in the high risk group, because a co a coexistence of an intrauterine extrauterine pregnancy is very rare.

In the no risk woman patient, it's one in 30,000, and in the high risk it's in one in 77,000.

In the presence of an ectopic pregnancy, you can have a normal pelvic ultrasound, and that can be seen in up to 20% of when you only do transabdominal study.

And with transvaginal, it can be seen in up to 8% of the cases.

And in these cases, your differential diagnosis would be either at very early into your own pregnancy, less than four weeks in which you can't see anything in the uterus or a complete or incomplete abortion.

And here you see in uterus a completely empty uterus in a patient with a positive beta HCG.

The new terminology today is to use pregnancy of unknown location in patients that you have a positive urine or serum pregnancy test, and no sonographic evidence of an interuterine or extrauterine pregnancy.

When using transvaginal ultrasound, visualization of an int fluid collection can be due to a most likely, most commonly, most likely due to a normal e early Ute pregnancy.

But it could be an abnormal Ute pregnancy or a pseudo gestational sac due to an ectopic pregnancy

Evaluation of the uterus is for, in patients with ectopic pregnancy is very important, as I said, because you want to be able to see if you can identify a new, an ute pregnancy.

A new Ute pregnancy is identified when you see an ute gestational sac with a ylk sac cardiac activity or an embryo.

Occasionally what you all will see is a u inter gestational sac without contents.

And in these cases, there are some signs that have been described such as a double deci sac sign or intertidal sac sign to better to help you differentiate in, into, in, into your pregnancy.

Pseudo hassal sac, which is a terminology many do not like to use anymore, or Deidre reaction, can be also identified in the uterus and help determine if it's an into uterine versus extrauterine pregnancy.

And the pseudo sational sac, which term this terminology probably should not be used any longer, is a small centrally flu endometrial fluid surrounded by a single echogenic re Here is a nice diagram on your left and on your right, and you can see an ultrasound, a transvaginal ultrasound seen in centrally located fluid collection surrounded by this echogenic rim.

Adjacent to it, you see a ruptured ectopic pregnancy.

The recommendation is to describe the sonographic findings instead of calling it a pseudo tal sock.

When you see these fluid collections, a small fluid interuterine fluid collection, sometimes it's difficult to determine if it's, if it is an interuterine pregnancy.

And in these cases, the double decid sac sign has been used to better delineate if it's an interuterine pregnancy.

And here is a fluid collection seen at five weeks, and you see two concentric rings surrounding a portion of the sac.

So here's a diagram on your right and your left is an ultrasound finding, and you can see the decid capsularis and decid peritus with a small fluid collection in between surrounding the sac.

So here is the decidua, a capsularis de decidua peritus, and a little fluid collection between the two deral.

This is not, does not confirm an Ute pregnancy a hundred percent, but is helpful, can be helpful.

The other sign, the intraprocedural sac sign, I find it more helpful.

And this was described by Dr. EA in 1986, and it's the eccentric locational fluid location collection, a fluid collection in respect to the endometrial stripe seen in two planes at approximately four and a half weeks after the last menstrual period.

And you can see nicely here, the endometrium, a transvaal study, the endometrium, and just to the side of the center of the endometrial cavity is this fluid collection, small fluid collection.

Now, the accuracy has in the past few years, other studies have shown that there's, that the accuracy of this sign is variable.

Dr. Ls sensitivity was 48%, specificity 66%, and Dr. Chen came out with a sensitivity of 60 to 68% and specificity 97 to a hundred percent very variable, the accuracy by different researchers.

And here is another, you can see in this patient on your top left, an end, a transvaal study showing the endometrium and just to one side extensively to that middle of the endometrial midline of the endometrial, there's a little sac.

There's not a hesitation, a yolk sac within it, no embryo, no cardiac activity.

But because of the location, this fluid collection, you wait a week, two weeks.

And this, the, this most likely will be an intu pregnancy as it was.

And here's another patient you can see nicely, perpendicular projection, and you sometimes color helps a little bit.

But you can see here that you see a little fluid collection and you see the deci cap, capsularis and peritus, the divided by a little bit rim of fluid.

The what, how does the endometrium usually look like with ectopic pregnancy?

Well, 54% of ectopic pregnancy will have a normal endometrium.

However, a small fluid collection can be seen in 10 to 20% of the cases prominent echos.

As you can see here on your left, we showed you this, this is a nice little centrally located fluid collection.

And a adjacent to it is an ectopic pregnancy.

Prominent echos, 'cause in this case, in the middle, can be seen in 13% of the patients.

And complex fluid collections, as you can see here on your right, with medial level echos within the endometrium can be seen in another 13% of the patients.

However, one thing for sure is the endometrium in the intrauterine pregnancy has a perro aplastic flow, which is not seen in ectopic pregnancy.

And this is related to the trophoblastic invasion that occurs in anterial pregnancy.

So here's a difficult view to see, but you, this is doppler of the endometrium and a patient who had an early intrauterine pregnancy.

And usually what you see in the endometrium in early into your pregnancy, high velocity, low resistant wave flow, or a low resistive index and a low positivity index, ectopic pregnancy will not have flow within the endometrial cavity, especially this low sistant wave form endometrium.

Dr. Dubinski and his group published a paper in 1997 in which they evaluated 2011 women to rule out ectopic pregnancy.

They found that the 156 women that had no ectopic pregnancy, 107 had an arterial endometrial flow identified, and they concluded that arterial blood flow within an endometrial lowers the risk for atopic pregnancy.

However, venous flow does not exclude ectopic pregnancy.

As you see in this Transvaal study, which was a thick and endometrium with venous flow, and patient had an ectopic pregnancy.

The importance of this study is that the negative predictive value for this color flow doppler or arterial blood flow identification of arterial blood flow, gives a high negative predictive value for excluding ectopic pregnancy decid cyst.

These have been described to be by Dr. Ackerman and her in their group to be an associated with ectopic pregnancy.

They evaluate 208 proved.

They evaluated 208, proved ectopic pregnancies, and found that 30 of them and 14% had residual cyst, and 12 of them, this was the first sign of an ectopic pregnancy.

So they concluded that patients with vestigial cyst are at high risk for ectopic pregnancy.

However, they can also be seen in patients with intrauterine pregnancy.

And here are two patients on the top perpendicular projections, longitudinal view on your left.

And here is a long review of the uterus, the endometrium.

And here you see a tiny Deral six deral cyst.

And this is a transfer of project trans projection, seeing a little deral cyst in a patient who did have an ectopic pregnancy.

On the bottom here, we see an Ute pregnancy first trimester with at least two residual cysts.

Definitive Sonographic Findings

Well, the only definite finding sonographic finding that there is an ectopic, that there's a definite ectopic pregnancy is a live extra urine embryo.

As you can see here, this was in the adex, an embryo, and it's can be seen in 10% of cases by transvaginal ultrasound in significantly more cases with transvaginal ultrasound.

We're fortunate that in lately we don't seek too many live extra uterine embryos because they're found much earlier.

One of more common sonographic finding the anex is a dilated fallopian tube filled with blood, which are the from product of conception.

And here we can see an a normal ovary, a dilated fallopian tube with blood, and the blood can be seen surrounding the capsule of the ovary hemal soft pinks.

Another sign seen in the adexo in patients with ectopic pregnancy is the ectopic ring sign or a complex solid mass.

On your left, you see a patient with the o the ovary is on one side the uterus, and between the uterus and the ovary, there is this donut shape or atopic ring.

So within it, you can see that there is a little yolk sock, which helps to identify or confirms that this is an ectopic pregnancy.

On your right, you see an a transabdominal study and uterus with nothing within the endometrium poster to the U endometrium.

The uterus is a complex mass.

The ovary is separate from it, and this was a ruptured ectopic pregnancy, ectopic tubal rings.

These are defined as a sac surrounded by two to four millimeter echogenic ring rim.

And here you can see on your left an ovary and just medial to the ovary a little mass ectopic tubal ring, which is a sac surrounded by a two to four millimeter echogenic rim.

I, Dr. Fleisch and his group identified in their publication in 1990, that 68% of non ruptured ectopics by transvaginal ultrasound will present with an ectopic tubal ring.

Here on your right, you see it again on perpendicular projection.

The ectopic tubal ring complex and solid mass.

These are non specifics and are can be seen in atopic pregnancy.

But the differential diagnosis includes a corpse lum cyst, endometrioma or abscess.

If the patient has a positive pregnancy test, however, the specificity is 99% sensitivity, 90%, and positive predictive value for an ectopic pregnancy, 63%.

If you add free fluid, the then your positive predictive value goes up to 94%.

So a patient that has a positive pregnancy test and add an exo mass and free fluid, especially echogenic flu fluid, the positive predictive value for ectopic pregnancy is 94%.

And here we have a patient with a large, the uterus is empty, but be behind a posterior to the uterus is huge mass.

It's hard to differentiate the borders from the uterus and the mass.

Here's the longitude view of the uterus.

The endometrium is empty and there's a large mass.

And here we see the mass in the cul-de-sac.

It's sent to the sac.

And within the mass you see that there is a tubal ring of the ectopic pregnancy.

Here, again, lots of echogenic free fluid.

And then in this situations, you do want to scan the flank, the right flank to see if there's blood, all the ascites, all the way up to the retroperitoneum.

Well, when you see these complex solid masses, how do you determine if this is an intra ovarian or an extra ovarian mass?

And that's very important in these cases because two wove pregnancies are usually extra ovarian masses.

The way you can differentiate an intra or extra ovarian mass is when scanning you perform gentle bimanual exam by using the transvaginal probe and a hand on the patient's abdomen trying to move the questionable mass.

If the mo the mass moves separately from the ovary, then it's extra ovarian and dual ectopic pregnancy should be considered.

If the mass moves with the ovary, then the masses int ovarian, such as a corpus lu cyst lava and his group published an article about concerning movement of ad exome masses.

And out of 20, one of the 23 patients with ectopic pre pregnancy, they showed me, showed that the movement of mass was per could be performed with palpation.

Six of the 49 patients without intu pregnancies showed some mu movement of the mass with a palpation.

Their negative predictive value was 96%, which meant that lack of movement of the adjacent mass and ovary as was associated with the absence of ectopic pregnancy.

And here we have a case.

On the top left, you see the ovary, the uterus, and a mass in between.

And as we put pressure be applied pressure, abdominal pressure, and pushing with a transvaginal problem, we were able to separate more the mass from this solid mass from the ovary and the uterus.

And here we see a flow that mass had a lot of flow within it.

Another patient in which by using palpation movement, we were able to separate the mass from the ovary and even identify that there was an intu.

And there was a live fetus within the ectopic pregnancy.

And here you see an empty endometrial with no flow.

Does color flow help in ectopic pregnancy?

Yes, it can help depict small ectopic pregnancy or more accurately.

It increases your sensitivity when you're using the transvaginal study as a probe.

And there's been studies that showed by Emerson dominant and more that if you use color flow with your transvaginal probe, you will significantly increase your sensitivity for detecting small, especially small ectopic pregnancies.

And the reason for this is that the ectopic pregnancy has the TRL signal or low resistant waveform high velocities.

So you may be able to detect that placenta flow in the ectopic pregnancy in about 85% of the cases.

And here we see a case which the ovary, the uterus, and in between all, we could see this significant amount of flow in this patient with ectopic pregnancy.

The problem is that the differential diagnosis, also S-corp cys have lower resistant waveform cystic ovarian neoplasm, and two ovarian abs also have lower resistant wave flow.

That's why it's more important the relationship of the mass to the ovary and the clinical history.

Is there a positive pregnancy test or a negative pregnancy test?

And here we have a nice tool ring, which shows that a ring of fire that people have described in low resistant wave foam, which is really trophoblastic wave foam that it can be seen in patients with an ectopic pregnancy, but can also be seen in the corpus luden, ovarian tumors, and two ovarian abscess.

And here we see a ring of fire again in an ectopic pregnancy on your left and within an ovary here was within an ovary, this ring of fire.

And this was a corpse lu cyst.

And here was a patient had both a corpse lu cys and an ectopic pregnancy.

Sometimes it's difficult to differentiate in atopic pregnancy from a corps cyst.

F Fred is in her group, evaluated 26 patients with tubal rings and yolk sac or embryo.

She found that 80% of the echogenicity was greater than the ovarian parenchyma in 13 patients with an empty ring, 77% of the echogenicity was greater than the ovarian parenchyma.

45 patients with in two interim pregnancy had a corpus luten cyst, and the echogenicity of the corpus luin was greater than the ovary in only 3% of the cases.

So conclusion was that when you compare ectopic practice with corpus luten cyst, and this is another study which was done by Stein in which they evaluate 79 patients, 41 had ectopic pregnancy, and they found that in ectopic pregnancy, the endometrial was more echogenic and 32% of the cases in the ovarian tissue was more echogenic and 76%.

And the internal texture of the mass and atopic pregnancy was usually complex or solid, the maturity of the time versus the corpus lu cyst, which had found that the endometrium was less echogenic in 84%, the ovarian tissue was less echogenic.

I mean, the corpus luum was less echogenic the ovarian tissue.

And usually that internal texture of the corpus corpus SL sis was clear.

And here was an interesting case that was given to me in when I gave a lecture in Mexico, and these were twin ectopic pregnancies.

And what helped here 3D was helpful, but also because you helped identify the yolk sacs within the each of these sacs fluid collections.

But you can see nicely in both of them, there was a yolk sac, which helped to make the diagnosis.

This is one in 100,000 ectopic, very rare at an exome masses.

Well, when you evaluate an exome masses, can you use flow?

Well, no flow can be identified in one third of ectopic pregnancy.

And one of the reasons probably is because of very early or the ectopic pregnancy is dead.

So avascular ectopics had been seen in patients with beta igs less than 6,000 milli international units.

One thing that may help is when you're looking for an ectopic pregnancy, 80, greater than 85% of the ectopic pregnancies are in the side of the corpus lube cyst.

Echogenic Free Fluid

Echogenic free fluid visualization of echogenic free fluid or hemo peritoneal can be seen in 66% of ectopic pregnancy.

And what this is do is the leakage of blood, or it could be blood from the fallopian tube, or it could be due to a ruptured ectopic pregnancy.

In 10 to 26% of the patients, Dr. Nyberg and his book found that echogenic free fluid could be seen in 15% of patient could be the only finding 15% of the patients with a giving a sensitivity of transvaginal ultrasound of 91%.

And here you can see transvaginal study showing an empty uterus, an epigenic free fluid.

And here there is an ectopic pregnancy.

Free fluid can be seen in 63% of patients with ectopic pregnancy, but can also be seen in 31 patients, 31% of patients within Ute pregnancy.

If the fluid is echogenic, it increases your positive predictive value for an ectopic pregnancy to up to 93% of the case.

Free fluid hemal peritoneal is complex free fluid with layering in the pregnant woman.

It can be due to a rupture of ectopic pregnancy or colu cyst always scanned by the kidneys.

If a patient's unstable, a diagnosis is not essential since a patient needs to be taken to surgery.

If the patient's sta stable, carefully examine the nexo and echogenic free fluid may give the uterus.

Sometimes Ill define margins.

It may be difficult to identify.

Specific Types of Ectopic Pregnancies

Interstitial Ectopic Pregnancy

Interstitial ectopic pregnancies are two to 3% of all ectopic pregnancies.

The risk factors include a prior ectomy and in vitro ization.

This is when the gestational sac implants in the intra my mutual segment of the fallopian tube.

It ruptures late.

The mortality rate is two times out of other tubal pregnancies, and this is due to increased vascularity and proximate proximity of the urine artery to the tube sonographic.

What you'll see is an eccentric location of gestational sac, thin myometrium less than five millimeters, and echogenic line that extends into the upper regions of the urine horns and borders the margins of the intramural gestational sac.

Occasionally you'll see the myometrial ment around the sac, and here you see a 3D Ma 3D 3D ultrasound has been very helpful in determining the lo the relationship between the endometrium and the sac.

Here is a patient with a interstitial ectopic pregnancy.

You see a transverse view and empty endometrium, and to one side you see this bulging and within this bulging you a little tial sac.

And this is corresponds to an ectopic inter interstitial ectopic pregnancy.

Ackerman and his group described this interstitial line, which is a thin echogenic line, which extends from the thick deci vera up to the center of tal sac.

This has been shown to be probably more sensitive and specific than the other signs that have been described such as eccentric tal sac location and myometrium thin thinning, which can be difficult to identified.

And here we see again, this is a transfer view showing an interstitial ectopic pregnancy, corneal pregnancy.

This is inter has been used interchangeable with interstitial pregnancy.

And should, this terminology should not be used because this is really implication of pla blast osteocytes within the cornea of the bico or septic uterus.

It's not an ectopic pregnancy.

Cervical Pregnancy

Cervical pregnancies, these are implantations that occur within the endo cervical canal.

They're rare.

Less than 1% of all atopic pregnancies, they're associated with in vitro virilization and history of prior care touch sono graphically.

The uterus is shaped like an hourglass or figure eight.

I see the uterus expands within the cervix.

The differential diagnosis is an abortion in progress, and the sliding sign present or the when the probe moves the sac, it confirms the sac is not a adherent to the cervix, can be very helpful in differentiating an abnormal an abortion in progress from cervical pregnancy.

And here we have a case in which launch Transvaal view, you can see this sack And it's within the cervix.

There's a yolk sac thickened deidra.

And here you see again, this is transabdominally how the ovary.

And you see nicely the in within the cervix, this cervical ectopic.

Here it is another patient with a cervical ectopic.

Ovarian Pregnancy

Ovarian pregnancy.

When an ovary is fertilized and retained within the ovary is considered an ovarian pregnancy.

These are less than 3% of the topic pregnancy and maybe heterotopic.

It's usually associated with an Ute pregnancy and it's sonographic.

What you'll see is a gestational sac or an atypical cyst within a echogenic rim within the ovary.

Here is on your top left, you see an empty uterus, and on your right is the ovary.

Within the ovary there is a sack and there was an embryo within it.

And this was a live ovarian ectopic pregnancy.

Very rare.

You may not see one in your lifetime.

Intraabdominal Pregnancy

Intraabdominal pregnancy, that's implantation within the intraperitoneal cavity.

Rare, less than 1%.

Maternal mortality is 7.7 times greater than other ectopic pregnancies.

And this is due to hemorrhage, sono graphically, you'll see an absence of a normal anterial tal sac, and the sac is located within the interperitoneal cavity.

Abdominal or pelvic hemorrhage will be seen.

Cesarean Scar Pregnancy

Cesarean scar pregnancy.

These are rare, less than 1% of our pregnancy.

And this is implantation within the scar of a prior C-section.

Separate from the endometrium within the scar, the blasto site is surrounded by myometrium and fibrous tissue.

The mechanism is the track connects the endometrial canal and myometrium, and it facilitates implantation into the scar.

These patients usually present with vaginal bleeding, five to six weeks to 16 weeks may rupture.

And the sonographic findings are gestational sac.

Within the anterior wall of the inferior aspect of the uterus.

There's thinning of the anterior myometrium.

And here we see a transvaal study, launch statue view of the uterus and endometrial is empty, right where the C-section scar is.

You see tal sac, you see the thicken or the residual reaction around it.

No York, so was seen within it.

But this is an tute, early tute pregnancy within the c-section scar.

Management of Ectopic Pregnancy

Well, what's the management for atopic pregnancy?

It used to be laparotomy or laparoscopic surgery.

And now there's a big movement to do medical treatment.

And there is me a potassium chloride, local injection of potassium chloride, usually used for the c-section scar ectopics and the cervical ectopics.

And the methotrexate in systemic or local systemic is used for the fallopian tube.

The ectopic pregnancy locals can be used for the C-section or cervical ectopic pregnancies.

The disadvantage of the medical treatment is that if it's in, it can cause tubal injury and blood loss.

Methotrexate is a folate antagonist.

It acts on rapidly proliferating trophoblastic tissue.

A single dose 50 milligrams from millimeter square intramuscular repeated.

If not, if the beta CG does not decline 15% in between days number four and seven, the sex, the sex rate, the sex rate is pretty high.

And because the la intramuscular rate is approximately 97%, that's the one that's used in when there's a fallopian tube.

Ectopic pregnancy, the advantage is no hospitalization, no anesthesia, no surgical risks, and no cost.

The disadvantage, it has to be a patient that you can follow up closely for signs of rupture.

And there are side effects of traine leukopenia, methotrexate.

Usually the po, there's a po there's a positive response when, if you see a 15% drop in the serum beta CT within 24 to 48 hours.

Sono graphically, we don't follow these patients with ultrasound because initially they have increased size of the hemato SOPs.

There's increased vascularity, and the sonographic findings can look pretty dangerous or serious when they're when it's the heal really actually a healing process.

And here on your left, you can see this ectopic pregnancy bled in.

It was a tubal ring.

It bled in due to the blood.

It's very vascular and it looks worse than it looked prior to treatment with methotrexate.

The only time we will repeat the ultrasound is if the patient becomes symptomatic.

Criteria for using methotrexate, the patient has to be hemodynamically stable.

There has to be no intrauterine pregnancy on transvaginal ultrasound with abnormal, no intrauterine pregnancy on transvaal ultrasound with abnormal rising of the beta ICG and the ultrasound findings.

An unruptured ectopic pregnancy, that mass, which measure the mass, has to measure in largest DME diameter, less than or equal to 3.5 centimeters.

And there needs to be no cardiac activity.

Diagnostic Algorithm

So if you suspect an ectopic pregnancy, first thing you do you wanna do is the pregnancy test.

If the pregnancy test is negative, you have excluded an ectopic pregnancy and also an injury on pregnancy.

You may still wanna do the pelvic ultrasound to look for another abnormality.

The cost of the symptoms for the patient, if the pregnancy test is positive, you do a pelvic ultrasound.

Most likely 50% of the time you're going to see evidence of an intrauterine pregnancy, and therefore you can exclude an ectopic pregnancy.

If you don't see an intitute pregnancy, then you're going to have to do serial beta ICGs and possibly follow up ultrasound.

Conclusion

In conclusion, ultrasound plays an important role in the diagnosis and management of atopic pregnancy.

If an extra extra ovarian mass is present with no interuterine pregnancy in patients with a positive pregnancy test, bleeding and pain, diagnosis of atopic pregnancy should be considered.

Treatment is determined by the clinical symptoms, ultrasound findings, and serial beta HTG.

Thank you very much.