 Now now what we're going to talk about is uncommon location of ectopic pregnancy So the first one I want to talk about is interstitial ectopic pregnancy That's what present about so they are in the interstitial portion of the fallopian tube as it joins With the animatrim at the at the corner of the uterus and The reason they represent about two to four percent of all ectopic pregnancy But the reason they are dangerous is that they tend to have a delayed presentation with more advanced gestation and because they're very large vessels in this area and they're surprised by uterine artery There is a high risk of life frightening hemorrhage when the pregnancy what these are the patients that may go You know become hyperpollinic and high potency very very quickly So they have a higher higher morbidity and mortality compared to the other ectopic pregnancy So let's just show some examples So this is a actually an example of interstitial ectopic pregnancy that was missed on the Point of care for something the ED. This is what they said. They said the patient had a abortion somewhere else she had FHM on the ED ultrasound but the patient wasn't doing well, so they wanted to form an ultrasound The first thing we see again why trans have done an ultrasound is so helpful There's a large amount of clots in the cul-de-sac and we do see this pregnancy and there was a live fetus But the pregnancy is very very eccentric right and if we look on The virtual ultrasound you can see that there is myometrium on one side, but no myometrium on this side here It's ultimately related to the uterus and there was a large amount of blood and this patient became Potency very quickly so very quickly shipped her to the OR and she didn't indeed have an interstitial ectopic pregnancy that had ruptured Here's her At the time of surgery So what are the findings? Okay? You have an eccentric gestational sac and you have the interstitial line sign Which is nicely shown on this clip where you see the endometrium and then it's That the corner portion is extending towards this gestational sac here There is no myometrium on the lateral aspect of the gestational sac and you can see very very large You draw in vessels oftentimes. These are these patients. This is a different patient You could see here's the ectopic pregnancy with these very very large vessels And you can imagine that if they ruptured the patient is going to become hypotency very very quickly This is an advanced case She was 14 weeks pregnant and in this case the pregnancy is eccentric But sitting on top of the u.s. Not level so again You have to be careful and recognize that this is actually not intrauterine It is too high and this patient was 14 weeks pregnant or she had an increasing abdominal pain the Transabdominal is I think as good as the vaginal study to show how eccentric This ectopic pregnancy is with no myometrium on this side here And again, she needed to have this section of a 10-some meter corneal mass So she didn't open that one So something about terminology a little bit Confusing but now the OB literature Recommend that we call these pregnancies interstitial and not corneal Corneal pregnancy is reserved for pregnancy that occur in the corner of a bicornad or septic uterus And then there is another entity called angular Pregnancy I shouldn't say topic angular pregnancy which implants in the lateral angle of the uterus Okay, so you have the interstitial ectopic. That's an interstitial portion of the fallopian tube You have angular pregnancy that are too lateral But still within uterus and then you have the corner pregnancy that are in the corner of a duplicated uterus And so sometimes it's difficult to differentiate those or 3d is maybe helpful because you can then obtain a true coronal point so again the differential diagnosis here is a Pregnancy in the this is a true corner pregnancy It's eccentric because it's one of the one of the bicornad uterus and again In this case you see my metrium around the gestational side unlike unlike the cases. I just showed you But if their diagnosis unclear, you can get a careful follow-up or you can get a pelvic MR Okay Now angular pregnancy is uncommon. Okay, this is implantation into the lateral angle of the uterus Medial to the tubular urine junction. It's technically intra uterine But it's fraught with complications with a high risk of urine rupture placenta acreta and spontaneous abortion And what you're going to see is a gestational side that is true lateral but still surrounded by my metrium and You can look for associated complications such as my metrial hematoma And this patient was actually she didn't want a pregnancy anyway So she was treated with metrotrexate, but we thought this was an angular pregnancy And again, I think the 3d can help. This is a case. I just showed you of Of the angular pregnancy, so you can see on the 3d that it's still within the and The uterus, but it's just at the edge instead of being more central here It's really at the edge, but there's some my metrium surrounding the side Whereas this is a true interstitial ectopic pregnancy, which is more eccentric And there is no my metrium on the lateral aspect here of this ectopic interstitial pregnancy Okay, another Less common type of ectopic pregnancy is cervical ectopic pregnancy, which are uncommon So there's implantation in the cervix, which would remain closed And it's really one of the main differential is whether it's a spontaneous abortion Which is much more common or cervical ectopic pregnancy But again, these also have a massive risk of bleeding if they're not treated accurately And the management usually methotrexate or KCL So here's some look at some example What you're going to see is a gestational site within the cervix that you have a live embryo like this case With a yolk sac. It's relatively easy to make the diagnosis but You can see the hourglass deformity of the cervix and if you're not sure Whether it's a cervical ectopic or an abortion in progress you can just get a follow-up and usually With abortion you have some change within 24 to 48 hours whether of course with a cervical ectopic The pregnancy will not move So this is an easy example because there was a live fetus in this cervical ectopic pregnancy This was very difficult to treat and what they did was they did a very careful DNC because there's a major risk of bleeding And then they put a fully in the cervix to try to temper it and actually this was successful Now what about this case So in this case You see this gestational sac and there was something in it This didn't have heart motion and we weren't sure whether it was a cervical ectopic with You know Demy's first and abortion. So what we did is get a follow-up ultrasound and 24 hours later This was gone But if you if you're not sure you can do an MR and you can see here these ectopic Implantation in the cervix with the cervical close in this sagittal MR and this was treated with Method like say Now abdominal pregnancies are very very uncommon. This is I've seen one or two examples What happens is that there's likely what a rupture to go like topic pregnancy that then runs into the abdomen What you're going to see in an empty uterus With a fetus that's separate oftentimes is oligo-hydramid or sometimes We have seen some cases that are more advanced and then MR is really great to make that diagnosis now another ectopic implantation that is becoming more and more common at least in the US because of more and more c-section is a Caesarean scar implantation technically again, they are intra-euroid, but it's still an abnormal implantation And so what happens is that this implants into the defect right there in the lower urine segment of previous caesarean section and Above something to think about because some of these patients are completely asymptomatic and you may be the first one You know making that diagnosis so what you're going to see as you can see here is that there is a Sack that is basically implanted into the C-section score. So it's a little bit It's too low an implantation, but only cervical ectopic is a little bit more Superior and oriented Entirely towards the bladder where the C-section score normally is and what you want to see is that there is if the pregnancy grows It is basically no myometrium between the pregnancy and the bladder And again, sometimes it's easier to see I think on the trans abdominal But you can see here. This is a patient with a history of lower to Seattle History of a prior myomectomy and C-section. She came for routine dating She was totally asymptomatic and you can see at the abnormal implantation of the gestational sack with no myometrium between the proper blast and the bladder and At lack rather than you could see this ectopic pregnancy Proving into the surgical defect again another example Same thing and if you're not sure the G1 wants to plan for treatment You can see on the MR again implantation in the C-section scar with no myometrium Or very thin myometrium between the bladder and the gestational sack. Now a very ectopic pregnancy is incredibly rare This is the only case I've ever seen so I always say if you see a mass in the ovaries It's not going to be an ectopic pregnancy. It's going to be a corpus serum This is the only exception I've seen of this lesion that was intimately related to the ovaries There is a yolk sack here and But that's really the only example I've ever seen so I think they're incredibly uncommon Something that's not as uncommon is ectotopic pregnancy Where you have an intravenous pregnancy with an ectopic pregnancy it's more common in patients treated or for infertility and The challenge again is that remember I said if you have an intravenous pregnancy in a patient's pregnant You can be easy except in these cases So what you're going to see is not only you're going to see an intravenous pregnancy But you're also going to see an ennexal mass Separate from the ovary and of course always look for blood in the pelvis or hemoparitoneum And we really have to have a high index of suspicion in this patient Any patient who is pregnant even if you see an IUP But there is blood in the pelvis or the patient's unusual amount of pain You should think very carefully and look very carefully Indian nexa and of course it's a management challenge as well Because you want to try most of these patients are fertility patients And so you want to try to save the viable intrauterine pregnancy So couple of example patient who IVF abdominal pain, so she has an IUP, but she has complex fluid and noisiness pouches the liver and So she has hemoparitoneum and so we look around very carefully and here's for ectopic Pregnancy so she had an IUP with an ectopic pregnancy and Fortunately, they were able to take out this ectopic pregnancy and her IUP remained viable and finally can we diagnose rupture of ectopic pregnancy basically the The bottom line is that you really cannot if you see a lot of see fluid or free blood That's a better predictor, but basically what I always say if I see a lot of Fluid in the pelvis or even more so in spots It could be a butthurt means the tube is actually busted or just leaking But the pregnancy itself is bleeding and the blood is coming out the Affinbiated end of the fallopian tube and basically probably doesn't matter because if there is a large amount of blood in the abdomen This patient will need to go to the OR Okay, so this was a large it's on the middle hematosepins with large amount of blood in the pelvis and This was a ruptured ectopic pregnancy and the other thing the important We should have mentioned that the mass was too large to be We move that easily from that roscopy this patient is a Unfortunate girl who was pregnant with large amount of blood tons of blood as you can see Here's for ectopic pregnancy and all the way for all the world look like it's a ruptured ectopic pregnancy in her case It was just unruptured the bleeding from the fimbriana in and she had worse amount of hemopere to me so in the end When you do the ultrasound report, it's really should be geared to work out management because I for potential management strategy So you're going to look at the size of the adnexal mass the presence of cardiac activity the presence and amount of abdominal and pelvic blood and if you need a follow-up you should you should recommend it because Basically, there are several things that can happen occasionally. We've seen spontaneous resolution of ectopic pregnancy and so this patient have a very small mass with low ACG of course, no handbrake and heart motion and Perhaps less vascularity on color Doppler also that's kind of questionable and these patients sometimes may be just followed If the pregnancy is very small and left to be resolved on its own Or of course, you can take with methotrexate, which is now fortunately one of the very common Thing we can offer to this patient avoid surgery on their fallopian tube provided that the adnexal mass is smaller than 4 zonin meters And there's no embryonic cardiac activity It's also the management of choice for this unusual location of ectopic pregnancy such as cervical ectopic pregnancy or interstitial ectopic pregnancy if they're diagnosed early enough And then of course either laparoscopy or lapwater knee is reserved for patients who are hemodynamically unstable Or have very large ectopic pregnancy or have embryonic cardiac activity or have failed methotrexate therapy And finally Or interventional Occasionally again in this unusual ectopic pregnancy You can either offer methotrexate or sometimes KCL injection to basically do You know kill the embryo or you can also offer you an artery embolization