 This last lecture is on ectopic pregnancy, meeting the challenge, and what I'm going to try to do is, you know, focus on the perhaps the less common aspect of ectopic pregnancy, the less common location. So I hope you find it interesting. So we all know that it has increased significance of ectopic pregnancy, it has increased significantly over the past several years. Probably for two reasons. First of all, there is a dramatic improvement in detection of ectopic pregnancy, thanks to endovatural ultrasound and combination of endovatural ultrasound and conundated cell and beta-ACG. And also there is an incidence of contributing with factors such as pelvic inflammatory disease, treatment for infertility, smoking, etc. The good news is that with endovatural ultrasound, we have been able to achieve early diagnosis which decrease not only mortality, but also morbidity, as well as allow less invasive treatment with better preservation of future fertility. We'll go one by one through these challenges. So first of all, just in any woman of reproductive age, think about the possibility of ectopic pregnancy, no matter what her presentation is. Because a classic trial of abdominal pain, vaginal bleeding, and capital ednexal mass is actually not that common. So this is a good example. This is a patient who came in here, so she said, oh, the patient, check for IUP, the patient's pregnant, and just write up a part of the pain, check for acute colostitis. For God's sake, that was normal. But she had some fluid, I should say. It's not a psilitis actually. In a young woman, always think about the possibility of ectopic pregnancy. So we looked in the pelvis, and of course she did not have an IUP, but she had an ectopic pregnancy with blood in the pelvis, as well as blood in the moist and spout, and that was what brought her to the emergency room was, her vital compartment pain. So always think about the possibility of ectopic pregnancy in a young woman. If a pelvic ultrasound is not a water, just look for it. Now, is trans-abdominal ultrasound still necessary? You know, again, we want to do things as quickly as possible, and often times, at least in the US, they just order transvaginal ultrasound. I really think in patients with ectopic pregnancy, it is absolutely necessary to do a trans-abdominal ultrasound. But overall, it allows you to very, do a very quick survey of the abdomen. So this patient who had here no IUP, large amount of clot, and probably the ectopic right here in the pelvis, we could quickly move the transducer up to the upper abdomen. She did send a primoperatinium and basically sent her to the OR. This other thing is, I think that trans-abdominal ultrasound is really, really helpful in clarifying ectopic pregnancies in unusual locations. Now, the other thing that is important is to distinguish early IUP from its mimic, because now one of the treatment for early ectopic pregnancy is intramuscular methotrexate, or for medical abortion or failed IUPs or misoprostos. So we do not want to give methotrexate to somebody who could have an early IUP, right? So, and now we're doing really many of these early topics with the treatment with our laparoscopy. So it's really important, in my opinion, to make sure that you know that there is no viable IUP. And actually, there have been lawsuits that in the U.S. for patients only being given methotrexate, when we weren't sure whether it wasn't made clear that that could be a viable IUP, you know, if the report is vague. So it's really, really important. Okay, so responsibility of our response is to make sure that we don't terminate a potential abnormal IUP. And because most women are human that may be stable, we're really, if you're not sure, we have opportunity to do follow-up either with serum or ACG or follow-up ultrasound. So when I have questions on ectopic pregnancy, the first thing I do is look at the universe, because it's easy to diagnose even for even pregnancy, right? So 90% of patients will refer to a real ectopic actually have an IUP. And heterotopic pregnancy or the presence of an IUP with an ectopic pregnancy is actually uncommon. So if you have a pregnant patient and you've located the pregnancy in the universe, you pretty much can breathe a lot easier, unless there are exceptional circumstances such as patients who are treated for infertility. So let's look at the first challenge. It's known to recognize very, very early IUP and differentiate it from its mimic. So here, this is an example of very early brain pregnancy. This is an intra-dissiduous sac and very small gestational sac. But the reason I think it's a gestational sac, it's just underneath the endometrium and it has this subtle ecogenic border, right? So this I would say that if I reported this case, I would say it's very likely that it's a very early brain pregnancy. However, of course, I don't see a young sac, I don't see fetal pose, I cannot comment on the viability of the pregnancy, but I think it's more likely that this patient will have an early IUP and just follow the data in CG. But in this case, this is very different. There is fluid in the endometrium, the endometrium will slip. This is inside the endometrium. So this is not a gestational sac. This is a pseudo-gestational sac in a patient that had an ectopic pregnancy. So just learn how to recognize a very, very early sign of a very small intra-uran gestational sac or early intra-uran pregnancy. So that this patient, you can be very clear that I think this could be an IUP and don't get this patient methotricent. So with ectopic pregnancy, what are the endometrial findings? Because the endometrium will undergo the decidural reaction from the hormone changes of the pregnancy. So you may have one more endometrium or you can have a thick endometrium just as we see in this case and this patient had a small ectopic pregnancy right there. Or you can have this decidural cyst, which are these eccentric cysts. Now why is this a decidural cyst and not an interstitial cyst? It can be a little tricky, but this one doesn't have as well defined ectogenic border. I have to admit this is a little tough, right? And we always look very carefully at the index sign this patient had an enoxal mass. And so she did have an ectopic pregnancy. In this old paper, Ryan's from Winnipeg thought that they had the 80% positive predictive value for early ectopic pregnancy if you saw this decidural cyst. I have to admit it's very, very uncommon to see that. So I'm not sure I buy what they said, but I just want to put it out there because it was published. So if you have cystic structure in the uterus, it could be just fluid or it could be early gestational sacs. This one, we don't see anything in there. This one, we see a little yolk sac. However, you have to be careful because what about this case? So this one kind of looks like a gestational sac, but it has internal echoes. And again, we always look very carefully at the index. So this patient happened to have also an ectopic pregnancy. And what we thought was that this was a pseudo-gestational sac. What happens is sometimes there is hemorrhage within the decidural reaction of the annumetrium, and it can look like a pseudo-gestational sac. This patient was treated with metrotrexate, failed, and underwent a sub-injective. So the other thing is we need to, if we see an annex on mass, we want to see is that in the ovary, because if it's in the ovary, it's much more likely to be a corpuscedum, or is it separate from the ovary in the fallopian tube, and that is much more likely to be an ectopic pregnancy. The vast majority of ectopic pregnancy are in the empyrean portion of the fallopian tube. So the ultrasound findings are pretty simple. No IUP and an annex on mass separate from the uterus. And this has a very high specificity and sensitivity in this really old study, but they still hold still today. So the direct sign of ectopic pregnancy is the annex on mass separate from the ovary. So sometimes if you're not sure whether a mass is in separate from the ovary or not, and here it's pretty clear this is a corpuscedum and this is ectopic pregnancy, you can kind of push on the ovary, do a bimanual, push on the ovary, or the mass with a vaginal probe and push on the belly with the other hand, and you'll see that these two moves kind of separately. And so you know that this is an annex on mass separate from the ovary. In this case you could see a yolk sac and pita pole as well. So that's pretty clear that this is an ectopic pregnancy. Now it's very uncommon to actually see a life fetus. That's a least common presentation. A more common presentation is in a gestational sac. Again, why is it calling an annex on wing? Because it has a cystic area with a nicotinic border. Now this one has a yolk sac, so it's clearly a small ectopic pregnancy and this was treated with mesotrexate with very good response. Or sometimes you will just see an annex on wing. In this case, the important thing here is that the patient was pregnant, has no IVP and has a mass which is separate from the ovary. She was treated with left septum justinum. This is another example. Again, variamorphous mass. Again, you have to make sure that you can separate this from the adjacent ovary because most ectopic pregnancies are in the fallopian tube. And sometimes all you'll see, and I saw a case recently, all you'll see is just basically hematosapines. You have a tubular structure filled with this amorphous material. But if you look very, very carefully in the hematosapines, sometimes you'll see the ectopic pregnancy. And this is a pregnancy that was bleeding inside the fallopian tube. Now, she had a very high CG. She was very symptomatic, so they did this up in justinum and was able to take the ectopic out. She also had hematosapines and they repair the fallopian tube. Now, again, just to show you how you differentiate a mass, is this mass in the ovary, or is it adjacent to the ovary? The ovary has a big copper student. This patient also was pregnant, had complex bleeding in the coliseum. Every time you have ectogenic fluid in the colostar, in a patient who is pregnant, they have to be concerned that this is an ectopic pregnancy, right? And again, you press, you do a bimaneral with the vaginal probe on one hand, the hand on the top of the woman's belly on the other hand, and you'll see that this moves separately from the ovary.