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Ectopic Pregnancy

Shieva Ghofrany: [00:00:00] Okay. Happy Tuesday. It's been a busy OB day, C-section. A lovely delivery on someone I've known forever. You know who you are. I love you. Um, some other people in labor going rounds, getting to chat with nice people. Okay, we're gonna talk about ectopic pregnancies cuz a bunch of people have been asking. So ectopic, E C T O P I C. 

It means outside of the place, literally in Latin EC means outside top means place. But in our case, the place would be the uterus. So a typical pregnancy, you know, is what we call an intrauterine pregnancy, the vernaculars, i u P. What happens is you find out you're pregnant if you are having any kind of. 

Side of just regular cramps or any sort of spotting, then you should go see your gynecologist because what he or she will do is if you're very early, like you've just missed your period, they'll do a blood test. I'm gonna talk about what [00:01:00] the blood test will show in a second. So they'll do a blood test knowing that that early on they won't be able to see an intrauterine pregnancy. 

Meaning if you've just missed your period and you are four weeks out from your last period, if you've had a 20. Cycle. Then it's way too early to see anything on an ultrasound in the uterus. An intrauterine pregnancy will only show up on some of the amazing machines at like four and a half to five weeks you'll see a gestational sack. 

Most machines in our offices, I would say around five weeks, we see what's called the gestational S sac. So the purpose of going in is whether or not they've told you this, Hey, I've got some pain on one side or the other. Hey, I'm spotting the nurses, secretaries. Doctors will say to you, okay, come on in. 

We'll do some blood work. We'll check things out. They're not saying it, but what they mean is we are constantly in our minds ruling things out and we are ruling out an ectopic pregnancy, and there's a bit of a process. The first blood test when you've just missed your period, meaning four weeks from your last period [00:02:00] or two weeks from when you think you've ovulated, if you have more than a four week cycle, that first blood test ideally is a little bit over a hundred. 

and your progesterone level. That is not always, um, run, but it can be run in certain labs. We're lucky that our lab can do it pretty quickly. The progesterone level, when it's above five, is pretty rare. To be an ectopic between five and let's say about 20 is a pretty good range above 20. Most people consider really good. 

So let's say I'll get that first blood test back and I'll have done an ultrasound and we'll talk about it in a second. And let's say the blood test says, oh, the number was like 110, and the progesterone is like 18 or 22. The blood work makes me happy. I will have already done an ultrasound in the office to rule out an ectopic that is obvious. 

And what that means is you look at the. Expecting to know that you will not see a pregnancy inside it, but you'll also look at the area next to the uterus, which is called the adnexa, which just means kind of next to the uterus, and it [00:03:00] involves where the ovaries and the tubes are. When an ectopic pregnancy occurs, the most common place for it to grow outside of the uterus is in the tube, and a tube is a very. 

Thin, much thinner than our finger. Even the opening or the lumen of the tube is a couple of millimeters, so when that little embryo attaches in that tube and it grows, you will see it because you'll see a distended tube even when you would not have seen a pregnancy in the uterus. Right? The only way to see the pregnancy in the uterus is when the embryo implants in the uterine wall and then, Sack is formed, and after the gestational sack, which just looks like a little black bubble, you'll see the yolk sack, which is another little black bubble. 

It's like what the baby kind of feeds off of early on, we say, and then you see a little, what I call the grain of rice. Um, and that's the fetal pole. And ultimately you'll see the heartbeat. What we say in our world is to prove it's an intrauterine pregnancy, you need to see not only the gestational sack, but also a yolk s sac, because the gestational sack can sometimes be actually just blood [00:04:00] and mimic. 

Intrauterine pregnancy. What you need to rule in an ectopic is basically visualization of something that is growing in typically the tube. But the truth is sometimes you don't see anything in the tube. You don't see anything anywhere outside the uterus. You don't yet. See an intrauterine pregnancy because the numbers would not show that enough, right? 

Because you're so early. So the next step is give the patient precautions. If you have worse pain, you need to go to the emergency room. Um, or the alternative is we're gonna wait and watch. We're gonna repeat your blood test in 48 hours because all the data shows that. 48 hours from the first blood test, the H c G level should go up at least 50%. 

We used to say double back in my day, 20 plus years ago. And then the data came out saying, really, it's okay to be 50%. And some of the new data would even tolerate lower levels of rise. But just to give you the numbers, that means if you started out at like a hundred the day you missed your period, by 48 hours later, it should be at least a hundred and.[00:05:00]  

In a patient who still doesn't have any pain. So you kind of keep watching until you get to the point at about five, five and a half weeks where you see an intrauterine pregnancy. Now between, I missed my period to seeing an intrauterine pregnancy. Either the ectopic can present itself. The first time you saw them, they were a little crampy. 

You didn't see anything. You give them good precautions. They come in two days later, three days later, four days later, and they all of a sudden an ectopic does show up on the ultrasound. That doesn't mean the ec. Didn't exist before, it's just that it wasn't able to be seen. And if the patient is not in pain, then you would not proactively go ahead and operate on them. 

For example, now let's say you go from four weeks past your, your period number is about 102 days later. Remember I said it should be at least one 50. Let's say it just goes from a hundred to 105 in a patient who now has inappropriately rising H C G or what we call quant, cuz it's h c G hormone. the quantitative value. 

So now you have an inappropriately rising [00:06:00] quant. Let's say it's coupled with a progesterone that is really low. Now you can counsel the patient that the likelihood is that it is an ectopic. You might see the ectopic on the ultrasound, meaning see a distended tube, or you might not see anything. And then we call it a pregnancy of unknown origin, p u O. 

And that is still considered an ectopic until proven other. Now there's always that chance that that inappropriately rising quant is actually just a, um, non-viable intrauterine pregnancy. But until you can prove that, you have to have a very high index of suspicion and a very low threshold to label it in ectopic for the safety of the patient. 

Because if it is growing in the tube, it can rupture and people can bleed briskly and. Sounding, um, inflammatory people in the past have died from ectopics, so inappropriately rising quant. Once we've kind of proven that, then the choice is, if you see it in the tube, you could do surgery, [00:07:00] but if there's under certain thresholds, so we have certain criteria like below a certain size and below a certain, um, amount of H CG hormone. 

You actually instead, which is preferable as avoid surgery and administer methotrexate. You guys might have heard of methotrexate because it's not only a drug that we use often for patients who have systemic lupus, rheumatoid arthritis, things like that. So autoimmune or rheumatology issues, but it's used for chemotherapy because it's way, it's mechanism of action is that it stops the dividing cells. 

So in this case, we're not using it for chemo. We're using it because the patient has cells where the egg and the sperm got together. They're growing in the wrong place. We have to help her by stopping the dividing cells. So we give methotrexate. It's a single dose. It's very safe. When you Google it, of course you freak out because you read all kinds of things about chemo. 

Um, and while there can be risks and ti side effects, those are usually rare. And your doctor will have already gotten a baseline of your liver, your kidneys, and your blood count to make sure that they're all okay. Been [00:08:00] some data in the news lately in certain states where they have talked about if you diagnose an ectopic, you should take the ectopic pregnancy and implant it into the uterus. 

People, if you have heard this, it is like bizarre that they are talking about this. We are not in like the year 3000 science fiction where maybe sometimes people will be able to do crazy things when the embryo has implanted into the, the inside of the tube, it is actually attached. And burrowed in there and it will grow. 

There's no way to detach it and then transplant it into the uterus and have it become a viable pregnancy. So any of you who are in those states, were there talking about that. I'm sorry. That they have led you down a path of like psychosis. It would not work. Okay, so we've discussed if you have pain or irregular bleeding. 

When I say pain, I don't just mean cramps, like a period pain, like irregular bleeding or irregular bleeding. You go to the doctor, they need to rule out an ectopic. There will be a gray area for some people where we're not sure, is it an ectopic. Or is it an intru pregnancy that's just not viable? [00:09:00] Um, so let's say we've had two points on the line. 

We've had the blood test today, we've had the blood test 48 hours later. It's not going up appropriately, but in a patient who really doesn't want methotrexate yet, then depending on the patient and depending on the relationship we have, and if we really feel like the patient understands and is very compliant and will come to us if the pain gets worse. 

Then I will sometimes let them go in extra 48 hours test again, because maybe if it's a non-viable pregnancy, we'll actually just see the HCG levels go down on their own. And then we've avoided methotrexate. But that's not always the case. And it also depends on where you live and how close you are to medical facilities and the relationship you have with the doctor because they have to feel like they can trust you for your sake, and they have to feel like they can trust you because if God forbid, something happens, they're the ones responsible. 

Okay, what if you have the ectopic, you get the methotrexate, then? Day zero is the day you get your methotrexate, and then you are checked again for your H CG hormone on day four and day seven. But here's the important part. From day zero to day four, your HCG level might go up. Infected often does, and [00:10:00] you might get crampier. 

Day four to day seven is when we want to see a drop of 15%, and so from day four to day seven, we don't see a drop of 15%. You sometimes need an extra shot of methotrexate or rarely surgery. Okay? Once you've gotten that 15%, Then you're followed weekly to make sure the HTD goes down to zero. And then guess what? 

You can get pregnant again and have a healthy pregnancy. But there is that chance that the ectopic was caused by scarring in your tube that might recur. So depending on your history and things like that, you'll talk to your doctor about should you do any tests? Should you do an hysterosalpingogram? What is your, is your risk of ectopic in the next pregnancy? 

Cuz it does go up a little bit and it just means the next time you're pregnant, you'll go in for blood work early on, regardless. Pain, bleeding, things like that. So I hope that all makes sense. Ectopics are, unfortunately not so rare. They're something that every OBGYN pretty much every day of their lives when they have pregnant patients, are always thinking of, thinking of, thinking of, just so that they can rule them out. 

Luckily, they're often ruled out. [00:11:00] Second lucky is they're treated with methotrexate. Third is that occasionally they happen, they're not picked up on early, not because of, um, lack of paying attention by your doctor. But it's not always so straightforward and in that period of time where we're still waiting and watching to see if we can declare whether or not it's an ectopic, that ectopic can sometimes burst. 

And the vast majority of time you get to the hospital, you have surgery. , that is not fun, but you will be okay once they get in there and remove the ectopic. Okay? I hope that helps. It's not an easy, quick subject.