OB-GYN-L Messages for October, 2006: Re: Second difficult pregnancy

Re: Second difficult pregnancy

From: Andrew Folley

agfolley@hotmail.com

Mon Oct 23 12:54:21 2006

The next ultrsound is 6 days later. In a normal developming pregnacy, over the course of 14 days one should expect to go from a gestational sac to seeing a yolk sac, to seeing a fetal pole (day 44) to seeing a fetal heart beat day 46 (6 weeks 4 days from LMP or 4 weeks 4 days from conception.

Most likely the perinatologist is correct. However, it would be nice to have 2 ultrasounds 2 weeks apart that do not show this nomrla progression before embarking down path of termination. Having a sac on 10/11 and 6 days later not seeing a fetal pole is not necessarily diagnositic of missed abortiion or blighted ovum. However, one should expect to see at least a 4-5mm yolk sac at the ultrasound on 10/17. (By the time one sees a 10mm gestationsal sac we should be able to see the 4mm yolk sac. By the time the gestational sac is 20mm (day 50) we should see a fetal pole)

You do not want to have a doctor who drags out needless hope for a patinet when it is obvious that there is no chance for a pregnancy. At the same time we do not want to be too quick to "right off" a potentiallynormal pregnancy. there is little risk , emotional or physical to rechecking a final trans vaginal ultrasound 7-8 days after the 10/17 ultrasound (ie this week). If there is no fetal pole then absolutely this is non viable and cytotec or out patient D&C or letting natrue take its course would be appropriate. agf

>From: jimwangmd@yahoo.com (Jim Wang)
>Reply-To: ob-gyn-l@obgyn.net
>To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>
>Subject: Second difficult pregnancy
>Date: Sat, 21 Oct 2006 11:22:22 -0500
>
>Dear physician colleagues:
>
>My wife's first pregnancy a year and a half ago was terminated at 22
>weeks after the baby was diagnosed with tetralogy of Fallot and other
>anatomical abnormalities. Chromosome analysis of both my wife and
>myself were normal. Aborted fetal tissue was contaminated/infected and
>therefore no analysis results were obtained.
>
>The current pregnancy: LMP was 8/20/06. She has been having spotting of
>brown and dark red blood since the beginning. We first saw OB doctor on
>9/27 regarding the bleeding. US was performed and showed no sac in the
>uterus. Serial BHCG were ordered, and we were referred to see a
>perinatalogist on 10/11. The perinatalogist performed TA and TV US on
>10/11 which showed 1 partially collapsed sac 1x0.3cm and another sac
>1x1cm, however, no fetal pole and no FMB (?fetal maternal bloodflow)
>were detected in either sacs. Serial BHCG were again ordered. US
>repeated by the perinatalogist on 10/17 showed both sacs slightly
>larger, however, no fetal pole nor FMB were detectable. Repeat
>chromosome analysis on parents are normal again. The brown spotting
>continues periodically throughout the day. The following were the
>serial BHCG results:
>
>9/27 BHCG = 2,700
>9/30 BHCG = 6,080
>10/03 BHCG = 12,189
>10/11 BHCG = 30,000
>10/17 BHCG = 45,343
>10/20 BHCG = 45,403
>
>We were given the diagnosis of missed AB and told that there is no
>chance of viable pregnancy and advised D&C, Cytotec or waiting for the
>body terminate and
>expell the pregnancy tissue. My wife would not want to wait if there is
>indeed no chance for a normal baby and would choose Cytotec. I believe
>waiting is useless. However, my wife found- from patient internet
>discussion websites- similar cases where initial "emty sac" on US
>imagings were later found at 10 weeks to have fetal presence. Now she
>is hesitant about intervention.
>
>1. Is there any reason to wait further? If so, how much longer?
>2. Any advise regarding prenatal studies or intervention prior to
>trying 3rd preganancy? Would IVF give better outcome than natural
>conception?
>
>Appreciate any input greatly.
>
>Regards,
>Jim Wang, MD
>A non-OB/GYN physician
>

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