an ectopic thread...
From: DRoss38040 (DRoss38040@aol.com)
Thu Dec 18 01:39:08 1997
Hi, folks!
I'm going to attempt to forward to you a thread from another list. I know you
will all be interested! I'm separating all the posts by dotted
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<<Dear colleagues :
Let me share this case with you.- 31 yrs. old female with 3 c-section
the last one was in 1991, she had IUD for 6 continued years until
January 1997.
No contraceptive methods the present year, LMP: Oct 9 97.
Positive quantitative blood pregncy tests (+) 17,000 IU Dec-1 97
34,000 IU Dec-8-97
62,000 IU Dec-11-97.
clinical findings: she started with a continues dark blood spotting
since 3 weeks ago with no clots and no pain at all , until now.
The first vaginal US Dec 8 97: showed a large occupied uterus with a
mixed shadow ( a sac ??) 6 x 5 x 5 cms no gestacional sac, no vitelin
sac neither, no embryo. There is a left adnexal cyst, 5 x 5 x 5 cms
Mixed also ( corpus luteum ??), and the rest of the vaginal US findings
are negative for an ectopic pregnancy so far.
Mild pain with bi-manual exploration.
Today Dec 11 97 the US findings are the same and the sub Chorionic B
unit is 62,000 IU. No acute syntoms. Just the dark blood spotting.
Our diagnostic possibilities are: alive (active) ectopic pregnancy (some
where), trophoblastic disease or uncompleted abortion.
Treatment.- an other quantitative pregnancy blood test and wait
Laparoscopy and D and C
Or just D and C.>>
ANSWERS:
In a message dated 97-12-13 17:59:24 EST, you write:
<< Positive quantitative blood pregncy tests (+) 17,000 IU Dec-1 97
> 34,000 IU Dec-8-97
> 62,000 IU Dec-11-97. >>
definitely an ectopic. repeat sono by outside lab and prepare for surgery.
Diana Ross, RDMS
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Why repeat the sono????? You just said it was definitely an ectopic. How
would repeating the sono help you???
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>>
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I thought it should be visible by now. Also, I always thought it helped you
surgeons to know the size and location and amount of free fluid, if any.
Otherwise, just go ahead! I am a sonographer, so I think in those terms,
that's all.
Diana Ross, RDMS,RT
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I agree with these diagnostic possibilities
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D&C + macroscopic examination +/- frozen section and laparoscopy if
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nothing in the uterus.
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My first differential would be an ectopic pregnancy and I would have
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laparoscoped her already!
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The only role of sonography in ectopic pregnancy is to say "It ain't in
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the uterus." I have had at least three diferent occasions where the
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sonographer has called an ectopic pregnancy and at surgery, it has been
intrauterine. The sonographer needs to see a clue line or not.
Size, location, and amount of fluid will not change what I am going to do.
If you can tell me the fluid in the peritoneum is blood, that could change
my approach.
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<< Size, location, and amount of fluid will not change what I am going to do.
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If you can tell me the fluid in the peritoneum is blood, that could change
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my approach. >>
Sorry, I wrote my message incorrectly. I meant size and location of the
ectopic, and presence or not of fluid. Transvaginal sonography is essential
for ectopic pregnancy confirmation, so this should be specified. Missing the
IUP three times is a pretty bad record. You should try to get better
sonography somewhere. If you make sure that the sonographers are
credentialled, you will have a better chance, I'm sure.
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The only reason to evaluate the fluid is in the case of a rupture, where there
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would be quite a lot of blood. Then you would need a good amount of blood
available for transfusion, wouldn't you? Of course the HCT would probably
tell you that as well.
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The other reason to repeat the sono before surgery is to confirm. An IUP
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which is missed at 4.5 weeks is much more easily seen at 5.0 weeks, 3-4 days
later. Same for an IUP of 5.0 weeks, which is much more obvious at 5.5 weeks.
Also, if there is an ectopic, a few days will increase the size quite a bit.
Sorry you've had such poor sonography service.
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My poor sonography service was provided by academic Radiologist
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sonographers. My point is that no one can call an ectopic with certainty
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by seeing it on ultrasound. My second point is that you can not tell me by
ultrasound whether the fluid in the peritoneal cavity is blood or
peritoneal fluid. I always get blood ready for transfusion anytime I have
an ectopic. I also never wait until the blood is ready to start.
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As an
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>Ob/Gyn/RE/Ultrasonographer, I have to take exception to your
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>statement that "no one can call an ectopic with certainty by seeing
>it on ultrasound". I find no other possible explanation for an
>adnexal fetal pole with FHTs - looks like a certain call to me.
Like a scan I just did on a woman who underwent bilateral
salpingectomies in the past and conceived through IVF--beautiful 7-week
viable IUP and not-so-beautiful 7-week embryo with heartbeat in the
right tubal remnant. :(
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I'm sorry to disagree with you, but it is not true that no one can call an
ectopic by ultrasound. I have no idea where you practice or even what country
you live in. In New York City, experienced sonographers are expected to be
able to call an ectopic based on the sonogram, using transvaginal sonography,
with some help from the BHCG numbers. Most often an ectopic has one of
several appearances. Those with little experience will see a corpus luteum
cyst and say they cannot rule out an ectopic pregnancy. Those who have the
specialized experience it takes to work on these cases, know that the ectopic
pregnancy is most often a separate mass between the uterus and the ovary. In
the instances when it is attached to the ovary, or in the ovary, we should
still be able to diagnose it. The BHCG numbers and the LMP should tell us
when we should see an IUP. Neg IUP, BHCG1,000-2000 and 5 weeks since LMP is
highly suspicious. Neg IUP at 5,000 is really a definite ectopic as long as
the numbers are still rising. Neg IUP at 5,000 with an adnexal solid mass or
douhgnut-shaped mass is a definite. Still, it doesn't hurt to repeat it just
before the surgery, just in case the IUP appears. This would avoid surgery on
IUP's, as you yourself have unfortunately experienced.
You are taking a rather strong attitude, but I don't blame you, since your
neighborhood sonography lab has disappointed you so often. But please don't
blame sonography on some poor practitioners. I don't know what Radiologist
sonographers are, but I suggest that you ask again if the sonographers are
experienced in Ob-Gyn and are credentialled by the ARDMS. You wouldn't
believe the variability in the technologists' talents out there, due to
financial and other concerns. Also, I question the abilities of the
Radiologists themselves.
Better yet, find a better lab...
Diana Ross, RDMS,RT
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Did this group of messages come through in an understandable fashion? I hope
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so....
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Any comments?
Diana Ross, RDMS, RT
