Re: intrauterine ectopic
From: art fougner, md (evsono@pipeline.com)
Mon Aug 26 07:28:54 2002
Terry -
sure as long as the measurements mean something - "measure twice, cut
once & you'll save a lot of wood" is an old carpenter's expression that
works. BUT - if your measurements have not been validated for a
particular situation - then garbage in -> garbage out may apply. in the
end we all subscribe to Hunter's theorem - "works for me!"
art
At Sun, 25 Aug 2002, Terry J DuBose wrote:
>
>No argument from me either. Obviously the larger the structure the more
>accurate the measurement because a few pixels at 1-3 mm will be a larger
>percent error than those same few pixels at 10 mm or more. For this
>reason the CRL continues to be more and more accurate until the
>embryo/fetus begins to flex and extend, or gets too large for the field
>of view. There are CRL tables out to 18-19 weeks, but the accuracy is
>less than that of the head at that late date. However, I have found
>that we can measure very early simply by measuring the mass of cells
>where the cardiac activity is observed.
>
>Often we are called upon to evaluate a pregnancy for early spotting and
>we don't always have the luxury of choosing the exact date. If it is at
>5-6 weeks, then I always measure the mean sac as well as the CRL and EHR
>for age. If all three give a similar age, then that is a "warm fuzzy",
>but if the EHR trails the CRL age by more than 6 days, then it is
>worrisome. The mean sac is more variable due to shape differences due to
>the placement in the uterus, degree of bladder pressure, myomas, etc.
>However, I did not like the sac after 7 weeks because the CRL is much,
>much better at that time. Even the EHR age is better than the mean sac
>in normal embryos, but nothing is better than the CRL after the 6th week.
>
>Granted, in the 5th week we are dealing with some variables we don't
>completely understand... the implantation date and it's influence on
>growth... and very small structures with larger percent errors.
>
>Not only was Robinson and Shaw-Dunn's CRL table very good for the
>equipment they used, their EHR was also remarkably accurate. Only they
>apparently could not see the EHR before about 7 weeks, and only saw the
>two week acceleration to the early 9th week. Others who measured the EHR
>later, with better equipment saw the earlier acceleration (Hertzberg,
>Mahony, Bowie: 1st Trimester Fetal Cardiac Activity; JUM 1988,
>7:573-575), but they completely missed the high peak rate in the early
>9th week that Robinson & Shaw-Dunn documented. They missed the peak
>because they did not use M-mode, but tried to visually count the heart
>rate that reaches 175+ and only found a plateau around 140-160 B/M.
>
>I like all the measurements I can get... the more the better, whenever it
>is...
>
>Peace, Terry J DuBose, M.S., RDMS
>Little Rock, Arkansas USA
>
>On Sun, 25 Aug 2002 19:07:38 -0500 evsono@pipeline.com (art fougner, md)
>writes:
>> i agree - anecdotally first tried to date a pregnancy from a 6 wk
>> fetal
>> pole only to find myself wiping the yolk off my face so to speak at
>> 13
>> wks when i not surprisingly redated the pregnancy. i avoid
>> assigning
>> dates until crl is at least 7 wks size. amazing how hugh
>> robinson's
>> table worked out - even with the old compound b scanner.
>>
>> art
>>
>> At Sun, 25 Aug 2002, Allen Worrall wrote:
>> >
>> >I am of the opinion that measuring the greatest embryonic length
>> (not
>> >properly called a CRL in a very early embryo) is a somewhat
>> imprecise thing
>> >at 5.5-6 menstrual weeks, because it is difficult to know exactly
>> where to
>> >put the cursors on a very early fuzzy embryonic pole. And MSD is
>> not very
>> >precise (but can be measured more precisely than greatest embryonic
>> length,
>> >since you can be pretty sure where to put the cursors when you are
>> measuring
>> >the gestational sac). I feel this way despite having a very good
>> machine,
>> >excellent transvaginal probe, and ability to enlarge the embryonic
>> pole as
>> >much as needed.
>> >
>> >I have the feeling that gestational age may be more accurate when
>> measured
>> >at 7-8 weeks, when the embryo is larger and you can see just where
>> to put
>> >the cursors.
>> >
>> >Anyone have a comment pro or con?
>> >
>> >Allen
>> >
>> >Joseph A Worrall MD RDMS
>> >OB/GYN Ultrasound at the Fairbanks Clinic
>> >Fairbanks, Alaska, USA
>> >jworrall@alaska.net
>> >http://www.obgynsono.com
>> >
>
>>>> >>----- Original Message -----
>> >From: "Terry J DuBose" <tjdubose@juno.com>
>> >To: "Multiple recipients of list ULTRASOUND"
>> ><ultrasound@mail.medispecialty.com>
>> >Sent: Sunday, August 25, 2002 9:52 AM
>> >Subject: Re: intrauterine ectopic
>> >
>> >> Dr. Fougner, I agree... I have also seen EHRs at 1 mm...
>> correlates to
>> >> about 5.0 weeks after LMP and a mean EHR of of 94 B/M (my table
>> 7-5,
>> >> Fetal Sonography, 1996. The heart rate will usually accelerate
>> at a rate
>> >> of 3.3 beats per minute per day from when it is first detected
>> until a
>> >> CRL of 2.6-2.8 mm or 9.2 weeks before beginning a deceleration
>> from a
>> >> peak of about 189 B/M at 9.2 weeks (+/-1 to 2 days). The EHR
>> time series
>> >> curve has the shape of a classic damping feed-back curve.
>> >>
>> >> Dr. Ronald Shats, Amsterdam 1991, TV Sonography in Early Human
>> Preg. said
>> >> that if you see cardiac activity you are seeing the embryonic
>> pole. He
>> >> also indicated that one of the problems in getting an exact age
>> is there
>> >> appears to be a variation in time of first heart beating due to
>> >> variations in implantation times. On page 39 of his dissertation
>> that
>> >> "References to days are given only as guidelines and thus are
>> >> approximations of the truth because early stages of implantation
>> of the
>> >> human blastocyst have not been observed. Most knowledge about
>> early
>> >> implantation is based on studies of the Rhesus monkey, but the
>> process is
>> >> thought to be essentially similar to man."
>> >>
>> >> Sonography has given us a very early window on embryonic
>> development.
>> >> The correlation of the CRL, EHR, and hCG have not been thoroughly
>> studied
>> >> and are not well understood. We have gotten to within about 3
>> days of a
>> >> "true" date, but can't seem to resolve it more than that.
>> >>
>> >> One of the most interesting questions in human development,
>> IMHO.
>> >>
>> >> Peace, Terry J DuBose, M.S., RDMS
>> >> Little Rock, Arkasas USA
>> >>
>> >> On Sun, 25 Aug 2002 11:08:06 -0500 evsono@pipeline.com (art
>> fougner, md)
>> >> writes:
>> >> > Martin -
>> >> >
>> >> > have seen as Terry so fondly calls it - embryonic cardiac
>> activity
>> >> > with
>> >> > 1 mm fetal poles using 7 - 8 Mhz frequency vaginal
>> transducers.
>> >> >
>> >> > Sharon -
>> >> >
>> >> > have seen for want of a better term - intra-amniotic yolk sacs
>> twice
>> >> > -
>> >> > both pregnancies ended in spontaneous Ab. wonder if your
>> findings
>> >> > could
>> >> > represent the early appearance of the extrachorial gestation?
>> do
>> >> > you
>> >> > have images? i sense a case report.
>> >> >
>> >> > art
>> >> >
>> >> > At Sat, 24 Aug 2002, Sharon Brown wrote:
>> >> > >
>> >> > >At Sat, 24 Aug 2002, Martin Necas wrote:
>> >> > >>
>> >> > >>Dear Sharon,
>> >> > >>
>> >> > >>I don't think it is possible to get fetal heart tones at 6-7
>> weeks
>> >> > GA.
>> >> > >>That's just way too early.
>> >> > >>
>> >> > >>>From your description, are you saying that the embryo is
>> outside
>> >> > the
>> >> > >>gestational sac and outside the endometrium... so that seems
>> to
>> >> > imply
>> >> > >>that the embryo is within the myometrium?
>> >> > >>
>> >> > >>A couple things that I thought of with your desciption was
>> for
>> >> > example
>> >> > >>small focal subchorionic clot pulsating with maternal heart
>> beat.
>> >> > >>
>> >> > >>Usually when I see something really strange on a first
>> trimester
>> >> > scan, I
>> >> > >>would ask myself:
>> >> > >>1) does bHCG correlate with the ultrasound findings?
>> >> > >>2) does LMP correlate with the ultrasound findings?
>> >> > >>3) does FH Rate correlate with CRL
>> >> > >>
>> >> > >>If I think I'm seeing a heartbeat, but I'm not entirely sure
>> if it
>> >> > may
>> >> > >>be from maternal pulsation or embryonic in origin, a neat
>> trick is
>> >> > to
>> >> > >>grab the patient's wrist and see if the embryonic heartbeat
>> is
>> >> > different
>> >> > >>rate. If not, it's probably transmitted pulsation from the
>> >> > mother.
>> >> > >>
>> >> > >>I hope this helps. A set of images would be great.
>> >> > >>
>> >> > >>Yours,
>> >> > >>
>> >> > >>--
>> >> > >>Martin Necas
>> >> > >>RDMS, RVT
>> >> > >>
>> >> > >>At Fri, 23 Aug 2002, Sharon Brown wrote:
>> >> > >>>
>> >> > >>>I need info if posible. Last week I was sent a patient from
>> the
>> >> > ER, in
>> >> > >>>which the doc told the woman that he found fetal heart
>> tones. I
>> >> > did a
>> >> > >>>transvag and found a gestational sac with a yolk sac
>> within.
>> >> > However,
>> >> > >>>hard as I looked I couldn't find a fetal pole. As I was
>> scanning
>> >> > the
>> >> > >>>uterus I found what the doc was talking about. The problem
>> is
>> >> > that the
>> >> > >>>fetal pole that I found was outside of the gestational sac
>> and it
>> >> > did
>> >> > >>>have heart motion, it was also hyperechoic. I am
>> completely
>> >> > baffeled by
>> >> > >>>this, and the Rad that I showed the images and talked with
>> >> > couldn't
>> >> > >>>quite figure it out either. How is it possible that a fetus
>> can
>> >> > reach
>> >> > >>>the 6-7 week stage outside of the gestational sac, and what
>> would
>> >> > cause
>> >> > >>>it to implant outside of the endometrious, yet still within
>> the
>> >> > uterus.
>> >> > >>>It was in the area where one would normally find a sub
>> chorionic
>> >> > bleed.
>> >> > >>>The fetal pole and the yolk sac both measured 4 mm. Any
>> help
>> >> > would be
>> >> > >>>appreciated. Thanks Sharon
>> >> > >>
>> >> > >--
>> >> > >Thanks for your input. Hopefully I will be able to speak with
>> the
>> >> > radiologist
>> >> > >that read the scan. He wanted to do some research and said
>> he
>> >> > would let me
>> >> > >know what he found out. The motion was too fast to be that of
>> the
>> >> > mother. The
>> >> > >heart motion was discovered by the ER doc before referring
>> the
>> >> > patient to me.
>> >> > >At first I thought he was mistaken because of the empty sac,
>> >> > however when I did
>> >> > >find what he was referring to I did my own testing and found
>> heart
>> >> > motion a
>> >> > >posibility in the absence of anyother logical conclusion. I
>> am not
>> >> > an expert
>> >> > >in ob and so far what I have seen has been pretty straight
>> forward.
>> >> > I was unprepared
>> >> > >for this finding. I will certainly let all know what it turns
>> out
>> >> > to be if possible.
>> >> > >again thanks for your response. Sharon
>> >> > >
>> >> > >I will try to get permission to upload a couple of images. At
>> this
>> >> > point I
>> >> > >don't know what to think.
>> >> > >
>> >> >
>> >> > --
>> >> > art fougner, md
>> >> > ich bin ein New Yorker
>> >> >
>> >>
>>
>> --
>> art fougner, md
>> ich bin ein New Yorker
>>
--
art fougner, md
ich bin ein New Yorker
