Re: intrauterine ectopic
From: art fougner, md (evsono@pipeline.com)
Tue Aug 27 08:40:19 2002
Terry,
more parameters may smooth datasets but problems arise with statistical
outliers. for example, does a short femur suggest down's, short stature
or a younger fetus?
art
At Mon, 26 Aug 2002, Terry J DuBose wrote:
>
>Yes, I know you are correct about garbage, but one person's garbage may
>be another's found treasure.
>
>Multiple fetal parameters do provide better data, and the more parameters
>the higher the statistical power. I really do miss the days before
>managed care when there was time to take measurements and study the
>results. Sonography is much more accurate than it is given credit for
>being, I am sure. There is a lot of sloppy work being done because the
>reputation is that it is fuzzy and highly variable. However, the normal
>embryos are quite uniform... it is the operator dependency that is the
>main variable... and the equipment, knowledge, and skill of some of those
>operators.
>
>Peace, Terry
>
>-------------------------------------------------
>
>-------------------------------------------------
>On Mon, 26 Aug 2002 16:59:30 -0500 evsono@pipeline.com (art fougner, md)
>-------------------------------------------------
>-------------------------------------------------
>writes:
>-------------------------------------------------
>
>--
>-------------------------------------------------
>> 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
>>
--
art fougner, md
ich bin ein New Yorker
