ULTRASOUND Messages for August, 2002: Re: intrauterine ectopic

Re: intrauterine ectopic

From: Terry J DuBose

tjdubose@juno.com

Tue Aug 27 18:24:56 2002

Peace, Terry

----------------

On Tue, 27 Aug 2002 14:47:56 -0500 evsono@pipeline.com (art fougner, md) ---------------- writes:

-- ---------------- > Terry > > in the third trimester all bets are off - diff people are diff sizes > and > size becomes a poor reflection of age the older we get. in the > second > trimester outliers are problematic - for example the short femur in > conjunction with a maternal serum screen suspicious for Down's. > including the femur in age assignment may factitiously lower the > sonographic age sufficient to alter the screen results. ignoring > the > femur's contribution may be preferable in this case. > > art > > At Tue, 27 Aug 2002, Terry J. DuBose wrote: > > > >Dr. Fougner, very good point... in fact seeing outliers is the > reason I like more measurements... you can "see" the fetal > proportionality. Granted, a short femur is not necessarily > diagnostically specific, but it is better to have the information > than not to have it. And "age range analysis" allows one to compare > all the parameters at once without a bunch of graphs that are much > more difficult to interpret, which is another reason I like more > measurements. > > > >For example look at this BBII report in the 23rd week with normal > proportions and all parameters falling within +/-1SD of the mean > (time-series plot across the bottom of the screen). > >http://www.io.com/~dubose/BB-REPT.GIF > > > >Then this case near term (38th week by head parameters), that has > short femurs and humeri.... > >http://www.io.com/~dubose/BB-38-1.GIF > > > >Granted from this information one can not Dx Downs or other > conditions, but I do believe that it is helpful to know that the > femur is at a -1.5SD and the humerus is at a -0.7SD below the mean. > > > >Are you saying we should ignore outliers? That is the same > argument that Dr. Sabbagha had with Dr. Hadlock in the 1980's... > Sabbagha felt that the average of multiple fetal parameters would > "dilute" the accuracy of the "true" or "correct" measurement. The > problem was that due to individuation of fetal proportions, some > long, some short, some fat, some thin, some brachicephalic, some > dolichol, and on and on, it was impossible to determine which > parameter in any given case was the "true" > >measurement. So we all now use Hadlock's average of multiple fetal > parameters' ages for dates. But that is only part of the "picture"… > there is also the question of how far from the mean or average of > the multiple fetal parameters can a single parameter be without > being "too far" out… an outlier? Thus the ARA to view the fetal > proportions as a distribution about the mean. Baslically, all > parameters' should be within +/-8% of the age... Hadlock & Bowie's > distribution... personally I prefer to > >use +/-10% of the age because it is easier to calculate, the 2% > difference is very small, gives the advantage to the fetus, and is > based upon the average of up to 12 parameters' ages rather than > Hadlock's 4. > > > >Of course, we must also realize that I am approaching this from a > non-physician sonographer's point of view... my job is to provide > the physician with as much accurate information as I can... not > nearly so difficult, I realize, as making the final Dx from all of > this. > > > >For more about BBII and Age Range Analysis (ARA) see: > >http://www.io.com/~dubose/BB-WEBH.HTM > >and http://www.io.com/~dubose/bbii.html > >Also, Fetal Sonography, chapter 7, Fetal Size/Age Analysis. > > > >Peace, Terry J DuBose, M.S., RDMS > >Little Rock, Arkansas USA > > > >---------------------------------------------------------- > > > >---------------------------------------------------------- > >ultrasound@obgyn.net writes: > >---------------------------------------------------------- > >---------------------------------------------------------- > >>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 > >> > >Peace, Terry J. DuBose, M.S., RDMS > >Assistant Professor & Director, Diagnostic Medical Sonography > Program > >University of Arkansas for Medical Sciences, CHRP > >4301 West Markham St. Mail Slot #563 > >Little Rock, Arkansas, 72205 USA > >501-686-6510 > >DuBoseTerryJ@UAMS.edu > >http://www.io.com/~dubose/ > >http://www.uams.edu/CHRP/dmshome.htm > >http://www.obgyn.net/us/panel/panel.htm > > > > -- > art fougner, md > ich bin ein New Yorker >

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