Re: Nuchal Cord
From: Allen Worrall (jworrall@alaska.net)
Tue Feb 24 06:55:11 2004
Frank Manning must be a genius. A genius, of course, is anyone who thinks
like you do.
Allen
>----- Original Message -----
From: "art fougner, md" <evsono@pipeline.com>
To: "Multiple recipients of list ULTRASOUND" <ultrasound@dns.obgyn.net>
Sent: Tuesday, February 24, 2004 4:44 AM
Subject: Re: Nuchal Cord
> Frank Manning weighed in on this issue in an editorial in the November
> 1999 issue of the White Journal -
>
> "...it is our opinion that the presence of
> nuchal cord(s) should be sought for and become an integral
> part of third-trimester ultrasonographic assessment of the
> fetus and its environment. When this diagnosis is suspected
> yet not confirmed with application of gray-scale real-time
> ultrasound, if available, color Doppler imaging and/or
> Doppler flow velocimetry should be utilized. Following
> prenatal ultrasonographic identification of nuchal cord(s)we believe
> that modification of clinical management of this
> condition is in order.
>
> Despite the lack of objective data, we believe that it is
> intuitive and of major importance that, in addressing clinical
> management following the prenatal ultrasonographic
> diagnosis of nuchal cord(s), a number of pertinent questions
> be addressed. These include the number of loops of
> cord involved, the amniotic fluid volume status, fetal
> growth, gestational age and current status of fetal wellbeing.
>
> It appears that, when further complicating issues are
> confronted, such as significantly decreased amniotic fluid
> volume, postdates, fetal growth restriction, and especially
> decreased fetal movements, that immediate and
> repeated fetal testing measures be sought. With less than
> optimal fetal testing, delivery should be considered. Such
> fetal testing should consist of fetal biophysical profile, nonstress
> testing and Doppler velocimetry of the umbilical
> artery (other fetal vessels might also be interrogated - the
> middle cerebral artery, ductus venosus). Possibly further
> evoked tests, such as vibratory acoustic stimulation, or
> oxytocin challenge testing to assess the presence of variable
> decelerations of the fetal heart rate, may assist in dictating
> management. We anticipate that application of the aboveoutlined
> suggested management may decrease the occurrence of third-trimester in
> utero fetal demise associated with nuchal cord(s).
>
> While, clearly, physicians will be required mostly to
> reassure patients and relieve significant associated anxiety, we
> strongly believe that notation of this not uncommon prenatal condition
> should be forwarded to the patient and her physician, recorded in the
> medical records, and managed with close fetal surveillance of fetal
> movement
> counts, interval fetal testing and, in selected cases, delivery."
>
> Ultrasound in Obstetrics and Gynecology, Volume 14, Issue 1 (p 1-8)
>
> There is one caveat here - data concerning either the predictive value
> of the ultrasound diagnosis of nuchal cord is sorely lacking.
> Additionally, the history of modern obstetrics suggests that the
> introduction of technology often leads to multiple interventions with
> negligible benefit. A large prospective trial should be done.
>
> art
>
> At Mon, 23 Feb 2004, Dave Berck wrote:
> >
> >This is all great. However --
> >
> >1) Most MDs in the US do NOT actually scan patients,
> >and, in fact, know nothing whatsoever about
> >ultrasound.
> >2) Most MDs go into a complete PANIC whenever the
> >sonographer tells them about any sort of finding. So
> >it's not just a simple solution to say that the MD
> >will arrive at a sensible plan.
> >
> >--- "Raul I. Limos" <rlimos@mozcom.com> wrote:
> >> On 21 Feb 2004 at 19:37, Philippe Jeanty wrote:
> >>
> >> > That is a sure way to get into conflicts. When the
> >> patient presses me
> >> > to tell her management options: 1) I just provide
> >> broad information 2)
> >> > I tell her that I am not qualified to make that
> >> decision 3) that her
> >> > referring MD has a much more complete picture of
> >> her situation and
> >> > that together they will explore the best approach
> >> in HER case.
> >>
> >> These are the same tenets that I follow in my
> >> ultrasound practice.
> >
> >=====
> >David J. Berck, MD, MPH
>
> --
> art fougner, md
> ich bin ein New Yorker
