Re: I: yolk sac and early pregnancy failure
From: Scotia Phillips, RT, RDMS (scotia@bellsouth.net)
Wed Jan 20 05:03:18 1999
In the past years, I too have seen many early preganancy failures with
the scenarios discussed. However, as everyone can say, there have been
a few that just don't adhere to the "standard" criteria. Particularly
interesting is a case of a woman who had early spotting, large
gestational sac for dates, 5 mm yolk and very tiny fetal pole with
heartbeat as well as serum HCG too low for estimated dates. Physician
counseled her, said "these pregnancies fail, let's do D&C now so you
won't have severe bleeding later." Patient decided to wait, no more
problems and a normal outcome to the pregnancy. Twice more with this
lady and once with her sister, the exact same situation occured. Again,
all babies progressed to term and were normal.
Of course, these outcomes are unusual, maybe even rare. We know that no
harm came to the patient by waiting, but there was a great deal of
mistrust for the doctor even though he was correct in his statement to
the patient, she perceived that he wanted "to kill her baby". His
compassion was not recognized by the patient.
Why not wait when there is doubt? I do tell patients who ask that it is
just too early for me to determine and direct them immediately to the
doctor.
At Tue, 19 Jan 1999, James S Smeltzer MD wrote:
>
>Martin,
>
>At 10:52 PM 1/18/1999 -0600, you wrote:
>>Dear Jim,
>>
>>I get the sense that you feel quite strongly about this topic.
>>>A funny YS? [Cure: Do more US]
>>
>>Certainly predicting that someting will inevitably happen is difficult in
>>many instances when it comes to human development, health, or disease. But I
>>feel that abnormal findings such as an enlarged yolk sac can help us
>>approach a patient with caution and can guide us in terms of follow-up. We
>>have recently had a case of an early pregnancy with yolk sac diameter just
>>over 7mm. I told the patient that the baby was alive, but that there is some
>>literature which suggests some of these babies may not do well and we need
>>to be a bit cautious. I advised her to see her doctor if she develops any
>>bleeding or if something is not quite right. I also suggested a re-scan for
>>viability in 2 weeks. The patient had a miscarriage a week later.
>>
>>By suggesting to "Do more US", are you implying that:
>>1) one should suggest follow-ups for these borderline suspicious cases
>>(which is how I understand it and what I like to do)
>>or
>>2) one should get more experience in ultrasound, and then you feel one would
>>agree with you?
>>
>>Yours,
>>
>>Martin Necas.
>>
>Those were very perceptive questions, and the answer to the second is yes
>in all cases given. The answer to the first is yes in almost all cases
>given. I hear from a fair number of patients and see a fair number for
>second opinions when they have been told their baby was dead, going to die,
>miscarriage was inevitable, based on what people thought they knew, saw or
>incomplete or misinterpreted (or just plain wrong) medical histories.
>
>The last 23 weeker I THOUGHT the same thing about, but treated as
>potentially viable, died in the first 3 days of life, as did the one before
>that. The one before that was brought in by Mom at corrected age of 6 mos,
>able to sit, play, maintain eye contact & able to conversationally phonate
>& interact en face (And this baby is also the one that had an abruption
>when the harmless intrauterine synichia broke).
>
>The last case I discussed is one in which I THINK the baby is doomed and
>would like to act, but wait because I have learned to wait.
>
>The first trimester findings that change what I do (other than a follow-up
>recommendation) or tell the patient are observed failure of the embryo to
>appear by 3 weeks after positive pregnancy test, hydropic placenta, nuchal
>edema or observed heart, limb, or CNS defect (Although I have seen many
>cases of hydrocephalus and nuchal edema called for the rhomboidal flexure).
>
>Scan enough with your eyes and ears open, and a little follow-up on
>abnormal calls and God will teach you humility. I am very proud of my
>prenatal diagnostic knowledge and skills and am confident that I am the
>best around, or close to it, but I am still careful about such. I can still
>remember every miss I made. My point was that we should be both careful and
>sure when we give bad news, or even hint at it. The time to hang crepe is
>when it is time for the funeral, IMHO.
>
>Jim S
>
>>-----Original Message-----
>>From: ultrasound@obgyn.net [mailto:ultrasound@obgyn.net] On Behalf Of James
>>S Smeltzer MD
>>Sent: Tuesday, January 19, 1999 3:31 PM
>>To: Multiple recipients of list
>>Subject: Re: I: yolk sac and early pregnancy failure
>>
>>Art & al,
>>
>>Tell the patient what you KNOW - that is what they want & need to hear -
>>that it is too soon to tell about their pregnancy. If you see a living
>>embryo tell them that you do and that this improves the odds on a viable
>>pregnancy later.
>>
>>What is so hard about this? Do you really believe that you can predict
>>demise from a slow heart rate? [Cure: Do more US] A funny YS? [Cure: Do
>>more US] A small thoracic diameter with oligo? [Cure: Do more US] A wide
>>ventricular diamter? [Cure: Do more US]
>>
>>I felt really bad today because at 23 weeks 6 days by CRL a fetus with what
>>was thought to be an agonal heart rate by my partner turned into 150 in a
>>patient with 375 g fetus, many large [HUGE] leiomyomata, unexplained 4 MoM
>>AFP previously, and recurrent abruption, before we went to do hysterotomy
>>for tumor previa, with cell saver because we were going to do myomectomies
>>also.
>>
>>Baby was moving, IUGR, partial abruptio & rete 150.
>>
>>Please leave to God all issues that God will resolve & only take on those
>>that God needs your help to resolve. I could fill an elementary school
>>with babies others said were dead, doomed or otherwise not going to make it.
>>
>>Jim S
>>
>>At 11:26 AM 1/16/1999 -0600, you wrote:
>>>Ok - a question. you've got a case in which an asymptomatic patient,
>>>say age 27, is referred to your lab for some vaginal staining. you see
>>>a approx. 6.5 weeker with FHR of 87 bpm and a 7 mm yolk sac. no
>>>subchorionic hematoma and closed cervix. aside from repeating the
>>>study, what else would you do and, more importantly, what would you tell
>>>the patient? as these situations come up frequently, i'm just tryin to
>>>get a sense of how others handle this difficult human situation.
>>>
>>>Art
>>>
>>>At Sat, 16 Jan 1999, Terry J. DuBose wrote:
>>>>
>>>>Dr. Corda, since you have indicated that these are viable embryos, I am
>>>>assuming that a heartbeat was observed or recorded (hopefully). I would
>>>>be interested in seeing the embryonic heart rate (EHR via M-mode) data
>>>>also correlated with these data. Because you are new to the Ultrasound
>>>>section of OBGYN.net, I will give you the URL(s) for an article about
>>>>the EHR. "Old Timers" here are probably tiring of hearing me raise the
>>>>issue ;-). But I believe it is important, and this article(s) explain
>>>>why.
>>>>
>>>>http://www.obgyn.net/ENGLISH/PUBS/FEATURES/dubose/ehr-age.htm
>>>>and
>>>>http://www.obgyn.net/US/present/9811/moroder2.htm
>>>>
>>>>I am also interested in your (or anyone's) comments & observations on
>>>>the above.
>>>>
>>>>Peace, Terry J. DuBose
>>>>
>>>>---
>>>>At Fri, 15 Jan 1999, Andrea Corda wrote:
>>>>>
>>>>>>> -----Original Message-----
>>>>>>> From: Andrea Corda [SMTP:acord@tin.it]
>>>>>>> Sent: Friday, January 15, 1999 7:40 AM
>>>>>>> To: obgyn-us@obgyn.net
>>>>>>> Subject: yolk sac and early pregnancy failure
>>>>>>>
>>>>>>> I've sent an E-mail to Peter W.Callen discussing about the prognostic
>>>>>>> significance of the yolk sac in very early pregnancy (i.e. 5th-7th
>>>>>>> week),namely its size (which sould not exceed 7 mm) and shape,its
>>growing
>>>>>>> rate related to that of the embryo at very early stages and the
>>>>>>> proportions one should expect to find to state a " normal pregnancy"
>>>>>>> between yolk sac,gestational sac and embryo.Anyone interested on this
>>>>>>> topic?I've already collected almost 50 cases and I would like to know
>>if
>>>>>>> others have similar experiences.Thank you,
>>>>>>> Dr.Andrea Corda.
>>>>>>> Cagliari,Italy E-mail:acord@tin.it
>>>>
>>>>--
>>>>Peace, Terry J. DuBose. M.S., RDMS
>>>>DMS Program Director, Univ. Arkansas for Medical Sciences, USA
>>>>Chair, Ultrasound @ OBGYN.net
>>>>Now is the time for all good folks to come to the aid of the Earth.
>>>>
>>>>---
>>>>
>>>--
>>>art fougner, md
>>>SonoScan/Genetic Sciences
>>>forest hills, ny
>>>evsono@pipeline.com
>>>
--
Scot
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