R: I: yolk sac and early pregnancy failure
From: Andrea Corda (acord@tin.it)
Wed Jan 20 13:32:15 1999
You've got the point,and wrote it:the Yolk sac diameter was 5 mm,so it was
NORMAL! Why should not the pregnancy go on ,then? Abnormal gestational sacs
are not our concern at this point,because they may be due to other reasons
than a possible chromosomal abnormality.I agree with you,though,about being
very careful in what to tell the patient about.In ANY case:Do more
scans.This will not harm anybody.
Thanks for your interest for this topic.
Dr.A.Corda
-----Messaggio originale-----
Da: Scotia Phillips, RT, RDMS <scotia@bellsouth.net>
A: Multiple recipients of list <ultrasound@talk.obgyn.net>
Data: mercoledì 20 gennaio 1999 13.05
Oggetto: Re: I: yolk sac and early pregnancy failure
>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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