Re: I: yolk sac and early pregnancy failure
From: Karen D. Stewart (cstewart@ruraltel.net)
Sat Jan 23 22:51:07 1999
Ditto!!!
"Scotia Phillips, RT, RDMS" wrote:
> 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
