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8th World Congress on Ultrasound in Obstetrics & Gynecology
November 3, 1998, Edinburgh, Scotland
Round Table on Early Pregnancy - 11/03/98
Terry J. DuBose, M.S., RDMS, OBGYN.net Editorial Advisor
This meeting has several "Round Table" panels or focus group discussions. The format is to have brief presentations by each panel member, then a Round Table discussion… or debate, as the case may be. The format has been very effective in those this sonographer has been able to attend, so much so that it is regrettably that the Round Tables are run three concurrently, which means participants much make careful choices of which to attend… or review.
The current report is on the Early Pregnancy Round Table, Chaired by Steven Goldstein giving the Overview, E. Jauniaux on Placental Anomalies at 10-14 Weeks, G. Pilu on Predicting Outcome of Pregnancy in Women with Threatened Miscarriage, P. Schwarzer on Selecting Women for Conservative Management of Miscarriage, can Color Doppler Refine our Criteria?, and D. Jurkovic covering Diagnosis and management of Ectopic Pregnancy.
It was a welcome relief to hear someone finally point out that the Trimester system of discussing pregnancy is arbitrary and antiquated by sonographic standards. Goldstein pointed out in his Early Pregnancy Overview that we can now discuss the embryonic and fetal periods with good reason. In fact, he also discussed the early pregnancy by using DAYS rather than the historical convention of weeks. This is a long awaited change, because the pregnancy is changing so rapidly during the first 70 days of embryonic organogenisis, and even beyond, and sonography can follow these changes with greater accuracy than weekly periods.
Januiaux pointed out that the ultrasound profession has, in his opinion, paid too little attention to the developing placenta. He said that the placenta often goes through some changes similar to those of the fetus in distress. Particularly that the placenta will be abnormally thick in many cases of fetal hydrops, developing a placental edema. A thickened placenta will also be associated with aneuploidy. He also recommended that the placenta should be localized as early as 12-14 weeks, with final diagnosis of placental previa taking place in the last half of the gestation.
Pilu gave cautions for giving out poor prognoses too early. He gave the results of the Rawling study in which gestational sacks greater than 8 millimeters without a yolk sac turned out to be normal pregnancies in 22% of the cases in that study. And 8% of the anembryonic gestational sacs greater than 16 mm were normal at subsequent examination. He also placed great emphasis on the fact that all the sonographic criteria require a great deal on the experience of the observer and equipment being used. Pilu suggested the following guidelines for embryonic demise.
Gestational sacs > 20mm without embryo & yolk sac
Gestational sacs > 10 mm without an embryonic heart rate detected on two exams in 7 days.
He also gave some more common cautions of bleeding in the 1st trimester, empty sacs at 16 mm (70% abort), and early oligohydramnios (gestational sac too small in comparison with the embryo crown-rump length).
Schwarzler presented images and discussion of works in progress for selecting women in the embryonic period based up on observations of the early perfusion using color Doppler.
Jurkovic seemed to be rather skeptical of the monies spent for b hCG assays because of poor sensitivity. He indicated this poor sensitivity is primarily due to the fact that many pregnancies never reach a b hCG level of 1000 IU/L, and the fact that many ectopic pregnancies can be diagnosed sonography without the serum analysis. He gave a brief discussion of the use of systemic methotrexate for the treatment of ectopics. He also advised the use of Timor-Trisch’s guidelines of > 1 cm between the edge of the sac and the edge of the uterine wall.
In the final Panel "debate" S. Goldstein took issue with Jurkovic’s skepticism of the use of the b hCG, but they finally reached a resolution by agreeing that perhaps the blood assays might not be needed until the second sonographic examination. In this way many ectopics might be diagnosed or abortions resolved without the added costs.
All in all it was a good overview with lively discussion. The Round Table Panel is a very good method of focusing on a specific topic of interest. Well done all.
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