0:00

So we talked a little bit earlier about follow-up.

0:03

So we, we need to figure out, well, how do we get from this

0:07

again, red light to this green light?

0:12

And again, we do a follow-up.

0:14

To be totally honest, I found the follow-up recommendations

0:17

from the consensus conference.

0:19

Uh, a little confusing in the way they worded it.

0:23

They left some stuff out,

0:25

but I'm gonna go over them here

0:27

so you're aware of what they are.

0:29

Um, but the, the British group also did a follow-up study

0:33

that I think, um, iron some

0:35

of those things out a little more

0:38

and makes it even easier for us to have our recommendations.

0:42

So from the consensus conference,

0:46

if we saw us empty sac less than 25 millimeters, pregnancy

0:50

of uncertain viability, if you did a follow-up in 14 days,

0:54

two weeks, now you could call it a definitive demise if no

0:59

embryo with a heartbeat was identified,

1:02

and in which case we are green-lighted for safe to evacuate.

1:06

And again, I just keep saying this,

1:07

but I'm gonna to emphasize it doesn't mean you need

1:11

to evacuate the uterus.

1:13

That's a decision for the gynecologist obstetrician,

1:16

but it's safe to do so.

1:18

If they were to so desire, what if we saw a sack

1:23

with a yolk sack?

1:24

Well, in that case, they wanted you to follow up in 11 days

1:27

and you could diagnose a demise if there's

1:30

no embryo with a heartbeat.

1:32

Strangely, they actually didn't say what

1:34

to do if you saw an embryo that was, say three millimeters

1:37

or an embryo less than seven millimeters without

1:39

a heartbeat, what to do?

1:42

So the British group, as I said, they came out

1:44

with a follow-up study

1:46

and they found using these follow-up guidelines

1:50

that I'm gonna cover here had a 100% positive predictive

1:53

value and specificity for pregnancy failure.

1:56

Now remember, these are the people that really wanted us

1:58

to operate on the very safe end of practice in order

2:03

to not have any chance

2:05

of harming a possible viable intru in pregnancy.

2:10

This is what we use.

2:11

If you see an embryo less than seven millimeters.

2:14

So this is a pregnancy of unknown viability

2:17

with no heartbeat.

2:19

You do a seven day follow-up and we will call it a demise.

2:23

If at that point we don't see an embryo with a heartbeat.

2:26

And why is this safe?

2:28

I, I told you I wouldn't talk about how fast embryos

2:31

or sacks grew, but I lied a little bit

2:33

and I don't expect you to remember it

2:35

because I barely remember it.

2:38

But I cover this just

2:39

to understand why this practice is so safe.

2:44

So if we identify an embryo, let's say one

2:48

of the smallest embryos, we could see two millimeters.

2:51

An embryo will grow at about a millimeter a day.

2:55

So in seven days, in theory that two millimeter

2:58

Embryo should be nine millimeters.

3:01

Well, that's way beyond the five millimeters we used to use.

3:04

And it's clearly beyond the seven millimeters

3:06

that we're supposed to use now.

3:08

And this is all not to mention, as I said

3:10

before, that really we see a heartbeat in almost

3:13

any embryo that's alive.

3:14

So point being a one week follow-up

3:19

for any embryo without a heartbeat

3:22

that's less than seven millimeters in one week, is going

3:25

to be a very safe practice

3:28

and a safe way to diagnose a definitive demise.

3:33

Now in the consensus statement, they distinguish

3:37

between a sack and a yolk sack or one without a yolk sack.

3:41

And they had differing time follow-ups.

3:44

But I actually liked what the British group came up with

3:47

and made this even simpler.

3:49

And they said, forget about the yolk sack or whatever.

3:52

I just wanna look at a sack that's less than 12 millimeters

3:56

or greater than 12 millimeters,

3:58

and we're going to not add in numbers like 11.

4:01

We're gonna keep it at numbers like seven in 14

4:03

days, one week, two week.

4:05

So if you saw a mean sac diameter

4:07

of less than 12 millimeters,

4:09

you could follow it up in 14 days.

4:12

And if you don't see an embryo with a heartbeat at

4:14

that time, it's a demise and it's safe to evacuate.

4:19

Now, um, sac with no embryo

4:21

that's greater than 12 millimeters greater than

4:23

or equal to 12 millimeters, obviously

4:25

that's gone even further.

4:27

So we only have to follow that up for seven days

4:31

and it's a demise if we don't see

4:33

an embryo with a heartbeat.

4:34

And then we're back to safe to evacuate.

4:37

So why is this one safe Again,

4:39

I told you I didn't talk about this,

4:40

but just so we understand, in a normal pregnancy,

4:44

the gestational sac shows up at five weeks

4:46

and an embryo usually at six weeks.

4:48

And you don't need to remember those numbers.

4:50

But what I wanna illustrate is that the time

4:53

between a gestational sack showing up

4:55

and an embryo showing up is only about a week.

4:58

So in the cases where we've already got a sack

5:01

that's bigger than 12 millimeters,

5:03

it's been there for a while.

5:05

So waiting one week should be very safe

5:09

if the sack is smaller, okay,

5:11

maybe it hasn't been there for a while.

5:12

So waiting two weeks again should be pretty safe.

5:16

And these were shown in their study to be 100% specific.

5:20

So we do need to make sure that we are using, uh, again,

5:23

the criteria for intrauterine pregnancy

5:26

that we talked about earlier,

5:28

but these guidelines of one week,

5:31

two week follow-up just based on sac size or what I use

5:34

and what I think are a lot easier to remember and to use.