0:00

Okay.

0:01

To break away from our little flow chart for a second, the

0:05

consensus panel did come up with what they called

0:08

signs suspicious for,

0:11

but not diagnostic of pregnancy failure.

0:14

And some of these we've actually already talked about in

0:18

embryo less than seven millimeters

0:20

or an empty sack less than 25 millimeters.

0:23

It is kind of interesting

0:24

that they included these suspicious findings.

0:27

I think it was almost a shout out to the, all

0:30

of the prior data on pregnancy failure

0:33

that they were basically kicking to the curb

0:35

because none of these findings,

0:37

and we'll go through them obviously, can be used

0:40

to diagnose demise.

0:42

Nonetheless, they are findings

0:43

that you will see when you're interpreting these exams.

0:46

So it's good to know what they are.

0:48

And I'm going to give you a little historical

0:51

context behind them.

0:53

So as I mentioned, we've already discussed these two.

0:56

So the other ones are subchorionic hemorrhage,

1:02

enlarged yolk sac greater than seven millimeters,

1:05

and empty amnion, something we call the expanded amnion sign

1:11

in a small gestational sac in relation to the embryo.

1:15

Another one they included was a slow heart rate,

1:19

but you know at that one also you're dealing

1:23

with a living embryo in that case.

1:25

So I'm not gonna even include that one.

1:28

So subc Corian a camera, let's talk about that.

1:32

Here's an an embryo.

1:34

We see the sac, we see probably the placental tissue,

1:38

and we see this hypo coic area around it.

1:42

So this is what we call a sub chorionic hemorrhage.

1:45

And people talk about subc chorionic hemorrhages a lot,

1:48

but I like you to understand what really causes it.

1:52

And I would argue to a certain degree it's actually an

1:55

expected outcome of a forming pregnancy.

1:57

We saw some blood in the endometrial canal

2:00

of several cases early on,

2:04

and this is basically an expected byproduct of the conceptus

2:09

or the, you know, the embryo trophoblastic tissue

2:13

burrowing into the wall.

2:15

So as this happens, we get some bleeding

2:18

and where does that blood go?

2:21

It goes right into this cavity.

2:23

And where does it go from there?

2:25

It goes right out the cervix and presents as bleeding.

2:29

So yes, there can be large subcate hemorrhages

2:34

as we see in this image.

2:35

And when they're large, we may feel

2:38

that this is more suspicious for pregnancy failure.

2:42

But just remember that seeing a quranic hemorrhage is not in

2:46

and of itself portend a huge

2:49

negative outcome.

2:51

And one, one sort of caveat here is

2:56

this is really the attachment of the, the gestational sat

3:00

to the decidua and this is the cavity.

3:04

Sometimes when we see the, the fluid

3:06

or the blood tracking beneath here,

3:10

that's almost like an abruption.

3:13

And in that case, yes, it is gonna be more suspicious.

3:17

And this is literally the mother of all

3:21

sub horran hemorrhages.

3:23

This blood essentially surrounds the

3:27

entire sack.

3:28

It's almost just floating in blood.

3:31

And I would agree that this is very concerning.

3:33

And the and interpretation here

3:36

was irregularly shaped fluid-filled sac,

3:39

likely representing a non-viable pregnancy.

3:43

In the lower uterine segment, a large quantity

3:46

of blood was seen in the endometrial canal.

3:48

This likely represents a spontaneous abortion in progress.

3:52

Now, do I agree that that is likely true?

3:57

The answer is yes.

3:59

However, let's go back to what our criteria really are.

4:03

We have an intruded in pregnancy.

4:05

We have a gestational sac, we have a yolk sac.

4:09

I don't have a zoomed in image of this, but let's say we do

4:12

or don't see an embryo,

4:14

we certainly don't see a seven millimeter embryo.

4:17

So technically without this blood, this is a pregnancy

4:22

of uncertain viability

4:24

and there is a large subcate hemorrhage,

4:27

which is a finding suspicious for,

4:30

but not diagnostic of pregnancy failure.

4:34

So I think they're right in dictating it this way.

4:37

I didn't dictate it this way,

4:39

but I don't think that's the terminology we

4:41

really should use.

4:43

I would call this a pregnancy of uncertain viability

4:46

as evidenced by a gestational sac

4:49

with a yolk sack period.

4:52

There is a large subc chorionic hemorrhage,

4:57

and this is a finding that is suspicious for,

5:01

or a negative prognostic finding or something like that.

5:05

But I would not call it a pregnancy failure

5:10

or an abortion in progress, just

5:12

because you don't necessarily know

5:14

and you are, when you're doing that,

5:16

you're diverting from the guidelines.

5:19

And when you divert from the guidelines,

5:20

you put yourself at risk.

5:21

So I'm trying to create a framework here

5:23

where we don't put ourselves at risk

5:26

when dictating these cases.

5:29

The next thing in, um, the list of suspicious findings was

5:34

a mean sec diameter that is small

5:38

in relation to the embryo.

5:40

And they actually gave us a number.

5:43

If you subtract the mean sec diameter

5:45

minus the crown rum length, and that is less than

5:49

or equal to five millimeters, then

5:51

that is a poor prognostic indicator.

5:53

So in this case, let's say this is maybe

5:57

Sac is maybe 11 millimeters.

5:59

This embryo we'll just say is eight 11 minus eight is three.

6:04

This is a poor prognostic indicator.

6:09

The next one was a large yolk sac greater

6:12

than seven millimeters.

6:14

So in this case we see a yolk sac.

6:16

It's actually kind of a deformed looking yolk sac.

6:21

We do a little measurement and it's 8.7 millimeters.

6:25

So this is greater than seven millimeters.

6:28

And this is, again, considered a negative predictor

6:31

of viable outcome.

6:33

But the degree of prediction was sort

6:36

of variable within the literature.

6:38

Again, in my experience, it almost always means a demise,

6:42

but it should not be used as definitive criteria for demise.

6:48

Also interesting, not listed in their su suspicious

6:50

findings, but I also find to be fairly, uh, suspicious

6:55

is a small calcified yolk sack

6:57

that was not included in their list.

7:00

Now there's gonna be two here that are a little different.

7:03

I'm gonna spend a little bit of extra time on these two

7:06

suspicious findings.

7:07

One is called the empty amnion or the amnion sign.

7:12

And the rule here is that any visible

7:16

amnion should have an embryo within it.

7:19

And the reason I'm spending a little more time is just

7:21

'cause it's a personal thing,

7:22

but also it was very highly predictive.

7:25

This sign was actually described by my father

7:28

and a couple, uh, uh, his group at UCSF,

7:32

and they found this to be a hundred percent

7:33

predictive of pregnancy failure.

7:35

And despite two people who were on this article,

7:39

and two people who were on the consensus panel,

7:42

my dad and Dr.

7:44

Goldstein, it was actually not included in the criteria

7:47

for definitive device only suspicious.

7:50

So if we see an amnion,

7:55

it should have an embryo within it,

7:57

or it is definitively a demise.

7:59

And that was a hundred percent

8:02

predictive of pregnancy failure.

8:04

In their article, however,

8:08

it is no longer considered a criteria for demise.

8:14

The other was what's called the expanded amnion sign,

8:17

also described by my father,

8:20

and I don't honestly love the name,

8:21

but what it states is that an embryo surrounded by

8:26

amnion should have a heartbeat regardless of its size.

8:29

So if it's a four millimeter embryo, if it's surrounded

8:32

by an amnion, it better have a heartbeat.

8:35

And that too was found in their paper

8:38

to be a hundred percent predictive of pregnancy failure,

8:41

but again, was not included in the guidelines.

8:44

So these two

8:46

amnion signs should not be used as definitive

8:51

for pregnancy failure.

8:53

So here was just an example, actually,

8:56

this is the one from before.

8:58

We have a large yolk sack.

9:00

We have an embryo that's surrounded by amnion.

9:03

It's three millimeters. It doesn't have a heartbeat.

9:06

It's actually got both of those findings.

9:08

But we cannot call this, we can argue, nor should we,

9:12

but we won't call this a definitive pregnancy failure.

9:17

We will call this a pregnancy of uncertain viability

9:20

and we'll follow it up in one week.

9:24

So do any of these suspicious findings matter?

9:28

Well, I mean, yes, they, they matter.

9:31

You're going to see them.

9:32

And the more you know,

9:33

the better you'll be at interpreting these studies when you

9:36

see these various findings.

9:37

But unfortunately, we can't use them.

9:40

And, and I do think the consensus panel really dumbed down

9:44

the diagnostic criteria, and I kind of wish they hadn't.

9:47

But again, the panel's recommendations

9:50

are there for a reason.

9:53

Not that subor hemorrhage was one of those definitive ones,

9:56

but here's an example of a subor hemorrhage.

9:59

It's pretty large. Comes back later

10:02

with a a living int treat in pregnancy.

10:05

So I highly recommend

10:06

that you do practice within the guidelines

10:10

and this will keep you out of trouble.