Monday, July 14, 2014

Pelvic Exam for the 21st Century

The American College of Physicians (ACP) certainly stirred up a hornets' nest with their pronouncement on the value of pelvic exams.

...“Routine pelvic examination has not been shown to benefit asymptomatic, average risk, non-pregnant women. It rarely detects important disease and does not reduce mortality and is associated with discomfort for many women, false positive and negative examinations, and extra cost,” said Dr. Linda Humphrey, a co-author of the guideline and a member of ACP’s Clinical Practice Guidelines Committee.

As I have posted previously, perhaps it's time to think about replacing the pelvic exam with ultrasound.

...So how would ultrasound stack up? Tayal et al conducted a study of emergency patients who were being evaluated for pain. Patients underwent both a transvaginal sonogram and the clinical pelvic examination. The order of examinations was randomized. The group found the sonographic pelvic exam superior to the digital pelvic exam across all BMI classes. And remember, these were patients already in pain.

When it comes to the issue of screening for ovarian cancer, the pelvic exam has failed miserably. Dr. Nick Summerton writes in the Spectator :

In seeking to pick up ovarian cancer at an early stage — with an improved chance of cure — much better alternatives to the vaginal examination are trans-vaginal ultrasound and CA125 testing. CA125 is a chemical given off by cancer cells that circulates in the bloodstream and women with ovarian cancer tend to have higher levels.

In 2015, the UKCTOCS screening trial for ovarian cancer will publish its results. Preliminary findings look very promising but, of course, "it ain't over 'til it's over."

Stay tuned.

For more information or to schedule an ultrasound, please call (718) 925-6277.

Tuesday, July 8, 2014

Where's Waldo?

We've all seen Waldo, the guy with the striped shirt and matching cap.



Seems pretty easy to spot, right?

But what if Waldo is in a large, busy crowd - is he still easy to spot?



Sometimes, an early pregnancy is harder to spot than Waldo. Because pregnancy tests are so sensitive, women are getting that first ultrasound quite early on in gestation. There is a window of about 2 - 3 weeks after conception when an early intrauterine pregnancy might not be visualized. This creates a quandary - is she really pregnant, is there a problem with the pregnancy or a problem with the dates, and, worst case scenario, is the pregnancy ectopic. Doctors refer to this clinical situation as "Pregnancy of Uncertain Location" or PUL. The usual management consists of serial measurements of the blood pregnancy hormone or Beta HCG and repeating the ultrasound until the situation is resolved. The protocol had been that failure to see a normally-situated pregnancy on ultrasound at a critical level of Beta HCG was highly suspicious for an ectopic pregnancy or a failed intrauterine pregnancy. Unfortunately, as we all are aware, life is not always so neat.

Doubilet et al, writing in the New England Journal of Medicine reviewed the diagnostic criteria of pregnancy of uncertain location and failed pregnancy and found that previously utilized criteria were a set up for diagnostic error, resulting in administration of a powerful teratogenic drug, Methotrexate, in cases subsequently found to be normal pregnancy. Nurmohamed et al found 8 cases of intrauterine pregnancy in which methotrexate was administered for suspected ectopic. None of these cases had a happy outcome.

Doubilet's review offered new consensus guidelines for the diagnosis of both early pregnancy failure and pregnancy of uncertain location, nicely summarized Here.

So if you find yourself in this situation, please review this post again and perhaps ask your doctor to review it as well.

For more information or to schedule an ultrasound, please call (718) 925-6277.

Monday, June 30, 2014

The Short Life of the Pregnant Fetus

The news of Mary Lambert's pregnant fetus spread like wildfire across the intertubes, the flames fanned by social media.

A pregnant woman in Portland, Oregon was hospitalized this week with extreme stomach pains, and doctors were extremely shocked at what they discovered.

Mary Lambert, who is 8 months pregnant, went to Silverstein Memorial Hospital in Portland when she thought she might be going into labor. Doctors examined her, and initially could not figure out what was causing Lambert’s pain. After an ultrasound to check on her baby, they were taken aback to find that her unborn daughter was also pregnant.

“I have never in my life seen anything like this.” Said Dr. Joseph Goldsmith, a pediatric surgeon at Silverstein. “I don’t think anyone has. This is the first time that an unborn baby has become impregnated. It’s so far beyond rare that we didn’t know it was possible.”


There was an obvious reason that this complication is so rare - it's a Hoax.

... But, of course, the report is fanciful nonsense. No unborn baby is pregnant, in Oregon, or anywhere else. The fictional report originates from the fake-news website, Empire News.

In fact, nothing published on Empire News is true. A disclaimer on the site notes: Empire News is a satirical and entertainment website. We only use invented names in all our stories, except in cases when public figures are being satirized. Any other use of real names is accidental and coincidental.


The internet is replete with tall tales and rumor-mongering. It pays to check out the sources before passing on incredible stories. Be careful out there.

One final note - there is a condition called Fetus In Fetu which can occur as a complication of embryogenesis during a twin pregnancy. In this condition, a nonviable twin fetus becomes enclosed within a normally developing twin fetus. This condition became the inspiration for Stephen King's The Dark Half. This, however, is far from the short-lived saga of the pregnant fetus.

For more information or to schedule a sonogram, please call (718) 925-6277.

Monday, June 23, 2014

It Ain't Over 'Til It's Over

This morning, I found this disturbing story from India.

A man upon finding his first born baby deformed created a ruckus in government women's hospital on Wednesday alleging that the administration had changed his baby after delivery. Dozens of villagers gathered in his support in the hospital and shouted slogans against the doctors. The man stated that he had twice got the sonography of his unborn baby done from a privated doctor who claimed that the baby was perfectly normal.

According to sources, Farhan of nearby Gagwana village, was very excited about his first child and he took his wife for sonography in her third and seventh months. "The doctor told me that the baby was perfectly alright and we were happy with it," said Farhan.

On Sunday, Farhan's wife delivered the baby in a government hospital and afterwards the baby was brought to the couple. "The child was deformed and we were shocked to see that. When I enquired the doctors, they said that the baby was born deformed," added Farhan.

Farhan again went to the same private doctor who had conducted the sonography of his wife, "The doctor claimed that it is not possible after looking at the sonography report that the baby would be born deformed," Farhan said.

Farhan on Wednesday came back to the hospital and returned the baby to the hospital administration demanding to return his real child, "They changed my baby with another and I demanded DNA test before taking the baby," said Farhan.

Dozens of villagers from Gagwana also gathered in the hospital and created ruckus. They shouted slogans against the hospital administration. Police was also called on the spot to control the situation.


Having a child with a birth defect is obviously difficult but when it's unexpected, it literally gut-wrenching for all concerned. At issue is the question: what are the reasonable expectations after an apparently normal 20 week scan?

In the Netherlands, Baardman et al reported on the introduction of a routine 20 week scan increased the detection rate for serious congenital heart defects. However, at best, 15% of the defects went undetected before birth.

Magriples and Copel analyzed a series of 901 patients who underwent ultrasound screening with referral for a targeted exam if an abnormality were suspected. The babies were then examined at birth. There were 28 abnormalities in total. Of these, 5 or 17.8% were missed. In general, the more severe were detected while some of those missed were more subtle.

So what's the take home message? Trying to perform a physical exam on someone who is inside someone else is often exceedingly difficult. Moreover, prenatally, the sonographer is not looking at the finished product.

As Yogi Berra once said in 1973, "It ain't over 'til it's over." To contact me or to schedule an ultrasound, call (718) 925-6277.

Thursday, June 19, 2014

Vitamin D: Let The Sunshine In

As a follow-up to my previous post on sunscreens, I need to point out that there is a downside. We are in the midst of a global epidemic of vitamin D deficiency.

Vitamin D ... regulates the functions of over 200 genes and is essential for growth and development. There are two forms of vitamin D. Vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol). Vitamin D status depends on the production of vitamin D 3 in the skin under the influence of ultraviolet radiation from sun and vitamin D intake through diet or vitamin D supplements. Usually 50 to 90% of vitamin D is produced by sunshine exposure of skin and the remainder comes from the diet. Natural diet, most human consume, contain little vitamin D. Traditionally the human vitamin D system begins in the skin, not in the mouth. However, important sources of vitamin D are egg yolk, fatty fish, fortified dairy products and beef liver.

Vitamin D3 deficiency can result in obesity, diabetes, hypertension, depression, fibromyalgia, chronic fatigue syndrome, osteoporosis and neuro-degenerative diseases including Alzheimer’s disease. Vitamin D may even contribute to the development of cancers, especially breast, prostate, and colon cancers.


Why is sun avoidance important?

...Exposure to sunshine each day helps human body to manufacture the required amount of vitamin D. However, due to fear of developing skin cancer most people avoid the sun exposure. To prevent vitamin D deficiency, one should spend 15 to 20 minutes daily in the sunshine with 40% of the skin surface exposed. High concentration of melanin in the skin slows the production of vitamin D; similarly aging greatly reduces skin production of vitamin D. Use of sunblock, common window glass in homes or cars and clothing, all effectively block UVB radiation – even in the summer. People who work indoors, wear extensive clothing, regularly use sunblock, are dark skinned, obese, aged or consciously avoid the sun, are at risk of vitamin D deficiency.

Balance, Daniel san - Balance.

For more information, or to schedule an ultrasound, call: (718) 925-6277.

Monday, June 16, 2014

Sunshine On Sunscreens

Once again, summer beach and pool days are upon us and we need to remind ourselves to deal prudently with exposure to the sun's rays. Sunscreens are the most widely promoted means of protection but there are more than a few caveats.

No Spray Ons - Too easy to miss a spot.

No super high SPFs - EWG advises avoiding products higher than SPF 50.

No oxybenzone - There can be significant absorption into the bloodstream, with an estrogen-like effect.

No retinyl palmitate - EWG recommends avoiding as research shows synergistic effect with sun exposure for tumor development.

No combined sunscreen/bug repellent - combining screens with repellent may increase repellent absorption.

No sunscreen towlettes or powders - FDA sunscreen rules bar these.

No tanning oils - products with SPF lower than 15 are worthless.

For more info, check out more useful info at EWG.org.

Let's be careful out there. H/T TotalBeauty.com Also, for more info or to schedule an ultrasound, call 718 - 925 - 6277.

Monday, June 2, 2014

New Fertility Hope For Chemo Patients

From this weekend's New York Times:

A commonly used drug can help young women with breast cancer retain the ability to have babies, apparently protecting their ovariesfrom the damage caused by chemotherapy, researchers reported here on Friday.

The treatment could provide a new option for dealing with one of the painful dilemmas faced by young cancer patients — that doing the utmost to save their lives might impair or even ruin their fertility. Researchers said the drug, goserelin, which temporarily shuts down the ovaries, appears to protect women from the more permanent premature menopause that can be induced by chemotherapy. In a clinical trial, women who were given goserelin injections along with chemotherapy had less ovarian failure and gave birth to more babies than women receiving only the chemotherapy.

“Premenopausal women beginning chemotherapy for early breast cancer should consider this new option to prevent premature ovarian death,” the study’s lead author, Dr. Halle Moore of the Cleveland Clinic, said at a news conference here at the annual meeting of the American Society of Clinical Oncology.


This is wonderful news indeed for many young women awaiting chemotherapy. There is one catch, however. On the GoodRx website, Zoladex (Goserelin) is listed as:

This drug is considered a specialty medication, which means:

It is very expensive. A typical fill can cost $1,326 or more for 1 kit of Zoladex 10.8mg.

Patients in need of this drug will usually find most of the cost paid by an insurance company, government or non profit organization. If you are uninsured or need help with your co-pay, the manufacturer may also offer assistance.

Most retail pharmacies will not stock this medication. The manufacturer may offer more information on how to fill this prescription.


Physicians and patients considering this therapy as always should do some homework first.

For more information, or to schedule an ultrasound, please call: (718) 925-6277.