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.

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.

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.

Lupus In Pregnancy - What Should I Know?

Continuing the lupus thread duing Lupus Awareness Month, let's look at lupus during pregnancy. First, you should know that having lupus does not preclude a successful pregnancy outcome. There are risks involved, however, for both mom and baby. The March of Dimes ists the following:

What problems can lupus cause during your pregnancy?

Lupus may increase the risk of these problems during pregnancy:

Lupus flares. You may experience flares during pregnancy or in the first few months after giving birth. If your lupus is in remission or under good control, you’re less likely to have flares.

Preeclampsia. This is a certain kind of high blood pressure that only pregnant women can get.

Premature birth. This is birth that happens too early, before 37 weeks of pregnancy.

Miscarriage. This is when a baby dies in the womb before 20 weeks of pregnancy.

Stillbirth. This is when a baby dies in the womb after 20 weeks of pregnancy.

If you’ve been in remission or had your condition under good control for at least 6 months before pregnancy, you’re less likely to have complications. Talk with your health care provider before getting pregnant about the safest time for pregnancy.

What problems can lupus cause in your baby?

Most babies of mothers with lupus are healthy. However, some babies may face health risks, like:

Premature birth. About 3 in 10 babies (30 percent) of mothers with lupus are born prematurely. Premature babies may need to stay in the hospital longer or have more health problems than babies born full term (39 to 41 weeks of pregnancy).

Neonatal lupus. About 3 in 100 babies (3 percent) are born with this temporary form of lupus. This condition causes a rash and blood problems but usually clear up by 6 months of age. However, up to half of these babies have a heart problem called heart block. This is a condition that causes a slow heartbeat. Heart block is often permanent. Some babies need a pacemaker to help make their heart beat regularly.

As you would expect, pregnancy for a lupus patient is hardly a walk in the park. However, there is ample evidence that remission in disease activity optimizes a woman's chances for a successful outcome.

During pregnancy, expect to see two consultants on a regular basis - the Maternal Fetal Subspecialist and your Rheumatologist. Expect to have many tests and frequent visits. Do keep your appointments to give yourself and your baby the best possible odds. And above all else, hang in there. You can emerge with a healthy, happy baby.

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

Miscarriage - Can It Be Lupus?

May is Lupus Awareness Month. Lupus is an autoimmune disease in which the immune system attacks the body's own tissues, causing inflammation, swelling, pain, and damage. Lupus symptoms include fatigue, joint pain, fever, and a lupus rash. But sometimes, adverse pregnancy outcomes such as repeated miscarriage are the first sign of this disease.

Although an uncommon cause, risk of miscarriage is higher in patients with an autoimmune disease such as lupus.

If you've had two or more miscarriages and are unsure, you should ask about a diagnostic investigation. Your health as well as a successful pregnancy outcome may depend on it.

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

Handle With Care

I'm sure everyone's seen the headlines trumpeting Powerball-sized verdicts in medical liability cases involving children born with severe neurological impairment. I mean it's common knowledge that these injuries are always caused by lack of oxygen during the birth process, right?

It turns out that in most cases, common knowledge is wrong.

From this week's New York Times:

... The truth is far more complex, according to an important new report by a committee of experts in obstetrics, pediatrics, neurology and fetal-maternal medicine. Many conditions that occur during or even before pregnancy can lead to neurological damage to full-term babies.

The document, called Neonatal Encephalopathy and Neurologic Outcome, updates a version published in 2003 that focused on oxygen deprivation, or asphyxia, around the time of birth. The new report, which highlights significant advances in diagnosis and treatment in the decade since, was published by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics. Brain injuries affect about three in 1,000 babies born full-term in the United States, but only half of these cases are linked to oxygen deprivation during labor and delivery, according to the new report. And even in those instances, a problem that occurred long before birth might have exaggerated the effects of a reduced oxygen supply that would have not otherwise caused a lasting brain injury.

According to the 2003 report, fewer than 10 percent of children with cerebral palsy, the most severe such brain injury, showed signs of asphyxia at birth. Unless certain clear-cut symptoms are present then, brain abnormalities are probably not the result of a complication during labor or delivery, the new report states.

The other side of the coin is that because of the way these cases are handled and the monumental cost involved, not only monetary by the way, many folks feel they have little choice but to find a lawyer. Additionally, obstetricians' response has been predictable with C-Section rates amounting to about one in three births in an effort to avoid the courtroom.

Surely, there has to be a better way.

My Placenta Is Low-Lying. Now What?

Now that most pregnant women have a midpregnancy ultrasound, they are often alerted to findings of uncertain significance. One of the most common of these involves the placenta. A placenta is low-lying when the lower edge extends to within 2 centimeters of the internal cervical opening or os. This is different from a placenta previa which actually covers the internal os. A group of investigators at the Brigham and Women's Hospital in Boston reported on their experience with the eventual outcome of pregnancies complicated by these low placentas.

Here's the short answer: Most of these situations resolve by the end of the pregnancy.

In total, 1220 of 1240 low-lying placentas (98.4%) that had sonographic follow up resolved to no previa before delivery; 89.9% of placentas cleared the cervix by 32 weeks, and 95.9% cleared by 36 weeks.

A small minority were not so lucky.

Twenty patients (1.6%) had persistent sonographic placenta previa or a low-lying placenta at or near term, including 5 complete previas, 7 marginal previas, 5 low-lying placentas, and 3 vasa previas; all had cesarean deliveries.

So, about 98/100 times all turns out well. In about 2/100 cases, the situation persists. Moreover, a very few unfortunate women were found to have vasa previa, a condition in which fetal blood vessels actually cross that internal os in front of the baby. Think about that for a moment. If the baby descends toward the birth canal and puts pressure on these blood vessels, those vessels can tear, resulting in a fetal hemorrhage, often severe.

So what should be the plan if they do find a low-lying placenta during your ultrasound? The authors suggest a repeat sonogram after 28-30 weeks to confirm resolution, repeating again at 34-36 weeks if the situation remains the same. During those studies, a search for vasa previa can also be conducted.

So if you're told you have a low-lying placenta, you should be optimistic but should follow up. The late Ronald Reagan said it best: "Trust but verify."

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

Maternal Weight And Stillbirth

This past week in the Journal of the American Medical Association, a statistical analysis of 38 studies of moms' weight either prior to pregnancy or in early pregnancy showed a relationship between maternal BMI and risk of stillbirth. The loss of a wanted pregnancy at any gestational age is tragic but the worst has to be a fetal death in the few weeks prior to birth. The nursery has been set up. The birth announcements prepared. Often, the room is packed with gifts from the baby shower. All this adds to the immense suffering of the loss of a child.

So how is maternal weight linked to stillbirth? The authors suggest the possibility that the increased amount of adipose tissue may exert metabolic effects which affect placental function. We already know the effect of weight, fat, and type 2 diabetes, for example. A similar altered biology may be at work here as well. Another possibility is that heavier women become less sensitive to fetal movement and are thus less apt to pick up on the signals of decreasing fetal movement. The lack of this alarm mechanism may miss that narrow window for life-saving intervention.

So what should a woman considering having a baby do in light of this information? The best, obviously, is to get as close to ideal body weight as possible prior to conception. When this is not possible, early prenatal care would be essential, with a special emphasis to nutritional counseling. As pregnancy enters the "home stretch," certain tests of fetal well-being can be considered - monitoring or non-stress tests, serial ultrasounds for fetal growth, and biophysical profiles. Additionally, fetal kick counts can be done at home which require no sophisticated equipment.

Moms to be should voice any concerns with their Obstetricians. For more information, or to schedule an appointment for an ultrasound, you can call my office at: (718) 925 - 6277.