herterotopic risk with prior ectopics?

[Hamhock]

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I was just listening to an ultrasound podcast about TVUS for 1st trimester VB.

The speaker, who is a pretty big name in EM bedside ultrasound (but not necessarily a big name in EM bedside TVUS) stated that an IUP on TVUS in the setting of previous ectopics (with implied frequent PID) is not sufficient for discharge.

That is, he stated that women on clomid (similar preg drugs), IVF, or with a history of ectopics can't be evaluated similarly to the general population.

My question:

How many of you are treating women with 1st trimester VB and a history of prior ectopic (+/- PID Hx) and an EM-identified IUP similarly to women on IVF or clomid?

HH

(also [but don't want to distract from my original question]: how many of you are uncomfortable with stated rates of heterotopics in the general population?)

HH

 

[Apollyon]

Dude, I get that you don't want people to read Rosen and Tintinalli and the ACLS book, but to get their own information (some sarcasm there) (although, by saying you throw out the ACLS book, what do you do that isn't in there?), but, if TVUS with SLIUP isn't enough, what is the next step? Admit (since you can't send them home)? Then what? Ex lap? Or undifferentiated U/S all over the abdomen looking for EUP? The stated rate on Clomid is 1/100. That is good enough for admit. Then, what do they do with them? I don't know.

And uncomfortable with the stated rate of heterotopics? Huh? One in 30K not on fertility tx? Since I am confident that, in my career, I shall not see 30 thousand pregnant patients, that number sounds good. On what would I base another number? One thing would NOT be any data that I've collected (as I believe that the 30K IS from studied numbers, but I took it as more or less gospel, and that, in my anecdote, I've yet to see a hetertopic), so what else do I do?

And, then, so what if I am not comfortable with the number? Do I put myself out there telling Ob/Gyn that "I know you go with 30K, but I think it is lower. No, I don't have anything on which to base this besides my discomfort." What do you think that will get me, apart from ridicule?

 

[Hamhock]

Dude, I get that you don't want people to read Rosen and Tintinalli and the ACLS book, but to get their own information (some sarcasm there) (although, by saying you throw out the ACLS book, what do you do that isn't in there?), but, if TVUS with SLIUP isn't enough, what is the next step? Admit (since you can't send them home)? Then what? Ex lap? Or undifferentiated U/S all over the abdomen looking for EUP? The stated rate on Clomid is 1/100. That is good enough for admit. Then, what do they do with them? I don't know.

And uncomfortable with the stated rate of heterotopics? H😕uh? One in 30K not on fertility tx? Since I am confident that, in my career, I shall not see 30 thousand pregnant patients, that number sounds good. On what would I base another number? One thing would NOT be any data that I've collected (as I believe that the 30K IS from studied numbers, but I took it as more or less gospel, and that, in my anecdote, I've yet to see a hetertopic), so what else do I do?

And, then, so what if I am not comfortable with the number? Do I put myself out there telling Ob/Gyn that "I know you go with 30K, but I think it is lower. No, I don't have anything on which to base this besides my discomfort." What do you think that will get me, apart from ridicule?

😕

I'm not sure I understand your response.

Or maybe I wasn't clear in my question.

I am asking about EM doc-performed TVUS for IUP and heterotopic risk.

The next step would not be ex-lap. 😕

The next step would be a "formal" ultrasound or OB-performed exam...a complete pelvic ultrasound...or other...

HH

 

[Rendar5]

😕

I'm not sure I understand your response.

Or maybe I wasn't clear in my question.

I am asking about EM doc-performed TVUS for IUP and heterotopic risk.

The next step would not be ex-lap. 😕

The next step would be a "formal" ultrasound or OB-performed exam...a complete pelvic ultrasound...or other...

HH

I'm not sure how a formal ultrasound is any better than an EM doc-performed one is when it comes heterotopic pregenancy, what are they going to find that you aren't, honestly. In the IVF patient, I'm not going to trust that one either. Now in the pt with a history of ectopics and/or PID and one in the pouch and a decent story, I can understand the need for a full ultrasound study, but that's more out of my concern for a cornuate pregnancy, which is a helluva lot more common than a heterotopic pregnancy.

 

[xaelia]

To miss an extraordinarily rare occurrence for which no bulletproof readily available non-invasive diagnostic testing exists would meet the standard of care.

For individual patient factors that raise the possibility of disease to the point where it becomes a reasonable consideration, obstetrics consultation for anything from diagnostic laparoscopy to observation to close follow-up may be warranted.

Don't let extremism poison the well of rational decision-making and thoughtful, honest communication with your patient.

 

[Apollyon]

😕

I'm not sure I understand your response.

Or maybe I wasn't clear in my question.

I am asking about EM doc-performed TVUS for IUP and heterotopic risk.

The next step would not be ex-lap. 😕

The next step would be a "formal" ultrasound or OB-performed exam...a complete pelvic ultrasound...or other...

HH

Well, I was clearly confused by your writing style (and, style tip - don't use smileys).

Now that you have clarified, I can clarify. I missed your stating "EM-identified IUP". So, as you didn't state, painless 1T vag bleeding with IUP noted on bedside U/S, and history of ectopic. (That wasn't too hard to state.) A commentator says that that is not enough. So, again, what do you do? The crux is that the formal U/S will stop at the uterus, as, if an IUP is noted, that's that. I don't know how you are going to convince an U/S tech to go searching all around. Likewise, if you press the radiologist, what are you going to get? What would your argument be? "I see an IUP on TVUS, but she had an ectopic in the past. As such, I am concerned for a heterotopic." Again, how far will that get you?

And, again, what's up with the incidence of the heterotopic?

 

[Hamhock]

Wow! I guess I am not expressing myself well at all...or perhaps my practice is greatly different than others on this EM-SDN.

First:

I believe there is a great difference between my (EM) TVUS and the "complete" pelvic ultrasound performed by true ultrasonographers/radiologists/most good OB-Gyns.

Our (EM) scope and EBM-proven abilities are very limited. We can in - uncomplicated - 1st trimester presentations, identify IUP. This case is closed IMO for recently trained grads.

However, complicated cases (clomid, IVF, indeterminate IUP) require a "formal" (please excuse the diction, my purists) ultrasound.

The reason? True ultrasonographers/radiologists scan the entire pelvis for other etiologies, pathologies, etc.

My pelvic ultrasounds get nothing close to those.

If I ever get a real IVF/clomid patient, I may ultrasound myself, but I am certainly ordering a "formal" ultrasound and contacting OB-Gyn.

If you folks are not doing similarly (are your skills that better than mine?), my question does not make sense.

However, if you folks agree that a clomid/IVF patient requires a "complete" ultrasound and likely discussion with OB-Gyn:

Do you treat prior ectopic (+/- PID Hx) patients similarly?

HH

 

[Rendar5]

Wow! I guess I am not expressing myself well at all...or perhaps my practice is greatly different than others on this EM-SDN.

First:

I believe there is a great difference between my (EM) TVUS and the "complete" pelvic ultrasound performed by true ultrasonographers/radiologists/most good OB-Gyns.

Our (EM) scope and EBM-proven abilities are very limited. We can in - uncomplicated - 1st trimester presentations, identify IUP. This case is closed IMO for recently trained grads.

However, complicated cases (clomid, IVF, indeterminate IUP) require a "formal" (please excuse the diction, my purists) ultrasound.

The reason? True ultrasonographers/radiologists scan the entire pelvis for other etiologies, pathologies, etc.

My pelvic ultrasounds get nothing close to those.

If I ever get a real IVF/clomid patient, I may ultrasound myself, but I am certainly ordering a "formal" ultrasound and contacting OB-Gyn.

If you folks are not doing similarly (are your skills that better than mine?), my question does not make sense.

However, if you folks agree that a clomid/IVF patient requires a "complete" ultrasound and likely discussion with OB-Gyn:

Do you treat prior ectopic (+/- PID Hx) patients similarly?

HH

Neither an EM-guided u/s nor a formal pelvic u/s is going to reveal a heterotopic pregnancy in your average patient.

 

[Hamhock]

Neither an EM-guided u/s nor a formal pelvic u/s is going to reveal a heterotopic pregnancy in your average patient.

Probably true, given how rare this is...but would you not order the formal for IVF/clomid?

And, if you would order it: would you also order it for a prior ectopic?

HH

 

[Rendar5]

Wow! I guess I am not expressing myself well at all...or perhaps my practice is greatly different than others on this EM-SDN.

First:

I believe there is a great difference between my (EM) TVUS and the "complete" pelvic ultrasound performed by true ultrasonographers/radiologists/most good OB-Gyns.

Our (EM) scope and EBM-proven abilities are very limited. We can in - uncomplicated - 1st trimester presentations, identify IUP. This case is closed IMO for recently trained grads.

However, complicated cases (clomid, IVF, indeterminate IUP) require a "formal" (please excuse the diction, my purists) ultrasound.

The reason? True ultrasonographers/radiologists scan the entire pelvis for other etiologies, pathologies, etc.

My pelvic ultrasounds get nothing close to those.

If I ever get a real IVF/clomid patient, I may ultrasound myself, but I am certainly ordering a "formal" ultrasound and contacting OB-Gyn.

If you folks are not doing similarly (are your skills that better than mine?), my question does not make sense.

However, if you folks agree that a clomid/IVF patient requires a "complete" ultrasound and likely discussion with OB-Gyn:

Do you treat prior ectopic (+/- PID Hx) patients similarly?

HH

Sensitivity for heterotopic pregnancy with a formal u/s is pretty low, 25-50%...If you're concerned about a heterotopic pregnancy, you're concerned about it, regardless of what your u/s shows and regardless of what the formal u/s shows.. You don't need to decide if your'e going to give up on your own u/s on a pt with a hx of PID or ectopic. You need to decide if you're going to consult with Obstetrics and document your conversation specifically in regards to heterotopic pregnancy on every single 1st trimester patient you see who has a hx of PID or ectopic, just as you would with the IVF doc.

Honestly, what's the % of conceptions of pt's with a hx of PID or ectopics that leads ot a heterotopic pregnancy? The general population is like 0.003% and the IVF population is 0.5-1%.

 

[Apollyon]

Probably true, given how rare this is...but would you not order the formal for IVF/clomid?

And, if you would order it: would you also order it for a prior ectopic?

HH

On IVF protocol, yes, or, if a question, I would call the radiologist. The 1/100 on Clomid is an easy sell.

As for prior ectopic, with one in the uterus, without pain? At most I would call the radiologist, and defer to their discretion. As Rendar notes, even a formal U/S won't usually show you a heterotopic.

I didn't look, but did you consider posting a similar question in the Ob/Gyn forum?

 

[Rendar5]

Probably true, given how rare this is...but would you not order the formal for IVF/clomid?

And, if you would order it: would you also order it for a prior ectopic?

HH

sorry for replying twice, i thought i was editing my first response...

I would order it for an IVF patient because the extra information would be of use to the Reproductive Doc on the other end of the phone, not specifically to determine if it's a heterotopic.

As for your other question, IVF has a relative risk of 300 for heterotopics, I doubt ectopic has such an exorbitant RR, so it's not a game changer in my mind when it comes to a baseline risk of 0.003% of badness. Cornuate pregnancy on the other hand comes with a baseline risk of 0.1%, and is readily identifiable with u/s (I think it has to do with mantle thicknesses or something like that) so that in my mind would be a driving factore in whether or not to get a formal u/s. I don't know what the RR a hx of ectopic hasin this particular case, but I doubt it's high enough to make the decision for a formal u/s black and white. It just casts greys in my mind. The short of my answer is that 1. overall clinical gestalt is going to determine formal u/s v. bedside u/s for me, 2. my reasoning on this has nothing to do with heterotopics, the prevalence pales in comparison to other badness, and 3. overall clinical gestalt also would make me pick up the phone to set up close f/u, regardless of u/s results.

I will have to further amend that my residency by and large depends on formal u/s regardless of the background history, with the exception of a few attendings. My license isn't on the line, and I don't know what I will actually do when it is next year. My opinion may change.

 

[WilcoWorld]

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