Loading summary
Transcript5 lines
- [00:01]
Podcast Sponsor/Ad Voice
This episode is brought to you by Accenture. When your advertising operations fall out of sync, everything else follows. Spotify and Accenture are working together to reinvent the rhythm of ad sales using automation, analytics and smarter workflows to simplify campaign delivery and access better data across the business. The result? Less time spent on operations, more time connecting brands with the moments and fandoms that matter most. Learn more@accenture.com Spotify
- [00:31]
this episode is brought to you by Google Chrome. You think you know a browser, but Gemini and Chrome? That's new. It can help you with practically anything on the web, like restoring a vintage motorcycle from a 50 page restoration block. Or finally break down that long article you've had open for weeks. Gemini and Chrome is here for it, ready to make anything online make sense. There's no place like Chrome. Check Responses Setup Required compatibility and availability various 18 foreign.
- [01:05]
Dr. Chapma
Let me just say it right here, right at the beginning. This episode is going to deal with one of the most clinically delicate and emotionally heavy scenarios that we do in obstetrics. Okay? So while we're talking about the follow up care to this event, I don't want to minimize the tragedy, the trauma, the heartbreak break, the disappointment, the stress, whatever else you want to add to that, that that follows a mid pregnancy spontaneous loss, specifically, let's just say like an 18 week spontaneous delivery of a child, right? It's devastating. I mean it's a second trimester miscarriage, spontaneous ab and it is heartbreaking. All right. Now we're going to talk about this. So even though we're going to talk about the subsequent management, I don't want to minimize the difficulty in that 18, 19 or 17 week delivery that is emotionally thick in that room. All right. Now we all get this scenario. So picture this in your head, right? You've gone through the stress of this and or as we had not long ago, patient presents just with pelvic pressure right under 20 weeks. It was some a little bit of weird discharge and lo and behold, you know, the bag and or child is already in the vagina. Delivering it's traumatic. Now once the delivery of the child occurs, if both fetus and placenta look like they have delivered, here's a question that we are tackling. That was the setup to get us to where we are going right now, which is this. Once the child and the placenta deliver and we're always supposed to look at the placenta with every delivery. That's just not a second trimester birth or delivery. It's at any delivery you're supposed to look for visual inspection of the placenta to look for anything retained. But if it looks intact and you did not go in there and piecemeal extract the placenta yourself. Is a routine protocol driven ultrasound of the uterus necessary or not? That is a question that we're asking. Is it routine for us to get an ultrasound transabdominate to look for anything retained in the uterus? Okay, so let me put it this way. Right now there's two ways to do this. There is standard protocol driven, which means everybody gets it. It's a no brainer, right? Don't ask. You're just gonna get an ultrasound to check that box. That is called standard or protocol driven. And then there's the indication based symptom driven approach. Which one is favored? We're gonna get into that in this episode and here it is. Is there any professional society guidance on this as hey, don't forget to do that trans abdominal ultrasound for that, you know, 18, 19 week delivery. Make sure nothing is stuck in the uterus. Or does SMFM say similar? So is there a best practice here? All right, so we're going to talk about this. Is it routine to get a transabdominal uterine ultrasound looking for something retained if there is an otherwise uncomplicated fetal and placental delivery that look intact? So should this be standard procedural, protocol based or indication symptom based? That is the question. Now you think, well, you know what man, who cares? Just get an ultrasound and be done and check the box, just get it on everybody, no problem. If you choose to do that, that's fine. But you choosing to do that is different than a guideline telling you to do that. And remember, nothing in medicine is free because if you're gonna do that routinely, then we can't be fooling ourselves. We have to understand and accept the possible risks of false pa. Cause there's always debris in the cavity, especially after a, you know, 17, 18, 19, 20 week delivery. We have to understand the false positives involved there and the risks of iatrogenic intervention when it may not be necessary. So that's where we're going here. Should this be standard protocol based or should it be indication, symptom based? It seems like a pretty straightforward question, but it's actually not. And we're gonna take a look at what the latest published data has to say about this from the start of the year 20. I think I've set it up enough. We will be right back. We're just trying to fulfill our life calling and Our mission. This is Dr. Choppa's OB GYN no Spin podcast. Well, I hope I really did do justice to the emotionally devastating event that is a second trimester loss. Now remember, we're talking about under 20 weeks here. We're still talking about this as if it was a spontaneous loss patient who presents, maybe the incompetent cervix or whatever. And the baby just delivers. And you inspect the placenta and you're like, hey, everything looks fine. Uterus is non tender, there's no active bleeding. It seems to be all the membranes are intact and. Or the baby delivers within the sac. That's called ncall. And you're like, okay, I think we're done. The follow up question is because you're gonna be asked that as an attending, as an MFM fellow, as a senior resident, hey, do we need to get an ultrasound, make sure nothing is in there. And you're gonna say, ah. So you're asking then, should this be a protocol standard based indication or should it be a symptom? An indication based symptomatology driven algorithm. Okay, so there's standard protocol based and then indication symptom based. Those are two different things. And just to be clear, look, guys, y' all can do whatever you want to do. There's nothing wrong with saying it's our hospital policies or our department's or our group's protocol that every second trimester loss is going to get an ultrasound, no problem. That's fine. Adhere to your PNPs. The issue is understand why there is no societal guidance to do that. So I've already spoiled it, right? So no acog, smfm. Do not say, be sure to check the uterus with an ultrasound to make sure nothing is retained. They do say, however, to definitely check and examine the tissue past to make sure it is there for completeness, knowing of course, that it's not perfect. All right? And there's a reason why that's the case. So yes, right now, all major professional societies say that checking the uterus with an ultrasound should be an indication symptom based assessment rather than universal standard protocol. Unless that's what your group does. And you want to make sure that you follow your policy and procedures. But as a societal instruction, as a societal guidance, no, it's all based on how the patient is doing. And I'll tell you, of course, which just makes sense, the clinical situations when you would say this is not normal. I need to check an ultrasound because I want to make sure that nothing got retained in there. Which puts the Patients at risk for postpartum hemorrhage or of course for infection, sepsis. Now, and remember, we're talking about transabdominal ultrasound. While you can do, you know, transvaginal, we're talking about 18 week delivery here. The value is gonna be in transabdominal to make sure that nothing is retained mainly at the mid corpus of the uterus and the fundus, right? So this is transabdominal. Now both camps make sense here, right? So on the one hand, for the case for routine screening, those proponents make sense. They have a good argument. They're like, look, just cause it looks intact doesn't mean that it's a guarantee that everything is out. So there could be a retained cotyledon, there could be a accessory lobe, there could be a little bit of trailing membranes. So failing to identify that early puts the patient at risk. That's totally logical. That's a good argument. So that makes the case for routine screening, that is standard and protocol driven. On the other hand, there's the argument for doing it when it's based on indication and symptoms guided as an algorithm. And the reason is, is that there's things that are hard to interpret inside the uterus immediately after passage of a fetus. There's blood clots, there's still debris, there can be thickened lining for which we don't know what is normal. And above all, as it was published in August, so a year ago, 2025, in the Journal of Clinical Medicine, the ultrasound diagnosis of retained products of conception is subject to significant inter observer variability. End quote. And even though seeing an echogenic mass, especially with internal vascularity on Doppler, raises a specificity, there's still a chance that those are normal findings and that that would shed on its own as part of the decidua.
- [09:51]
Podcast Sponsor/Ad Voice
All right, this episode is brought to you by Accenture. When your advertising operations fall out of sync, everything else follows. Spotify and Accenture are working together to reinvent the rhythm of ad sales using automation, analytics and smarter workflows to simplify campaign delivery and access better data across the business. The result? Less time spent on operations, more time connecting brands with the moments and fandoms that matter most. Learn more@accenture.com Spotify so just to be
- [10:23]
Dr. Chapma
very clear, both camps have good arguments. Yes, we should do this routinely. I understand why that's a good argument. And then the other camp, no, let's wait for symptomatology and our own assessment of what's passed to guide that. That is currently what most professional societies Say now, I told you I was gonna give you some data from this year. This did come out January of 2026 in the international Journal of Gynecology and Obstetrics. The title of this review is Triage and care for women with symptoms or a diagnosis of pregnancy loss and between 14 and 18 weeks gestation. So exactly what we're talking about here. All right, so this is right in the ballpark of the issue at hand. Should we do this, and this is what this addresses. Should we do a routine ultrasound for these patients? And as it says right here again, January 2026, according to this review, quote, a low threshold for offering surgical evacuation should be considered if the placenta or membranes appear incomplete or if there is excessive bleeding. Now here, don't lose this, guys. Here it is. Quote, in cases of suspected retained poc, ultrasound assessment should be arranged, end quote. So you notice even there it says if you suspect something is incompletely passed, then that should automatically trigger, have a low threshold for an ultrasound. But to say it's routine part of the care, it's just not based on the current peer reviewed evidence and current society guidance. All right, so what are we supposed to do with this? Well, of course, this came out of a course of a real case, not with our group. But somebody asked me, you know, a question about this, and the question was, should I have gotten an ultrasound to check to make sure that nothing was retained when this patient had this heartbreaking passage of a child at 18 weeks? And the answer was, well, how was she doing? She was fine, you know, physically, not emotionally, but there was no uterine tenderness, uterus seemed to have sub involution, bleeding was controlled, and I examined, you know, the contents and everything seemed to be intact. I'm like, then you're good. If you documented that it looked intact and bleeding is controlled and there's no clinical factors, that is our responsibility. That is the minimum due diligence that we must comply with. All right? And to be very clear, nothing wrong with saying every second trimester loss. I'm gonna get an ultrasound, no problem. Just understand that there's a lot of intra observer variability there and we don't want to cause an intervention and cause more, you know, psychosocial or psychological trauma to a patient who's already gone through a lot. See how complicated this is? So this is exactly what I do. So I follow peer reviewed evidence and I follow the current society guidance, which is I document and I look to make sure that everything looks okay. Now, when to get a targeted uterine ultrasound to make sure that nothing is retained makes a lot of sense. If there's any suspicion that the placenta didn't come out intact or there's persistent bleeding or there's weird pain or I had to manually, of course, and go in and try to extract the placenta. Anytime you try to manually remove any parts of conception, you've just ordered yourself an ultrasound to confirm because that is different than having spontaneous passage. All right? So absolutely, if there's any clinical issues that are outside the norm, like excessive bleeding, manual removal of products of conception, subinvolution pain, and of course, any evidence of metritis or of endometritis, you've got to get an ultrasound to make sure that nothing is left in there to prevent patient harm. So it's very interesting and this is very traumatic. I didn't really want to talk about this because it's such a kind of a bummer of a, of a topic, but it's something that we all can learn from. So yes, there are absolutely indication or symptom based protocols for this which seem to be favored by most professional societies, mainly here in the US ACOG and smfm. But even with the Royal College, you're like, hey, you know, don't go looking for problems. The problems will identify themselves. However, it does not mean that you ignore the patient and see her back in six weeks after this happens. These patients need close follow up. If you don't get a trans abdominal ultrasound to say, look, I suspect everything is out as part of patient education. I need to see you back. I know you've been through a lot. I need to see you back within five days or a week or so to make sure you're okay. And if there's any, any continued weird bleeding, you've got to come back immediately, especially if there's fever. Because we got to get ahead of this because this is a risk for two things, hemorrhage and sepsis. So we've got to pay attention to these things. But the indications, the symptom based protocol makes sense over a standard protocol driven approach because of the possibility of false positives. All right? Now if you're going to do it or you suspect that there's something retained, as I already mentioned, the two main factors here repetitively, in ultrasound article after ultrasound article, including the data from aium, they say that the combination of an echogenic mass that's discrete, not a thickened stripe that's too insensitive or non specific. But if you have a localized collection of a heterogeneous mass with echogenicity. And especially if that highlights with Doppler, that raises your suspicion that there's something retained and that should be addressed. And that doesn't necessarily mean a D and C, you can do medical management. Maybe you can do hysteroscopic removal with a morsel later. You can do that if you choose to do that. It's been very well documented to be safe. Or you can do standard D and C and the best practice in that case would be to do it under ultrasound if it's available to try to ensure that you do remove what was retained. We don't want to put any patient in harm's way and we don't want to give a patient the risk of hemorrhage or infection. But we also don't want to do unnecessary intervention by doing things that are standard and protocol based rather than indication and symptom based. So guys, this is deep and I know it's not a kind of a fun topic, but it's something I think we can all learn from here. Again, nothing wrong. If your hospital wants you to do this after every 19 week delivery, that's fine. But just understand that there are a lot of issues here. There's a lot of inter variability and the last thing we want to do is introduce more trauma, both physical and mental to the patient when it may not be necessary. Let the patient and the symptoms guide your follow up care. If you want more information on color risk stratification of retained products, that's called the Gutenberg Scale. G U T E N B E R G. The Gutenberg Scale, you can look that up. We're not going to get into it, but it's just another way to stratify the possibility that what you're seeing on ultrasound is real and that you really do have to get it out. The Gutenberg Index podcast family, as always, we're thankful for you. We're glad your podcast. We're glad your podcast. We're glad you're part of our podcast community. It's been a long day, guys. I'm trying to get through this and as always, we'll see you on the next episode of the no Spin podcast. Michael. Oh my gosh. Let's go ahead and end this. I don't know where this is going. We'll see you on the next episode. This is Dr. Chapma's OBGYN no Spin podcast.