WEBVTT 00:00:07.459 --> 00:00:10.419 Podcast family, as I've said many times before, 00:00:10.660 --> 00:00:13.839 we get ideas for episodes based on something 00:00:13.839 --> 00:00:17.120 hot and fresh off print, something that potentially 00:00:17.120 --> 00:00:20.719 is practice changing, or sometimes we do something 00:00:20.719 --> 00:00:23.600 that just makes us think about what we do or 00:00:23.600 --> 00:00:27.140 don't do. Other times we get podcast topic ideas 00:00:27.140 --> 00:00:29.879 from our podcast family, from great questions 00:00:29.879 --> 00:00:33.780 that come in or from podcast topic suggestions. 00:00:34.299 --> 00:00:36.640 And then the third way that we get ideas is by 00:00:36.640 --> 00:00:39.179 stuff that happens to us during our daily practice. 00:00:39.579 --> 00:00:42.780 Well, that's how this episode topic came to be. 00:00:42.960 --> 00:00:46.060 Just the other day we were doing our OB ultrasounds 00:00:46.060 --> 00:00:49.619 and we had a routine ultrasound. It was the patient's 00:00:49.619 --> 00:00:52.840 first for gestational dating and she was 16 weeks 00:00:52.840 --> 00:00:55.299 by gestational age by her last menstrual period. 00:00:55.740 --> 00:00:58.780 No problem, right? 16 weeks, dating, first ultrasound, 00:00:59.280 --> 00:01:03.759 good to go. Well, her AUA, her ultrasound composite 00:01:03.759 --> 00:01:07.060 gestational age, totally supported her EGA by 00:01:07.060 --> 00:01:09.480 her last menstrual period, so we did a re -date. 00:01:09.819 --> 00:01:12.540 Placenta looked good, amniotic fluid quantity 00:01:12.540 --> 00:01:15.079 looked fine, and the cervical length was normal. 00:01:15.760 --> 00:01:19.400 However, however... At the end of the scan, as 00:01:19.400 --> 00:01:22.159 we were getting ready to finish, we noted that 00:01:22.159 --> 00:01:25.159 at the bottom of the amniotic sac, at its most 00:01:25.159 --> 00:01:28.079 dependent portion, at the internal os, there 00:01:28.079 --> 00:01:33.799 was this amorphous, freely floating blob of echogenic 00:01:33.799 --> 00:01:36.760 material. And when I mean blob, I mean it literally 00:01:36.760 --> 00:01:40.760 was an echogenic orb. All right, so it had this 00:01:40.760 --> 00:01:43.180 little ball that was freely floating in the cavity. 00:01:43.680 --> 00:01:45.579 Now, if you're thinking, was that connected to 00:01:45.579 --> 00:01:48.219 the child? It was not. I mean, we looked in multiple 00:01:48.219 --> 00:01:51.040 planes, and we looked even with a different resolution 00:01:51.040 --> 00:01:55.420 of the transducer. No, not connected to the child. 00:01:55.640 --> 00:01:57.959 And if you're thinking, was that something potentially 00:01:57.959 --> 00:02:00.780 connected to the placenta, good for you, because 00:02:00.780 --> 00:02:03.219 that's exactly what we thought too. And it was 00:02:03.219 --> 00:02:06.659 not. This was clearly free -floating and with 00:02:06.659 --> 00:02:10.069 position movements, saw this thing. unattached 00:02:10.069 --> 00:02:13.550 to either the amniotic sac, unattached to the 00:02:13.550 --> 00:02:17.590 placenta, and unattached to the child. So, here 00:02:17.590 --> 00:02:19.830 it is. Remember, everything else is fine, dates 00:02:19.830 --> 00:02:22.250 are appropriate, even though the fetal weight 00:02:22.250 --> 00:02:25.490 was a little bit small, but the weeks were congruent, 00:02:25.930 --> 00:02:28.990 and the cervical length was normal, no funneling, 00:02:29.330 --> 00:02:31.550 and the cervical length was absolutely normal 00:02:31.550 --> 00:02:36.120 at 16 weeks. But yet, there was this... Two centimeter. 00:02:36.319 --> 00:02:38.319 Two centimeters, guys. It was 20 millimeters. 00:02:38.639 --> 00:02:42.099 Two centimeter blob that kept changing shape 00:02:42.099 --> 00:02:45.199 like a lava lamp. What in the world? Now, let 00:02:45.199 --> 00:02:47.680 me be very clear. There are times where we see 00:02:47.680 --> 00:02:51.180 debris in the amniotic cavity as a direct reflection 00:02:51.180 --> 00:02:53.460 of gestational age. Y 'all with me, right? So 00:02:53.460 --> 00:02:55.699 if you see somebody and you ultrasound them at 00:02:55.699 --> 00:02:57.919 38 weeks, maybe they're doing antepartum surveillance, 00:02:58.199 --> 00:03:01.240 and the amniotic fluid looks a little particulate 00:03:01.240 --> 00:03:03.419 because there's echogenic material, little flakes 00:03:03.419 --> 00:03:06.479 in there. We see that at times. And you can see 00:03:06.479 --> 00:03:09.400 that also with clinical chorioamnionitis, where 00:03:09.400 --> 00:03:13.300 that could be an inflammatory milieu. Typically, 00:03:13.620 --> 00:03:17.099 as you advance in gestation, there's deschromated 00:03:17.099 --> 00:03:20.039 cells, there's a lot of vernix in there, especially 00:03:20.039 --> 00:03:22.740 at 40 weeks or beyond. It could be some aconium. 00:03:23.060 --> 00:03:25.659 So some of these things happen. You see ecogenic 00:03:25.659 --> 00:03:28.900 material as a direct reflection of gestational 00:03:28.900 --> 00:03:31.860 age. However, remember what we said just at our 00:03:31.860 --> 00:03:35.719 intro here. This was at 16 weeks. So here's a 00:03:35.719 --> 00:03:37.300 question, and here's what we're talking about. 00:03:38.060 --> 00:03:42.199 Does amniotic fluid ecogenic debris, does amniotic 00:03:42.199 --> 00:03:44.659 fluid sludge, that's what it's called in print, 00:03:44.800 --> 00:03:50.150 okay? So this is sludge material. S. AFS, AFS, 00:03:50.330 --> 00:03:54.930 amniotic fluid sludge, AFS. Does that mean anything 00:03:54.930 --> 00:03:58.490 for this patient at 16 weeks? Now remember, this 00:03:58.490 --> 00:04:00.530 is measurable. Even though it was changing shape, 00:04:00.629 --> 00:04:02.750 it looked like a little ball of lava in a lava 00:04:02.750 --> 00:04:04.810 lamp, we couldn't ignore it. We saw it, we told 00:04:04.810 --> 00:04:06.389 the patient, we're gonna follow this up, and 00:04:06.389 --> 00:04:08.430 you're gonna need a detailed Level 2 ultrasound 00:04:08.430 --> 00:04:12.090 to make sure that the baby has no other abnormalities, 00:04:12.110 --> 00:04:14.490 even though none were seen at this time. What 00:04:14.490 --> 00:04:16.670 does that mean? Well, we're gonna cover this 00:04:16.670 --> 00:04:19.399 in this episode. Once again, amniotic fluid sludge 00:04:19.399 --> 00:04:23.160 is not that unusual as you advance in gestation, 00:04:23.540 --> 00:04:27.579 but this patient was in the early second trimester. 00:04:27.720 --> 00:04:30.180 Now, trust me, guys, this is not something that's 00:04:30.180 --> 00:04:32.100 kind of out there and something that you're not 00:04:32.100 --> 00:04:34.360 going to see, because based on some data, you're 00:04:34.360 --> 00:04:37.720 going to see this anywhere from 3 % of the time 00:04:37.720 --> 00:04:41.620 up to 4 % of the time. So it's not 10, it's not 00:04:41.620 --> 00:04:45.240 20%. I get that, but 3 % to 4 % is a lot. This 00:04:45.240 --> 00:04:47.560 goes all the way back to a publication that came 00:04:47.560 --> 00:04:52.319 out of Israel in 1996 in ultrasound in obstetrics 00:04:52.319 --> 00:04:56.019 and gynecology. 1996, ultrasound in obstetrics 00:04:56.019 --> 00:04:58.290 and gynecology. So we're going to start there. 00:04:58.529 --> 00:05:00.209 And because you guys know I'm not going to give 00:05:00.209 --> 00:05:03.769 you data that's 30 years old or so, there actually 00:05:03.769 --> 00:05:06.870 is a new systematic review and meta -analysis 00:05:06.870 --> 00:05:10.050 that looked at this very thing that came out 00:05:10.050 --> 00:05:15.050 February 2024, that's just last year, in archives 00:05:15.050 --> 00:05:17.389 of gynecology and obstetrics. So those are going 00:05:17.389 --> 00:05:19.709 to be our two main articles here that we're going 00:05:19.709 --> 00:05:22.310 to cover, because this happened to us, guys, 00:05:22.370 --> 00:05:24.269 just a couple of days ago in ultrasound clinic. 00:05:24.670 --> 00:05:27.990 I've asked Morgan, our sonographer extraordinaire, 00:05:28.389 --> 00:05:30.810 she's fantastic. I'm like, hey, can you de -identify 00:05:30.810 --> 00:05:33.589 that clip, make sure there's no name on it, and 00:05:33.589 --> 00:05:35.250 send me that little cine clip, so I'm gonna try 00:05:35.250 --> 00:05:37.750 to share that on our Instagram. And if not, there's 00:05:37.750 --> 00:05:41.629 plenty of nice images online of second trimester 00:05:41.629 --> 00:05:45.730 amniotic fluid sludge, AFS. And what does this 00:05:45.730 --> 00:05:48.470 mean? So we're gonna get into that in this episode. 00:05:49.110 --> 00:05:54.189 Amniotic fluid sludge, AFS. in the second trimester. 00:05:54.290 --> 00:05:56.730 We're gonna cover these two data pieces to figure 00:05:56.730 --> 00:05:58.509 out what we're gonna do with this lady. And if 00:05:58.509 --> 00:06:01.350 you see this next time, now you'll have the info. 00:06:01.649 --> 00:06:03.069 All right, Podcast Family, I think I've set it 00:06:03.069 --> 00:06:13.290 up enough. Let's get to it. Tired of all the 00:06:13.290 --> 00:06:19.850 spin in women's health education? Yeah, so are 00:06:19.850 --> 00:06:25.319 we. This is Dr. Chapa's OBGYN No Spin Podcast. 00:06:47.720 --> 00:06:51.060 All right, so let's get to LFS, amniotic fluid 00:06:51.060 --> 00:06:54.300 sludge. This was the wildest thing, guys. I hope 00:06:54.300 --> 00:06:56.480 Morgan is able to send me that little de -identified 00:06:56.480 --> 00:06:59.459 clip. And as always, patients do sign, guys. 00:06:59.500 --> 00:07:02.279 They sign permission to release things as educational 00:07:02.279 --> 00:07:04.519 value, as long as their name is not on there. 00:07:04.540 --> 00:07:07.160 There's no identifying issues, because they know 00:07:07.160 --> 00:07:10.620 that we're part of a academic medical complex. 00:07:11.000 --> 00:07:12.819 So it's okay to do that. We've got permission. 00:07:13.040 --> 00:07:14.860 But hopefully I can get that, because this thing 00:07:14.860 --> 00:07:16.720 was so freaky. I mean, there was this little 00:07:18.069 --> 00:07:21.629 mobile ball -shifting shape kind of things. It 00:07:21.629 --> 00:07:26.050 was like an orb, but it was echogenic and kind 00:07:26.050 --> 00:07:28.029 of floating in the cavity and then kind of settled 00:07:28.029 --> 00:07:30.149 right by the internal cervical loss. Notice, 00:07:30.209 --> 00:07:33.689 remember, super important, no funneling and the 00:07:33.689 --> 00:07:35.870 cervical length was normal, even though we are 00:07:35.870 --> 00:07:37.610 definitely gonna track that, because that's one 00:07:37.610 --> 00:07:40.189 of the things that you're supposed to do. Spoiler 00:07:40.189 --> 00:07:42.670 alert on some of the issues on management, which 00:07:42.670 --> 00:07:44.069 we're gonna talk about in just a minute, all 00:07:44.069 --> 00:07:46.720 right? But this was so wild, because Morgan came 00:07:46.720 --> 00:07:50.019 out, she's like, there's like a ball in the amniotic 00:07:50.019 --> 00:07:53.079 cavity. And so my first thing was, holy crap, 00:07:53.180 --> 00:07:54.800 is that an intestine? I mean, we're talking about, 00:07:55.160 --> 00:07:57.360 is this like an omphalocele or gastroschisis? 00:07:57.459 --> 00:07:58.439 What are we talking about? She's like, nope, 00:07:58.639 --> 00:08:00.939 nope, it's not attached to the kid, you need 00:08:00.939 --> 00:08:03.560 to come see this. Of course, so we went in, and 00:08:03.560 --> 00:08:05.600 it's not vascular. Guys, that's the first thing 00:08:05.600 --> 00:08:08.339 to do. Is this connected to the child? Is this 00:08:08.339 --> 00:08:10.740 connected to the amniotic sac? Is this connected 00:08:10.740 --> 00:08:13.060 to the placenta? Those are the big three things 00:08:13.060 --> 00:08:15.660 to look for. Where is it coming from? And then 00:08:15.660 --> 00:08:18.180 put Doppler on it. So we put a color Doppler 00:08:18.180 --> 00:08:21.160 and it did not highlight. So this was amorphous, 00:08:21.399 --> 00:08:25.180 freely floating, ecogenic blob, otherwise known 00:08:25.180 --> 00:08:30.920 as the orb. So, amniotic fluid sludge at 16 weeks. 00:08:31.350 --> 00:08:33.669 What the hell do we do with that? So this is 00:08:33.669 --> 00:08:35.169 a great discussion. I told Morgan, I'm like, 00:08:35.190 --> 00:08:36.649 look, we're super busy right now. Let me just 00:08:36.649 --> 00:08:39.190 follow that away in my head. That's not right. 00:08:39.990 --> 00:08:41.789 But short of it is, let me just tell the patient 00:08:41.789 --> 00:08:43.750 we're gonna follow her up. I'll get some more 00:08:43.750 --> 00:08:46.009 data in a minute, but that's kind of a flag. 00:08:46.669 --> 00:08:48.350 And sure enough, we're gonna go through, again, 00:08:48.590 --> 00:08:50.490 brief data here, because one of my things as 00:08:50.490 --> 00:08:54.370 we launch our brand new episode, podcast 2 .0 00:08:54.370 --> 00:08:58.529 peeps. Oh boy, that's right. I told Michael that 00:08:58.529 --> 00:09:02.389 don't forget that we have to plug. Our new show. 00:09:02.750 --> 00:09:04.950 Oh, what is that? That's supposed to be is that 00:09:04.950 --> 00:09:09.710 clapping? That sounds like a rain. What the hell 00:09:09.710 --> 00:09:14.070 is that? That's supposed to be crowd cheering. 00:09:14.250 --> 00:09:18.259 Okay, fine Yep, quick plug. It's our podcast 00:09:18.259 --> 00:09:21.840 2 .0 as clinical pearls at some point will phase 00:09:21.840 --> 00:09:24.580 out. Now, why are we doing that? For a variety 00:09:24.580 --> 00:09:26.559 of reasons. One is you've got to stay fresh. 00:09:26.659 --> 00:09:28.539 You got to stay new. You got to do a wardrobe 00:09:28.539 --> 00:09:31.620 change sometimes in the middle of the show. I 00:09:31.620 --> 00:09:33.899 don't know guys, if you get my analogies, good 00:09:33.899 --> 00:09:35.600 for you. But my point is we want to keep things 00:09:35.600 --> 00:09:38.159 fresh, plus this aligns with some of the things 00:09:38.159 --> 00:09:41.379 that we have planned because we're on the move. 00:09:41.460 --> 00:09:43.220 So I'm very thankful. We do have some things 00:09:43.220 --> 00:09:45.539 that are in our back pocket. I'm not ready to 00:09:45.539 --> 00:09:47.960 discuss yet, but all to say I'm thankful that 00:09:47.960 --> 00:09:51.539 we are on the move and we are not going away. 00:09:51.879 --> 00:09:53.779 So anyway, Clinical Pearls at some point will 00:09:53.779 --> 00:09:59.759 go away as we go into Dr. Chapa's OBGYN No Spin. 00:10:00.450 --> 00:10:04.149 podcast that is live already. It's on iHeartRadio. 00:10:04.330 --> 00:10:07.309 So I encourage you to not miss out. Guys, we've 00:10:07.309 --> 00:10:11.029 got like 15 ,000 members and listeners around 00:10:11.029 --> 00:10:13.580 the world. 15 ,000. Think about that. And I'm 00:10:13.580 --> 00:10:15.419 very thankful for that. We don't wanna lose anybody. 00:10:15.899 --> 00:10:18.500 So just find us. I think it's also on Apple. 00:10:18.659 --> 00:10:21.139 Yep, it's on Apple. And right now, both shows 00:10:21.139 --> 00:10:24.299 are on Spotify, but at one point, even though 00:10:24.299 --> 00:10:26.360 we're doing this and we're gonna cover, we're 00:10:26.360 --> 00:10:29.340 gonna paste this material, paste this on both 00:10:29.340 --> 00:10:32.259 feeds, at one point, Clinical Pearls, at some 00:10:32.259 --> 00:10:35.460 point, will be going away as we launch Podcast 00:10:35.460 --> 00:10:39.480 2 .0. After 10 years, it's time to change the 00:10:39.480 --> 00:10:42.759 vibe. Same great material. Same stupid comments, 00:10:43.100 --> 00:10:47.080 because this is what you get when I'm the host, 00:10:47.639 --> 00:10:50.700 but we're just changing this to Dr. Chapa's OBGYN 00:10:50.700 --> 00:10:52.700 No Spin Podcast. All right, what the hell was 00:10:52.700 --> 00:10:56.360 I talking about? Oh, the sludge. Okay, so AFS. 00:10:56.700 --> 00:10:59.720 So check this out. AFS. Let's go back to 1996. 00:10:59.940 --> 00:11:03.320 Time warp, 1996, ultrasound and obstetrics and 00:11:03.320 --> 00:11:06.019 gynecology. This is out of a place that I've 00:11:06.019 --> 00:11:08.799 been many times. This is out of Haifa, out of 00:11:08.799 --> 00:11:12.220 Israel. Okay, Haifa, super cool place. Of course, 00:11:12.519 --> 00:11:14.399 probably best to go when... The country's not 00:11:14.399 --> 00:11:16.820 under warfare. But nonetheless, out of Haifa, 00:11:16.840 --> 00:11:20.779 Israel in 1996, listen to this title, guys. So 00:11:20.779 --> 00:11:24.159 I showed this to Morgan, I'm like, damn, this 00:11:24.159 --> 00:11:27.899 is exactly what I'm talking about. Quote, ultrasonic 00:11:27.899 --> 00:11:31.559 features of intra -amniotic unidentified debris 00:11:31.559 --> 00:11:35.940 at 14 to 16 weeks gestation. End quote, did y 00:11:35.940 --> 00:11:38.580 'all get that? Ultrasound features of intra -amniotic 00:11:38.580 --> 00:11:41.740 unidentified debris at 14 to 16 weeks gestation. 00:11:42.190 --> 00:11:44.710 Wow, so here's what they did. So they said, look, 00:11:44.730 --> 00:11:48.590 let's take a look. In the early second trimester, 00:11:48.710 --> 00:11:51.230 not at term, junk floating around in the cavity 00:11:51.230 --> 00:11:55.330 when you're 41 weeks is either baby poo poo or 00:11:55.330 --> 00:11:59.929 vernex or sloughed off cells or potentially inflammation. 00:12:00.129 --> 00:12:03.149 That's your differential for sludge when you're 00:12:03.149 --> 00:12:06.070 at term, because stuff happens, all right? But 00:12:06.070 --> 00:12:10.320 early on... Stuff debris kind of congeals together 00:12:10.320 --> 00:12:13.679 kind of forms together in a little ball and looks 00:12:13.679 --> 00:12:16.679 either Particular like scattered material or 00:12:16.679 --> 00:12:22.500 it can look like this amorphous fluid non -connected 00:12:22.500 --> 00:12:25.120 Orb, okay, so that's what they were looking at 00:12:25.120 --> 00:12:27.460 here. They wanted to look specifically at 14 00:12:27.460 --> 00:12:30.620 to 16 weeks and figure out what happens Okay, 00:12:30.620 --> 00:12:35.019 so perfect, perfect topic for what we're talking 00:12:35.019 --> 00:12:39.419 about here. Now they looked at 6 ,500 examinations, 00:12:39.580 --> 00:12:45.779 6 ,500, and they found 249 cases with this, okay? 00:12:46.000 --> 00:12:50.440 So 6 ,500, and of those, 249. If you do the math, 00:12:50.980 --> 00:12:53.039 compute, compute, yada, yada, computer, computer, 00:12:53.960 --> 00:12:55.759 iPhone calculator, iPhone calculator, that comes 00:12:55.759 --> 00:13:01.500 out to 3 .8%, 3 .8%. Now remember, this is 1996. 00:13:02.100 --> 00:13:05.200 This is one publication. Out of Israel, like, 00:13:05.480 --> 00:13:07.639 what does that mean for the general population? 00:13:07.779 --> 00:13:11.899 They say it's 3 .6. Is that a valid number? Well, 00:13:12.120 --> 00:13:15.019 good question, because based on other data, this 00:13:15.019 --> 00:13:17.659 is what's wild, guys, based on other data, like 00:13:17.659 --> 00:13:21.759 a review of the literature that came out in 2024 00:13:21.759 --> 00:13:25.409 out of Journal of Clinical Medicine, and the 00:13:25.409 --> 00:13:27.429 separate meta -analysis that came out in archives 00:13:27.429 --> 00:13:30.549 in gynecology and obstetrics, both of those, 00:13:30.649 --> 00:13:33.370 listen to this, this is wild, place the estimate 00:13:33.370 --> 00:13:37.250 of this in the early second trimester as high 00:13:37.250 --> 00:13:41.250 as from three to four percent. That's exactly 00:13:41.250 --> 00:13:44.549 what they found in 1996. So the numbers seem 00:13:44.549 --> 00:13:48.490 to be repeating here. So the good news is it's 00:13:48.490 --> 00:13:51.370 not like 10%, it's not 15%, but I consider three 00:13:51.370 --> 00:13:54.840 to four percent. Pretty significant. Guys, that's 00:13:54.840 --> 00:13:58.120 kind of high. So again, even though it was 1996, 00:13:58.259 --> 00:14:00.100 we've got two publications that have repeated 00:14:00.100 --> 00:14:02.659 those numbers. One is out of the Journal of Clinical 00:14:02.659 --> 00:14:05.720 Medicine, with that title being a review of the 00:14:05.720 --> 00:14:09.100 literature, amniotic fluid sludge, clinical significance, 00:14:09.299 --> 00:14:12.399 and perinatal outcomes. And then the second publication 00:14:12.399 --> 00:14:15.279 that mentions that is in the meta -analysis that 00:14:15.279 --> 00:14:18.179 we're also gonna dive deep into in just a moment, 00:14:18.519 --> 00:14:21.500 which is the antibiotic therapy. in patients 00:14:21.500 --> 00:14:23.940 with amniotic fluid sludge and risk of preterm 00:14:23.940 --> 00:14:26.039 birth, a meta -analysis. So that's going to be 00:14:26.039 --> 00:14:27.200 something we're going to talk about when we get 00:14:27.200 --> 00:14:29.340 into management. So we already talked about, 00:14:29.539 --> 00:14:32.600 if you find this, don't ignore it. Now, the good 00:14:32.600 --> 00:14:38.440 news is that its implication for problem is probably 00:14:38.440 --> 00:14:41.129 closely linked to gestational age. Again, if 00:14:41.129 --> 00:14:43.309 you're at term, it could be a marker of infection, 00:14:43.490 --> 00:14:45.889 it could be passage of meconium, it could be 00:14:45.889 --> 00:14:48.629 just normal vernex. So there's a lot of issues 00:14:48.629 --> 00:14:52.149 there that mainly are benign because the majority 00:14:52.149 --> 00:14:54.049 of those are vernex or sloughed -off skin cells. 00:14:54.470 --> 00:14:58.590 But if you find sludge in the second trimester, 00:14:59.230 --> 00:15:01.730 mainly, of course, under 28 weeks, so either 00:15:01.730 --> 00:15:03.870 early or late into the second trimester, but 00:15:03.870 --> 00:15:06.570 before 28 weeks, or you enter into the third, 00:15:07.239 --> 00:15:09.740 This is an issue. One of the management issues 00:15:09.740 --> 00:15:12.419 is checking cervical length, which we already 00:15:12.419 --> 00:15:15.610 spilled the beans on. But the question is, if 00:15:15.610 --> 00:15:18.629 this is potentially an infectious issue, if this 00:15:18.629 --> 00:15:22.009 comes from inflammation and colonization of the 00:15:22.009 --> 00:15:25.409 fluid by some kind of bacteria or fungal organism, 00:15:26.169 --> 00:15:29.509 does therapy seem to help? So that is the focus 00:15:29.509 --> 00:15:31.409 that we're going to get into in a minute of the 00:15:31.409 --> 00:15:35.470 meta -analysis from February 2024. Again, that 00:15:35.470 --> 00:15:38.549 title is antibiotic therapy in patients with 00:15:38.549 --> 00:15:41.649 amniotic fluid sludge and risk of preterm birth. 00:15:42.189 --> 00:15:44.350 End quote. So again, we're not there yet. I'm 00:15:44.350 --> 00:15:46.269 just kind of laying out our plan. All right, 00:15:46.350 --> 00:15:48.309 so y 'all with me. So in our patient 16 weeks, 00:15:48.649 --> 00:15:52.870 she had this ball of gook. This orb of ecogenic 00:15:52.870 --> 00:15:55.970 material that Morgan picked up, and sure enough, 00:15:56.070 --> 00:15:58.210 non -vascular, freely floating, and not connected 00:15:58.210 --> 00:16:01.230 to anything. So let me start here in 1996, and 00:16:01.230 --> 00:16:05.009 let me give you their take on these 249 cases 00:16:05.009 --> 00:16:09.409 out of 6 ,500. Now, they discussed and identified 00:16:09.409 --> 00:16:13.049 several classes of issues. Little floating particles, 00:16:13.250 --> 00:16:15.409 like little snowflakes. They found some that 00:16:15.409 --> 00:16:19.009 were round structures that had a diameter anywhere 00:16:19.009 --> 00:16:23.830 from 10 15 up to 20 millimeters in size. They 00:16:23.830 --> 00:16:25.990 had some that looked like cystic structures. 00:16:26.070 --> 00:16:27.470 Remember, we're talking about all of these are 00:16:27.470 --> 00:16:29.629 not connected to the placenta, not connected 00:16:29.629 --> 00:16:31.590 to the membranes, and not connected to the child. 00:16:31.990 --> 00:16:35.230 These are free -floating. They also found some 00:16:35.230 --> 00:16:38.669 solid or semi -solid material. That was ours. 00:16:39.129 --> 00:16:41.669 And then the fifth category was this echogenic 00:16:41.669 --> 00:16:45.950 material that looked calcified. And again, we're 00:16:45.950 --> 00:16:49.590 talking about things from 15 millimeters up to 00:16:49.590 --> 00:16:52.710 around 20 millimeters. Now for the calcified 00:16:52.710 --> 00:16:55.889 issue, their proposed explanation, their theory 00:16:55.889 --> 00:16:58.090 was this may have been a small part of the yolk 00:16:58.090 --> 00:17:00.929 sac that kind of broke off, became calcified 00:17:00.929 --> 00:17:05.250 as a small little calculus, but it's freely floating 00:17:05.250 --> 00:17:09.400 into the cavity and leave it at that, okay? So 00:17:09.400 --> 00:17:12.259 once again, what they discussed or what they 00:17:12.259 --> 00:17:14.119 described are these five issues, either small 00:17:14.119 --> 00:17:16.519 floating particles, not what we saw, these little 00:17:16.519 --> 00:17:19.880 round structures of low -level echogenicity that 00:17:19.880 --> 00:17:23.480 are amorphous, that's what we saw, they had cystic 00:17:23.480 --> 00:17:25.779 structures, not what we saw, and then again, 00:17:25.940 --> 00:17:28.240 this solid, semi -solid material that also fits 00:17:28.240 --> 00:17:31.559 with ours, and this highly echogenic, almost 00:17:31.559 --> 00:17:34.500 calcified type of material. That's kind of the 00:17:34.500 --> 00:17:37.500 five categories that they found. Now, even though 00:17:37.500 --> 00:17:41.519 it's only 3 .8, I consider 3 .8 % to be something 00:17:41.519 --> 00:17:44.180 to take note of as we've already discussed. So 00:17:44.180 --> 00:17:47.619 what happened? So let's just get to it here as 00:17:47.619 --> 00:17:50.940 we try to get more focused on our plan here. 00:17:52.859 --> 00:17:54.960 Everything can happen. So while the majority 00:17:54.960 --> 00:17:57.700 of the time, this was found as an incidental 00:17:57.700 --> 00:18:01.319 finding, what they concluded is this can be an 00:18:01.319 --> 00:18:05.519 independent risk factor. for preterm birth. However, 00:18:05.660 --> 00:18:08.240 remember, we're talking about 1996. However, 00:18:08.319 --> 00:18:09.799 they're like, we don't know what to do with this. 00:18:10.099 --> 00:18:12.960 Don't ignore it. At the minimum, do a detailed 00:18:12.960 --> 00:18:15.579 fetal anatomical survey to make sure that there's 00:18:15.579 --> 00:18:18.980 no congenital anomalies visible. So that's step 00:18:18.980 --> 00:18:22.000 one in management, guys. That's a level two detailed 00:18:22.000 --> 00:18:24.779 fetal survey just to make sure because the amniotic 00:18:24.779 --> 00:18:27.500 cavity should be sterile cockpit zone and if 00:18:27.500 --> 00:18:29.000 there's something in it you got to make sure 00:18:29.000 --> 00:18:33.059 the child is anatomically okay to check that 00:18:33.059 --> 00:18:36.039 box. It's also important again to check for vascularity 00:18:36.039 --> 00:18:38.380 as we've already discussed and then the third 00:18:38.380 --> 00:18:42.759 for management is is serial assessment of cervical 00:18:42.759 --> 00:18:45.910 lane. Now Definitely start. You can start when 00:18:45.910 --> 00:18:48.329 you find it and then do it again at 18 up to 00:18:48.329 --> 00:18:51.789 22 weeks. But how frequently to keep repeating 00:18:51.789 --> 00:18:54.869 that is unclear. Now remember, I'm not talking 00:18:54.869 --> 00:18:57.490 about a history with preterm labor. That's a 00:18:57.490 --> 00:18:59.769 whole separate algorithm for surveillance for 00:18:59.769 --> 00:19:01.289 preterm birth. That's not what we're talking 00:19:01.289 --> 00:19:03.529 about here. In this case, because this patient 00:19:03.529 --> 00:19:06.630 was a G1, when this is found as an incidental 00:19:06.630 --> 00:19:09.250 finding without a history of preterm birth, yes, 00:19:09.470 --> 00:19:11.609 track cervical length, although there's no agreement 00:19:11.609 --> 00:19:14.130 as to what that means. Do you do it once? Do 00:19:14.130 --> 00:19:15.670 you repeat it again in two weeks? Do you just 00:19:15.670 --> 00:19:19.529 wait for symptoms? It is unclear. But just to 00:19:19.529 --> 00:19:23.829 lay out the data here at this point and to let 00:19:23.829 --> 00:19:26.509 you know which way we're going, this can be a 00:19:26.509 --> 00:19:29.390 totally benign finding, but it can also be a 00:19:29.390 --> 00:19:32.349 marker of some kind of inflammatory response 00:19:32.349 --> 00:19:35.150 that could be an independent risk factor for 00:19:35.150 --> 00:19:38.849 preterm birth. So that leads us now into this 00:19:38.849 --> 00:19:41.789 second review, which is the meta -analysis from 00:19:41.789 --> 00:19:45.589 February of 2024, which is if this is inflammatory, 00:19:46.190 --> 00:19:50.099 do antibiotics help? So when you find amniotic 00:19:50.099 --> 00:19:52.930 fluid sludge... Do antibiotics help? Now, to 00:19:52.930 --> 00:19:54.109 be very clear, because we're gonna talk about 00:19:54.109 --> 00:19:55.369 this as soon as we come back from the break. 00:19:55.769 --> 00:19:58.049 You can be as aggressive as you want to, and 00:19:58.049 --> 00:20:00.069 you tell the patient, I can be as aggressive 00:20:00.069 --> 00:20:03.190 as you want me to be with this, but nothing is 00:20:03.190 --> 00:20:05.529 free, everything has its risks. So at the most 00:20:05.529 --> 00:20:08.769 aggressive is you would do an amniocentesis, 00:20:08.990 --> 00:20:12.609 draw that out, and then send that for either 00:20:12.609 --> 00:20:15.890 PCR and or culture to see, hey, oh my goodness, 00:20:15.990 --> 00:20:20.230 is this bacteroides? Is this some kind of atypical 00:20:20.230 --> 00:20:23.200 pathogen? you can get as involved as you want 00:20:23.200 --> 00:20:24.720 to, knowing, of course, that that has its own 00:20:24.720 --> 00:20:27.460 set of risks, especially in the early second 00:20:27.460 --> 00:20:30.680 trimester, all right? Or, as we told our patient, 00:20:30.720 --> 00:20:32.819 look, this could be inconsequential, you're a 00:20:32.819 --> 00:20:35.200 G1, you have no history of preterm birth, I don't 00:20:35.200 --> 00:20:37.000 know what to do with this, let's check the baby's 00:20:37.000 --> 00:20:38.900 anatomy, let's put you into surveillance for 00:20:38.900 --> 00:20:41.440 your cervical length. But then the question is, 00:20:41.480 --> 00:20:44.279 do you need antibiotics? If this is potentially 00:20:44.279 --> 00:20:47.720 an inflammatory marker, because it's inflammatory 00:20:47.720 --> 00:20:51.400 crap floating around into the cavity, Do antibiotics 00:20:51.400 --> 00:20:54.380 help? We're going to talk about that and summarize 00:20:54.380 --> 00:20:57.319 the meta -analysis from February 2024 out of 00:20:57.319 --> 00:20:59.680 archives in gynecology and obstetrics when we 00:20:59.680 --> 00:21:33.990 come back. Okay, so we're back. By the way, there's 00:21:33.990 --> 00:21:37.650 a weird echo. I am doing this on Call. I feel 00:21:37.650 --> 00:21:40.049 like I'm on Call a lot. Do y 'all feel like I'm 00:21:40.049 --> 00:21:42.650 on Call a lot? Because I do. I love what I do. 00:21:42.670 --> 00:21:44.470 I really don't mind being on Call, especially 00:21:44.470 --> 00:21:46.829 if I've got time to knock something out like 00:21:46.829 --> 00:21:48.869 this, but it is right now. What's today? Is it 00:21:48.869 --> 00:21:52.650 Friday? Today's Friday. It is 7 -11. Oh, 7 -11. 00:21:53.109 --> 00:21:54.910 Isn't it like Slurpee Day? Do they still do that? 00:21:55.069 --> 00:21:57.470 You go to 7 -Eleven and you get a Slurpee. For 00:21:57.470 --> 00:21:59.430 those of you who are outside of the U .S. or 00:21:59.430 --> 00:22:00.690 parts of the country where you don't have a 7 00:22:00.690 --> 00:22:03.630 -Eleven, is that even a thing? Or did I just 00:22:03.630 --> 00:22:05.869 age myself there? There was a convenience store 00:22:05.869 --> 00:22:08.349 named 7 -Eleven and you could go in and get Slurpees. 00:22:09.650 --> 00:22:11.430 Michael on my screen is shaking his head like 00:22:11.430 --> 00:22:13.170 he has no idea what I'm talking about. Brother, 00:22:13.250 --> 00:22:15.569 7 -Eleven was a thing, trust me. Like Circle 00:22:15.569 --> 00:22:19.369 K. Anyway. Wow. It's 7 -Eleven. Anyway. What 00:22:19.369 --> 00:22:21.430 am I point? Oh, it's Friday so I'm doing this 00:22:21.430 --> 00:22:23.809 at the hospital and then I think I have the weekend 00:22:23.809 --> 00:22:26.349 off as far as I can tell. Alright, so let's see 00:22:26.349 --> 00:22:28.930 where we're at. Antibiotics. Do antibiotics work? 00:22:29.539 --> 00:22:32.140 So, as a quick recap, where are we at? We saw 00:22:32.140 --> 00:22:33.960 a patient at 16 weeks, dates were appropriate, 00:22:34.039 --> 00:22:35.740 although the baby was measuring kind of small, 00:22:36.140 --> 00:22:39.259 a normal cervical length, no attachment to the 00:22:39.259 --> 00:22:42.500 fetus placenta or the amniotic sac itself, but 00:22:42.500 --> 00:22:46.140 there was this little blob of about 20 millimeters, 00:22:46.259 --> 00:22:49.299 two centimeters, definitely ecogenic, definitely 00:22:49.299 --> 00:22:51.640 amorphous, because it was kind of changing shape 00:22:51.640 --> 00:22:54.660 like lava, and it was kind of settling itself 00:22:54.660 --> 00:22:57.819 in the internal cervical os, still within the 00:22:57.819 --> 00:23:01.819 amniotic fluid. Wild. So that is called AFS, 00:23:02.000 --> 00:23:05.819 amniotic fluid sludge. No universal protocol 00:23:05.819 --> 00:23:09.279 for this. Nobody has one set of management. My 00:23:09.279 --> 00:23:10.920 point I'm trying to make here, guys, here's your 00:23:10.920 --> 00:23:14.140 take -home message. Don't ignore it. Note it, 00:23:14.359 --> 00:23:16.400 follow it up, do a detailed fetal survey, look 00:23:16.400 --> 00:23:20.380 for vascularity, and tell the patient, um, antibiotics 00:23:20.380 --> 00:23:24.099 likely don't work. This comes from the Archives 00:23:24.099 --> 00:23:28.279 in Gynecology and Obstetrics in 2024 out of February's 00:23:28.279 --> 00:23:31.420 publication. And the title is Antibiotic Therapy 00:23:31.420 --> 00:23:33.700 in Patients with Amniotic Fluid Sludge and the 00:23:33.700 --> 00:23:35.880 Risk of Preterm Birth. Now, this was a good idea 00:23:35.880 --> 00:23:38.680 because the authors themselves state, yes, there's 00:23:38.680 --> 00:23:42.339 been this association of this sludge, this inflammatory 00:23:42.339 --> 00:23:46.700 junk, this garbage floating around into the cavity. 00:23:47.039 --> 00:23:50.259 Let's try to hit it with an antibiotic or a combination 00:23:50.259 --> 00:23:53.099 of antibiotics so that we can get ahead of this. 00:23:53.099 --> 00:23:54.920 And that's why most of these antibiotics have 00:23:54.920 --> 00:23:59.130 included things like Zithromax or Rosefin. to 00:23:59.130 --> 00:24:03.089 try to cover kind of a broad range of GU pathogens, 00:24:03.490 --> 00:24:06.529 okay? Well, they did a lot of data search, they 00:24:06.529 --> 00:24:08.289 looked through PubMed, of course they looked 00:24:08.289 --> 00:24:10.690 through Scopus, Cochrane Review, and they ended 00:24:10.690 --> 00:24:15.259 up with four, that's one, two, three, four. for 00:24:15.259 --> 00:24:17.839 retrospective cohort studies. Why? Because it's 00:24:17.839 --> 00:24:19.480 hard to follow this prospectively, because it 00:24:19.480 --> 00:24:20.900 doesn't happen a lot, and there's definitely 00:24:20.900 --> 00:24:23.220 not going to be an RCT on this. So some things 00:24:23.220 --> 00:24:25.660 you've got to get retrospectively, like this 00:24:25.660 --> 00:24:28.140 data. And what they did, they did a systematic 00:24:28.140 --> 00:24:30.700 review, and then they attempted to do the meta 00:24:30.700 --> 00:24:33.180 -analysis, but the data was so heterogeneous, 00:24:33.359 --> 00:24:35.539 they're like, nah, here's a take -home point, 00:24:35.579 --> 00:24:38.140 even though the meta -analysis was really hindered 00:24:38.140 --> 00:24:41.599 by... the degree of heterogenicity in these four 00:24:41.599 --> 00:24:43.779 studies. But what they were trying to get at, 00:24:43.819 --> 00:24:45.359 here's a simple question guide. I'm gonna give 00:24:45.359 --> 00:24:46.599 you the answer and then we're gonna call it a 00:24:46.599 --> 00:24:49.460 day. Do antibiotics help? Can we do something 00:24:49.460 --> 00:24:51.880 here outside of just surveillance to try to get 00:24:51.880 --> 00:24:55.119 on top of this thing? And the short answer, according 00:24:55.119 --> 00:24:58.700 to 2024 in the latest meta -analysis and systematic 00:24:58.700 --> 00:25:04.019 review, not so much. Quote. Overall, four retrospective 00:25:04.019 --> 00:25:06.700 cohort studies were included in the president's 00:25:06.700 --> 00:25:11.339 systematic review and a total of 369 women were 00:25:11.339 --> 00:25:13.779 enrolled." End quote. So again, not thousands 00:25:13.779 --> 00:25:18.420 of women. The N was 369. Here's what they found. 00:25:18.519 --> 00:25:21.900 Quote, we demonstrated that preterm delivery 00:25:21.900 --> 00:25:28.079 prior to 34... 32 and 28 weeks of gestation was 00:25:28.079 --> 00:25:31.200 comparable among the women who had antibiotics 00:25:31.200 --> 00:25:35.859 and those that did not. However, the statistical 00:25:35.859 --> 00:25:39.839 heterogenicity of these studies was very high 00:25:39.839 --> 00:25:42.500 for each of those gestational ages, which kind 00:25:42.500 --> 00:25:45.980 of limited the ability to do a full and solid 00:25:45.980 --> 00:25:48.640 meta -analysis." End quote. So short of it is, 00:25:49.059 --> 00:25:51.079 you can treat these patients with antibiotics. 00:25:51.390 --> 00:25:55.029 but it didn't seem to do anything because if 00:25:55.029 --> 00:25:58.430 you have some kind of inflammatory or infectious 00:25:58.430 --> 00:26:01.569 process going on that's severe enough for you 00:26:01.569 --> 00:26:06.269 to see on ultrasound, damn, the cascade of dominoes 00:26:06.269 --> 00:26:08.990 has already started to fall. Does that make sense? 00:26:09.289 --> 00:26:11.890 Now, I'm not saying you ignore a clinical presentation 00:26:11.890 --> 00:26:13.690 of infection. That's different. That's treatment. 00:26:13.829 --> 00:26:16.369 Please treat that if you think she has active 00:26:16.369 --> 00:26:19.369 metritis. That's different. But in patients who 00:26:19.369 --> 00:26:22.619 are asymptomatic, with the rational understanding 00:26:22.619 --> 00:26:26.019 that is plausible and evidence -based to say, 00:26:26.339 --> 00:26:28.400 I believe there's some kind of subclinical infection 00:26:28.400 --> 00:26:31.279 going on here, let's get on top of that with 00:26:31.279 --> 00:26:36.480 ampicillin and augmentin or zithromax or gentamicin, 00:26:36.599 --> 00:26:39.599 rosefin, whatever, that doesn't seem to change 00:26:39.599 --> 00:26:43.539 the outcome. That's the sad part of this. So 00:26:43.539 --> 00:26:46.000 I know it's kind of a bummer. It's kind of a 00:26:46.000 --> 00:26:47.819 letdowns that I thought we're gonna get something 00:26:47.819 --> 00:26:50.839 to what to do here. And we don't have all of 00:26:50.839 --> 00:26:55.250 that guidance universally. What we do have is 00:26:55.250 --> 00:26:57.630 conservative care, which is I tell the patient, 00:26:57.950 --> 00:26:59.809 give her the information, say we're limited in 00:26:59.809 --> 00:27:01.769 what to do with this, but we're gonna check the 00:27:01.769 --> 00:27:03.750 child, we're gonna keep checking for this debris, 00:27:03.910 --> 00:27:05.789 we're gonna follow you closely, and we're gonna 00:27:05.789 --> 00:27:08.509 check your cervical length to put you kind of 00:27:08.509 --> 00:27:11.069 on surveillance. Now this does not mean, I wanna 00:27:11.069 --> 00:27:13.109 be very clear, if you see this in the early second 00:27:13.109 --> 00:27:16.609 trimester, it does not mean that this child is 00:27:16.609 --> 00:27:18.829 doomed to prematurity. It does not mean that. 00:27:19.009 --> 00:27:22.210 It's not a 100 % correlation, thankfully. It's 00:27:22.210 --> 00:27:26.640 not one -to -one. But it is it is a significant 00:27:26.640 --> 00:27:29.779 risk factor for that occurrence or preterm birth 00:27:29.779 --> 00:27:33.440 But the odds ratios here guys. It's odd because 00:27:33.440 --> 00:27:36.200 the odds ratios for risk for preterm birth are 00:27:36.200 --> 00:27:38.720 all over the place because of this heterogenicity 00:27:38.720 --> 00:27:40.940 in the studies. So I don't want to give you a 00:27:40.940 --> 00:27:42.579 true number here, because they're very based 00:27:42.579 --> 00:27:45.359 on who you read, but so just suffice it to say 00:27:45.359 --> 00:27:49.119 as a category, that early second trimester sludge, 00:27:49.380 --> 00:27:53.319 AFS, amniotic fluid sludge, can be a marker for 00:27:53.319 --> 00:27:56.200 preterm birth above baseline, but its degree 00:27:56.200 --> 00:27:58.869 of impact is unclear. So if you're asked on the 00:27:58.869 --> 00:28:01.109 oral boards, you're doing your ultrasound and 00:28:01.109 --> 00:28:04.069 she's under 22 weeks and you see sludge in the 00:28:04.069 --> 00:28:06.769 cavity, what would you do? Well, number one is 00:28:06.769 --> 00:28:09.089 you do a clinical assessment to get a good history. 00:28:09.329 --> 00:28:11.150 Does she have a history of preterm birth? So 00:28:11.150 --> 00:28:13.529 everything in the context of history, physical 00:28:13.529 --> 00:28:15.890 and the clinical presentation. That's number 00:28:15.890 --> 00:28:19.329 one. Number two is that patient needs surveillance. 00:28:19.430 --> 00:28:21.769 She needs a detailed fetal survey. She needs 00:28:21.769 --> 00:28:24.450 a further tracking of cervical length, although 00:28:24.450 --> 00:28:27.609 the frequency of repeating that is not universally 00:28:27.740 --> 00:28:30.619 clear. And then number three, it's all about 00:28:30.619 --> 00:28:33.539 patient information and education. This does 00:28:33.539 --> 00:28:35.980 not mean the pregnancy is doomed by any means. 00:28:36.200 --> 00:28:40.400 It simply is a prognostic factor towards preterm 00:28:40.400 --> 00:28:44.380 birth, the risk of which we cannot fully categorize 00:28:44.380 --> 00:28:46.759 or quantify because of the heterogeneity of the 00:28:46.759 --> 00:28:50.079 studies. That's the answer. Podcast family one 00:28:50.079 --> 00:28:51.980 of our commitments again as we try to evolve 00:28:51.980 --> 00:28:55.980 the show is Doing a more focused presentation 00:28:55.980 --> 00:28:58.400 a more focused episode just to let you know. 00:28:58.440 --> 00:29:00.299 What do I need to know? What does this mean? 00:29:00.480 --> 00:29:02.059 What do I do? And what do they tell the patient 00:29:02.059 --> 00:29:05.000 and I hope we've done this with this amniotic 00:29:05.000 --> 00:29:08.690 fluid sludge episode As always, I'm gonna remind 00:29:08.690 --> 00:29:11.049 you until those clinical pearls goes away, don't 00:29:11.049 --> 00:29:14.490 forget to look up Dr. Chapa's OBGYN No Spin Podcast 00:29:14.490 --> 00:29:17.430 as we start to phase out one avenue and one channel 00:29:17.430 --> 00:29:20.009 and move towards the other. And as always, podcast 00:29:20.009 --> 00:29:22.410 family, we're thankful for your support. We thank 00:29:22.410 --> 00:29:25.750 you for your podcast suggestions and thank you 00:29:25.750 --> 00:29:28.109 for your patience as we go through this transition. 00:29:28.269 --> 00:29:30.410 Podcast family, now that we've done all that, 00:29:30.410 --> 00:29:42.950 I think we can now take it home. Podcast family, 00:29:43.170 --> 00:29:44.789 we're thankful for all of the support that you've 00:29:44.789 --> 00:29:47.529 given us throughout the years. This has been 00:29:47.529 --> 00:29:52.309 the OBGYN No Spin Podcast. We'll see you on the 00:29:52.309 --> 00:29:52.990 next episode.