Podcast family, as I've said many times before,
we get ideas for episodes based on something
hot and fresh off print, something that potentially
is practice changing, or sometimes we do something
that just makes us think about what we do or
don't do. Other times we get podcast topic ideas
from our podcast family, from great questions
that come in or from podcast topic suggestions.
And then the third way that we get ideas is by
stuff that happens to us during our daily practice.
Well, that's how this episode topic came to be.
Just the other day we were doing our OB ultrasounds
and we had a routine ultrasound. It was the patient's
first for gestational dating and she was 16 weeks
by gestational age by her last menstrual period.
No problem, right? 16 weeks, dating, first ultrasound,
good to go. Well, her AUA, her ultrasound composite
gestational age, totally supported her EGA by
her last menstrual period, so we did a re -date.
Placenta looked good, amniotic fluid quantity
looked fine, and the cervical length was normal.
However, however... At the end of the scan, as
we were getting ready to finish, we noted that
at the bottom of the amniotic sac, at its most
dependent portion, at the internal os, there
was this amorphous, freely floating blob of echogenic
material. And when I mean blob, I mean it literally
was an echogenic orb. All right, so it had this
little ball that was freely floating in the cavity.
Now, if you're thinking, was that connected to
the child? It was not. I mean, we looked in multiple
planes, and we looked even with a different resolution
of the transducer. No, not connected to the child.
And if you're thinking, was that something potentially
connected to the placenta, good for you, because
that's exactly what we thought too. And it was
not. This was clearly free -floating and with
position movements, saw this thing. unattached
to either the amniotic sac, unattached to the
placenta, and unattached to the child. So, here
it is. Remember, everything else is fine, dates
are appropriate, even though the fetal weight
was a little bit small, but the weeks were congruent,
and the cervical length was normal, no funneling,
and the cervical length was absolutely normal
at 16 weeks. But yet, there was this... Two centimeter.
Two centimeters, guys. It was 20 millimeters.
Two centimeter blob that kept changing shape
like a lava lamp. What in the world? Now, let
me be very clear. There are times where we see
debris in the amniotic cavity as a direct reflection
of gestational age. Y 'all with me, right? So
if you see somebody and you ultrasound them at
38 weeks, maybe they're doing antepartum surveillance,
and the amniotic fluid looks a little particulate
because there's echogenic material, little flakes
in there. We see that at times. And you can see
that also with clinical chorioamnionitis, where
that could be an inflammatory milieu. Typically,
as you advance in gestation, there's deschromated
cells, there's a lot of vernix in there, especially
at 40 weeks or beyond. It could be some aconium.
So some of these things happen. You see ecogenic
material as a direct reflection of gestational
age. However, remember what we said just at our
intro here. This was at 16 weeks. So here's a
question, and here's what we're talking about.
Does amniotic fluid ecogenic debris, does amniotic
fluid sludge, that's what it's called in print,
okay? So this is sludge material. S. AFS, AFS,
amniotic fluid sludge, AFS. Does that mean anything
for this patient at 16 weeks? Now remember, this
is measurable. Even though it was changing shape,
it looked like a little ball of lava in a lava
lamp, we couldn't ignore it. We saw it, we told
the patient, we're gonna follow this up, and
you're gonna need a detailed Level 2 ultrasound
to make sure that the baby has no other abnormalities,
even though none were seen at this time. What
does that mean? Well, we're gonna cover this
in this episode. Once again, amniotic fluid sludge
is not that unusual as you advance in gestation,
but this patient was in the early second trimester.
Now, trust me, guys, this is not something that's
kind of out there and something that you're not
going to see, because based on some data, you're
going to see this anywhere from 3 % of the time
up to 4 % of the time. So it's not 10, it's not
20%. I get that, but 3 % to 4 % is a lot. This
goes all the way back to a publication that came
out of Israel in 1996 in ultrasound in obstetrics
and gynecology. 1996, ultrasound in obstetrics
and gynecology. So we're going to start there.
And because you guys know I'm not going to give
you data that's 30 years old or so, there actually
is a new systematic review and meta -analysis
that looked at this very thing that came out
February 2024, that's just last year, in archives
of gynecology and obstetrics. So those are going
to be our two main articles here that we're going
to cover, because this happened to us, guys,
just a couple of days ago in ultrasound clinic.
I've asked Morgan, our sonographer extraordinaire,
she's fantastic. I'm like, hey, can you de -identify
that clip, make sure there's no name on it, and
send me that little cine clip, so I'm gonna try
to share that on our Instagram. And if not, there's
plenty of nice images online of second trimester
amniotic fluid sludge, AFS. And what does this
mean? So we're gonna get into that in this episode.
Amniotic fluid sludge, AFS. in the second trimester.
We're gonna cover these two data pieces to figure
out what we're gonna do with this lady. And if
you see this next time, now you'll have the info.
All right, Podcast Family, I think I've set it
up enough. Let's get to it. Tired of all the
spin in women's health education? Yeah, so are
we. This is Dr. Chapa's OBGYN No Spin Podcast.
All right, so let's get to LFS, amniotic fluid
sludge. This was the wildest thing, guys. I hope
Morgan is able to send me that little de -identified
clip. And as always, patients do sign, guys.
They sign permission to release things as educational
value, as long as their name is not on there.
There's no identifying issues, because they know
that we're part of a academic medical complex.
So it's okay to do that. We've got permission.
But hopefully I can get that, because this thing
was so freaky. I mean, there was this little
mobile ball -shifting shape kind of things. It
was like an orb, but it was echogenic and kind
of floating in the cavity and then kind of settled
right by the internal cervical loss. Notice,
remember, super important, no funneling and the
cervical length was normal, even though we are
definitely gonna track that, because that's one
of the things that you're supposed to do. Spoiler
alert on some of the issues on management, which
we're gonna talk about in just a minute, all
right? But this was so wild, because Morgan came
out, she's like, there's like a ball in the amniotic
cavity. And so my first thing was, holy crap,
is that an intestine? I mean, we're talking about,
is this like an omphalocele or gastroschisis?
What are we talking about? She's like, nope,
nope, it's not attached to the kid, you need
to come see this. Of course, so we went in, and
it's not vascular. Guys, that's the first thing
to do. Is this connected to the child? Is this
connected to the amniotic sac? Is this connected
to the placenta? Those are the big three things
to look for. Where is it coming from? And then
put Doppler on it. So we put a color Doppler
and it did not highlight. So this was amorphous,
freely floating, ecogenic blob, otherwise known
as the orb. So, amniotic fluid sludge at 16 weeks.
What the hell do we do with that? So this is
a great discussion. I told Morgan, I'm like,
look, we're super busy right now. Let me just
follow that away in my head. That's not right.
But short of it is, let me just tell the patient
we're gonna follow her up. I'll get some more
data in a minute, but that's kind of a flag.
And sure enough, we're gonna go through, again,
brief data here, because one of my things as
we launch our brand new episode, podcast 2 .0
peeps. Oh boy, that's right. I told Michael that
don't forget that we have to plug. Our new show.
Oh, what is that? That's supposed to be is that
clapping? That sounds like a rain. What the hell
is that? That's supposed to be crowd cheering.
Okay, fine Yep, quick plug. It's our podcast
2 .0 as clinical pearls at some point will phase
out. Now, why are we doing that? For a variety
of reasons. One is you've got to stay fresh.
You got to stay new. You got to do a wardrobe
change sometimes in the middle of the show. I
don't know guys, if you get my analogies, good
for you. But my point is we want to keep things
fresh, plus this aligns with some of the things
that we have planned because we're on the move.
So I'm very thankful. We do have some things
that are in our back pocket. I'm not ready to
discuss yet, but all to say I'm thankful that
we are on the move and we are not going away.
So anyway, Clinical Pearls at some point will
go away as we go into Dr. Chapa's OBGYN No Spin.
podcast that is live already. It's on iHeartRadio.
So I encourage you to not miss out. Guys, we've
got like 15 ,000 members and listeners around
the world. 15 ,000. Think about that. And I'm
very thankful for that. We don't wanna lose anybody.
So just find us. I think it's also on Apple.
Yep, it's on Apple. And right now, both shows
are on Spotify, but at one point, even though
we're doing this and we're gonna cover, we're
gonna paste this material, paste this on both
feeds, at one point, Clinical Pearls, at some
point, will be going away as we launch Podcast
2 .0. After 10 years, it's time to change the
vibe. Same great material. Same stupid comments,
because this is what you get when I'm the host,
but we're just changing this to Dr. Chapa's OBGYN
No Spin Podcast. All right, what the hell was
I talking about? Oh, the sludge. Okay, so AFS.
So check this out. AFS. Let's go back to 1996.
Time warp, 1996, ultrasound and obstetrics and
gynecology. This is out of a place that I've
been many times. This is out of Haifa, out of
Israel. Okay, Haifa, super cool place. Of course,
probably best to go when... The country's not
under warfare. But nonetheless, out of Haifa,
Israel in 1996, listen to this title, guys. So
I showed this to Morgan, I'm like, damn, this
is exactly what I'm talking about. Quote, ultrasonic
features of intra -amniotic unidentified debris
at 14 to 16 weeks gestation. End quote, did y
'all get that? Ultrasound features of intra -amniotic
unidentified debris at 14 to 16 weeks gestation.
Wow, so here's what they did. So they said, look,
let's take a look. In the early second trimester,
not at term, junk floating around in the cavity
when you're 41 weeks is either baby poo poo or
vernex or sloughed off cells or potentially inflammation.
That's your differential for sludge when you're
at term, because stuff happens, all right? But
early on... Stuff debris kind of congeals together
kind of forms together in a little ball and looks
either Particular like scattered material or
it can look like this amorphous fluid non -connected
Orb, okay, so that's what they were looking at
here. They wanted to look specifically at 14
to 16 weeks and figure out what happens Okay,
so perfect, perfect topic for what we're talking
about here. Now they looked at 6 ,500 examinations,
6 ,500, and they found 249 cases with this, okay?
So 6 ,500, and of those, 249. If you do the math,
compute, compute, yada, yada, computer, computer,
iPhone calculator, iPhone calculator, that comes
out to 3 .8%, 3 .8%. Now remember, this is 1996.
This is one publication. Out of Israel, like,
what does that mean for the general population?
They say it's 3 .6. Is that a valid number? Well,
good question, because based on other data, this
is what's wild, guys, based on other data, like
a review of the literature that came out in 2024
out of Journal of Clinical Medicine, and the
separate meta -analysis that came out in archives
in gynecology and obstetrics, both of those,
listen to this, this is wild, place the estimate
of this in the early second trimester as high
as from three to four percent. That's exactly
what they found in 1996. So the numbers seem
to be repeating here. So the good news is it's
not like 10%, it's not 15%, but I consider three
to four percent. Pretty significant. Guys, that's
kind of high. So again, even though it was 1996,
we've got two publications that have repeated
those numbers. One is out of the Journal of Clinical
Medicine, with that title being a review of the
literature, amniotic fluid sludge, clinical significance,
and perinatal outcomes. And then the second publication
that mentions that is in the meta -analysis that
we're also gonna dive deep into in just a moment,
which is the antibiotic therapy. in patients
with amniotic fluid sludge and risk of preterm
birth, a meta -analysis. So that's going to be
something we're going to talk about when we get
into management. So we already talked about,
if you find this, don't ignore it. Now, the good
news is that its implication for problem is probably
closely linked to gestational age. Again, if
you're at term, it could be a marker of infection,
it could be passage of meconium, it could be
just normal vernex. So there's a lot of issues
there that mainly are benign because the majority
of those are vernex or sloughed -off skin cells.
But if you find sludge in the second trimester,
mainly, of course, under 28 weeks, so either
early or late into the second trimester, but
before 28 weeks, or you enter into the third,
This is an issue. One of the management issues
is checking cervical length, which we already
spilled the beans on. But the question is, if
this is potentially an infectious issue, if this
comes from inflammation and colonization of the
fluid by some kind of bacteria or fungal organism,
does therapy seem to help? So that is the focus
that we're going to get into in a minute of the
meta -analysis from February 2024. Again, that
title is antibiotic therapy in patients with
amniotic fluid sludge and risk of preterm birth.
End quote. So again, we're not there yet. I'm
just kind of laying out our plan. All right,
so y 'all with me. So in our patient 16 weeks,
she had this ball of gook. This orb of ecogenic
material that Morgan picked up, and sure enough,
non -vascular, freely floating, and not connected
to anything. So let me start here in 1996, and
let me give you their take on these 249 cases
out of 6 ,500. Now, they discussed and identified
several classes of issues. Little floating particles,
like little snowflakes. They found some that
were round structures that had a diameter anywhere
from 10 15 up to 20 millimeters in size. They
had some that looked like cystic structures.
Remember, we're talking about all of these are
not connected to the placenta, not connected
to the membranes, and not connected to the child.
These are free -floating. They also found some
solid or semi -solid material. That was ours.
And then the fifth category was this echogenic
material that looked calcified. And again, we're
talking about things from 15 millimeters up to
around 20 millimeters. Now for the calcified
issue, their proposed explanation, their theory
was this may have been a small part of the yolk
sac that kind of broke off, became calcified
as a small little calculus, but it's freely floating
into the cavity and leave it at that, okay? So
once again, what they discussed or what they
described are these five issues, either small
floating particles, not what we saw, these little
round structures of low -level echogenicity that
are amorphous, that's what we saw, they had cystic
structures, not what we saw, and then again,
this solid, semi -solid material that also fits
with ours, and this highly echogenic, almost
calcified type of material. That's kind of the
five categories that they found. Now, even though
it's only 3 .8, I consider 3 .8 % to be something
to take note of as we've already discussed. So
what happened? So let's just get to it here as
we try to get more focused on our plan here.
Everything can happen. So while the majority
of the time, this was found as an incidental
finding, what they concluded is this can be an
independent risk factor. for preterm birth. However,
remember, we're talking about 1996. However,
they're like, we don't know what to do with this.
Don't ignore it. At the minimum, do a detailed
fetal anatomical survey to make sure that there's
no congenital anomalies visible. So that's step
one in management, guys. That's a level two detailed
fetal survey just to make sure because the amniotic
cavity should be sterile cockpit zone and if
there's something in it you got to make sure
the child is anatomically okay to check that
box. It's also important again to check for vascularity
as we've already discussed and then the third
for management is is serial assessment of cervical
lane. Now Definitely start. You can start when
you find it and then do it again at 18 up to
22 weeks. But how frequently to keep repeating
that is unclear. Now remember, I'm not talking
about a history with preterm labor. That's a
whole separate algorithm for surveillance for
preterm birth. That's not what we're talking
about here. In this case, because this patient
was a G1, when this is found as an incidental
finding without a history of preterm birth, yes,
track cervical length, although there's no agreement
as to what that means. Do you do it once? Do
you repeat it again in two weeks? Do you just
wait for symptoms? It is unclear. But just to
lay out the data here at this point and to let
you know which way we're going, this can be a
totally benign finding, but it can also be a
marker of some kind of inflammatory response
that could be an independent risk factor for
preterm birth. So that leads us now into this
second review, which is the meta -analysis from
February of 2024, which is if this is inflammatory,
do antibiotics help? So when you find amniotic
fluid sludge... Do antibiotics help? Now, to
be very clear, because we're gonna talk about
this as soon as we come back from the break.
You can be as aggressive as you want to, and
you tell the patient, I can be as aggressive
as you want me to be with this, but nothing is
free, everything has its risks. So at the most
aggressive is you would do an amniocentesis,
draw that out, and then send that for either
PCR and or culture to see, hey, oh my goodness,
is this bacteroides? Is this some kind of atypical
pathogen? you can get as involved as you want
to, knowing, of course, that that has its own
set of risks, especially in the early second
trimester, all right? Or, as we told our patient,
look, this could be inconsequential, you're a
G1, you have no history of preterm birth, I don't
know what to do with this, let's check the baby's
anatomy, let's put you into surveillance for
your cervical length. But then the question is,
do you need antibiotics? If this is potentially
an inflammatory marker, because it's inflammatory
crap floating around into the cavity, Do antibiotics
help? We're going to talk about that and summarize
the meta -analysis from February 2024 out of
archives in gynecology and obstetrics when we
come back. Okay, so we're back. By the way, there's
a weird echo. I am doing this on Call. I feel
like I'm on Call a lot. Do y 'all feel like I'm
on Call a lot? Because I do. I love what I do.
I really don't mind being on Call, especially
if I've got time to knock something out like
this, but it is right now. What's today? Is it
Friday? Today's Friday. It is 7 -11. Oh, 7 -11.
Isn't it like Slurpee Day? Do they still do that?
You go to 7 -Eleven and you get a Slurpee. For
those of you who are outside of the U .S. or
parts of the country where you don't have a 7
-Eleven, is that even a thing? Or did I just
age myself there? There was a convenience store
named 7 -Eleven and you could go in and get Slurpees.
Michael on my screen is shaking his head like
he has no idea what I'm talking about. Brother,
7 -Eleven was a thing, trust me. Like Circle
K. Anyway. Wow. It's 7 -Eleven. Anyway. What
am I point? Oh, it's Friday so I'm doing this
at the hospital and then I think I have the weekend
off as far as I can tell. Alright, so let's see
where we're at. Antibiotics. Do antibiotics work?
So, as a quick recap, where are we at? We saw
a patient at 16 weeks, dates were appropriate,
although the baby was measuring kind of small,
a normal cervical length, no attachment to the
fetus placenta or the amniotic sac itself, but
there was this little blob of about 20 millimeters,
two centimeters, definitely ecogenic, definitely
amorphous, because it was kind of changing shape
like lava, and it was kind of settling itself
in the internal cervical os, still within the
amniotic fluid. Wild. So that is called AFS,
amniotic fluid sludge. No universal protocol
for this. Nobody has one set of management. My
point I'm trying to make here, guys, here's your
take -home message. Don't ignore it. Note it,
follow it up, do a detailed fetal survey, look
for vascularity, and tell the patient, um, antibiotics
likely don't work. This comes from the Archives
in Gynecology and Obstetrics in 2024 out of February's
publication. And the title is Antibiotic Therapy
in Patients with Amniotic Fluid Sludge and the
Risk of Preterm Birth. Now, this was a good idea
because the authors themselves state, yes, there's
been this association of this sludge, this inflammatory
junk, this garbage floating around into the cavity.
Let's try to hit it with an antibiotic or a combination
of antibiotics so that we can get ahead of this.
And that's why most of these antibiotics have
included things like Zithromax or Rosefin. to
try to cover kind of a broad range of GU pathogens,
okay? Well, they did a lot of data search, they
looked through PubMed, of course they looked
through Scopus, Cochrane Review, and they ended
up with four, that's one, two, three, four. for
retrospective cohort studies. Why? Because it's
hard to follow this prospectively, because it
doesn't happen a lot, and there's definitely
not going to be an RCT on this. So some things
you've got to get retrospectively, like this
data. And what they did, they did a systematic
review, and then they attempted to do the meta
-analysis, but the data was so heterogeneous,
they're like, nah, here's a take -home point,
even though the meta -analysis was really hindered
by... the degree of heterogenicity in these four
studies. But what they were trying to get at,
here's a simple question guide. I'm gonna give
you the answer and then we're gonna call it a
day. Do antibiotics help? Can we do something
here outside of just surveillance to try to get
on top of this thing? And the short answer, according
to 2024 in the latest meta -analysis and systematic
review, not so much. Quote. Overall, four retrospective
cohort studies were included in the president's
systematic review and a total of 369 women were
enrolled." End quote. So again, not thousands
of women. The N was 369. Here's what they found.
Quote, we demonstrated that preterm delivery
prior to 34... 32 and 28 weeks of gestation was
comparable among the women who had antibiotics
and those that did not. However, the statistical
heterogenicity of these studies was very high
for each of those gestational ages, which kind
of limited the ability to do a full and solid
meta -analysis." End quote. So short of it is,
you can treat these patients with antibiotics.
but it didn't seem to do anything because if
you have some kind of inflammatory or infectious
process going on that's severe enough for you
to see on ultrasound, damn, the cascade of dominoes
has already started to fall. Does that make sense?
Now, I'm not saying you ignore a clinical presentation
of infection. That's different. That's treatment.
Please treat that if you think she has active
metritis. That's different. But in patients who
are asymptomatic, with the rational understanding
that is plausible and evidence -based to say,
I believe there's some kind of subclinical infection
going on here, let's get on top of that with
ampicillin and augmentin or zithromax or gentamicin,
rosefin, whatever, that doesn't seem to change
the outcome. That's the sad part of this. So
I know it's kind of a bummer. It's kind of a
letdowns that I thought we're gonna get something
to what to do here. And we don't have all of
that guidance universally. What we do have is
conservative care, which is I tell the patient,
give her the information, say we're limited in
what to do with this, but we're gonna check the
child, we're gonna keep checking for this debris,
we're gonna follow you closely, and we're gonna
check your cervical length to put you kind of
on surveillance. Now this does not mean, I wanna
be very clear, if you see this in the early second
trimester, it does not mean that this child is
doomed to prematurity. It does not mean that.
It's not a 100 % correlation, thankfully. It's
not one -to -one. But it is it is a significant
risk factor for that occurrence or preterm birth
But the odds ratios here guys. It's odd because
the odds ratios for risk for preterm birth are
all over the place because of this heterogenicity
in the studies. So I don't want to give you a
true number here, because they're very based
on who you read, but so just suffice it to say
as a category, that early second trimester sludge,
AFS, amniotic fluid sludge, can be a marker for
preterm birth above baseline, but its degree
of impact is unclear. So if you're asked on the
oral boards, you're doing your ultrasound and
she's under 22 weeks and you see sludge in the
cavity, what would you do? Well, number one is
you do a clinical assessment to get a good history.
Does she have a history of preterm birth? So
everything in the context of history, physical
and the clinical presentation. That's number
one. Number two is that patient needs surveillance.
She needs a detailed fetal survey. She needs
a further tracking of cervical length, although
the frequency of repeating that is not universally
clear. And then number three, it's all about
patient information and education. This does
not mean the pregnancy is doomed by any means.
It simply is a prognostic factor towards preterm
birth, the risk of which we cannot fully categorize
or quantify because of the heterogeneity of the
studies. That's the answer. Podcast family one
of our commitments again as we try to evolve
the show is Doing a more focused presentation
a more focused episode just to let you know.
What do I need to know? What does this mean?
What do I do? And what do they tell the patient
and I hope we've done this with this amniotic
fluid sludge episode As always, I'm gonna remind
you until those clinical pearls goes away, don't
forget to look up Dr. Chapa's OBGYN No Spin Podcast
as we start to phase out one avenue and one channel
and move towards the other. And as always, podcast
family, we're thankful for your support. We thank
you for your podcast suggestions and thank you
for your patience as we go through this transition.
Podcast family, now that we've done all that,
I think we can now take it home. Podcast family,
we're thankful for all of the support that you've
given us throughout the years. This has been
the OBGYN No Spin Podcast. We'll see you on the
next episode.