Dr. Steven Inglis joins Healthful Woman to discuss ultrasounds in obstetrics. He and Dr. Fox review the advances in ultrasound use due to better technology, embryology, genetics, and training for OB/GYNs, from just “make sure there is a head there” to making diagnoses based on “the difference of a millimeter or two.” They also discuss what OB/GYNs are looking for on an ultrasound and why, and the shortcomings of ultrasound exams.
“The Anatomy Ultrasound: Your Baby’s First Physical” – with Dr. Steven Inglis
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal fetal medicine specialist practicing in New York City. At Healthful Woman I speak with leaders in the field to help you learn more about women’s health, pregnancy and wellness. All right, Steve Inglis. Steve, welcome to “Healthful Woman” it’s great to finally have you on the podcast.
Dr. Inglis: Thank you so much Naty.
Dr. Fox: Although we work together every day, we couldn’t actually be in the same room at the same time. So we’re doing this over the phone even though we’re both sitting at work.
Dr. Inglis: Yes.
Dr. Fox: Yeah. And it’s not even COVID related. This is just general scheduling things.
Dr. Inglis: Exactly. The usual chaos of New York City.
Dr. Fox: Steve, just so our listeners know who you are a little bit about you, tell us a little bit your background where you from, where do you train, how did you end up from where you started to here?
Dr. Inglis: Sure, sure. So I grew up not in New York City but outside in Westchester and went to college down in New Orleans. Then I came almost back home for medical school in New York Medical College and then into my residency up in Albany, New York. And then when I finished the obstetrics and gynecology residency, I felt like I really wanted to learn much more about obstetrics and maternal diseases and fetal diseases, so I applied to get a fellowship and and got one at Cornell in New York City, about two years there, had a fabulous time. And then since then, I’ve been working at various jobs, usually for chunks of time all around New York City.
Dr. Fox: Right, and that’s I guess the reason we originally met is because I did my fellowship at Cornell a few years after you and then just part of the same network, you know, I say, “Hey, do you know Steve Inglis?” And you were at an affiliate and then you did your fellowship there. And so we got to meet then and then who knew, years later, we’re working together.
Dr. Inglis: Exactly. That’s a fabulous place we have.
Dr. Fox: Pretty cool how does that translate make us before where you are now with us at the Maternal Fetal Medicine in Carnegie, you were the chairman of a department of a big city hospital.
Dr. Inglis: Correct.
Dr. Fox: Right. So tell us a little bit about that.
Dr. Inglis: You know, with time as I’ve gotten away from those jobs, I should say, I feel like I did my piece to push ahead on public health, I literally spent I think it’s 23 years total time really kind of in the trenches trying to push ahead hospital that we’re dealing with very impoverished patients, and I learned a lot. But unfortunately, I kept getting further and further, higher and higher positions with more and more responsibility, and more and more administrative stuff. And I’m not alone. A lot of people through their career, they end up in doing administrative stuff that they don’t really, at the end of the day, love doing. And so after all of those years of doing great work of getting places to do better and as best they can to keep up with a big University Hospitals try to do the same work they do, even in their community hospitals try to provide the same care, I was just tired of it. I’m 60 now and I was like, “You know what, I’ve struggled enough with all of that,” and I looked around and then I saw your practice where the goal is very simple. It’s to be the best possible medical doctor, not administrator. You know, not, at least for me, not businessman. It’s just try to do the best possible medicine. And thankfully, I feel like I never got far away from medicine. I do know chairmen who are no good at medicine. I literally saw it and I was like, “That I don’t wanna do.” I don’t want when I walked in the room for them to say, “Okay, I need to protect the patient from the chairman.”
Dr. Fox: Right, yeah it’s hard. [crosstalk 00:04:00.]
Dr. Inglis: Yeah, thankfully I like just refused to do that. Always kept my hands wet in all of medicine. And thankfully, I always had good relationship with Cornell and other big places so I could stay linked up with those places. But now I get to really focus with your practice and hopefully just do fabulous work every day for patients who have super complicated pregnancies. It’s a great challenge. Yep. I love it.
Dr. Fox: Yeah, it’s such an interesting idea that in medicine, the way it often works in hospitals and departments is someone who’s the most prestigious and well published and great teacher and great doctor, he or she sort of gets promoted up the ranks, but the promotion usually involves a shift in increasing proportion of administrative duties and a decreasing proportion of actual clinical care and teaching and all the things that made them great. And so taken to an extreme you can have a chairperson who is essentially an administrator, they’re not seeing patients, they’re not doing operations or whatever it is, procedures in patients, teaching, doing research, and they’re basically just running meetings.
And again, it’s valuable, and it is important work and it can help people. It’s not that it’s inherently a problem, but it sort of they got promoted out of what they do into something else. And I think the really successful ones, maybe not necessarily as administrators, but successful ones as doctors are able to maintain that clinical relevance at the same time, number one, because that’s ultimately why most people went into medicine is to take care of patients and do this and so they don’t lose that. And number two, I do think it makes you a better administrator because you understand what it’s like for people sort of speak on the front lines or whatever phrase you wanna use to explain what the doctors are doing. I think if the leadership does not have a good grasp of what’s going on, then it becomes hard for them to be leaders as well.
Dr. Inglis: Well, I can tell you, there’s some giant institution. I don’t know if they still do it, but Parkland down in Dallas, Texas was just a giant in the world of OB-GYN in terms of discoveries and research and so on. They, at least when I was there, had a rule that the chairman had to be turned over every few years. It wasn’t that long. There’s literally no one…[crosstalk 00:06:20]
Dr. Fox: Right, like, the term limit.
Dr. Inglis: Yeah, there was no one who was stuck there forever. Which, I think maybe it’s good idea.
Dr. Fox: Yeah, I mean, my father was a chairman for a neurology for a very, very long time. And he told me that he could never tolerate more than 50% administrative. He said, if my job ever got more than… meaning, he’s gonna have to spend at least 50% of my time seeing patients and doing clinical care and teaching because otherwise he goes, “Meetings, I can’t stand meetings.” It’s sounds like, it’s what you do all the time, you have meetings. And so I think he was both very skilled at it, but probably a little lucky that he got into position that was able to do that. And so he was able to sort of function as a chair for a very long time and still was very busy clinically and people respected him and still do and in terms of patient care, but also was able to lead a good department because the doctors saw him as one of their own, one of their peers and not just some random person who they don’t even know if they could take care of patients anymore. Well, we’re sure happy you came over to us. It’s good for us.
Dr. Inglis: But the saying is getting meeting to death literally, just for lack of a better words. But it’s just been a great change of pace for me and different focus and it’s such a great place to work with super skilled people. I mean, they’re just so great. They’re just so good at the work and clinical care and judgment, making the right decisions and listening to others being able to ask questions. Fabulous.
Dr. Fox: And your commute got a hell of a lot better.
Dr. Inglis: This is true. Absolutely. In the days of COVID, now I just walk.
Dr.Fox: Yeah, you walk as well.
Dr. Inglis: Even Giselle.
Dr. Fox: Yeah, but no more electric scooter, Steve. Those are bad.
Dr. Inglis: That’s right. Yeah.
Dr. Fox: Electric scooter was Steve’s initial mode of transportation until it broke you. It broke Stephen too. I thought it’d be really neat for us to talk today about the anatomy, ultrasound, the ultrasound that we do in the middle of pregnancy, either a 20 weeks or 16 weeks or both to look at the baby head to toe. And really, because number one, you and I both trained in the same fellowship, where it was very strong and ultrasound each fellowship has their own strengths. I mean, I don’t wanna say strengths or weaknesses because they’re all certified and qualified and you have to be above a certain bar for all aspects of maternal fetal medicine, but certainly some are more strong in some areas than other others.
And at Cornell in particular, a lot because the person in charge both when you’re there, and I was there, Frank Chervenak. Dr. Chervenak was really a leader in ultrasound. And so it was a very strong program in terms of ultrasound training. So that’s number one. And number two, I’ve been around the block and you’ve been around the block couple more times, and I’ve been around the block, but just how much it’s changed over the past 10, 20 years. And I thought that’d be really neat perspective about ultrasound and what we can see and what we used to be able to see and what women should expect to understand and what’s going into that ultrasound. And so I thought that’d be pretty cool for us to talk about that in terms of the evolution of this anatomy, ultrasound, I think if you can maybe take us back to when you started training, what were you seeing at the time compared to what you’re seeing now?
Dr. Inglis: Anyone who’s listening to this might be a concern when they hear this but the reality was back when I was being trained, they literally had an ultrasound machine and labor delivery that was donated by one of the doctors. And it was just basically a piece of junk. And the training and how to do an ultrasound was just, “Take it in there, you know how to do it,” and you just literally figure it out on your own. And in those days, it was very, very crude. You were just basically trying to make sure there is a head there and which way the baby was facing and make sure the abdomen was there and there was a stomach bubble that you could see. And that was about it. There really was not anything remotely like what we’re doing today.
Dr. Fox: Right. It was like, if you’re lucky if you could tell them that they’re having twins.
Dr. Inglis: I myself had a case where they had a diagnosis of twins and that patient had had I think, since it was twins, like seven or eight ultrasounds at three different units with twin pregnancy, and then the patient came in in the middle of the night, and I am a junior resident, but I’m on call and like, they say, “Doctor, please evaluate. I can’t feel the heart rate of one other twins.” I go in there and I see one look fine. The other one I can’t see very well. I don’t know what’s going on here. So I call the attending we rush her back do a Cesarean and lo and behold, there’s only one baby. “No, there’s only one?” “There’s only one. There’s only one,” and the patient had so many ultrasounds at different units, they all had weights and sizes. So you could just see from that, that is, things have just changed so tremendously.
Dr. Fox: Right. And why is that? Is that is because skills have gotten better? Or because just technology of ultrasounds gotten better?
Dr. Inglis: Certainly both. And I would argue that thankfully, there has been people, docs who have been able to discover amazing stuff over the years on how to do it on ways to figure out whether there’s a problem with his baby and we’ll come back to it. But the other story I wanted to say was…another thing with that in those days was we routinely had, you know, a baby come out with Down syndrome or come out with this, or that, or whatever, routinely because we only looked at women who were 35. So we would often have babies come out with Down syndrome at, who were under 35. We we’re like, “Oh, well under 35 that’s why we miss all of those.” Because you could never see anything on ultrasound that would catch it. And then you’d be in there doing the delivery and the baby comes out and it has some big anomaly. And you literally have to hold it together because the poor patient is there in and just having her child. And you can’t say like, “Holy whatever,” you can’t, that would just like crush her. So you literally say, “Everything’s okay.” Like control your natural response. Just say, “Everything’s okay.” Bring the baby over to the warmer, tell the mom everything’s okay. And then slowly over time, let the pediatrician figure out what’s happening and then begin to let her know that… because it’s just in the theater stuff, we saw the effects where we just never saw it. And that was the way it was just as it was.
Dr. Fox: And it’s really amazing. I mean, because number one the actual machine technology, and what we call sort of the resolution, for example, which is the ability to see things differently one to the next is gotten so much better. And when we look at the old, like, pictures of what people used to see on ultrasound, you’re like, “Oh my God, can you possibly see what’s going on?” That has been a huge improvement, but also, like you said, people have done a lot of research. And so there are sometimes very subtle things you would see an ultrasound that if you didn’t know to look for them, or know to measure them, or know to do something with the ultrasound parameters to do something to it, you just wouldn’t know that it meant anything. And I think that since there’s been a lot of people using and dabbling with and researching ultrasound, we’ve just learned a lot more about how it can be used to identify things. It’s not just like taking a photo it’s using the clues that we see it like the classic is that new culture lucency measurements. So that’s something at 12 weeks, someone noticed was able to put together that babies with certain genetic abnormalities have a slightly thicker back of the neck and you’re talking the difference of a millimeter or two. It’s not like necessarily something you would look at the baby and say, “Oh, that baby’s abnormal.” And once I figured out all right, we standardized it. This is the picture you take, this is how you take it. This is how you do the measurement. And they came up to do it thousands of times to come up with an algorithm of exactly how thick and how much it raises your risk. And so that took years, and years, and years, and years, to develop. Not because the technology got better, but because the people doing the ultrasound, their knowledge got better.
Dr. Inglis: Essentially, over the years, the researchers who actually discovered how to do it slowly but surely, figured out basically, for the baby, from head to toe, how to efficiently kind of do a physical exam with your ultrasound. And two very specific views if you’re able to obtain those views you can pre well rule out chunks of problems that the baby could possibly have the more common stuff the very rare stuff that we can’t look for, but for the more common stuff so that over the years, they’ve researched it to the point where it’s something that’s relatively simple, a relatively simple picture to obtain. It has to be something you can do every day. And that’s examples of what you just said it’s nuchal translucency, when that first came out, so just me now Dr. Fox, just me. I thought, “That’s garbage. That’s garbage. You can’t get that you that you is too hard. I don’t know what they do. That’s different in England and Dr. [inaudible 00:15:39] lab, but she keeps talking about it.” And on and on, and then years later, it’s like, “No, it’s actually easily doable, even on patients that are more challenging to get them whatever.
Dr. Fox: What you said is also true, because if someone goes and gets a 20 week anatomy ultra sound pretty much at any qualified place pretty much in the world, but let’s just say in the U.S., the images obtained will be nearly identically the same, identical. And because everyone says, “This is the way you image the heart,” you get this view, you get this view, you get this view, and everyone knows how to get in. That’s how they train. And so it’s quite standardized. So even though it’s done at different places by different people on different fetuses, obviously, they’re gonna look remarkably similar. And also, it’s just another indicator of how cool it is that humans look the same, like internally that all of us are built nearly the exact same way is so fascinating, that you look at 100 fetal hearts, and 99 of them will look exactly the same.
And it’s just amazing that that works out and you’re talking about at 12 weeks, it’s gonna look the same. This is like, just 10 weeks after conception that’s how embryology works that these babies own 99% of the time. sort of grow and develop in the exact same patterns, which is just it’s always astounding to me that that’s how it is there’s obviously variability in how we are in terms of how we look and our behaviors and this. But those organs are built and situated the same way 99% of the time, it’s really remarkable.
Dr. Inglis: It is absolutely amazing to meet think that the designer of these people who walk around every day was able to start out with ourselves and it has it divides and it divides and divides. And then each of those cells slowly but surely realizes, “Oh, I need to go this way I need to grow longer that way and divide some more that way. And now we need to make a pancreas, right now I need to make a stomach.” And it can all just…
Dr. Fox: Happen.
Dr. Inglis: Slowly but surely happen exactly. And I don’t tell patients this often but I’m just amazed is that it goes correctly as often as it does.
Dr. Fox: I see that all the time because when people, you know, when we see an abnormality or and usually causes of age when we see like a minor after melody that doesn’t have major consequences. And I tell them, the crazy thing is not that this happens, the crazy thing is that it usually doesn’t happen. The fact that it goes right 99% of the time is so remarkable. And I think one of the other things that that brings into play is, when it doesn’t go, right, there’s a few reasons that can happen. It can either be just by chance, like, okay, let’s say the way it’s set up is that just the odds of it are 99%, it’s gonna work out and 1% of won’t. That’s one reason. Another one is there some sort of like, insults like, people worried as in what I’m eating, what I’m drinking some environmental exposure. And the truth is, that’s probably the overwhelming majority of causes for differences. But then what you’re talking about how the cell knows, and that’s the DNA and every year we learn more and more about the connection between genetics, and what we see on ultrasound, how abnormalities that we’ve known about for a long, long time, with time we’ve learned about the genetics of that. And each year that passes, we come to learn how certain abnormalities have a genetic basis for it that just was undiscovered until now. And we’re discovering more and more. And maybe it’ll be that all of these things are really genetic. Who knows, but it’s just been more and more.
And so part of ultrasound has really been coupled with the advances in genetics and they’ve gone Hand-in-Hand over time, and the link between them has gotten stronger and stronger. What is the like you said, it’s sort of like a physical exam, the anatomy ultrasound, looking at the baby, head to toe, what’s the goal of that? Like, why do we do that? As opposed to just say, “Hey, let’s wait till the baby’s born.”
Dr. Inglis: This is the exact question they asked me on my oral boards, MFM it must have been MFM oral boards. They literally said, “Here’s your ultrasound exam, and they gave me a video to watch and it was a normal exam. What they were actually doing is we’re seeing whether anybody would actually see something that’s actually not even abnormal, and so the opposite there’s nothing wrong, and you’re actually saying something’s wrong so you can get into trouble that way too. But since it was nothing to talk about that was abnormal on this and again they then asked, “Why do you do these in the first place?” I would just say, basically, it’s an opportunity for us to figure out if there’s anything that we actually need to do that will help this kid, either during the pregnancy, or during delivery, or even long term? Over the years I can think of cases where we found stuff that we didn’t make a big deal about. But then it turns out later on the kids, whatever it was six months or a year old, all of a sudden, there’s a big problem, and they knew about it, and they knew there was something going on there. And they’re able to intervene because they knew something was going on with that child. So that’s why I kind of think of it as a physical exam for the kid early because it’s a chance to see what’s happening with this kid and see if there’s anything that needs to get done. And with time, there’s some success with fetal surgery so that if you really find some stuff, you could even in the middle of the pregnancy intervene and help out pretty limited at this point. I mean, there’s a few diseases where they actually do have surgeries that they can help out kids, right during the pregnancy.
And then basically the same thing at delivery there may be something structurally wrong with the child where it would be unsafe to go through and have a normal delivery. Or there may be something wrong with the child where the minute it comes out, you need to have very specific people there to release pressure, or to work on the heart or whatever. And so you can have a team available to do and be prepared for us. In those days. They actually probably the reason they gave me that board exam question was because it really wasn’t even a standard of care. It was not absolutely, everybody must have a detailed and a timely survey. And as it is now, finally, I think everyone agrees that everybody is better off with that.
Dr. Fox: Yeah, I think that it’s important for people to realize that when we do this, our expectation is that, 95%, 97% of the time, everything’s gonna be normal, right? Because that’s the truth, the baby’s most babies are built perfectly fine. And again, normal when we see that means that what we can see appears normal, right? We can look at the brain and say the brain looks normal. But that doesn’t tell us well, what the baby’s intelligence will be, how the baby is gonna behave. I mean, like those things, just like if I looked at a child and looked at an X ray, or a CT-scan of their brain, you can’t necessarily know that. So when I say norm, I mean looks normal, fine. So we expect that 95%, 97% of the time, everything’s good, their, [inaudible 00:22:41] everything looks normal, everything’s good, have a good day, go home.
And then the other like, 2% to 5% of the time, which is the world we live in. So for most people, they’re gonna come and get reassurance and that’s the main reason they get the ultrasound. They come in they’re told whatever, 18, 20 weeks, “Everything looks great, your baby looks wonderful.” It gives a certain amount of reassurance that we’re not gonna be dealing with A,B, C and D, okay. And then if we see a concern, there’s basically the ones that are amenable to some sort of intervention. And again, the intervention like you said could be during pregnancy, we do something which is probably the exception, right? So that we can fix this, or fix that, or do this, or do that, or give them medicine, or whatever. That’s the exception it’s possible that sometimes happens. But most of the time, it’s about planning, right planning the rest of the the pregnancy, planning the, delivery. If this is a baby who’s gonna have a heart condition well, it’s a lot easier if the family has four months to process that meet with the pediatric cardiologists, meet with the cardiac surgeon meet with the team in the NICU deliver at the right hospital with the right doctors available, and know that this baby needs it rather than just like after birth, the baby suddenly turning blue and then having to figure it out then which is a disaster beyond a disaster.
And so here it sort of gets… it could optimize medically for the baby what happens but also just the experience of the family going through it is a little bit more, I would say, measured, then sort of emergent in that sense. And that’s a pretty important aspect of all this sort of planning for, I would say a minority of patients sometimes we’ll find something which is so horrible that’s maybe incompatible with life or any quality of life and patients choose to terminate but that’s not the reason we do the ultrasound. It’s not like we’re doing an ultrasound to find babies determinate, it’s to really improve outcomes for babies. And again A, give reassurance or B, for some babies try to improve outcomes. Unfortunately, there are situations where we pick up things that are really exceptionally bad outcomes and bad prognosis and people make different decisions about that, but again, mostly it’s reassurance or for planning for the for birth, during birth, or after birth, as you said.
Dr. Inglis: Like, if you pick out some common stuff that we see, for example, a clubfoot, which is when the foot instead of just being flat underneath, it’s kind of angled over, and the kid will have difficulty walking and ambulating, and so on. If you found that or if you found a cleft lip, which is where the lip has a defect right in the middle or the palate, those are common things one of the more common things that we will be able to detect. And if you think about it from the patient’s perspective, they can get this information early on in the pregnancy can make sure there’s nothing else wrong with their child, make sure that every other part of the baby looks fine. If they need to get some genetic testing done to make sure that it’s not part of something bigger. And if you think about it, they’re also able to meet their future persons and take care of clubfoot and patients can read on the internet, look up this way, and that way, and find a doctor go meet the doctor, even before the child comes out. If it’s cleft lip, or all, scared, what the baby’s gonna look like and all this stuff, but you can actually go to doctors who can show you pictures of what they do and past experiences and stuff.
But it is so nice for the patient to be able to have on information in advance rather than go through the craziness, as you described in labor delivery when they find they see something wrong, and then they’re adding a lot of problems going crazy at the time of delivery.
Dr. Fox: Yeah, and it’s such a hard time because not only is it condense all of that processing from weeks or months into hours, but you’re talking about parents who have a newborn and women just want to birth so she’s physically, you know, it’s hard. It’s a very difficult time to sort of be dealing with these things new having a normal “ultrasound” does not mean that that scenario can’t happen, right? There are things that we can miss. Some things are more classically missed than others either because they’re difficult to see which happens like in all babies. There’s some things like we can’t visualize the esophagus, for example it’s just not something you can see by ultrasound. So certain things you won’t know. Other times it’s things that we can see in some women and not others. For example, sometimes if a woman is heavier, it’s sometimes harder to see certain aspects of the baby or sometimes in twins, you can’t see things or, sometimes the baby’s position was just never in a good way to see certain organs.
And that’s a reason and other times because there are organs that change over the course of pregnancies. So for example, when we see that the heart is structurally normal at 20 weeks, right? There’s four chambers, the valves are there, the walls are there, everything’s in the right place, pointing in the right direction. So that’s not gonna change from the middle of pregnancy to the end. But sometimes the function of the heart can change, how is it pumping? What’s the rhythm? Things like that. So sometimes, even if it was normal at 20 weeks, there are certain things that can change in pregnancy, which could be the reason for something new at birth, but for the most part, particularly for major abnormalities, things like big heart defects, brain defects, spina bifida, limb defects, things of that sort. It’s unusual to miss them at 20 weeks it happens, but it’s unusual. And so most families will know about it in advance and have a lot of information before the baby’s born, which I’ve always found to be helpful in the situation, which it’s never great. I mean, families, it’s very difficult to go through that situation, but it’s definitely less difficult when you have more time.
Dr. Inglis: Correct. They can research it to kind of get their head wrapped around what’s happening, I have some familiarity with and to think about it, they can also kind of have an expectation of what will likely occur. They’re gonna do an ultrasound, they’re gonna do with this, they’re gonna check to see if that….
Dr. Fox: Prognosis is another thing. I mean, take a heart defect, for example. I mean, when we suspect there’s an abnormality in the heart, and we look at the heart,45,000 different ways. And then, if we suspect there’s an abnormality we have to meet very shortly thereafter with a pediatric cardiologist they do an ultrasound themselves. But not only are they gonna talk to the patient about what they see, they’ll tell her, “Well, we take care of these children, here’s what to expect, what is the chance your child will need surgery? And if so, what are the outcomes from that surgery? How many babies after that surgery survive and survive and are healthy and live long, healthy lives? Or if the baby doesn’t need surgery will the baby have a heart condition for life? Or will they grow out of it?” And this is information parents wanna know I mean, to say, “My child has a heart defect,” is such a wide range between a small hole in the heart that’s gonna close and your baby will need nothing ever for his or her life, compared to someone who’s gonna need a heart transplant. And there’s everything in between. And so getting that information to be more precise about what to expect, even in childhood and potentially adulthood is just so important they’re trying to make decisions about what to do, and where, and when.
Dr. Inglis: Same thing with with, you know, spina bifida. We had a big case last year where the neurosurgeons she met with the neurosurgeons away in advance months, after month, after month, of meeting with them and meeting with us, back and forth. But that patient got a lot of information. So she really kind of knew what to expect, what are the long term? Short term? What have you seen before? What kind of cases have you had before from those people? And they just did a fabulous job with that kid, but the patient knew what was happening way early and got lots of time to plan and so on.
Dr. Fox: What are the things we look at? So if you were to sort of go through head to toe, I mean, just so our listeners understand how comprehensive this assessment is, it usually takes like 30 to 60 minutes for a typical…well, 30 minutes is fast if like we see everything quickly and but it could definitely up to 60 minutes and we’re this is really just on the baby. And so what do we look at maybe starting head to toe, what kind of…what organs are we looking at?
Dr. Inglis: It’s gonna go through all of the systems more or less. For the CNS, for the central nervous system, which is the brain and the spine, if you start up in the head, there’s a whole bunch of landmarks that we use that should be there, should be visible. There’s a cerebellum in the back of that brain this helps how it helps us balance, in the middle of the brain there’s a central piece where there’s a connection from one side of the brain to the other, you wanna be able to see that. There are channels of the cerebral spinal fluid, which are little holes, actually, that are supposed to be in the head, where the center of the cerebral spinal fluid flows. And you wanna see those, they wanna look right and you look at the lobes themselves, make sure that they look normal. Look at the skull itself, make sure the bones are all formed correctly, and then you go down the spine and down the spine, you should be able to see that the spine is closed, all the way down. And then that’s that, and then as you go further down, you go into the chest at the heart, as you already mentioned, you wanna be able to see that the four chambers are there. Slowly over time, we’ve added on a little bit more, and a little bit more, and a little bit more.
Other views than just the four chambers. Because it’s been found over time that if you just get a few extra views of the heart, you can largely rule that anything wrong with that heart that the kids should come out should have a very functional and good heart for life. And so we also then are checking vessels checking the outflows from the heart because some of the blood from the heart goes into the lungs, and some of the blood that’s coming out of the heart goes all the way into the system. So then you will check those two outflows, you’ll check the main aorta, make sure that it’s big enough and functional, and going all the way down toward the lower part of the baby. You look in the lung area, make sure the lungs themselves look fine. You wanna make sure the diaphragm is in one piece all sealed off because what can happen is there can be what we call a hernia where there’ll be a little hole, and some of the bowel can go up into the lungs. You wanna make sure that the bowel is down below and the lungs are up above everything is in their right place.
And then when you go down into the abdomen, you’re just gonna kind of check the systems make sure the GI system is good, make sure that GU which is genital urinary system are good. For the bowel, you obviously wanna see a stomach, you wanna be able to see that the rest of the bowel has a kind of a uniform look to it. You can’t really see the bowel because it’s dilated up until later in pregnancy where you can see the bowel more clearly. For the kidneys, super important, make sure everything looks good there. You wanna see two kidneys that are the right size and right shape and you wanna see that the urine that the kidneys produce is coming out correctly and then running down little connections to get to the bladder, make sure the bladder looks okay and the right size and so on.
You’ll also be looking at the extremities. You’ll look for make sure that there are four extremities that you see all the bones. The bones look appropriate you wanna look at the hands and make sure that you can see all the fingers everything looks normal. Any of these things that we’re looking at if they become abnormal then we got to think “Okay, is there anything else wrong with this kid?” Go through the hands go to the feet make sure that feet look correct.
Dr. Fox: I mean, it’s pretty comprehensive I mean, we basically look at everything that’s there to look at and in addition to the baby we’re also looking at the uterus, the fluid, the placenta, I mean, if we can the mom’s ovaries, I mean there’s a lot of things we look at. But what I think is so important and what you’re talking about is number one, how comprehensive it is and that sort of a double edged sword. On the one side it’s really great because then everything looks normal. You get so much reassurance you can see the heart looks good, the kidneys looks good, the brain looks good, the spine looks good, the arms, the legs and there’s so much you see and it’s so reassuring when it looks normal. But the the flip side to that is there’s so much opportunity to find something that’s minor right? So obviously if you see a major abnormality, like a big deal, all right, that’s a serious conversation. “Here’s what we see. It may mean a genetic problem, we maybe this, we have to do this.” That’s a situation. But when you look at something so closely, what if some measurements slightly too big or slightly too small? Or what if something is slightly too bright or something not bright enough? Or what if that fluid areas is a little bit more filled than it normally would be?
So the problem is, we don’t always know what that time is that problem, or is it just a variation, right? If you look at everybody, we’re all slightly different like, we have different heights and different weights and our eyes are different, you know, with apart from each other and our arms are different lengths. And so you’re trying to determine is this just a variation of normal? Or is this an abnormality? And I think that what happens a lot, right? When someone has a normal ultra sound pretty straightforward. It’s normal. You’re great. Have a good day. If there’s a very abnormal ultrasound or something markedly abnormal, an obvious abnormality, a clear abnormality. It’s a very difficult situation, obviously. But it’s not unclear, usually, right? Like, we’re clear the baby has spina bifida, it’s a problem. Here’s why it’s a problem. Here’s what we need to do or whatever.
And so again, it’s a very troubling situation, but it’s not vague. The problem is there’s so much in between. and this is I find a lot of times when women get very distressed unnecessarily or confused by their doctors, and we frequently see a lot of second opinions for things in this regard. And it’s important for everyone to have perspective, that there are variations in how babies look, even though like we said, things are remarkably similar. There’s some variation. And so it’s our job to help women understand which things we think are a big deal and a real problem versus which things we think are probably just variation, and how are we going to be more sure about that? Meaning, when I say I see something, it doesn’t mean it’s a problem, it just means I see something and I just wanna make sure that it’s just a variation a normal as opposed to a problem and how you have that conversation with someone can change the entire tenor of the pregnancy from one that is reassuring and relaxed and sort of as you would expect, versus terrifying. And it’s hard to do. It’s not easy, because this is a very high stress situation for people because we’re talking about their babies. It’s a big deal.
Dr. Inglis: Those conversations can be very long.
Dr. Fox: And sometimes they need to be and that’s why we try to do them seated at a table meaning we don’t like to have these conversations while a woman is still on the ultrasound table having her scan. That’s a very difficult way for her to hear and speak and speak her mind and process and ask questions. You really wanna be sitting at a desk, door closed, plenty of time, sometimes it requires coming back or speaking on the phone later because you know, that initial shock, even if it isn’t a “Big issue,” it may feel that way to a woman. So it’s hard to process sometimes. And I think that we spend a lot of time trying to reassure people that the things we’re finding aren’t really problematic, and trying to sort of explain that, as opposed to trying to convince someone that there’s a problem and they’re not getting it, it’s almost always trying to help people work through something that probably isn’t a problem.
Dr. Inglis: I think what you’re describing is also just good medicine. You know, good medicine is where the physician and the patient set and have time to properly communicate what’s going on. You know, sometimes I’ll actually ask the patient, “Tell me what you’re thinking.” Because if I’m looking at them and I can see that she’s freaking out. And she’s really thinking about her mother what her mother’s gonna say or whatever. I like stop and just give them a moment just like, “Tell me what you’re thinking about? Because you can’t just blast information to the patient and so good medicine is really like stopping, and listening, and communicating, and ensuring that the patient really understands and has time to answer all of your questions. And as you say, you’re right, sometimes they can’t even get it the first time they literally, “Can you say it all over again?”
Dr. Fox: And it’s hard. You know, one of the interesting things about what we do is when you do Maternal Fetal Medicine, you are an OB-GYN, you do take care of patients, you know how to deliver babies, I mean, some do some don’t, but like you’ve gone through that training, but we’re also partially radiologists, right? We’re doing ultrasound and we’re interpreting ultrasound and doing ultrasound. And it’s a little bit different because when people go to a radiologist for the most part, the radiologist he or she has nothing to do with the treatment of that condition right?
They say, “Okay, you have appendicitis.” The radiologist isn’t gonna operate on you right? So you have I’m seeing I don’t know evidence of Crohn’s disease like, their not gonna manage your Crohn’s disease like, it doesn’t work like that. But the unique thing is in what we do, is we’re both diagnosing and treating weather it’s the mom or the baby we’re involved in that whole process. So we have the opportunity and I would say the privilege to be able to do the imaging and then right away sit down and speak to the patients not only what we’re seeing but what we’re gonna do about it further testing or treatments or whatever. Whereas frequently if you’re going to radiologist and I’m not knocking the radiologist for this it’s just the nature of what they do and what they they’re trained to do is you go there you get a test and then you walk out the door and you didn’t know what the results are right?
You have no idea like, they do a CAT scan and you leave and you’re like, “Do I have a tumor?” Like you don’t even know sometimes until you see your doctor two or three says later and they got the report from the radiologist and they go over it with you. But typically in what we do it’s not like that. You come in you’re gonna get your results on the spot, the doctors gonna talk you about it, what did we find. And again everything looks normal, you’re good, come back at this time, or you don’t come back or whatever. And if it’s some concern whether it’s small or medium, large or whatever we’ll talk to you about it say, “Here’s what it is, here’s what we need to do here’s what test we need to run.” And then we speak to their doctor, their OB-GYN and we sort of loop everything together. But that’s one of the nice things about how we are able to do that just based on our training that’s not just the training but it’s also the management.
Dr. Inglis: Absolutely. And then I would argue also you also just learn from the cases, from the patient to know how things went. I’ve had patients who’ve come back and say, “Would you do it all over again?” And I’m thinking they think it was horrible or it didn’t really work very well or whatever, and they’re absolutely totally good with everything that happens. You just learn that that what I think may not be at all what the patients thinking and you just need to have an open mind and sit with them and give them the best information you can and let them ask questions or see where they’re coming from and have an open mind as to where they wanna go.
Dr. Fox: Yeah, I mean, I totally agree. It’s such an interesting thing because I mean, pregnancy itself is obviously fascinating. I mean, just the idea of pregnancy it’s so fascinating and maybe I think that because that’s what I do, you know, it’s my life. But it’s such a unique experience where you have a woman who’s she is who she is, she’s healthy, she’s got this whatever and now suddenly she’s pregnant and there’s this like, person growing inside of her and not only are we trying to keep an eye on how she’s doing which is critical but now were also trying to make sure that her baby is okay. And so we have this idea that the ultrasound and the anatomy ultrasound and the technology’s gotten so good. I man, we can see such amazing detail which number one is awesome because then we can see this things. Number two, it’s still humbling how it doesn’t tell us everything like, how something looks does not tell you how it’s gonna function potentially. So, there’s definitely humility in that.
But also this idea that when women are coming for anatomy ultrasound, it really, number one, it’s a serious exam that we’re doing. Again, for most people it ends up being, “Oh, the baby looks cute. We’ll get some pictures everyone’s great it’s a happy smiley day.” But we’re doing a real thorough check. I mean, we’re looking at everything and there is that potential that we’re gonna find something. Hopefully, it’s something that is significant to the baby’s health and well-being and future and that’s obviously. And all those things that we find it’s so important to have a real open conversation with the doctor like, “What exactly are you seeing? What does it mean? Is it a problem is it not? What do w need to do to find out if it’s a problem or not or there’s more tests I need to do, do I have to come back?” And sort of to get as much information and to have those conversations. But it’s not a test which you should just expect just walk in and walk out and get nothing. There should be some feedback either everything looks good or, “I have some concerns.” Or, “I have big concerns.” And to sort of go from there. Unfortunately, the people who do this everyday are trained to do that like, we’re not just looking were actually interpreting and helping to manage this conditions.
Dr. Inglis: As I say you learn through patients. I’m thinking back when I was a fellow where there was a patient who they fund an abnormality in the brain and the patient was like, “That’s fine. No problem at all. It’s okay, I’m just having my baby.” And it wasn’t even my…I think it was actually our chairman or boss, Dr. Chervenak’s patient and the kid comes back and she see’s this kid three years later and the kid is walking and doing totally, totally fine. So the patients like,” I’m okay, with it, leave me alone. We’re good.” And let them do what they wanna do and you will learn and then that opens up your mind as to the effects and like, what do we really know? How much should be really say? Do we really know that this is a problem? Are we sure the diagnosis are right? As you saying, the second opinion, “Do you really know that this is abnormal?” And if it’s abnormal, do we really know what that that’s gonna cause a problem? And as you say, we got to be humble. It might not be a problem.
Dr. Fox: Wow Steve I really appreciate this. This is a great conversation and it’s again something you and I do almost everyday of the week and it’s always fascinating. I mean, we have great, great jobs I mean, it’s just an amazing feel of the medicine to work in. There’s a lot coming in this, we’re gonna keep learning and getting more information and hopefully keep making our abilities to diagnose and predict and that makes thing just better and better. But thanks for coming on the podcast to talk abut this I really appreciate it.
Dr. Inglis: You bet. You bet.
Dr. Fox: All right, Steve, will have you on again. Hopefully we do this face-to-face one time.
Dr. Inglis: Sure.
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