Art Fougner, MD

Articles

TRV Uterus IUCD Fragment post IUCD Removal

3D Uterus Reconstruction: Bicornuate Uterus


 Implantation in the scar of a previous Cesarean is thought to be the rarest of  ectopic pregnancies.

 With the increasing numbers of Cesareans  performed, scar implantation may become more frequent as well. We present an  illustrative case.




 Our patient is a 32 year old P 1001 who was referred for evaluation of a  continued first trimester vaginal bleeding. She had previously undergone  Cesarean delivery for dystocia. Subsequently, she developed an  incisional mass.  Surgical excision revealed endometriosis. 

 TVS and TAS were both performed. Ultrasound revealed an enlarged uterus with  blood within the uterine cavity. A gestational sac was noted implanted in the  anterior lower uterine segment in the region of the previous uterine incision.  An approximately 8 week live fetus was seen within the sac.

She underwent treatment with local injection of methotrexate  into the gestational sac. Serial titers of B-HCG progressively fell; however,  after two weeks, profuse vaginal bleeding ensued. Emergency hysterectomy was  performed.


 Although an admittedly rare entity, the rise in Cesarean births may affect its  incidence. The spate of recent articles suggests this may be the case.  Therefore, all who provide prenatal care need to be aware of this form of  ectopic pregnancy. In our case, the incisional endometriosis undoubtedly became  an additional risk factor.

 Since scar ectopic is so rare, a consensus about treatment does not exist. Most  reviews consist of case reports.

 Both medical and surgical therapies  have been utilized successfully. In our case, local injection met with initial  success. Despite falling levels of HCG, the onset of hemorrhage necessitated  emergency surgery.

 One technical note concerning the ultrasound needs mentioning. After Cesarean,  we have found the uterus often adherent anteriorly and pulled superiorly out of  the focal range of the vaginal transducer, negating the higher resolution.  Therefore, TAS, with its more panoramic field of view, can be more helpful in  demonstrating the true nature of the pathology. Moreover, with the development  of harmonic technology, diagnostic images are usually obtained without the need  for bladder-filling.

Fylstra DL Ectopic pregnancy within a Cesarean scar: a review. Obstet Gynecol Survey 2002; 57: 538-543.

Implantation in the scar of a previous Cesarean is thought to be the rarest of ectopic pregnancies. With the increasing numbers of Cesareans performed, scar implantation may become more frequent as well. We present an illustrative case.

Cesarean Scar Ectopic Pregnancy - A Case Presentation

:  "I'm Dr. Allen Worrall from Fairbanks, Alaska and  I'm an OB-GYN doctor who does a good deal of prenatal and GYN  ultrasound.  My job today is to interview Dr. Art Fougner from Forest  Hills, New York, and I'm interested in that because I was born and  raised on Long Island and used to drive by Forest Hills on the Long  Island Railroad when I went into New York City.  It used to be a big  tennis center; I remember that when I was a kid.  Art is going to talk  about       the prenatal assessment of the risk of Down's syndrome, and my  interest in this was started by several things; I'm due to give a talk  on April 21st and I chose that as my topic.  I had a very recent case  that sparked my interest even more; I scanned a thirty-four year old  woman who would be thirty-five at the time of her delivery and her  biophysical triple screen risk was something like 1 in 7,000 - very low  risk.  I scanned her at about nineteen weeks and found what I  interpreted to be echogenic bowel.  I was not sure whether the echogenic  bowel overrode the very low triple screen risk or whether an  amniocentesis was indicated or not indicated.  I decided that I should  recommend to my obstetrical colleague that he do an amniocentesis and he  did.  He is also here in Orlando at Walt Disney World but on vacation  and not coming to this meeting.  By one chance in five million, I ran  into him yesterday and he told me that the amniocentesis revealed a  mosaic for 46-XY and 45-X.  I don't know what that's got to do with  echogenic bowel but, Art, tell us how do you integrate these two  findings - the age of the patient and the triple screen and, of course,  the triple screen includes the age of the patient and the ultrasound  risk?  We could talk about lowering the risk and raising the risk."
       
       

:  "In order to do that, we almost have to  go back to the beginning.  Amniocentesis was first used to diagnose Down  syndrome in the older woman.  It was first used prenatally in the  1970's and the situation used to be very easy, the counseling and risk  assessment simply consisted of asking a woman - how old are you and that  was it.  If you were over a certain age you were offered amniocentesis,  and if you were under a certain age you weren't.  That's the way it  stood until Merkatz in the eighties serendipitously discovered four  fetuses with Down syndrome whose maternal serum AFP's were much lower  than the medium.  Then this progressed rapidly into using other analytes  to nail down and make the test even more sensitive without sacrificing  specificity so now by serum screen we have Down syndrome detection rates  of conservatively around 60%-70%.  Subsequently several investigators,  most notably the group out of Massachusetts headed by Dr. Beryl       Benacerraf, reported on several ultrasound findings which might  also be used to rule in or rule out or I should say modify risks for  Down's such as nuchal folds and then later certain characteristics of  the fetal hand and the fetal heart.  It's almost gotten to the point now  that there are so many markers - I counted over twenty the last time I  looked - for Down's syndrome that one could almost justify an  amniocentesis on virtually every pregnant woman simply based on the  presence or absence of markers.  One of the problems with risk  assessment is you have to know what the individual relative risk is of  the individual finding.  You bring up echogenic bowel, for example,  what's not well appreciated is that the most common correlate with  echogenic bowel and probably the most common cause is bleeding into the  amniotic fluid and subsequent fetal swallowing that let's you get some  bio breakdown and that shows up as inspissated meconium and echogenic  material.  The second thing is that the equipment over the years is  getting better and so the transducer frequencies are getting higher and  higher and produce more and more false-positives.  Now we can detect  things that we never saw previously so the first thing we need to know  is relative risk of the individual findings.  The reason that's  important is if you want to modify risks you have to know by how much  does this finding contribute to a risk.  That's not well defined in  various populations, as a matter of fact, in any population and the  problem with jumping in using markers right now is that all these things  were first described in populations that were already considered to be  at high risk because the original use of ultrasound was not to rule in  an amniocentesis, it was to tell which patient was truly reluctant -  actually your risks are probably lower because your fetus really doesn't  have any of these findings.  Now it's gone completely the opposite  where we're taking       young women who are very happy with their pregnancy and all of a  sudden you see the jaws begin to drop and now they're rapidly becoming  scared to death.  Yesterday it was announced that there's going to be a  consensus panel over the summer to address many of these issues.  In  answer to your question, I'm not sure that really answers your question  because we're all kind of stuck so the best you can do is what you did -  you present the findings to your patient, you have to tell her that  these things have been associated with things, and ultimately the final  choice is up to her.  I think if this were a cancer-screening test, we  wouldn't be doing any of these things because the yield is so poor.  No  cancer detections test would pass muster if a positive finding consisted  of 1 in 300, it just wouldn't pass muster which leaves me to believe  that, perhaps, the only thing our society tolerates less than cancer is  Down syndrome.  Now whether that's a positive or negative can be debated  but that seems to be what the facts are right now."
       
       

:  "Is it true that you can reduce a woman's risk between the ages of 35 and 40 by a negative ultrasound?"
       
       

:  "Yes, I believe that you can.  You can  probably reduce it conservatively by a factor of 75%, 3 out of 4 and  some centers aggressively claim that their detection rates are around  90%.  I'm always leery of that because my own personal bias is that if  you want to see the chromosomes you have to do a specific test that's  for chromosomes.  As of yet, ultrasound hasn't gotten down to the high  frequency necessary to visualize chromosomes so, therefore, you almost  have to look but I do believe that you could at least modify the risks."
       
       

:  "Now how about the woman under 35,  let's say, a low risk woman who has a triple screen that indicates a  risk of 1 in 200 but a negative ultrasound.  How would you advise her?"
       
       

:  "Again, the trick is given the practice  environment in which we live, you can't advise anybody to do anything.   What you can do is you can say - these are your risks and ultimately  it's your pregnancy, you need to talk to people.  This is a decision  that I can't make for you, you need to make that decision that your  risks have to be reduced but they're not zero.  A common analogy I use  is that in our neighborhood we have Queen's Boulevard, it's easily one  of the widest thoroughfares in the world, and people get killed  periodically crossing the street so the risk of getting killed on  Queen's Boulevard given the number of people that cross the street is  very low but it's not zero.  I think this is an analogous situation."
       
       

:  "We do expect a paper, I believe, this  afternoon from Dr. Nyberg.  He has some interesting new information I  think about the independence of ultrasound and biochemistry.  This is a  field that is important and we know that we're overusing these minor  markers, and Doctors Filly and Benacerraf have written recent papers on  this subject that stimulated the AIUM to call a consensus panel so we  all will know how to use these things.  I think it takes a good deal of  courage to find a soft marker in an otherwise low risk patient and just  ignore it and not even mention it because       any baby can be born with Down syndrome, and if that one is born  with Down syndrome and the patient gets it to a lawyer, and the lawyer  finds that the baby had an echogenic focus that you didn't mention - why  you might be in trouble so that's the problem."

OBGYN.net Conference CoverageFrom 45th Annual Conference of the AIUM - Orlando, FL 2001

The Prenatal Ultrasound Assessment for the Risk of Down's Syndrome

:  "Hi, I'm Art Fougner an obstetrician-gynecologist in New York whose practice now is limited to ultrasound."
       
       

:  "And I'm Eric Blackwell.  I'm one of  the Co-Chairs of the History of Ultrasound project for OBGYN.net along  with Joan Baker and with a lot of help from our advisor, Terry DuBose."
       
       

:  "I'd like to ask you, Eric, how did you get started on this History of Ultrasound project?"
       
       

:  "I was there for part of it - you do  notice the grey in this beard here.  I started training back in the  mid-seventies and ventured into ultrasound; I was the first ultrasound  'fellow' out of the Bowman Gray School of Medicine.  I've done nothing  but ultrasound since the beginning which makes me a very odd bird in the  field so I've known a lot of people including some of the true pioneers  like Joe Holmes and those people just in passing.  I got to thinking  about the stuff I have, I have slides and material that I thought I'd  like to put it together, and Terry DuBose gave me the opportunity to get  some of that on the web.  I've put up some things already; pictures  from the early days and people that I couldn't identify, for example,  and already by e-mail have gotten wonderful feedback.  It's an  opportunity to do what Terry calls 'poly-biography' - which means  history by the many of the many events where's there's no end to how  much input and linkage, and the Internet's just the perfect tool for the  job so that's kind of how I got in the back door."
       
       

:  "I first came across ultrasound also  back in the seventies, interestingly enough, at Bellevue.  We had one of  those old Siemens Vidoson, you know the big Tyrannosaurus rex attached  to a gel bag, and we called that real-time back then.  I knew the folks  at NYU and they'd carry around their Aeroflex B-scan transducers in  their pockets, just screw them right on, move the gantry back and forth,  and at the end kind of like a little swoosh as the signature."
       
       

:  "Did you know Dr. Fred Winsberg at all?"
       
       

:  "No, Dr. Winsberg I didn't know."
       
       

:  "He was a wonderful teacher and a real  pioneer but he used to carry his own transducer for cardiac work  wherever he went.  He'd go into somebody else's lab and he'd pull out  his transducer and screw it in and get to work because he'd finally  found the one with the perfect characteristics."
       
       

:  "It looks like ultrasound has sure come a long way from looking for a shift of the midline echo on neuro patients."
       
       

:  "Did you ever do that?"
       
       

:  "Actually, in medical school on rounds  we used to look at these pictures and say - oh, the line is slightly  deviated to one side."
       
       

:  "That's what I started doing.  I was a  neurology resident and my mentor, Dr. Bill McKinney was a neurologist  and he's the one that started the Center for Ultrasound at Bowman Gray  so I started out doing midline echo before we had CT.  We literally had  one piece of equipment and it was kept in a broom closet.  You'd go open  the broom closet, haul it out, go down to the ER at two in the morning,  and try to figure out if there was a midline shift.  Then the next step  was we got a wonderful piece of equipment from Merrill Spencer and Jack  Reid for looking at carotid and that's what actually got me into the  field, and it's just continued to grow and grow since then.  And the  things we've looked at around here just in the last few days, the little  Terason unit that plugs into a personal computer and the new unit that  Kretz has for Medison that's the size of a large textbook, things just  keep improving and changing and there's more choices out there for us to  use."
       
       

:  "I'm convinced that what we're going  to end up doing certainly in OB is instead of handing patients a little  picture of their baby, we're going to hand them a little computer disk,  they're going to put it into their DVD player, and on their coffee table  will be a little dancing hologram from Ally McBeal."
       
       

:  "Absolutely, it's inevitable.  I think  the technology is there; it's probably going to happen.  I have to ask  more specifically how did you get into the ultrasound end of things  because apparently you were keeping an eye on it from the early days?"
       
       

:  "I got into it when I was a young  attending just out of residency at Albert Einstein.  I'd remembered  actually how much fun I had playing with the first ADR unit that they  brought onto the labor floor at Bellevue to demonstrate.  I just simply  started getting my hands on it every chance I got and went down to the  ultrasound lab in the radiology department.  Actually, I pushed for the  hospital to get one up to OB and started doing it and that's how I got  it pretty much like most people.  There was no certification or formal  training program, you just went in and started doing it and went to the  hard knocks school."
       
       

:  "One thing that always really  interested me about the field was in the early days you really could  come in to it from any background.  There was a lady named Henrietta  Givens at Bowman Gray, and Henrietta was our patient transporter.  She  started kind of looking at what was going on when she'd bring these  people down to the lab and then asked if she could watch.  Then she  asked if she could be in the training program and then she became Head  of the Cardiac Ultrasound Unit."
       
       

:  "She died there last June, it was a  sad loss to us.  But it was really a wide-open thing where all you had  to have was the enthusiasm and some support from a mentor of some kind.   Were there any people that really stand out in your memory as people  you looked to for advice or mentoring in ultrasound - your pioneers?"
       
       

:  "Actually the person I respected the  most was a fellow by the name of Oberlander who is now at Saint Lukes  Roosevelt.  He has nothing to do with ultrasound interestingly enough  but this guy was the most experienced obstetrician I ever met in my  life.  He is an Israeli and he went to South Africa and worked for years  in the black hospital in Johannesburg and then came to the Bronx.  He  was scared to death but he sat through the OB-GYN boards anyway, passed,  and now is a big name in diabetes and pregnancy.  This guy said - you  should get involved with this, you should do this, and so that was my  mentor basically."
       
       

:  "And I take it you've not regretted it?"
       
       

:  "I've not regretted it a single bit.  Thanks a lot, that was fun."
       
       

The History of Ultrasound

:  "Hi, I'm Eric Blackwell, and I'm Co-Chairman of  the History of Ultrasound project for OBGYN.net and the Society of  Diagnostic Medical Sonographers along with Joan Baker and with  tremendous technical help and support from Terry DuBose.  We're  delighted to have visiting with us today Dr. Gregg DeVore who is  currently at the Fetal Diagnostic Center of Pasadena in California.  Dr.  DeVore, of course, is well known to most of you out there I'm sure if  you're in ultrasound.  He's a true pioneer in fetal echo and in the  teaching methods, which make this understandable to the rest of us.  I'd  first like to ask how you first got into ultrasound and how did you  become one of the first in line?"
       
       

:  "When I was at Yale University as an  intern in internal medicine in 1975, I decided to switch into obstetrics  and gynecology.  I moved over to the Department of Obstetrics and  Gynecology, and John Hobbins was a new faculty member.  John had  ultrasound that he was using and he thought that this was a useful tool  so after my first year of residency I realized that ultrasound may have a  future so I stayed and did a fellowship at Yale in Maternal-Fetal  Medicine with a heavy emphasis in Ultrasound."
       
       

:  "What sort of equipment were you using in those early days with Dr.       Hobbins?"
       
       

:  "We initially had what are called  'static scanners' where you had an articulated arm and you would move it  across the abdomen and obtain a still image.  Then when real-time first  came out, they had green screens and they had little images that would  flicker on the screen that you would think could be a fetal head or a  fetal leg.  So we had the very first real-time units in the United  States at Yale and from that evolved the current experiences."
       
       

:  "As far as the fetal heart, as opposed to anything else specific, that seems to be a niche that you are very, very good at."
       
       

:  "What happened was when I was at Yale  I was preparing for my fellowship, and ATL came out with a machine that  for the very first time allowed the clinician with real-time imaging to  place an M-mode cursor through the heart and know where you were going  so you record the M-mode from the real-time image.  It was a  breakthrough in echocardiography and so I applied for a research grant  from a foundation and received over $75,000.  We bought one of these  machines, which were the hottest item at the time and the question was -  could we apply this to the fetus?  Because of the size of the heart,  which is the size of, perhaps, a thumbnail in the second trimester, we  had to ask could we see in a miniature heart the detail that we would  see in a newborn or adult heart?  So those were the first questions that  we addressed."
       
       

:  "The topic that I think we really  ought to move to is you've certainly been a pioneer in the use of  multimedia and computer assisted teaching aides and have done it right,  at least in my book, in terms of making things that bring clarity  instead of confusion to the field.  How did you first come to do that?"
       
       

:  "It's interesting, when I was  thinking about writing a textbook on fetal echocardiography unlike other  images in ultrasound like a liver or a kidney that can be a still  image, because the heart is moving the question was how do I teach the  features of a moving heart to identify pathology or other abnormalities  that the clinician needs to know about.  So I realized that multimedia  with the ability to show the beating heart was a priority, and I went  out and contacted professionals who'd created multimedia programs in the  educational arena and asked them which programs they used.  The first  program I used was a program called 'Quest' and it sold for over $4,000.   I wrote the check, and my wife killed me when she saw the stub.  I  created my first multimedia program using Quest and from that point I  then evolved to using software that was even better so it was just a  matter of a need.  I taught myself, I didn't have any formal schooling,  and I didn't go to any classes.  I got the manual, used the program and  tried to figure it out, and with time I was pretty successful doing  that."
       
       

:  "I understand that your first sales  efforts were you at a table with a few hundred that you'd burned or had  burned.  It was quite popular."
       
       

:  "Yes, we were at an international  meeting in Rotterdam, I sat at a table next to a publisher, and I had my  laptop computer.  I had brought with me about 300 or 400 CD's in my  briefcase, I started showing it, and pretty soon I had 1, 2, 20, 30, 40  people around the table.  For three days they bought every CD; it was so  embarrassing in the sense that we walked out and I had money coming out  of my pockets, I didn't know what to do with it all.  We sold it to  them for something like $35 or $39 and it was an instant success."
       
       

:  "Now how many generations of product have you gone through from your first $39 CD?"
       
       

:  "A year after that I developed a 2-CD  ROM series, and it evolved from maybe having 30 video clips on the CD  to over 500 so now we have a full featured 2-CD ROM set on fetal  echocardiography.  I have a new program coming out this summer to  address the use of ultrasound in identified Down syndrome for genetic  ultrasound, and we'll have many cases of Down syndrome with a lot of  features with that one as well."
       
       

:  "On aside to our viewers, just before  this meeting of the 45th Annual Convention of AIUM which is in Orlando,  there was a pre-meeting conference.  Dr. DeVore along with several other  people including Phillippe Jeanty, a gentleman from Brazil, and a woman  from Mexico - all very knowledgeable in multimedia and teaching -  presented a wonderful program.  So if those names show up and it's  something you're interested in, I would encourage you to catch them the  next time they're able to offer this.  Also, Dr. DeVore has a website at       

        so that would be another place you could go for more information  about what he's up to in this realm.  One final thing, I always like to  ask people - where do you see things going from here both in terms of  educational approaches and media and in the field itself?"
       
       

:  "I think if we compare ultrasound  today with what it was years ago when I first started, the technology is  superior.  There are more dials, knobs, and buttons to learn about, and  I think that education using multimedia will help shorten the learning  curve because many people who buy this very expensive equipment often  don't know how to use it to its fullest capacity.  So I think the  multimedia will allow companies and other physicians to teach their  colleagues how to better use the equipment because it's like anything  else, if you know how the car functions, you can drive it better.  If  you fly a plane and you know all the instruments, you ultimately won't  crash as often.  Same thing with ultrasound, the better you use the  tool, the better the diagnostician you're going to be."
       
       

:  "Thank you very much, Dr. DeVore.   We're delighted that you've been with us, and we look forward to hearing  what you're up to a year or two down the line."
       
       