Category Archives: OB

Empowering OB/GYN Trainees Through Point-of-Care Ultrasound: Bridging Imaging and Clinical Care

Posted on by
Reply

Point-of-care ultrasound (POCUS) has rapidly become an essential advancement in modern clinical practice. By bringing real-time imaging directly to the bedside, POCUS allows the same clinician who examines the patient to also visualize anatomy, assess pathology, and immediately act on findings. This integration of imaging and decision-making has made POCUS indispensable across multiple specialties, and obstetrics and gynecology are no exception.

The American Institute of Ultrasound in Medicine (AIUM) has long recognized the importance of standardization and quality in ultrasound practice. Its Practice Parameter for the Performance of Point-of-Care Ultrasound1 provides clear specifications for evaluating the abdomen, retroperitoneum, thorax, heart, and extremities for deep venous thrombosis. These guidelines form the foundation for ensuring that the benefits of POCUS—speed, accuracy, and accessibility—are balanced with safety and quality.

POCUS in Everyday OB/GYN Practice

Within obstetrics and gynecology, POCUS is a natural extension of bedside care. On labor and delivery units, it enables rapid assessment of fetal presentation, amniotic fluid, and placenta and fetal well-being through biophysical profiles. In emergency and postoperative settings, clinicians can use POCUS to quickly evaluate for intraperitoneal free fluid, aiding in the diagnosis of ruptured ectopic pregnancy or postoperative bleeding.

Evidence continues to support the diagnostic reliability of POCUS in OB/GYN. For instance, Boivin et al2 evaluated its accuracy in diagnosing retained products of conception in 265 patients. They found that point-of-care ultrasound demonstrated a sensitivity of 79% and specificity of 93.8%, validating its value in streamlining diagnosis and guiding timely management.

Training Gaps and the Case for Structured Education

Despite its broad applicability, ultrasound training in OB/GYN residency and MFM fellowship remains highly variable. Currently, emergency medicine is the only specialty with formal requirements for ultrasound training and credentialing. This gap has led to inconsistent proficiency among new OB/GYN graduates, even though ultrasound is fundamental to the specialty.

A structured curriculum in POCUS can address this gap. Training should combine didactic instruction, hands-on scanning, and supervised image review, building both technical skills and diagnostic reasoning. Defining competency benchmarks and maintaining image portfolios reviewed by credentialed sonographers or MFM faculty can help standardize skill acquisition and ensure quality.

Expanding POCUS Applications in Obstetric Critical Care

POCUS offers unique advantages beyond fetal and gynecologic imaging, particularly in the management of acutely ill obstetric patients. In the setting of hypertensive disorders, sepsis, or peripartum cardiomyopathy, bedside ultrasound can provide immediate insights into maternal cardiopulmonary status.

  • Lung ultrasound helps identify pulmonary edema, distinguishing cardiac from non-cardiac causes of dyspnea.
  • Cardiac views allow assessment of contractility and pericardial effusion.
  • Inferior vena cava (IVC) measurements help estimate fluid status and guide resuscitation in acutely ill patients.

Learning Early, Learning Effectively

Training in ultrasound doesn’t have to wait until residency. Vyas et al3 demonstrated that even first-year medical students could perform a basic obstetric triage scan after only twelve hours of training. Students correctly identified fetal lie, placental location, amniotic fluid index, biparietal diameter, and head circumference in more than 90% of cases, showing that structured, feedback-driven instruction can produce reliable results even among novice learners.

Sustaining Competence Through Practice

Ultrasound is a skill that requires repetition, reflection, and review. A comprehensive program should integrate longitudinal opportunities for scanning, image storage, and expert feedback. Access to curated image archives can help trainees build pattern recognition and diagnostic confidence. Incorporating POCUS assessments into rotations, such as emergency triage, obstetric critical care, or ultrasound electives, reinforces learning through real-world application.

Conclusion

Point-of-care ultrasound represents both an art and a science, merging clinical intuition with immediate visual data. For OB/GYN residents and MFM fellows, POCUS is not simply a diagnostic adjunct but a core competency that enhances patient safety, efficiency, and confidence at the bedside.

By embedding structured POCUS training and competency assessment into OB/GYN education, we can ensure the safe and effective use of ultrasound in medicine. Doing so ensures that the next generation of clinicians will not only interpret images but truly see their patients more completely, more immediately, and more compassionately.

References

1. American Institute of Ultrasound in Medicine. AIUM Practice Parameter for the Performance of Point-of-Care Ultrasound Examinations. J Ultrasound Med 2021; 40(8):E34–E52. https://doi.org/10.1002/jum.14972

2. Boivin J, et al. Utility of Point-of-Care Ultrasound in the Diagnosis of Retained Products of Conception. J Obstet Gynaecol Can 2020; 42(4):440–446. https://doi.org/10.1016/j.jogc.2019.08.026

3. Vyas KS, et al. Point-of-Care Obstetric Ultrasound Training for First-Year Medical Students in Rural Settings. J Ultrasound Med 2018; 37(3):715–722. https://doi.org/10.1002/jum.14404

Ruchira Sharma, MBBS, MD, FACOG, is a Maternal-Fetal Medicine Specialist, Director of MFM Fellowship, and Director of the Obstetric Ultrasound and Antenatal Testing Unit at Rutgers Robert Wood Johnson Medical School.

Sara Buhmaid, MD, is a Maternal-Fetal Medicine Fellow at Rutgers Robert Wood Johnson Medical School.

A professional headshot of a smiling woman with shoulder-length dark hair, wearing a patterned blouse and a dark blazer, against a blurred blue background.
Ruchira Sharma, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ. 10/25/2021 Photo by Steve Hockstein/HarvardStudio.com

Advanced Imaging of the Fetal Heart

Posted on by
Reply

Following the first demonstration of the fetal face in 1989 and the advent of fast processors around 2000, 3D and 4D ultrasound have become important tools in obstetric imaging over the past decade. Unlike 2D imaging, 3D ultrasound provides a volume of a region of interest that contains an infinite number of 2D planes. Mechanical and electronic transducers have the ability to acquire volumes of target organs through sweeps, and fast processors are able to display the acquired information within seconds. The operator can then choose to display this information in a multiplanar format of 2D images or as a spatial volume projecting the external or internal anatomic features on the screen.

Static 3D, spatiotemporal image correlation (STIC), or 4D imaging can be used to acquire a cardiac volume with a mechanical or electronic transducer. The best cardiac volumes are acquired using the STIC technique. Ideally, it can be used for offline assessment of cardiac structures and movements. Color Doppler, power Doppler, bidirectional power Doppler (high-definition flow), and B-flow modes can be combined with STIC acquisitions.

These volumes can be displayed with the color information alone, the grayscale information alone, or a combination of both, referred to as “glass-body” mode. A light source can emphasize the effect of depth.

If anomalies involving the four-chamber anatomy can be visualized similarly to the 2D image with color Doppler, anomalies involving the great vessels clearly demonstrate the superiority of 3D. Size difference, flow direction, and spatial relationship of the great vessels are some of the information that can be visualized with 3D color Doppler and “glass-body” mode. 3D imaging can, therefore, be used to explain anomalies to future parents and explore treatment options with colleagues.

The major limitations of the STIC technique include delayed acquisition time and movement artifacts due to fetal movements or maternal breathing movements.

Here are two examples where 3D color Doppler and “glass-body” mode are superior to 2D imaging in the assessment of fetal heart anomalies. 

A double aortic arch results from the persistence of right and left aortic arches. The left ductus arteriosus persists while the right ductus arteriosus regresses. Each aortic arch gives rise to a subclavian and a common carotid artery. A double aortic arch forms a tight vascular ring around the trachea and esophagus. This condition requires surgical intervention postnatally.

3D ultrasound image displaying major fetal heart structures, including the left and right aortic arches (LAo and RAo), pulmonary artery (PA), ductus arteriosus (DA), and superior vena cava (SVC).
3D ultrasound with the grayscale information alone in a fetus with the diagnosis of double aortic arch. The aorta can be seen bifurcating into a right and left aortic arch, forming a complete vascular ring around the trachea.

The part of the complete ring behind the trachea is not seen in this plane. It is better demonstrated with 3D color Doppler.

3D ultrasound image showing a fetus diagnosed with a double aortic arch, labeling the right aortic arch (RAo), left aortic arch (LAo), ductus arteriosus (DA), and pulmonary artery (PA). The image highlights the complete vascular ring formed around the trachea.
3D ultrasound in color Doppler in the same fetus. Note the bifurcation of the aortic arch into right and left aortic arches with the left ductus arteriosus, thus forming a vascular ring surrounding the trachea.

A coronary artery fistula (CAF) is an abnormal connection between a coronary artery and a cardiac chamber or a great vessel.

3D color Doppler ultrasound image showing the positioning of the pulmonary artery (PA) and aortic arch (Ao) in fetal heart anatomy.
3D color Doppler image showing fetal aortic arch (Ao) and pulmonary artery (PA) with visual indicators of blood flow direction.
3D ultrasound image of a fetal heart showing the right ventricle (RV), left ventricle (LV), right atrium (RA), and left atrium (LA) with color Doppler overlay.

3D color Doppler and “glass-body” mode allowed the visualization of the CAF over an entire cardiac cycle.

References:

Chaoui R, Heling K-S. 3D Ultrasound in Prenatal Diagnosis: A Practical Approach. 2nd ed. Berlin, Germany: DeGruyter; 2024.

Abuhamad A, Chaoui R. A Practical Guide to Fetal Echocardiography: Normal and Abnormal Hearts. 4th ed. Philadelphia, PA: Lippincott-Williams Wilkins; 2022.

Tekesin I, Uhlemann F. Prenatal diagnosis of coronary artery fistula using 2D and 3D/4D ultrasound. Ultrasound Obstet Gynecol 2017; 51:274-275.

Vladimir Lemaire, MD, RDMS (Ob/Gyn, FE), is a Maternal-Fetal Medicine Sonographer at UT Southwestern Medical Center in Dallas, Texas.

This posting has been edited for length and clarity. The opinions expressed in this posting are the author’s own and do not necessarily reflect the view of their employer or the American Institute of Ultrasound in Medicine.

Understanding the Impact of Preeclampsia on Fetal Heart Health

Posted on by
Reply

Preeclampsia, a serious condition marked by high blood pressure and potential organ damage during pregnancy, affects about 4–5% of pregnancies worldwide. While its dangers to mothers are well-documented, growing attention is being paid to how it affects unborn children, particularly their heart health.

A study in 2023 explored how the severity of preeclampsia and the level of proteinuria (protein in urine) influence fetal cardiac function.

Why Fetal Heart Health Matters in Preeclampsia

The fetal heart plays a critical role in adapting to the stressors of an abnormal intrauterine environment caused by preeclampsia. With placental blood flow compromised due to poor vascular development and high resistance, the fetus often experiences hypoxia and increased pressure. These conditions can subtly alter heart function even before birth.

Previous research has suggested that fetuses exposed to preeclampsia may have a higher risk of cardiovascular disease later in life. But how early do these changes start? And does the severity of the mother’s condition make a difference?

Signs of Stress in the Fetal Heart

In the 2023 study, fetuses in the preeclampsia group showed notable changes in both systolic (pumping) and diastolic (filling) heart functions compared to the control group. Specifically, the researchers observed:

  • Reduced ventricular relaxation and compliance — evidenced by lower early and late diastolic velocities (E and A waves) and longer isovolumetric relaxation times.
  • Diminished myocardial contractility — reflected in reduced mitral and tricuspid annular plane systolic excursion (MAPSE and TAPSE) and lower systolic velocities (S0 values).

These findings suggest that even before birth, the hearts of fetuses in preeclamptic pregnancies may be under increased strain.

The Role of Proteinuria and Severity

Interestingly, the study also revealed that more severe preeclampsia and higher proteinuria levels (>3 g/24 hr) were associated with more pronounced changes in fetal heart function. This is especially relevant given that proteinuria was removed from the official diagnostic criteria for preeclampsia in 2013. Yet, clinical observations and studies like this one highlight its continued relevance in assessing risks to both the mother and the fetus.

For example, fetuses in the group with higher proteinuria had significantly lower values in key diastolic function markers, suggesting reduced ventricular compliance. This could mean that fetuses in these pregnancies rely more on atrial contraction to fill their ventricles, which is an early sign of cardiac strain.

A Call for Enhanced Monitoring

One of the study’s most significant takeaways is the value of tissue Doppler imaging (TDI) in detecting early and subtle changes in fetal heart function. Because TDI can assess the movement of myocardial tissue independently of blood flow, it’s particularly useful in identifying subclinical dysfunction before more overt signs of distress appear.

Given these findings, enhanced fetal cardiac monitoring may be warranted in pregnancies complicated by preeclampsia, especially those with higher levels of proteinuria or classified as severe. Earlier detection could guide better perinatal care and potentially inform follow-up strategies after birth.

For More Information

The full research article, titled “Evaluation of Fetal Cardiac Functions in Preeclampsia: Does the Severity or Proteinuria Affect Fetal Cardiac Functions?” by Derya Uyan Hendem et al., is published in the Journal of Ultrasound in Medicine (2023). You can read the detailed study here.

Hydrops Fetalis and the Role of Ultrasound in Its Diagnosis and Management

Posted on by
Reply

Hydrops fetalis is severe swelling (edema) in a fetus or a newborn baby, and it is a life-threatening problem. There are two types; immune and nonimmune depending on the cause.

Immune hydrops

The immune version is usually a consequence of Rh incompatibility between the mother and fetus, leading to hemolytic disease of the fetus and newborn (HDFN). If the mother is Rh-negative and is having an Rh-positive baby, the mother’s immune system attacks the unborn baby’s red blood cells. This causes anemia. Hydrops occurs if the developing fetus’s organs are not able to overcome the anemia. Large amounts of fluid will build up in the fetus’s tissues and organs and the heart likely will begin to fail. This type of hydrops is not common today because Rh-negative women are often treated with Rh immunoglobulin to prevent this problem.

Nonimmune hydrops

This is the more common type of hydrops. This type can be caused by many other diseases or complications that may interfere with how a fetus manages fluid. Most of the conditions that can cause nonimmune hydrops are

  • Severe anemia,
  • Infections present before birth,
  • Heart or lung abnormalities,
  • Chromosomal abnormalities and birth defects, and
  • Liver disease and twin-to-twin transfusion.

During pregnancy, symptoms may include large amounts of amniotic fluid, thickened placenta, and ultrasound of the unborn baby may show enlarged liver, spleen, or heart. It may also show fluid buildup around the fetus’s abdominal organs, heart, or lungs.

Post delivery, symptoms include pale coloration, overall severe swelling, especially in the baby’s abdomen, trouble breathing, enlarged liver and spleen.

How to Diagnose Hydrops Fetalis

Ultrasound: This test uses sound waves to create images of blood vessels, tissues, and organs of the fetus. The healthcare provider will use the ultrasound to look at how a fetus’s internal organs are working and can see how blood flows through different vessels.

The first sign of hydrops fetalis on ultrasound is usually the abnormal accumulation of fluid in fetal compartments. This can include skin edema (thickening of the skin), ascites (fluid in the abdomen), pleural effusion (fluid around the lungs), and pericardial effusion (fluid around the heart). These findings are often accompanied by polyhydramnios (excess amniotic fluid) and placental thickening.

Fetal blood sampling: This is done by placing a needle through the mother’s uterus and into one of the fetus’s blood vessels or the umbilical cord.

Amniocentesis: This test is done by removing some of the amniotic fluid around the fetus for testing.

Assessment of Severity: Once hydrops fetalis is identified, ultrasound is used to assess the severity of the condition. Measurements such as the cardiothoracic ratio, the thickness of the skin edema, and the amount of fluid in each compartment help determine the extent of the disease. Doppler ultrasound is also utilized to evaluate fetal blood flow, particularly in cases of suspected anemia or cardiac issues, providing insights into the fetus’s hemodynamic status.

Determining the Underlying Cause: While ultrasound can easily identify the presence of hydrops fetalis, determining the underlying cause requires a more comprehensive approach. For instance, fetal echocardiography, a specialized form of ultrasound, can assess structural heart defects or cardiac dysfunction. In cases of suspected genetic abnormalities, ultrasound findings may prompt further testing, such as amniocentesis or chorionic villus sampling, to analyze the fetal karyotype.

How is hydrops fetalis treated?

Treatment of hydrops depends on the cause. During pregnancy, hydrops may be treatable only in certain cases. The management of hydrops fetalis is complex and depends largely on the underlying cause, gestational age, and the severity of the condition. Ultrasound continues to play a crucial role in monitoring the fetus and guiding therapeutic interventions.

Fetal Monitoring: For ongoing pregnancies, serial ultrasounds are essential to monitor the progression of hydrops fetalis. Regular assessments of fluid levels, fetal growth, and Doppler studies help guide clinical decisions, such as the timing of delivery. In some cases, ultrasound-guided procedures may be performed to relieve fluid accumulation, such as thoracentesis for pleural effusions or paracentesis for ascites.

Intrauterine Interventions: In certain cases, intrauterine interventions may be considered to improve fetal outcomes. For example, in cases of severe fetal anemia, ultrasound-guided intrauterine transfusions can be performed to deliver blood to the fetus. These procedures are highly specialized and require careful planning and execution.

Delivery Planning: The timing and mode of delivery for a fetus with hydrops fetalis are critical and must be carefully planned based on ultrasound findings. In cases of severe hydrops or fetal compromise, early delivery may be necessary to prevent stillbirth or to provide neonatal care. Ultrasound aids in determining fetal lung maturity and guiding the decision on whether antenatal corticosteroids should be administered to enhance fetal lung development. A mother may need to deliver the baby early.

In a newborn baby, treatment may include:

  • Help for breathing problems. This may be with extra oxygen or a breathing machine (ventilator).
  • Removing extra fluid from spaces around the lungs, heart, or inside the belly using a needle.
  • Fetal blood transfusion in cases with immune hydrops.

The Complications of Hydrops Fetalis

The severe swelling that occurs with hydrops can overwhelm the baby’s organ systems. Approximately 50% of live-born babies with hydrops don’t survive and for those that do, there are risks for other problems. Survival often depends on the cause and treatment.

Key Points on Hydrops Fetalis

  • Hydrops fetalis is severe edema in a fetus or newborn baby.
  • It is a life-threatening problem.
  • Hydrops develops when too much fluid leaves the fetus’s blood and goes into the tissues.
  • It is almost always diagnosed during pregnancy or right at birth.
  • Treatment of hydrops depends on the cause.
  • Approximately 50% of live-born babies with hydrops don’t survive.

Conclusion

Hydrops fetalis is a serious and often fatal condition that requires prompt diagnosis and careful management. Ultrasound is an indispensable tool in both the diagnosis and management of hydrops fetalis, offering detailed insights into the severity of the condition, the underlying causes, and the appropriate course of action. By utilizing ultrasound effectively, healthcare providers can improve the prognosis for affected fetuses, offering the best possible outcomes in challenging situations.

Gerald Walter Mosota is a Diagnostic Medical Sonographer in Mombasa, Kenya.

Gerald Walter Mosota

Optimizing Prenatal Imaging: The Role of Maternal-Fetal Medicine Sonographers

Posted on by
Reply

Ultrasound imaging is a cornerstone of care in high-risk pregnancies, providing essential insights into both maternal and fetal well-being and structural development. But who ensures that these images are not only accurate but also of diagnostic quality, capturing even the smallest details?

A maternal-fetal medicine (MFM) sonographer.

MFM sonographers are the unsung heroes of prenatal imaging, acting as the eyes of Maternal-Fetal Medicine specialists. Imagine being the first to see a tiny heartbeat on the screen of a patient with a history of multiple losses or detecting a complication early enough to save a baby’s life—that’s the kind of impact MFM sonographers have every day. Their expertise goes beyond basic imaging, making their role indispensable in managing high-risk pregnancies.

So, what sets MFM sonographers apart? Their training and skills are specialized and essential to optimizing prenatal care and improving outcomes. Below are some key aspects of their work that demonstrate their unique contributions.

Expertise in Complex Obstetric Cases

MFM sonographers specialize in handling challenging and high-risk pregnancies. These may involve conditions such as congenital anomalies that require detailed anatomical assessment, multiple gestations, where each fetus must be carefully monitored for growth and complications, and maternal health conditions like preeclampsia, diabetes, or autoimmune disorders, which can impact fetal development.

Take, for example, a case where a mother presents for a late anatomy at 32 weeks. The sonographer notices vessels near the lower uterine segment with color Doppler and decides to perform transvaginal imaging to get an optimal view. The transvaginal imaging demonstrates cord vessels crossing the cervix, which is consistent with vasa previa. The sonographer’s detection of vasa previa prompts immediate medical intervention, preventing delivery complications.

With their unique skillset, MFM sonographers can identify and recognize sonographic findings or complications early on. Their ability to provide comprehensive imaging enables Maternal-Fetal Medicine Specialists to make timely, critical decisions affecting both short-term and long-term outcomes for mother and baby.

Specialized Examinations and Advanced Imaging Techniques

In high-risk obstetrics, standard imaging alone may not be sufficient to capture the whole picture. MFM sonographers develop proficiency in various specialized examinations and advanced imaging techniques. Some examples below:

  • Doppler studies to evaluate blood flow in key vessels, such as the umbilical artery, middle cerebral artery, ductus venosus, and maternal vessels, too! (Figure 1.)
Figure 1. Doppler ultrasound.
  • Fetal echocardiography to assesses complex cardiac structures and detect congenital heart defects. (Figure 2.)
Figure 2. Fetal echocardiography.
  • Fetal neurosonography focuses on detailed imaging of the fetal brain and central nervous system. (Figure 3.)
Figure 3A.
Figure 3B.
  • In certain cases, 3D imaging may also be used to aid in diagnoses and management. (Figure 4.)
Figure 4A, Spine.
Figure 4B, Brain.
  • Detailed Anatomy (76811) and Detailed First Trimester Ultrasounds (DFTUs). (Figure 5.)
Figure 5A, Detailed anatomy.
Figure 5B, Detailed first-trimester ultrasound.

Beyond the Image: Critical Thinking in High-Risk Obstetrics

MFM sonographers must possess strong critical thinking skills to adapt to complex obstetric cases’ dynamic and often unpredictable nature. Each scan involves real-time assessment and decision-making. Sonographers must quickly discern between normal and abnormal findings, usually flagging fetal structural anomalies that may require further imaging or immediate intervention. High-risk pregnancies frequently demand deviations from standard imaging protocols, prompting sonographers to use their judgment to determine which additional views or techniques—such as Doppler studies or 3D imaging—are necessary to obtain a complete and accurate assessment. In urgent situations, such as fetal distress or signs of preterm labor, sonographers must prioritize findings and swiftly communicate critical information to the maternal-fetal medicine specialist to facilitate immediate action. These cognitive skills are essential for delivering comprehensive, high-quality imaging that enables timely and accurate diagnoses, ultimately contributing to improved outcomes for mothers and babies.

Becoming an MFM Sonographer: What You Need to Know

Sonographers typically begin their careers by obtaining Registered Diagnostic Medical Sonographer (RDMS) credentials with a specialty certification in Obstetrics & Gynecology (OB/GYN), followed by clinical experience in obstetric imaging. The more experience you gain in performing obstetric and gynecologic imaging, the better prepared you will be. Those who pursue a career in maternal-fetal medicine (MFM) undergo additional training to develop proficiency in high-risk obstetric imaging. Many also pursue advanced certifications, such as fetal echocardiography, to further validate their skills in this specialized field. The role requires a combination of technical proficiency, critical thinking, adaptability, and a commitment to continuous learning to stay current with advancements in ultrasound technology and best practices.

A career in maternal-fetal medicine (MFM) sonography is both rewarding and impactful, offering opportunities to make a real difference in the lives of mothers and babies. Sonographers play a pivotal role in high-risk pregnancies, often being the first to detect critical conditions that can change the course of care. Beyond the emotional rewards, the field also offers career growth opportunities. With advancements in ultrasound technology and an increasing focus on women’s health, MFM sonographers can pursue advanced roles as educators, advanced practice sonographers, or administrative leaders, allowing them to expand their expertise and advance their careers. For many, the opportunity to combine cutting-edge science with compassionate care makes this profession impactful and fulfilling.

Are you interested in learning more about the role of MFM sonographers or how to become one? Join the AIUM’s interactive community discussion hub, “The Ultrasound Forum: Specialized Skills of Perinatology Sonographers,” on March 19, 2025, at 7 pm EST. Hear firsthand from MFM sonographers, physicians, and other experts in the field. Don’t miss this opportunity to ask questions, gain insights, and connect with professionals shaping the future of maternal-fetal care.

Mishella Perez, BS, RDMS, RDCS, FAIUM, is a Clinical Ultrasound Educator at Scripps Health’s Division of Maternal-Fetal Medicine (MFM) in San Diego. She is also Chair of the American Institute of Ultrasound in Medicine’s (AIUM’s) Obstetric Ultrasound Community and is on the AIUM Board of Governors.

Cesarean Scar Ectopic Pregnancy—The Importance of Ultrasound for Early Detection

Posted on by
Reply

Cesarean scar ectopic pregnancy occurs when an embryo implants into or on a prior cesarean scar, and carries a high burden of maternal morbidity and increased risk of maternal mortality when left untreated.1 The estimated incidence is approximately 1 in 1800–2000 pregnancies after cesarean delivery.2 The key to prompt treatment is early identification, most commonly and easily accomplished with transvaginal ultrasound.

Cesarean delivery is the most commonly performed surgery in the world. In the United States, according to the Centers for Disease Control’s Stats of the States data from 2021,  the cesarean delivery rate varies from 24.3% in Utah to a high of 38.3% in Mississippi.3 While cesarean is often a necessary procedure in cases of fetal intolerance of labor, fetal malpresentation, or labor arrest, this surgery impacts future pregnancy, increasing the risks of the need for repeat surgical deliveries, uterine rupture during attempted labor, and placenta accreta spectrum disorders, the latter of which experts now recognize start as cesarean scar ectopic pregnancies.

Following any full-thickness myometrial surgery, just as with any other muscle, the transected myometrial fibers never truly heal together as they once were. Rather, the reapproximated ends are joined by a line of fibrosis, which may partially dehisce, and lack the usual thickness and elasticity of uncompromised myometrium. This scar sometimes retains some structural integrity, but often results in a “niche” or hollowed-out area within the muscle,4,5 where an embryo may implant.

Cesarean scar ectopic pregnancy (CSEP) is easiest to detect sonographically early in the early first trimester, when it can be recognized as a low implantation that is offset more anteriorly than normal, often leaving the endometrial cavity and cervical canal empty.6 Additional criteria for the diagnosis of  CSEP include thin or undetectable myometrium between the placenta and bladder and unusually increased vascularity between the placenta/sac and bladder or internal cervical os. 

Some experts have proposed simple-to-perform measurements, such as the “crossover sign,” whereby a line is drawn in the sagittal plane connecting the internal os with the fundus by drawing a line along the endometrial canal.7 When the superior-inferior diameter of the gestational sac is measured perpendicularly to this line, the relationship of the gestational sac to the endometrial line can be determined.6 In CSEPs in which a majority of the gestational sac is closer to the anterior wall (crosses over the endometrial line), there is a higher rate of severe forms of placenta accreta spectrum and risk for rupture when CSEPs are managed conservatively.7,8

As pregnancy progresses, the gestational sac may grow into the endometrial cavity, making the diagnosis more difficult. Treatment is also more difficult as pregnancy progresses, whereby medical or mechanical management options, such as use of a double balloon catheter are less effective, and surgical resection or combination therapy may be required. The risk of complications including uterine rupture, massive bleeding, and need for emergent hysterectomy that approaches 53% of reported cases are reasons why expectant management is not recommended, especially as early treatment has efficacy rates that are reported between 65% to more than 99% with low complication rates, and with a high likelihood of fertility preservation.  

Early recognition and referral are paramount and provide one more example of how ultrasound can and does save lives.

References:

1. Calì G, Timor-Tritsch IE, Palacios-Jaraquemada J, et al. Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2018; 51:169–175. doi:10.1002/uog.17568

2. Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol 2012; 207:14–29.

3. Centers for Disease Control. Stats of the States – Cesarean Delivery Rates. https://www.cdc.gov/nchs/pressroom/sosmap/cesarean_births/cesareans.htm. Accessed March 30, 2024.

4. Einerson BD, Comstock J, Silver RM, Branch DW, Woodward PJ, Kennedy A. Placenta accreta spectrum disorder: uterine dehiscence, not placental invasion. Obstet Gynecol 2020; 135:1104–1111. doi:10.1097/AOG.0000000000003793.

5. Jauniaux E, Jurkovic D, Hussein AM, Burton GJ. New insights into the etiopathology of placenta accreta spectrum. Am J Obstet Gynecol 2022; 227:384–391. doi:10.1016/j.ajog.2022.02.038.

6. Timor-Tritsch IE, Monteagudo A, Calì G, D’Antonio F, Kaelin Agten A. Cesarean scar pregnancy: diagnosis and pathogenesis. Obstet Gynecol Clin North Am 2019; 46:797–811. doi:10.1016/j.ogc.2019.07.009.

7. Cali G, Forlani F, Timor-Tritsch IE, Palacios-Jaraquemada J, Minneci G, D’Antonio F. Natural history of Cesarean scar pregnancy on prenatal ultrasound: the crossover sign. Ultrasound Obstet Gynecol 2017; 50:100–104. doi:10.1002/uog.16216.

8. Calì G, Calagna G, Khalil A, Polito S, Labate F, Cucinella G, D’Antonio F. First trimester prediction of uterine rupture in cesarean scar pregnancy [published online ahead of print April 20, 2022]. Am J Obstet Gynecol. doi: 10.1016/j.ajog.2022.04.026.

9. Miller R, Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine consult series #63: cesarean scar ectopic pregnancy. Am J Obstet Gynecol 2002 Sep: 227(3):B9–B20. doi: https://doi.org/10.1016/j.ajog.2022.06.024.

Karin A. Fox, MD, MEd, FACOG, FAIUM, is a Professor of Maternal-Fetal Medicine and Director of the Placenta Accreta Spectrum Disorders Program at the University of Texas Medical Branch at Galveston.

You Won’t Be Left in the Dark at UltraCon (except during the total eclipse!)

Posted on by
Reply

Have you considered how you will spend April 8 (well, April 6–10, 2024, actually)? The place to be on the 8th is somewhere you can be in the path of totality during the total solar eclipse, and what better place to be than Austin, TX, where you can see the eclipse and get your fill of everything ultrasound?

(and probably the cheapest way to get a hotel room is to register for UltraCon 2024 and grab a room while we still have affordable rooms in our block).

The AIUM brings our annual meeting to Austin, TX, for the first time, and there will be lots to take in. We are bringing back Educational Tracks. No matter where your interests lie, MSK or Fetal Echo or General US or OB or GYN, there is a track for you! There is something for you, whether you are early in your career or an experienced sonographer/sonologist. You will hear presentations from experts that will keep you up to date on changes in the field and tell you what is coming down the pike. For our members who are deep into the basic sciences, some presentations will stimulate new thinking and show you what other colleagues are up to. One of the best parts of the program is that you aren’t stuck in one track—you can mix and match to customize your experience. Check out the tracks here.

UltraCon brings you more than just the educational tracks. Is there a product that you have always wanted to develop and commercialize? Perhaps an invention, a training program, or another idea you are sure could be monetized? If so, the AIUM’s Shark Tank is for you! Put together your best proposal and present it to our panel of experts from industry, venture capital, and academia. $1,000 is up for grabs, but win or lose, you will gain valuable insights and critical appraisal of your concept, along with suggestions for what you need to do to take your proposal to the next step.

Scientific sessions run throughout the meeting, allowing you to hear cutting-edge research that will help answer some of the questions you might be having or possibly give you ideas to pursue on your own. You will hear from young researchers just starting out their careers as well as experienced scientists who have gotten us where we are today but aren’t done leading us yet.

One of the best aspects of the annual meeting is the chance to hear from luminaries and others with cutting-edge ideas, whether in ultrasound directly or in fields that will impact ultrasound, such as artificial intelligence and other new technologies. This year’s plenary sessions will be captivating as we hear from Dr Omar Ishrak on the future of ultrasound technology and from Dr Gil Weinberg on an amazing application of ultrasound to offer amputees the opportunity to play musical instruments.

Other talks will cover how CPT codes are developed, how to efficiently complete your application for accreditation, and so much more that will round out your experience in Austin.

UltraCon 2024 promises to be a Top Shelf event that you really don’t want to miss—and yes, we have scheduled a break to go outside to see the eclipse, so you won’t be asked to decide between these 2 once-in-a-lifetime events! Note that our hotel block is probably the least expensive deal in town, as our rates were negotiated years ago before many were paying attention to this eclipse. It is entirely possible we will sell out our block of rooms, so make your plans and register as soon as possible!

David C. Jones, MD, FACOG, FAIUM, the AIUM’s President Elect, is a Professor at the University of Vermont and the Director of the Fetal Diagnostic Center at the University of Vermont Medical Center.

Why Have Your Ultrasound Done at an Accredited Practice?

Posted on by
1

Ultrasound scans are being performed everywhere. Not only in the standard radiology department in your local hospital, but also in the emergency room, urgent care clinics, your doctor’s office, and even at the local mall. But are you getting the same value for your money at each of these different sites? I have personally witnessed a very wide variety of skill levels within each of these departments. What can help you identify a reputable ultrasound unit? Look for an accredited ultrasound practice.

Applying for and obtaining your ultrasound accreditation is a vigorous process. It requires that all physician and sonographer staff have earned the appropriate credentials for the scans being performed and that they are up to date on their CME (continued medical education). Studies must be submitted for review to the accrediting team to ensure that the appropriate anatomy is being captured, image quality is optimal, and images are labeled. The ultrasound report is reviewed to confirm that the patient information and required imaging components for the study have been assessed and documented correctly.

Accreditation can help reassure the patient and the referring physician that their selected ultrasound department is aware of and following the current accepted standard guidelines for their exam. This can lead to reduced patient anxiety regarding the quality of the ultrasound scan. The goal is to help ultrasound departments achieve the best imaging possible to improve overall patient care and safety.

Each specialty area has an accreditation system that provides confirmation that an ultrasound department has achieved and is maintaining the current national standards. Each system provides guidelines and learning resources to help departments meet these standards.

Accreditation Systems:

Why is accreditation important? So that images like these are not reported as normal.

The initial scan was done in a physician’s office. The gestational age by the known last menstrual period was 11 weeks, 2 days; however, the crown-rump length (CRL) by ultrasound measured 10 weeks. This pregnancy was re-dated using the ultrasound-estimated delivery date.

At 19 weeks, 6 days, the patient was referred for an anatomy scan and was diagnosed with acrania-exencephaly-anencephaly sequence. This malformation has no calvarium and the fetal brain is exposed to the amniotic fluid. The amniotic fluid is toxic to the exposed brain and eventually causes the disintegration of this tissue. Exencephaly is a precursor to anencephaly. The absence of the fetal skull (acrania) exposes the brain (exencephaly), which eventually leads to anencephaly. The degenerative process of the brain gives the amniotic fluid an echogenic appearance.

This patient’s maternal serum alpha-fetoprotein (MSAFP) was 7.69 MoM (multiple of the median); the cutoff for a normal scan is <2.50 MoM.

Ultrasound technology and image quality have improved tremendously. The accreditation process helps a department discover where its deficiencies are and can provide guidance on how to meet the minimum standards. Further training and education of the Sonographers and Sonologists will lead to improved patient safety and outcomes.

Why pursue an ultrasound-accredited practice? Maybe the better question would be, why not make accreditation mandatory?

Headshot of Jane K. Burns, RDMS

Jane K. Burns, RDMS, is the MFM Ultrasound Manager at Texas Children’s Hospital/Pavilion for Women.

Exploring the Future of Ultrasound: 5 Trends to Watch

Posted on by
1

Ultrasound technology has come a long way since its inception and continues to evolve at a rapid pace. As we look ahead to the near future, it’s clear that ultrasound will play an even more vital role in healthcare. In this blog post, we’ll explore 5 trends (in no particular order) that are set to shape the field of ultrasound in the coming years.

1. Portable and Handheld Ultrasound Devices

The trend of portable and handheld ultrasound devices is on the rise. In the past, ultrasound machines were hundreds of pounds, carted around on wheels, and costly to manufacture. These new, compact, and lightweight devices offer healthcare professionals the convenience of conducting ultrasound examinations at the patient’s bedside, in remote areas, or during emergency situations, and wearable devices will become part of the ultrasound tool kit. Their affordability and ease of use make them accessible to a broader range of healthcare providers, expanding the potential applications of ultrasound. I predict that, under a doctor’s care and orders, the ways in which ultrasound is used will expand!

2. Artificial Intelligence (AI) Integration

AI is revolutionizing the field of medical imaging, and ultrasound is no exception; however, sonographers and doctors are not going anywhere. AI algorithms can assist in image analysis, automate measurements, enhance quantitative imaging, and aid in the detection of abnormalities. In the near future, we can anticipate more sophisticated AI integration into ultrasound systems, which will not only enhance diagnostic accuracy but also improve workflow efficiency. AI will play a significant role in making ultrasound more accessible and reliable in terms of scanning, reading images, and delivering accurate results.

3. 3D and 4D Imaging

Three-dimensional (3D) and real-time 3D (4D) ultrasound imaging will continue to advance, providing clinicians with more detailed and interactive views of anatomical structures. This trend will be particularly valuable in obstetrics for capturing fetal development and in various other medical specialties where enhanced visualization and quantification are crucial. Expect to see more applications for complex anatomical assessments and dynamic studies.

4. Point-of-Care Ultrasound (POCUS)

Point-of-care ultrasound, or POCUS, is transforming the way medical professionals diagnose and manage patients. POCUS is expected to see increased adoption in various clinical settings, including emergency medicine, anesthesiology, primary care, and critical care. As training programs expand, more healthcare providers will be equipped to use POCUS for rapid and accurate assessments, which can lead to improved patient care and outcomes on the spot. With increased adoption, interest in ultrasound practice accreditation in this area is rising.

5. Therapeutic Ultrasound Applications

Beyond its diagnostic role, ultrasound is making great advances in therapeutic applications. Techniques like High-Intensity Focused Ultrasound (HIFU) are being employed for noninvasive surgeries, cancer treatments, and targeted drug delivery. In the coming years, we can expect to see further developments in therapeutic ultrasound, offering less invasive treatment options for a wide range of medical conditions and increasing the potential for ultrasound theranostics.

The future of ultrasound is incredibly promising with these 5 trends at the forefront of its evolution. From portable devices and AI integration to advanced imaging techniques and expanding applications in point-of-care and therapeutics, ultrasound is set to become even more integral to modern healthcare. Stay tuned as these trends continue to shape the landscape of medical imaging and patient care. We’re excited to witness the many possibilities that lie ahead for this versatile technology.

Therese Cooper, BS, RDMS, is a sonographer and the Director of Accreditation at the American Institute of Ultrasound in Medicine.

Fetal Neurosonography

Posted on by
1

A call for increased awareness and training within the United States

Routine evaluation of the fetal brain is performed during the second-trimester anatomical survey. This screening is conducted by transabdominal scan in 3 axial planes, namely, the transventricular, transthalamic, and transcerebellar planes.1 Targeted neurosonography, however, is a dedicated, detailed, and diagnostic examination of the fetal brain that is preferably performed with high-resolution transvaginal ultrasound via a transfontanelle approach, providing multiplanar assessment of the brain anatomy. Like fetal echocardiography in the context of suspected cardiac malformation, neurosonography provides greater diagnostic capacity for fetal brain malformations compared to the routine transabdominal screen in the axial planes.

Neurosonography involves extensive evaluation in multiple successive coronal planes (Figure 1), the midsagittal/median plane (Figure 2), as well as successive parasagittal planes (side to side) to provide high-resolution imaging of detailed brain anatomy. These include structures such as the cavum septi pellucidy and cavum vergae, corpus callosum, vermis, 3rd and 4th ventricles, vein of Gallen, ganglionic eminence, the caudate nuclei and brain stem, the fetal brain cortex, gyration, sulcation, and parenchyma as well as detailed evaluation of the entire ventricular system and periventricular tissue.2

Figure 1: 3D tomographic display of successive coronal planes from the front to the back of the fetal brain. The top left box displays the midsagittal plane with several successive lines, each representing a coronal slice displayed in the following boxes.
Figure 2A–C: Midsagittal/median plane of a 21-week fetus obtained via transfontanelle approach. Detailed evaluation of the midline structures (A) with arrows to identify some important landmarks (B). Color high definition used to depict the course of the anterior cerebral artery and the pericallosal artery (C). Bs indicates brain stem; cc, corpus callosum; csp, cavum septi pellucidi; cm, cysterna magna; cv, cavum vergae; qc, quadrigeminal cistern; qp, quadrigeminal plate; tc, tela choroidea; V, vermis; 3v, third ventricle; 4v, fourth ventricle.

The use of 3D ultrasound is also frequently utilized to facilitate expert neurosonographic evaluation, obtain the diagnostic planes, and use display modalities, which may further enable the diagnostic process.3 This technique has been used to adequately diagnose multiple fetal brain pathologies including birth defects, fetal infections, brain tumors, vascular insults, AV malformations, and destructive lesions.

Given that the anatomy of the fetal brain evolves and changes throughout gestation, correlation of the anatomy to the gestational age is a key element required by experts in neurosonography. Thus, different pathologies in the development of the fetal brain can be appropriately detected at different gestational ages. For example, whereas a major malformation such as alobar holoprosencephaly can be reliably detected in the first trimester, most abnormalities of the corpus callosum and cerebellar vermis are reliably diagnosed during the second-trimester scan, while malformations of cortical development, migrational disorders, and some tumors and destructive lesions may not be appropriately detected until the third trimester.

Despite its great diagnostic strength, fetal neurosonography is not commonly practiced in the US. Most providers who provide fetal anatomy scans are not adequately trained to perform transvaginal transfontanelle brain scans, interpret fetal brain images in the nontraditional axial planes (such as the coronal and sagittal planes), or correlate these images with the evolution of the brain anatomy throughout the different gestational ages. Therefore, in some centers, the mere suspicion of a fetal brain malformation may result in immediate referral for a fetal MRI. Although MRI is a complementary method to image the fetal brain that in expert hands may provide valuable information to neurosonography, it is a second-line imaging modality, which is far more expensive and less accessible. Importantly, like neurosonography, fetal MRI is also highly operator-dependent, requiring a high level of expertise in both obtaining the appropriate sequences as well as interpreting the images and correlating them with the gestational age. Moreover, the value of fetal MRI increases in the third trimester when evaluation of the cortex and parenchyma is feasible, whereas neurosonography provides superior images during the first- and second-trimester evaluations.4

Of note, current American guidelines for neurosonography are limited to evaluation of neonates and infants5 rather than fetuses. The most comprehensive guidelines for fetal neurosonography are published by the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG).6  These guidelines also define the indications for detailed neurosonography: such as suspicion of brain malformation on routine screening ultrasound or nuchal translucency scan, family history or prior pregnancy affected by brain malformation, fetal congenital heart disease, monochorionic twins, suspected congenital intrauterine infection, exposure to teratogens affecting neurogenesis, and microarray findings of unknown significance.

Not only does neurosonography facilitate accurate diagnosis of a large variety of brain malformations, it also enables us to reassure many anxious patients in which malformation was suspected on a basic scan whereas detailed neurosonography confirmed normal brain development with no pathology.

Therefore, increased awareness of the value of fetal neurosonography and appropriate utilization may result in the referral of patients with appropriate indications to centers with expertise in neurosonography, as well as highlighting the need for specific education and training. Additionally, there is no specific Current Procedural Terminology (CPT®) code for fetal neurosonography in the US. Creation of such a code will facilitate the acceptance of this practice for indicated cases and help solidify training programs and providers’ interest in becoming proficient.

References:

  1. Malinger G, Paladini D, Haratz KK, Monteagudo A, Pilu G, Timor-Tritsch IE. ISUOG Practice Guidelines (updated): sonographic examination of the fetal central nervous system. Part 1: performance of screening examination and indications for targeted neurosonography. Ultrasound Obstet Gynecol 2020; 56:476–484.
  2. Timor-Tritsch IE, Monteagudo A. Transvaginal fetal neurosonography: standardization of the planes and sections by anatomic landmarks. Ultrasound Obstet Gynecol 1996; 8:42–47.
  3. Bornstein E, Monteagudo A, Santos R, Strock I, Tsymbal T, Lenchner E, Timor-Tritsch IE. Basic as well as detailed neurosonograms can be performed by offline analysis of three-dimensional fetal brain volumes. Ultrasound Obstet Gynecol 2010 Jul; 36(1):20–25. doi: 10.1002/uog.7527. PMID: 20069671.
  4. Malinger G, Paladini D, Pilu G, Timor-Tritsch IE. Fetal cerebral magnetic resonance imaging, neurosonography and the brave new world of fetal medicine. Ultrasound Obstet Gynecol 2017; 50:679–680.
  5. AIUM practice parameter for the performance of neurosonography in neonates and infants. J Ultrasound Med 2020; 39: E57–E61. https://doi.org/10.1002/jum.15264.
  6. Paladini D, Malinger G, Birnbaum R, Monteagudo A, Pilu G, Salomon LJ, Timor IE. ISUOG practice guidelines (updated): sonographic examination of the fetal central nervous system. Part 2: performance of targeted neurosonography. Ultrasound Obstet Gynecol 2021; 57: 661–671. https://doi.org/10.1002/uog.23616.

About the Author

Eran Bornstein, MD, FACOG, is an associate professor of Obstetrics & Gynecology in the Zucker School of Medicine/HOFSTRA, and the Director of the Center for Maternal Fetal Medicine and Ultrasound in OBGYN, at Lenox Hill Hospital, Northwell, in New York.

Interested in learning more about fetal neurosonography? Check out the following articles from the American Institute of Ultrasound in Medicine’s (AIUM’s) Journal of Ultrasound in Medicine (JUM). Members of AIUM can access them for free after logging in to the AIUM. Join the AIUM today!