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.
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?
Jane K. Burns, RDMS, is the MFM Ultrasound Manager at Texas Children’s Hospital/Pavilion for Women.
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.
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:
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.
Timor-Tritsch IE, Monteagudo A. Transvaginal fetal neurosonography: standardization of the planes and sections by anatomic landmarks. Ultrasound Obstet Gynecol 1996; 8:42–47.
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.
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.
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.
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!
“Is ultrasound safe for my baby?” and “I know someone whose baby was born too small because of all the ultrasound she received during her pregnancy”. These are two sentences that you might hear during your busy day in the ultrasound unit. The AIUM Official Statement “Conclusions Regarding Epidemiology for Obstetric Ultrasound” states: “Based on the available epidemiologic data, there is insufficient justification to warrant conclusion of a causal relationship between diagnostic ultrasound and recognized adverse effects in humans. The epidemiologic evidence is based primarily on exposure conditions existing prior to 1992, the year in which maximum recommended levels of acoustic output for ultrasound machines were substantially increased for fetal/obstetric applications. Some older studies have reported effects of exposure to diagnostic ultrasound during pregnancy, such as low birth weight, delayed speech, dyslexia, and non-right-handedness. Other more recent studies have not demonstrated such effects. The absence of definitive epidemiologic evidence does not preclude the possibility of adverse effects of ultrasound in humans.”
Why is this statement important to all practitioners of ObGyn ultrasound?
Because knowing the information will enable you to answer patient questions and comments mentioned at the beginning of this post. What the AIUM statement explains is that studies performed on specific large human populations, with defined methods did not show that diagnostic ultrasound is responsible for harm in humans. (Studies such as this are what epidemiology does: examine how often diseases occur in different groups of people and why.)
While in the past, there were some publications that suggested some effects, such as low birth weight, more controlled studies have not been able to demonstrate such effects in humans. An important point is that many studies are relatively old and were performed before maximum recommended output of ultrasound machines meant for OB use was increased from 94mW/cm2 to 720mW/cm2. This increase was intended to obtain more detailed images. The US Food and Drug Administration (USFDA) agreed with ultrasound instrument manufacturers’ requests to allow this increase, on the condition that two numbers were displayed in real-time on the monitor of the ultrasound system:
The thermal index (TI) to show the possibility of increased temperature, secondary to energy absorption by the tissues, and
The mechanical index (MI) to convey the risk of direct effects of the sound waves.
If these are kept low, no noxious effects are demonstrable, as expressed in the Epidemiology statement. This includes physical as well as mental effects. What are low indices? If the TI is <1 (the scientific number is 0.7, but 1 is easier to remember), there appears to be no risk of thermal effects for exposure under 1 hour. Regarding non-thermal or mechanical effects, based on the absence of gas bubbles in the fetal lungs and bowels (the two organs where effects were shown in animals after birth), no effects are expected in human fetuses. Demonstrating long-term effects or lack thereof, particularly if subtle, is much more complicated.
The statements issued by the AIUM’s Bioeffects Committee are intended as baseline considerations in practice. As ultrasound continues to be adopted into clinical use, the Bioeffects Committee will continue to monitor outcomes in order to inform and educate the community.
Jacques S. Abramowicz, MD, is a professor in the Department of Obstetrics and Gynecology at the University of Chicago.
Interested in learning more about the bioeffects of ultrasound? Check out the following AIUM Official Statements:
Abramowicz JS, Fowlkes JB, Stratmeyer ME, Ziskin MC. Bioeffects and Safety of Fetal Ultrasound Exposure: Why do we Need Epidemiology? In: Sheiner E, (ed.): Textbook of Epidemiology in Perinatology. New York: Nova Science Publishers, Inc.; 2010.
Screening for chromosomal and congenital anomalies has evolved significantly with the use of ultrasound. Adding Serum analytes to the evaluation of congenital anomalies has increased the detection rate. This addition includes maternal serum alpha fetoprotein (MSAFP), b-HCG, Estriol, Inhibin A, Free bHCG, and Pregnancy Associated Plasma Protein A (PAPP-A).
Sequential screening consists of two steps:
Nuchal translucency (NT), with Free b-HCG and PAPP-A during the first trimester, and
Quadruple testing during the second trimester. This modality takes the detection of trisomy 21 (T21) to 95%.
More recently, tests that measure the cell free fetal DNA (NIPT) in the maternal serum have become commercially available. The detection rate for T21 is 99%.
Many patients have opted for a first-trimester NT measurement, NIPT, and a 20-week ultrasound for anatomical survey. My concern and question to our group is where do we leave the MSAFP screening? Does your practice offer MSAFP to patients that opt for this approach?
Luis A. Izquierdo, MD, MBA, CPE, FAIUM, is a professor of OB GYN and Maternal Fetal Medicine at the University of New Mexico.
Adnexal (ovarian) tumors present a complex problem. Ovarian cancer (Ovca) is the second most common gynecologic cancer in the United States with the highest mortality rate of all gynecologic cancer, 7th among all cancers, and with a general survival rate of 50%.1 Thus, missing Ovca when performing any kind of test (false negative) will have grave consequences but suspecting it when not present (false positive) can have almost as critical results with morbidity and mortality secondary to (unnecessary) intervention.
The purpose of this post is not to review the differential diagnosis of ovarian tumors nor to discuss chemical markers such as CA125 or cancer-specific signal found on cell-free DNA (cfDNA) but to concentrate on ultrasound. Some tumors are relatively easy to recognize because of defined ultrasound characteristics: corpus luteum with the classic “ring of fire” or endometrioma with the ground-glass appearance content, for instance (image 1a and b). Conversely, a large, multilocular lesion with solid components and profuse internal Doppler blood flow leaves little doubt about its malignant nature (image 2).
Image 1a: Corpus luteum with the classic “ring of fire”.Image 1b: Endometrioma with the ground-glass appearance.
Image 2: A large, multilocular lesion with solid components.
What are the ultrasound characteristics we look at?
Size: Unilocular cystic ovarian tumor < 10 cm in diameter or simple septated cystic ovarian tumor < 10 cm in diameter rarely, if ever, are neoplastic.2
Volume: Normal volume for premenopausal and postmenopausal ovaries are < 20 cm3 and 10 cm3, respectively.
Appearance: Risk of malignancy in simple, unilocular anechoic cyst, less than 5 cm is < 1% in premenopause and about 2.8% in postmenopause.3
Blood flow criteria: The rationale is that arteries formed by neovascularization in malignant tumors lack tunica media, resulting in lowered impedance (= less resistance to blood flow). Thus, resistance indices will be lower in cancer than in benign tumors. Malignancy was suspected with Doppler indices: pulsatility index (PI)<1 and/or resistive index (RI)<0.4.4 However, too much overlap makes reliance on only Doppler unjustified.
A very important point is that the expert performs very well when analyzing the ultrasound images of an ovarian mass, with a sensitivity of 92–98% and a specificity of 89%. The issue is how to help the non-expert decide whether he/she can continue the care of the patient or needs to refer her to a specialist. Based on several ultrasound criteria, scoring systems were implemented. The first one, in 1990, included appearance (unilocular, unilocular solid, multilocular, multilocular solid, or solid cyst) and presence of papillae (graded according to their number: 0 [none], 1 [one to five], or 2 [more than five]). This method had a sensitivity (true positive rate, or chance that person testing positive actually has Ovca) for malignancy of 82% with a specificity (true negative rate or chance that person with a negative test does not have Ovca) of 92%.5 Two important additional scoring systems were described later: the Morphology Index (MI) combining tumor volume, wall structure, and septal structure and the Risk of Malignancy Index (RMI), the product of ultrasound morphology score, CA 125 level, and menopausal status.6 Additional systems included the Logistic Regression 1 (LR1) and 2 (LR2). None of the published scoring systems were superior to image assessment by an expert, including in a meta-analysis of 47 articles, including over 19000 adnexal masses7 and, in reality, were not used widely in clinical practice.
The International Ovarian Tumor Analysis (IOTA) models
In 2000, a large group of European experts (gynecologists, radiologists, statisticians, biology, and computer experts) published a standardized terminology for the characterization of adnexal masses.8
The two important systems are the Simple Rules (SR) and the Assessment of Different NEoplasias in the adneXa (ADNEX) model. These were externally validated in numerous centers across the world but not in the USA.9 Recently, however, validation on the largest hitherto US population was published.10 This study showed for the first time that the models were effective in this population, regardless of menopausal status or race. These models are easy to learn and are geared towards non-experts.11 It is important to note that the IOTA group was one of the first to incorporate acoustic shadow as a key feature, and the acoustic shadow has been shown to be an important sonographic feature to consider.12
Simple Rules: The IOTA Simple-Rules consist of 2 sets of 5 elements each: benign and malignant.13 Three simple rules are applied: if only benign characteristics are present, the mass is classified as benign. If only malignant features are present, the mass is considered malignant. If no features or both are, the findings are inconclusive. This model works well in about 80% of cases. The other 20% should be referred to an expert.
ADNEX model14: This is a multiclass prediction model to differentiate between benign and malignant tumors and allows automatic calculation of sub-classification of malignant tumors into borderline tumors, Stage I, and Stage II–IV primary cancers, and secondary metastatic tumors. “The advantage of this model is that it gives a personalized risk score for each patient, based on age, whether the patient is seen at an oncology center or not, maximal diameters of the lesion and the solid parts, number of cysts and papillary projections, whether acoustic shadows are present, whether ascites is present and CA125 value (if available, not mandatory for calculation). With a cut-off value for malignancy risk set at 10%, the ADNEX model (with CA125) had a sensitivity of 94.3%, with a specificity of 74%, positive predictive value of 76%, and negative predictive value of 93.6%.”14
The O-RADS model
In 2020, the American College of Radiology convened an international multidisciplinary committee that developed an ultrasound model based on an MRI model used in mammography (the BI-RADS atlas), the O-RADS model (the Ovarian-Adnexal Reporting and Data System) to facilitate differentiation between benign and malignant ovarian tumors.15 It relies on the sonographic nomenclature developed by the IOTA group, but it classifies tumors into 1 of 6 categories (O-RADS 0–5), from normal to high risk of malignancy. O-RADS also includes guidelines for the management of the findings. It should be noted that the O-RADS first model did not take into account the presence or absence of an acoustic shadow, although this has now been amended.
A description of the most recent common ultrasound scoring systems (SR, ADNEX, and O-RADS) is available in the Journal of Ultrasound in Medicine (JUM): Yoeli-Bik R, Lengyel E, Mills KA, Abramowicz JS. Ovarian masses: The value of acoustic shadowing on ultrasound examination. J Ultrasound Med 2023; 42:935–945.
Saunders et al. Risk of malignancy in sonographically confirmed septated cystic ovarian tumors. Gynecol Oncol 2010; 118:278–282.
Valentin et al. Risk of malignancy in unilocular cysts: a study of 1148 adnexal masses classified as unilocular cysts at transvaginal ultrasound and review of the literature. Ultrasound Obstet Gynecol 2013; 41:80–89.
Bourne et al. Transvaginal colour flow imaging: a possible new screening technique for ovarian cancer. BMJ 1989; 299:1367–370.
Granberg S et al. Tumors in the lower pelvis as imaged by vaginal sonography. Gynecol Oncol 1990; 37: 224–229.
Yamamoto Y, Yamada R, Oguri H, Maeda N, Fukaya T. Comparison of four malignancy risk indices in the preoperative evaluation of patients with pelvic masses. Eur J Obstet Gynecol Reprod Biol 2009; 144:163–167.
Meys EM et al. Subjective assessment versus ultrasound models to diagnose ovarian cancer: A systematic review and meta-analysis. Eur J Cancer 2016; 58:17–29.
Timmerman D, Van Calster B, Testa A, et al. Predicting the risk of malignancy in adnexal masses based on the simple rules from the international ovarian tumor analysis group. Am J Obstet Gynecol 2016; 214:424–437.
Abramowicz JS, Timmerman D. Ovarian mass-differentiating benign from malignant: the value of the International Ovarian Tumor Analysis ultrasound rules. Am J Obstet Gynecol 2017; 217:652–660.
Yoeli-Bik R, Longman RE, Wroblewski K, Weigert M, Abramowicz JS, Lengyel E. Diagnostic performance of ultrasonography-based risk models in differentiating between benign and malignant ovarian tumors in a US cohort. JAMA Netw Open 2023; 6:e2323289.
Valentin L, Ameye L, Jurkovic D, et al. Which extrauterine pelvic masses are difficult to correctly classify as benign or malignant on the basis of ultrasound findings and is there a way of making a correct diagnosis? Ultrasound Obstet Gynecol 2006; 27:438–444.
Yoeli-Bik R, Lengyel E, Mills KA, Abramowicz JS. Ovarian masses: The value of acoustic shadowing on ultrasound examination. J Ultrasound Med 2023; 42:935–945.
Timmerman D, Testa AC, Bourne T, et al. Simple ultrasound-based rules for the diagnosis of ovarian cancer. Ultrasound Obstet Gynecol 2008; 31:681–90.
Van Calster B, et al. Evaluating the risk of ovarian cancer before surgery using the ADNEX model to differentiate between benign, borderline, early and advanced stage invasive, and secondary metastatic tumours: prospective multicentre diagnostic study. BMJ 2014; 349:g5920.
Andreotti RF, Timmerman D, Strachowski LM, et al. O-RADS US risk stratification and management system: a consensus guide-line from the ACR ovarian-adnexal reporting and data system committee. Radiology 2020; 294:168–185.
Appendix
Classification of primary ovarian tumors
Ovulatory: functional or corpus luteum cyst; theca lutein cyst; polycystic ovary
Infectious or inflammatory: tubo-ovarian abscess; hydrosalpinx
Benign: serous or mucinous cystadenoma; endometrioma; mature cystic teratoma (most common primary benign tumor of the ovary); paraovarian/paratubal cysts
Ovarian lesions are a common finding among women, with etiologies ranging from ovarian changes related to normal hormonal function to aggressive malignancies. Therefore, the proper diagnosis and management of ovarian lesions are critical to women’s health. Here, I’ll give a brief description of ovarian tumor analysis, including descriptors, pattern recognition, and the application of the International Ovarian Tumor Analysis (IOTA) group’s Simple Rules, the IOTA ADNEX model, and O-RADS ultrasound characterization.
Descriptive Analysis of Ovarian Tumors
The first step in the diagnosis of ovarian tumors is descriptive analysis. This step involves a detailed examination of the tumor’s characteristics, including its size, shape, texture, and location. This information is obtained through various imaging techniques, such as ultrasound, MRI, and CT scans. The following descriptors are used in descriptive analysis:
Size: The size of the tumor is measured in centimeters and is one of the critical factors in determining the type of tumor.
Shape: The shape of the tumor is described as either round or irregular. An irregular shape is often associated with malignant tumors.
Texture: The texture of the tumor is classified as either solid, cystic, or mixed.
Location: The location of the tumor is described as either unilateral or bilateral. Unilateral tumors are located on one ovary, while bilateral tumors are located on both ovaries.
Pattern Recognition of Ovarian Tumors
An essential aspect of ovarian tumor analysis is pattern recognition. It involves identifying specific patterns associated with malignant and benign tumors. The following patterns are commonly observed in ovarian tumors:
Solid: Solid tumors are characterized by the absence of cystic components and are often associated with malignancy.
Cystic: Cystic tumors are characterized by the presence of fluid-filled spaces and are typically benign.
Mixed: Mixed tumors have both solid and cystic components and can be either benign or malignant.
Application of the Simple Rules, the IOTA ADNEX Model, and O-RADS Ultrasound Characterization
The Simple Rules, the IOTA ADNEX Model, and O-RADS ultrasound characterization are 3 widely used methods for differentiating ovarian tumors.
The Simple Rules: The Simple Rules are a set of guidelines that assist in the diagnosis of ovarian tumors. The rules are based on the tumor’s size, shape, texture, and location. According to the Simple Rules, a tumor is considered benign if it meets all 3 of the following criteria: 1) it is purely cystic, 2) it is less than 10 cm in size, and 3) it has a thin, smooth wall.
IOTA ADNEX Model: The IOTA ADNEX Model is a predictive model that uses a combination of clinical and ultrasound findings to diagnose ovarian tumors. The model considers the tumor’s size, shape, texture, location, and other factors, such as the patient’s age and menopausal status. Then, the model provides a probability score for each tumor, indicating the likelihood of malignancy.
O-RADS Ultrasound Characterization: O-RADS is a standardized ultrasound reporting system that categorizes ovarian tumors based on their likelihood of malignancy. The system uses a 5-point scale, ranging from 1 (very low risk) to 5 (very high risk). The O-RADS system considers the tumor’s size, shape, texture, location, and vascularity.
The proper diagnosis and management of ovarian lesions are critical to women’s health. Descriptive analysis, pattern recognition, and the application of the Simple Rules, the IOTA ADNEX Model, and O-RADS ultrasound characterization are essential aspects of ovarian tumor analysis. These methods aid in accurately diagnosing and differentiating ovarian tumors and can guide appropriate treatment decisions.
Are you a healthcare professional looking to enhance your skills in gynecologic ultrasound and ovarian tumor analysis? Look no further than the Advanced Gynecologic Ultrasound course offered by the American Institute of Ultrasound in Medicine (AIUM) in partnership with the International Ovarian Tumor Analysis (IOTA) group.
This course offers a unique and valuable opportunity for healthcare professionals looking to enhance their skills in gynecologic ultrasound and ovarian tumor analysis. The comprehensive curriculum, hands-on training, and networking opportunities make it a worthwhile investment for healthcare professionals looking to improve patient outcomes and advance their careers. Register now for the course, taking place this June, at the AIUM Headquarters in Laurel, Maryland.
First-trimester screening for Down syndrome, a genetic disorder caused by the presence of an extra chromosome, usually involves a combination of maternal blood tests and an ultrasound exam (ie, a combined first-trimester screening [FTS]), which is performed between 11 and 14 weeks of pregnancy.
During the ultrasound exam, the healthcare provider evaluates various markers that can indicate an increased risk of Down syndrome, such as the thickness of the nuchal translucency (a fluid-filled space at the back of the fetus’s neck) and the presence of certain physical features, including the nasal bone. Because research has shown that fetuses with Down syndrome are less likely to have a visible nasal bone on ultrasound than fetuses without the condition, evaluating the nasal bone can help healthcare providers assess the risk of Down syndrome more accurately.
Although visualizing the nasal bone is not a mandatory component of the screening, the inclusion of fetal nasal bone evaluation in the screening improves the clinical performance of the screen for the detection of fetal Down syndrome. Unfortunately, factors such as maternal body habitus (such as increased body mass index [BMI]), poor acoustic windows, unfavorable fetal position, delayed nasal bone ossification, and early gestational age can hinder nasal bone visualization then. In addition, ethnicity may also affect the visualization of the fetal nasal bone as the development of the fetal nasal bone differs between populations. Acknowledging and integrating the differences in facial structure between different racial and ethnic groups can help to promote equity in prenatal imaging and ensure the provision of accurate, personalized risk counseling across patient populations.
Therefore, a recent study aimed to determine if repeat nasal bone evaluation provided a significant improvement in refining the specificity of Down syndrome risk assessment by combined FTS, as well as determine the efficacy of a repeat nasal bone evaluation across various maternal ethnicities.
The study reviewed the medical records of patients who underwent a first-trimester ultrasound evaluation in an American Institute of Ultrasound in Medicine (AIUM)-accredited center between January 2015 and January 2018. The study focused on patients with fetal nasal bone labeled as “absent or hypoplastic” or “unable to be adequately visualized” during the ultrasound. The researchers reviewed the records to assess factors such as patient age, ethnicity, follow-up evaluations, and fetal anomalies. They analyzed the combined FTS results and followed up with patients with abnormal results. They then conducted statistical analyses to compare patient ethnicity and nasal bone visualization on the second exam, as well as to compare patient ethnicity and fetal Down syndrome risk by combined FTS.
The study identified 589 cases (8.7%) of absent or uncertain fetal nasal bone on initial nuchal translucency (NT) ultrasound evaluation among the 6780 total NT ultrasounds performed, with the most frequently represented ethnicities being African American/Caribbean (46.2%) and White (36.8%). Of the total, 125 patients (21.2%) did not complete a repeat nasal bone evaluation, and 105 patients with additional risk factors pursued genetic counseling. Of these patients, 20 pursued chorionic villus sampling (CVS), and 11 of these cases (55.0%) reported abnormal karyotypes. Of the 376 eligible patients who completed a second nasal bone evaluation (exam 2), 82 patients (21.8%) had an absent fetal nasal bone, 26 (6.9%) had an uncertain fetal nasal bone, and 268 (71.2%) had a present fetal nasal bone. White patients were statistically significantly more likely than African American/Caribbean patients to have a present nasal bone on exam 2 (82.9% and 59.2% respectively, P < .0001), as were Asian Indian patients (100% and 59.2%, respectively, P < .0001).
Combined FTS can identify fetuses at high risk for aneuploidy, but it has a relatively high false positive rate. Therefore, proper identification of the absence or presence of the fetal nasal bone during FTS plays a critical role in identifying and counseling patients at increased risk for fetal aneuploidy. The study found that repeat nasal bone evaluation could reduce false positive FTS results, particularly in African American/Caribbean populations.
Even with the widespread use of cell-free DNA screening, combined FTS, including nasal bone assessment, remains an important tool for first-trimester aneuploidy risk assessment.
Are you still on the fence about deciding whether or not to attend UltraCon, a reimagined take on the American Institute of Ultrasound in Medicine’s annual meeting? The transformation of the AIUM’s annual ultrasound meeting into UltraCon is an exciting step forward for the field. It will provide a platform to connect professionals, share ideas, and learn from each other.
Previously, we’ve highlighted the benefits of attending Day 1 and Day 2 of UltraCon, but what about Day 3? Just one look at the UltraCon schedule, and you can tell that this is going to be its busiest day yet! Despite the jam-packed program, there are a ton of amazing professional development opportunities ready for you to explore. On Tuesday, four new symposia will kick off, covering topics from 3D/4D imaging to musculoskeletal sonography. There’s also a shark tank competition, an e-poster kiosk hall, the annual AIUM Awards session, and don’t forget about the William J. Fry Memorial Lecture.
Let’s dive into the first new symposia, Early Pregnancy Ultrasound: Implications and Impacts on Care. This TED-talk-style forum is a great resource for learning about critical issues in the first trimester, such as providing equitable care in the emergency department and managing life-threatening situations. It has not only valuable information for medical professionals but also provides important insight into how to support patients after Dobbs. Participants can earn up to 1.5 CMEs.
Next, we have Optimizing Outcomes in Prenatal Imaging. During this symposia, participants can increase the quality and patient experience in obstetric imaging with a multidisciplinary approach. A group of specialists will present TED talks on topics such as early trimester issues, health inequities, and maternal/fetal life-threatening situations. Improve imaging outcomes via a perception bias workshop, challenging cases, and using the 3D world to understand ultrasound. Plus, roundtables with industry on image optimization and a special session on understanding the lifecycle of prenatal imaging. Participants can earn up to 3.0 CMEs.
POCUS: Cutting-Edge Uses and Controversies is the third symposium of Day 3. Point-of-care ultrasound (POCUS) is revolutionizing the way clinicians diagnose and treat patients. By providing real-time insights, POCUS offers quick, accurate, and cost-effective diagnosis of clinical problems. From development to bedside, POCUS has changed the game for clinicians worldwide. Are you seeking an engaging and informative symposium to discuss current POCUS advancements in medical ultrasound? Look no further than POCUS: Cutting-Edge Uses and Controversies symposium, which discusses topics such as global health, first-trimester concerns, scan ownership, POCUS workflow, and more. With an array of activities, including lectures, panel discussions, and workshops, this is sure to be a stimulating symposium that will leave you informed and inspired.
Breaking the Sound Barrier: Shaping the Future of Ultrasound is the last symposium of the day. The highly interactive symposium on ultrasound technologies is a great opportunity for clinicians, technologists, researchers, industry, and other stakeholders to learn about the latest advancements in ultrasound technology. This symposium will provide an invaluable platform for experts to share their knowledge and insights on how to utilize ultrasound techniques in clinical settings effectively. Attendees will have a chance to interact with leading professionals from around the world and discuss potential solutions for existing challenges within this field.
Outside of attending the symposia, there are several other interactive activities for participants to engage in. Firstly, the AIUM supports an ePoster program every year where attendees can explore and learn at their own pace through self-guided exploration. Secondly, attendees who have a great ultrasound idea and want to pitch it to industry can submit an application to pitch their ideas to venture capitalists, leaders from the industry, and an IP attorney, for the chance to win a cash prize of $1,000. Lastly, don’t forget to attend the 2023 William J. Fry Lecture given by pioneer in gynecologic ultrasound, Dr. Steven R. Goldstein, entitled “Do You Do POCUS: Why reinvent the wheel?”.
UltraCon will be the must-attend event of the year for medical professionals who want to stay up-to-date on the latest advancements in ultrasound technology. With a wide variety of engaging sessions and workshops, there’s something for everyone, so avoid getting caught with FOMO. All of this is just what is available on the third day of symposia at UltraCon. Check out the Full Schedule to start planning out your UltraCon journey.
Arian Tyler, BS, is the Digital Media and Communications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).
The keys to optimizing screening of the fetal heart are to understand how the ultrasound machine’s functions and controls can affect your image, utilize the entire maternal abdomen, adjust your image presets, and optimize your angle of insonation. So how do you do all that?
You start with the transducer. Be sure to select a transducer that allows for adequate penetration and optimal resolution. All transducers have different operating frequencies and capabilities; high frequencies produce better detail resolution but, of course, with limited sound penetration. These frequencies can be applied in all trimesters, particularly since the advent of high-resolution transducers, which are helpful when imaging delicate heart structures, such as the valves and vessel walls. If, however, the imaging is subpar with a high-frequency transducer, switch to a low-frequency transducer, which is more useful in your patients with a high body mass, in the late second trimester, in the third trimester, and in the event that there is also polyhydramnios syndrome, even when there is rib shadowing. Keep in mind too, that transvaginal imaging is helpful for evaluating the fetal heart in the first or early second trimester, in the event that there is suspected fetal cardiac abnormality, and even when maternal body habitus causes imaging to be difficult.
For your next step, adjust your image presets to optimize your temporal resolution so that you maintain a high frame rate of greater than 25 frames per second. A few of the technical settings that affect temporal resolution are the frame rate (in Hz), frequency selection, depth & focus, sector angle width, and zoom magnification. The better the temporal resolution, the improved detail resolution. To optimize your image, avoid unnecessary depth and make sure your focus is on the region of interest. A multiple focal zone may be applied to structures that don’t move, such as the placenta, but when looking at the 4-chamber heart, you will need a single focal zone. In addition, adjust your sector angle width. Reducing it increases lateral line density, which improves the image quality. Finally, make small adjustments to your settings, such as applying speckle-reduction imaging, adjusting the dynamic range (more or less gray), and scanning in different tones.
When incorporating color Doppler, the color box, color gain, wall motion filter, velocity scale/pulse repetition frequency (PRF), balance, and angle of insolation can each affect the image. The color box slows the frame rate by a significant degree so the smaller the color box, the higher the frame rate. Set color gain initially on low (ie, less color) and gradually increase it until you have optimized the amount of color. The wall motion filter eliminates signals caused by wall motion and low velocities. The velocity scale is the range of mean velocities or PRF in the region of interest. If it is too low, it can produce aliasing, which could lead to a misdiagnosis; too high and the low-velocity flow will not be displayed. Here is a sample of potential ideal velocity flows:
High-velocity flow (>60–80 cm/sec)
Low-velocity flow (<30 cm/sec)
Atrioventricular valves
Pulmonary veins
Semilunar valves
Bicaval (IVC/SVC)
The great vessels (3VV)
Evaluating atrial and ventricular septum
The scale is dependent on factors such as body mass index and fetal positioning within the uterus.
The balance allows you to display how much grayscale and color Doppler information you would like to see. Reducing the balance will show grayscale elements within the color box. And, finally, the angle of insonation is very important to keep in mind as the signal from the transducer should be parallel to the direction of blood flow.
J of Ultrasound Medicine, Volume: 35, Issue: 1, Pages: 183-188, First published: 01 January 2016, DOI: (10.7863/ultra.15.02036)
One of the major challenges in ultrasound imaging is scanning a morbidly obese patient. This is a result of the increased distance between the transducer and fetal anatomy, causing degraded resolution. Some techniques for optimizing your imaging in these cases include scanning above the tissue, when the patient’s bladder is full, through the umbilicus, or when the patient is in the Sim’s position (with the patient on their left side), which allows the extra tissue to fall to the left side. Also, keep in mind that when scanning an obese patient, the color doesn’t always fill in. Lowering the color attenuation can help clarify the image.
So, remember, the key to optimizing your fetal heart imaging is in understanding your machines’ functions and controls and how they can affect your image, utilizing the entire maternal abdomen, adjusting your image presets, and optimizing your angle of insonation!
To learn more and see case scenarios, see the American Institute of Ultrasound in Medicine’s (AIUM’s) on-demand webinar with speaker Mishella Perez, MS, RDMS, RDCS, “Fetal Heart Image Optimization: The Key to Screening”, from which this post was adapted. AIUM members can access the webinar for free.
Interested in learning more about fetal imaging? Check out the following resources from the American Institute of Ultrasound in Medicine (AIUM):
