Category Archives: OB

O-RADS: Standardizing the way we assess adnexal lesions (and an app to make it easy!)

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“When a word has many meanings, it has no meaning at all”. (Anonymous)

Let’s face it: ovarian lesions seen on ultrasound can be some of the most challenging to assess and describe. When not a simple cyst, generic terms such as “complex” are commonly used providing limited insight to the provider and patient regarding the level of concern for risk of malignancy. For instance, shown here are 3 different lesions that could all be described as “complex” or “heterogeneous”, yet range from nonneoplastic to malignant.

Figure 1. Hemorrhagic cyst
Figure 2. Benign dermoid cyst
Figure 3. Endometriod carcinoma

Compound the ambiguity of nonspecific descriptors in the imaging report with the angst of possibly missing an ovarian cancer, a rare but deadly disease, and the result is “over treatment”. Too often, surgery or additional imaging are performed for physiologic and benign findings with the added unintended consequences of associated morbidity and patient anxiety.

Enter O-RADS, an acronym for the Ovarian/Adnexal Reporting and Data System.

Similar to other American College of Radiology (ACR) “RADS” systems (ie, BI-RADS for breast imaging), O-RADS gets everyone speaking the same language AND provides a risk of malignancy using a numeric scale of 0 to 5 (Table 1).

Table 1. Risk of malignancy (ROM) associated with O-RADS Risk Stratification and Scoring System for US and MRI. (NOTE: US systems allow for greater sensitivity at the expense of specificity to avoid not missing a cancer.)

In O-RADS, there are two arms: 1) ultrasound (US), the primary imaging modality for the adnexa used by practitioners from many disciplines; and 2) magnetic resonance imaging (MRI), considered a problem-solving tool for radiologists. With O-RADS ultrasound, management guidance is also provided on triaging lesions to follow-up (clinical or imaging surveillance), additional characterization (by a specialist in US or with an MRI exam), or surgery. For the latter group, this is further divided into those lesions that can be excised by a general gynecologist, and those best managed by a gynecologic-oncologist, an important factor in improving long-term survival in the setting of ovarian malignancy.

Using the available descriptors in the O-RADS lexicon and an algorithmic approach, characterizing adnexal lesions is simplified. First, determine whether a finding in a menstruating patient meets criteria for a physiologic finding (follicle or corpus luteum). If it does not, or the patient is postmenopausal, assess for a “classic benign lesion”, a phrase coined for fairly common lesions that are almost certainly benign when typical features are seen (hemorrhagic cyst, endometrioma, dermoid cyst, paraovarian cyst, hydrosalpinx or peritoneal inclusion cyst). The remainder of lesions are assigned to 1 of 5 categories based on their solid or cystic appearance, and if cystic, the presence of septations and solid components as follows: solid lesion, unilocular cystic ± solid component(s), multilocular cystic ± solid component(s). Subsequently, features such as degree of internal vascularity, lesion size, ascites, and peritoneal nodules may come into play.

To score a lesion, color-coded O-RADS risk stratification tables are readily available and a useful resource. I personally find the O-RADS smartphone app to be an efficient and handy tool to quickly obtain a score and management recommendations. On average, I can reach a score in under 30 seconds and all the information I need for the imaging report is literally at my fingertips.

Since we started using O-RADS, our referring clinicians are asking for an O-RADS score whenever we describe an adnexal lesion as it gives them so much more useful information to counsel their patients. For instance, the patient in figure 1 with a hemorrhagic cyst did not require any imaging follow-up, the patient in figure 2 with a dermoid cyst has safely elected to undergo US surveillance in 1 year, and the patient in figure 3 with endometrioid cancer is doing well under the care of her gynecologic-oncologist.

For me, replacing vague terms (with many meanings) with standardized reporting systems not only makes sense, it’s truly meaningful.

Additional resources:

Dr. Lori Strachowski is a Clinical Professor of Radiology at the University of California, San Francisco, where she holds an adjunct title in the department of Obstetrics, Gynecology and Reproductive Sciences. She is a member of the ACR O-RADS committee serving on the steering committee and chairs the education committee for O-RADS US.

Ultrasound-Guided Obstetric and Gynecologic Procedures in the Pelvis

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Ultrasound guidance can be a safe and effective technique in obstetric and gynecologic procedures. Before beginning such a procedure, consider which approach will you take, transabdominal, transgluteal, or transvaginal. The approach that uses the shortest distance to the area of interest without transversing other structures is usually the best tolerated by the patient and will rarely result in complications, which are uncommon and usually minor, such as pain or self-limited bleeding. To select the shortest and safest path for access, review prior cross-sectional imaging and determine it on a case-by-case basis.

In cases of fluid management, such as benign adnexal cyst or peritoneal inclusion cyst fluid collection, note that you may need a larger needle gauge (18+) in those instances in which the fluid is thick. If you intend to test for malignancy, also take into account that fluid is generally less likely than solid tissue to give up the cells needed for a diagnosis.

Fine-needle aspiration in a case with mixed cyst and solid mass.

Ultrasound guidance can also enable delivery of vascular acting medications directly where it is needed, as well as to guide direct gestation sac injection of potassium chloride (KCl) and/or methotrexate for cervical, interstitial, or C-section ectopic or heterotopic pregnancies in appropriate patients.

In conclusion, transvaginal or percutaneous ultrasound guidance can be used in the search for a diagnosis, in fluid collections, and to treat obstetric and gynecologic pathology, such as delivering medications to treat ectopic pregnancy or vascular conditions in select cases.

To learn more about this topic and see examples of its use, watch the full on-demand webinar, “Ultrasound-Guided Interventions to Treat Obstetric and Gynecologic Disease” presented by Tara A. Morgan, MD. Members of the American Institute of Ultrasound in Medicine can access it for free. Join today!

Read more from Tara A. Morgan, MD, on ultrasound guidance in the Journal of Ultrasound in Medicine:

Getting Sonography Students Hands-on Experience

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As the Program Director of a Commission on Accreditation of Allied Health Education Programs (CAAHEP)-accredited General sonography program, I have a request for all OB/GYN practices. Please open your practice to accept sonography students. The future of the OB sonographer depends upon it.

If schools cannot provide graduates with good entry-level OB skills, there will not be enough sonographers to fill the OB sonography positions within private practices and this includes the MFM specialties.

Student rotations are down because the sonographers are too busy to allow students to scan. I have been given the following reasons why they are too busy:

  1. Patients are scheduled every 30 minutes all day.
  2. Work-ins are expected to be added daily into the already booked schedule
  3. It is not uncommon for a single sonographer to perform 15–20 patients per day.
  4. There are usually no breaks except for lunch, maybe.
  5. Some practices have more than one sonographer but each performs the same amount of studies so there is no relief person to help out.

This type of scheduling (over-scheduling) sets up a whole new set of questions.

  1. How long can one sonographer sustain such a schedule without suffering from burn-out and choose to leave employment?
  2. How long can one sonographer sustain such a schedule without suffering from repetitive stress injuries that will force their retirement?
  3. If sonographers are having to rush through studies to get all of the patients through, what are they missing?
  4. What is the satisfaction level of the patient who feels they are on an assembly line when getting their sonogram?  I do believe this is one reason many “peek-a-boo -see your baby” businesses are flourishing; OB patients want to experience fetal bonding with their families, time for which the private practice schedules do not allow. (“The AIUM advocates the responsible use of diagnostic ultrasound and strongly discourages the non-medical use of ultrasound for entertainment purposes.” See The Issue with Keepsake Ultrasounds for more information.)

Although there is value in observation, which the students may be allowed to do, nothing can replace a hands-on experience with supervision and instruction. And, yes, labs help, but the accrediting bodies require our students to scan patients not models.

For at least 2 decades, educators have struggled to find OB clinical sites that would allow their students to gain the scanning skills needed to complete their clinical competency exams, which are required for graduation. With no resolution in sight, even the Joint Review Committee on Education in Diagnostic Medical Sonography (JRC-DMS) and CAAHEP have recognized that some General accredited programs could not meet all the standards and, therefore, have now provided us a way to separate out the specialties. This allows for the deletion of the OB specialty from their accredited programs. This is a way for educators to deal with the problem of not being able to gain access to 2nd- and 3rd-trimester OB patients for their students, but it will ultimately be bad news for the OB community in general.

I believe the sonography community is an intelligent and creative group. We can find ways to integrate students into a busy environment. I actually have some clinical sites that do a very good job of it. I encourage you to think outside of the box and let’s get creative so that the schools will be able to provide qualified graduates when they are needed. If we don’t, we will begin seeing private OB “cross-training” on the job, again.

Is that what we really want? Comments, opinions, rebuttals, suggestions are encouraged and I look forward to reading them all.

Kathy A. Gill, MS, RT, RDMS, is a Program Director of the Institute of Ultrasound Diagnostics in Spanish Fort, Alabama. Kathy has been a Registered Diagnostic Medical Sonographer since 1977 and has been involved in sonography education for 30+ years.

Interested in learning more about ultrasound in medical education? Check out the following posts from the Scan:

COVID Life in the Prenatal Ultrasound Suite

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It is crazy to think that we are approaching the end of the second year of the worldwide COVID-19 pandemic. If the pandemic were a child, it would be walking, talking, and soon entering the “terrible twos”. In fact, my son was born in late February 2020, so all he knows is the pandemic. To him, masks are normal. He has even started to ask to wear a mask because that’s what everyone else does—mom, dad, his daycare teachers, his grandparents, his cousins. Though once he has one on, he quickly realizes that he prefers life without a mask.

Don’t we all, Andy?

As with most people, work life since the pandemic has changed. As a maternal-fetal medicine fellow, I’ve dedicated my training to the care of pregnant people and their fetuses, and I find the most fulfillment in the ultrasound suite. As cases rose, rooms filled with family and friends waiting for the words on the screen, “It’s a girl!”, during an anatomic survey became rooms with only a masked pregnant person and a masked sonographer (and the unmasked fetus, of course). While one adult support person has always been allowed to accompany each patient at our institution, they were frequently absent, whether they were working from home, caring for other children who are not allowed at appointments, or trying to limit exposures. Sonologists that previously were in and out of ultrasound rooms, scanning and counseling patients, were reading exams and counseling remotely.

Despite all the changes, the work continued. In fact, the pandemic has reminded us all that prenatal ultrasound is a medical necessity. At the height of the pandemic, elective medical procedures were canceled across the country. But the prenatal sonographers and maternal-fetal medicine specialists donned their N95s and face shields, and the prenatal ultrasound suite continued operation. In fact, cases that would have previously been managed with twice weekly non-stress tests were managed with weekly biophysical profiles instead to minimize potential exposures for a patient. Even with a current maternal diagnosis of COVID, arrangements were made to continue weekly umbilical artery Doppler studies for cases of fetal growth restriction. Some scans just cannot be delayed for 2 weeks. Despite all the changes, our purpose was clearer than ever—to provide excellent care for our patients, maternal and fetal.

With the widespread distribution of the vaccine and the decrease in cases, work life has settled into a “new normal”. Children have returned to in-person school, and the support person has returned to the ultrasound suite. N95s have been replaced by more comfortable surgical masks. Counseling a patient and their partner is no longer accompanied by the same degree of fear of a COVID exposure. But life is still far from my expectation of normal. The smiles after receiving the good news that there is one healthy intrauterine pregnancy with a strong heartbeat are still hidden behind cloth, as is the discomfort of an amniocentesis and the anguish when informed of a lethal fetal diagnosis. The impact that the mask continues to make on my ability to connect with and care for my patients cannot be understated.

As we head into the “terrible twos”, I know the pandemic will continue on and there will continue to be ups and downs. Misinformation regarding vaccination still limits widespread acceptance, but as research continues to demonstrate the safety and efficacy of vaccination, I still hold on to the hope that one day I will again be able to sit in a room with a patient unmasked and take in the unspoken communication I’ve so missed. But in the meantime, I’ll take the “new normal” and make the best of it for myself, my family, my colleagues, and my patients.

Kathy Bligard, MD, MA, FACOG, is a loving mom and third-year maternal-fetal medicine fellow at Washington University School of Medicine in St. Louis, MO.

Interested in learning more about patient care? Check out the following posts from the Scan:

The Eyes and Ears of The Patient(s)

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I began my ultrasound career in 2001 after graduating from the DMS program, but truth be known, it began sooner than that. I was incidentally placed at a maternal-fetal medicine clinic to do a rotation to get my clinical hours due to a preceptor being absent for an extended period of time at my “established” site, unbeknownst to me or anyone else just how much this would impact not only my career but my life.

When I was exposed to high-risk obstetrics (OB), I was instantly intrigued. I was told that I would need a minimum of 5 years of scanning experience before I could enter that field. For those that know me, know I’m always up for a challenge! I was prepared to do what it took.

At the end of my rotation, my preceptor, the one who would become the most impactful mentor I’d ever had, Ivy Myles, asked if I would be interested in returning to finish my clinicals at their practice, of course, I jumped on it.

Fast forward to today, I have learned that we, as sonographers, are the eyes and ears of the patient, and being in high risk, we are the eyes and ears of TWO patients. That is an incredible amount of responsibility and should not be taken lightly.

So, what does it mean when the job you love comes with so much responsibility? It means that we are in a position to advocate for the patient(s); we listen to them, ask questions that may seem out of curiosity to the patient, but in fact, tell a story of what may or may not be happening with mom and baby. I believe that we are not “picture takers,” we are “storytellers,” presenting our cases to the providers that have learned to trust our skills, talents, and insights.

Over the years, I have fallen more in love with this field and it has become a passion of mine. I want to learn more, teach more, and do more. I have a special place in my heart for the students and new sonographers that want to delve into the high-risk world because of how I entered this field. So, I carry on what my preceptor and mentor gave to me. She saw my skills and my heart for the field and gave me a chance. When a patient is told they are “high risk” and need specialty care at a perinatal center, this is typically not taken lightly. The patient is concerned for her baby and herself. In most perinatal centers where I have worked, the sonographers have a unique position and freedom to talk with our patients, explain the ultrasound, any concerns we may have about the ultrasound (without a diagnosis), we are able to provide a tour of their baby before they meet them, and let the family see their baby being a baby before meeting them on the outside. What a blessing for all!

Carrie Bowen, RDMS, RDCS​, is a sonographer at Perinatal Associates of New Mexico.

Interested in learning more about obstetric ultrasound? Check out the following posts from the Scan:

Ultrasound for Undescended Testicles: Tailoring Use

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In the early 1980s, prenatal ultrasound imaging opened the curtains to a “real-time” view of fetal anatomy. What we saw helped limit invasive diagnosis and therapy to those that benefited our unborn patient, and taught us that patiently waiting until after delivery was often the best approach to abnormalities detected in the womb. In other words, wanting to know was no longer a good reason for pursuing an immediate answer; needing to know, to benefit the child, was the rule to follow.

So, let’s skip over 40 years of “boring” fetal diagnostics, genetic testing, treatment, surgeries, and other distractions and talk about the great mystery on everyone’s mind, the hunt for the impalpable testicle—or as I call it, “following the bouncing ball”.

Every fetal sonographer knows what a testicle nestled in the scrotum looks like and will often be required to quickly gloss over the classic image in order to avoid the unwelcome or undesired “reveal”. As depicted in the diagram below, imaging after 20 weeks may show the scrotum (B) and after 30 weeks (C) may show “ball in sac” if the rest of the child behaves. If, however, the testicle(s) are not cooperative, nobody panics.

Schematic of testicular descent under normal influences with abdominal (A) position; descent to the internal ring (B); scrotal descent with patent processus vaginalis (C); descent complete with complete regression of the gubernaculum and occlusion of processus vaginalis (D). CSL indicates cranial suspensory ligament; T, testosterone; AMH, anti-mullerian hormone; S, sertoli cells; L, leydig cells, INSL3, insulin-like factor 3; GFN, genitofemoral nerve.

But after birth, if one or both testicles fail to stare the waiting observer in the eye, or happily make themselves easily ballotable in their pocket, the alarms go off and rational processes falter. In this vacuum of clinical reason, the reflex order for an ultrasound (US) emerges and sadly obscures best care of both the child and parents. Why should you wait to order an US? Because I am a pediatric Urologist and I said so! If that answer doesn’t suffice, as it never has for me at home or office, let me try and explain.

Case 1

Both testicles are absent to examination at birth. Well, if a newborn of male appearance and yet unknown genotype has no testicles, that neonate is a girl until proven otherwise. Genetic testing will answer that and other potential questions of chromosomal gender.

The lone cry in the wilderness that ultrasound can “find” nonpalpable testes, ignores the literature that shows that in an examination, a specialist will feel the previously un-felt testicle in over 80% of children, which is equivalent to US success. Add to that the false-positive rate of 15% (generous here) where an immobile abdominal or clinically absent gonad is “found” in the groin on US and we are rapidly approaching the poster-child for unwarranted examinations. I do not deny the HUGE contribution of US to the work-up of ambiguous genitalia and intersex conditions, supplanting fluoroscopy and even MRI in many centers, but please do not confuse garden-variety “lost balls” with these more complex issues.

Case 2

The infant or child has one or no balls in their pocket on subsequent examination after birth. Referral to a specialist often comes after US, MRI, and even CT scans seeking to see “where” the ball has strayed along its path to the scrotum. MR and CT for this concern are unjustified as a result of their expense and risk exposure, so I will speak of them no further.

If we go back to our rule that imaging is done to help the child or parents, how does the pre-specialty referral US play out? If the US finds a testis, I would have found it anyway, but the US will not define whether it is retractile (normal with a reflex requiring observation, not surgery), or truly undescended, where surgery is warranted after 6 months of age.

If US fails to find a testicle, I will need to do surgery for certainty (US false negatives on intrabdominal gonad are 10%—again generous) as testicular cancer is possible in undescended testes at 5 times the rate of the general population and direct surgical inspection is as near to 100% certainty of whether a testicle exists or not, as one can get.

So, tell me, where’s the harm in noninvasive, nonpainful, nonionizing, inexpensive imaging. Well? I’m waiting. Never mind. Let me tell you.

Imagine you are a parent. Testicles are absent on US, where does your mind go? Testicles are in the inguinal canal, where does your mind go? Now remember, not because I say so; not because I am some gifted guy; but because of my training and experience, I eliminate the worry after 60 seconds in the office and reverse the concerns set in motion in over 90% of visits after imaging. I would say that’s a lot of “Google-worry-stress time” avoided, so, it is therefore worth foregoing US before the specialist exam.

Finally, in the worst-case scenario, US finds testicles, and, as a result, the primary care physician tells the parents it’s OK, and an infant is denied time-sensitive surgery to maximize testicular function and possibly decrease cancer risk simply because the “presence” was interpreted as “normal”. The US window to gonadal and urogenital anatomy is evolving and brilliant, with contrast-enhanced ultrasound (CEUS), molecular imaging, and elastography promising even more advances. Our common goal is to have our tools create better outcomes and minimize the potential for harm.

Robert Mevorach, MD, is Chief of Pediatric Urology at the University of South Alabama, Mobile, and is Secretary of the American Institute of Ultrasound in Medicine (AIUM) Urology Community (2021–2023).

Interested in learning more about urologic ultrasound? Check out the following resources from the AIUM:

The New Genetics: Is Ultrasound Dead?

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There are those who pretend that we do not need ultrasound anymore to detect fetal anomalies, “Just use maternal blood and with various forms of genetic testing and you will be able to detect the majority of fetal anomalies.”

Well, let me rebuke this insinuation.

3D ultrasound image of a fetus.
Acrania in a fetus at 11 weeks.

Genetics

There is no doubt that prenatal genetic testing has come a long way from using only maternal age to assume a risk of Down syndrome (for instance 1 in 1250 at age 25 and 1 in 385 at age 35). Maternal serum screening came next. At first, levels of alpha-feto-protein (AFP) were found to be lower in mothers carrying fetuses affected with Down syndrome.

Then, other markers, such as human chorionic gonadotropin (hCG), unconjugated estriol, and dimeric inhibin A, were determined to display characteristic patterns in pregnancies with Down syndrome, with the introduction of the double, triple, and quadruple screening in the second trimester. This moved to the first trimester, with incorporation of fetal nuchal translucency (NT), pregnancy-associated plasma protein A (PAPP-A), and the beta subunit of human chorionic gonadotropin (β-hCG). A high detection rate of 85–90% was attained for Down syndrome and 90–95% for trisomy 18, with a 5% false-positive.

A combination of both the first and second trimester was introduced, to further improve the detection rate and, at the same time, decrease the false-positive rate.  In some of these tests only serum fetal-placental protein markers were considered (integrated) and in others ultrasound findings (NT) and various serum markers were combined (integrated, sequential, and contingent).   

It is widely accepted that testing of the type used nowadays originated from a Lancet paper in 1997 by Lo and colleagues, describing circulating cell-free fetal DNA (ccffDNA) in the plasma of pregnant women. It took almost 15 years for the technology to become clinically available1. At first, it was used to determine the risk of trisomies and sex chromosome anomalies. Originally designed as noninvasive prenatal diagnosis (NIPD) or noninvasive prenatal testing (NIPT), the general opinion is that these are still screening (and not diagnostic) tests, hence the designation noninvasive prenatal screening (NIPS). I prefer noninvasive DNA screening (NIDS) because, after all, ultrasound is NIPT!

Nowadays, NIDS can be used to identify Rhesus group and some single-gene fetal conditions, autosomal dominant, recessive or sex-linked (eg, cystic fibrosis, achondroplasia, thanatophoric dysplasia, sickle cell disorder, congenital adrenal hyperplasia, spinal muscular atrophy, and hemophilia). Most conditions require using a maternal blood sample only but many require a paternal blood sample. Normal karyotype doesn’t mean everything is fine, hence chromosomal microarray, introduced in the prenatal diagnosis clinical setting in 2005. Looking for submicroscopic aberrations <5Mb can provide additional diagnostics in about 10% of fetuses with multiple anomalies1. The latest reiteration of the technology is genome-wide monogenic NIDS2.

Screening beyond the common trisomies is currently not recommended by the American College of Obstetricians and Gynecologists3. So where does ultrasound stand?

Ultrasound is alive and doing fine, thank you

In the general population, chromosomal abnormalities are less frequent than structural abnormalities. A large number of fetal structural abnormalities, especially many lethal ones, can be diagnosed in the first trimester of pregnancy, therefore, ultrasound remains an essential part of the story. Ultrasound diagnosis of fetal anomalies has now moved from the mid-second trimester (18–22 weeks) to the late first–early second-trimester (approximately 11–14 weeks). It should be noted that a repeat scan at the “classical” time (18–22 weeks) is still recommended by most.

Ultrasound image of a fetus with the NT measurement marked.
Image courtesy of Sergiu Puiu, MD

Two major reasons for the early scan: it’s a perfect time to perform a nuchal translucency (NT) measurement and, at that stage, most structural anomalies that are already present are detectable. A few examples of what is observable include all 4 limbs and all digits, cranial anatomy, estimation of the cardiac axis, and omphalocele (which is associated with Beckwith-Wiedemann and CHARGE syndromes, limb-body stalk anomaly, and Pentalogy of Cantrell, to name a few). Amputations or other unusual cleft due to amniotic band syndrome are visible and cardiac position and orientation can also be determined. In incidences of heart defects, dextrocardia is associated with 90% and situs inversus with levocardia with over 95%.

Most of the above anomalies will be associated with an increased NT, as will pulmonary, gastrointestinal and genitourinary conditions, diaphragmatic hernia, skeletal dysplasia, fetal anemia, and abnormal lymphatic drainage4. A third of congenital abnormalities occurring in fetuses with increased NT may remain undetected in the first trimester of pregnancy, unless cfDNA is used in combination with fetal sonographic NT assessment. When karyotype is normal, 10% of fetuses with an increased NT (>95th percentile) have structural abnormalities5.

In one study5, 65% of structural abnormalities would have potentially been missed in the first trimester if cfDNA had been used as a first-trimester screening test without an early ultrasound scan. Furthermore, if cfDNA only was used, besides structural defects, one third of other anomalies would have been missed: sex chromosome abnormalities, triploidy, single gene disorders, and submicroscopic aberrations <5Mb. In addition to NT measurements and detection of structural anomalies, several other sonographic markers have been described: nasal bone, ductus venosus Doppler anomalies and tricuspid regurgitation, helping to determine a high-risk group for whom genetic screening will have a high yield.

When these or/and other ultrasound-diagnosed fetal anomalies are present, whole-exome-sequencing can add relevant information in cases when an etiology could not be elucidated by fetal karyotype testing or chromosomal microarray6.

In a very recent article, Bedei et al. propose several conclusions, one of them being: “NIPT should always be combined with a skilled ultrasound examination.”7

My thoughts, exactly8.

I purposely do not wish to initiate a discussion on the ethical, moral, philosophical, religious, or emotional values or demerits of prenatal diagnosis. While some will say that all this is a veiled “search and destroy” exercise, others will explain that knowledge is power. Power to choose but also power to be ready when the baby is born or power to correct certain anomalies in the womb or intervene immediately at birth. Both sides of this argument may be defensible, but that is for another blog.

References

1. Talkowski ME, Rehm HL. Introduction of genomics into prenatal diagnostics. Lancet 2019 Feb 23; 393(10173):719–721.

2. Rabinowitz T, Shomron N. Genome-wide noninvasive prenatal diagnosis of monogenic disorders: Current and future trends. Comput Struct Biotechnol J 2020; 18:2463–2470.

3. American College of Obstetricians and Gynecologists screening for fetal chromosomal abnormalities: ACOG practice bulletin summary, number 226. Obstet Gynecol 2020; 136:859–867.

4.  Baer RJ, Norton ME, Shaw GM, et al. Risk of selected structural abnormalities in infants after increased nuchal translucency measurement. Am J Obstet Gynecol 2014; 211:675.e1–19.

5. Bardi F, Bosschieter P, Verheij J, et al. Is there still a role for nuchal translucency measurement in the changing paradigm of first trimester screening? Prenat Diagn 2020; 40:197–205.

6. Petrovski S, Aggarwal V, Giordano JL, et al. Whole-exome sequencing in the evaluation of fetal structural anomalies: a prospective cohort study. Lancet 2019;393(10173):758-767

7. Bedei I, Wolter A, Weber A, Signore F, Axt-Fliedner R. Chances and challenges of new genetic screening technologies (NIPT) in prenatal medicine from a clinical perspective: A narrative review. Genes (Basel) 2021; 12:501. 8. Rauch KM, Hicks MA, Adekola H, Abramowicz JS. Aneuploidy screening: the changing role of ultrasound. In: Abramowicz JS (ed). Ultrasound in the First Trimester, a Comprehensive Guide. Switzerland: Springer International Publishing AG; 2016:131–152.

Jacques S. Abramowicz, MD, FACOG, FAIUM, is a professor of OB-GYN and Director of Ultrasound Quality Assurance in the Department of Obstetrics and Gynecology at the University of Chicago.

More from Jacques Abramowicz, MD:
COVID-19: How to Prepare Yourself and Your Ultrasound Equipment During the Pandemic, an on-demand webinar from the AIUM (a collaborative activity with Samsung).

Interested in learning more about obstetric ultrasound? Check out the following posts from the Scan:

Ultrasound Imaging of Obese Pregnant Women

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As the rate of obesity continues to increase worldwide (last reported by the CDC as 42.4% as of 2017–2018), it has become even more evident that there is a great need to improve fetal cardiac visualization in obese pregnant women. Less than 50% of morbidly obese women have successful fetal 4-chamber and outflow tract visualization, compared to almost 90% of nonobese women.

Obese women are also significantly more likely than normal-weight women to have children with a congenital heart disease, with an even higher risk in morbidly obese women, who give birth to children who have higher odds of having atrial septal defects, hypoplastic left heart syndrome, aortic stenosis, pulmonic stenosis, and tetralogy of Fallot.

And when obese pregnant women have reduced rates of complete anatomic surveys, lower detection rates, and increased risk of fetal anomalies due to less than perfect anatomy visualization, how do we improve the fetal cardiac visualization?

A team of researchers from Eastern Virginia Medical School looked into whether ultrasound (US) imaging in early gestation could help.

Amara Majeed, MD; Alfred Abuhamad, MD; Letty Romary, MD; and Elena Sinkovskaya, MD, PhD, performed a study in which all study participants (obese pregnant women) with a gestational age of 13 weeks to 15 weeks 6 days, underwent an US exam using a transvaginal or transabdominal approach and color Doppler US for fetal cardiac screening, which they defined as complete when all components of the 4-chamber, right ventricular outflow tract, left ventricular outflow tract, and 3-vessel views were clearly visualized. The participants also underwent a traditional transabdominal examination at 20 to 22 weeks, and if that exam was incomplete, underwent another 2 to 4 weeks later.

What they found was that the addition of early-gestation US to the 20- to 22-week US exam of obese pregnant women substantially improved the visualization of fetal cardiac anatomy. And for the women with a BMI of greater than 40 kg/m2, the cardiac screening completion rate was even higher (significantly so) for the early-gestation exam plus a traditional exam (90%) than for the traditional exam plus the second traditional exam (72.7%).

Adding an ultrasound exam at a gestation age of 13 weeks to 15 weeks 6 days substantially improved the visualization of fetal cardiac anatomy, particularly for the women with a BMI of greater than 40 kg/m2. Having complete or more complete anatomy screening can enable an earlier, accurate diagnosis.

To read more about this study, download the Journal of Ultrasound in Medicine article, “Can Ultrasound in Early Gestation Improve Visualization of Fetal Cardiac Structures in Obese Pregnant Women?”. Members of the American Institute of Ultrasound in Medicine can access it for free. Join today!

If you have any questions about the study, please ask in the comments; the authors of the article will be happy to respond.

What’s Your Dialogue?

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Ultrasound image of a uterus showing the crown rump length of the fetus is 0.34 centimeters.

Beneath the paper drape of the “2:30 OB Confirmation” lies your next patient. Despite the application of the ultrasound study performed, a variety of stressors wreak havoc on a patient’s mental state prior to examination. The impact of what we say and how we say it, or the very lack of it, can shape a person’s view of testing, staff, or even healthcare as a whole. Yet, how much of an emphasis in ultrasound training is placed on effective communication? Especially in obstetrics where early pregnancy loss is prevalent, a blank stare at the monitor and averted eyes feels disconnected and insensitive. Let’s ask ourselves:

  • How do we, as ultrasound providers, communicate with our patients?
  • Do we attempt to provide comfort or empathy when needed?
  • How important is this interaction to our patients?

We owe it to quality patient care to take a deeper dive.

In settings where our patients show fear, stress, or grief, what’s your dialogue?
How should it look and sound?

Perhaps your patient, waiting nervously under the drape, presents with a poor OB history. Performing an ultrasound examination should encompass more than the stoic mechanical bedside manner. We should engage with the person behind the diagnosis code.

We see it often in OB. Despite reassurances of last week’s scan and normally-rising labs post early spotting, the patient leaves her appointment only to consult Dr. Google where she absorbs every related link about bleeding in pregnancy from previa to placental abruption. It’s been the L O N G E S T week of her life, and she’s sure fate will deliver yet another D&C instead of the child she desires. Miscarriage is the kind of trauma that leaves a woman emotionally scarred and fearful that history will repeat itself. It’s imperative we contemplate the real trepidation some patients feel for their examinations—and act accordingly.

Photo credit: Kat Jayne, pexels.com

For the brief time a patient resides in our care, we sonographers control the environment. We drive the equipment, manage the time, and guide our patients. It is completely within our power to greet them with warmth and direct eye contact, to adopt a caring tone in our explanations, to ensure comfort in our care, and to assure answers for their questions—where we can.

It’s a fine balancing act, isn’t it? …A tightrope walk between what we sonographers can share with an inquiring patient and what we cannot. Though protocols vary, we all surely must learn what information we are allowed to impart. Precisely how we convey it is up to us. After all, our patients must disrobe before a perfect stranger who is not their physician; in turn, we must overcome the propensity for a swift robotic contest against the clock to be more attentive. We may not manage a patient’s care, but for a short time, we are a patient’s provider and caregiver. The interchange with our patients is as much an integral part of our job as is concise reporting.

Effective patient communication should be a cornerstone of every curriculum and commence as early as learning sagittal versus transverse. Every veteran sonographer who relishes the confidence of cultivated skill and experience began the same way. Typically, navigating this technology for most students requires a long learning curve to perform it well and accurately. It’s quite easy for the initial focus to lie with capturing textbook images, not connecting with the patient. Learning appropriate and competent dialogue is as imperative as exam protocol. The new sonographer must observe and mimic this personal interaction before the first steps beyond the classroom.

Photo credit: Stas Knop, pexels.com

Conversely, the skillful sonographer, buried in the demands of a hectic patient load, may lose the tendency over time to prioritize this communication. Juggling the demands of a full schedule with urgent add-ons and after-hours call, we sometimes end up fanning the flames of burnout where a slide into the hurried robotic pace of patient-in, patient-out feels unavoidable. Don’t lose sight of the importance of your work and who depends on you. Every patient you scan lies on your table, and your’s alone. We are each responsible for the level of quality care we provide.

Now, examine your own daily patient interactions. Are they mechanical and rushed? Or do you take the time to employ earnest conversation? Do you attempt to allay fears or offer an empathetic tone when needed? Do you extend the care you would want, need, and expect if on the receiving end of healthcare? I challenge each of you to put forth the very same degree of consideration you’d like for your mother, your sister, your daughter, yourself…if the white coat fear was your own, if the anxiety of a test result was your own, if the pregnancy loss was your own. The appreciation our patients show can mystifyingly renew a sense of purpose in our work today and fuel our career tomorrow.

So, what’s your dialogue?

Sandra M. Minck, RDMS, is the creator of UltrasoundUnwrapped.com and @ultrasound_unwrapped on Instagram, a resource for accurate ultrasound information for expectant parents. She is the author of Ultrasound Unwrapped: A Pregnancy Image Guide, soon to be published.

Interested in learning more about communicating with patients? Check out the following posts from the Scan:

Point-of-Care Ultrasound for Pregnant Patients?

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Point-of-care ultrasound, or POCUS, has become fully incorporated into almost every aspect of clinical care over the past 5 years. COVID-19 has further solidified the use of POCUS for the evaluation of dyspnea and cough given its portability. But what about the use of POCUS for a woman during pregnancy?

Ultrasound has been consistently employed to evaluate the fetus in all 3 trimesters. There is another patient, though; the mother! Rising maternal morbidity and mortality secondary to cardiovascular disease requires the obstetrical care provider to employ point-of-care clinical assessment that targets the maternal cardiovascular system.  This is the problem and the solution may be “getting a CLUE” by implementing cardiac limited ultrasound evaluation (CLUE) at the bedside as suggested by Kimura et al.

In contrast to fetal imaging, which utilizes higher frequency transabdominal and transvaginal ultrasound probes, penetration of the chest wall requires a lower frequency probe (2–4 mHz). Ideally, a low frequency probe that is compatible with most commonly used obstetrical equipment would facilitate ease of utilization. The CLUE protocol employs the following views: parasternal long axis view, lung anteroapex view, lung posterolateral base view, subcostal view, and right sub-xyphoid view. These views allow the clinician to evaluate the patient for pathophysiologic findings including the presence of pleural or pericardial effusion; abnormal contractility, chamber enlargement, and valvular dysfunction. Assessment of the size and collapsibility of the inferior vena cava can be a noninvasive marker of right-sided filling pressures to evaluate volume status in an oliguric patient with preeclampsia.

I propose that CLUE be extrapolated from the non-pregnant patient population for applicability in the pregnant patient population. This may be particularly relevant in certain scenarios including: triage of pregnant women with cardiac symptoms in an outpatient or in-patient setting as an adjunct to the physical exam; and labor and delivery units with lack, or limited immediate availability, of formal echocardiography. While anecdotal case experience suggest utility, formal studies designed to compare CLUE in pregnancy to the gold standard of transthoracic echocardiography will confirm the feasibility of CLUE in this unique population. Even though obstetricians are trained to perform obstetrical and gynecologic ultrasound, and are well versed with the existing ultrasound equipment on their units, additional training may be required. In addition to obstetrical care providers, other clinicians, such as emergency room and internal medicine providers, may also perform CLUE to assess the maternal cardiopulmonary system.

Limitations of point-of-care cardiac examination of the heart include both patient characteristics and technique. Large body mass size and enlarged breast tissue common in pregnancy can lead to imaging acquisition challenges. Off-axis imaging technique can lead to false positive or false negative diagnoses. Patient positioning should be optimized and shifted to left lateral tilt to accommodate aortocaval compression.

CLUE demonstrates potential as an innovative diagnostic point-of-care technique that can be adapted to maternal use. Timely future clinical studies that compare CLUE with formal echocardiography during pregnancy will further clarify its feasibility and full utility in the clinical arena as a tool to combat rising maternal morbidity in the new millennium.

  1. Kimura BJ, Shaw DJ, Amundson SA, Phan JN, Blanchard DG, DeMaria AN. Cardiac Limited Ultrasound Examination Techniques to Augment the Bedside Cardiac Physical Examination. J Ultrasound Med. 2015;34:1683–1690.

Carolyn M. Zelop, MD, is a Director of Perinatal Ultrasound and Research at The Valley Hospital, Ridgewood, New Jersey; a Clinical Professor of Ob/ Gyn at NYU School of Medicine; and she is a senior member of the AIUM and the ACOG rep to women’s imaging for ACR.

Interested in learning more about ultrasound and pregnancy? Check out the following posts from the Scan: