Category Archives: OB

Obstetric Ultrasound: Tips for Sharing Outcomes With Your Patient

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“Are you comfortable? Am I pressing too hard?” I ask my patient these questions to assuage my own concerns and delay the inevitable as I study the ultrasound image of her 20-week-old fetus. Although she says she’s fine, my patient appears expectant and anxious as she, too, searches the black and white image of her unborn child. I wonder, of course, if she sees what I see—a cleft lip and palate.

If you’ve conducted ultrasounds for routine evaluation of your obstetric patients, you know that patients and their partners typically experience a mix of emotions, namely joy and worry, as they await results. You know, too, that delivering positive results is a pleasure as you share in your patient’s happiness and relief. In all likelihood, you also are relieved at escaping the discomfort of delivering bad news to your patient.

Dr and patient

Delivering Abnormal Ultrasound Results

Telling your patient about any pregnancy or fetal abnormality, however common or rare, can be devastating for her, her husband/partner, and her family. After all, every patient wants to know her pregnancy is progressing as expected and her fetus is developing normally. It also can be difficult for you to tell your patient there is a problem. But as a practitioner, you must be prepared to deliver all results, good and bad, to your patients.

A key to delivering abnormal results to your patient includes knowing and using phrases that clearly and honestly apprise your patient of the results without stirring alarm.

Sound easy? It’s not! Even the most seasoned practitioners suggest they never become comfortable giving patients abnormal results.

When results aren’t cause for alarm, patients, especially those in a first pregnancy, still can be highly sensitive to even the slightest aberration. Furthermore, the situation can become complex given varied models for delivering care. For example, when a primary obstetrician sends a patient for scanning at an antenatal testing unit that a maternal-fetal medicine (MFM) specialist oversees, the question is whether the MFM or primary obstetrician should deliver the results. In some cases, patients have scans in emergency departments. What then? Does the radiologist, emergency physician, or primary obstetrician deliver the results?

As an MFM specialist in an antenatal testing unit, I follow my center’s policy to immediately inform patients about their ultrasound results, whatever the outcome. With empirical knowledge to support them, practitioners in my unit know that the longer patients await results, the more likely they are to ruminate, worry, and, in some cases, develop unfounded concerns about their ultrasound results.

With focus on the shared humanity between physician and patient, we treat each patient with careful consideration for her dignity and the compassion we would want for ourselves and our family members.

Once you have told your patient her results, get in touch with her primary obstetrician. In addition to giving the primary obstetrician an opportunity to prepare for a discussion with her/his patient, this approach is integral to delivering high-quality, comprehensive, and continued care.

Follow these tips for delivering abnormal results to your patient:

  • Write down phrases you are comfortable using and practice them with a simulated patient (a family member or friend)
  • Consider how you would feel if you were in the same situation
  • When face to face with your patient, take a moment to gather your thoughts before speaking if necessary
  • Use a calm voice
  • Speak slowly and clearly
  • Look at your patient when talking to her; if her husband/partner is in the exam room, also look at him/her
  • Be straightforward and honest without creating alarm
  • Be sensitive to emotional ques from your patient to pace discussion appropriately. A sobbing patient is unlikely to hear what you’re saying, so wait patiently until she’s ready to listen
  • Ask your patient if she has questions; ask her husband/partner if he/she has questions
  • Answer as many questions as you can; if the patient asks a question you cannot answer on the spot, tell her you will get an answer within the next day
  • Reassure your patient of potential solutions for the situation without making promises
  • Recommend educational material that can help your patient better understand the problem
  • If the problem is genetic in origin, explain the value of genetic counseling before any future pregnancies
  • Take extra time to address your patient’s concerns if necessary
  • Ask your patient if she would like a referral for a counselor so that she can work through feelings about the results
  • Follow up with your patient the next day with a phone call

Telling Your Patient About Ultrasound Results: Practice and Prepare!

All fetal abnormalities on ultrasound, even the most insignificant, are understandably upsetting for parents to be. But being prepared before you break the news can help you and your patients feel more comfortable discussing the situation, including potential outcomes and solutions.

GuptaOne of the privileges of practicing obstetrics in the 2000s is that many of us deliver good news more often than bad news. But this also means that being adept at delivering abnormal ultrasound results requires practice outside as well as inside the office.

How do you deliver bad news to a patient? When do you provide counseling? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Vivek Gupta, MD, is a clinical instructor and fellow in maternal-fetal medicine at the University of Wisconsin School of Medicine and Public Health in Madison, Wisconsin.

My Chilean Experience

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Earlier this year, I had the opportunity to travel to Chile to present at the 18th Congress of Medical Technology meeting in Santiago. It was an amazing experience that I will never forget! The total travel time was about 14 hours, which began in Orlando with a flight delay and an emergency change to an earlier flight that had one seat left and was just about to
close its doors!Chile

Sonographers, as well as other allied health professionals, begin their education in the Colegio de Tecnologos Medicos (College of Medical Technologies); and the Capitulo de Ecografia (Sonography Chapter) is an arm of the College.  It is estimated that there are about 300 sonographers in the country of Chile. I was invited to speak at the meeting of the congress and the preconference, which was the inaugural meeting of the Sonography Chapter.

The evening before the preconference, I was invited to meet with a group of sonographers at a reception to discuss professional issues, certification, and education. The reception was hosted by the President of the College of Medical Technologies, Veronica Rosales, and the President of the Sonography Chapter and AIUM member, Mario Gonzalez Quiroz. At the reception, I was introduced to Fernando Lopez, known as the first sonographer in Chile with about 30 years of experience. I found the sonographers of Chile to be very welcoming and gracious, as well as curious about the role of sonographers in the U.S. They are also eager for educational opportunities to expand their knowledge and expertise.

I gave a total of 6 lectures during the 2 meetings on a variety of topics, including point-of-care, acute abdomen, obstetrical pathology, and pediatric sonography. Oh…did I mention that I don’t speak Spanish? I had synchronous translation of my lectures, and then I was able to enjoy other lectures that were then translated into English for me. As I was developing my lectures, I learned that with asynchronous translation, presentations should be shorter and you need to speak slowly. For me, that meant I had to reduce my typical image-heavy 100-120 slide presentation down to 70-80 slides. Luckily that worked within the time I was given.

This was my first time having lectures translated, my first international lectures, and my first time in Chile (actually my first time in South America)…lots of firsts! It was a true honor to present at this meeting and to meet the sonographers of Chile. I feel like I have made lifelong friendships, expanded my professional family, and experienced the beauty of a new country.

Have you given talks to an international audience? What was your experience? How can U.S.-based physicians and sonographers support their counterparts in other countries? Share your thoughts and ideas here and on Twitter: @AIUM_Ultrasound.

Charlotte Henningsen, MS, RT(R), RDMS, RVT, is the Chair & Professor of the Sonography Department at Adventist University of Health Sciences and the Director of the Center for Advanced Ultrasound Education. She currently serves as the AIUM 2nd Vice President.

Rare and Sometimes Disappearing: The Tough Life of the Sonographic Expert

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Everyday obstetricians hear the same questions: “Is my baby OK?” “Is there anything abnormal?” or, and this is may be the worst, “Should I be worried about anything?”

While innocent enough, these questions get for far more difficult when you consider that in the patient’s mind sonographic experts should be able to “see everything.” For Hershkovitz scanpatients, ultrasound has become a routine obstetrical practice that experts should be able to use to perform every type of diagnosis at the earliest gestational age—with 100% accuracy. This perception, however, means that developmental anomalies or disappearing findings are very confusing for the patient and her spouse.
An example of such a confusing sonographic condition is prenatal diagnosis of congenital lung lesions. One of the rarest lung lesions is Congenital Lobar Emphysema (CLE). This is a rare developmental anomaly of the lower respiratory tract characterized by hyperinflation of one or more of the pulmonary lobes and subsequent air trapping. The main fetal sonographic features of CLE include a bright echogenic lung with or without cystic or mixed cystic lesions (see image) without abnormal blood flow. A mediastinal shift, polyhydramnios, and fetal hydrops can also be observed and are predictors of severe respiratory distress or mortality.

CLE can decrease in size during pregnancy and even disappear on prenatal sonography or become apparent at postnatal evaluation, even though it is not observed during pregnancy. This can, obviously, become confusing for the patient. The main differential diagnosis of CLE is with congenital cystic adenomatoid malformation, pulmonary sequestration, and congenital high airway obstruction syndrome (CHAOS).

Once such a diagnosis is suspected, the patient is usually invited to a multidisciplinary meeting with the pediatric pulmonologypulmonologist, geneticist, and surgeon. Evaluation of the fetus is usually performed every 2 weeks and sometimes prenatal MRI is also suggested.

In many cases, depending on the size of the CLE and whether the fetus is hydropic by the time the fetus is delivered, the neonate is not in respiratory distress immediately after birth. However, sometimes CLE can lead to neonatal respiratory distress, and these neonates need to undergo surgical resection of the affected lobe. In the past, this has meant open thoracotomy, although recent advances in minimally invasive thoracoscopic surgery have resulted in decreased morbidity associated with resection of these lesions.

While innocent enough, the question, “Should I be worried about anything?” can get confusing and difficult when dealing with conditions like CLE. How would you handle it?

In a case like this how would you answer the question, “Should I be worried about anything?” How and when do you provide counseling to patients? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Professor Reli Hershkovitz is the Head of the Ultrasound Unit at the Department of Obstetrics and Gynecology of the Soroka University Medical, located in Beer Sheva in the Southern part of Israel. This medical center serves nearly 2 million people, with an average of 16,000 deliveries a year.

Our Accreditation Experience

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Ultrasound accreditation.

I’m sure you’ve heard about it, but you may be wondering: what does it really mean? Does it really matter if my practice site is accredited?

At one point I know that I wondered this myself! However, as a 17-year chief sonographer, and as the Ultrasound Technical Consultant for Allina Health Clinics, I can now tell you that for our sites, it absolutely does.

As a quality measure to ensure all ultrasound examinations are being performed and reported with the same standards of excellence, we decided to seek accreditation with the AIUM. Included under one AIUM accreditation, we have multiple clinic sites where the OB/GYN physicians read the ultrasound studies. It is a strict policy in our organization that any OB/GYN physician who wishes to read and bill for ultrasound exams must be added to our current AIUM accreditation.

With so many employees included in our accreditation, we knew that we needed to come up with a way to be able to facilitate new additions in a proficient manner, so that all sites received the same information and training. Thus (cue the climactic music), the “AIUM Physician Orientation and Mentoring” program was born!

We created this program for our organization as a virtual checklist of education and documentation needs, report over-reads, and competencies for the new physicians wishing to be added to our accreditation. We have a similar program for the sonographers that incorporates information and requirements for protocols, procedures, processes, and safety.

The Process

When I first started working with site accreditations everything was done on paper and case studies were submitted either on film or CDs. Now this process has been streamlined and all information that is required is easily uploaded to the AIUM site for their review.

For an accreditation such as ours that includes multiple sites, it was essential that we create a timeline to help us stay on track of what needed to be done and by when. The truth is, this is a very good way for any size site to make sure it stays on task and on time.
AIUM Accred Timeline

For us, this time around was a reaccreditation. So it is good to note that our information and supporting documents were due to the AIUM 6 months before the end of our current accreditation cycle. As you can see by the timeline, I set a goal of submitting 1 month before the due date. And that ended up being a good call because our actual submission date was only one week before the AIUM deadline.

Once all of our information was submitted, the Accreditation Team at the AIUM responded to us with any items that needed tweaking or were not quite hitting the mark. We replied to the AIUM on the changes that we would make and the education that we would provide our staff, and have been able to improve our services even more based on what we learned from those responses.

As one item of note, for us, the case submission selection and preparation was the longest and most time-consuming aspect of the process. Next time, we will start this task even earlier than outlined. Live and learn!

The Questions, Oh the Questions!
I had gone through an accreditation process before, but not with the AIUM. Since this was the first time for me, I had a ton of questions. I can’t even count how many times I emailed or called the AIUM staff, but I am sure they were groaning every time they heard from me.

However, each person that I spoke with was very understanding, helpful, and friendly. In fact, we communicated on such a regular basis that by the time I had submitted all of our information, they felt like good friends to me and I was tempted to invite them over for Thanksgiving dinner!

So Was It Worth It?
We expect our multiple sites to operate as one to ensure that patients are getting the same level of high-quality care when they go to site “A” for an OB/GYN  ultrasound, as when they go to site “B” for an OB/GYN ultrasound. For us accreditation has helped us accomplish that. The result has been higher patient satisfaction levels and improved quality and proficiency of our work.

Continuity of care. Improved quality. Higher patient satisfaction levels. Is accreditation worth it?

You bet it is!

Thinking about going through the AIUM practice accreditation process? Have any insights, tips, or ideas to share? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Laura M. Johnson, RDMS, RVT, is an Ultrasound Technical Consultant with Allina Health.

Handle the Scan with Care

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Anytime one begins an obstetrical scan, there is a ritual that precedes our privileged access into an otherwise inaccessible place pulsating with life, hope and promise. The trilogy of preparing the patient, applying the gel, and selecting the transducer helps us transition as we open a window to the womb, sharing a highly anticipated and treasured moment with the family.

old windowWhile this privileged access may provide priceless reassurance, it is accompanied by a huge responsibility for the sonologist who is attempting to make sense of what is seen while trying to decide how to share the information with the family.

As diagnosticians, we are taught to be vigilant, careful and meticulous, making note of every single finding. We employ the most sophisticated machines and the importance of being non-paternalistic is deeply engrained in our brains. Yet at the same time, care and caring must come into play if we need to break news that may shatter dreams or induce significant parental anxiety.

Personally I find that the most challenging cases are those in which various isolated sonographic markers may be detected. The struggle between wanting to be scientific, factual and transparent and the fear of labeling an otherwise healthy being and worrying a hopeful parent becomes paramount. This is becoming more commonplace nowadays with the advancing technology as we delve into fetal evaluations with much more detail and at earlier points in gestation. We must not mistake normal developmental findings with pathology. We must be careful with enhanced image resolution and the employment of harmonics as these may increase tissue echogenicity and lead to over diagnosis of physiologic “cysts” in fluid producing structures.

With the continuing advancement of the technological capabilities of this most versatile of medical diagnostic modalities and its evolving portability, the number of probe-handlers globally is increasing exponentially across the disciplines. The problem is that education, training and experience are not uniform. The expertise to discuss the implications of various sonographic findings, particularly soft markers, and to recognize serious abnormalities, may be lacking. Despite the well-established positive impact of prenatal diagnosis, allowing us to prepare families and formulate the optimal plan of care, it may also be a double-edged sword, particularly in inexperienced hands.  As such, and in keeping with the mission of the AIUM and its communities of practice, the importance of proper training cannot be overstated. One must adhere to the basic sonographic teachings, employ the ALARA principle, and implement practice parameters when incorporating sonography into daily clinical practice. Referral to centers of excellence, whenever there may be doubt, is critical. Sound judgment remains the key to utilizing ultrasound first.

A new life is purity in the absolute form: a blank sheet of paper. Much caution must be exercised before any marks are made. Every word uttered has the potential of tainting the page, of taking away hope, of falsely “labeling” this promising life before it has even come into physical being. “First do no harm” should continue to echo in our brains and we must always proceed with caution, and tread with care.

What’s your opinion on the quality issue? Do you see a wide range of quality in ultrasound scanning?  Comment below or let us know on Twitter: @AIUM_Ultrasound.

Reem S. Abu-Rustum, MD, FACOG, FACS, FAIUM, is the Director of the Center For Advanced Fetal Care in Tripoli, Lebanon. She has served the AIUM in several capacities, including her current role on the AIUM Board of Governors.

  • Image adapted from A Practical Guide to 3D Ultrasound. RS Abu-Rustum. CRC Press 2015.

16 Years and Counting

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Every year I look forward to February for a number of reasons. One is that I know spring in North Carolina is just around the corner. Another is that I know I will be escaping to Florida for a long weekend to attend my favorite ultrasound course, the AIUM Advanced Ultrasound Seminar: OB/GYN.

NC spring

Spring in North Carolina from http://www.visitnc.com.

I am a general OB/GYN and have been in practice in Durham, North Carolina, since 1998. I chose my current position because of its location, my family, and the chance to continue teaching OB/GYN residents.

In my early years as a resident educator, it was easy to teach the residents. But as time has passed and I have gotten busier, it seems that the residents have gotten smarter. They know about changes in protocols, new medications, new technology, and more. Therefore it is important for me to continue to educate myself through reading, listening, and attending courses.

I have always had an interest in ultrasound and received a great introduction to scanning as a resident at the Medial University of South Carolina in Charleston. My program directors put a strong emphasis on using ultrasound as a tool for caring for OB and GYN patients. So I probably have an interest in ultrasound beyond most generalists and I have enjoyed coming to the AIUM course since 1999.

One of the great things about the course is that it has adapted so well with the times. I remember the first 3D and 4D imaging that this course covered and how many questions people had about how they would be used. I remember discussions about whether an anatomy scan would be worthwhile and if insurance carriers would pay for it.

In the early years of the course there would be many long lectures about the frequency of X, the p values of certain markers, the RR of this thing or that thing, unreadable tables and presentations, and more. Recently, however, the course has become more evidence-based and clinically relevant for all participants. This has made the course even more worthwhile and shows that the enthusiastic and collegial faculty have dedicated their lives to medical ultrasound.

As we begin to move into fall and then winter, I start to long for February—for obvious reasons. I hope to see you in Florida.

Is there anything you have attended for more than a decade? What made it special? Have questions about the AIUM OB Course? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Frank Frenduto, M.D., is a managing partner and a board member for the Women’s Health Alliance in Durham, NC. His special interests are high-risk pregnancies, laparoscopic surgery, and gynecologic ultrasound.

I Enjoy Being a Detective

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I chose the specialty of radiology, and subsequently diagnostic ultrasound, because I enjoy the “detective” aspect of medicine. It is exciting to use diagnostic imaging to attempt to determine the cause of a patient’s illness. Obstetrical ultrasound has been of interest because most pregnant patients are healthy and happy and one always got an answer, whether right or wrong, 20-30 weeks hence.

I began my career in ultrasound in 1976 joining Dr. Roy Filly at UCSF. He and I are still practicing (perhaps the longest pair in academic medicine). The early days of arguing whether it was better to view images as white on a black background or black on a white background and whether static articulated arm scanning was better than “real-time scanning” are long gone, replaced by incredible technology.

Peter CallenThe pitfalls of image analysis has been a curiosity of mine. I have always been intrigued as to how one looks at a series of images and achieves the right (or occasionally wrong) conclusion. I am thrilled that most medical centers are introducing diagnostic ultrasound to medical student teaching early in their training. This has helped generate a lot of awareness and better understanding of our specialty. I am proud to have been a member of our organization, the AIUM. While there are some that only know the AIUM for its guidelines, it has served as a strong core of support for our specialty for the past several decades with support and advice to and from ultrasound professionals, including physicians, sonographers, scientists, engineers, other healthcare providers, and manufacturers of ultrasound equipment. This award is especially meaningful to me to be included with the true founders and leaders of our specialty.

What is your story? Why did you start using ultrasound? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Dr Peter Callen received the 2015 Joseph H. Holmes Clinical Pioneer Award from the AIUM. Dr Callen’s contributions span decades and he is currently Emeritus Professor of Radiology, Obstetrics, and Gynecology at the University of California, San Francisco.

Ultrasound Can Catch What NIPT Misses

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A few months ago a young couple, Michele and Dan, came to my office for a mid-trimester fetal anatomic survey at 21 weeks’ gestation. They were excited to see their fetus in 3D-4D ultrasound, and were wowed by the 3D image of their baby’s face. During the scan the couple related that they were sure their baby was OK “because the blood test came back negative,” and had decided to forego first trimester screening, despite their OB strongly recommending it.

unnamedThe blood tests, nuchal translucency measurement, and other sonographic parameters evaluated in first trimester screening are considered together to provide a risk profile for fetal chromosomal anomaly, particularly the risk of Down syndrome. If there is an increased risk, the parents may be advised to undergo invasive testing, such as chorionic villus sampling (CVS) or amniocentesis. In addition, first trimester screening can raise warning flags for structural anatomic malformations in the fetus, as well as other problems for the pregnancy. If first trimester screening includes a full fetal anatomic survey, it can spot about 40% of fetal malformations at a very early stage.

While I was reassured that Michele and Dan’s results on noninvasive prenatal testing (NIPT) meant the risk of their baby having Down syndrome and certain other aneuploidies was extremely low, I explained that structural malformations were still a much more common concern than chromosomal anomalies, and that a negative NIPT result did not rule out other conditions. Michele protested, “On the Internet it said that the blood test rules out Down syndrome 100%, that we didn’t have to worry.”

“The screening tests only give you a risk profile,” Dan insisted, “they don’t tell you if the baby is really affected. So we thought the blood test was the way to go.”

“I don’t want to have an amnio,” Michele continued, “I had a miscarriage in my last pregnancy,” she continued, as I proceeded to the echocardiography portion of the examination.

“Your baby appears to have a heart defect,” I said, as gently as I could, and began to explain the nature of transposition of the great arteries (TGA).

NIPT is the name applied to new techniques that use a sample of a pregnant woman’s blood to examine her fetus’s chromosomes. As early as 10 weeks of pregnancy there is sufficient fetal genetic material, called cell-free DNA, found in the maternal serum to allow analysis. A negative result from NIPT is a very good test to rule out Down syndrome in the fetus: it is highly specific, meaning that in almost all cases, a negative result is truly negative. NIPT is also highly sensitive, which means that in almost all cases, a positive result is truly positive. However, because there is a chance (however small) of a false positive (a healthy fetus may have a result showing him/her to have Down syndrome), a positive test result always needs to be confirmed with invasive testing, such as CVS or amniocentesis, before any decisions are made regarding the further management of the pregnancy. NIPT has also been found useful in identifying fetuses with other chromosomal anomalies and certain other genetic conditions. NIPT can also be used to determine the fetal sex.

However, while NIPT does a very good job at what it is designed for: looking at fetal chromosomal complement in specific conditions, it does not examine all the fetal chromosomes, nor does it look at the anatomy of the fetus. Fetal anatomy is examined in detail by ultrasound scanning. There is some debate among practitioners regarding the optimal week of pregnancy when full early fetal anatomy scanning should be performed. Some practitioners prefer performing the scan at the time of nuchal translucency screening, 11-13 weeks, while others prefer 14-16 weeks, when the fetal organs are more developed. The important point to remember: a fetus with a normal (negative) NIPT result can have an anatomic structural malformation. It has been shown that while fetuses with malformations may be at increased risk of chromosomal anomaly, the majority have healthy chromosomes. The diagnosis of a malformation by ultrasound should prompt invasive testing such as CVS or amniocentesis. In some centers, more detailed investigation by chromosomal microarray analysis (CMA), which may discover subtle anomalies, will also be ordered. CMA detects duplicated or deleted chromosomal segments and translocations—rearrangements of chromosomal structure, which may not be evident on traditional karyotyping.

NIPT is a very reliable test. But patients may have a false sense of security regarding their baby’s well-being. A negative NIPT result cannot rule out anatomic structural malformations in the fetus, nor does it rule out all chromosomal anomalies. There is ongoing debate surrounding the integration of NIPT into existing screening programs.

I continued to follow Michele and Dan in the weeks and months that followed. They were, of course, shocked and dismayed by their diagnosis. With Michele at 21 weeks, we immediately arranged multidisciplinary consultation with the cardiologists, who explained the procedures the baby would have to undergo, and how Michele’s plans for the birth would have to change. Prenatal diagnosis of TGA can improve the baby’s surgical outcome, and with prompt intervention, prognosis is excellent. They met with a genetic counselor, and despite Michele’s fears, underwent amniocentesis. CMA is performed in all such cases in our center. Testing ruled out genetic syndromes that we suspected based on the anatomic malformation, none of which could have been diagnosed by NIPT.

With comprehensive information in hand about their baby’s prognosis and the options open to them, Michele and Dan decided to continue the pregnancy, despite the difficult road they knew was ahead. They made arrangements for delivery in the tertiary care center where the baby would undergo surgery, so she would not have to be transferred from their community hospital and would be under constant surveillance. “I fell in love when I first saw the baby’s face in 3D,” she told me. “Whatever comes, we’ll handle it together.”

How do you think NIPT should be integrated into prenatal care? How do you advise your patients who ask about NIPT? Have you encountered patients with negative NIPT results whose fetus has a structural anomaly? Have you encountered patients with false negative or false positive NIPT? Comment below or let us know on Twitter: @AIUMultrasound.

Simcha Yagel, MD, is Head of the Division of Obstetrics and Gynecology Hadassah-Hebrew University Medical Centers, Jerusalem, Israel, and Head of the Center for Obstetric and Gynecological Ultrasound at the Hadassah-Hebrew University Medical Centers, Mt. Scopus, Jerusalem. He served as moderator for a panel discussion, “Noninvasive Prenatal Testing and Fetal Sonographic Screening,” that appeared in the March 2015 issue of the Journal of Ultrasound in Medicine.

Why 76811 Accreditation?

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Starting in 2013, the AIUM and the Society for Maternal-Fetal Medicine (SMFM) co-led a task force of medical societies to explore what distinguished a 76811 examination from the more routine 76805 examination. The result of that task force was the “Consensus Report on the Detailed Fetal Anatomic Ultrasound Examination,” which was published in the February 2014 edition of the Journal of Ultrasound in Medicine.

aium_accredThe report concludes that the 76811 is a distinct examination that requires special expertise. While many obstetricians and radiologists perform the 76805 on a routine basis, the skills and detail required for a 76811 generally require additional training and expertise—frequently through a Maternal-Fetal Medicine fellowship or similar targeted radiology fellowship.

Unfortunately in practice, what constitutes a “detailed obstetrical ultrasound” (or a 76811 examination) varies tremendously. It was for this reason that the AIUM felt it was critically important to promote standardization of what is required of such an examination and work to ensure that individuals performing these are competent and qualified. Additionally, given the move by some payors to reimburse only examinations performed by accredited practices, the AIUM felt it was prudent to have a mechanism in place to accredit practices that would be qualified to perform these examinations before it was directed by the insurers.

To address these concerns the AIUM developed the 76811 accreditation. This new accreditation is an “adjunctive” accreditation for practices that have, or are seeking, accreditation in 2nd/3rd trimester obstetrical ultrasound. It operates very similarly to how 3-D gynecologic ultrasound accreditation is an adjunct to the basic GYN ultrasound accreditation.

If your practice is performing detailed ultrasound examinations for women at high risk of, or who are suspected of having, an anomaly, you should consider adding the 76811 accreditation.

The structure for this accreditation submission is a little different however. Because the consensus statement provided a long list of “always must show” anatomy, and an additional list of “when clinically indicated” anatomy, the accreditation submission must show all of the “always” anatomy on each of the normals, but only needs to show an example of a selection of the “when clinically indicated anatomy” structures on at least one of the studies. In this way, you can exhibit competence getting the views that are occasionally, but not always, needed without having to add a lot of extra views to all of your study submissions.

This newly added accreditation option is live now. The AIUM is excited about letting you demonstrate your expertise so that you can get the credit and recognition that you deserve. Once again, the AIUM is involved in setting the standards for quality, and we know our members are up to the challenge!

Have questions about this new accreditation option? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Dr. David C. Jones is Director, Univerisity of Vermont Medical Center Fetal Diagnostic Center and Professor, Obstetrics, Gynecology & Reproductive Sciences at the University of Vermont, Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Maternal-Fetal Medicine. He serves as Vice Chair of the AIUM’s Ultrasound Practice Accreditation Council.

The Issue with Keepsake Ultrasounds

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Every cousmiling 3rd triple of weeks, the AIUM office receives a call from a reporter asking about keepsake (or entertainment) ultrasounds. Most of these calls result from a keepsake ultrasound facility opening in the community. A number of them came when the FDA reaffirmed its warning against the practice. Occasionally we get the oddball like the one about the ultrasound booth at a flea market.

Regardless of why the AIUM receives the call or inquiry, our response is the same. Since 1999, the AIUM has had the following official position:

“The AIUM advocates the responsible use of diagnostic ultrasound and strongly discourages the non-medical use of ultrasound for entertainment purposes. The use of ultrasound without a medical indication to view the fetus, obtain images of the fetus, or determine the fetal gender is inappropriate and contrary to responsible medical practice. Ultrasound should be used by qualified health professionals to provide medical benefit to the patient.”

AIUM, and a number of other professional associations in the U.S. and other countries, discourage the entertainment use of ultrasound for several reasons, including:

  1. The lack of training of the individuals obtaining the images. When it comes to keepsake ultrasound facilities, there are no regulations governing training requirements for those obtaining the images, either through certification or accreditation.
  2. The concern about potential biological effects that could result from scanning for a prolonged period, inappropriate use of color or pulsed Doppler ultrasound without a medical indication, or excessive thermal or mechanical index settings. As stated in the FDA’s position, “ultrasound can heat tissues slightly, and in some cases, it can also produce very small bubbles (cavitation) in some tissues.”
  3. The potential that pregnant women will visit a keepsake ultrasound facility in lieu of routine prenatal appointments with their medical doctor.

Despite government and medical association warnings against the use of keepsake ultrasounds, the number of facilities performing these scans appears to be increasing. Many theorize that this increase has been driven by the use of 3D ultrasound technology which provides detailed, in-depth images of the fetus and its appeal to expecting parents.

As the number of facilities increases, some states have taken action to ban the practice of keepsake ultrasounds based on the reasons outlined above. In 2009 Connecticut became the first state to ban keepsake ultrasounds. It took 5 years for the second state to take a similar action. Oregon’s law took effect in January of 2014.

Although the issue of keepsake ultrasounds has been around for decades, the recent proliferation of facilities offering this service has prompted action by medical organizations, the federal government, and state governments. Only time will determine the ultimate fate of keepsake ultrasound practices. Until then, the AIUM will continue to advocate for the responsible use of medical ultrasound.

What’s your take on keepsake/entertainment ultrasounds? Comment below or let us know on Twitter: @AIUM_Ultrasound.