Tag Archives: AIUM

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

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

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

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

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

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

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

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

References:

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

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

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

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

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

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

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

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

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

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

Ultrasound: The Therapy of the Future Coming to a Clinic Near You!

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Ultrasound is most commonly known for diagnostic imaging and image-guided interventions, but there is also the potential to harness its power for therapeutic benefits. The use of ultrasound as a therapy is growing, with more than 1,900 active clinical investigations underway. There are also avenues to get insurance reimbursement for the treatment of certain ailments with ultrasound therapy, including bone metastases, essential tremor, and prostate.

In order to help guide physicians that may become involved in the use of ultrasound therapies, the Bioeffects Committee of the American Institute of Ultrasound in Medicine (AIUM) has issued new and updated statements on the AIUM website. These statements help to identify what to consider when using ultrasound therapies, including what happens to the targeted tissue and safety. Some highlights from these statements include:

  • Although safe when used properly for imaging, ultrasound can cause biological effects associated with therapeutic benefits when administered at sufficient exposure levels. Ultrasound therapeutic biological effects occur through two known mechanisms: thermal and mechanical. Thermal effects occur as the result of absorption of ultrasound waves within tissue, resulting in heating. Mechanical effects, such as fluid streaming and radiation force, are initiated by the transfer of energy/momentum from the incident pulse to tissue or nearby biofluids. Indirect mechanical effects can also occur through interaction of the ultrasound pulse with microbubbles such as ultrasound contrast agents. Importantly, thermal and mechanical mechanisms can trigger biological responses that result in desired therapeutic endpoints.
  • The type of bioeffects generated by ultrasound depend on many factors, including the ultrasound source, exposure conditions, presence of cavitation nuclei, and tissue type. Different bioeffects will require different amounts of ultrasound, and thermal and mechanical mechanisms can occur simultaneously for some exposure conditions.
  • There is the possibility of adverse effects in therapeutic ultrasound for targeted and untargeted tissue. Practitioners using these modalities must be well trained on the safe and effective use of therapeutic devices, knowledgeable about potential adverse events, aware of contraindications, and diligent in performing safe procedures. Image guidance should be used to ensure accurate targeting and dosing to maximize the outcomes for patients.

The statements issued by the AIUM’s Bioeffects Committee are intended as baseline considerations when a new therapy device is being put into practice. As ultrasound therapies continue to be adopted into clinical use, the Bioeffects Committee will continue to monitor outcomes in order to inform and educate the community.

Interested in learning more about the bioeffects of ultrasound? Check out the following Official Statements from the American Institute of Ultrasound in Medicine (AIUM):

Preventing Work-Related Musculoskeletal Disorders Among Ultrasound Operators

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Up to 90% of sonographers and other operators of diagnostic medical sonography report having painful work-related injuries affecting the muscles, nerves, ligaments, or tendons.1 These work-related musculoskeletal disorders (WRMSDs) result from the multiple times a day the operators repeatedly make the same movements and maneuvers while performing ultrasound examinations.2 For the ultrasound operator, the most common locations of WRMSDs include the shoulder, neck, wrist, and hands, and the results of WRMSDs can lead to serious health issues, absenteeism, presenteeism, and even leaving the field of ultrasound altogether.3

The following are some of the critical factors that can lead to the development of WRMSDs:

  • Poor ergonomics, including poor posture and machines with poor ergonomic design.3
  • Poor workflow, including the positions of the machine, bed, and workstation, leads to unnecessary arm abduction and overreaching.3
  • Lengthy exams with an increasing workload and number of exams to be performed during the workday.4
  • Inadequate breaks between examinations in addition to an increasing workload.5
  • Psychological stress and psychosocial factors in the workplace.6
  • Unsupportive or inflexible environments that fail to account for the diverse abilities and experiences of individual operators.7

The Occupational Safety and Health Administration has placed the primary responsibility for protecting workers on the employer.8,9 So, when developing WRMSD prevention protocols, administrators should collaborate with ultrasound operators to create policies that support their safety.10 Such policies should take into account scheduling to limit overtime work and provide breaks, staffing levels to optimize patient care, proper ergonomic equipment and adjustable equipment, and room designs that facilitate proper ergonomics, such as adequate space for patients and equipment. The workplace culture should support wellness and also have transparent policies regarding reporting and tracking of WRMSDs.

The operator also needs to ensure their working space is set up in the best manner possible for preventing WRMSDs during their workday. They can do so by customizing their ultrasound environment to promote proper ergonomic technique.

  1. At the beginning of each examination, the operator should properly position and make adjustments depending upon the body habitus of each patient.11 Reaching movements should be avoided by keeping the operator, machine, bed, and patient as close together as possible and at appropriate heights.
  2. The operator’s head and the screen/monitor should be on the same axis, and the eye-screen distance should be at least 60 cm. The top of the screen should be aligned with the level of the operator’s eyes; then, the top of the screen should be tilted back slightly to encourage proper neck posture.11,12
  3. The operator’s neck should be straight, and neck extension should be avoided.6
  4. The operator should be positioned in order to allow the arm to be in a relaxed position with the upper arm close to the body (minimal flexion, ideally abduction <30 degrees) and the elbow at a 90-degree angle, ie, the forearm should be horizontal to the floor allowing the shoulder to remain in a neutral positionwhenever possible.
  5. A “wearable transducer cable support device,”13 such as a cable brace, can be utilized to reduce arm strain during scanning. Also, the ultrasound transducer cable should not be passed around the operator’s neck as any traction force could result in a poor neck position.11,12
  6. A scanning chair should be equipped with a backrest for lumbar support and adjustable height to mold the lumbar lordosis. Moreover, a seatback inclined between 10° and 20° is recommended. The back should be well supported on the seat. A slight gap should remain between the edge of the seat and the back of the knee, and the body should be on the axis of the screen. The chair should be height adjustable so the operator can be properly positioned relative to the patient and ultrasound system. Exam chairs should not have armrests as they may restrict access to the patient.
  7. Exam tables should be height adjustable to encourage proper positioning by minimizing extended reaching, elevated arms, and wrist deviation, and allowing operators to stand and/or sit while performing procedures.
  8. The ultrasound machine keyboard should be easy to move and adjust.
  9. Removing the transducer from the patient and relaxing the hand to allow for brief micro-breaks during the examination can help reduce muscle strain.
  10. With the exception of point-of-care imaging, portable diagnostic exams should be limited to critically ill patients and those patients who are unable to come to the ultrasound department.

Specific types of ultrasound examinations also bring unique challenges. Some of these challenges are addressed, by specialty, in the AIUM Practice Principles for Work-Related Musculoskeletal Disorder.14

Increased awareness of the magnitude of the problem and local quality improvement (QI) efforts are necessary to ensure that these standards are translated into the successful reduction of WRMSDs among ultrasound operators.

A QI program should include ongoing tracking or logging of the following:

  • Ergonomic education for employees
  • Safety and resource utilization
  • Equipment updates
  • The numbers and types of reported symptoms and/or injuries, and
  • Organizational (ie, policies and practices) changes or updates made to improve employee safety and well-being.

A review of these data, along with a status check on overall workplace culture and worker well-being, should be conducted annually. To do so, a QI team composed of individuals from all levels of the organization (eg, administration, management, staff) should review aggregated data from tracking logs and any annual workplace environment reports to identify and prioritize areas for improvement.

The protection of our frontline workforce is paramount in retaining individuals with valuable skills. This protection requires a change in industry mindset that acknowledges the shared responsibility among both employers and ultrasound operators.

This post was created from the AIUM Practice Principles for Work-Related Musculoskeletal Disorder, which was developed by the American Institute of Ultrasound in Medicine in collaboration and with the expressed support of the American College of Emergency Physicians (ACEP), American College of Obstetricians and Gynecologists (ACOG), American College of Radiology (ACR), American Registry for Diagnostic Medical Sonography (ARDMS), American Society of Echocardiography (ASE), Australasian Society for Ultrasound in Medicine (ASUM), Fetal Heart Society (FHS), Intersocietal Accreditation Commission (IAC), International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), Joint Review Committee on Education in Cardiovascular Technology (JRC-CVT), Joint Review Committee on Education in Diagnostic Medical Sonography (JRC-DMS), Perinatal Quality Foundation (PQF), Society of Diagnostic Medical Sonography (SDMS), and Society for Maternal-Fetal Medicine (SMFM). The Practice Principle was developed to expand on the “Industry Standards for the Prevention of Work-Related Musculoskeletal Disorders in Sonography”13 to include safety practices for all health care professionals who utilize ultrasound.

References

  1. Evans K, Roll S, Baker J. Work-related musculoskeletal disorders (WRMSD) among registered diagnostic medical sonographers and vascular technologists. A representative sample. J Diagn Med Sonog 2009; 25:287– 299.
  2. Wareluk P, Jakubowski W. Evaluation of musculoskeletal symptoms among physicians performing ultrasound. J Ultrason 2017; 17:154– 159. https://doi.org/10.15557/JoU.2017.0023.
  3. Bowles D, Quinton A. The incidence and distribution of musculoskeletal disorders in final-year Australian sonography students on clinical placement. Sonography 2019; 6:157– 163. https://doi.org/10.1002/sono.12203.
  4. Gibbs V, Young P. A study of the experiences of participants following attendance at a workshop on methods to prevent or reduce work-related musculoskeletal disorders amongst sonographers. Radiography 2011; 17:223– 229. https://doi.org/10.1016/j.radi.2011.02.003.
  5. Baker JP, Coffin CT. The importance of an ergonomic workstation to practicing sonographers. J Ultrasound Med 2013; 32:1363– 1375. https://doi.org/10.7863/ultra.32.8.1363.
  6. Harrison G, Harris A. Work-related musculoskeletal disorders in ultrasound: can you reduce risk? Ultrasound 2015; 23:224– 230. https://doi.org/10.1177/1742271X15593575.
  7. Chari R, Chang CC, Sauter SL, et al. Expanding the paradigm of occupational safety and health: a new framework for worker well-being. J Occup Environ Med 2018; 60:589– 593.
  8. United States Department of Labor, Occupational Safety and Health Administration. Ergonomics website. https://www.osha.gov/ergonomics. Accessed November 12, 2021.
  9. United States Department of Labor, Occupational Safety and Health Administration. Solutions to control hazards website. https://www.osha.gov/ergonomics/control-hazards. Accessed November 12, 2021.
  10. United States Department of Labor, Occupational Safety and Health Administration. Identity problems website. https://www.osha.gov/ergonomics/identify-problems. Accessed November 12, 2021.
  11. Rousseau T, Mottet N, Mace G, Franceschini C, Sagot P. Practice guidelines for prevention of musculoskeletal disorders in obstetric sonography. J Ultrasound Med 2013; 32:157–164. https://doi.org/10.7863/jum.2013.32.1.157.
  12. BP Bernard (ed). Musculoskeletal Disorders and Workplace Factors; A Critical Review of Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back. U.S. Department of Health and Human Services July; 1997 DHHS (NIOSH) Publication No. 97B141.
  13. Industry standards for the prevention of work related musculoskeletal disorders in sonography. J Diagn Med Sonogr 2017; 33:370–391.
  14. AIUM practice principles for work-related musculoskeletal disorder [published online ahead of print January 24, 2023]. J Ultrasound Med. https://doi.org/10.1002/jum.16124.

When Data Isn’t Enough!

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“I’m looking for volunteers, not hostages.”
            — Mike Tomlin (Head Coach of the Pittsburgh Steelers Football Team)

I enjoy quotes that help keep things in perspective (even though I’m more an ice hockey fan than an American football fan), and I could have used coach’s advice after my Emergency Ultrasound Fellowship concluded in 2002. I believed, then, that every Emergency Physician would find the allure of ultrasound’s rapid, portable diagnosis irresistible and abruptly begin using it. A string of successful research and equally enthused editors would publish article after article and ease the path to acceptance of “emergency medicine ultrasound” or “point-of-care ultrasound” (POCUS).

As if data would impose ultrasound adoption.

The hard pivot did not come as quickly as I hoped. As an example, my early work examined how ultrasound improved the safety of central venous cannulation. The fields of Anesthesia and Interventional Radiology learned this years before Emergency Medicine, and it seemed natural that, once adopted, finding a vein with ultrasound anywhere would prove too irresistible for the Emergency Physician to pass up.

I soon discovered that trainees embraced ultrasound (they knew no alternative) but more experienced providers passed on it, stubbornly reverting to what they found more comfortable. They rationalized that learning something new disrupted their workflow. Besides, their cases rarely had complications.

Make no mistake, youth alone would not resolve the disrupted workflow dilemma. A few years later, motivated by the work of Peter Pronovost in intensive care units and championed by Atul Gawande’s Checklist Manifesto, my research team attempted to incorporate ultrasound-guided central line checklists in the Emergency Department to decrease central line-associated bloodstream infections. After presentations at journal club and grand rounds, we measured checklist adherence at exactly zero! I distinctly remember trainees’ wry joy in seeing my face as the paper with the printed checklist was ceremoniously discarded, the central line expertly inserted under ultrasound, and the patient stabilized. The academic journals and even the lay press had done their part disseminating the new information but implementation of a checklist…that was a new challenge unto itself.

Examining what changes behavior in healthcare feels like psychoanalysis. Lesson one is we’re not rational beings moved by published data. The AIUM promotes guidelines, education, and training, and offers a stage to persuade and model the benefits of ultrasound-assisted medicine. But is this enough?

The growing field of Implementation Science suggests there’s more to do. A salient theory pertinent to changing behavior in health care is known as the COM-B system. Capability, Opportunity, and Motivation are essential conditions that underpin Behavior. In our checklist example, we possessed the capability and opportunity but the motivation was so low it sank adoption. Behavior didn’t change. Data was not enough.

Our team, led by Dr. Enyo Ablordeppey, took a different approach to adopting new ultrasound techniques, which we presented at AIUM 2022 in San Diego. Before we imposed confirming central line placement solely by ultrasound, precluding the chest x-ray and saving radiation exposure, we worked backward from COM-B to create a framework of interventions. We gathered the group of end-users and began by listening to them. Out of these sessions, we developed seven strategies:

  1. Training
  2. Supervision
  3. Feedback
  4. Organizational buy-in
  5. Decision support
  6. Planned adaptation (ie, prizes for, and promotion of, early adopters)
  7. Algorithm development

Our program to De-Implement Routine Chest Radiographs after Adoption of Ultrasound Guided Insertion and Confirmation of Central Venous Catheter Protocol is called DRAUP. It’s a mouthful and a mound of work but, 6 months into it, we increased ultrasound adoption and decreased chest x-ray utilization by 50% with identical complication rates to conventional behavior. For comparison, 10 years later, we still don’t utilize the central line insertion checklists!

At the root of it, implementing innovative ultrasound requires addressing an interplay of environmental, cognitive, sensory, and emotional processes. All ultrasound users have experienced the implementation challenge when an innovation seems blithely disregarded despite impact. Procedural guidance, nerve blocks, spectral Doppler diagnostics (all topics expertly covered in San Diego at AIUM 2022) lack traction despite concluding slides with imperceptible font sizes to document volumes of references!

Why isn’t the evidence enough? Perhaps we’ve taken the wrong approach? Perhaps we need to uncover barriers from our non-ultrasound using hostages and promote facilitators from our ultrasound volunteers! What’s worked at your shop?

A headshot of Dr. Daniel Theodoro, MD, MSCI.

Dr. Daniel Theodoro, MD, MSCI, is the Division Director of Washington University’s Emergency Medicine Ultrasound Program. In 2002, he completed the first Emergency Medicine Ultrasound Fellowship at North Shore University Hospital in Manhasset, New York. His team’s current projects include how to de-implement dogmatic chest x-rays after ultrasound-driven central line placement confirmation, how well COVID lung findings prognosticate future oxygen requirements, and how TEE can inform CPR quality. Tweet him @TeddyDanielz!

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

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:

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:

Access the Portal Venous System Safely

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Transjugular intrahepatic portosystemic shunt (TIPS) placement is a well-studied procedure for patients with variceal bleeding, refractory ascites, and hepatic hydrothorax on optimal medical therapy. Despite its efficacy, TIPS remains one of the more technically challenging procedures, particularly related to safely gaining access into the portal venous system.

A typical TIPS procedure involves internal jugular venous access, hepatic vein catheterization, venography, and wedged CO2 portography, and the most challenging step—retrograde portal vein access prior to tract dilatation and stent placement. When using CO2 portography as a landmark for portal venous access, usually several needle passes are required and each additional needle pass increases the risk of adverse events, such as hepatic artery injury, hemobilia, and damage to surrounding structures (kidney, colon, and lung parenchyma).

There have been multiple ways to mitigate this issue, such as biplanar angiography, percutaneous transhepatic guidewire placement within the portal venous system, and cone-beam CT guidance. These methods have had various successes but may require increased procedure time, increased radiation dose, or alternative access sites (for example when placing a microwire into the portal venous system via the transhepatic route).

In our opinion, the best solution for accessing the portal venous system during the TIPS procedure is using intravascular ultrasound guidance with a side-firing intracardiac echocardiographic tip (ICE). The benefit of having ICE guidance is intuitive: it allows for direct visualization of the portal venous target, proper selection of the closest hepatic vein to the respective portal vein, and needle guidance using real-time ultrasound visualization. Therefore, ICE guidance reduces the number of needle passes, the risk of hitting critical structures, and the length of the procedure. Previously, ICE guidance has proven its worth in managing complicated TIPS cases, such as portal vein thrombosis, distorted anatomy from prior surgery or neoplastic disease, as well as TIPS for Budd-Chiari syndrome (direct IVC to portal venous access in these cases).

There have been a few retrospective investigations comparing fluoroscopic guidance to ICE guidance for the TIPS procedure. In a study by Kao et al., the authors did a retrospective comparison between ICE and fluoroscopic guidance. It is interesting to note that the ICE operators were only 2 and 3 years out of fellowship versus 20+ years of experience in the conventional group. The data showed that ICE catheter guidance significantly decreased the number of needle passes, contrast volume, fluoroscopy time, procedure time, and radiation exposure. More importantly, ICE largely reduced the number of “outliers” —those occasional cases in which 30+ needle passes and a few hours of fluoroscopy times are required. It is likely in clinical practice that exactly these outlier cases drive up complication rates.

In a different study, by Ramaswamy et al., the authors did a propensity-matched retrospective review. The data showed the procedure time and outcomes were not significantly different between ICE and conventional techniques. However, there was a significant reduction in contrast volume and radiation in the ICE guidance group. The major caveat of the study was that the ICE operators were much earlier in their career than the conventional group, with an average experience of 4.2 years versus 11 years. The difference in operator experience probably indicates that ICE has the potential to decrease the procedure time when adjusted for operator experience.

Based on the available retrospective studies and our experience, a few points can be confirmed.

  1. ICE decreases the number of needle passes, radiation exposure (to both the patient and operator), and contrast volume.
  2. ICE most likely decreases the procedure time, accounting for differences in operator experience.
  3. ICE will largely eliminate outlier cases that are more likely associated with complex anatomy/clinical scenario and have a higher potential to cause major complications.

In our experience, ICE catheter guidance makes the procedure safer in tough situations. Of course, ICE adds costs (~ $1,000/probe). The modality has a pretty steep learning curve, and it requires an additional venipuncture. In addition, the (more inexperienced) conventional operator can achieve excellent results in routine and/or complex scenarios without using ICE.

In our view, ICE guidance is most helpful in dealing with complex TIPS cases in which a large number of needle passes are expected and complications are frequent. Furthermore, it offers a back-up option when a conventional TIPS procedure runs into unexpected challenges. Instead of blindly sticking another 20 times, we should become familiar with using the available tool (ICE catheter guidance) in our procedural arsenal to provide a safer experience for our patients, ultimately improving outcome in the end-stage liver disease population.

This is a patient referred for re-attempt TIPS from an outside hospital, where multiple attempts of accessing the portal venous system have failed and, therefore, TIPS procedure in the outside hospital had to be aborted. Image A shows the access needle (skinny arrow) directed from the hepatic vein towards a right portal branch (fat arrow). Image B shows the access needle and Bentson guidewire (skinny arrow) within the same right portal branch (fat arrow), indicating successful cannulation. Image C confirms the guidewire (white circle) advanced into the main portal vein. Image D shows the TIPS stent connecting the right portal vein (arrow) with the hepatic vein with free flow of contrast. Portal access was successful on the second puncture with ICE guidance for this (challenging) re-attempt TIPS procedure.

All comments are welcomed; Sasan Partovi can be reached at partovs@ccf.org.

References:

Ramaswamy RS, Charalel R, Guevara CJ et al. Propensity-matched comparison of transjugular intrahepatic portosystemic shunt placement techniques: Intracardiac echocardiography (ICE) versus fluoroscopic guidance. Clin Imaging. 2019; 57:40–44.

Kao SD, Morshedi MM, Narsinh KH, Kinney TB et al. Intravascular Ultrasound in the Creation of Transhepatic Portosystemic Shunts Reduces Needle Passes, Radiation Dose, and Procedure Time: A Retrospective Study of a Single-Institution Experience. JVIR. 2016; 27:1148–1153.

Sasan Partovi, MD, is a staff physician in interventional radiology at The Cleveland Clinic Main in Cleveland, Ohio. Dr. Partovi’s research interests are focused on innovative endovascular treatment options for end-stage renal disease and end-stage liver disease patients. Dr. Partovi has been elected as secretary of the American Institute for Ultrasound in Medicine’s (AIUM’s) Interventional-Intraoperative Community of Practice.

Xin Li, MD, is a radiology resident at the Hospital of the University of Pennsylvania in Philadelphia, Pennsylvania. Dr. Li attended Case Western Reserve University School of Medicine in Cleveland, Ohio, and is pursuing a career in interventional radiology. He currently serves on the Resident, Fellow, and Student Governing Council of the Society of Interventional Radiology.

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

A Loss of Great Magnitude

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Good-bye, Harvey Leonard Nisenbaum, MD

Head shot of Harvey Leonard Nisenbaum, MD, FACR, FAIUM, FSRU.

We have lost a leading expert in ultrasound education, AIUM Past President, Harvey Leonard Nisenbaum, MD, FACR, FAIUM, FSRU, who died on October 8, 2020.

Dr Nisenbaum was a leader in the field of ultrasound even just out of school, when, after completing his residency in diagnostic radiology at Montefiore Medical Center in the Bronx, New York, he became a lieutenant commander in the U.S. Navy and served as the director of ultrasound at the former Naval Regional Medical Center in Philadelphia until 1976. That is when he joined the faculty of Albert Einstein Medical Center in Philadelphia, where he became the head of the Ultrasound section, acting chairman of Einstein’s Department of Radiology, and president of the medical center’s staff.

Dr Nisenbaum couldn’t help but share what he knew to encourage the next generation of ultrasound advocates. And, in 1993, enabling him to connect with more students, he moved on to the Department of Radiology at the University of Pennsylvania Perelman School of Medicine and, ultimately, chairman of the Department of Medical Imaging at Penn Presbyterian Medical Center (PPMC) from 2001 to 2018 and Emeritus Associate Professor CE of Radiology.

“Under his leadership, the Department introduced tremendous scientific advances in Medical Imaging into clinical practice and greatly expanded its contribution to the hospital’s mission.”

— Penn Presbyterian Medical Center

To honor his legacy, they will award the Harvey Nisenbaum Award for Medical Imaging Research at PPMC for the first time in 2021, which Dr Nisenbaum learned of before his passing. The award will recognize medical students, residents, and fellows who continue his legacy at the Department of Medical Imaging by creating new scientific intelligence through research. He had also earned a Special Dean’s Award for his help in developing and implementing the ultrasound curriculum for the Perelman School of Medicine.

Dr Nisenbaum was an active volunteer, he served on numerous committees, both at his hospital and for the many societies and organizations to which he was a member, including the American Institute of Ultrasound in Medicine (AIUM), which he joined in 1975. By 2009, he became President of the AIUM. During his tenure, donations to the Endowment for Education and Research to increased significantly, AIUM membership grew by 11%, and the online Career Center was launched as a new member benefit. Dr Nisenbaum was awarded the AIUM Presidential Recognition Award (twice; in 2006 and in 2012), and the Peter H. Arger, MD, Excellence in Medical Student Education Award (2020), which honors an individual whose outstanding contributions to the development of medical ultrasound education warrant special merit. Dr Nisenbaum earned this award for being instrumental in incorporating ultrasound into medical school curricula.

The Society of Ultrasound in Medical Education (SUSME), presented Dr Nisenbaum with the SUSME Legacy Award in 2013 for his outstanding contributions to ultrasound education. He served as president of the World Federation for Ultrasound in Medicine and Biology (WFUMB; 2015–2017), during which time 3 Centers of Education were created, in Paraguay, Moldova, and Sudan. Following his presidency, in 2018, he took a year-long sabbatical to volunteer even more of his time organizing projects to bring ultrasound to underserved countries.

In addition to these worldwide contributions, Dr Nisenbaum was also a past-president of the Pennsylvania Radiological Society, the Philadelphia Roentgen Ray Society, and the Greater Delaware Valley Ultrasound Society.

Dr Nisenbaum’s enthusiasm for ultrasound education along with his vast well of ultrasound knowledge and his willingness to share it have influenced countless students, physicians, and other medical professionals. He will be sorely missed.

Clear Reporting About Adnexal Torsion

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The Challenge: “Can you please rule out torsion?” is a common request ED teams have of their radiologists and gynecologists. Unfortunately, a straightforward answer to this question is rare. The diagnosis of adnexal torsion is full of uncertainty and to make matters worse, we humans are terrible at communicating uncertainty.

Indeed, there are pathognomonic sonographic findings of torsion– whirlpool sign and/or absent flow in the setting of an enlarged, edematous ovary. But certainty is rare. Thus, many reports hedge that “torsion cannot be ruled out.”

We acknowledge that the radiologist interpreting the images is not at fault for this uncertainty. The issue is that the tool itself is imperfect. Ultrasound, as a test, is great at “ruling things in,” but quite mediocre at “ruling things out.” And torsion, as we know, is a surgical diagnosis. However, going to the OR means subjecting a patient to the potential risks of surgical complications, “tying up” healthcare resources, and is expensive.

The Crux: Most imaging is helpful to “rule in,” NOT “rule out” a diagnosis. The complexity and uncertainty of pelvic ultrasonography in the evaluation of women with acute pelvic pain in and of itself is challenging. On top of that, how do we best communicate the uncertainty of NOT seeing something – like looking for a black cat in a dark room — is it even there?

The language we use in ultrasound reports can further complicate the situation. This is especially true when images are interpreted out of context, and a broad differential diagnosis offered. There are incidental findings in asymptomatic patients that warrant further evaluation in the outpatient setting, and there are others that require emergent evaluation in the correct clinical context. A cyst or mass may be an incidentaloma. Torsion is not.

The verbiage used in reports carries significant weight in clinical decision-making and management. When humans read “cannot rule out xyz,” they usually interpret this (for better or worse) as “xyz should be ruled out.” And so, we would love to start a conversation about the linguistics of report-writing for female pelvic ultrasonography.

Cases: Here are a couple of clinical scenarios that illustrate our concern:

  1. A 14-year-old female patient presents to the ED with right upper abdominal and flank pain. Her ultrasound was performed to evaluate the kidneys (area where pain was originating from), however, it also demonstrated an enlarged right ovary (4.9 cm in largest dimension). The report reads “intermittent torsion cannot be excluded.” We agree; it in fact cannot. However, now intermittent torsion MUST be excluded, and we are consulted.

The patient’s lower abdominal examination is benign. Our suspicion for torsion is exceedingly low. However, ultrasound cannot rule out torsion, only surgery can rule out torsion. Now this teenager has been given an additional, unrelated stressor (“your ovary can die”) that was unlikely to ever have significant medical repercussions. To top it off, the report recommends a follow-up scan at 8–12 weeks for what appears to be a physiologic hemorrhagic corpus luteum — an additional expense and time taken from the patient and her family to follow-up.

Final Diagnosis: Pyelonephritis

  1. A 43-year-old female patient scheduled for hysterectomy later in the month presents to the ED with persistent left lower quadrant pain that has been present for several weeks. She has a long-standing history of fibroids and was diagnosed with a 5-cm anechoic left ovarian cyst 2 months ago. Ultrasonography re-demonstrates a leiomyomatous uterus and the left ovary was not visualized.

The report reads “torsion of the left adnexa could not be excluded.” Agreed, it in fact cannot. However, the reason why it cannot be excluded is not that the ovary was not visualized. Additionally, torsion could not be excluded because ultrasound is NOT a test to exclude torsion.  

On examination, there was focal tenderness and point-of-care ultrasonography confirmed its location over a pedunculated fibroid (likely degenerating). An overnight, unscheduled diagnostic laparoscopy, in this case, would’ve resulted in a reassuring adnexal evaluation and possible myomectomy, not the procedure the patient truly needed (a laparoscopic hysterectomy).

Final Diagnosis: Degenerating fibroid (noted on hysterectomy later that week)

Why now?

Prior to COVID-19, healthcare overutilization and defensive medicine were problematic. Now, with limited resources and increased demand, the burden is even higher. ER providers, gynecologists, and radiologists must work in tandem to:

  1. prioritize imaging studies when relevant,
  2. report in clear, objective language in the context of the clinical scenario, and
  3. prioritize emergency and inpatient consultations.

Why does this matter?

Most imaging is helpful to “rule in,” not “rule out” a diagnosis. Language and semantics may significantly affect management, especially in the context of less experienced providers. For patients, it may mean the difference between an unscheduled abdominal surgery or observation. In our prior commentary (1) we referenced the language used by our obstetrics colleagues wherein they acknowledge the limitations of the imaging modality and thus, we suggest the following modification to the current style of reporting:

“Ultrasound is not intended to rule out ovarian torsion.”

We understand that this suggestion, for some, is a change of established practice patterns and we would love to hear your thoughts. Please leave comments below or tweet at @StethoscopeOn and @Dmitry_Fridman to continue the conversation!

Reference

  1. Meljen V,  Fridman D. Gynecologist’s Perspective: Semantics of “Ruling Out” Ovarian Torsion. J Ultrasound Med 2020; 39:1013. Available at: https://onlinelibrary.wiley.com/doi/10.1002/jum.15175.

Vivienne Meljen, MD, is a resident, and Dmitry Fridman, MD, PhD, is an Assistant Professor of Obstetrics and Gynecology, in the Department of Obstetrics and Gynecology at  Duke University Health System in Durham, North Carolina, USA.

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

To Treat or Not to Treat – That is the Question!

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What if your newborn has a patent ductus arteriosus?

Some might ask, what is a ductus arteriosus?

During fetal development, a patent ductus arteriosus (PDA, see Figure) is important for diverting well-oxygenated blood returning from the placenta past the fluid-filled lungs and directly into the systemic circulation in order to perfuse organs.

Blood Flow with Patent Ductus Arteriousus

A patent ductus arteriosus allows for diverting aortic blood to flow into the lungs and thus pressurize the pulmonary circulation as well as allow for deoxygenated blood to enter into the aortic arch if the flow is reversed. Very low birth weight infants are prone to this condition and choice of appropriate treatment is in question. Image provided by Blausen.com.(4)

In full-term newborns, the PDA closes within two days of birth by means of vasoconstriction and anatomic remodeling.(1) Or it doesn’t. In 65% of premature infants born at 30 weeks’ gestation or less, the PDA fails to close within the first 7 days.(2, 3) Therefore, the pulmonary and systemic circulations remain connected. Consequently, blood is shunted away from the general systemic circulation to the lungs and can lead to severe flow-related problems such as central nervous system ischemia and hemorrhage, necrotizing enterocolitis, and renal failure. Such a Patent Ductus Arteriosus (PDA) leads to the ultimate question of to treat or not to treat? The two schools of thought in neonatology are watchful waiting, treating with nonsteroidal anti-inflammatory drugs (NSAID) or an invasive procedure to close the ductus.

Possible concerns are multifactorial. Intervention risks side effects from medications and procedural complications. Watchful waiting risks diminished blood and oxygen supply to the brain and abdominal organs. Quantifying blood flow and oxygen supply in these fragile humans is nearly impossible, especially since most of them are actually very low birth weight babies (VLBW, i.e. <1,500 grams). They are tiny.

In rare cases, clinicians use MRI to image and quantify PDA and carotid flow. That, however, requires specialized facilities in which the neonates can remain in their protective incubators while being in the magnet.

Imagine you could use ultrasound to assess not only the PDA but also the blood flow to the brain and the abdomen. Ultrasound is the ideal modality as it is non-ionizing, can be used at the bedside and is already a part of neonatal care. Yet, assessing blood flow quantitatively using 2D pulsed-wave ultrasound has been a challenge in and of itself. It not only requires user-selected angle correction as well as lumen diameter measurements but also neglects flow outside of the 2D image plane. Others may use simple velocity measurements or surrogate markers, but those do not represent flow.

A possible solution has been proposed by our group at the University of Michigan (UM). It is using 3D ultrasound to employ Gauss’ Theorem to quantify flow. While high-frequency ultrasound is excellent for VLBW babies, imaging a 1-mm diameter PDA lumen may still be a challenge. The UM team has previously shown the benefits of 3D color flow for quantification of blood flow. We hypothesize that even a PDA lumen could be assessed accurately, despite its challenging diameter. In addition, if successful, clinicians should be able to measure flow in the PDA within 6 seconds after obtaining a cross-sectional color flow image of the PDA with minimal to no user dependence. This presupposes a 2D matrix array capable of recording 5 color flow volumes per second.

In an American Society of Echocardiography (ASE) and AIUM co-sponsored investigation (E21 and EER funding), we will assess the effects of PDAs before and after treatment. Baseline blood flow for cardiac output, total brain blood flow, blood flow to the small intestines, and renal blood flow will be determined in full-term healthy neonates. An inter- and intraoperator variability study will be employed to warrant scientific rigor and target an end-organ flow estimation with <10% variation for test-retest and <10% between operators. Blood flow measurements in VLBW cohorts scheduled for intervention will yield estimates before and after intervention and thus provide insight in the predictive value for this method.

The ultimate goal is that 3D ultrasound will help caregivers to determine if adequate flow to end organs exists and if intervention is required. Furthermore, stable and unstable VLBW cohorts can possibly be differentiated by their flow to end organs and through the PDA. Thus, answering the question of whether to treat or not to treat.

Principle Investigators: Oliver D. Kripfgans, Ph.D. and Jonathan M. Rubin, M.D., Ph.D.
Co-Investigators: Gary Weiner, M.D. and Marjorie C. Treadwell, M.D.

References:

  1. Deshpande P, Baczynski M, McNamara PJ, Jain A. Patent ductus arteriosus: The physiology of transition. Semin Fetal Neonatal Med 2018;23(4):225–231. doi: 10.1016/j.siny.2018.05.001
  2. Clyman RI, Couto J, Murphy GM. Patent ductus arteriosus: are current neonatal treatment options better or worse than no treatment at all? Semin Perinatol 2012;36(2):123–129. doi: 10.1053/j.semperi.2011.09.022
  3. Egbe A, Uppu S, Stroustrup A, Lee S, Ho D, Srivastava S. Incidences and sociodemographics of specific congenital heart diseases in the United States of America: an evaluation of hospital discharge diagnoses. Pediatr Cardiol 2014;35(6):975–982. doi: 10.1007/s00246-014-0884-8
  4. Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.

 

Oliver D. Kripfgans, PhD, FAIUM, is a Research Associate Professor in the Department of Radiology at the University of Michigan. Jonathan Rubin, MD, PhD, FAIUM, is a Professor Emeritus in the Department of Radiology at the University of Michigan.

 

Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

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