Dating Pearls

Assisted reproductive technology (ART) dating trumps all other sonographic dating. If the dating is off with ART, think about asking if the embryo was put in the uterus at 5 days, and not zero days, as that is how it is often calculated. This can be important if the embryo is larger than expected, as ART pregnancies have an increased incidence of Beckwith Weidman Syndrome, which is an overgrowth syndrome. If the embryo is smaller than expected, then the embryo should be followed more closely for possible congenital or chromosomal anomalies.

If the pregnancy is not ART, dating should be based on the 2014 ACOG/AIUM Committee Recommendations (Methods for Estimating the Due Date. Committee Opinion No, 700. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017; 129:e150–154).

Measurement of the embryo or fetus in the first trimester is the most accurate method to determine gestational age. In the first trimester, the 2014 Recommendations state that if the pregnancy is less than 8 weeks 6 days, the embryo should be within 5 days of LMP (last menstrual period) and otherwise should be re-dated using ultrasound dates of the crown rump length. One mistake often made at this time is to include the gestational sac size in dating; the crown rump length is more accurate than the sac size and thus it should not be averaged into the estimated gestational age.

Crown rump length growth curves have been updated by Pexsters et al (Ultrasound Obstet Gynecol 2010; 35:650–655) using 4387 exams, whereas Hadlocks curves (Hadlock et al Radiology 1992; 182:501–505) were only based on 416 exams. These have some significant discrepancies in the 5–7 weeks gestational age range so we recommend using the Pexsters curves.

Crown Lump Length

From 9 weeks to 16 weeks 6 days, the 2014 Recommendations suggest that the dating should be within 7 days and be re-dated if greater than “7-day” discrepancy.

From 16 weeks to 21 weeks 6 days, the 2014 Recommendations suggest that the dating should be within 10 days and be re-dated if greater than “10-day” discrepancy.

From 22 weeks to 27 weeks 6 days, the 2014 Recommendations suggest that the dating should be within 14 days and be re-dated if greater than “14-day” discrepancy.

From 28 weeks and beyond, the 2014 Recommendations suggest that the dating should be within 21 days and be re-dated if greater than “21-day” discrepancy.

We should not re-date a pregnancy in the second or third trimester if there are good ultrasound dates in the first trimester. If the patient gives “excellent dates” based on history (eg keeping a temperature chart, knowing date of conception based on specific dates of being with partner) and there is a greater than expected discrepancy of dates, then a follow-up sonogram should be recommended in 2–4 weeks, depending on the time of gestation (4 weeks in the second trimester and 2 weeks in the third trimester) so that appropriate growth can be assessed.

Serial growth is important in assessing dating. A fetus that grows 4 weeks in a 4-week period is likely dated appropriately. When the fetus grows more than 4 weeks in a 4-week period then accelerated growth should be reported, suggesting either an LGA (large for gestational age) or macrosomic fetus. History of prior pregnancies can be particularly helpful in these cases. Placement of the calipers at the outer edge of the subcutaneous tissue is particularly important in these cases. We often require 3 measurements, which are averaged to assess LGA/macrosomic fetuses.

When fetuses grow less than 4 weeks in a 4-week period then SGA (small for gestational age) or IUGR (intrauterine growth restriction) are suspected. Additional studies for well-being should be performed, such as umbilical artery Doppler, middle cerebral artery Doppler, maximum vertical pocket of amniotic fluid, biophysical profile, cerebroplacental ratio (CPR), or antenatal testing.

 

Do you have any tips on sonographic dating? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Dolores H. Pretorius, MD, is a Professor of Radiology at University of California, San Diego, and Director of Imaging at UC San Diego Maternal-Fetal Care and Genetics, an AIUM-accredited practice.

Andrew D. Hull, MD, is a Professor of Clinical Reproductive Medicine at University of California, San Diego, and Director of UC San Diego Maternal-Fetal Care and Genetics, an AIUM-accredited practice.

Do You Allow Patients to Video?

An expecting new mother comes into your practice for a routine ultrasound exam. During the exam she pulls out her cell phone to capture a few photos and maybe a short video. What do you do?

As cell phone use has become ubiquitous, the AIUM has been receiving more and more calls and messages asking about cell phone use policies during obstetric exams. Practices are searching for guidance on how to set such a policy and what should be included.

To get a sense of how practices are dealing with this issue, last month, the AIUM sent a short survey to 1,652 individuals in 1,138 AIUM OB-accredited practices. Nearly 22% of recipients completed the survey.

video

Allow patients to record exams?

According to the results, 88% said their practice does not allow videotaping during OB exams. However, only 51% said their practice has a written policy that supports this.

Why Have a Policy?
Those practices that forbid or restrict videotaping do so for a number of reasons. Some of the most commonly cited reasons include:

policy

Written policy in place?

  • It is distracting. Several respondents mentioned that having people videotaping is very distracting to the sonographers and physicians who are trying to conduct a medical examination. To help these individuals focus on medical care, videotaping is not allowed.
  • Legality. In order to protect the patient’s medical information and staff identity, practices do not allow videotaping.
  • Findings. When a sonographer or physician begins an examination, they do not know what they might find. To avoid the widespread sharing of unread studies or potentially personal information or decisions, practices ask that patients keep their phones off.

Enforcement
While nearly half of AIUM-accredited practices stated they do not have a written policy, there are several ways in which patients are told or asked to refrain from videotaping. Those methods include:

  • Information in new patient packages
  • Signs posted throughout the practice: waiting rooms, exam rooms, on the ultrasound machines
  • Verbal statements from sonographers and physicians

Even using these methods, survey respondents acknowledge that enforcement is difficult because people still pull out their phones and hit record. Some practices do empower their employees by allowing them to stop the exam should a visitor not comply with the videotaping rules.

When Is It OK?
Of those practices that allow videotaping, most have rules about when and how it is allowed.

  • Some practices allow short videos showing certain anatomy.
  • Others state that patients can’t videotape staff or require that staff stay silent when patients are videotaping.
  • In some practices, the sonographers and physicians use their discretion to control when and for how long videotaping can occur.
  • Others allow unlimited videotaping after the diagnostic portion of the exam.
  • Some practices will allow FaceTime (non-permanent) video during the exam but prohibit permanent videotaping.
  • And still others are completely open and allow the entire exam to be videotaped.

Even among those practices that forbid videotaping, some may be allowed. The typical exceptions are for deployed parents or foreign parents of a surrogate. Many practices mentioned that they try to avoid the videotaping issue altogether by stating their policy and then following that by telling the patient they will supply some pictures or short video clips.

What can you do?
If your practice is looking to set a policy or even seeking resources to support your policy, here are some items that might help.

  • Legal Counsel—If you are concerned about the legal aspect of allowing videotaping, or you are looking to set an official policy, seek legal advice and counsel.
  • AIUM’s Keepsake Imaging Official Statement—This resource may help you in framing your policy, and it serves as a great document to share with patients.
  • HIPAA—Several practices mentioned HIPAA compliance in their policies or statements as a reason for not allowing the use of videotaping during exams.
  • Consent Law—In setting your policy, you may have support through your state’s consent laws.

In most cases, obstetric patients are not videotaping with ill intent. But as physicians and sonographers, there are legitimate and medical reasons to consider whether your practice should institute a policy on the use of videotaping equipment. While it can be a challenge to balance legal liability, best practice guidelines, and customer service, working with your staff, your legal counsel, and your customers, you can create a policy that works for all.

Obstetric Ultrasound: Tips for Sharing Outcomes With Your Patient

“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

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

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

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

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.