Pre-eclampsia, Growth Restriction, and a Placenta Bank

Our Maternal-Fetal Medicine fellow was talking about a delivery that occurred while I was away. The fetus was growth-restricted and developed worsening indices on Doppler ultrasound of the umbilical arteries. What was initially an increased Systolic/Diastolic ratio became first absent and then reversed end-diastolic flow. As this occurred over several weeks, the patient herself had worsening blood pressures and symptoms related to her pre-eclampsia and the fetal tracing became more concerning. She was ultimately delivered and her tiny and premature baby was now in the care of the neonatologists.201500581_Hill-7

The fellow’s presentation focused on the ultrasound findings and the surveillance of pregnancies that become complicated in this way. What was known was the best current management in this case. The unknown was why this had happened in the first place. I was about to interrupt the presentation when our fellow, knowing what I was going to ask, looked over at me and said “Yes, I did collect the placenta.”

Pre-eclampsia is a common condition and growth restriction, by definition, occurs in 10% of pregnancies. The conditions are highly related. We have risk factors for both, but we seldom know the cause. Our treatments seem crude to a bench researcher; try to control the condition as long as you can, and if either patient or her fetus becomes too sick, deliver the pregnancy.

As an obstetrics and gynecology resident I was fascinated by developmental programming in these fetuses and sent in a grant application to the American Institute of Ultrasound in Medicine requesting seed funding to look at the hormonal associations with growth restriction. Their contribution to my research was a turning point for me. I had always thought of myself as a clinical researcher and this was my first exploration of translational research. During my fellowship in Maternal-Fetal Medicine I collected ultrasound data on growth restricted pregnancies and sampled placentas and cord blood from the pregnancies when they delivered. What I had thought would be a one-off project became a jumping off point for continued exploration into placental biology.

Five years later, I have established a placenta bank at the University of Arizona. What was a small study focusing on just one condition has inspired the creation of a bigger project. Our residents and fellows now contribute to the bank and have the ability to answer their own questions with the samples already collected. The bank is a resource to all of us and has fostered collaborations with the University of Arizona Biorepository and the department of Animal and Comparative Biomedical Sciences. My initial work focused on changes in leptin, renin, and C-reactive protein in cord blood, but as I learned more, the objective changed to include RNA analysis of the placental tissue. We noted that the structural protein expression was different in the growth-restricted pregnancies. This has led to the proposal of a whole different model regarding the causation of preeclampsia and growth restriction.

We will wait and see how this baby does in the neonatal intensive care unit. As we go about our conservative management until the risk becomes too great to continue, it is a comfort to know we are looking for reasons; if we understand possible mechanisms better, there is the potential to mitigate or reverse the development of fetal and maternal morbidities.

 

How has ultrasound shaped your career? Has an ultrasound study led you down an unexpected path? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Meghan Hill, MBBS, is Assistant Professor at The University of Arizona College of Medicine, Department of Obstetrics & Gynecology.

Determining Umbilical Cord Blood Flow

Umbilical cord blood flow is among the most highly desired parameters for monitoring fetal well-being. This is because cord blood flow directly reflects placental volume flow, which is considered to be as important in the fetus as cardiac output and lung perfusion are in adults.1 Yet, presently employed noninvasive methods, such as umbilical artery Doppler waveform analyses, use surrogate flow evaluation parameters, such as systolic/diastolic ratios, which do not directly reflect placental-fetal blood flow.2,3 Volume flow estimation overcomes this by measuring true flow, and it has been shown that volume flow changes in the umbilical vein occur before umbilical artery flow indices become abnormal.4

Yet, the present volume flow measurement method has severe problems limiting its utility. These include technical difficulties in flow measurement in umbilical cords and faulty assumptions employed in the measurement. The present method using spectral Doppler is

                 Q = V × A                    (1),

where Q is volume flow, V is the mean velocity through the Doppler sample volume, and A is the cross-sectional area of the vessel of interest. This formula assumes that the 2D flow profile is cylindrically symmetric with a circular cross-section, and the line of the Doppler sampling cuts perfectly through the center of the sampled vessel. The velocity estimates require angle correction, and if the vessel is tortuous, as in umbilical cords, the sampling position placement and angle correction are hard to perform. Multiple investigators have warned that small errors in volume flow components can result in large errors in the calculation of volume flow.5-7

A new, easy-to-perform volume flow method overcomes almost all of the limitations of the standard technique. The new method is angle independent, flow profile independent, and vessel geometry independent. It works as follows:

Volume flow is defined as the total flux across any surface, S, intersecting the vessel. This is written as

Eq2

where Q is again volume flow, V is the local velocity through each area element dA, and “” is the dot product which projects the local velocity V onto the normal vector for each area element. This is known as Gauss’s theorem. The intersecting surface, known as the “C” surface, is very simple to obtain using 3D ultrasound (Figure8). In order to validate this method, we obtained an AIUM EER-funded research grant.

Fig

Figure: (A) Four-panel view of a single 3D color flow acquisition of the umbilical cord. The four views are as follows: upper-left is axial-lateral, upper-right is axial-elevational, bottom-left is elevational-lateral (ie, the c-surface), and bottom-right is a rendered 3D reconstruction. Arteries are shown in blue and the vein is shown in red. The schematic in (B) illustrates the orientation of the probe and the corresponding c-surface in the elevational-lateral imaging plane. The vessel colors in (B) match the directionality in (A). The entire umbilical cord passes through the c-surface but only the cross-sections of the umbilical arteries and umbilical vein are illustrated in (B). The two arteries are separated in power Doppler (not shown). (Printed with permission from Pinter et al. J Ultrasound Med. 2012;31(12):1927-34. © 2016 by the American Institute of Ultrasound in Medicine)

We had 2 specific aims: 1) Test the reproducibility of the volume flow measurement, and 2) evaluate the relationship of volume flow to clinical outcome in a high-risk patient population.

In the first aim, we performed studies on 35 subjects between the gestational ages of 22–37 weeks, 26 high risk and 9 normal.9 We attempted to measure umbilical cord blood flow at 3 sites in the cord in each subject, and we averaged 28.3 ± 3.3 (mean ± standard deviation) samples per site. We used a GE LOGIQ E9 ultrasound system with a 2.0–8.0 MHz bandwidth convex array transducer to acquire multiple volume 3D color and power mode data sets. Since we were measuring mean blood flow, we assessed variability using relative standard error (standard error /mean) (RSE). The average RSE for blood flow at each cord position was ±5.6% while the average RSE among the measurements in each subject was ±12.1%.

For the second aim, we compared the volume flow measurements in 5 subjects that developed preeclampsia with the 9 normal subjects. Even with these small numbers, we detected a significant difference between the mean depth-corrected, weight-normalized umbilical vein blood volume flows in the two groups (P = .035). Further, blood flow abnormalities were detected either at the same time or preceded the hypertensive disorder in 4 of the 5 subjects. This is consistent with our prior publication where blood flow changes preceded the onset of pre-eclamptic symptoms in a study subject.8

With the introduction of 2D array transducers, umbilical cord volume flow estimates can be performed in seconds and given the valuable information provided by this method, umbilical cord volume flow will hopefully become a standard component of fetal examinations.

 

References:

  1. Tchirikov M, Rybadowski C, Huneke B, Schoder V, Schroder HJ. Umbilical vein blood volume flow rate and umbilical artery pulsatility as ‘venous-arterial index’ in the prediction of neonatal compromise. Ultrasound Obstet Gynecol. 2002;20:580-5.
  2. Newnham JP, Patterson LL, James IR, Diepeveen DA, Reid SE. An evaluation of the efficacy of Doppler flow velocity waveform analysis as a screening test in pregnancy. Am J Obstet Gynecol. 1990;162:403-10.
  3. Acharya G, Wilsgaard T, Bernsten GKR, Maltau JM, Kiserud T. Doppler-derived umbilical artery absolute velocities and their relationship to fetoplacental volume blood flow: a longitudinal study. Ultrasound Obstet Gynecol. 2005;25:444-53.
  4. Rigano S, Bozzo M, Ferrazzi E, Bellotti M, Battaglia FC, Galan HL. Early and persistent reduction in umbilical vein blood flow in the growth-restricted fetus: a longitudinal study. Am J Obstet Gynecol. 2001;185:834-8.
  5. Evans DH. On the measurement of the mean velocity of blood flow over the cardiac cycle using Doppler ultrasound. Ultrasound Med Biol. 1985;11(5):735-41.
  6. Gill R. Measurement of blood flow by ultrasound: accuracy and sources of error. Ultrasound Med Biol. 1985;11:625-41.
  7. Lees C, Albaiges G, Deane C, Parra M, Nicolaides KH. Assessment of umbilical arterial and venous flow using color Doppler. Ultrasound Obstet Gynecol. 1999;14:250-5.
  8. Pinter SZ, Rubin JM, Kripfgans OD, Treadwell MC, Romero VC, Richards MS, Zhang M, Hall AL, Fowlkes JB. Three-dimensional sonographic measurement of blood volume flow in the umbilical cord. J Ultrasound Med. 2012;31(12):1927-34.
  9. Pinter SZ, Kripfgans OD, Treadwell MC, Kneitel AW, Fowlkes JB, Rubin JM. Evaluation of umbilical vein blood volume flow in preeclampsia by angle-independent 3D sonography [published online ahead of print December 15, 2017]. J Ultrasound Med. doi:10.1002/jum.14507.

 

How do you determine umbilical cord blood flow? What problems have you encountered using the traditional method? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Jonathan Rubin, MD, PhD, FAIUM, is Professor Emeritus of Radiology at University of Michigan.

 

To My Fellow Sonographers

Dear fellow sonographers,

I am proud to say that I have worked as a sonographer since 1983 and have been on an incredible journey for 34 years. I started out at the Washington Hospital Center in Washington, DC, as a radiologic technologist and had the privilege to work on the job as a sonographer. I have evolved, grown, and through my profession I have continued to educate myself. When I passed the ARDMS certification in 1984, I decided that I would continue to set goals for myself and keep my career in ultrasound exciting and challenging.

Over the next 33 years, I worked in a Radiology office, in private practice, and in maternal fetal medicine. Now, I am honored to be part of the American Institute of Ultrasound (AIUM). So, why am I saying all this? Because I now want to encourage all of you to use my experiences to take your profession to the next level.

My personal goal is to educate sonographers. To encourage sonographers to love their jobs and be the best. Times have changed, especially in the ultrasound world. Doing an OB exam and showing only a 4-chamber heart is no longer enough. Now, we are expected to do outflow tracts, aorta, ductus, and sometimes the infamous 3-vessel trachea view.

If you are asking what is the 3-vessel trachea view? Well, let me just tell you about this amazing cardiac image. If you can acquire and document a normal 3-vessel trachea you can rule out Transposition of the Great Arteries (TGA), Tetralogy of Fallot (TOF), and Right-sided Aortic Arch. You can also be the hero of the office when you go to your doctor at your practice and say “Hey, the 3-vessel trachea view looks abnormal, what do you think?” Not only will you impress them and possibly save a life, but you will earn respect and, hopefully, you are reminded as to why you wanted to be a sonographer in the first place.

I have always loved my job and continue to learn every day. There is a whole world of ultrasound information out there. I challenge you to go beyond what you know to get the job done, be the best, and always treat your patient as your best friend, whoever that might be. My challenge for you is to read about the 3-vessel trachea view and, if it is not a part of your daily OB routine, add it.

Please join me and expand your education!

Haylea Weiss, RDMS (AB FE OB/GYN)
American Institute of Ultrasound in Medicine

Apply for AIUM’s new Sonographer Scholarship Grant, a program that provides $500 and free registration to an AIUM post-graduate event. Applications due March 1.

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.