16 Years and Counting

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

NC spring

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

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

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

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

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

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

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

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

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

I Enjoy Being a Detective

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

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

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

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

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

Ultrasound Can Catch What NIPT Misses

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

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

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

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

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

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

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

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

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

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

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

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

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

Why 76811 Accreditation?

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

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

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

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

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

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

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

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

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

The Issue with Keepsake Ultrasounds

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

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

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

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

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

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

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

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

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

Record-setting OB Course

Last week, a record number of 444 physicians and sonographers gathered in Orlando, Florida, for the 38th Annual Advanced Ultrasound Seminar: OB/GYN. The program, which was co-directed by Lennard Greenbaum, MD, and Frederick Kremkau, MD, featured an impressive array of speakers, all of whom have been presidents (plus the incoming president-elect) of the AIUM.

Over thOB course 2015e course of 3 days, attendees heard from these experts on a wide variety of topics, including ovarian cancer screening, fetal malformations, endometriosis, fetal cardiac imaging, and adnexal masses. You can find the full schedule, plus a list of the faculty here.

By all accounts, this year’s event was a success. Here are just a few comments from attendees:

  • “I love this course. This is my 8th year attending and every year I take home a couple of real ‘pearls’ to assist me in improving the studies that I do in our office.”
  • “Overall excellent course – well organized, great venue/location, excellent lectures which are clinically relevant.”
  • “I have attended this conference several times in the past and always learn either a new technique or something very beneficial I can bring back and share to help improve patient care.”
  • “I’m really impressed with how clear and applicable this information was.”

And these comments played out in the survey results, as 64% said that this course was better than others they have attended and 97% said they would recommend this course to their colleagues.

The co-directors and AIUM are already hard at work planning next year’s course, which will be held February 18–20 at Walt Disney World’s Yacht and Beach Club Resorts. Keep an eye on The Scan and the AIUM website for details as they become available. And if you are interested, register as soon as it opens because 91% of this year’s attendees said they were very likely to attend another AIUM post-graduate course.

Did you attend this year’s event? If so, share your thoughts. Going next year? Let us know what you want to learn! Comment below or let us know on Twitter: @AIUM_Ultrasound.

Peter Magnuson is AIUM’s Director of Communications and Member Services.