Obstetric ultrasonography

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Obstetric ultrasonography
Intervention
Obsteric ultrasonograph.jpg
Obstetric sonogram of a fetus at 16 weeks. The bright white circle center-right is the head, which faces to the left. Features include the forehead at 10 o'clock, the left ear toward the center at 7 o'clock and the right hand covering the eyes at 9:00.
ICD-9-CM 88.78
MeSH D016216
OPS-301 code: 3-032, 3-05d

Obstetric ultrasonography is the application of medical ultrasonography to obstetrics, in which sonography is used to visualize the embryo or fetus in its mother's uterus (womb). The procedure is a standard part of prenatal care, as it yields a variety of information regarding the health of the mother and of the fetus, the progress of the pregnancy, and further information on the baby.

In those who are at low risk it is unclear if obstetric ultrasound before 24 weeks makes a significant difference in outcomes.[1] Routine ultrasound imaging after 24 weeks gestation does not improve outcomes in either the mother or the baby and might increase the risk of a cesarean section.[2] It is thus is not recommended.[1]

Types[edit]

Traditional obstetric sonograms are done by placing a transducer on the abdomen of the pregnant woman. One variant, a transvaginal sonography, is done with a probe placed in the woman's vagina. Transvaginal scans usually provide clearer pictures during early pregnancy and in obese women. Also used is Doppler sonography which detects the heartbeat of the fetus. Doppler sonography can be used to evaluate the pulsations in the fetal heart and bloods vessels for signs of abnormalities.[3]

Early pregnancy[edit]

The gestational sac can sometimes be visualized as early as four and a half weeks of gestational age (approximately two and a half weeks after ovulation) and the yolk sac at about five weeks gestation. The embryo can be observed and measured by about five and a half weeks. The heartbeat may be seen as early as 5 weeks of gestational age. It is usually visible by 7 weeks.[3][4] Coincidentally, most miscarriages also happen by 7 weeks gestation. The rate of miscarriage, especially threatened miscarriage, drops significantly if normal heartbeat is detected.[5]

Dating and growth monitoring[edit]

Biparietal diameter is taken as the maximal transverse diameter of in a visualization of the horizontal plane of the head.
Biparietal diameter (the transverse diameter of the head) by gestational age, with the blue line representing the mean and the green area representing the 90% prediction interval.[6]

Gestational age is usually determined by the date of the woman's last menstrual period, and assuming ovulation occurred on day fourteen of the menstrual cycle. Sometimes a woman may be uncertain of the date of her last menstrual period, or there may be reason to suspect ovulation occurred significantly earlier or later than the fourteenth day of her cycle. Ultrasound scans offer an alternative method of estimating gestational age. The most accurate measurement for dating is the crown-rump length of the fetus, which can be done between 7 and 13 weeks of gestation. After 13 weeks of gestation, the fetal age may be estimated using the biparietal diameter (the transverse diameter of the head), the head circumference, the length of the femur, the crown-heel length (head to heel), and other fetal parameters.[7] Dating is more accurate when done earlier in the pregnancy; if a later scan gives a different estimate of gestational age, the estimated age is not normally changed but rather it is assumed the fetus is not growing at the expected rate.[3]

Not useful for dating, the abdominal circumference of the fetus may also be measured. This gives an estimate of the weight and size of the fetus and is important when doing serial ultrasounds to monitor fetal growth.[3]

Fetal sex discernment[edit]

Sonogram of male fetus, with scrotum and penis in center of image

The sex of the fetus may be discerned by ultrasound as early as 11 weeks gestation. The accuracy is relatively imprecise when attempted early.[8][9][10] After 13 weeks gestation, a high accuracy of between 99% to 100% is possible if there is no malformed external genitalia.[11]

The following is accuracy data from two hospitals:

Gestational Age King's College Hospital Medical School[9] Taipei City Hospital & Li Shin Hospital[10]
11 weeks 70.3% 71.9%
12 weeks 98.7% 92%
13 weeks 100% 98.3%

Influencing factors[edit]

The accuracy of fetal sex discernment depends on:[8]

  • Gestational age
  • Precision of sonographic machine
  • Expertise of the operator
  • Fetal posture

Ultrasonography of the cervix[edit]

Fetus at 14 weeks (profile)

Obstetric sonography has become useful in the assessment of the cervix in women at risk for premature birth. A short cervix preterm is undesirable: At 24 weeks gestation a cervix length of less than 25 mm defines a risk group for preterm birth, further, the shorter the cervix the greater the risk.[12] It also has been helpful to use ultrasonography in women with preterm contractions, as those whose cervix length exceed 30 mm are unlikely to deliver within the next week.[13]

Abnormality screening[edit]

In some countries, routine pregnancy sonographic scans are performed to detect developmental defects before birth. This includes checking the status of the limbs and vital organs, as well as (sometimes) specific tests for abnormalities. Some abnormalities detected by ultrasound can be addressed by medical treatment in utero or by perinatal care, though indications of other abnormalities can lead to a decision regarding abortion.

Perhaps the most common such test uses a measurement of the nuchal translucency thickness ("NT-test", or "Nuchal Scan"). Although 91% of fetuses affected by Down syndrome exhibit this defect, 5% of fetuses flagged by the test do not have Down syndrome.

Ultrasound may also detect fetal organ anomaly. Usually scans for this type of detection are done around 18 to 23 weeks of gestational age. Some resources indicate that there are clear reasons for this and that such scans are also clearly beneficial because ultrasound enables clear clinical advantages for assessing the developing fetus in terms of morphology, bone shape, skeletal features, fetal heart function, volume evaluation, and general fetus well being.[14]

3D ultrasound[edit]

Main article: 3D ultrasound

Modern 3D ultrasound images provide greater detail for prenatal diagnosis than the older 2D ultrasound technology.[15] While 3D is popular with parents desiring a prenatal photograph as a keepsake,[16] both 2D and 3D are discouraged by the FDA for non-medical use,[17] but there are no definitive studies linking ultrasound to any adverse medical effects.[18] The following 3D ultrasound images were taken at different stages of pregnancy:

History[edit]

Scottish physician Ian Donald was one of the pioneers of medical use of ultrasound. His article "Investigation of Abdominal Masses by Pulsed Ultrasound" was published in The Lancet in 1958.[19] Donald was Regius Professor of Midwifery at the University of Glasgow.[20]

In 1962, after about two years of work, Joseph Holmes, William Wright, and Ralph Meyerdirk developed the first compound contact B-mode scanner. Their work had been supported by U.S. Public Health Services and the University of Colorado. Wright and Meyerdirk left the university to form Physionic Engineering Inc., which launched the first commercial hand-held articulated arm compound contact B-mode scanner in 1963.[21] This was the start of the most popular design in the history of ultrasound scanners.

Obstetric ultrasound has played a significant role in the development of diagnostic ultrasound technology in general. Much of the technological advances in diagnostic ultrasound technology are due to the drive to create better obstetric ultrasound equipment. Acuson Corporation's pioneering work on the development of Coherent Image Formation helped shape the development of diagnostic ultrasound equipment as a whole.[citation needed]

Safety issues[edit]

3D rendering of the fetal spine in a scan at 19 weeks of pregnancy

Current evidence indicates that diagnostic ultrasound is safe for the unborn child, unlike radiographs, which employ ionizing radiation. Randomized controlled trials have followed children up to ages 8–9, with no significant differences in vision, hearing, school performance, dyslexia, or speech and neurologic development by exposure to ultrasound.[22] In one randomized trial, the children with greater exposure to ultrasound had a reduction in perinatal mortality, and was attributed to the increased detection of anomalies in the ultrasound group.[22]

A 2006 study on genetically modified mice exposed to ultrasound (5–240 minutes a day) showed neurological changes in the exposed fetuses. Some of the rodent brain cells failed to migrate to their proper position and remained scattered in incorrect parts of the brain.[23]

The 1985 maximum power allowed by the U.S. Food and Drug Administration (FDA) of 180 milliwatts per square cm [24] is well under the levels used in therapeutic ultrasound, but still higher than the 30-80 milliwatts per square cm range of the Statison V veterinary LIPUS device.[25] LIPUS has been shown to affect tissue growth in as little as 20 minutes of time with repeated daily applications. Adding to the similarity, LIPUS and medical ultrasound both operate in the 1 to 10 MHz range.

Doppler ultrasonography examinations has a thermal index (TI) of about five times that of regular (B-mode) ultrasound examinations.[22] Several randomized controlled trials have reported no association between Doppler exposure and birth weight, Apgar scores, and perinatal mortality. One randomized controlled trial, however, came to the result of a higher perinatal death rate of normally formed infants born after 24 weeks exposed to Doppler ultrasonography (RR 3.95, 95% CI 1.32–11.77), but this was not a primary outcome of the study, and has been speculated to be due to chance rather than a harmful effect of Doppler itself.[22]

While the benefits of medical ultrasound outweigh any risks, vanity uses such as making 3D ultrasound movies without a doctor's order present a possibly unnecessary, but unknown risk to a developing fetus. The FDA discourages its use for non-medical purposes such as fetal keepsake videos and photos, even though it is the same technology used in hospitals. The demand for keepsake ultrasound products in medical environments has prompted commercial solutions such as self-serve software that allows the patient to create a "keepsake" from the ultrasound imagery recorded during a medical ultrasound procedure.[26]

Social Implications[edit]

The increasingly widespread use of ultrasound technology in monitoring pregnancy has had a great impact on the way in which women and societies at large conceptualise and experience pregnancy and childbirth.[27] The pervasive spread of obstetric ultrasound technology around the world and the conflation of its use with creating a ‘safe’ pregnancy as well as the ability to see and determine features like the sex of the fetus impact the way in which pregnancy is experienced and conceptualised.[27] This “technocratic takeover” [27] of pregnancy is not limited to western or developed nations but also effects conceptualisations and experiences in developing nations and is an example of the increasing medicalisation of pregnancy, a phenomenon that has social as well as technological ramifications.[27] Ethnographic research concerned with the use of ultrasound technology in monitoring pregnancy can show us how it has changed the embodied experience of expecting mothers around the globe.[27]

See also[edit]

References[edit]

  1. ^ a b "Screening for Ultrasonography in Pregnancy". U.S. Preventive Services Task Force. Retrieved 6 March 2013. 
  2. ^ Bricker L, Neilson JP, Dowswell T; Neilson; Dowswell (Oct 8, 2008). "Routine ultrasound in late pregnancy (after 24 weeks' gestation)". In Bricker, Leanne. Cochrane database of systematic reviews (Online) (4): CD001451. doi:10.1002/14651858.CD001451.pub3. PMID 18843617. 
  3. ^ a b c d Woo, Joseph (2006). "Why and when is Ultrasound used in Pregnancy?". Obstetric Ultrasound: A Comprehensive Guide. Retrieved 2007-05-27. 
  4. ^ Boschert, Sherry (2001-06-15). "Anxious Patients Often Want Very Early Ultrasound Exam". OB/GYN News (FindArticles.com). Retrieved 2007-05-27. 
  5. ^ "Miscarriage". A.D.A.M., Inc. 21 Nov 2010. Retrieved 28 February 2012. 
  6. ^ Snijders, RJ.; Nicolaides, KH. (Jan 1994). "Fetal biometry at 14-40 weeks' gestation.". Ultrasound Obstet Gynecol 4 (1): 34–48. doi:10.1046/j.1469-0705.1994.04010034.x. PMID 12797224. 
  7. ^ "Pregnancy Week by Week". OPregnancy.com. 2009. Retrieved 17 March 2012. 
  8. ^ a b Merz, Eberhard (2005). Ultrasound in obstetrics and gynecology (2nd ed.). Stuttgart: Thieme. p. 129. ISBN 1-58890-147-5. 
  9. ^ a b Efrat, Z.; Akinfenwa, O. O.; Nicolaides, K. H. (1999). "First-trimester determination of fetal gender by ultrasound". Ultrasound in Obstetrics and Gynecology 13 (5): 305–7. doi:10.1046/j.1469-0705.1999.13050305.x. PMID 10380292. 
  10. ^ a b Hsiao, C.H.; Wang, H.C.; Hsieh, C.F.; Hsu, J.J. (2008). "Fetal gender screening by ultrasound at 11 to 13+6 weeks". Acta Obstetricia et Gynecologica Scandinavica 87 (1): 8–13. doi:10.1080/00016340701571905. PMID 17851807. 
  11. ^ Odeh, Marwan; Grinin, Vitali; Kais, Mohamad; Ophir, Ella; Bornstein, Jacob (2009). "Sonographic Fetal Sex Determination". Obstetrical & Gynecological Survey 64: 50. doi:10.1097/OGX.0b013e318193299b. 
  12. ^ Iams, Jay D.; Goldenberg, Robert L.; Meis, Paul J.; Mercer, Brian M.; Moawad, Atef; Das, Anita; Thom, Elizabeth; McNellis, Donald et al. (1996). "The Length of the Cervix and the Risk of spontaneous Premature Delivery". New England Journal of Medicine 334 (9): 567–72. doi:10.1056/NEJM199602293340904. PMID 8569824. 
  13. ^ Leitich, Harald; Brunbauer, Mathias; Kaider, Alexandra; Egarter, Christian; Husslein, Peter (1999). "Cervical length and dilatation of the internal cervical os detected by vaginal ultrasonography as markers for preterm delivery: A systematic review". American Journal of Obstetrics and Gynecology 181 (6): 1465–72. doi:10.1016/S0002-9378(99)70407-2. PMID 10601930. 
  14. ^ http://www.layyous.com/ultasound/clinicaladvantages.htm
  15. ^ Dimitrova V, Markov D, Dimitrov R (2007). "[3D and 4D ultrasonography in obstetrics]". Akush Ginekol (Sofiia) (in Bulgarian) 46 (2): 31–40. PMID 17469450. 
  16. ^ Sheiner E, Hackmon R, Shoham-Vardi I, et al. (2007). "A comparison between acoustic output indices in 2D and 3D/4D ultrasound in obstetrics". Ultrasound Obstet Gynecol 29 (3): 326–8. doi:10.1002/uog.3933. PMID 17265534. 
  17. ^ Rados C (January–February 2004). "FDA Cautions Against Ultrasound 'Keepsake' Images". FDA Consumer Magazine. Archived from the original on 13 May 2009. Retrieved 28 February 2012. 
  18. ^ Kempley R (9 August 2003). "The Grin Before They Bear It; Peek-a-Boo: Prenatal Portraits for the Ultrasound Set". Washington Post. 
  19. ^ Donald, I; MacVicar, J; Brown, TG (1958). "Investigation of abdominal masses by pulsed ultrasound". Lancet 1 (7032): 1188–95. doi:10.1016/S0140-6736(58)91905-6. PMID 13550965. 
  20. ^ Ian Donald's paper in the Lancet in 1958 by Joseph Woo[self-published source?]
  21. ^ Woo, Joseph (2002). "A short History of the development of Ultrasound in Obstetrics and Gynecology". ob-ultrasound.net. Retrieved 2007-08-26. [self-published source?]
  22. ^ a b c d Houston, Laura E.; Odibo, Anthony O.; Macones, George A. (2009). "The safety of obstetrical ultrasound: a review". Prenatal Diagnosis 29 (13): 1204–1212. doi:10.1002/pd.2392. ISSN 0197-3851. 
  23. ^ Ang, Eugenius S. B. C.; Gluncic, Vicko; Duque, Alvaro; Schafer, Mark E.; Rakic, Pasko (2006). "Prenatal exposure to ultrasound waves impacts neuronal migration in mice". Proceedings of the National Academy of Sciences 103 (34): 12903–10. Bibcode:2006PNAS..10312903A. doi:10.1073/pnas.0605294103. PMC 1538990. PMID 16901978. 
  24. ^ Freitas, Robert A. (1999). Nanomedicine. Austin, TX: Landes Bioscience. ISBN 978-1-57059-645-2. [page needed]
  25. ^ "Statison V Operations Manual". Statison Medical, Inc. 1997. Archived from the original on 27 May 2008. 
  26. ^ "Fetal Keepsake Videos". Food and Drug Administration. Retrieved 2011-05-21. 
  27. ^ a b c d e [Gammeltoft, Tine, 2007, Sonography and Sociality – Obstetrical Ultrasound Imagining in Urban Vietnam, Medical Anthropology Quarterly, 21:2, 133-153]

External links[edit]