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Molloholli M, Napolitano R, Ohuma EO, Ash S, Wanyonyi SZ, Cavallaro A, Giudicepietro A, Barros F, Carvalho M, Norris S, Min AM, Zainab G, Papageorghiou AT. Image-scoring system for umbilical and uterine artery pulsed-wave Doppler ultrasound measurement. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:251-255. [PMID: 29808615 DOI: 10.1002/uog.19101] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 05/21/2018] [Accepted: 05/22/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To develop an objective image-scoring system for pulsed-wave Doppler measurement of maternal uterine and fetal umbilical arteries, and evaluate how this compares with subjective assessment. METHODS As an extension to the INTERGROWTH-21st Project, we developed a scoring system based on six predefined criteria for uterine and umbilical artery pulsed-wave Doppler measurements. Objective evaluation using the scoring system was compared with subjective assessment which consisted of classifying an image as simply acceptable or unacceptable. Based on sample size estimation, a total of 120 umbilical and uterine artery Doppler images were selected randomly from the INTERGROWTH-21st image database. Two independent reviewers evaluated all images in a blinded fashion, both subjectively and using the six-point scoring system. Percentage agreement and kappa statistic were compared between the two methods. RESULTS The overall agreement between reviewers was higher for objective assessment using the scoring system (agreement, 85%; adjusted kappa, 0.70) than for subjective assessment (agreement, 70%; adjusted kappa, 0.47). For the six components of the scoring system, the level of agreement (adjusted kappa) was 0.97 for anatomical site, 0.88 for sweep speed, 0.77 for magnification, 0.68 for velocity scale, 0.68 for image clarity and 0.65 for angle of insonation. CONCLUSION In quality assessment of umbilical and uterine artery pulsed-wave Doppler measurements, our proposed objective six-point image-scoring system is associated with greater reproducibility than is subjective assessment. We recommend this as the preferred method for quality control, auditing and teaching. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Molloholli
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
- Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - R Napolitano
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
- Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - E O Ohuma
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - S Ash
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
- Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - S Z Wanyonyi
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
- Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - A Cavallaro
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
- Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - A Giudicepietro
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
- Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - F Barros
- Programa de Pos-Graduacao em Epidemiologia, Universidade Federal de Pelotas, Pelotas, Brazil
- Programa de Pos-Graduacao em Saude e Comportamento, Universidade Catolica de Pelotas, Pelotas, Brazil
| | - M Carvalho
- Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya
| | - S Norris
- Developmental Pathways for Health Research Unit, Department of Pediatrics and Child Health, University of Witwatersrand, Johannesburg, South Africa
| | - A M Min
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - G Zainab
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - A T Papageorghiou
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
- Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
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Cavallaro A, Ash ST, Napolitano R, Wanyonyi S, Ohuma EO, Molloholli M, Sande J, Sarris I, Ioannou C, Norris T, Donadono V, Carvalho M, Purwar M, Barros FC, Jaffer YA, Bertino E, Pang R, Gravett MG, Salomon LJ, Noble JA, Altman DG, Papageorghiou AT. Quality control of ultrasound for fetal biometry: results from the INTERGROWTH-21 st Project. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:332-339. [PMID: 28718938 DOI: 10.1002/uog.18811] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 07/01/2017] [Accepted: 07/05/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To assess a comprehensive package of ultrasound quality control in the Fetal Growth Longitudinal Study of the INTERGROWTH-21st Project, a large multicenter study of fetal growth. METHODS Quality control (QC) measures were performed for 20 313 ultrasound scan images obtained prospectively from 4321 fetuses at 14-41 weeks' gestation in eight geographical locations. At the time of each ultrasound examination, three fetal biometric variables (head circumference (HC), abdominal circumference (AC) and femur length (FL)) were measured in triplicate on separately generated images. All measurements were taken in a blinded fashion. QC had two elements: (1) qualitative QC: visual assessment by sonographers at each study site of their images based on specific criteria, with 10% of images being re-assessed at the Oxford-based Ultrasound Quality Unit (compared using an adjusted kappa statistic); and (2) quantitative QC: assessment of measurement data by comparing the first, second and third measurements (intraobserver variability), remeasurement of caliper replacement in 10% (interobserver variability), both by Bland-Altman plots and plotting frequency histograms of the SD of triplicate measurements and assessing how many were above or below 2 SD of the expected distribution. The system allowed the sonographers' performances to be monitored regularly. RESULTS A high level of agreement between self- and external scoring was demonstrated for all measurements (κ = 0.99 (95% CI, 0.98-0.99) for HC, 0.98 (95% CI, 0.97-0.99) for AC and 0.96 (95% CI, 0.95-0.98) for FL). Intraobserver 95% limits of agreement (LoA) of ultrasound measures for HC, AC and FL were ± 3.3%, ± 5.6% and ± 6.2%, respectively; the corresponding values for interobserver LoA were ± 4.4%, ± 6.0% and ± 5.6%. The SD distribution of triplicate measurements for all biometric variables showed excessive variability for three of 31 sonographers, allowing prompt identification and retraining. CONCLUSIONS Qualitative and quantitative QC monitoring was feasible and highly reproducible in a large multicenter research study, which facilitated the production of high-quality ultrasound images. We recommend that the QC system we developed is implemented in future research studies and clinical practice. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Cavallaro
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - S T Ash
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - R Napolitano
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - S Wanyonyi
- Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya
| | - E O Ohuma
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - M Molloholli
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - J Sande
- Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya
| | - I Sarris
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - C Ioannou
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - T Norris
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - V Donadono
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - M Carvalho
- Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya
| | - M Purwar
- Nagpur INTERGROWTH-21st Research Centre, Ketkar Hospital, Nagpur, India
| | - F C Barros
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal de Pelotas, Pelotas, RS, Brazil
- Programa de Pós-Graduação em Saúde e Comportamento, Universidade Católica de Pelotas, Pelotas, RS, Brazil
| | - Y A Jaffer
- Department of Family & Community Health, Ministry of Health, Muscat, Sultanate of Oman
| | - E Bertino
- Dipartimento di Scienze Pediatriche e dell'Adolescenza, Cattedra di Neonatologia, Università degli Studi di Torino, Torino, Italy
| | - R Pang
- School of Public Health, Peking University, Beijing, China
| | - M G Gravett
- Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), Seattle, WA, USA
| | - L J Salomon
- Maternité Necker-Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
| | - J A Noble
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - D G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - A T Papageorghiou
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
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Palermo FG, Albuquerque DDPSDM, Martins WP, Araujo Júnior E, Bruns RF. Auditing fetal nasal bone images in the first trimester of pregnancy: results from a peer review program. J Matern Fetal Neonatal Med 2015; 29:2874-7. [PMID: 26465391 DOI: 10.3109/14767058.2015.1107899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To establish a structured review process to facilitate the identification of the fetal nasal bone (NB) in the first trimester ultrasound scan to improve the quality images. METHODS We conducted a retrospective observational study in fetal NB images obtained during ultrasound exams of singleton pregnancies that underwent first trimester screening (crown-rump length 45-84 mm). When the images were obtained the examiner was not aware of the study. Audit was conducted by an examiner according criteria established by the Fetal Medicine Foundation. Fetal NB images were assessed regarding adequate magnification, mid-sagittal view and transducer held parallel to the direction of the nose. The transvaginal and transabdominal as well as anterior and posterior fetal back groups were compared using χ(2) test. RESULTS We considered 874 fetal NB images for auditing. Fetal NB was considered present in 865 images (99%). During the audit process, we identified 72 (8.2%) cases of disagreement between examiner and auditor assessments. Disagreement was higher when image quality was poor (62 cases = 7%). Transvaginal approach performed better in the following criteria: adequate magnification (p < 0.001), midline (p < 0.001) and completely adequate (p < 0.001). CONCLUSION A peer reviewed audit program for fetal NB is feasible in a clinical scenario. Image quality appears to play an important role in compliance to image standards audited and in agreement between examiner and auditor.
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Affiliation(s)
- Fernanda Gasparin Palermo
- a Department of Obstetrics and Gynecology , Federal University of Paraná (UFPR) , Curitiba-PR , Brazil
| | | | - Wellington P Martins
- b Department of Obstetrics and Gynecology , Ribeirão Preto Medical School, University of São Paulo (DGO-FMRP-USP) , Ribeirão Preto - SP , Brazil , and
| | - Edward Araujo Júnior
- c Department of Obstetrics , Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP) , São Paulo - SP , Brazil
| | - Rafael Frederico Bruns
- a Department of Obstetrics and Gynecology , Federal University of Paraná (UFPR) , Curitiba-PR , Brazil
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Wanyonyi SZ, Napolitano R, Ohuma EO, Salomon LJ, Papageorghiou AT. Image-scoring system for crown-rump length measurement. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:649-654. [PMID: 24677327 DOI: 10.1002/uog.13376] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 03/14/2014] [Accepted: 03/18/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To develop and evaluate an objective image-scoring system for crown-rump length (CRL) measurements and to determine how this compares with subjective assessment. METHODS A total of 125 CRL ultrasound images were selected from the database of the International Fetal and Newborn Growth Consortium for the 21(st) Century study group. Two reviewers, who were blinded to the operators' and to each others' results, evaluated all images both subjectively and objectively. Subjective evaluation consisted of rating an image as acceptable or unacceptable, while objective evaluation was based on six criteria. Reviewer differences for both the subjective and objective evaluations were compared using percentage of agreement and adjusted kappa values. RESULTS The distribution of individual scores and differences between subjective and objective evaluation for the two reviewers was similar. Overall agreement between the reviewers was higher for objective evaluation (95.2%; adjusted κ, 0.904), than for subjective evaluation (77.6%; adjusted κ, 0.552). There was a high level of agreement for horizontal position (κ = 0.951), magnification (κ = 0.919), visualization of crown and rump (κ = 0.806) and caliper placement (κ = 0.756), while agreement for mid-sagittal section (κ = 0.629) and neutral position (κ = 0.565) were moderate and poor, respectively. CONCLUSION The proposed six-point scoring system for CRL image rating is more reproducible than is subjective evaluation and should be considered as a method of quality assessment and audit.
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Affiliation(s)
- S Z Wanyonyi
- Nuffield Department of Obstetrics & Gynaecology, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Yeo GSH, Lai FM, Wei X, Lata P, Tan DTH, Yong MH, Tan ETH, Kwek KYC. Validation of first trimester screening for trisomy 21 in Singapore with reference to performance of nasal bone. Fetal Diagn Ther 2012; 32:166-70. [PMID: 22710343 DOI: 10.1159/000338656] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 03/29/2012] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The aim of this study is to describe the performance of first trimester screening (FTS) for trisomy 21 using maternal age, serum biochemistry and fetal nuchal translucency (NT) in a single center and to evaluate the effect of nasal bone on screening performance. MATERIAL AND METHODS In 12,585 singleton pregnancies, the NT and nasal bone were examined. The majority of these mothers also had their serum biochemical markers analyzed. Risk was computed using different combinations of maternal age, biochemistry, NT and nasal bone. Down syndrome cases were confirmed by karyotyping. RESULTS There were 12,519 normal pregnancies, 31 with trisomy 21 and 35 with other chromosomal abnormalities. Without considering the nasal bone, the combined FTS detected 87.1% of trisomy 21 fetuses (false positive rate 5.1%), using 1:300 as the risk threshold, and this was further improved to 96.8% with the policy that classifies all fetuses with an absent nasal bone as high risk. Subgroup analysis showed that the detection rate would be 90.9%, with a false positive rate of 3.7%, if nasal bone was incorporated in the risk algorithm, compared to 81.8% and a false positive rate of 5.4% if it was not used. DISCUSSION FTS is very effective in early detection of trisomy 21 in Singapore. The nasal bone is a useful marker that can substantially improve the screening performance.
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Affiliation(s)
- George Seow Heong Yeo
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore, Singapore.
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