Routine ultrasound screening of congenital anomalies. An overview of the European experience

Enhancing trainee performance in obstetric ultrasound through an artificial intelligence system: randomized controlled trial

OBJECTIVE

Performing obstetric ultrasound scans is challenging for inexperienced operators; therefore, the prenatal screening artificial intelligence system (PSAIS) software was developed to provide real-time feedback and guidance for trainees during their scanning procedures. The aim of this study was to investigate the potential benefits of utilizing such an artificial intelligence system to enhance the efficiency of obstetric ultrasound training in acquiring and interpreting standard basic views.

METHODS

A prospective, single-center randomized controlled study was conducted at The First Affiliated Hospital of Sun Yat-sen University. From September 2022 to April 2023, residents with no prior obstetric ultrasound experience were recruited and assigned randomly to either a PSAIS-assisted training group or a conventional training group. Each trainee underwent a four-cycle practical scan training program, performing 20 scans in each cycle on pregnant volunteers at 18-32 gestational weeks, focusing on acquiring and interpreting standard basic views. At the end of each cycle, a test scan evaluated trainees' ability to obtain standard ultrasound views without PSAIS assistance, and image quality was rated by both the trainees themselves and an expert (in a blinded manner). The primary outcome was the number of training cycles required for each trainee to meet a certain standard of proficiency (i.e. end-of-cycle test scored by the expert at ≥ 80%). Secondary outcomes included the expert ratings of the image quality in each trainee's end-of-cycle test and the discordance between ratings by trainees and the expert.

RESULTS

In total, 32 residents and 1809 pregnant women (2720 scans) were recruited for the study. The PSAIS-assisted trainee group required significantly fewer training cycles compared with the non-PSAIS-assisted group to meet quality requirements (P = 0.037). Based on the expert ratings of image quality, the PSAIS-assisted training group exhibited superior ability in acquiring standard imaging views compared with the conventional training group in the third (P = 0.012) and fourth (P < 0.001) cycles. In both groups, the discordance between trainees' ratings of the quality of their own images and the expert's ratings decreased with increasing training time. A statistically significant difference in overall trainee-expert rating discordance between the two groups emerged at the end of the first training cycle and remained at every cycle thereafter (P < 0.013).

CONCLUSION

By assisting inexperienced trainees in obtaining and interpreting standard basic obstetric scanning views, the use of artificial intelligence-assisted systems has the potential to improve training effectiveness. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Development and validation of an artificial intelligence assisted prenatal ultrasonography screening system for trainees

OBJECTIVE

Fetal anomaly screening via ultrasonography, which involves capturing and interpreting standard views, is highly challenging for inexperienced operators. We aimed to develop and validate a prenatal-screening artificial intelligence system (PSAIS) for real-time evaluation of the quality of anatomical images, indicating existing and missing structures.

METHODS

Still ultrasonographic images obtained from fetuses of 18-32 weeks of gestation between 2017 and 2018 were used to develop PSAIS based on YOLOv3 with global (anatomic site) and local (structures) feature extraction that could evaluate the image quality and indicate existing and missing structures in the fetal anatomical images. The performance of the PSAIS in recognizing 19 standard views was evaluated using retrospective real-world fetal scan video validation datasets from four hospitals. We stratified sampled frames (standard, similar-to-standard, and background views at approximately 1:1:1) for experts to blindly verify the results.

RESULTS

The PSAIS was trained using 134 696 images and validated using 836 videos with 12 697 images. For internal and external validations, the multiclass macro-average areas under the receiver operating characteristic curve were 0.943 (95% confidence interval [CI], 0.815-1.000) and 0.958 (0.864-1.000); the micro-average areas were 0.974 (0.970-0.979) and 0.973 (0.965-0.981), respectively. For similar-to-standard views, the PSAIS accurately labeled 90.9% (90.0%-91.4%) with key structures and indicated missing structures.

CONCLUSIONS

An artificial intelligence system developed to assist trainees in fetal anomaly screening demonstrated high agreement with experts in standard view identification.

Effect of maternal obesity on the ultrasound detection of anomalous fetuses

OBJECTIVE

To estimate the effect of maternal habitus on detection of fetuses with major structural anomalies during second-trimester standard and targeted ultrasound examinations.

METHODS

This was a retrospective cohort study of pregnancies 18 to 24 weeks that underwent ultrasonography over a 5-year period. An anomalous fetus was considered detected if a major abnormality of the relevant organ system was identified, regardless of the anticipated ultrasound detection. Anomalies were verified using a prospectively maintained database. Body mass index (BMI) was based on weight at first prenatal visit.

RESULTS

There were 10,112 standard examinations in low-risk pregnancies and 1,098 targeted examinations in pregnancies with either high-risk indications or with an abnormality detected during standard ultrasonography. Detection of anomalous fetuses decreased with increasing BMI. For normal BMI, overweight, and class I, II, and III obesity, detection with standard ultrasonography was 66%, 49%, 48%, 42%, and 25%, respectively, and with targeted ultrasonography, 97%, 91%, 75%, 88%, and 75%, respectively, both P< or =.03. Residual anomaly risk after a normal ultrasound examination increased with increasing BMI, from 0.4% among women of normal BMI to 1.0% among obese women, P=.001. Anomaly detection was lower among women with pregestational diabetes than in those with other high-risk indications, 38% compared with 88% respectively, P<.001.

CONCLUSION

With increasing maternal BMI, we found decreased detection of anomalous fetuses with either standard or targeted ultrasonography, a difference of at least 20% when women of normal BMI were compared with obese women. Anomaly detection was even less in pregnancies complicated by pregestational diabetes. Counseling may need to be modified to reflect the limitations of ultrasonography in obese women.

A critical analysis on Italian perinatal mortality in a 50-year span

BACKGROUND

Perinatal mortality rate is used as an indicator of reproductive health worldwide. In western countries, national mortality registers are usually accurate and reliable.

METHODS AND AIMS

We reviewed the data recorded in the past 50 years in Italy on perinatal and infant mortality. Each single class of mortality rate (according to WHO definitions) was assessed on temporal trends allowing a critical speculative analysis, mainly focusing on the last 20 years, in an attempt to evaluate the impact of prenatal diagnosis.

RESULTS

Infant mortality rate (IMR) constantly decreased in the study period whereas early neonatal mortality rate progressively diminished in a 5-year comparison till the early 1990s. Perinatal mortality showed a linear negative trend until the 1980s, after which the decrease steadied at about 23% in the following 5-year period. Infant mortality attributable to congenital anomalies throughout a 20-year span (1980-2000) was steady at about 23% although a progressive reduction in general infant mortality was reported.

CONCLUSIONS

A higher reduction in neonatal and perinatal mortality rate was found before the wide availability of the ultrasonographic prenatal diagnosis and the introduction of the law on voluntary abortion in Italy. Given these data, it seems that advances in neonatal care have improved the infant survival rates more than prenatal diagnosis, whereas obstetric care is linked to a reduction of the early perinatal mortality rate.

Population genetic screening programmes: principles, techniques, practices, and policies

This paper examines the professional and scientific views on the principles, techniques, practices, and policies that impact on the population genetic screening programmes in Europe. This paper focuses on the issues surrounding potential screening programmes, which require further discussion before their introduction. It aims to increase, among the health-care professions and health policy-makers, awareness of the potential screening programmes as an issue of increasing concern to public health. The methods comprised primarily the review of the existing professional guidelines, regulatory frameworks and other documents related to population genetic screening programmes in Europe. Then, the questions that need debate, in regard to different types of genetic screening before and after birth, were examined. Screening for conditions such as cystic fibrosis, Duchenne muscular dystrophy, familial hypercholesterolemia, fragile X syndrome, hemochromatosis, and cancer susceptibility was discussed. Special issues related to genetic screening were also examined, such as informed consent, family aspects, commercialization, the players on the scene and monitoring genetic screening programmes. Afterwards, these questions were debated by 51 experts from 15 European countries during an international workshop organized by the European Society of Human Genetics Public and Professional Policy Committee in Amsterdam, The Netherlands, 19-20, November, 1999. Arguments for and against starting screening programmes have been put forward. It has been questioned whether genetic screening differs from other types of screening and testing in terms of ethical issues. The general impression on the future of genetic screening is that one wants to 'proceed with caution', with more active impetus from the side of patients' organizations and more reluctance from the policy-makers. The latter try to obviate the potential problems about the abortion and eugenics issues that might be perceived as a greater problem than it is in reality. However, it seems important to maintain a balance between a 'professional duty of care' and 'personal autonomy'.

[Parent's information and prenatal diagnosis of cerebral malformation with an uncertain prognosis]

Fetal ultrasounds examinations allow identification of brain malformations; announce of diagnosis and information about prognosis may be difficult when malformation is rare and prognosis uncertain.

OBJECTIVES

In this study we tried to analyze how fetal imaging for prenatal screening was organized and how couples were managed and supported.

METHODS

We focused on the procedures used to inform couples: content, method of delivery and consequences. A referent physician in each large multidisciplinary center for prenatal diagnosis in Paris area was questioned by semi-directed interview.

RESULTS

Our study showed that it is difficult to standardize the way in which information is supplied before and after fetal ultrasounds examination; uncertainty about prognosis led more often to abortion.

CONCLUSION

Thus, couples should have clear and complete information provided by a multidisciplinary team including specialists particularly concerned by the malformation (neuropediatrician and/or neurosurgeon)--moreover when prognosis is uncertain, in order to support them, and to accompany their decision concerning pregnancy.

Affective state of women following a prenatal diagnosis: predictors of a negative psychological outcome

OBJECTIVE

The benefits of prenatal diagnostic procedures are well documented. However, the investigation of psychological consequences related to these procedures has remained a surprisingly neglected area of research. The main aim of the present study was to investigate the potential relationship between psychological outcome and associated (socio-demographic, psychological and obstetric) variables in women attending a tertiary referral center for prenatal diagnosis and therapy for ultrasound scanning (due to the suspicion of a fetal malformation raised by the gynecologist in private practice), amniocentesis or chorionic villus sampling.

METHODS

Affective state was assessed by means of standardized measures of anxiety and depression (State-Trait Anxiety Inventory; Mood Scale) in 77 consecutive, unselected women. A follow-up investigation, including an additional assessment of coping mechanisms, took place 6 months after the first contact. Given the considerable number of intervening and correlating factors, a path analysis was undertaken.

RESULTS

We found that all women in our sample experienced acute distress, not only those with proven fetal malformations, genetic disorders or intrauterine fetal death, but also those with the diagnosis of a sonographic sign. At baseline (i.e. immediately after the diagnostic procedure), mood and anxiety scores in our sample were found to be comparable to those of patients with a major depressive episode. A high trait anxiety level, implementation of negative coping strategies and loss of the child during pregnancy were found to be predictive of a negative psychological outcome at follow-up. Socio-demographic variables did not have a significant predictive function for the psychological outcome.

CONCLUSIONS

We assume that a considerable number of women undergoing prenatal diagnostic procedures experience psychological distress, which may be underestimated by workers in prenatal care. Establishment of interdisciplinary treatment settings, in which access to psychological support is facilitated, may be extremely beneficial for women following a prenatal diagnosis.

Prenatal diagnosis of cerebral malformation with an uncertain prognosis: a study concerning couple’s information and consequences on pregnancy

Fetal ultrasound (FU) is used during almost all pregnancies and makes a large contribution to the identification of fetal malformation. It is particularly difficult to announce a malformation, particularly those affecting the brain, because there are often doubts concerning both the diagnosis and the prognosis.

AIM

The aim of this study was to analyze how imaging for prenatal screening is organized and how couples are managed and supported. We concentrated on the procedures used to inform couples: content, method of delivery and consequences.

METHOD

Study amongst large multidisciplinary centers in Paris and the Paris region, by semi-directed interviews using a questionnaire.

RESULTS

We showed that it is difficult to standardize the way in which information is supplied before and after the examination, and that doctors tend to recommend abortion when the prognosis is uncertain.

DISCUSSION

These results provide information that will help decision-making concerning a standardized procedure allowing couples to benefit from all the capacities of prenatal screening, particularly when the diagnosis and prognosis are uncertain. There is a need for multidisciplinary teams to support and to accompany the decision concerning whether to have an abortion or to continue the pregnancy.

A community-based obstetric ultrasound service

OBJECTIVES

To investigate the impact of an ultrasound dating service on obstetric services.

METHODS

A prospective trial with 3009 unselected women presenting for antenatal care at two Midwife Obstetric Units in a socioeconomically deprived urban area, South Africa. In the study unit, student ultrasonographers provided a basic ultrasound service. In the control unit, obstetric ultrasound was only available for specific indications. The main outcome measures were number of antenatal visits and referrals for fetal surveillance.

RESULTS

The two cohorts were comparable except for the number of primigravidas but stratified analysis according to parity did not affect the results. Ultrasonography did not alter pregnancy outcome but reduced the number of perceived preterm labors/ruptured membranes (12.0 vs. 16.7%, P<0.003), post-term deliveries (8.1 vs. 10.8%, P<0.04) and referrals for fetal surveillance [15.9 vs. 29.6%, P<0.000, RR 0.79 (0.71-0.88)].

CONCLUSIONS

This community-based basic ultrasound service significantly reduced referrals to a regional center for fetal surveillance and delivery.

Post-diagnostic abortion in Germany: reproduction gone awry, again?

Routine use of prenatal diagnostic technologies (PDTs) such as ultrasound and amniocentesis result in the detection of a small percentage of fetal anomalies. For those women faced with the diagnosis of fetal disability, a decision must be made to continue or terminate the pregnancy. When the diagnosis is merely hypothetical, the discursive specter of post-diagnostic abortion is shaped by social and historical contexts in which interested discourses (regional, political, ethical, and religious) weigh in with varying degrees of authority and influence. However, when the diagnosis is actual, in this sample population of women, an estimated minimum of 90% opt to terminate their pregnancies. Data collected at two German hospitals-one in former East Germany, one in former West Germany-illuminate rates of PDT use and provide data with which to discuss the specter of post-diagnostic abortion in relation to mainstream medical discourses, Germany's divided history, abortion politics, feminism, disability activism, and religion. These data demonstrate how reproductive discourses are shaped by ideological and historical contingencies, even when women's ultimate reproductive decisions are not.

Impact of prenatal diagnosis on livebirth prevalence of children with congenital anomalies

The objectives of this study were to describe the impact of prenatal diagnosis on the birth prevalence of congenital anomalies over 21 years (1979-1999) in a well defined population in northeastern France (13,500 births per year). The material for this study came from the analysis of data from multiple sources on births and terminations of pregnancy after prenatal diagnosis of congenital anomalies in 279,642 consecutive pregnancies of known outcome. The study period was divided into three subgroups 1979-1988, 1989-1993 and 1994-1999. Between 1979-1988, 1989-1993 and 1994-1999, prenatal detection of congenital anomalies increased, respectively, from 12.0% to 25.5% and to 31.7%. Termination of pregnancy (TOP) increased in the same proportions during the three time periods. However, the increase of TOP was much higher for chromosomal anomalies than for nonchromosomal congenital anomalies. The birth prevalence of Down's syndrome fell by 80% from 1979-1988 to 1994-1999. Sensitivity of prenatal detection of congenital anomalies and TOPs were lower for isolated cases (only one malformation present in the fetus) than for multiple malformations in the same fetus. Sensitivity varied with the type of malformations: it was high for neural tube defect (79.7%) and urinary anomalies (50.7%) and low for congenital heart defects (16.4%). In conclusion, the introduction of routine prenatal diagnosis has resulted in a significant fall in the birth prevalence of children with congenital anomalies. However, this fall varied with the types of congenital anomalies.

Ultrasound in prenatal diagnosis: polemics around routine ultrasound screening for second trimester fetal malformations

Ultrasound for routine fetal malformation screening has been polemical from its early beginning because of the very broad range of diagnosis rates disclosed, i.e. from 13% to 82%, average 27.5%. A review of available studies is proposed to assess objectively the efficacy of ultrasound, considering also economical, ethical and methodological aspects as influential factors for choosing a routine screening policy. The utility of fetal malformation diagnosis before birth is brought forward, including second opinion, karyotyping, poly-disciplinary case discussion prior to management. Method and material of reviewed studies considerably vary and might influence the sensitivity results, as the choice of the population sample and selection of pregnant women, gestation age at screening, distribution of malformation among systems or tracts, exclusion of some fetal malformation and the routine practice of autopsy. Efficiency of screening studies is compared, and among them Radius and Eurofetus studies. Average sensitivity is finally considered as satisfactory in the daily practice when operated by trained personnel. The importance of additional factors for successful screening are emphasized such as education, equipment quality and fetal ultrasound examination at different gestation age for a better understanding of natural history of fetal morphology.

Receipt of information and women's attitudes towards ultrasound scanning during pregnancy

OBJECTIVE

To audit women's receipt of information during routine antenatal ultrasound investigations; and to investigate women's perceptions of, and attitudes towards, routine screening.

DESIGN

Analysis of the records of 384 women from in and around Nottingham, UK, who maintained a diary throughout the course of their pregnancies.

RESULTS

The mean number of ultrasound scans received by each women during her pregnancy was 2.6, with more than 96% of women receiving at least one scan. Women initially scanned earlier received more scans in total. Women appeared aware of the specific reasons for each scan being undertaken, and only a minority were dissatisfied by the information they had received. The preponderance of information received during the scans related to results and arrangements for subsequent visits, with only 10% of women reporting receiving information about the procedure itself. Most women reported positive feelings towards scanning, and few gave indications that they would prefer changes in the conduct of the procedure.

CONCLUSIONS

The great majority of the women in our study were satisfied with their experiences of routine ultrasound scanning, accepting the procedure uncritically.