Obstetric ultrasound: where are we and where are we going?

Assessing the applicability of obstetrical randomized controlled trials in real-world practices

This article examines the applicability of obstetrical randomized controlled trials (RCTs) in the real-world and proposes a classification of the value of these trials based on their potential for achieving sustainable practices. In the context of this discussion, real-world results pertain to the potential impact of the RCT on sustainable interventions and practices, and its implications for healthcare practice or policy, in the country (or countries) that was conducted. While RCTs are generally regarded as the gold standard of medical evidence, their effectiveness in producing meaningful real-world results depends, among various other factors, on the clarity and specificity of the trial definitions used for diagnosis (characteristics of the study group or enrollment criteria) and treatment (intervention). The definitions used for diagnosis and treatment, especially in pragmatic trials, can influence the likelihood for real-world implementation. By analyzing notable obstetrical RCTs, the authors find that trials with well-defined diagnoses and treatments that can be implemented without specialized expertise are more likely to generate results that are relevant to general practice, indicating higher value. In contrast, RCTs with ambiguous or undefined diagnoses and treatments often lead to variations in practice and produce unreliable real-world outcomes and practices suggesting lower value. Recognizing this variability can offer valuable guidance for the design and evaluation of RCTs in obstetrics.

The association between uterine fibroid number and size and risk of preterm birth

BACKGROUND

While the association between uterine fibroids and preterm birth is well known, data regarding whether fibroid characteristics such as number and size modify such risk are limited.

OBJECTIVE

To evaluate the association between fibroid number and size and risk of preterm birth and determine whether these characteristics impact the severity of preterm birth.

STUDY DESIGN

Multicenter retrospective cross-sectional study including all patients with singleton gestations who had at least one prenatal ultrasound at 18 0/7 weeks of gestation or later and delivered within a large university health system from January 1, 2019 to December 31, 2022. When fibroids were identified on ultrasound, their characteristics (i.e., number, size, and location) were documented. Patients with more than one delivery during the study period had only their first included for analysis. The primary outcome of preterm birth, stratified by gestational age (<37, <34, <32, and <28 weeks), was assessed based on fibroid number (1, 2, ≥3) and size (largest dimension <5 cm, 5-10 cm, >10 cm) separately in patients who had prenatally detected fibroids compared to those with no fibroids. Multivariate logistic regression was performed to adjust for potential confounders. Data were presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

Among the 65,950 patients studied, 4,421 (6.7%) had at least one fibroid. The prevalence of preterm birth <37 weeks was 8.6%. The presence of any fibroid, regardless of number, was associated with an increased risk of preterm birth <37 weeks compared to no fibroids (1 fibroid: 12.8% vs. 8.2%, aOR 1.26, 95% CI 1.10-1.44; 2 fibroids: 12.7% vs. 8.2%, aOR 1.27, 95% CI 1.01-1.58; ≥3 fibroids: 18.5% vs. 8.2%, aOR 1.60, 95% CI 1.29-1.99). Patients with 2 fibroids were at increased risk of preterm birth <34, <32, and <28 weeks compared to those without fibroids, while patients with ≥3 fibroids were at increased risk of preterm birth <34 and <28 weeks compared to those without fibroids. The presence of at least one fibroid, regardless of the size of their largest dimension, was associated with an increased risk of preterm birth <37 weeks compared to no fibroids (<5 cm: 12.4% vs. 8.2%, aOR 1.19, 95% CI 1.04-1.36; 5-10 cm: 15.5% vs. 8.2%, aOR 1.47, 95% CI 1.23-1.75; >10 cm: 21.4% vs. 8.2%, aOR 2.26, 95% CI 1.55-3.28). Increasing fibroid size by largest dimension was associated with an increased risk of preterm birth <34 weeks. Patients with fibroids >10 cm by largest dimension were at increased risk of preterm birth <28 weeks compared to those without fibroids. There was no association between increasing fibroid size by largest dimension and preterm birth <32 weeks.

CONCLUSIONS

Data from this large cohort suggest that fibroid characteristics such as number and size are associated with preterm birth and impact the severity of preterm birth. Increasing fibroid number and size is associated with a higher risk of earlier preterm birth compared to those without fibroids.

Enhancing ultrasound education in obstetrics and gynecology in Germany: insights and innovations from postgraduate training

BACKGROUND

Ultrasound (US) has become integral to obstetrics and gynecology (Ob/Gyn), necessitating proficient training during residency. Despite its clinical importance, there is a perceived gap in the quality and structure of postgraduate ultrasound education in Germany.

METHODS

A cross-sectional survey was conducted among Ob/Gyn residents in Germany from October 2023 to March 2024, using the LimeSurvey platform. The survey, distributed via email, social media, and physical flyers, garnered 211 participants, with 115 completing all sections. The questionnaire covered demographic details, US training experiences, and the perceived importance of US in clinical practice.

RESULTS

Although US was highly valued by respondents, with an average of 26.1% of their clinical activity devoted to it, there was significant dissatisfaction with the training quality. Key issues included inadequate supervision, the necessity of self-training, and low participation in certification courses. Despite 93.0% awareness of professional US organizations like the German Society for Ultrasound in Medicine (DEGUM), engagement with structured training programs was minimal.

DISCUSSION

The study highlights a critical need for standardized US training protocols and curricular reform in Ob/Gyn residencies in Germany. The discrepancy between the recognized importance of US and the quality of training indicates a pressing need for improvements. Addressing these gaps through comprehensive, structured educational reforms could significantly enhance the proficiency and confidence of future Ob/Gyn specialists, ultimately improving patient care.

Clinical Ultrasound Applications in Obstetrics and Gynecology in the Year 2024

Ultrasound imaging stands as a fundamental technology in the realms of obstetrics and gynecology, utilizing high-frequency sound waves to create detailed images of the internal structures of the body [...].

B-Flow/Spatiotemporal Image Correlation M-Mode and Contrast-Enhanced/Microbubble Ultrasonography Quantification of Spiral Artery Distensibility and Placental Intervillous Perfusion in the First Trimester in a Primate Model of Impaired Spiral Artery Remodeling

OBJECTIVE

During early human pregnancy, placental trophoblasts remodel spiral arteries into distensible low-resistance vessels to promote placental perfusion. We have established a model of impaired spiral artery remodeling (SAR) by elevating estradiol levels in the first trimester of baboon pregnancy. In the present study, B-flow/spatiotemporal image correlation (STIC) M-mode ultrasonography, a non-Doppler technology for sharp rendering of vessel dimensions, was used to determine whether spiral artery distensibility was altered in SAR-suppressed baboons. Contrast-enhanced ultrasound/microbubble imaging was also performed to determine whether it detected changes in placenta intervillous space perfusion in SAR-suppressed baboons.

METHODS

The two imaging procedures were performed in the first trimester in baboons not treated or treated with estradiol to suppress SAR.

RESULTS

Spiral artery distensibility, that is, luminal diameter at systole minus diameter at diastole, and volume flow as quantified by B-flow/STIC M-mode were 26% (p = 0.03) and 55% (p = 0.059) lower, respectively, in SAR-suppressed baboons. However, placental intervillous space flow rate and video intensity plateau levels reflecting blood perfusion, quantified by contrast-enhanced ultrasound/microbubble imaging, were unaltered in SAR-suppressed baboons.

CONCLUSION

The results indicate that B-flow/STIC M-mode ultrasonography provides a non-invasive method to detect reduced distensibility and, thus, function of spiral arteries across the cardiac cycle in the first trimester in a primate model of impaired SAR. This study represents a first step in determining whether B-flow/STIC M-mode detects a similar defect in SAR early in adverse human pregnancy. This would provide an avenue to develop therapeutic modalities to prevent the devastating consequences of impaired SAR.

The effect of China's many-child policy on the number of births and the prevalence of serious teratogenic and disabling defects in Hunan Province

BACKGROUND

To research the effect of China's many-child policy on the number of births and the prevalence of serious teratogenic and disabling defects (STDDs) in Hunan province.

METHODS

We performed an observational study based on the Birth Defect (BD) Surveillance System of Hunan Province and chose STDD case cards. From 2012-2022, we defined the following 4 periods: the one-child policy (OCP) (2012.01-2013.12), partial two-child policy (PTCP) (2014.1-2015.12), universal two-child policy (UTCP) (2016.1-2020.12), and the early stage of the three-child policy (ETCP) (2021.1-2022.12). Crude odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to examine the association of policy changes with STDDs. Crame'r's V was calculated to estimate the effect sizes. Joinpoint regression analysis and annual percent change (APC) were used for each segment of the trend.

RESULTS

A total of 1,652,079 births were included in this analysis. Joinpoint regression analysis showed that the number of perinatal births increased from 2012 to 2017, with APC = 9.52 (95% CI: 7.2 to 11.8), and decreased from 2017 to 2022, with an APC = -10.04 (95% CI: -11.9 to -8.1). The number of mothers over 30 years old gradually increased, from 25.54% during the OCP period to 54.05% during the ETCP period (Ptrend < 0.001). With policy changes, the total prevalence of STDDs increased from 28.10 per 10,000 births during the period of OCP into 46.77 per 10,000 births during the ETCP period by 66.44%. The live birth prevalence of STDDs increased only during the ETCP period (PTCP: OR = 1.27, 95% CI: 0.99-1.24, p = 0.057, UTCP: OR = 1.22, 95% CI: 0.99-1.52, p = 0.067, ETCP: OR = 1.75, 95% CI: 1.37-2.24, p < 0.001). Over the past ten years, there was a decrease in the gestational age at diagnosis (*F = 772.520, p < 0.001), from 24.49 ± 5.65 weeks in 2012 to 20.77 ± 5.17 weeks in 2022. From 2012 to 2022, the percentage of deaths within 7 days decreased with APC = -18.85 (95% CI: -26.4- -10.5, P > 0.05).

CONCLUSION

Many-child policies were associated with a moderate increase in fertility especially for women in urban areas and older women. However, they have lost the ability to control birth since 2017. The total prevalence of STDDs increased over the entire period, but the live birth prevalence increased only during the ETCP period. The gestational age at diagnosis decreased and the percentage of deaths within 7 days decreased.

A cost minimization analysis comparing asynchronous tele-expertise with face-to-face consultation for prenatal diagnosis in France

Timely detection of congenital anomalies using ultrasound improves neonatal care. As specialist sonographers are often geographically dispersed, they are sometimes requested to provide a second opinion via tele-expertise. The present study aimed to evaluate the economic impact of asynchronous tele-expertise in obstetric ultrasound care in private medical practice through a comparison with face-to-face consultations. We conducted a cost minimization analysis using decision tree modeling in order to determine whether asynchronous tele-expertise or face-to-face consultation had the lowest cost, under the assumption of equivalent effectiveness in terms of prenatal diagnosis. Costs were measured from the societal perspective. The data for the base case of our modeling came from a retrospective analysis of the clinical practice of an expert who had been conducting asynchronous tele-expertise for 4 years in France. The study included 260 patients for whom 322 requests for expert opinions were made by physicians/midwives from January 2016 to January 2020. The expected average total cost for tele-expertise for a patient was €74.45 (95% CI: €66.36-€82.54) compared to €195.02 (95% CI: €183.90-€206.14) for the conventional face-to-face strategy. Accordingly, using tele-expertise led to a statistically significant reduction of €120.57 in the average total cost per patient. A sensitivity analysis confirmed the robustness of the model produced. The results of the present study underline the efficiency of tele-expertise and highlight related economic benefits. Accordingly, they could inform public health policy on the dissemination of tele-expertise in the field of obstetric ultrasound care.

Obstetric Ultrasonography in Postgraduate Radiology Training: A National Survey Study

ABSTRACT

There is no study in the literature that reveals the adequacy of obstetric ultrasonography (US) training in Turkey. We aimed to evaluate the adequacy of obstetric US training radiologists had received during their residency and determine how competent they considered themselves to be in this regard.A survey (27 items for residents, 21 items for specialists) was sent to all the radiology residents and specialists in Turkey through the mail list of the Turkish Society of Radiology.Ninety-one residents and 217 specialists participated in our study. Sixteen residents (17.6%) had received theoretical courses, 21 residents (23.1%) and 59 specialists (27.2%) had attended in-house obstetric US rotations, and 5 residents (5.5%) and 23 specialists (10.6%) had attended obstetric US rotations in another institution. When questioned separately for each trimester, only 11% to 36.3% of the residents stated that they took care of a sufficient number of patients. In general, 62.6% of the residents and 25.3% of the specialists did not consider themselves to be absolutely competent in obstetric US. The competency sources were specified as residency training by 44 residents (48.6%) and 55 specialists (25.3%), postgraduate training by 2 residents (2.2%) and 78 specialist (35.9%).In Turkey, current obstetric US training does not provide the experience that will allow physicians with radiology training to easily perform and interpret obstetric US. The main reasons for this situation include the limited number of patients the physicians took care of as a resident, insufficient rotation time, and lack of theoretical courses they attended.

Evaluation of antenatal Point-of-Care Ultrasound (PoCUS) training: a systematic review

INTRODUCTION

There is limited access to life-saving antenatal ultrasound in rural and low-resource settings largely due to shortages in skilled staff. Studies have shown healthcare practitioners can be upskilled in PoCUS through focused training, offering a viable solution to this deficit. However, standards for training and competency assessment are unclear and regulation surrounding practice is lacking. We aimed to review published literature examining antenatal PoCUS training programs, comparing teaching approaches and study methodologies.

METHODS

A search of electronic databases EMBASE, MEDLINE and Google Scholar was conducted. Original research articles evaluating antenatal PoCUS training of healthcare professionals worldwide were identified for analysis. Articles with limited detail on the PoCUS training intervention and those describing comprehensive diagnostic training programs were excluded. Evaluations were compared against the Kirkpatrick Evaluation Framework (KEF).

RESULTS

Twenty-seven studies were included from an initial search result of 484 articles. There was considerable heterogeneity between the PoCUS training programs described. Course duration ranged from 3 hours to 2 years, with 11 of the 27 studies delivering obstetric-exclusive content. 44% trained multidisciplinary groups of health professionals. Long-term follow-up training and skills assessments were lacking in over half of the reviewed studies. Study quality and reporting detail varied, but overall beneficial outcomes were reported with 3/4s of the studies reaching upper KEF levels 3 and 4.

CONCLUSION

PoCUS performed by upskilled healthcare professionals offers an attractive solution to the problem of inequitable access to antenatal ultrasound. A review of available literature highlighted a paucity of comparable high-quality studies needed to establish a stronger evidence base for antenatal PoCUS, and a need to standardise training and competency assessment. This review may inform educators, researchers and policy-makers on existing training formats and methodologies to assist in establishing best practice antenatal PoCUS training methods for safe service delivery by remote healthcare professionals.

Imaging fetal anatomy

Due to advancements in ultrasound techniques, the focus of antenatal ultrasound screening is moving towards the first trimester of pregnancy. The early first trimester however remains in part, a 'black box', due to the size of the developing embryo and the limitations of contemporary scanning techniques. Therefore there is a need for images of early anatomical developmental to improve our understanding of this area. By using new imaging techniques, we can not only obtain better images to further our knowledge of early embryonic development, but clear images of embryonic and fetal development can also be used in training for e.g. sonographers and fetal surgeons, or to educate parents expecting a child with a fetal anomaly. The aim of this review is to provide an overview of the past, present and future techniques used to capture images of the developing human embryo and fetus and provide the reader newest insights in upcoming and promising imaging techniques. The reader is taken from the earliest drawings of da Vinci, along the advancements in the fields of in utero ultrasound and MR imaging techniques towards high-resolution ex utero imaging using Micro-CT and ultra-high field MRI. Finally, a future perspective is given about the use of artificial intelligence in ultrasound and new potential imaging techniques such as synchrotron radiation-based CT to increase our knowledge regarding human development.

Function and Safety of SlowflowHD Ultrasound Doppler in Obstetrics

SlowflowHD is a new ultrasound Doppler imaging technology that allows visualization of flow within small blood vessels. In this mode, a proprietary algorithm differentiates between low-speed flow and signals attributed to tissue motion so that microvessel vasculature can be examined. Our objectives were to describe the low-velocity Doppler mode principles, to assess the bone thermal index (TIb) safety parameter in obstetric ultrasound scans and to evaluate adherence to professional guidelines. To achieve the latter goals, we retrospectively reviewed prospectively collected ultrasound images and video clips from pregnancy ultrasound scans at >10 wk of gestation over 4 mo. We used a custom-built optical character recognition-based software to automatically identify all images and video clips using this technology and extract the TIb. Overall, a total of 185 ultrasound scans performed by three fetal medicine physicians were included, of which 60, 54 and 71 scans were first-, second- and third-trimester scans, respectively. The mean (highest recorded) TIb values were 0.32 (0.70), 0.23 (0.70) and 0.32 (0.60) in the first, second, and third trimesters, respectively. Thermal index values were within recommended values set by the World Federation for Ultrasound in Medicine and Biology American Institute of Ultrasound in Medicine and British Medical Ultrasound Society in all scans.

A 10-Year Retrospective Review of Prenatal Applications, Current Challenges and Future Prospects of Three-Dimensional Sonoangiography

Realistic reconstruction of angioarchitecture within the morphological landmark with three-dimensional sonoangiography (three-dimensional power Doppler; 3D PD) may augment standard prenatal ultrasound and Doppler assessments. This study aimed to (a) present a technical overview, (b) determine additional advantages, (c) identify current challenges, and (d) predict trajectories of 3D PD for prenatal assessments. PubMed and Scopus databases for the last decade were searched. Although 307 publications addressed our objectives, their heterogeneity was too broad for statistical analyses. Important findings are therefore presented in descriptive format and supplemented with the authors’ 3D PD images. Acquisition, analysis, and display techniques need to be personalized to improve the quality of flow-volume data. While 3D PD indices of the first-trimester placenta may improve the prediction of preeclampsia, research is needed to standardize the measurement protocol. In highly experienced hands, the unique 3D PD findings improve the diagnostic accuracy of placenta accreta spectrum. A lack of quality assurance is the central challenge to incorporating 3D PD in prenatal care. Machine learning may broaden clinical translations of prenatal 3D PD. Due to its operator dependency, 3D PD has low reproducibility. Until standardization and quality assurance protocols are established, its use as a stand-alone clinical or research tool cannot be recommended.

Applications of Advanced Ultrasound Technology in Obstetrics

Over the years, there have been several improvements in ultrasound technologies including high-resolution ultrasonography, linear transducer, radiant flow, three-/four-dimensional (3D/4D) ultrasound, speckle tracking of the fetal heart, and artificial intelligence. The aims of this review are to evaluate the use of these advanced technologies in obstetrics in the midst of new guidelines on and new techniques of obstetric ultrasonography. In particular, whether these technologies can improve the diagnostic capability, functional analysis, workflow, and ergonomics of obstetric ultrasound examinations will be discussed.