Looking at the Unborn: Historical aspects of obstetric ultrasound

Edited trascript of a Witness Seminar held at the Wellcome Institute for the History of Medicine,in London, on 10 March 1998. First published by the Wellcome Trust, 2000. ©The Trustee of the Wellcome Trust, London, 2000. All volumes are freely available online at: www.history.qmul.ac.uk/research/modbiomed/wellcome_witnesses/Annotated and edited transcript of a Witness Seminar held on 10 March 1998. Introduction by E M Tansey.Annotated and edited transcript of a Witness Seminar held on 10 March 1998. Introduction by E M Tansey.Annotated and edited transcript of a Witness Seminar held on 10 March 1998. Introduction by E M Tansey.Annotated and edited transcript of a Witness Seminar held on 10 March 1998. Introduction by E M Tansey.The obstetric ultrasound scanner had its major origins in a programme of research undertaken in Glasgow in the 1950s and 1960s, under the leadership of the obstetrician, Professor Ian Donald. Donald’s work was characterized by a remarkable series of collaborations between engineers and clinicians, many of whom took part in this Witness Seminar to consider the early history of ultrasound imaging, its technical development and significant clinical applications in the diagnosis of fetal abnormalities. Technical and engineering developments of the scanner were discussed and it was practical demonstrations of the early scanners that gradually convinced the majority of obstetricians to invest time and training in this new technology. Participants include: Mr Usama Abdulla, Mr Thomas Brown, Professor Dugald Cameron, Professor Stuart Campbell, Mr John Fleming, Professor John MacVicar, Professor Peter Wells and Dr James Willocks. Tansey E M, Christie D A. (eds) (2000) Looking at the unborn: Historical aspects of obstetric ultrasound, Wellcome Witnesses to Twentieth Century Medicine, vol. 5. London: The Wellcome Trust.The Wellcome Trust is a registered charity, no. 210183

Focal Spot, Winter 2006/2007

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Looking at the unborn: historical aspects of obstetric ultrasound

The obstetric ultrasound scanner had its major origins in a programme of research undertaken in Glasgow in the 1950s and 1960s, under the leadership of the obstetrician, Professor Ian Donald. Donald’s work was characterized by a remarkable series of collaborations between engineers and clinicians, many of whom took part in this Witness Seminar to consider the early history of ultrasound imaging, its technical development and significant clinical applications in the diagnosis of fetal abnormalities. Technical and engineering developments of the scanner were discussed and it was practical demonstrations of the early scanners that gradually convinced the majority of obstetricians to invest time and training in this new technology. Participants include: Mr Usama Abdulla, Mr Thomas Brown, Professor Dugald Cameron, Professor Stuart Campbell, Mr John Fleming, Professor John MacVicar, Professor Peter Wells and Dr James Willocks. Introduction by E M Tansey, v, 80pp. 15 illustrations, glossary, subject and name index

Inexperienced sonographers can successfully visualize and assess a three-dimensional image of the fetal face using a standardized ultrasound protocol

Introduction: A standardized three-dimensional ultrasonographic (3DUS) protocol is described that allows fetal face reconstruction. Ability to identify cleft lip with 3DUS using this protocol was assessed by operators with minimal 3DUS experience. Material and Methods: 260 stored volumes of fetal face were analyzed using a standardized protocol by operators with different levels of competence in 3DUS. The outcomes studied were: (1) the performance of post-processing 3D face volumes for the detection of facial clefts; (2) the ability of a resident with minimal 3DUS experience to reconstruct the acquired facial volumes, and (3) the time needed to reconstruct each plane to allow proper diagnosis of a cleft. Results: The three orthogonal planes of the fetal face (axial, sagittal and coronal) were adequately reconstructed with similar performance when acquired by a maternal-fetal medicine specialist or by residents with minimal experience (72 vs. 76%, p = 0.629). The learning curve for manipulation of 3DUS volumes of the fetal face corresponds to 30 cases and is independent of the operator's level of experience. Discussion: The learning curve for the standardized protocol we describe is short, even for inexperienced sonographers. This technique might decrease the length of anatomy ultrasounds and improve the ability to visualize fetal face anomalies

Diagnostic accuracy of intracranial translucency in detecting spina bifida: a systematic review and meta-analysis

OBJECTIVE: To evaluate the diagnostic accuracy of intracranial translucency (IT) in the detection of spina bifida (SB) in the first trimester of pregnancy. METHODS: We included study assessing the accuracy of sonographic measurements of IT in a mid-sagittal view of the fetal face in prediction of SB in the first trimester of pregnancy. The primary outcome was the accuracy of IT in prediction of spina bifida. Summary estimates of sensitivity, specificity, positive and negative likelihood ratios (LR), and diagnostic odds ratio for the overall predictive accuracy of IT were computed. RESULTS: Nine studies (21 070 fetuses) were included in the analysis. IT was successfully assessed in the majority of fetuses 97.8% (95% CI 97.6-98.0). The diagnostic performance of IT in detecting SB was as follows: sensitivity: 53.5% (95% CI 42.4-64.3), specificity: 99.7% (95% CI 99.6-99.8), positive LR: 62.1 (95% CI 12.2-317), negative LR:0.55 (95% CI 0.45-0.68), and diagnostic odds ratio: 223 (95% CI 25-2039). CONCLUSIONS: Intracranial translucency had low diagnostic accuracy in prediction of open spina bifida, thus questioning its role as a screening marker for open SB in an unselected population. When looking at the individual study data, it appears that IT assessment for open SB prediction can be affected by a high rate of false positive results potentially leading to unnecessary parental anxiet

Two- versus three-dimensional ultrasound in the second and third trimester of pregnancy: impact on recognition and maternal-fetal bonding. A prospective pilot study

Objective: To assess the impact of three-dimensional (3D) versus two-dimensional (2D) ultrasound (US) on maternal-fetal bonding. Study design: Prospective randomized pilot study among low risk women with singleton fetuses in the second and third trimester. Dependent on the randomization pattern, US was commenced either with 2D US or 3D US and the effects were recorded with standardized questionnaires. Results: Sixty patients were included. Although the quality of 2D US, assessed by the examinator, was superior to 3D US, maternal recognition was higher with 3-D US (P=0.004). With 2D US, nulliparous patients had significantly more difficulties visualizing the fetus, than multiparous (P=0.03). However, the maternal preference of 3D US had no significant impact on maternal-fetal bonding. Conclusion: Ultrasound had no significant effect on maternal-fetal bonding. Three-dimensional images may facilitate recognition of the fetus, but 3D US did not have higher impact on maternal-fetal bonding. This finding may be a reason not to consider 3D ultrasound for routine scannin

Amnion cells engineering: A new perspective in fetal membrane healing after intrauterine surgery?

In this study we aimed to set up an in vitro culture of the rabbit amnion in order to support in vivo fetal membrane healing capacity following fetoscopy. Fetal membranes were collected from a mid- gestational rabbit, and cultured on collagen support material for 14 days. 34 rabbits at 22 - 23 days gestational age ( GA) underwent fetoscopy. The entry site was randomly allocated to 4 closure technique study groups: group I, human amnion membrane ( n = 23); group II, collagen foil ( n = 16); group III, collagen plug ( n = 19), and group IV, collagen plug with cultured amnion cells ( n = 19). In all groups membrane access sites were additionally sealed with fibrin sealant, and the myometrium was closed with sutures. Fetal survival, amnion membrane integrity, and the presence of amniotic fluid were evaluated at 30 days GA. Cultures showed good survival in the collagen support material. Increased cellularity, survival and proliferations were observed. The amnion at the access site resealed in 58 - 64% of cases in groups II - IV, but none of the tested techniques was significantly better than the other. Histological examination indirectly revealed the anatomic repair of the membranes, since no entrapment of the membranes could be demonstrated in the myometrial wound. Copyright (c) 2006 S. Karger AG, Basel

Women’s experiences and reactions when a fetal malformation is detected by ultrasound examination

Background: Second trimester ultrasound examination among pregnant women in Sweden is almost universal. The detection of a fetal malformation on ultrasound puts health care providers and pregnant women in a difficult and precarious situation. What information and how it is communicated is crucial to women’s decision-making about continuing or terminating at pregnancy. The main aim of this thesis was to describe and analyze women’s experiences and reactions following the detection of a fetal malformation on an ultrasound scan. Methods: Two semi-structured in-depth interviews were performed, with women informed of a fetal malformation following an ultrasound scan. A total of 27 women took part in the first round of interviews: women continuing their pregnancy were interviewed, either in gestational week 30 or three weeks after the diagnosis; those terminating their pregnancy were interviewed two to four weeks after termination (Paper I). A second interview with 11 women who terminated their pregnancy was conducted six months after termination (Paper III). Two questionnaires were also administered. The first, answered by 99 women (Paper II) and comprising 22 study- specific questions along with emotional well-being and socio-demographics variables and medical and obstetric history, was conducted at the same time as the first stage of interviews. The other questionnaire, answered by 56 women incorporated common self- report instruments and was performed three times: first in gestational week 30, and then two respectively six months postpartum (Paper IV). Qualitative data were analyzed through content analysis, and quantitative data were analyzed through descriptive statistics. Results: The timing, duration, and manner of women’s initial counseling and ongoing support were shown to be important in the interaction between women and caregivers. Positive interactions improved the women’s ability to understand the information and fostered feelings of trust and safety, which in turn reduced their anxiety. Most of the women who expected a baby with an abnormality expressed their need for information on several occasions to help them make this difficult decision. They also wished for information from different specialists and continuity of care. These needs were even stronger in women who chose to terminate their pregnancy. We found women continuing their pregnancy to be at high risk of depressive symptoms, major worries, and high anxiety levels, both in mid-pregnancy, and at two months and one year postpartum. Despite these findings, the results of the maternal-fetal attachment scale for women who continued their pregnancy with a fetus diagnosed with a malformation indicated a high level of attachment. Conclusions and Clinical Implications: Effective communication, empathy and compassion, and consistent follow-up routines are important to ensure good treatment and care of this group of women. Taking these results into account may improve caregivers’ ability to counsel these vulnerable patients and to ensure that their needs are properly met

Staging achilles tendinopathy using ultrasound imaging: The development and investigation of a new ultrasound imaging criteria based on the continuum model of tendon pathology

AimTo develop a standardised ultrasound imaging (USI)-based criteria for the diagnosis of tendinopathy that aligns with the continuum model of tendon pathology. Secondary aims were to assess both the intra-rater and inter-rater reliability of the criteria.MethodsA criteria was developed following a face validity assessment and a total of 31 Achilles tendon ultrasound images were analysed. Intra-rater and inter-rater reliability were assessed for overall tendinopathy stage (normal, reactive/early dysrepair or late dysrepair/degenerative) as well as for individual parameters (thickness, echogenicity and vascularity). Quadratic weighted kappa (kw) was used to report on reliability.ResultsIntra-rater reliability was ‘substantial’ for overall tendinopathy staging (kw rater A; 0.77, 95% CI 0.59 to 0.94, rater B; 0.70, 95% CI 0.52 to 0.89) and ranged from ‘substantial’ to ‘almost perfect’ for thickness (kw rater A; 0.75, 95% CI 0.59 to 0.90, rater B; 0.84, 95% CI 0.71 to 0.98), echogenicity (kw rater A; 0.78, 95% CI 0.62 to 0.95, rater B; 0.73, 95% CI 0.58 to 0.89) and vascularity (kw rater A; 0.86, 95% CI 0.74 to 0.98, rater B; 0.89, 95% CI 0.79 to 0.99). Inter-rater reliability ranged from ‘substantial’ to ‘almost perfect’ for overall tendinopathy staging (kw round 1; 0.75, 95% CI 0.58 to 0.91, round 2; 0.81, 95% CI 0.63 to 0.99), thickness (kw round 1; 0.65, 95% CI 0.48 to 0.83, round 2; 0.77, 95% CI 0.60 to 0.93), echogenicity (kw round 1; 0.70, 95% CI 0.54 to 0.85, round 2; 0.76, 95% CI 0.58 to 0.94) and vascularity (kw round 1; 0.89, 95% CI 0.79 to 0.99, round 2; 0.86, 95% CI 0.74 to 0.98). Inter-rater reliability increased from ‘substantial’ in round 1 (kw 0.75, 95% CI 0.58 to 0.91) to ‘almost perfect’ in round 2 (0.81, 95% CI 0.63 to 0.99).ConclusionIntra-rater and inter-rater reliability were ‘substantial’ to ‘almost perfect’ when utilising an USI-based criteria to diagnose Achilles tendinopathy. This is the first study to use the continuum model of tendon pathology to develop an USI-based criteria to diagnose tendinopathy