The code word my sonographers and I use on this is "best", as in I did my ..., or this was the ... possible under the conditions present. If it was a matter of position and other factors - some non-obese patients are harder to scan - that are deemed to be likely to improve with time, we work patients in for repeat attempts, gratis. If a problem is suspected, they get to pay for a targeted study.
On the other hand, training and attention to detail and persistent attention to outcomes and quality are VERY important. The harder you try the better you get. With our current practice we identify the large majority of babies with subsequently identified chromosomal anomalies, including Down syndrome with NO identifiable structural anomalies. We have been humbled in this regard twice, so it is wrong to promise that a "genetic" sonogram is as good for detection of chromosomal anomalies as an amniocentesis. We do say that it is safer for a normal baby. We perform extremely few amniocenteses, and about 20% to a third are positive.
Excellent suggestion... I will add it to the possible topics for papers in
the Current Issues in Sonography course.
Terry J. DuBose, M.S., RDMS, FSDMS, FAIUM
4301 West Markham St. Mail Slot #563
P Please consider the environment before printing this e-mail
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-----Original Message-----
From: ultrasound@obgyn.net [mailto:ultrasound@obgyn.net] On Behalf Of
jworrall@alaska.net
Sent: Saturday, July 12, 2008 12:25 PM
To: Multiple recipients of list ULTRASOUND
Subject: Re: Birthweight Prediction in Obese Gravidas
And there certainly is no shortage of obese pregnant patients these days. I
am finding obesity is becoming a major factor in reducing the accuracy of
prenatal ultrasound and nuchal translucency measurement. Maybe, as the
Philips ultrasound ads say, the answer is in better transducer crystals and
better ultrasound machines.
A serious study needs to be done, entitled "The impact of obesity on the
practice of prenatal ultrasound". Or a metaanalysis of the studies already
done: "Does obesity really impact the practice of prenatal ultrasound?"
Also, does obesity play a role in the medical liability cases brought
against sonographers and sonologists for alleged misdiagnosis or failure to
diagnose in prenatal cases? Do we assume greater medical liability risk when
we scan a very obese patient?
And what is the impact of obesity on the incidence of injury to the
sonographer? I have already told my referring physicians that I will not do
second trimester or third trimester triplets - I am old and it just is
physically too demanding. There are other places they can be scanned in our
community. I wish I could pass a similar rule about not accepting patients
above a certain BMI, but I do not think that would fly. But I find that
trying to scan under a heavy pannus while holding up the pannus with my
scanning hand and arm, is physically very difficult, and I actually have to
stop the scan and rest my right arm every few minutes. I have one husband
who was willing to hold up the pannus for me, difficult with all the gel on
the abdomen.
Here is how I try to deal with the problem: My ultrasound report routinely
records the patient's weight, height, and BMI. I make a statement as to my
evaluation of the quality of the imaging, ranging from "superb!" to "very
poor". I may qualify this by saying that the imaging was good except for the
fetal heart or the fetal brain or whatever part did not image well. Or I
might say the imaging was poor except for the parts that did scan well. In
doing the fetal biometry, if I have low confidence in a measurement (the AC
when there is no fluid around the fetal abdomen, and you are pretty much
guessing where to place the cursors) I will say that in my report. In other
words, I try to give the person reading the report an idea of how much
confidence to have in the report.
In a lighter vein, I think we should charge for prenatal ultrasound by the
pound, with the understanding that there are patients who scan so well, and
it is such a pleasure scanning them , that we pay them for the privilege of
scanning them.
And we should have a rule that at major ultrasound conventions, the models
that the manufacturers hire to demonstrate their machines must have a BMI of
40 or more. Then we could really tell what their machines could do.
Allen
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From: "art fougner, md" <evsono@pipeline.com>
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Sent: Saturday, July 12, 2008 6:28 AM
To: "Multiple recipients of list ULTRASOUND" <ultrasound@mail.obgyn.net>
Subject: Birthweight Prediction in Obese Gravidas
> Birth weight projection based on ultrasound measurements earlier in
> pregnancy may be better than standard prediction methods for obese
> women, researchers said.
>
> One such method using ultrasound measurement at 34 to 36 weeks predicted
> birth weight within 20% accuracy in more than 90% of cases, reported
> Loralei Thornburg, M.D., of the University of Rochester Strong Memorial
> Hospital here, and colleagues in the July issue of Ultrasound in
> Obstetrics and Gynecology.
>
> In their retrospective study, this gestation-adjusted prediction (GAP)
> method had lower sensitivity among morbidly obese women for the
> clinically important prediction of macrosomia, but could exclude
> macrosomia with more than 90% accuracy regardless of maternal body mass
> index.
>
> http://www.medpagetoday.com/OBGYN/Pregnancy/tb/10090
>
> Terry - this looks like a good research project for one of your
> students.
>
> Art
>
> --
> art fougner, md
> "May The Wings of Liberty Never Lose a Feather." - Jack Burton
>
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