Cesarean Scar Ectopic Pregnancy—The Importance of Ultrasound for Early Detection

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Cesarean scar ectopic pregnancy occurs when an embryo implants into or on a prior cesarean scar, and carries a high burden of maternal morbidity and increased risk of maternal mortality when left untreated.1 The estimated incidence is approximately 1 in 1800–2000 pregnancies after cesarean delivery.2 The key to prompt treatment is early identification, most commonly and easily accomplished with transvaginal ultrasound.

Cesarean delivery is the most commonly performed surgery in the world. In the United States, according to the Centers for Disease Control’s Stats of the States data from 2021,  the cesarean delivery rate varies from 24.3% in Utah to a high of 38.3% in Mississippi.3 While cesarean is often a necessary procedure in cases of fetal intolerance of labor, fetal malpresentation, or labor arrest, this surgery impacts future pregnancy, increasing the risks of the need for repeat surgical deliveries, uterine rupture during attempted labor, and placenta accreta spectrum disorders, the latter of which experts now recognize start as cesarean scar ectopic pregnancies.

Following any full-thickness myometrial surgery, just as with any other muscle, the transected myometrial fibers never truly heal together as they once were. Rather, the reapproximated ends are joined by a line of fibrosis, which may partially dehisce, and lack the usual thickness and elasticity of uncompromised myometrium. This scar sometimes retains some structural integrity, but often results in a “niche” or hollowed-out area within the muscle,4,5 where an embryo may implant.

Cesarean scar ectopic pregnancy (CSEP) is easiest to detect sonographically early in the early first trimester, when it can be recognized as a low implantation that is offset more anteriorly than normal, often leaving the endometrial cavity and cervical canal empty.6 Additional criteria for the diagnosis of  CSEP include thin or undetectable myometrium between the placenta and bladder and unusually increased vascularity between the placenta/sac and bladder or internal cervical os. 

Some experts have proposed simple-to-perform measurements, such as the “crossover sign,” whereby a line is drawn in the sagittal plane connecting the internal os with the fundus by drawing a line along the endometrial canal.7 When the superior-inferior diameter of the gestational sac is measured perpendicularly to this line, the relationship of the gestational sac to the endometrial line can be determined.6 In CSEPs in which a majority of the gestational sac is closer to the anterior wall (crosses over the endometrial line), there is a higher rate of severe forms of placenta accreta spectrum and risk for rupture when CSEPs are managed conservatively.7,8

As pregnancy progresses, the gestational sac may grow into the endometrial cavity, making the diagnosis more difficult. Treatment is also more difficult as pregnancy progresses, whereby medical or mechanical management options, such as use of a double balloon catheter are less effective, and surgical resection or combination therapy may be required. The risk of complications including uterine rupture, massive bleeding, and need for emergent hysterectomy that approaches 53% of reported cases are reasons why expectant management is not recommended, especially as early treatment has efficacy rates that are reported between 65% to more than 99% with low complication rates, and with a high likelihood of fertility preservation.  

Early recognition and referral are paramount and provide one more example of how ultrasound can and does save lives.

References:

1. Calì G, Timor-Tritsch IE, Palacios-Jaraquemada J, et al. Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2018; 51:169–175. doi:10.1002/uog.17568

2. Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol 2012; 207:14–29.

3. Centers for Disease Control. Stats of the States – Cesarean Delivery Rates. https://www.cdc.gov/nchs/pressroom/sosmap/cesarean_births/cesareans.htm. Accessed March 30, 2024.

4. Einerson BD, Comstock J, Silver RM, Branch DW, Woodward PJ, Kennedy A. Placenta accreta spectrum disorder: uterine dehiscence, not placental invasion. Obstet Gynecol 2020; 135:1104–1111. doi:10.1097/AOG.0000000000003793.

5. Jauniaux E, Jurkovic D, Hussein AM, Burton GJ. New insights into the etiopathology of placenta accreta spectrum. Am J Obstet Gynecol 2022; 227:384–391. doi:10.1016/j.ajog.2022.02.038.

6. Timor-Tritsch IE, Monteagudo A, Calì G, D’Antonio F, Kaelin Agten A. Cesarean scar pregnancy: diagnosis and pathogenesis. Obstet Gynecol Clin North Am 2019; 46:797–811. doi:10.1016/j.ogc.2019.07.009.

7. Cali G, Forlani F, Timor-Tritsch IE, Palacios-Jaraquemada J, Minneci G, D’Antonio F. Natural history of Cesarean scar pregnancy on prenatal ultrasound: the crossover sign. Ultrasound Obstet Gynecol 2017; 50:100–104. doi:10.1002/uog.16216.

8. Calì G, Calagna G, Khalil A, Polito S, Labate F, Cucinella G, D’Antonio F. First trimester prediction of uterine rupture in cesarean scar pregnancy [published online ahead of print April 20, 2022]. Am J Obstet Gynecol. doi: 10.1016/j.ajog.2022.04.026.

9. Miller R, Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine consult series #63: cesarean scar ectopic pregnancy. Am J Obstet Gynecol 2002 Sep: 227(3):B9–B20. doi: https://doi.org/10.1016/j.ajog.2022.06.024.

Karin A. Fox, MD, MEd, FACOG, FAIUM, is a Professor of Maternal-Fetal Medicine and Director of the Placenta Accreta Spectrum Disorders Program at the University of Texas Medical Branch at Galveston.

Recommendations for Improved Safety of Lung Ultrasound

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Lung ultrasound (LUS) has been emerging as a vital clinical tool. LUS aids in diagnosing a range of conditions, from pneumonia to respiratory distress syndrome or pulmonary edema. LUS was also very significant at the height of the COVID-19 pandemic, when point-of-care lung monitoring modalities were crucial.  

Diagnostic ultrasound standards and safety guidelines were established in the late 20th century to ensure the safety of ultrasound imaging and avoid ultrasound bioeffects in tissues. The Thermal Index (TI) and Mechanical index (MI) are two ultrasound exposure indices that respectively indicate the risks of tissue heating and cavitation and which must be displayed in real time during scanning. However, the lung is a tissue like no other, and the bioeffects observed in animal studies (in mice, rabbits, pigs, and monkeys) are very different from the bioeffects observed in other tissues. Capillary pulmonary hemorrhage is a unique bioeffect that is correlated to the MI. In order to avoid such specific ultrasound bioeffects, a new safety paradigm must be created for LUS.

Despite guidelines recommending MI ≤ 0.4, recent research suggests that a further reduction to MI ≤ 0.3 for enhanced safety might be needed. In addition, it is critical to account for the actual MI in situ, which is influenced by the thickness of the chest wall. This is particularly concerning in neonatal LUS safety, due to thin chest walls and intensive use.

Existing safety education varies among practitioners, and surveys indicate a lack of knowledge regarding lung ultrasound safety. In the absence of an appropriate preset, pre-installed on all machines, for neonatal LUS guaranteeing an MI ≤ 0.3, the risk of error and exposure to higher MI is significant. In pediatric and adult patients with a thicker chest wall, a higher MI would be acceptable, as long as adherence to the “as low as reasonably achievable” (ALARA) safety principle is maintained.

Overall, the recommendations for Improved Safety  of Lung Ultrasound are:

  1. To install a preset on all ultrasound machines limiting MI to ≤ 0.3 for neonatal cases.
  2. To provide a user-friendly means for practitioners to select the safety preset without manual adjustments.
  3. To allow higher MI values for pediatric and adult patients when needed for optimal imaging, considering higher ultrasound attenuation in thicker chest walls.
  4. To guide practitioners in adhering to the As Low As Reasonably Achievable (ALARA) principle and by considering the chest wall attenuation for MI > 0.3.
  5. To develop a specific Mechanical Index for Lung (MIL). The creation of a unique MIL for LUS, displayed on-screen to estimate pleural exposure accurately would increase safety and safety awareness among practitioners.

Enhancing safety in LUS requires a multifaceted approach, encompassing preset implementation, practitioner education, and technological advancements. The proposed recommendations aim to address current safety challenges, ensuring the continued effectiveness and safety of lung ultrasound in diverse clinical settings and for diverse populations (from neonates to high BMI patients). By combining technological innovations with user-friendly controls, the proposed safety paradigm seeks to strike a balance between optimal imaging outcomes and patient safety in the evolving landscape of LUS.

For more information, see the “Statement and Recommendations for Safety Assurance in Lung Ultrasound” from the American Institute of Ultrasound in Medicine (AIUM)

Marie Muller, PhD, is an Associate Professor of Mechanical and Aerospace Engineering at NC State University.

Introduction to the Emerging Field of Post Cranioplasty Neurosonography

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The field of neurosonography has evolved in the past few decades facilitating detailed anatomical evaluation of the central nervous system (CNS) of the unborn fetus (fetal neurosonography)1–2 and newborn child (neonatal neurosonography).3 During these early stages of life, neurosonography is possible due to the presence of physiologic acoustic windows such as the fontanelle and unfused sutures of the skull, allowing the ultrasound waves to penetrate the brain tissue. Both 2D and 3D ultrasound have been used to obtain the required images of neurosonography.4 This technique enables a high-resolution, safe, readily available, and relatively inexpensive modality to obtain a detailed evaluation of the intra-cranial anatomy and vascular system that may be comparable in quality to that of other imaging modalities such as MRI.5 As the fontanelle and cranial sutures close during early childhood and the skull bone thickens, ultrasound can no longer be used to generate images of the brain. Therefore, adult neurosonography has significant limitations with use limited to transcranial Doppler imaging.

Recently, full or partial replacements of skull composed of an ultrasound-penetrable synthetic substitute, ie sonolucent cranial implants, have been available for post craniotomy skull replacement. Early experience by neurosurgeons that elect to use this technique offer their patients the potential of postoperative bedside sonographic assessment of the CNS of these individuals.6

In this report, we share our collaborative experience and enthusiasm about the emerging field of post cranioplasty neurosonography. Craniotomy is one of the most common surgical procedures performed in the US with indications ranging from surgical evacuation of intracranial bleed, hydrocephalus, brain tumors, and vascular lesions. Sonolucent cranial implants may replace a portion of the native skull or be used as a fully customized implant to restore form and function for cranial reconstruction procedures. In addition to the different sizes and shapes, these next-generation implants allow for postoperative imaging with ultrasound.

The sonolucent implant provides an acoustic window via a synthetic adult “fontanelle”. Depending on the location and size of the device, the assessment of the brain may be facilitated in different planes and points of view. Most commonly, the implants are located above the pathology (figure 1) and off the skull midline with the sagittal sinus preserved. Thus, the acoustic window enables the ability to easily image the brain in the coronal (Figure 2) and axial (Figure 3) planes. In cases where the implant approaches or covers the midline, evaluation in the sagittal plane (paramedian and even midsagittal/median) is possible (Figure 4) in addition to that of the coronal plane. Moreover, the closer the implant is to the midline, the easier the access is to image both hemispheres.

Image demonstrating the sonolucent burr hole cover and its use for ultrasound of the adult brain.
Figure 1: Left, An adult skull with a sonolucent implant. Right, Ultrasound of the adult brain in the coronal plane through a sonolucent implant.
Figure 2: Coronal view of the brain through a temporal sonolucent implant.
Figure 3: Axial view of the brain through a temporal sonolucent implant.
Figure 4A: Sagittal view through the lateral ventricle (paramedian).
Figure 4B: Median/midsagittal view through a sonolucent implant over the sagittal suture.

Post cranioplasty neurosonography can be done with point-of-care ultrasound by the neurosurgical or neurology teams in the acute postoperative period, in-office surveillance visit, or as a detailed evaluation in a neuro-radiology unit set up. We have used this technique in these setups to assess several postoperative parameters such as evaluation for possible midline shift, lateral ventricles for size, shape, potential bleed, and location of a shunt or ventricular catheter, patency of vascular anastomosis, as well as the evaluation of the brain parenchyma for postoperative pathologies such as presence of tumor or intracranial hemorrhage. Sequential surveillance is facilitated by the fact that the acoustic window is fixed so images are easily obtained in the exact same anatomical plane on subsequent scans.

As the clinical utilization of sonolucent grafts and experience with post cranioplasty neurosonography expand, there is much to be determined on how to best incorporate this emerging technology into patient care. For example, identifying the ideal diagnostic probe as there is no designated probe currently in the market. We have used both a curvilinear probe with a high-resolution abdominal setting and a cardiac phased array probe, ie, small footprint probes, with success. Indeed, the probe characteristics may vary between different lesions requiring different levels of penetration. As the implant is hard, and in many cases convex and of small size, a wide-sector, small footprint, high-resolution probe may offer the best access.

Future utilization and study will determine how post cranioplasty neurosonography influences the utilization of other imaging modalities (CT and MRI). Additional benefits potentially include decreased exposure to radiation, better point-of-care access to imaging, and a direct impact on healthcare costs.

Lastly, it is still to be determined which clinicians (neurosurgeons, neurologists, radiologists, neuro-intensivists, ACPs), and in which setup (point of care vs radiology suite) will master the techniques and take the lead in this emerging field. Regardless, it appears that the ultrasound community has a new and exciting opportunity at hand. 

References:

  1. Malinger G, Paladini D, Haratz KK, Monteagudo A, Pilu G, Timor-Tritsch IE. ISUOG Practice Guidelines (updated): sonographic examination of the fetal central nervous system. Part 1: performance of screening examination and indications for targeted neurosonography. Ultrasound Obstet Gynecol 2020; 56:476–484.
  2. Paladini D, Malinger G, Birnbaum R, et al. ISUOG Practice Guidelines (updated): sonographic examination of the fetal central nervous system. Part 2: performance of targeted neurosonography. Ultrasound Obstet Gynecol 2021; 57:661–671. https://doi.org/10.1002/uog.23616.
  3. Rossi A, Argyropoulou M, Zlatareva D, et al; ESNR Pediatric Neuroradiology Subspecialty Committee; ESPR Neuroradiology Taskforce. European recommendations on practices in pediatric neuroradiology: consensus document from the European Society of Neuroradiology (ESNR), European Society of Paediatric Radiology (ESPR) and European Union of Medical Specialists Division of Neuroradiology (UEMS). Pediatr Radiol 2023; 53:159–168. doi: 10.1007/s00247-022-05479-4.
  4. Bornstein E, Monteagudo A, Santos R, et al. Basic as well as detailed neurosonograms can be performed by offline analysis of three-dimensional fetal brain volumes. Ultrasound Obstet Gynecol 2010 Jul; 36(1):20–25. doi: 10.1002/uog.7527.
  5. Malinger G, Paladini D, Pilu G, Timor-Tritsch IE. Fetal cerebral magnetic resonance imaging, neurosonography and the brave new world of fetal medicine. Ultrasound Obstet Gynecol 2017; 50:679–680.
  6. Williams AL, Abu-Bonsrah N, Lee RP, et al. Letter: The role of sonolucent implants in global neurosurgery. Neurosurgery 2024; 94:e1–e5. doi: 10.1227/neu.0000000000002723.

Eran Bornstein, MD, FACOG, FAIUM

Dr Bornstein is an Associate Professor of Obstetrics & Gynecology at the Zucker School of Medicine at Hofstra, and the Director of the Center for Maternal Fetal Medicine and Ultrasound in OBGYN, at Lenox Hill Hospital, Northwell, in New York.

Netanel Ben-Shalom MD, FNPS

Dr Ben-Shalom is an Assistant Professor of Neurosurgery at the Zucker School of Medicine at Hofstra, and a neurosurgeon at Lenox Hill Hospital/Northwell, in New York.

David Langer, MD, FNPS

Dr Langer is an Associate Professor of Neurosurgery at the Zucker School of Medicine at Hofstra, and the Chair of the department of neurosurgery at Lenox Hill Hospital/Northwell, in New York.

You Won’t Be Left in the Dark at UltraCon (except during the total eclipse!)

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Have you considered how you will spend April 8 (well, April 6–10, 2024, actually)? The place to be on the 8th is somewhere you can be in the path of totality during the total solar eclipse, and what better place to be than Austin, TX, where you can see the eclipse and get your fill of everything ultrasound?

(and probably the cheapest way to get a hotel room is to register for UltraCon 2024 and grab a room while we still have affordable rooms in our block).

The AIUM brings our annual meeting to Austin, TX, for the first time, and there will be lots to take in. We are bringing back Educational Tracks. No matter where your interests lie, MSK or Fetal Echo or General US or OB or GYN, there is a track for you! There is something for you, whether you are early in your career or an experienced sonographer/sonologist. You will hear presentations from experts that will keep you up to date on changes in the field and tell you what is coming down the pike. For our members who are deep into the basic sciences, some presentations will stimulate new thinking and show you what other colleagues are up to. One of the best parts of the program is that you aren’t stuck in one track—you can mix and match to customize your experience. Check out the tracks here.

UltraCon brings you more than just the educational tracks. Is there a product that you have always wanted to develop and commercialize? Perhaps an invention, a training program, or another idea you are sure could be monetized? If so, the AIUM’s Shark Tank is for you! Put together your best proposal and present it to our panel of experts from industry, venture capital, and academia. $1,000 is up for grabs, but win or lose, you will gain valuable insights and critical appraisal of your concept, along with suggestions for what you need to do to take your proposal to the next step.

Scientific sessions run throughout the meeting, allowing you to hear cutting-edge research that will help answer some of the questions you might be having or possibly give you ideas to pursue on your own. You will hear from young researchers just starting out their careers as well as experienced scientists who have gotten us where we are today but aren’t done leading us yet.

One of the best aspects of the annual meeting is the chance to hear from luminaries and others with cutting-edge ideas, whether in ultrasound directly or in fields that will impact ultrasound, such as artificial intelligence and other new technologies. This year’s plenary sessions will be captivating as we hear from Dr Omar Ishrak on the future of ultrasound technology and from Dr Gil Weinberg on an amazing application of ultrasound to offer amputees the opportunity to play musical instruments.

Other talks will cover how CPT codes are developed, how to efficiently complete your application for accreditation, and so much more that will round out your experience in Austin.

UltraCon 2024 promises to be a Top Shelf event that you really don’t want to miss—and yes, we have scheduled a break to go outside to see the eclipse, so you won’t be asked to decide between these 2 once-in-a-lifetime events! Note that our hotel block is probably the least expensive deal in town, as our rates were negotiated years ago before many were paying attention to this eclipse. It is entirely possible we will sell out our block of rooms, so make your plans and register as soon as possible!

David C. Jones, MD, FACOG, FAIUM, the AIUM’s President Elect, is a Professor at the University of Vermont and the Director of the Fetal Diagnostic Center at the University of Vermont Medical Center.

Echocardiography: Visualizing Our Most Vital Organ—The Heart

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Among the constant advances in medical imaging, one innovation, ultrasound, stands out for its ability to assist us in the care of our most vital organ—the heart. Ultrasound imaging is commonly associated with monitoring pregnancies and, as a result, has become established in cardiology. This imaging modality is a noninvasive means of viewing the heart’s chambers and valves, and, in honor of Heart Health Month, I will give an overview of echocardiography and how ultrasound is a safe and effective tool in the medical care of the heart.

The Symphony of Sound Waves

Ultrasound technology relies on sound waves beyond the range of human hearing to create detailed images of the heart. Echocardiography, the specialized use of ultrasound for cardiac imaging, enables healthcare professionals to visualize the heart’s structure, function, and blood flow in real time. This noninvasive procedure has become a cornerstone in diagnosing and managing various cardiovascular conditions.

Diagnosis With Precision

One of the most remarkable aspects of ultrasound in cardiac care is its precision in diagnosing a wide array of heart conditions. From detecting congenital heart defects in newborns to assessing valve function and identifying structural abnormalities, echocardiography provides clinicians with a comprehensive view of the heart’s health.

Real-Time Insight Into Function

Unlike static imaging techniques such as X-rays or CT scans, echocardiography allows for dynamic, real-time assessment of the heart’s function. This invaluable feature aids in diagnosing conditions like heart failure, where the heart’s pumping efficiency is compromised. Clinicians can observe the heart’s ejection fraction, chamber dimensions, and wall motion, facilitating prompt and accurate treatment decisions.

Guiding Treatment Strategies

Ultrasound not only assists in diagnosis but also plays a crucial role in guiding treatment strategies. For patients with heart rhythm abnormalities, echocardiography helps identify the underlying causes, allowing for the implementation of targeted interventions such as ablation procedures. Additionally, it provides essential guidance during surgical interventions, ensuring precise and successful outcomes.

Monitoring Cardiovascular Health

Cardiac care extends beyond diagnosis and treatment; ongoing monitoring is essential for individuals with chronic cardiovascular conditions. Ultrasound enables clinicians to track changes in the heart over time, adjusting treatment plans as needed. This proactive approach enhances patient outcomes and contributes to the overall management of cardiovascular health.

Advancements in Technology

As technology continues to advance, so does the capability of ultrasound in cardiac care. 3D and 4D echocardiography now offer even more detailed and immersive views of the heart’s anatomy and function. These innovations provide clinicians with enhanced diagnostic tools, fostering a deeper understanding of cardiac physiology and pathology.

Patient-Friendly and Accessible

Beyond its diagnostic and therapeutic benefits, ultrasound in cardiac care is remarkably patient-friendly. The procedure is noninvasive, painless, and does not involve ionizing radiation, making it a safe option for individuals of all ages when performed by professionals. Moreover, the widespread availability of ultrasound machines ensures accessibility for patients across diverse healthcare settings.

Conclusion

As technology continues to evolve, so too will the capabilities of ultrasound, promising an even brighter future for the millions whose hearts need extra care.

Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Interested in learning more about echocardiography? Check out the following posts from the Scan:

Navigating the World of Ultrasound: The ABCs of Accreditation

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In the fast-evolving world of healthcare, technological advancements have played a pivotal role in enhancing diagnostic accuracy and patient care. Ultrasound imaging has made significant strides in ease of use and availability. Ensuring the highest quality standards is where accreditation enters the scene, setting the gold standard for ultrasound practices. In this blog post, we will explore the ABCs of accreditation and understand its importance in the context of ultrasound imaging.

A is for the AIUM: The Beacon of Accreditation

Ultrasound accreditation is at the heart of the American Institute of Ultrasound in Medicine (AIUM). Established with the mission to advance the safe and effective use of ultrasound in medicine, the AIUM has become the trusted source for healthcare professionals seeking accreditation. The AIUM’s comprehensive guidelines set the stage for quality assurance, encompassing everything from equipment specifications to the competence of the personnel operating the ultrasound machines.

The AIUM’s accreditation program acts as a seal of approval, signifying that a facility meets or exceeds the rigorous standards set by the institute. This commitment to excellence ensures that patients receive accurate diagnoses while maintaining the highest levels of safety.

B is for Benefits: The Value Proposition of Accreditation

Accreditation offers a myriad of benefits that contribute to the overall improvement of healthcare services. First and foremost, it instills confidence in both healthcare providers and patients. When a facility proudly displays its accreditation credentials, it is a tangible testament to the facility’s commitment to delivering quality care.

Furthermore, the accreditation process encourages continuous improvement. Facilities seeking accreditation undergo thorough evaluations, identifying areas that may need refinement. This self-assessment leads to an ongoing improvement cycle, fostering an environment of innovation and excellence.

From a patient’s perspective, choosing an accredited facility ensures they are in capable hands. Accreditation signifies that the healthcare professionals have undergone rigorous training, adhere to industry best practices, and utilize state-of-the-art equipment, all of which contribute to accurate diagnoses and effective treatment plans.

C is for Compliance: Navigating the Accreditation Criteria To achieve and maintain accreditation, healthcare facilities must navigate a set of criteria meticulously outlined by the AIUM. These criteria cover a broad spectrum, ensuring that every facet of ultrasound imaging is held to the highest standards.

  1. Personnel Qualifications: Accreditation requires personnel operating ultrasound equipment to have the necessary education, training, and experience. This criterion ensures that professionals have the expertise to produce accurate and reliable results.
  2. Equipment Specifications: Accredited facilities must adhere to stringent guidelines regarding the specifications of ultrasound equipment. This includes regular calibration and maintenance to guarantee optimal performance.
  3. Image Quality: The core of ultrasound lies in the clarity and accuracy of the images produced. Accreditation demands that facilities consistently achieve high-quality images, promoting precision in diagnosis and treatment.
  4. Patient Safety: Ensuring the safety of patients during ultrasound procedures is a top priority. Accredited facilities implement and adhere to strict safety protocols, minimizing risks and providing a secure environment for both patients and staff.
  5. Record-Keeping and Reporting: Accurate and thorough record-keeping is essential for effective patient care. Accreditation requires facilities to maintain comprehensive records and produce detailed reports, contributing to a seamless continuum of care.

In conclusion, the ABCs of accreditation in ultrasound imaging represent the cornerstone of quality and safety. As technology continues to advance, the AIUM’s accreditation program ensures that healthcare facilities keep pace with these changes while maintaining the highest standards. Choosing an accredited facility not only benefits healthcare providers in terms of professional development but, most importantly, ensures that patients receive the best possible care. So, whether you’re a healthcare professional or a patient seeking ultrasound services, remember the ABCs – because when it comes to quality healthcare, accreditation is the key to unlocking excellence.

Catherine Knight, BS, RDMS, is a Quality of Practice Specialist for the AIUM, and Cynthia Owens, BA, is the Publications Coordinator for the AIUM.

Why Have Your Ultrasound Done at an Accredited Practice?

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Ultrasound scans are being performed everywhere. Not only in the standard radiology department in your local hospital, but also in the emergency room, urgent care clinics, your doctor’s office, and even at the local mall. But are you getting the same value for your money at each of these different sites? I have personally witnessed a very wide variety of skill levels within each of these departments. What can help you identify a reputable ultrasound unit? Look for an accredited ultrasound practice.

Applying for and obtaining your ultrasound accreditation is a vigorous process. It requires that all physician and sonographer staff have earned the appropriate credentials for the scans being performed and that they are up to date on their CME (continued medical education). Studies must be submitted for review to the accrediting team to ensure that the appropriate anatomy is being captured, image quality is optimal, and images are labeled. The ultrasound report is reviewed to confirm that the patient information and required imaging components for the study have been assessed and documented correctly.

Accreditation can help reassure the patient and the referring physician that their selected ultrasound department is aware of and following the current accepted standard guidelines for their exam. This can lead to reduced patient anxiety regarding the quality of the ultrasound scan. The goal is to help ultrasound departments achieve the best imaging possible to improve overall patient care and safety.

Each specialty area has an accreditation system that provides confirmation that an ultrasound department has achieved and is maintaining the current national standards. Each system provides guidelines and learning resources to help departments meet these standards.

Accreditation Systems:

Why is accreditation important? So that images like these are not reported as normal.

The initial scan was done in a physician’s office. The gestational age by the known last menstrual period was 11 weeks, 2 days; however, the crown-rump length (CRL) by ultrasound measured 10 weeks. This pregnancy was re-dated using the ultrasound-estimated delivery date.

At 19 weeks, 6 days, the patient was referred for an anatomy scan and was diagnosed with acrania-exencephaly-anencephaly sequence. This malformation has no calvarium and the fetal brain is exposed to the amniotic fluid. The amniotic fluid is toxic to the exposed brain and eventually causes the disintegration of this tissue. Exencephaly is a precursor to anencephaly. The absence of the fetal skull (acrania) exposes the brain (exencephaly), which eventually leads to anencephaly. The degenerative process of the brain gives the amniotic fluid an echogenic appearance.

This patient’s maternal serum alpha-fetoprotein (MSAFP) was 7.69 MoM (multiple of the median); the cutoff for a normal scan is <2.50 MoM.

Ultrasound technology and image quality have improved tremendously. The accreditation process helps a department discover where its deficiencies are and can provide guidance on how to meet the minimum standards. Further training and education of the Sonographers and Sonologists will lead to improved patient safety and outcomes.

Why pursue an ultrasound-accredited practice? Maybe the better question would be, why not make accreditation mandatory?

Headshot of Jane K. Burns, RDMS

Jane K. Burns, RDMS, is the MFM Ultrasound Manager at Texas Children’s Hospital/Pavilion for Women.

Member Spotlight: A Celebration of AIUM Membership

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In honor of Member Appreciation Month, we interviewed Eliza Fridlin, RDMS, FE, and Eran Bornstein, MD, to discover why they are members of the American Institute of Ultrasound in Medicine (AIUM).

Headshot of Eliza Fridlin, RDMS, FE
Eliza Fridlin, RDMS, FE
Headshot of Eran Bornstein, MD
Eran Bornstein, MD

Why did you choose to join the AIUM?

Eliza: I hold the AIUM community in high regard and take great pride in being an active member. The collective pursuit of excellence within the AIUM community further underscores the significance of my association with this esteemed organization. As a member of the AIUM, I have access to a wealth of resources and pivotal networking avenues at the forefront of advancements within the discipline; also, the membership enables opportunities to attend conferences and engage in structured professional development initiatives in the latest research and technological breakthroughs in medical ultrasound. 

Eran: I joined the AIUM early in my imaging career and have remained a member for almost 2 decades. As the leading organization responsible for education, accreditation, and guidelines of ultrasound standards in the U.S., it is important that clinicians who use ultrasound maintain their membership to maintain their clinical standards, obtain updates, and maintain certification to allow for the standards to advance as technology and evidence amounts of improvements in Ultrasound utilization.

What is your favorite AIUM benefit? 

Eliza: My favorite AIUM benefits are having the ability to earn free CME credits, learn with case challenges, and stay current with monthly webinars in the dynamic field of medical ultrasound.

Eran: Access to the JUM articles and discounted annual conference.

What does the AIUM mean to you? 

Eliza: The AIUM embodies a standard of excellence in the realm of ultrasound, and it is an organization that unites the ultrasound community and champions a vision characterized by unparalleled expertise. The AIUM cultivates a collective commitment to the highest standards of proficiency.

Eran: The AIUM, for me, is the highest American authority on the utilization of ultrasound in medicine, assuring appropriate quality, safety, education, accreditation, and research. As such, I hold it with the highest respect and responsibility to assure our field advances and is not stagnant, that the technological advances in ultrasound machines can be appropriately utilized to improve the diagnostic capacity. It is the body responsible for determining minimal criteria to meet the standard of care but also to push forward for higher standards, as well as reinforce safety measures in clinical practice, provide educational opportunities such as conferences and online materials, CME, etc, so that providers are up to date despite busy clinical schedules. Another important aspect is their accreditation, which is a crucial quality measure to ensure that centers and providers meet minimum standards set by the AIUM for specific tests.

Has being a member of the AIUM helped you in your career? If so, how? 

Eliza: The AIUM serves as an invaluable resource for enhancing standards of patient care and elevating education within the healthcare sector. This commitment to excellence empowers me as a healthcare professional to stay abreast of industry advancements and ultimately contribute to the delivery of high-quality patient care.

Eran: Being an AIUM member for almost two decades has helped me network with like-minded dedicated experts in Ultrasound and prenatal diagnosis. Having our ultrasound unit accredited was always important as a basic measure of quality. Recently, we were one of the first few units in the U.S. to be accredited in performing and interpreting first-trimester anatomical survey, which we have been performing for many years already. The fact that the AIUM recently developed this accreditation brings this clinical tool new merit and supervised quality.

Is there anything else you’d like to share?

Eran: I would recommend providers who use ultrasound as a tool in their clinical practice to become active AIUM members. This is an important step in assuring quality of care for their patients.

Eliza Fridlin, RDMS, FE, is Lead Sonographer at Lenox Hill Hospital Maternal Fetal Medicine.

Eran Bornstein, MD, is the Director of Obstetrics of Obstetrics and Gynecology at Lenox Hill Hospital in New York.

Exploring the Future of Ultrasound: 5 Trends to Watch

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Ultrasound technology has come a long way since its inception and continues to evolve at a rapid pace. As we look ahead to the near future, it’s clear that ultrasound will play an even more vital role in healthcare. In this blog post, we’ll explore 5 trends (in no particular order) that are set to shape the field of ultrasound in the coming years.

1. Portable and Handheld Ultrasound Devices

The trend of portable and handheld ultrasound devices is on the rise. In the past, ultrasound machines were hundreds of pounds, carted around on wheels, and costly to manufacture. These new, compact, and lightweight devices offer healthcare professionals the convenience of conducting ultrasound examinations at the patient’s bedside, in remote areas, or during emergency situations, and wearable devices will become part of the ultrasound tool kit. Their affordability and ease of use make them accessible to a broader range of healthcare providers, expanding the potential applications of ultrasound. I predict that, under a doctor’s care and orders, the ways in which ultrasound is used will expand!

2. Artificial Intelligence (AI) Integration

AI is revolutionizing the field of medical imaging, and ultrasound is no exception; however, sonographers and doctors are not going anywhere. AI algorithms can assist in image analysis, automate measurements, enhance quantitative imaging, and aid in the detection of abnormalities. In the near future, we can anticipate more sophisticated AI integration into ultrasound systems, which will not only enhance diagnostic accuracy but also improve workflow efficiency. AI will play a significant role in making ultrasound more accessible and reliable in terms of scanning, reading images, and delivering accurate results.

3. 3D and 4D Imaging

Three-dimensional (3D) and real-time 3D (4D) ultrasound imaging will continue to advance, providing clinicians with more detailed and interactive views of anatomical structures. This trend will be particularly valuable in obstetrics for capturing fetal development and in various other medical specialties where enhanced visualization and quantification are crucial. Expect to see more applications for complex anatomical assessments and dynamic studies.

4. Point-of-Care Ultrasound (POCUS)

Point-of-care ultrasound, or POCUS, is transforming the way medical professionals diagnose and manage patients. POCUS is expected to see increased adoption in various clinical settings, including emergency medicine, anesthesiology, primary care, and critical care. As training programs expand, more healthcare providers will be equipped to use POCUS for rapid and accurate assessments, which can lead to improved patient care and outcomes on the spot. With increased adoption, interest in ultrasound practice accreditation in this area is rising.

5. Therapeutic Ultrasound Applications

Beyond its diagnostic role, ultrasound is making great advances in therapeutic applications. Techniques like High-Intensity Focused Ultrasound (HIFU) are being employed for noninvasive surgeries, cancer treatments, and targeted drug delivery. In the coming years, we can expect to see further developments in therapeutic ultrasound, offering less invasive treatment options for a wide range of medical conditions and increasing the potential for ultrasound theranostics.

The future of ultrasound is incredibly promising with these 5 trends at the forefront of its evolution. From portable devices and AI integration to advanced imaging techniques and expanding applications in point-of-care and therapeutics, ultrasound is set to become even more integral to modern healthcare. Stay tuned as these trends continue to shape the landscape of medical imaging and patient care. We’re excited to witness the many possibilities that lie ahead for this versatile technology.

Therese Cooper, BS, RDMS, is a sonographer and the Director of Accreditation at the American Institute of Ultrasound in Medicine.

Time to Pause and Reflect

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During my early career as an Urgent Care Physician, I worked in busy, under-served, and rural Urgent Care Centers (UCCs). At that time, Point-of-Care Ultrasound (POCUS) was not popular. I practiced in high acuity UC settings, where we would often have US machine and US tech during business hours with an on-call tech after hours, as well as CT scan, STAT labs, and IV placement capabilities. However, I was interested in learning more about POCUS – so I attended a few CME courses that taught MSK and soft tissue, led by companies like Sonosite.

After these courses, I returned to work excited and attempted to convince my medical director to incorporate POCUS into our UC workflow. My idea was rejected. As time passed and I moved to other jobs, I would again ask at each new urgent care clinic and would be met with the same response. They claimed it is cost-prohibitive and that training providers would be cumbersome.

The basic skills I learned from these courses withered away from lack of practice shortly after finishing these 2-day seminars. Years passed by, and I forgot about POCUS, having felt discouraged following many unsuccessful attempts to integrate it into my practice.

Yet, over the past 5 years, I have noticed a shift in the operation of UCCs nationwide. There has been a tendency to eliminate US and CT from UC, reserving it for emergency department (ED) patients and scheduled outpatient orders. Our UCC still maintained STAT labs and IV placement capabilities, but this shift created bigger problems. Mainly, it led to increases in unnecessary ED transfers, which led to longer ED wait times, unsatisfied patients, more UC bounce-backs, and delayed patient care. At the same time, the shortage of primary care providers (PCPs) continued to grow, and the wait to get timely appointments with their PCP remained difficult, resulting in many patients not receiving the care they needed.

When I first started practicing UC Medicine, the goal of many UCCs was to reduce ED burden through managing stable patients while at the same time reducing primary care burnout by offering primary care services to bridge the gap in access to care. Nonetheless, the lack of imaging in the UCCs has caused the urgent care world to fall short of these goals – including duplicate and incomplete workups and increased costs to patients (particularly when labs are ordered only to discover the need to go to the ED to finish the workup). Add on top of this the fact that many insurance companies will not pay for 2 visits on the same day and the lack of consistent X-ray staffing due to shortages, and it becomes clear that there is a dire need for POCUS and POCUS-trained providers in our UCCs.

Two years ago, I decided to dedicate my time to learning and practicing POCUS. Recently, I decided to do a fellowship in POCUS. I wanted to refine my skills to provide the best care for my patients. Many patients come in with presentations such as undifferentiated dyspnea. Is it CHF? Pneumonia? COPD? POCUS can help with medical decision-making and finalize safe disposition to the ED or home.

What about that popliteal DVT that you strongly suspect on your shift? It is 7:00 pm on a Friday night, and outpatient imaging will not be able to get your patient in until the following week. How would you handle this situation? Unfortunately, many times patients must go to the ED and sit for many hours to get a DVT study done. Or what about the early-pregnancy patient that comes in with some vaginal bleeding and pelvic pain? Is it an intrauterine pregnancy (IUP) or a miscarriage?

POCUS helps you treat each of these patients with clinical accuracy and speed. For example, one day in our clinic, we had no x-ray tech on shift. I didn’t want to ask the patient to travel, as they, like many in our patient population, have difficulty finding affordable and timely transport. Instead, I was able to diagnose a fracture and treat it using my hand-held ultrasound.

Another time, I was able to diagnose a shoulder dislocation and do postreduction imaging to confirm placement. I’ve been able to rule out cardiac tamponade on a young patient with chest pain and pericarditis on EKG and send him home safely. POCUS enabled me to see a foreign body inside an abscess I would have missed. The list of what POCUS has enabled me to diagnose and treat goes on: a right lower quadrant mass on a patient with suspected appendicitis, with expedited care as the ED saw these images and took him straight to CT scan; several Pneumonias on the ultrasound that were missed on chest x-ray; the ability to differentiate between biliary colic and acute cholecystitis while doing a right upper quadrant scan.

One day, a colleague came and asked me if I could do a Renal Ultrasound on her patient, an elderly female who had been seen in the ED the day before with flank pain and hematuria. She received a CT scan in the ED showing moderate hydronephrosis and a partially obstructed ureteric stone. She came to the UC 24 hours later with worsening flank pain and vomiting. My bedside POCUS showed severe hydronephrosis and a completely obstructed ureteric calculus, with the added advantage of ruling out abdominal aortic aneurysm (AAA) at the same time. We were able to transfer her to the ED and expedite her care.

I offer all of these examples to showcase POCUS’s diverse breadth and depth in urgent care medicine. Undoubtedly, it saves lives, improves patient outcomes, and reduces costs. It is time to take a step back and consider the long-term benefits of POCUS.

The money spent now on machines and training will pay dividends in the future. While it seems like a longer-term investment, it will be recouped quickly, and the benefits will continue year after year.

Amera Gaballa, MD, is an Advanced Primary Care Ultrasound Fellow at the University of Michigan in Ann Arbor.