Ultrasound Screening In Pregnancy Research Articles

Trends over 50 years with liberal abortion laws in the Nordic countries.

During the 1970s the Nordic countries liberalized their abortion laws. We assessed epidemiological trends for induced abortion on all Nordic countries, considered legal similarities and diversities, effects of new medical innovations and changes in practical and legal provisions during the subsequent years. New legislation strengthened surveillance of induced abortion in all countries and mandated hospitals that performed abortions to report to national abortion registers. Published data from the Nordic abortion registers were considered and new comparative analyses done. The data cover complete national populations. After an increase in abortion rates during the first years following liberalization, the general abortion rates stabilized and even decreased in all Nordic countries, especially for women under 25 years. From the mid-1980s higher awareness about pregnancy termination led women to present at an earlier gestational age, which was accelerated by the introduction of medical abortion some years later. Most terminations (80-86%) are now done before the 9th gestational week in all countries, primarily by medical rather than surgical means. Introduction of routine ultrasound screening in pregnancy during the late 1980s, increased the number of 2nd trimester abortions on fetal anomaly indications without an overall increase in the proportion of 2nd relative to 1st trimester abortions. Further refinement of ultrasound screening and non-invasive prenatal diagnostic methods led to a slight increase in the proportion of early 2nd trimester abortions after the year 2000. Country-specific differences in abortion rates have remained stable over the 50 years of liberalized abortion laws.

Undiagnosed uterine anomalies revealed by breech on ultrasound prior to external cephalic version – A chance to take a closer look

ObjectiveUterine anomalies (UA) occur in up to 6.7% of women. Breech is eight times more likely to occur with UA which may not be diagnosed prior to pregnancy and may only be found in the third trimester with breech. The objective of the study is to assess the prevalence of both already known and newly sonographically diagnosed UA in breech from 36 weeks of gestation and its impact on external cephalic version (ECV), delivery options and perinatal outcomes. Study DesignWe recruited 469 women with breech at 36 weeks of gestation over a 2-year period at the Charité University Hospital, Berlin. Ultrasound examination was performed to rule out UA. Patients with known and newly ‘de novo’ diagnosed anomalies were identified and delivery options and perinatal outcomes analyzed. ResultsThe ‘de novo’ diagnosis of UA at 36–37 weeks of pregnancy with breech was found to be significantly higher compared to the diagnosis prior to pregnancy with 4.5% vs 1.5% (p < 0.001 and odds ratio 4 with 95% confidence interval 2.12–7.69). Anomalies found included 53.6% bicornis unicollis, 39.3% subseptus, 3.6% unicornis and 3.6% didelphys. A trial of vaginal breech delivery was successful in 55.5% of cases when attempted. There were no successful ECVs. ConclusionBreech is a marker for uterine malformation. Diagnosis of UA with breech can be up to four times improved with focused ultrasound screening in pregnancy even from 36 weeks of gestation prior to ECV to identify missed anomalies. Timely diagnosis aids antenatal care and delivery planning. Importantly, definitive diagnosis and treatment can be planned postpartum to improve outcomes in future pregnancies. ECV plays a limited role in selected cases.

Information leaflets in medical screening

breast cancer. 5 Some medical screening is so non-specific that it is described in terms of the technology used rather than the disorder that is being screened for (e.g. ultrasound screening in pregnancy), and usually little or no information on benefit is provided in these cases. Most people who participate in a screening programme take its value on trust and expect to be given the 'all clear'. Unfortunately, a screen negative result in most screening programmes does not rule out the disorder being screened for, and this should be made clear. Information leaflets are best produced locally. The variation in style and content is helpful. Professionals can learn from each other by comparing leaflets and then revising their own if necessary. Variation should therefore not be regarded as a disadvantage. The leaflet should give a dedicated telephone number so that people can speak to a member of the screening team who is able to answer questions confidently and accurately, and who is familiar with the details of the local service. The process of producing an information leaflet on a screening programme helps to clarify the specification of the programme and what can be expected from it both procedurally and in terms of health outcomes. This helps to engage members of a particular screening team in the process - an educational benefit in itself. The understanding this fosters encourages confidence and a sense of ownership in the programme. This improves its quality and its appreciation by those who participate in the programme. A checklist of what needs to be considered in assessing the value of a screening test has been published. 6 This sets out what needs to be known before a screening test is introduced, but it may also be useful in drafting what the public need to know once it has been introduced. The leaflet should provide information that individuals who are considering whether they wish to be screened need to know, so that they can make a fair decision. Providing details on what they want to know is necessary but secondary. The leaflet should be quantitative and precise rather than general (e.g. 'one in six', not 'some'). The text should be clear (easier said than done!) and simple, but not too simple. The following six items are probably needed in most leaflets on screening:

Syrian Women's Perceptions and Experiences of Ultrasound Screening in Pregnancy: Implications for Antenatal Policy

Ultrasound scanning is firmly embedded in antenatal maternity care around the world. This paper reports on a qualitative study carried out in 2003 of 30 Syrian women's perceptions and experiences of routine ultrasound in pregnancy. It was part of a larger study of the experiences of pregnancy and childbirth of 500 women from Damascus and its suburbs who had recently given birth to healthy newborns. The women had had multiple scans during pregnancy and accepted its use uncritically nearly all the time. The scans gave them reassurance that the baby was healthy, the pregnancy was progressing well and allowed them to learn the sex of the baby. The women also reacted positively to the antenatal educational messages that were conveyed using scans. However, we found the excessive use of this technology worrying. We believe private doctors, who attend 80% of pregnant women, use ultrasound primarily to attract women to their clinics and increase their income. We recommend that maternity care in Syria should be better regulated; that women and their doctors should be made aware of the essential components of antenatal care; that national guidelines for antenatal care should be developed and that Syrian women should be empowered to ask questions about pregnancy and childbirth and the care they receive.

The cost effectiveness of prenatal ultrasound screening for trisomy 21

The cost-effectiveness of opportunistic nuchal translucency ultrasound screening in pregnancy was compared with alternative screening strategies for trisomy 21 in Australia. A decision analytic model was used of various pregnancy screening strategies based on a systematic review of the literature on the effectiveness of nuchal translucency ultrasound and serum screening and costs based on current reimbursement fees. The model included the likelihood and cost of terminations after diagnostic testing and the associated risk of fetal loss. All prices are in 2001 Australian dollars. With a twenty percentage point difference in detection rate, the incremental cost for a combination of nuchal translucency and serum screening with age in the first trimester compared with maternal serum screening in the second trimester was 105,484 dollars per extra case detected and 374,779 dollars per live trisomy 21 birth avoided. Serum screening in the second trimester had an incremental cost per extra case detected of between 61,700 dollars and 117,100 dollars per extra live birth avoided when compared with no screening. The cost-effectiveness of ultrasound screening for trisomy 21 would appear to be more attractive if it were done at the same time as current dating ultrasound. Any funding mechanism for screening should take this strategy into account by incorporating, as far as possible, provision of nuchal translucency screening into existing services provided in early pregnancy.

Ultrasound screening in pregnancy: advancing technology, soft markers for fetal chromosomal aberrations, and unacknowledged ethical dilemmas

Fetal ultrasound screening has become routine practice in many western countries. During the last decade, such screening has led to frequent situations characterised by clinical uncertainty due to the disclosure of soft markers in the unborn child. Soft markers are minor anatomical variations indicating a somewhat increased likelihood that the fetus has a chromosomal aberration, most frequently trisomy 21 (Down syndrome). This paper presents the results of a comprehensive literature search of the National Library of Medicine with emphasis on the chronological development of scientific knowledge in relation to soft markers and the link between advancing imaging technology and clinical counselling dilemmas. An analysis of the literature makes evident that many ultrasound examiners have counselled individual pregnant women on the basis of insufficient data. Moral dilemmas have thus emerged as a direct result of advancing medical technology, and healthy fetal lives prove to have been lost due to invasive diagnostic testing aimed at resolving clinical uncertainty. Ultrasound examiners have warned against a policy of disclosing all findings of soft markers to expectant parents, but no exploration of experiential aspects linked to the disclosure of fetal soft markers has yet been published in the medical literature. The emotional reactions of mothers are important to consider given their potential impact on the biological development of the fetus. In conclusion, this paper stresses the need for paying close attention to the crucial distinction between technology development and technology implementation in relation to prenatal testing. Furthermore, it provides strong arguments for scrutinising the interface between prenatal testing and human experience.

Antenatal ultrasound screening for fetal abnormalities: a systematic review of studies of cost and cost effectiveness.

To review systematically and critically evidence to derive estimates of costs and cost effectiveness of routine ultrasound screening for fetal abnormalities. A systematic review of the literature using explicit criteria for inclusion of primary research studies, a stated electronic strategy to identify relevant material, and an explanation of why apparently relevant studies have not been included. All countries of origin were included. The results of this review are important to obstetricians and to health service managers in the allocation of resources, and others who are considering conducting further research in this area. Formal economic evaluations and cost studies of routine ultrasound screening. Costs of routine anomaly scans and costs of other procedures carried out as part of antenatal screening by ultrasound. One hundred and ninety-nine studies were identified in total, 24 reaching the final stage of the review. Nine studies were formal economic evaluations and 15 reported costs studies or clinical effectiveness studies with some assessment of cost. The studies were carried out mainly in Europe and in the United States. After quality criteria were applied, data were extracted from six of the economic evaluations and six of the costs studies. One economic evaluation conducted alongside a randomised trial concluded that screening for fetal abnormalities by ultrasound in the second trimester was cost effective, compared with routine antenatal care. The costs of routine scans ranged from Pound Sterling 18 to Pound Sterling 204 and for non-routine ranged from Pound Sterling 32 to Pound Sterling 113. There is a lack of good quality primary studies of the costs of ultrasound screening in pregnancy. Typically, economic evaluations of ultrasound screening have been based on poor quality evidence of clinical effectiveness. There is a need for more published data on the costs and cost effectiveness of routine ultrasound screening for fetal anomalies, and of the longer term consequences of screening for anomalies.

Antenatal ultrasound screening for fetal abnormalities: a systematic review of studies of cost and cost effectiveness

Objective To review systematically and critically evidence to derive estimates of costs and cost effectiveness of routine ultrasound screening for fetal abnormalities. Design A systematic review of the literature using explicit criteria for inclusion of primary research studies, a stated electronic strategy to identify relevant material, and an explanation of why apparently relevant studies have not been included. Setting All countries of origin were included. The results of this review are important to obstetricians and to health service managers in the allocation of resources, and others who are considering conducting further research in this area. Main outcome measure Formal economic evaluations and cost studies of routine ultrasound screening. Costs of routine anomaly scans and costs of other procedures carried out as part of antenatal screening by ultrasound. Results One hundred and ninety-nine studies were identified in total, 24 reaching the final stage of the review. Nine studies were formal economic evaluations and 15 reported costs studies or clinical effectiveness studies with some assessment of cost. The studies were carried out mainly in Europe and in the United States. After quality criteria were applied, data were extracted from six of the economic evaluations and six of the costs studies. One economic evaluation conducted alongside a randomised trial concluded that screening for fetal abnormalities by ultrasound in the second trimester was cost effective, compared with routine antenatal care. The costs of routine scans ranged from £18 to £204 and for non-routine ranged from £32 to £113. Conclusions There is a lack of good quality primary studies of the costs of ultrasound screening in pregnancy. Typically, economic evaluations of ultrasound screening have been based on poor quality evidence of clinical effectiveness. There is a need for more published data on the costs and cost effectiveness of routine ultrasound screening for fetal anomalies, and of the longer term consequences of screening for anomalies.

P154Psychological stress and ultrasound screening in pregnancy: a risk‐group comparison

BackgroundWe intended to assess the psychological stress experienced by mothers during ultrasound screenings in pregnancy.MethodsBetween 1997 and 1999, 136 women (age 17–41, pregnancy week 9–41) were asked to record their stress level before, during and after the ultrasound exam on a scale from 1 to 10. 81 patients were generally concerned about their pregnancy, 22 were over age 35, 21 had specific pregnancy risks (family history, preeclampsia, first‐trimenon medication‐intake/infection, pathological ultrasound findings).ResultsWomen generally concerned or with known pregnancy risk report significantly more stress before the exam (mean 3.8 vs. 1.9 and 4.6 vs. 2.8; P &lt; 0.01). However, during or after the exam, stress levels are equal in all groups (5.1 vs. 4.3, 2.9 vs. 2.3; P &gt; 0.01). We also find no significant differences between women above or below age 35 (3.0 vs. 3.1 before, 4.3 vs. 4.4 during, 2.5 vs. 2.2 after ultrasound exam; P &gt; 0.01). Overall, all women experienced the most stress during, and the least stress after the exam (P &lt; 0.01).ConclusionOr results show that we need to anticipate an equal level of anxiety in all women we examine. We cannot assume that a young mother without risk will experience the exam any more or less distressful than a woman with predisposed risk. The results cautions us to give adequate consideration to every individual patient, regardless of pregnancy risk.

Ultrasound screening in pregnancy: a systematic review of the clinical effectiveness, cost-effectiveness and women's views.

Background Advantages of early pregnancy ultrasound screening are considered to be more accurate calculation of gestational age, earlier identification of multiple pregnancies, and diagnosis of non-viable pregnancies and certain fetal malformations. Objective The objective of this review was to assess the use of routine (screening) ultrasound compared with the selective use of ultrasound in early pregnancy (i.e. before 24 weeks). Search strategy The Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register (up to July 1998) were searched. Selection criteria Adequately controlled trials of routine ultrasound imaging in early pregnancy. Data collection and analysis One reviewer assessed trial quality and extracted data. Study authors were contacted for additional information. Main results Nine trials were included. The quality of the trials was generally good. Routine ultra- sound examination was associated with earlier detection of multiple pregnancies (twins undiag- nosed at 26 weeks, OR 0.08; 95% CI, 0.04 to 0.16) and reduced rates of induction of labour for post- term pregnancy (OR 0.61; 95% CI, 0.52 to 0.72). There were no differences detected for substantive clinical outcomes such as perinatal mortality (OR 0.86; 95% CI, 0.67 to 1.12). When detection of fetal abnormality was a specific aim of the exam- ination, the number of terminations of pregnancy for fetal anomaly increased. Reviewers’ conclusions Routine ultrasound in early pregnancy appears to enable better gestational age assessment, earlier detection of multiple pregnancies and earlier detection of clinically unsuspected fetal malformation at a time when termination of pregnancy is possible. However, the benefits for other substantive outcomes are less clear.

Choosing options for ultrasound screening in pregnancy and comparing cost effectiveness: a decision analysis approach.

To compare the cost effectiveness of different programmes of routine antenatal ultrasound screening to detect four key fetal anomalies: serious cardiac anomalies, spina bifida, Down's syndrome and lethal anomalies, using existing evidence. Decision analysis was used based on the best data currently available, including expert opinion from the Royal College of Obstetricians and Gynaecologists, Working Party and secondary data from the literature, to predict the likely outcomes in terms of malformations detected by each screening programme. Results applicable in clinics, hospitals or GP practices delivering antenatal screening. The number of cases with a 'target' malformation correctly detected antenatally. There was substantial overlap between the cost ranges of each screening programme demonstrating considerable uncertainty about the relative economic efficiency of alternative programmes for ultrasound screening. The cheapest, but not the most effective, screening programme consisted of one second trimester ultrasound scan. The cost per target anomaly detected (cost effectiveness) for this programme was in the range 5,000 pound silver-109,000, pound silver but in any 1000 women it will also fail to detect between 3.6 and 4.7 target anomalies. The range of uncertainty in the costs did not allow selection of any one programme as a clear choice for NHS purchasers. The results suggested that the overall allocation of resources for routine ultrasound screening in the UK is not currently economically efficient, but that certain scenarios for ultrasound screening are potentially within the range of cost effectiveness reached by other, possibly competing, screening programmes. The model highlighted the weakness of available evidence and demonstrated the need for more information both about current practice and costs.

Routine Ultrasound Screening in Pregnancy and the Children’s Subsequent Neurologic Development

Objective: To test the null hypothesis of no association between ultrasound exposure in early fetal life and impaired neurologic development in childhood. Methods: Study of children age 8–9 years whose mothers participated in a randomized controlled trial of ultrasound screening during pregnancy in Sweden during 1985–1987. Of 4637 eligible singletons, 3265 (70%) were studied through a questionnaire to their mothers. Assessment of neurologic development was based on parents’ report of their child’s speech and motor development. Behavioral disorders were assessed by a ten-item parent scale. Analyses were performed according to both assignment and ultrasound exposure. With a sample size of 1600 children in each group, a two-sided α of .05 and β of .10, a risk ratio of less than 1.4 for the studied variables could not be detected. Results: Delayed speech development was reported by 2.9% in the screening group compared with 2.4% in the nonscreening group (odds ratio [OR] 1.21; 95% confidence interval [CI] 0.79, 1.88). Similar prevalences were found when analysis was according to ultrasound exposure (OR 1.19, 95% CI 0.78, 1.83). Delayed motor development was reported by 7.6% in the screening group compared with 7.2% in the nonscreening group (OR 1.05; 95% CI 0.81, 1.37). Corresponding figures for ultrasound-exposed and -unexposed were 7.7% and 7.2%, respectively (OR 1.08; 95% CI 0.83, 1.40). There also were no significant differences in behavioral disorders between screened and unscreened children or between exposed and unexposed children, respectively, according to parents’ ratings. Conclusion: No significant difference in impaired neurologic development between ultrasound-exposed and -unexposed children was found in this study.

Routine Ultrasound Screening in Pregnancy and the Childrenʼs Subsequent Neurologic Development

Routine Ultrasound Screening in Pregnancy and the Childrenʼs Subsequent Neurologic Development

Routine ultrasound screening in pregnancy and the children's subsequent handedness

Objective: To study a possible association between ultrasound screening in early pregnancy and altered cerebral dominance measured by the prevalence of non-right handedness among children, particularly boys. Methods: Follow-up of 8 to 9 year old children to women who participated in a randomised controlled trial on ultrasound screening during pregnancy in 1985–1987. The children were followed up through a questionnaire sent to their mothers. The dominant hand of the child was assessed by eleven questions. The dominant foot by one question. Results: No differences were found in non-right handedness between children in the screening and non-screening group. In separate analyses on ultrasound exposure and non-right handedness among boys a significant difference was found (odds ratio 1.33; 95% confidence interval 1.02–1.74). Conclusion: This study could not rule out a possible association between non-right handedness among boys and ultrasound exposure in early fetal life. The association was, however, confined to analyses comparing exposed and non-exposed boys and no associations were found when the comparisons were performed according to the randomised groups.

Cost-Effectiveness of One-Stage Ultrasound Screening in Pregnancy

The objective of this study was to evaluate, in a controlled clinical trial, the costs of standardized one-stage ultrasound screening in pregnancy in relation to the reduction in perinatal mortality. A trial population of 9310 pregnant women was randomly allocated to ultrasound screening or a control group. Two obstetric hospitals and 64 recruiting antenatal health centers were involved. The costs included actually realized costs, i.e. positive costs, and gains, i.e. negative costs, resulting from lower health-care use. Cost-accounting data were obtained by a questionnaire to all attenders and measurements at the screening, and later complemented by a questionnaire to a random sample of 534 screened women. Internal accounting and other hospital data, national statistics and health-market sources were also used. The actually realized cost of each avoided perinatal death was FIM 84 378 ($21 938), while the net over-all estimate combining all positive and negative costs showed a cost saving of FIM 65 680 ($17 077). The total positive unit cost of ultrasound screening was FIM 393 ($102). Longer ultrasound examination time and more numerous advanced examinations were rewarded by clearly fewer perinatal deaths and a better cost-effectiveness ratio. One-stage second-trimester ultrasound screening is cost-effective when all significant costs and effects are taken into account. Copyright © 1996 International Society of Ultrasound in Obstetrics and Gynecology

Prenatal sonographic diagnosis of thanatophoric dwarfism

A case of thanatophoric dwarfism is reported in a 35-year-old woman. The diagnosis was made at 34 weeks gestation by ultrasound. Marked shortening of the extremities, macrocephaly, narrow thorax and polyhydramnios were observed. The importance of routine ultrasound screening in pregnancy is emphasized, since such malformations can be detected prenatally.

Effects of Routine One-Stage Ultrasound Screening in Pregnancy

WALDENSTRÖM, URBAN; NILSSON, STAFFAN; FALL, OLE; AXELSSON, OVE; EKLUND, GUNNAR; LINDEBERG, SOLVEIG; SJODIN, YLVA Author Information

Long-term experience of general ultrasound screening in pregnancy

Since January 1, 1974, 43,000 routine ultrasound examinations have been performed on 22,400 pregnant women in the Department of Obstetrics and Gynecology, MalmöGeneral Hospital. At the present time, one examination is performed in the seventeenth week of pregnancy and one in thirty-third week. At the first examination, the number of fetuses, fetal anatomy, cardiac activity, and placental site are indicated. Fetometry is performed. Gestational age is adjusted according to the value of the biparietal diameter. The second ultrasound examination is aimed at detecting fetal growth deviations and malformations. In 15% of all pregnancies, ultrasound corrected gestational age by more than 14 days. Ultrasound appeared to be superior to the clinical assessment in 88% of these discrepant pregnancies in predicting date of delivery. The early examination detected 98% of the twin pregnancies, with no false positive results. If an ultrasound examination had been performed within 3 weeks of delivery, 92% of the fetuses with growth retardation were detected. Altogether, the program detected 60% of the growth-retarded fetuses. In 0.4% of the examinations, malformations were detected (0.6% during the last 2 years). A cost-benefit analysis suggested that large economical gains are to be realized by screening. However, organizational and educational problems must be properly solved before general screening is offered to a healthy pregnant population.