Ultrasound care and ACOG standards

[sriracha]

I thought I'd just put this here because I haven't seen this information really anywhere else. In the debates about the Virginia and Texas (and soon to be Alabama?) ultrasound laws:

This policy is based in part on The American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin on Ultrasonography in Pregnancy and guidelines from the Society for Maternal-Fetal Medicine (SMFM).

Ultrasonography in pregnancy should be performed only when there is a valid medical indication. ACOG (2009) stated, “The use of either two-dimensional or three-dimensional ultrasonography only to view the fetus, obtain a picture of the fetus, or determine the fetal sex without a medical indication is inappropriate and contrary to responsible medical practice.â€

Indications for a first-trimester ultrasound (performed before 13 weeks and 6 days of gestation) include:

As adjunct to chorionic villus sampling, embryo transfer, or localization and removal of an intrauterine device

To assess for certain fetal anomalies, such as anencephaly, in patients at high risk

To confirm cardiac activity

To confirm the presence of an intrauterine pregnancy

To diagnosis or evaluate multiple gestations

To estimate gestational age

To evaluate a suspected ectopic pregnancy

To evaluate maternal pelvic or adnexal masses or uterine abnormalities

To evaluate pelvic pain

To evaluate suspected hydatidiform mole

To evaluate vaginal bleeding

To screen for fetal aneuploidy.

http://www.aetna.com/cpb/medical/data/100_199/0199.html

This is only Aetna's policy but I think most other insurance companies also adhere to the ACOG standard of not practicing sonography just to obtain pictures of fetuses in order to coerce women or keep the pretty pictures in their medical files.

“CIGNA covers one routine two-dimensional (2D) standard obstetrical ultrasound examination during pregnancy. CIGNA covers additional ultrasound examinations as medically necessary when performed for specific medical indications.

CIGNA does not cover an obstetrical ultrasound examination performed solely to determine gender or to provide photographic representation of the fetus, because it is considered not medically necessary for the management of a pregnancy.â€

http://www.cigna.com/customer_care/heal ... e_3d4d.pdf

More doctors agreeing with ACOG:

http://www.quadrant.net/cpss/resource/ultrasound.html

As to whether or not an ultrasound is medically necessary before all abortions:

“Not all physicians will do an ultrasound before an abortion.â€

http://aetna-health.healthline.com/smar ... ame/tw5328

because it's not necessary.

"Once the woman’s choice to proceed with an abortion has been clearly established and written informed consent has been obtained, there is no need for further delay, which may only increase the risk of complications. Counseling should be offered only if the woman requests it or there is a perceived need for it.The blood-group rhesus type should be determined and Rh immune globulin should be administered in Rh-negative women. Cytologic screening of the cervix and screening for sexually transmitted diseases should be offered as appropriate. Ultrasonographic examination of the uterus is common, but it is not required routinely before a first-trimester abortion is performed.â€

Kulier R, Kapp N. Comprehensive analysis of the use of pre-procedure ultrasound for first- and second-trimester abortion. Contraception 2011;83:30-33

http://www.nejm.org/doi/full/10.1056/NE ... #t=article

I guess I'm just fucking sad that the government in several states has decided to ram legislation down women's throats (or, up their vaginas in this case) for medically unnecessary procedures that even insured women will have to pay out of pocket for. "Informed consent" is a misuse of sonography.

Sad and angry!!! Thank you for letting me rant.

[NurseNell]

I have yet to meet a woman in the past 15 years who has NOT had at least one ultrasound done, many have had two, and a few, high risk women, have had multiple. The last person I knew not to have one was my co-worker Julie, in 1990. We kept saying she was having twins because, believe me, she was incredibly huge, and she was a very thin person. But no ultrasound. Sure enough, twins, a total surprise to her, her husband, and doctor. We couldn't understand why her doctor hadn't done at least one ultrasound because even then they were routine. Anyway, I'm not sure physicians and even licensed midwives are following this policy when almost 100% of pregnant women today have ultrasounds.

That said, I don't see the necessity of doing them pre abortion. A positive pregnancy test, yes but not an ultrasound.

[ilovetchotchkes]

I have yet to meet a woman in the past 15 years who has NOT had at least one ultrasound done, many have had two, and a few, high risk women, have had multiple. The last person I knew not to have one was my co-worker Julie, in 1990. We kept saying she was having twins because, believe me, she was incredibly huge, and she was a very thin person. But no ultrasound. Sure enough, twins, a total surprise to her, her husband, and doctor. We couldn't understand why her doctor hadn't done at least one ultrasound because even then they were routine. Anyway, I'm not sure physicians and even licensed midwives are following this policy when almost 100% of pregnant women today have ultrasounds.

That said, I don't see the necessity of doing them pre abortion. A positive pregnancy test, yes but not an ultrasound.

I think the ONLY time it should be done for an abortion is to determine the age of the pregnancy. Which to some extent they can get an idea IF they need to do an ultrasound by checking the HCG levels. - Because from my understanding, either they can give you drugs for if its before 8 weeks or so, or if its after 8, you'd need basically a D&C. AND if that's the case, that's quick, easy, and a 5 minute deal. None of this "show the woman the heartbeat" bullshit.

[YPestis]

I'm just glad the state that wanted to have mandatory US done prior to any abortions recinded the requirement for a transvaginal US. Common medical practice states that we do not perform medical procedures unless there is a medical indication blah blah blah, but at least an abdominal US is relatively noninvasive (ew, that goo is kind of gross....).

[nomi]

I thought an u/s was common practice before an abortion. I've taken two friends to clinics and they were both given scans, one in FL and the other in NC. They had it done to confirm dating.

[sriracha]

The short answer is yes, ultrasounds before abortion are very very common.

The long answer is that there are doctors that choose not to do them, that they aren't really required if a woman does not present with a problem that would necessitate it's use - except that they are now by the government regardless of whether or not a physician feels it's necessary.

And because of the nature of the ultrasounds (informed consent and not medical necessity), insurance will probably not cover them.

[sassyNoz47]

I also thought they were always done before a abortion. Years ago I saw a tv program that implied doing a ultrasound first reduced the number of abortions. Something about if the mother SEES the fetus/beating heart in some cases its harder for her to abort. Seems like in one of the 16 and pg shows one of the teens planned a abortion but she stated when she saw the ultra-sound before the procedure she then couldn't abort. She decided at least to go adoption but I cant remember if in the end she kept the baby or not. It was a girl who never went on to do either of the teen mom series, so I don't know what ever happened to her.

I had to beg for a sono gram in 1991, but I finally got one paid out of pocket. With baby 2 I had 2, and due to a placenta previa I had 4 with baby #3. By the time I had # 4 it was 2003 and I think I had 5 or 6 total. They also were always off by at least 3lbs on size of the baby on all 4 kids. my 3rd baby in 96 was the first one they would even tell u the gender but at 20 weeks he was a boy then at 36 weeks they said girl! By 2003 they had made alot of improvements it really looked like a baby and not a blob..and they were able to tell us at 18 weeks the gender (correct this time).

Now my daughter is pg first baby shes 21 not high risk and shes had at least 12 already including 2 3d . shes only 30 weeks they said they would start doing them weekly next month WHY???

[lovefromgirl]

My mom had a grand total of... none. This was between 1985-1986 and there was considerable debate as to how far along she was, but her choice not to bother was respected. She thinks the current ultrasound madness is, well, madness, especially the forced ones. I'd probably choose to have an ultrasound after the abortion, to make sure the doctor got it all, but before? Why? So he knows where to aim? Honey, if he ain't got that one down, he has no business going anywhere near a woman with a curette or a vacuum.

[LadyBlue]

Now my daughter is pg first baby shes 21 not high risk and shes had at least 12 already including 2 3d . shes only 30 weeks they said they would start doing them weekly next month WHY???

To make more money.

She should know that ultrasounds are not proven safe, there are a lot of proven issues with them & no one knows what they mean for the long term health, especially brain health. Ultrasound is not a toy, although a lot of doctors and parents act like they are. (Quick summary, ultrasound has been shown to cause brain cells to migrate differently, to increases left handedness, to increase the chance of speech & hearing issues, among other things). Your daughter can and should refuse any further ultrasounds unless there's a genuine medical need. And since she's low risk and already had at least 10 too many, there really isn't any need.

I'm just glad the state that wanted to have mandatory US done prior to any abortions recinded the requirement for a transvaginal US. Common medical practice states that we do not perform medical procedures unless there is a medical indication blah blah blah, but at least an abdominal US is relatively noninvasive (ew, that goo is kind of gross....).

Virginia may have dropped it, but Texas has been forcing transvaginal ultrasounds on anyone who wants an abortion there for the last 31 days. http://www.rhrealitycheck.org/article/2 ... tate-state

They're also trying to do these nasty bills in Alabama & Pennsylvania.

[NurseNell]

To make more money.

She should know that ultrasounds are not proven safe, there are a lot of proven issues with them & no one knows what they mean for the long term health, especially brain health. Ultrasound is not a toy, although a lot of doctors and parents act like they are. (Quick summary, ultrasound has been shown to cause brain cells to migrate differently, to increases left handedness, to increase the chance of speech & hearing issues, among other things). Your daughter can and should refuse any further ultrasounds unless there's a genuine medical need. And since she's low risk and already had at least 10 too many, there really isn't any need.

To make money is a big reason.

I don't know about whether they've been proven unsafe or not but I've always wondered about the long term effects. When I did my OB rotation in 1964 we routinely gave DES injections to every woman admitted with spotting. Women were almost always admitted with spotting because it was thought then to mean an impending miscarriage. We now know the spotting in the first trimester is common and only rarely are women admitted. DES was thought to help the pregnancy to continue. Of course many years later we learned what the long term effects of DES on the fetus is. And it wasn't good. I can't help but feel down the road we'll learn that ultrasounds do have effects on the developing fetus.

[browngrl]

[

I think the ONLY time it should be done for an abortion is to determine the age of the pregnancy. Which to some extent they can get an idea IF they need to do an ultrasound by checking the HCG levels. - Because from my understanding, either they can give you drugs for if its before 8 weeks or so, or if its after 8, you'd need basically a D&C. AND if that's the case, that's quick, easy, and a 5 minute deal. None of this "show the woman the heartbeat" bullshit.

I disagree. An ultrasound done to determine accurate dates is important BUT another reason is to determine the location of the pregnancy (i.e. ectopic pregnancy). Another reason would be to determine if the embryo is live/demised (the medical management of a failed early pregnancy is obviously quite different from an abortion). Ultrasound should never be used as a weapon to force the patient to follow a political or religious agenda but there are actually solid medical reasons to do endovaginal ultrasound(s) in pregnancy.

LadyBlue wrote:

She should know that ultrasounds are not proven safe, there are a lot of proven issues with them & no one knows what they mean for the long term health, especially brain health. Ultrasound is not a toy, although a lot of doctors and parents act like they are. (Quick summary, ultrasound has been shown to cause brain cells to migrate differently, to increases left handedness, to increase the chance of speech & hearing issues, among other things). Your daughter can and should refuse any further ultrasounds unless there's a genuine medical need. And since she's low risk and already had at least 10 too many, there really isn't any need.

I disagree with this as well. Ultrasound is a tried and tested imaging modality which is safe as far as we know. Could future research find risks - yes of course that is the nature of science/medicine/research. This is also why ultrasound should only be used only for medical indications and why techniques such as doppler, 3D ultrasound should be used judiciously. However it is an overstatement to say that ultrasound has not been proven safe.

I am also concerned with this statement: "your daughter can and SHOULD REFUSE any further ultrasounds......had at least 10 too many..REALLY ISN'T ANY NEED". Unless you are directly involved in the patient's care - you do not truly know the medical situation. You can not assume that the pregnancy is "low risk" because the grandmother says that it is. There are many medical issues that would necessitate multiple obstetric ultrasound examinations. In many cases - these reasons may not be apparent during non medical/social interactions with the patient - so people might easily assume someone is low risk when this is far from the truth. Please be careful in advising people to decline tests because there "really isn't any need". It is reasonable and safe to advise that the patient discuss the situation with her doctor but it is neither reasonable or safe to advise her to decline ultrasound when you do not know all the medical information.

note to moderator: please moderate - this rant might be off topic

[sriracha]

I guess I was a tad ahead of the curve, either that or someone at FORBES likes my comments at Jil St4nek!

http://www.forbes.com/sites/rickungar/2 ... cologists/

[ilovetchotchkes]

I disagree. An ultrasound done to determine accurate dates is important BUT another reason is to determine the location of the pregnancy (i.e. ectopic pregnancy). Another reason would be to determine if the embryo is live/demised (the medical management of a failed early pregnancy is obviously quite different from an abortion). Ultrasound should never be used as a weapon to force the patient to follow a political or religious agenda but there are actually solid medical reasons to do endovaginal ultrasound(s) in pregnancy.

LadyBlue wrote:

She should know that ultrasounds are not proven safe, there are a lot of proven issues with them & no one knows what they mean for the long term health, especially brain health. Ultrasound is not a toy, although a lot of doctors and parents act like they are. (Quick summary, ultrasound has been shown to cause brain cells to migrate differently, to increases left handedness, to increase the chance of speech & hearing issues, among other things). Your daughter can and should refuse any further ultrasounds unless there's a genuine medical need. And since she's low risk and already had at least 10 too many, there really isn't any need.

I disagree with this as well. Ultrasound is a tried and tested imaging modality which is safe as far as we know. Could future research find risks - yes of course that is the nature of science/medicine/research. This is also why ultrasound should only be used only for medical indications and why techniques such as doppler, 3D ultrasound should be used judiciously. However it is an overstatement to say that ultrasound has not been proven safe.

I am also concerned with this statement: "your daughter can and SHOULD REFUSE any further ultrasounds......had at least 10 too many..REALLY ISN'T ANY NEED". Unless you are directly involved in the patient's care - you do not truly know the medical situation. You can not assume that the pregnancy is "low risk" because the grandmother says that it is. There are many medical issues that would necessitate multiple obstetric ultrasound examinations. In many cases - these reasons may not be apparent during non medical/social interactions with the patient - so people might easily assume someone is low risk when this is far from the truth. Please be careful in advising people to decline tests because there "really isn't any need". It is reasonable and safe to advise that the patient discuss the situation with her doctor but it is neither reasonable or safe to advise her to decline ultrasound when you do not know all the medical information.

note to moderator: please moderate - this rant might be off topic

DERP! you're totally right. I was just thinking from my medical history when If we went by LMP, my son would have been over 2 weeks "late" and thing #2's due date would also been over a week later than thought. I think my ADHD logic went with the fact too, that when they do dating ultrasounds, they also (at least have for me!) check out the ovaries/position. (with thing #2 they actually showed me the folicle the egg burst out of , it was COOL for me to see, for me though, this was a planned, WANTED pregnancy and I told her to show me everything she could!)

[LadyBlue]

I disagree with this as well. Ultrasound is a tried and tested imaging modality which is safe as far as we know. Could future research find risks - yes of course that is the nature of science/medicine/research. This is also why ultrasound should only be used only for medical indications and why techniques such as doppler, 3D ultrasound should be used judiciously. However it is an overstatement to say that ultrasound has not been proven safe.

As far as we know. Largely because we don't know very much at all, they've only really started testing it. The information that ultrasound affects fetal brain cell migration comes from a study in the last couple years. But like with all studies on ultrasound right now, we don't know what that means for long term outcomes. Could the massive rise in autism and other disorders affecting the brain be due to increasing ultrasound use? No one knows. We do know that fetus' attempt to "run away" from ultrasounds, dopplers & fetal monitoring equipment (the latter two both use higher dosage of ultrasound than imaging ultrasounds). I remember how the nurses thought it was so funny when my eldest tried to get away. I wonder now what it might have been doing to him, since he was clearly aware of it and didn't like it.

How many other things have pregnant women been told were completely safe, only for us to later find out they were causing damage? Too many. There is zero reason for 12x ultrasounds in one pregnancy, no matter the risk level. Zero. There is nothing that can learned from that level of excessive use that couldn't be learned by other methods or isn't completely irrelevant. Ultrasound isn't treatment, it's diagnostic and overuse is huge problem.

Here's the British Medical Ultrasound Society on the safety of ultrasound. Even they admit we only think it's safe, we can't be sure. And that if machines aren't calibrated properly they can definitely be unsafe http://www.bmus.org/about-ultrasound/au ... tement.asp

And this link has a list of all the studies showing areas of concern with regard to ultrasound, both safety and accuracy. http://www.facebook.com/note.php?note_id=421151867561 Or for a quick summary of some of the major issues http://www.greenhealthwatch.com/newssto ... -hurt.html

I am also concerned with this statement: "your daughter can and SHOULD REFUSE any further ultrasounds......had at least 10 too many..REALLY ISN'T ANY NEED". Unless you are directly involved in the patient's care - you do not truly know the medical situation. You can not assume that the pregnancy is "low risk" because the grandmother says that it is. There are many medical issues that would necessitate multiple obstetric ultrasound examinations. In many cases - these reasons may not be apparent during non medical/social interactions with the patient - so people might easily assume someone is low risk when this is far from the truth. Please be careful in advising people to decline tests because there "really isn't any need". It is reasonable and safe to advise that the patient discuss the situation with her doctor but it is neither reasonable or safe to advise her to decline ultrasound when you do not know all the medical information.

Sorry for assuming that the mother would know whether or not her daughter's pregnancy was high risk. But really, it doesn't matter if the pregnancy is high or low risk, 12 ultrasounds over 7 months is excessive. Adding another (probably) 10 or more to that is sheer lunacy.

[treemom]

Lady blue, there are actually lots of reasons for 12 u/s in one pregnancy. Monitored for suspected iugr is one.

You are also doing a hell of a lot of implying correlation =causation there as well.

I am so tired of the mama guilting in general. I saw a doctor I trusted. I had had two late term losses at this point. My permiatologist and ob were not just looking to make money from me. They were treating me as an actual human being. I had risks that were immense and I was willing to take the slight risk of u/s to have a live baby. (and matter of fact that was a real concern for me). Glad to know that you think there is only a reason for a couple of u/s....

Btw, with the pregnancy I terminated, I had 5 u/s in about 14 days.