The ETHICS of Ultrasound in Clinical Practice

Ma. Victoria Valmonte- Torres, MD, FPOGS

INTRODUCTION:
Outline of the lecture:

The “ethics” of sonologists- clinicians’… knowledge and skill on giving-out “sound & clinically
substantial” results and relationship with referring doctors and with the patients

Word of wisdom on sonologist- clinicians’ knowledge & skills:

“ Sonologists- clinicians must be “ethically” equipped with genuine desire to be cognitively
and technically skilled in signing out clinically substantial sonologic reports, so that we can
aid our referring doctors to make equally sound clinical judgement and management.”

Different OB-GYNE scenarios:

1. Establishing AOG
2. Validating viability in early pregnancy
3. Small fetus: normal or abnormal?
4. Gynecologic pathology:
Ex. Fallopian tube abnormalities

How to properly establish AOG in the

1st trimester: Clinico-sonologic Pearls…

If urine HCG (pregnancy test) is (+)à at least 3 weeks AOG…Clinical scenarios (unknown LMP):
TVS findings at 3weeks à decidualized endometrium

(+) PT –May 1, 2015; TVS - May. 22, 2015; AOG?

à 6 weeks AOG = expect presence of embryo by TVS

Sonographic Milestone (TVS)

Note: AOG maybe predicted by TVS even without measuring the structures (at 3-7 weeks AOG)
…just remember the different sonologic “milestones” (structures/AOG)...

a. Decidualized endometrium = 3 weeks

b. Gestational sac = 4 weeks
c. Yolk sac = 5 weeks
d. Embryo/ cardiac activity = 6 weeks
e. Amniotic sac = 7 weeks

CRL measurement = most accurate predictor of AOG (SD +/- 3- 5days)

For documentation of AOG

Very little size variability during this time
Late 2nd/3rd trimester à affected by individual genetic expression in fetal size à
heterogenous results

Remember:
Once AOG is SET by CRL, MUST never be changed again based on biometric measurements
later.

If the difference in AOG based on CRL & LMP is 7 days or less, may follow LMP and must not be
changed based on sonar aging later
VIABILITY: Clinical Pearls:
Facts to Remember!
* Apply the principle of “sono-embryologic development sequence”
* TVS : (+) yolksac at MSD of 8 mm & (+) embryo at 16 mm
* GS grows at a rate of 1 mm/day
* Embryo grows at a rate of 1 mm/day
* (+) cardiac activity when CRL = 7 mm

Take home message…

AGING and VIABILITY…
* Remember the “sono-embryologic sequence”
* CRL – most accurate predictor of AOG
“ once AOG SET by the CRL NEVER change based on latter sonar aging”

Small fetus: normal or abnormal? Things to remember….

Small fetus…Normal (constitutionally/genetically small fetus) bersus IUGR
Pathologic (Symmetric or asymmetric”hypoxic” IUGR)

Things to remember:
Must always investigate on ”established” AOG
Basis of diagnosis: SERIAL scan done at least 3 weeks apart
If asymmetric (hypoxic) IUGRà may suggest antenatal fetal surveillance (BPS/ Doppler)

Type I or Symmetric IUGR

Etiology:
1. First trimester “accidents”
2. Chromosomal aberration

Diagnosis:Serial UTZ - growth lag in HC & AC

Long Term Prognosis : Neurologic deficits

Type II or Asymmetric or Head Sparing IUGR

Etiology: Uteroplacental insufficiency
Diagnosis: Serial UTZ - normal growth pattern in HC with growth lag in AC

Long Term Prognosis: Good

Clinical Pearls:
Make a Comprehensive REPORTing…
… comparison from previous especially if done in your institution…
… better if can provide “graphical” report of the serial scan

Gynecologic scan:
Fallopian Tubes
HYDROSALPINX with “sausage-like” appearance
Hydrosalpinx w/ “Beads-on-a-string” Appearance

PID: “cog-wheel” sign

Tubo-ovarian complex
Tubo-ovarian abscess

CLINICAL PEARLS…
 Always correlate your grayscale “sonologic morphology” with the patient’s signs and
symptoms

Never be a Sonologist- MORPHOLOGIST

R-ead and/or R-efer

There must be continous medical education in every aspect of our clinical life.
Reading about new/unusual findings we saw or Referring to colleagues and/or previous
mentors will help you become more seasoned scanners!
Make ultrasound books always available in your clinic!

Relationship with referring MDs:

S- ound but safe ultrasound reports
C- omfortable with the referring doctors
A- void comments to the patients which may incite complaints/ litigation against the
attending doctors
N- ever “over represent “ yourself to the patient à “pirating”

• How to guide them in making targetted clinical management decisions

• Detailed descriptions of pelvic pathology
• Follicle monitoring
• Sensible/logical suggestions
• How to make them “comfortable” with you both in your clinical and interpersonal
dealings

Ex. Call them directly; make sensitive comments & suggestions verbally,”urgent” results
Relationship wth referring MDs

How NOT to “pirate” their patients (without you knowing it?)

Ex. “impressing” the patient thru explanations; your ultrasound within your clinic

How NOT to put them into a” litigation” mess ( unintentionally?)

Ex.Incomplete curettage; S/P cystectomy

Relationship to the patient:

S- hould always put yourself in the “shoes” of the patients
O- ffenses unintentionally commited during the scan
U- nderstanding and pleasant staff
N- ice in telling them that “we cannot explain” the results
D- o the gesture in bridging the immediate communication between the patient and her
doctor

Relationship with patients:

How to make your scan enjoyable to them
Ex.showing parts of the fetus, reassure if scan is normal

How to “partially” reveal the results of their scans without “bypassing” their attending MDs’
role in explaining
Ex. “There are findings but not really alarming”, Explain a little about myoma,the
rest will be explained by their AP

Relationship to patients…
How to say “we cannot explain the details of the results” without them feeling rejected
Ex. “ Please don’t get offended…we are really willing to explain but unethical…I hope you
understand”

What MUST be revealed to them during the scan

Ex. FDIU, no heart beats ( if patient asked), urgent call to her MD

How NOT to “unintentionally” offend them

Ex. Call fellows discreetly to show an interesting finding (teaching rounds, seeing patient as a
case)

Words of Wisdom…
The measure of being a fulfilled & seasoned clinician-sonologist is not only how much you
know but by how pleasant you communicate your findings with clinicians and patients……how
much willing you are to unselfishly teach and share your knowledge and experiences with
others…how your good name and reputation precede you wherever you go…