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Overview of imaging in pregnancy: History to the present, including economic impact

John C. Hobbins, MD
University of Colorado Health Science Center, Denver, CO

1. Brief history of ultrasound in obstetrics and gynecology

It has been only four decades since Professor Ian Donald modeled the concept of using sonar to nd submarines during the Second World War into a diagnostic method that has become an essential part of Obstetrical and Gynecological practice. He and a small team of engineers in Glasgow created a primitive static B-mode apparatus, the size of an on-end refrigerator, which was capable of producing black-and-white images that did require a vivid imagination to interpret. Despite its basic beginnings, this machine and those that sprang up from other sources were capable, as never before, to identify a gestation sac, to nd the placenta in patients with vaginal bleeding, to diagnose twins and polyhydramnios, and to date pregnancy by crownrump length and, later, by bi-parietal diameter. From then on, the equipment became less cumbersome and the static B-mode images became exponentially clearer through better resolution. In only a few years the images improved incrementally from simple, single-dimension spikes to static 2-D pictures constructed from information stored through sweeping a transducer across the patient's abdomen. In the mid-1970s, real-time ultrasound came on the scene, which further expanded the clinical scope of ultrasound. Gray-scale renement created the ability to see subtle soft tissue texture differences, thereby enabling the denition of fetal organs. In addition, although pulse Doppler had been available in the early 1980s to evaluate resistance in maternal uterine arteries, it was not until the 1990s that investigators began exploring the fetal circulation, especially in fetal growth restriction. In the late 1990s, transvaginal ultrasound emerged as a classic example of how manufacturers responded to the desires of their clients, the providers. The availability of this methodology opened up a way to explore pregnancies soon after conception and to use higher
E-mail address: jane.berg@ucdenver.edu

frequencies to visualize portions of the fetus that were close to the transducer. Starting in 2000, fetal echocardiography ourished with the advent of new color Doppler imagery. Manufacturers began offering 3-D on their products more than a decade ago, but it was not until the last few years that the equipment began to produce remarkable imagery, and sonographers and sonologists became well-versed on how to exploit the true value of 3-D.

2. The evolution of the clinical utility of ultrasound

Now, after only a few decades of exponential improvement in every aspect of ultrasound imagery, we are now at a point where ultrasound plays a critical role in almost every facet of basic obstetrics. For example: 1. Almost every pregnant woman in the United States (USA) has at least one ultrasound. 2. Dating pregnancy should no longer be an issue. 3. Most major fetal anomalies can be diagnosed early in pregnancy. 4. It is benecial in every complication of pregnancy. 5. The management of under-grown fetuses can be optimized. 6. Needles can be placed into 3-mm targets (Chorionic Villus Sampling, amniocentesis, cordocentesis, and intrauterine transfusion).

3. How practice models have affected ultrasound use

At rst, primitive images limited ultrasound's clinical utility to a few task-specic endeavors to sort out a few common problems such as follows:

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1. Ruling out an ectopic pregnancy by demonstrating a gestation sac in the uterus and/or demonstrating the viability by M mode of the fetal heart. 2. Locating the placenta in patients with vaginal bleeding. 3. Determining gestational age by measurements of fetal biometry. With the advent of gray scale and further sophistication of the imagery, it was possible to obtain useful information about the fetus and its intrauterine environment that extended beyond answering the specic questions at hand. Soon sonographers and sonologists were systematically examining the fetus in a regimented fashion. Initially, this examination was originally labeled as a level I scan. Almost simultaneously, a level II scan sprang up to deal with more complicated clinical situations. Unfortunately, this concept got out of hand when the level categories began to apply to two different qualities of examinations, personnel, types of operation, and, of course, reimbursement. This further developed into a race to be the rst to offer a level III or even a level IV examination. To respond to this concerning development, the American Institute of Ultrasound in Medicine (AIUM) developed a set of guidelines for the use of obstetrical ultrasound rst in 1985. Later, the AIUM joined with the American College of Radiology (ACR) in 2003 and together developed guidelines regarding the names and contents of three types of examinations: the standard examination, which would suit the needs of the majority of pregnant women; the targeted examination, which would be employed to investigate pregnancy complications, especially fetal anomalies; and a third limited examination, which was meant to simply answer a single clinical question (for example, how much amniotic uid was in the uterus) and did not require a full fetal anatomy survey. Although these guidelines have undergone some modication through the years, the concept remains that in most cases there should be a uniform, systematic approach to the fetus, placenta, and uid with each standard examination. In addition, in an effort to improve the delivery of ultrasound care, the AIUM and ACR in 1996 set up systems to accredit ultrasound practices. Each practice seeking accreditation was evaluated according to the training of the sonographers and sonologists, the quality of the images and reports, and the ability of practices to demonstrate adherence to preset operational guidelines.

following rough calculation of ultrasound cost will represent a gross underestimation of the real gures. Many patients in the USA still have had no obstetrical care, but far more have had more than one ultrasound examination. Therefore, I arrived at an average of 1.5 examinations for each of the 4 million women pregnant per yearyielding more than 6 million examinations. Based on a very rough estimate of cost per examination (not the amount billed) of about $200 per examination, the public-health cost of ultrasound per year would be more than $1.2 billion.

5. The changing dynamics of delivery of ultrasound care in the United States

Ultrasound examinations are conducted in various sites: the primary providers' ofces, the hospital radiology or obstetrical departments, and freestanding ultrasound specialty centers. The mix of who does what varies from region to region or even town to town in the USA. Very recently, there has been a trend toward more obstetrical scans, especially the basic examinations, being done in the ofces of the primary care providers. It does make sense that patients would be more conveniently served by having point-of-entry ultrasounds done by a familiar provider rather than being referred for a separate examination at a removed, specialty center. However, this trend may be related to nancial considerations as reimbursement for ultrasound services has remained steady despite decreased reimbursement for global obstetrical care. If this trend continues, then it is extremely important that sonographers and sonologists in the primary care ofces have proper training to provide basic ultrasound services. At the moment, sonographers have far more rigid training and certication standards than physicians, who in many cases are purely dependent upon any ultrasound training they might have obtained during their residencies, topped off with later on-the-job training. These trends come and go, but one priority today must be to improve the quality of ultrasound training in every residency program in the country. Among other priorities, this group must tackle are ways to diminish redundant and unnecessary examinations, to make recommendations for when, in an uncomplicated pregnancy, an ultrasound scan is most efcacious, and to draft some sensible guidelines regarding the amount and types of examinations that would be of benet in various clinical circumstances. The cost of health care continues to sky-rocket, and we are hopeful that our recommendations will not only make future ultrasound services more efcient, but less expensive. We think that the fruits of this group's labor will represent a call to those in other elds of clinical medicine to do their part to analyze in a similar way every aspect of their delivery of care.

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Cost of obstetric ultrasound in the USA

In his article, Dr. Dan O'Keefe provides extremely useful data regarding the number and types of ultrasound examinations that are being done in the USA today. These gures have been difcult to come by for me, and I strongly suspect that the