Ultrasound - Weighing The Propaganda Against The Facts - by Beverley Lawrence Beech

Ultrasound: Weighing the Propaganda Against the Facts - by Beverley La...
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Ultrasound: Weighing the

Propaganda Against the Facts
by Beverley Lawrence Beech
1999 Midwifery Today, Inc. All rights reserved.
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[Editor's note: This article first appeared in Midwifery Today

Issue 51, Autumn 1999.]
The use of ultrasound in antenatal care is big business, and in
any big business marketing is all-important. As a result of
decades of enthusiastic marketing, women believe they can
ensure the well-being of their babies by reporting for an early
ultrasound scan and that early detection of a problem is
beneficial for these babies. That is not necessarily so, and
there are a number of studies which show that early detection
can be harmful.
In response to womens desire for information about the
implications of routine ultrasound examinations, Jean Robinson
and I wrote the book Ultrasound? Unsound, in which we
reviewed the research evidence and drew attention to some of
the hazards (Beech and Robinson, 1996). But since then more
evidence has accumulated. For example:
Miscarriage
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It is ironic that women who have had previous miscarriages

often have additional ultrasound examinations in order to
"reassure" them that their baby is developing properly. Few are
told of the risks of miscarriage or premature labour or birth.
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Obstetricians in Michigan (Lorenz et al., 1990) studied

fifty-seven women who were at risk of giving birth prematurely.
Half were given a weekly ultrasound examination; the rest had
pelvic examinations. Preterm labour was more than doubled in
the ultrasound group52 percentcompared with 25 percent in
the controls. Although the numbers were small the difference
was unlikely to have emerged by chance.
A large randomised controlled trial from Helsinki (SaariKemppainen et al., 1990) randomly divided over 9,000 women
into a group who were scanned at sixteen to twenty weeks
compared with those who were not. It revealed twenty
miscarriages after sixteen to twenty weeks in the screened
group and none in the controls.
A later study in London (Davies et al., 1993) randomised 2,475
women to routine Doppler ultrasound examination of the
umbilical and uterine arteries at nineteen to twenty-two weeks
and thirty-two weeks compared with women who received
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It is not only pregnant patients who are at risk, however.

Physiotherapists use ultrasound to treat a number of
conditions. A study done in Helsinki (Taskinen et al., 1990)
found that if the physiotherapist was pregnant, handling
ultrasound equipment for at least twenty hours a week
significantly increased the risk of spontaneous abortion. Also,
the risk of spontaneous abortions occurring after the tenth
week was significantly increased for deep heat therapies given
for more than five hours a week and ultrasound more than ten
hours a week.
Diagnosis of placental praevia
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The Saari-Kemppainen study also revealed the lack of value in

early diagnosis of placenta praevia. Of the 4,000 women who
were scanned at sixteen to twenty weeks, 250 were diagnosed
as having placenta praevia. When it came to delivery, there
were only four. Interestingly, in the unscanned group there were
also four women found at delivery to have this condition. All the
women were given caesarean sections and there was no
difference in outcomes between the babies. Indeed, there are
no studies which demonstrate that early detection of placenta
praevia improves the outcome for either the mother or the
baby. The researchers did not investigate the possible effects
on the 246 women who presumably spent their pregnancies
worrying about having to undergo a caesarean section and the
possibility of a sudden haemorrhage.
Since the publication of Ultrasound? Unsound further studies
have raised questions about the value of routine ultrasound
scanning.
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Babies with serious defects

Almost all babies receive a dose of ultrasound, but even at the
best centres wide variations occur in detection rates for babies
with major heart abnormalities. Both national and international
detection rates differ widely in published studies (which are
usually undertaken in centres of excellence), but the majority of
mothers will be exposed to older machines in ordinary hospitals
and clinics. The skill of the operators will vary (everybody has
to learn sometime), but even with the best machines and the
best operators misdiagnoses occur. A study from Oslo (Skari
et al., 1998) looked at how many babies born with serious
defects had been diagnosed by antenatal scans, and whether
the early diagnosis made any difference to the outcomes.
Women in Norway have a scan at seventeen to twenty-one
weeks done by trained midwives, who refer to obstetricians if
an abnormality is suspected.
In nineteen months, thirty-six babies were referred from a
population of 2.5 million. They had diaphragmatic hernias,
abdominal wall defects, bladder extrophy or meningomyelocele.
Only thirteen of the thirty-six defects had been detected before
birth (36 percent). They found that only two of eight congenital
diaphragmatic hernias were picked up on ultrasound, half the
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cases of abdominal wall defects (six out of twelve), 38 percent

of the meningomyelocele (five out of thirteen) and none of the
three cases of bladder extroversion. The mothers had an
average of five scans (from one to fourteen); those in whose
cases abnormality was detected had an average of seven.
Three out of the thirteen babies diagnosed antenatally died.
There was one death in the twenty-three undiagnosed. All
thirteen babies with antenatal diagnosis were delivered by
caesarean. Nineteen of the twenty-three undiagnosed babies
had an uncomplicated vaginal delivery. The diagnosed babies
had lower birth weight and two weeks shorter gestation.
Although the babies with pre-diagnosed abdominal wall defects
received surgery more quickly (four hours versus thirteen
hours), the outcomes were the same in both groups. Although
small, this is an important study.
Pregnant women often automatically assume that antenatal
detection of serious problems in the baby means that lives will
be saved or illness reduced. Knowing about the problem in
advance did not benefit these babies; more of them died. They
got delivered sooner, when they were smaller, a choice that
could have long-term effects. All twelve babies with abdominal
wall defects survived. But for the six detected on the scan, their
length of hospital stay was longer and they spent longer on
ventilators, though the numbers are too small to be significant.
They were operated on sooner (four hours rather than thirteen
hours) but the outcomes were the same.
Growth Retarded Babies

One of the promises held out by antenatal scanning is that
obstetricians will be able to identify the baby with problems and
do something to help it. A German study from Wiesbaden
hospital (Jahn et al., 1998) found that out of 2,378 pregnancies
only fifty-eight of 183 growth retarded babies were diagnosed
before birth. Forty-five fetuses were wrongly diagnosed as
being growth retarded when they were not. Only twenty-eight
of the seventy-two severely growth-retarded babies were
detected before birth despite the mothers having an average of
4.7 scans.
The babies diagnosed as small were much more likely to be
delivered by caesarean - 44.3 percent compared with 17.4
percent for babies who were not small for dates. If the baby
actually had intrauterine growth retardation (IUGR) the section
rate varied hugely according to whether it was diagnosed
before birth (74.1 percent sectioned) or not (30.4 percent).
So what difference did diagnosis make to the outcome for the
baby? Pre-term delivery was five times more frequent in those
whose IUGR was diagnosed before birth than those who were
not. The average diagnosed pregnancy was two to three
weeks shorter than the undiagnosed one. The admission rate
to intensive care was three times higher for the diagnosed
babies.
The long-term emotional impact

The effects of screening on both parents can be profound. For
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example, women waiting for the results of tests try not to love
the baby in case they have to part with it. The medical literature
has little to say about the human costs of misdiagnosis unless
the baby was mistakenly aborted, and even then it tends to
focus on legal action. However, a letter in the British Medical
Journal revealed how a diagnosis of a minor anomaly can have
serious long-term implications for the family:
A couple was referred for amniocentesis during the wifes
second pregnancy on the grounds of maternal age, thirty-five
years, and anxiety. Their three-year-old son played happily
during the consultation. When his wife and son had left the
room after the procedure the husband confided that they had
opted for amniocentesis to avoid having another "brain
damaged" child. On questioning it became apparent that an
ultrasound examination before their sons birth had shown a
choroid plexus cyst. Despite having a healthy child, the husband
remained convinced that this cyst could cause his son to be
disabled. (Mason and Baillie, 1997).
Evaluating the risks

When ultrasound was first developed researchers suggested
that "the possibility of hazard should be kept under constant
review" (Donald, 1980), and they said that it would never be
used on babies under three months. However, as soon as
vaginal probe ultrasound was developed, which could get good
pictures in early pregnancies (and get nearer to the baby giving
it a bigger dose), this initial caution was ignored.
Research by Lieberskind revealed "the persistence of abnormal
behaviour . . . in cells exposed to a single dose diagnostic
ultrasound ten generations after insonation." She concluded, "If
germ cells were . . . involved, the effects might not become
apparent until the next generation" (Lieberskind, 1979). When
asked what problems should be looked for in human studies,
she suggested: "Subtle ones. Id look for possible behavioural
changes, in reflexes, IQ, attention span" (Bolsen, 1982).
Because ultrasound has been developed rapidly without proper
evaluation it is extremely difficult to prove that ultrasound
exposure causes subtle effects. After all, it took over ten years
to prove that the gross abnormalities found in some newborn
babies were caused by thalidomide. However, there are a
number of ultrasound studies which raise serious questions that
still have to be addressed.
The first evidence we saw of possible damage to humans
came in 1984 when American obstetricians published a
follow-up study of children, aged seven to twelve years born in
three different hospitals in Florida and Denver, who had been
exposed to ultrasound in the womb (Stark et al., 1984).
Compared with a control group of children who had not been
exposed they were more likely to have dyslexia and to have
been admitted to hospital during their childhood, but no other
differences were found.
In 1993 a study in Calgary, Alberta which examined the
antenatal records of seventy-two children with delayed speech
of unknown cause were compared with those of 142 controls
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who were similar in sex, date of birth and birth order within the
family. The children were similar in social class, birthweight and
length of pregnancy. The children with speech problems were
twice as likely as controls to have been exposed to ultrasound
in the womb. Sixty-one percent of cases and only 37 percent of
controls had had at least one exposure.
A Norwegian study (Salvesen, 1993) showed an increase in left
handedness, but no increase in dyslexia. While the increase in
left handedness was not large, it does suggest that ultrasound
has an effect on the development of the brain. It should be
noted, however, that the scanners used in this study emitted
very low doses of ultrasoundlower than exposures from many
machines nowadaysthe women had only two exposures, and
it was real time, not Doppler, a more powerful form of
ultrasound.
Assessing the risks

"Present day ultrasonic diagnostic machines use such small
levels of energy that they would appear to be safe, but the
possibility must never be lost sight of that there may be safety
threshold levels possibly different for different tissues, and that
with the development of more powerful and sophisticated
apparatus these may yet be transgressed" (Donald, 1979).
Donalds foresight was remarkable. The machines in use today
are far more powerful than the machines used a decade or
more ago, and new variants are being developed all the time.
There has been inadequate research into the potential
long-term effects. Measuring the outcome of any intervention in
pregnancy is very complicated because there are so many
things to look at. Intelligence, personality, growth, sight,
hearing, susceptibility to infection, allergies and subsequent
fertility are but a few issues which, if affected, could have
serious long-term implications, quite apart from the numbers of
babies who have a false positive or false negative diagnosis.
Because a baby grows rapidly, exposing it to ultrasound at
eight weeks can have different effects than exposure at, for
example, ten, eighteen or twenty-four weeks (this is one of the
reasons the effects of potential exposure are so difficult to
study). Women are now exposed to so many different types of
ultrasound: Doppler scans, real-time imaging, triple scans,
external fetal heart-rate monitors, hand held fetal monitors.
Unlike drugs, whereby every new drug must be tested, the
rapid development of each new variation of ultrasound machine
has not been accompanied by similar careful evaluation by
controlled, large-scale trials.
Despite decades of ultrasonic investigation, no one can
demonstrate whether ultrasound exposure has an adverse
effect at a particular gestation, whether the effects are
cumulative or whether it is related to the output of a particular
machine or the length of the examination. How many exposures
are too many? What is the mechanism by which growth is
affected? A large-scale study (Newnham et al., 1991) showed
decreased birthweight, although a later study suggested the
babies soon make up the deficit. It should not be forgotten,
however, that numerous studies on rats, mice and monkeys
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over the years have found reduced fetal weight in babies that
had ultrasound in the womb compared with controls. Nor should
it be forgotten that in the monkey studies (Tarantal et al., 1993)
the ultrasound babies sat or lay around the bottom of the cage,
whereas the little control monkeys were up to the usual monkey
tricks. Long-term follow up of the monkeys has not been
reported. Do they reproduce as successfully as the controls?
And, as Jean Robinson has noted: "Monkeys do not learn to
read, write, multiply, sing opera, or play the violin." Human
children do, and perhaps we should consider seriously whether
the huge increases in children with dyslexia and learning
difficulties are a direct result of ultrasound exposure in the
womb. Furthermore, when a woman is scanned her babys
ovaries are also scanned. So if the woman had seven scans
during her pregnancy, when her pregnant daughter eventually
presents years later at the antenatal clinic, her developing baby
will already have had seven scans. Do women really know what
they consent to when they rush to hospital to have their first
ultrasound scan, then trustingly agree to further scans?
Beverley A Lawrence Beech, honourary chair of the
Association for Improvements in the Maternity Services
(AIMS), is a freelance writer and lecturer and lives in the United
Kingdom.
References
Beech, B. & Robinson, J. (1996). Ultrasound? Unsound.
London: Association for Improvements in the Maternity
Services (AIMS).
Bolsen, B. (1982). Question of risk still hovers over
routine prenatal use of ultrasound. JAMA, 247:
2195-2197.
Donald, I. (1979). Practical Obstetric Problems. (5th
ed). London: Lloyd-Luke, Medical Books Ltd.
Donald, I. (1980). SonarIts present status in medicine.
In A. Jurjak (Ed), Progress in Medical Ultrasound, 1:
00104. Amsterdam: Excerpta Medica.
Jahn, A. et al. (1998). Routine screening for intrauterine
growth retardation in Germany; low sensitivity and
questionable benefit for diagnosed cases. Acta Ob Gyn
Scand, 77: 64389.
Lorenz, R.P. et al. (1990, June). Randomised
prospective trial comparing ultrasonography and pelvic
examination for preterm labor surveillance. Am. J.
Obstet. Gynecol, 160310.
Mason, G. and Baillie, C. (1997). Counselling should be
provided before parents are told of the presence of
ultrasonographic soft markers of fetal abnormality
(Letter). BMJ 315: 18081.
Newnham, J.P. et al. (1991). Effects of frequent
ultrasound during pregnancy: a randomised controlled
trial. The Lancet, 342: 88790.
Saari-Kemppainen et al. (1990). Ultrasound screening
and perinatal mortality: controlled trial of systematic
one-stage screening in pregnancy. The Lancet, 336:
38791.
Salvesen, K.A. et al. (1992). Routine ultrasonography in
utero and school performance at age 89 years. The
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Lancet, 339.
Skari, H. et al. (1998). Consequences of prenatal
ultrasound diagnosis: a preliminary report on neonates
with congenital malformations. Acta. Ob Gyn Scand,
177: 63542.
Tarantal, A.F. et al. (1993). Evaluation of the bioeffects
of prenatal ultrasound exposure in the Cynomolgus
Macaque (Macaca fascicularis). Chapter III in
Developmental and Mematologic Studies, Teratology
47: 15970.
Taskinen, H. et al. (1990). Effects of ultrasound,
shortwaves, and physical exertion on pregnancy
outcome in physiotherapists. Journal of Epidemiology
and Community Health 44: 196201.
Resources:
Understanding Obstetric Ultrasound (2nd edition) by
Jean Proud
Midwifery Today Issue 51
Theme: Fathers in Pregnancy and Birth; articles on
ultrasound, natural family planning, the "call" to
midwifery, placenta previa and much more round out the
issue.
Midwifery Today Issue 50
Theme: Homebirth; from this issue, read online
Ultrasound: More Harm Than Good? by Marsden
Wagner
If you enjoyed this article, you'll enjoy Midwifery Today
magazine! Subscribe now!
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