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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5786_Библиотеки_им_академика_М_И_Перельмана.pdf
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CLINICAL TOPICS
COMPETENCE AND REFERRAL IN ULTRASOUND EXAMINATION
The ethical obligation to provide competent obstetric ultrasound examinations
derives from both beneficence and respect for autonomy. Either principle alone,
and certainly both in combination, requires physicians to provide patients with
accurate and reliable clinical information. To meet this ethical obligation, the clinician must address the following ethical considerations. First, ensuring an appropriate level of competence imposes a rigorous standard of training and continuing
education. Two problems result when physicians do not maintain this baseline
level of competence in the techniques and interpretation of ultrasound imaging.
First, they may cause unnecessary harm to the woman or fetal patient, e.g. from
mistaken diagnosis of fetal anomalies, thus violating beneficence-based obligations. Second, incomplete or inaccurate reporting of results by the physician to
the pregnant woman undermines the informed consent process regarding the
management of pregnancy. This constitutes an unacceptable ethical violation of
autonomy-based obligations of the physician to the pregnant woman. Because
physicians may rely on them, the general competence of obstetric sonographers
is essential to avoiding these ethically unacceptable consequences for the exercise
of the pregnant woman's autonomy.
Second, these obligations have important implications for physicians who
employ a sonographer. Such physicians are ethically obligated to adequately supervise the sonographer's clinical work. To do this properly, the physician should
know more than the sonographer, especially about the application of sonographic
findings to the diagnosis of anomalies. This more advanced fund of clinical and
scientific knowledge is essential for the physician to fulfill his or her additional
ethical obligation to regularly review the sonographer's work. In addition, physicians should provide the opportunity for continuing education of obstetric sonographers. This is an especially important consideration for achieving strandards of
quality, e.g. in nuchal translucency measurement in the first trimester.
In medical care, patients properly rely for their protection on the personal and
professional integrity of their clinicians. A crucial aspect of that integrity is willingness on the part of physicians to refer to specialists when the limits of their
own knowledge are being approached. Like other virtues, such as self-sacrifice
and compassion, integrity directs physicians to focus primarily on the patient's
interests, as a way to blunt mere self-interest.
44
47
Ethics and patient information
ROUTINE ULTRASOUND SCREENING AND RISK ASSESSMENT OF PREGNANT WOMEN
The clinical ethical issues here focus on the physician's responsibilities under
informed consent, an autonomy-based concern. This process includes disclosure
of and discussion about what obstetric ultrasound examinations can and cannot
detect, the level of sophistication of the ultrasound techniques employed, and the
incomplete and sometimes uncertain interpretation of ultrasound images.
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In the face of medical uncertainty about the clinical goods and harms of routine
ultrasound, it is obligatory to inform pregnant patients about that uncertainty and
to give them the opportunity to make their own choices about how that uncertainty
should be managed. We have argued that prenatal informed consent for sonogram
(PICS) should be an indication for the routine use of obstetric ultrasound.
The timing of routine ultrasound should be governed, as a rule, by the ethical
principle of respect for autonomy, because the information obtained is relevant to
the woman's decision about whether she will seek an abortion (assuming that is
legally available to her). In pregnancies that will be taken to term, routine ultrasound during the second trimester can enhance a pregnant woman's autonomy.
If anomalies are detected and she does not choose abortion, she may begin to
prepare herself for the decisions that she will confront later about the management
of those anomalies in the intrapartum and postpartum periods. Providing this information early in pregnancy permits a pregnant woman ample time to deal with its
psychological and other sequelae before she must confront such decisions.
Respect for autonomy has important implications for first-trimester ultrasound screening for trisomy 21. First-trimester screening provides sophisticated
Ultrasound in obstetrics and gynaecology
information about risk to pregnant women that they can incorporate into their
subsequent decisions about invasive testing.48 Many women prefer not to have an
invasive test when provided with risk estimates based on first-trimester screening,
which is reassuring.
11,62
Many women may find it important to have a diagnosis
of an abnormal fetus early, in order to make an earlier decision about whether to
continue or terminate their pregnancies.
12,13
Both of these aspects of first-trimester
screening are important enhancements of the autonomy of pregnant women. To
prevent information overload from presenting too many choices unnecessarily,
all pregnant women in the first trimester should be offered risk assessment and
invasive diagnosis. Physicians should be guided by the autonomous decisions of
pregnant women in response to this offer.
24
26,44
348
DISCLOSURE OF RESULTS OF ULTRASOUND EXAMINATIONS
Significant clinical ethical issues arise about the disclosure of results of ultrasound
examinations. The first clinical ethical topic here concerns the phenomenon of
apparent bonding of pregnant women to their fetuses as a result of the woman
seeing the ultrasound images.10 Such bonding can sometimes benefit pregnancies
that will be taken to term but can also at other times complicate decisions to
terminate a pregnancy. We recommend that these matters, like abnormal findings,
should be discussed with the pregnant woman.
A second topic is a matter of ongoing debate: the disclosure of the fetus's
gender.
frankly to requests from the pregnant woman for information about the fetus's
gender. The woman should be made aware of the uncertainties of ultrasound gender identification, as part of the disclosure process. The sonographer can use his or
her own experience to help the pregnant woman understand those uncertainties.
Polaroid photography of ‘baby pictures’. There is nothing intrinsically wrong with
44,60
We propose that respect for maternal autonomy dictates responding
A third clinical topic may, at first, seem a non-issue, i.e. videotaping or the
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the practice if it is a side product of a legitimate ultrasound examination. In
fact, it may help the bonding of the prospective parents to the fetal patient.
However, when videotaping or Polaroid photography are performed to generate
revenues, this practice trivializes the ultrasound examination and may result in
harm because problems that could be diagnosed could be missed.
16
CONFIDENTIALITY OF FINDINGS
Confidentiality concerns the obligation of physicians to protect clinical information about patients from unauthorized access.44 The obligation of confidentiality
derives from the principles of beneficence (patients will be more forthcoming)
and respect for autonomy (the patient's privacy rights are protected). Others,
including the pregnant woman's spouse, sex partner and family, should be understood as third parties to the patient relationship, in respect to information about
the results of obstetric or gynaecological ultrasound. Diagnostic information
about a woman's condition or pregnancy is confidential. It can therefore be justifiably disclosed to third parties only with the pregnant woman's explicit permis-
sion. This is because a potentially acceptable condition for releasing confidential
information, avoiding grave harm to others, does not apply in this context.
To avoid awkward situations, physicians should establish policies and procedures
that reflect this analysis of the ethics of confidentiality.
19
5,44
Ethics and patient information
CONCLUSION
Ethics complements the scientific and technological aspects of obstetric and
gynaecological ultrasound. In this chapter we have provided an ethical framework
for clinical judgement and practice in communicating information about obstetric
and gynaecological ultrasound and subsequent decision making. Implementing this
framework on a daily basis is essential to creating and sustaining the physician–
patient relationship in this important subspecialty of obstetrics and gynaecology.
This framework emphasizes preventive ethics to clinical topics in obstetric and
gynaecological ultrasound, i.e. an appreciation that the potential for ethical conflict
is built into clinical practice and the use of effective communication and informed
consent to prevent such conflict from occurring.
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Ethics and patient information
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Test yourself – questions and answers
CHAPTER 2 BIOLOGICAL EFFECTS AND SAFETY ASPECTS
1. Which mode of operation can give the highest output intensity?
a. B-mode
b. Doppler imaging
c. Spectral Doppler
d. M-mode
2. Which of the following fetal tissues is likely to heat most during an
ultrasound examination?
a. skull bone
b. brain
c. eye
d. myocardium
3. Which of the following safety indices is most appropriate for second- and
third-trimester scanning?
a. TIS
b. MI
c. TIC
d. TIB
4. A diagnostic exposure that produces a maximum in situ temperature rise of
no more than
a. 1.5°C
b. 2.5 °C
c. 3.5°C
above normal physiological levels (37°C) may be used without reservation on
thermal grounds.
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5. Which of the following statements are correct? Prenatal ultrasound exposure
has been clearly shown to induce:
a. childhood malignancies
b. hearing impairment
c. reduced birthweight
d. dyslexia
Select one choice from the following:
a. only a, b and c
b. only a and c
c. only b, c and d
d. none of them
CHAPTER 3 SCANNING TECHNIQUES IN OBSTETRICS
AND GYNAECOLOGY
1. Transrectal scan can provide important information if transvaginal scanning is
Ultrasound in obstetrics and gynaecology
not feasible or contraindicated in the following cases except:
a. obesity
b. ruptured membranes
c. virginal patients
d. senile atrophic vagina
e. vaginal malformations
2. Which statements about orientation are true?
a. If the uterus is retroverted the bladder and the uterine fundus are on
opposite sides of the screen.
b. If the uterus is anteverted the uterine fundus and the bladder are on
opposite sides of the screen.
c. On a transverse section the right and left sides of the gynaecological
patient are matching those on an MRI picture.
d. On a transverse section the right and the left sides of the gynaecological
patient are the exact reverse of those on a CT picture.
e. b and c are true.
f. a and c are true.
3. The basic fetal ultrasound exam contains all features below except:
a. document fetal number, presentation
b. placental location and amniotic fluid volume
c. survey of fetal anatomy including the brain
d. evaluation of the adnexa of the patient
e. documentation of fetal heartbeats
4. Which of the statements below is not correct regarding the endometrium?
a. Endometrial thickness varies with the day in the menstrual cycle.
b. Endometrial measurements should be done preferably on the transverse
section of the uterus.
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c. If fluid is in the cavity the anterior and posterior stripes should be
measured separately and then added up for a single number representing
the total thickness.
d. In postmenstrual patients an echo less than 5 mm thick is usually
consistent with lack of significant tissue on sampling.
e. Saline infusion sonohysterography is the best tool to demonstrate
endocavitary findings.
5. A full urinary bladder is useful for the following except:
a. chorionic villus sampling
b. localizing the placenta and measuring its distance from the internal os
c. in every gynaecological patient using transvaginal scanning
d. evaluating placenta accreta close to the bladder wall
CHAPTER 4 INVESTIGATION OF EARLY PREGNANCY
(Note: more than one answer can be correct)
1. The following statements about multiple pregnancies are correct
except one.
a. The chorionicity of the multiple pregnancy is established before
5 LMP-based weeks.
b. The identification of the amnionicity is made earlier than the
chorionicity.
c. In dichorionic pregnancies, the dividing wall consists of four layers.
d. In the early second trimester, the lambda sign allows differentiation
between mono- and dichorionicity.
2. One of the following sonographic findings is suggestive for early pregnancy
failure.
a. The crown–rump length (CRL) is twice the expected length.
b. The diameter of the yolk sac is less than 6 mm.
c. The heart rate of the embryo is less than 70 beats per minute (bpm).
d. The diameter of the amniotic cavity is larger than the diameter of the
yolk sac.
3. Two of the following ultrasound findings are possible signs for an ectopic
pregnancy (positive pregnancy test).
a. haemoperitoneum without an intrauterine gestational sac
b. cyst in the ovary and an intrauterine trophoblast ring
c. fluid in the uterine cavity and an extraovarian solid mass
d. two yolk sacs in the gestational cavity without embryonic echo
4. Three of the following first-trimester findings are suspicious for a
chromosomal disorder.
a. The placenta is large and contains cysts; the embryo is alive.
b. The fetus at 12 weeks seems to have an oedema; there is a nuchal
translucency of >3 mm.
Test yourself – questions and answers
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c. The embryo has a CRL of 25 mm; the heart rate is as high as 185 bpm.
d. The embryo has a CRL of 10 mm; the yolk sac diameter is 7 mm.
5. One of the following findings is probably consistent with a normal early
pregnancy.
a. CRL 4 mm, diameter of yolk sac 5 mm, diameter of amniotic cavity
7 mm, heart rate 110 bpm
b. CRL 23 mm, diameter of yolk sac 5 mm, diameter of amniotic cavity
24 mm, heart rate 170 bpm
c. CRL 29 mm, diameter of yolk sac 5 mm, diameter of amniotic cavity
34 mm, heart rate 150 bpm
d. CRL 2 mm, diameter of yolk sac 3 mm, diameter of amniotic cavity
4 mm, heart rate 90 bpm
e. CRL 13 mm, diameter of yolk sac 9 mm, diameter of amniotic cavity
12 mm, heart rate 130 bpm
CHAPTER 5 NORMAL FETAL ANATOMY AT 18–22 WEEKS
Ultrasound in obstetrics and gynaecology
1. Basic guidelines by the American Institute of Ultrasound in Medicine include
views of:
a. the great vessels of the heart
b. hands and feet
c. anterior abdominal wall
d. face
e. all of the above
2. A sequential segmental approach to the heart would include specifice views
of all of the following except:
a. view of the upper abdomen to show normal solitus
b. left and right ventricular outflow views
c. four-chamber view
d. ductus venosus
e. pulmonary artery and ductal arch
3. Markedly echogenic bowel has been associated with what types of
outcome?
a. normal
b. aneuploidy
c. fetal infection
d. fetal demise
e. all of the above
4. All of the following is true about the fetal anatomic survey except:
a. it is usually performed during the second trimester
b. it is the ideal time for nuchal translucency evaluation
c. it requires a systematic approach
d. it gives the opportunity to provide important information about
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the fetus
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CHAPTER 6 AMNIOTIC FLUID AND PLACENTAL LOCALIZATION
1. The water content of amniotic fluid is:
a. 50–60%
b. 70–80%
c. 98–99%
2. The normal amniotic fluid index ranges between:
a. 5 and 25 cm
b. 10 and 30 cm
c. 20 and 40 cm
3. There is a high association with pulmonary hypoplasia when severe
oligohydramnios develops:
a. before 20–25 weeks of gestation
b. at 30–35 weeks of gestation
c. at 35–40 weeks of gestation
4. The association between chronic polyhydramnios and fetal anomalies is
approximately:
a. 1 in 25
b. 1 in 15
c. 1 in 5
Test yourself – questions and answers
CHAPTER 7 ASSESSMENT OF THE PLACENTA
AND UMBILICAL CORD
1. All the following statements concerning placenta accreta are correct except one.
a. This anomaly is characterized by myometrial invasion by placental villous
tissue.
b. It occurs when the decidua basalis is partially or completely absent.
c. It is more common in primigravidae than multigravidae.
d. Placentas accreta have an overall maternal and fetal mortality of around 10%.
e. Caesarean hysterectomy is often needed.
2. The only statement about chorioangioma that is correct is:
a. Chorioangiomas are malignant tumours characterized by a proliferation of
villous capillaries and trophoblastic tissue.
b. Chorioangiomas are often diagnosed during the first trimester of pregnancy.
c. Most chorioangiomas are large, single, round, encapsulated, near the cord
insertion.
d. All chorioangiomas can be complicated by fetal hydrops, due to the
chronic shunting, and by polyhydramnios.
e. The fetal risk depends more on the proportion of angiomatous versus
myxoid tissue inside the tumour than on its exact size.
3. The only ultrasound feature mentioned below that is specific to a triploid
partial mole is:
a. fetal bilateral cerebral ventriculomegaly
b. severe fetal growth restriction
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