The Level I Obstetrical Sonogram - UCSF CME
嚜燜he Level I Obstetrical Sonogram
No disclosures.
An Update on AIUM/ACR/ACOG/SRU Guidelines
Lori Strachowski, MD
Clinical Professor of Radiology
University of California, San Francisco
Chief of Ultrasound, Zuckerberg San Francisco General
Lecture Goals
? Nomenclature, history of ※Levels§
? 2013 Practice Guidelines
每 General issues:
? Practitioner training, equipment
specifications, documentation,
fetal safety, etc.
每 Trimester specific components
Level I
Highlight updates
Helpful tips and
references
? Standard
? Routine
? 2nd or 3rd tri exam
? ※Screening§
Level I
Level II
? Standard
? Routine
? 2nd or 3rd tri exam
? ※Screening§
? Detailed
? Targeted
? Directed
? ※High-risk§
Level I
Level II
? Standard
? Routine
? 2nd or 3rd tri exam
? ※Screening§
? Detailed
? Targeted
? Directed
? ※High-risk§
OB US Levels
The ※level§ of exam is predicated by the
INTENT of the examination.
History of ※Levels§
? MS-AFP screening program
? Level I US: to detect obstetric problems
每 Incorrect dates
每 Multiple gestations
每 Demise
? Level II US: to detect fetal anomalies
每 Open NTD
每 Abdominal wall defects
History: OB US Practice Guidelines
ACR and AIUM
1986 (rev. ＆90, ＆93, ＊96)
※AIUM§ Guidelines
?
每 Practice Guidelines
? Obstetric
ACOG
1988 (rev. ＊93)
ACR, AIUM, ACOG
2003 (rev. 2007)
? Goal:
每 Provide a minimum
standard for all
practitioners of obstetrical
ultrasound
SRU
ACR, AIUM, ACOG, SRU
2013
2013 additions and modifications in blue
General Requirements
General Requirements
? Practitioner
每 Initial certification
每 MOC
? Exam request
? Documentation and retention
每 Images
每 Report
? Equipment specifications
? Fetal safety
? Practitioner
每 Initial certification
每 MOC
? Exam request
? Documentation and retention
每 Images
每 Report
? Equipment specifications
? Fetal safety
General Requirements
General Requirements
? Practitioner
每 Initial certification
每 MOC - 170 exams/yr + 30 hrs Category 1 Credits/3 yrs
? Exam request
? Documentation and retention
每 Images
每 Report
? Equipment specifications
? Fetal safety
? Practitioner
每 Initial certification
每 MOC - 170 exams/yr + 30 hrs Category 1 Credits/3 yrs
? Exam request
? Documentation and retention
每 Images
每 Report
? Equipment specifications
? Fetal safety
Fetal Safety
? Generally considered safe, when:
每 Performed for a valid medical
indication
每 Using lowest possible exposure
settings under ALARA principle
? Any pulsed Doppler (color,
spectral or power) should be
used only when there is a
clear benefit/risk advantage
Fetal Safety
? In keeping with the ALARA
principle§, to document
embryonic/fetal heart rate:
每 M-mode should always
be used 1st
每 Only if unsuccessful,
spectral may be briefly
used (4-5 heart beats)
? Keeping TI < 1.0
Measure blip to blip
AIUM Statement on Measurement of Fetal Heart Rate
Bioeffects of US
AIUM Statement on the Safe Use of Doppler Ultrasound
During 11-14 week scans (or earlier in pregnancy)
Abramowicz, J, Lewin, P, et al, Glob. libr. women's med.,(1756-2228) 2011
What can (and should) you do to limit the
thermal energy imparted upon an embryo/fetus
during an US exam?
90%
Increase the dwell time
Use a lower frequency transducer
Increase use of zoom/resolution box
Select the lowest energy scan mode
9%
y.
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es
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NOTE: Not displayed if transducer/system
incapable of exceeding an MI or TI of 1.0.
2%
e
0%
es
t
A.
B.
C.
D.
w
Where is TI displayed?
e l
o
BIG issue
for OB
ct
Not an issue
for OB
? Definition:
? Ratio of power used to that required to produce a 1∼C
increase
? For obstetrics, subdivided as:
每 TIS (soft tissues) < 10 wks
每 TIB (bone) ≡ 10 wks
? Value: should always be < 1.0
每 Doppler exposure time < 5-10 min (never > 60 min)
Se
le
? Two major categories:
每 Mechanical:
? Energy imparted on gas particles to
create movement ↙ cavita on
每 MI (mechanical index)
每 Thermal:
? Absorbed energy ↙ heat
每 TI (thermal index)
Thermal Index
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