Routine prenatal ultrasonography as a screening tool
- Anna K Sfakianaki, MD
Anna K Sfakianaki, MD
- Associate Professor
- Obstetrics, Gynecology and the Reproductive Sciences
- Yale University School of Medicine
- Joshua Copel, MD
Joshua Copel, MD
- Obstetrics, Gynecology and the Reproductive Sciences, and Pediatrics
- Yale University School of Medicine
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Deborah Levine, MD
Deborah Levine, MD
- Section Editor — Imaging
- Professor of Radiology
- Director of Ob/Gyn Ultrasound
- Department of Radiology
- Beth Israel Deaconess Medical Center
Prenatal ultrasonography is a common procedure in many countries [1-4]. It is an accurate technique for determining gestational age, number of fetuses, fetal cardiac activity, and placental location. In addition, many congenital structural anomalies and significant abnormalities in fetal growth can be identified. However, whether all obstetrical patients should undergo ultrasound screening and whether such screening improves pregnancy outcome is controversial.
Many countries have developed local guidelines for the practice of prenatal ultrasonography and most offer at least one mid-trimester ultrasound examination as part of standard prenatal care, although worldwide obstetric practice varies . In the United States, the American College of Obstetricians and Gynecologists (ACOG) recommends ultrasound examination for all pregnant patients and advises against nonmedical use of prenatal ultrasonography (eg, to accommodate parental curiosity about fetal sex or parental desire to view and/or obtain an image of the fetus) . ACOG also stated that the benefits and limitations of ultrasonography should be discussed with all patients. In addition, a 2006 workshop organized by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) reached a consensus that “all fetuses should have a screening ultrasonogram for the detection of fetal anomalies and pregnancy complications” .
An evidence-based discussion of the application of ultrasound to an unselected obstetric population as a screening tool will be presented here. The use of prenatal ultrasonography for specific obstetrical indications is reviewed separately. (See "Ultrasound examination in obstetrics and gynecology".)
CRITERIA FOR A GOOD SCREENING TEST
In general, a good screening test should be safe, have high sensitivity and specificity, ideally take only a few minutes to perform, require minimum preparation by the patient, and be inexpensive. It should identify individuals with an important disease or condition and be cost-effective, allowing for control of health care costs by identifying disease early and treating before the consequences of the disease are overwhelming. (See "Evidence-based approach to prevention", section on 'Methodologic issues in evaluating screening programs'.)
RATIONALE FOR ROUTINE SCREENING PRENATAL ULTRASOUND
It is hypothesized that routine use of ultrasound in all pregnancies will prove beneficial since adverse outcomes may occur in pregnancies without risk factors and clinical conditions that place the fetus at high risk may not be detected by clinical examination. The primary objective is to obtain information that will enable delivery of optimal antenatal care and thus the best possible outcomes for mother and fetus . However, the benefit of such prenatal sonographic screening on neonatal outcomes remains unproven.
- Murakami K, Tsujino K, Sase M, et al. Japanese women's attitudes towards routine ultrasound screening during pregnancy. Nurs Health Sci 2012; 14:95.
- Banta HD, Oortwiin W. Health technology assessment and screening in The Netherlands: case studies of mammography in breast cancer, PSA screening in prostate cancer, and ultrasound in normal pregnancy. Int J Technol Assess Health Care 2001; 17:369.
- Vermeulen V, Coppens K, Kesteloot K. Impact of health technology assessment on preventive screening in Belgium: case studies of mammography in breast cancer, PSA screening in prostate cancer, and ultrasound in normal pregnancy. Int J Technol Assess Health Care 2001; 17:316.
- Wild C. Screening in Austria: the cases of mammography, PSA testing, and routine use of ultrasound in pregnancy. Int J Technol Assess Health Care 2001; 17:305.
- Salomon LJ, Alfirevic Z, Berghella V, et al. Practice guidelines for performance of the routine mid-trimester fetal ultrasound scan. Ultrasound Obstet Gynecol 2011; 37:116.
- Practice Bulletin No. 175: Ultrasound in Pregnancy. Obstet Gynecol 2016; 128:e241.
- Reddy UM, Filly RA, Copel JA, Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Department of Health and Human Services, NIH. Prenatal imaging: ultrasonography and magnetic resonance imaging. Obstet Gynecol 2008; 112:145.
- Whitworth M, Bricker L, Mullan C. Ultrasound for fetal assessment in early pregnancy. Cochrane Database Syst Rev 2015; :CD007058.
- Bennett KA, Crane JM, O'shea P, et al. First trimester ultrasound screening is effective in reducing postterm labor induction rates: a randomized controlled trial. Am J Obstet Gynecol 2004; 190:1077.
- Ewigman BG, Crane JP, Frigoletto FD, et al. Effect of prenatal ultrasound screening on perinatal outcome. RADIUS Study Group. N Engl J Med 1993; 329:821.
- Saari-Kemppainen A, Karjalainen O, Ylöstalo P, Heinonen OP. Ultrasound screening and perinatal mortality: controlled trial of systematic one-stage screening in pregnancy. The Helsinki Ultrasound Trial. Lancet 1990; 336:387.
- Hughey MJ, Olive DL. Routine ultrasound scanning for the detection and management of twin pregnancies. J Reprod Med 1985; 30:427.
- Levi S. Ultrasound in prenatal diagnosis: polemics around routine ultrasound screening for second trimester fetal malformations. Prenat Diagn 2002; 22:285.
- Saari-Kemppainen A, Karjalainen O, Ylöstalo P, Heinonen OP. Fetal anomalies in a controlled one-stage ultrasound screening trial. A report from the Helsinki Ultrasound Trial. J Perinat Med 1994; 22:279.
- Crane JP, LeFevre ML, Winborn RC, et al. A randomized trial of prenatal ultrasonographic screening: impact on the detection, management, and outcome of anomalous fetuses. The RADIUS Study Group. Am J Obstet Gynecol 1994; 171:392.
- Grandjean H, Larroque D, Levi S. The performance of routine ultrasonographic screening of pregnancies in the Eurofetus Study. Am J Obstet Gynecol 1999; 181:446.
- Institute for Quality and Efficiency in Health Care: Executive Summaries [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG). Ultrasound screening in pregnancy: test accuracy with regard to detection rates of foetal abnormalities: Executive summary of final report S05-03, Version 1.0. 2008.
- Friedberg MK, Silverman NH, Moon-Grady AJ, et al. Prenatal detection of congenital heart disease. J Pediatr 2009; 155:26.
- Tworetzky W, McElhinney DB, Reddy VM, et al. Improved surgical outcome after fetal diagnosis of hypoplastic left heart syndrome. Circulation 2001; 103:1269.
- Bonnet D, Coltri A, Butera G, et al. Detection of transposition of the great arteries in fetuses reduces neonatal morbidity and mortality. Circulation 1999; 99:916.
- Clayton DB, Brock JW 3rd. Prenatal ultrasonography: implications for pediatric urology. J Pediatr Urol 2011; 7:118.
- Rossi AC, Prefumo F. Accuracy of ultrasonography at 11-14 weeks of gestation for detection of fetal structural anomalies: a systematic review. Obstet Gynecol 2013; 122:1160.
- Bricker L, Medley N, Pratt JJ. Routine ultrasound in late pregnancy (after 24 weeks' gestation). Cochrane Database Syst Rev 2015; :CD001451.
- Sovio U, White IR, Dacey A, et al. Screening for fetal growth restriction with universal third trimester ultrasonography in nulliparous women in the Pregnancy Outcome Prediction (POP) study: a prospective cohort study. Lancet 2015; 386:2089.
- Arbeille P, Leguyader P, Fignon A. Fetal Hemodynamics and Flow Velocity Indices. In: Doppler Ultrasound in Obstetrics and Gynecology, Copel JA (Ed), Raven Press, New York 1995.
- Alfirevic Z, Stampalija T, Medley N. Fetal and umbilical Doppler ultrasound in normal pregnancy. Cochrane Database Syst Rev 2015; :CD001450.
- Cnossen JS, Morris RK, ter Riet G, et al. Use of uterine artery Doppler ultrasonography to predict pre-eclampsia and intrauterine growth restriction: a systematic review and bivariable meta-analysis. CMAJ 2008; 178:701.
- Kleinrouweler CE, Bossuyt PM, Thilaganathan B, et al. Value of adding second-trimester uterine artery Doppler to patient characteristics in identification of nulliparous women at increased risk for pre-eclampsia: an individual patient data meta-analysis. Ultrasound Obstet Gynecol 2013; 42:257.
- Conde-Agudelo A, Villar J, Lindheimer M. World Health Organization systematic review of screening tests for preeclampsia. Obstet Gynecol 2004; 104:1367.
- Chien PF, Arnott N, Gordon A, et al. How useful is uterine artery Doppler flow velocimetry in the prediction of pre-eclampsia, intrauterine growth retardation and perinatal death? An overview. BJOG 2000; 107:196.
- Papageorghiou AT, Yu CK, Nicolaides KH. The role of uterine artery Doppler in predicting adverse pregnancy outcome. Best Pract Res Clin Obstet Gynaecol 2004; 18:383.
- Yu CK, Smith GC, Papageorghiou AT, et al. An integrated model for the prediction of preeclampsia using maternal factors and uterine artery Doppler velocimetry in unselected low-risk women. Am J Obstet Gynecol 2005; 193:429.
- Myatt L, Clifton RG, Roberts JM, et al. The utility of uterine artery Doppler velocimetry in prediction of preeclampsia in a low-risk population. Obstet Gynecol 2012; 120:815.
- Stampalija T, Gyte GM, Alfirevic Z. Utero-placental Doppler ultrasound for improving pregnancy outcome. Cochrane Database Syst Rev 2010; :CD008363.
- Vintzileos AM, Ananth CV, Smulian JC, et al. Routine second-trimester ultrasonography in the United States: a cost-benefit analysis. Am J Obstet Gynecol 2000; 182:655.
- Saari-Kemppainen A. Use of antenatal care services in a controlled ultrasound screening trial. Acta Obstet Gynecol Scand 1995; 74:12.
- Leivo T, Tuominen R, Saari-Kemppainen A, et al. Cost-effectiveness of one-stage ultrasound screening in pregnancy: a report from the Helsinki ultrasound trial. Ultrasound Obstet Gynecol 1996; 7:309.
- Geerts LT, Brand EJ, Theron GB. Routine obstetric ultrasound examinations in South Africa: cost and effect on perinatal outcome--a prospective randomised controlled trial. Br J Obstet Gynaecol 1996; 103:501.
- Roberts T, Henderson J, Mugford M, et al. Antenatal ultrasound screening for fetal abnormalities: a systematic review of studies of cost and cost effectiveness. BJOG 2002; 109:44.
- Chervenak FA, McCullough LB. Ethical dimensions of ultrasound screening for fetal anomalies. Ann N Y Acad Sci 1998; 847:185.
- Getz L, Kirkengen AL. Ultrasound screening in pregnancy: advancing technology, soft markers for fetal chromosomal aberrations, and unacknowledged ethical dilemmas. Soc Sci Med 2003; 56:2045.
- Larsen T, Nguyen TH, Munk M, et al. Ultrasound screening in the 2nd trimester. The pregnant woman's background knowledge, expectations, experiences and acceptances. Ultrasound Obstet Gynecol 2000; 15:383.
- Whynes DK. Receipt of information and women's attitudes towards ultrasound scanning during pregnancy. Ultrasound Obstet Gynecol 2002; 19:7.
- Gudex C, Nielsen BL, Madsen M. Why women want prenatal ultrasound in normal pregnancy. Ultrasound Obstet Gynecol 2006; 27:145.
- Lalor JG, Devane D. Information, knowledge and expectations of the routine ultrasound scan. Midwifery 2007; 23:13.
- Georgsson Ohman S, Waldenström U. Second-trimester routine ultrasound screening: expectations and experiences in a nationwide Swedish sample. Ultrasound Obstet Gynecol 2008; 32:15.
- Ekelin M, Crang-Svalenius E, Dykes AK. A qualitative study of mothers' and fathers' experiences of routine ultrasound examination in Sweden. Midwifery 2004; 20:335.
- Boukydis CF, Treadwell MC, Delaney-Black V, et al. Women's responses to ultrasound examinations during routine screens in an obstetric clinic. J Ultrasound Med 2006; 25:721.
- Molander E, Alehagen S, Berterö CM. Routine ultrasound examination during pregnancy: a world of possibilities. Midwifery 2010; 26:18.
- CRITERIA FOR A GOOD SCREENING TEST
- RATIONALE FOR ROUTINE SCREENING PRENATAL ULTRASOUND
- BENEFITS OF ROUTINE PRENATAL ULTRASOUND EXAMINATION
- Better estimate of gestational age/delivery date
- - Reduction in intervention for postterm pregnancy
- - Better detection of aneuploidy
- Better identification of multiple gestation
- Better detection of congenital anomalies
- - Factors affecting detection rates
- - First trimester screening
- POTENTIAL BENEFIT OF ROUTINE SCREENING
- Prevention of preterm birth
- UNPROVEN OR UNCLEAR BENEFIT OF ROUTINE SCREENING
- Better diagnosis of deficient growth and improvement in perinatal outcome
- Assessment of placental position, fetal presentation, amniotic fluid volume, macrosomia
- Doppler ultrasound screening
- - Umbilical artery
- - Uterine artery
- OTHER CONSIDERATIONS
- Safety issues
- Resource utilization
- Ethical considerations
- Women's views
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS