Proceedings: Beyond Ultrasound First Forum on Improving the Quality of Ultrasound Imaging in Obstetrics and Gynecology

Controlled Prospective Study on the Use of Systematic Simulator-Based Training with a Virtual, Moving Fetus for Learning Second-Trimester Scan: FESIM III

OBJECTIVES

To analyze the feasibility of structured ultrasound simulation training (SIM-UT) in teaching second-trimester ultrasound screening using a high-end simulator with a randomly moving fetus.

METHODS

This was a prospective, controlled trial. A trial group of 11 medical students with minimal obstetric ultrasound experience underwent 12 hours of structured SIM-UT in individual hands-on sessions within 6 weeks. Learning progress was assessed with standardized tests. Performance after 2, 4, and 6 weeks of SIM-UT was compared with two reference groups ((A) Ob/Gyn residents and consultants, and (B) highly skilled DEGUM experts). Participants were asked to acquire 23 2nd trimester planes according to ISUOG guidelines in a realistic simulation B-mode with a randomly moving fetus as quickly as possible within a 30-minute time frame. All tests were analyzed regarding the rate of appropriately obtained images and the total time to completion (TTC).

RESULTS

During the study, novices were able to improve their ultrasound skills significantly, reaching the physician level of the reference group (A) after 8 hours of training. After 12 hours of SIM-UT, the trial group performed significantly faster than the physician group (TTC: 621±189 vs. 1036±389 sec., p=0.011). Novices obtained 20 out of 23 2nd trimester standard planes without a significant time difference when compared to experts. TTC of the DEGUM reference group remained significantly faster (p<0.001) though.

CONCLUSION

SIM-UT on a simulator with a virtual, randomly moving fetus is highly effective. Novices can obtain standard plane acquisition skills close to expert level within 12 hours of self-training.

Optical ultrasound simulation-based training in obstetric sonography

Ultrasound is an imaging modality that is highly operator dependent. This article reviews the challenges in learning how to perform obstetric sonography, as well as the processes necessary to acquire expert performance skills in sonography. Simulation-based education and learning, and the value of medical simulation are also discussed. Ultrasound simulators are an effective means of teaching obstetric sonography, because it provides training, deliberate practice, and performance evaluation/feedback which allows continuous and critical self-evaluation. We review evidence that simulation can improve performance in obstetric ultrasound examination, review current simulators, and discuss the current problems/gaps in ultrasound simulation. Optical positioning ultrasound simulation is a novel high-fidelity simulation learning system, which addresses many of these problems/gaps and is introduced for the first time here.

The Use of Artificial Intelligence in Automation in the Fields of Gynaecology and Obstetrics - an Assessment of the State of Play

The long-awaited progress in digitalisation is generating huge amounts of medical data every day, and manual analysis and targeted, patient-oriented evaluation of this data is becoming increasingly difficult or even infeasible. This state of affairs and the associated, increasingly complex requirements for individualised precision medicine underline the need for modern software solutions and algorithms across the entire healthcare system. The utilisation of state-of-the-art equipment and techniques in almost all areas of medicine over the past few years has now indeed enabled automation processes to enter - at least in part - into routine clinical practice. Such systems utilise a wide variety of artificial intelligence (AI) techniques, the majority of which have been developed to optimise medical image reconstruction, noise reduction, quality assurance, triage, segmentation, computer-aided detection and classification and, as an emerging field of research, radiogenomics. Tasks handled by AI are completed significantly faster and more precisely, clearly demonstrated by now in the annual findings of the ImageNet Large-Scale Visual Recognition Challenge (ILSVCR), first conducted in 2015, with error rates well below those of humans. This review article will discuss the potential capabilities and currently available applications of AI in gynaecological-obstetric diagnostics. The article will focus, in particular, on automated techniques in prenatal sonographic diagnostics.

Fetal biometry in ultrasound: A new approach to assess the long-term impact of simulation on learning patterns

CONTEXT

Simulation-based education (SBE) has demonstrated its acceptability and effectiveness in improving ultrasound training. Because of the high cost of its implementation (investment in equipment and supervision), a pragmatic assessment of the transfer of skills learned in SBE to clinical practice and the identification of its optimal scheduling conditions have been requested to optimize its input.

OBJECTIVES

To quantify the long-term impact of simulation-based education (SBE) on the adequate performance of ultrasound fetal biometry measurements (I). The secondary objective was to identify the temporal patterns that enhanced SBE input in learning (II).

METHODS

Trainees were arbitrarily assigned to a 6-month course in obstetric ultrasound with or without an SBE workshop. In the SBE group, the workshop was implemented 'before' or at an 'early' or a 'late-stage' of the course. Those who did not receive SBE were the control group. The ultrasound skills of all trainees were prospectively collected, evaluated by calculating the delta between OSAUS (Objective Structured Assessment of Ultrasound Skills) scores before and after the course (I). Concomitantly, the accuracy of trainees' measurements was assessed throughout the course by verifying their correlation with the corresponding measurements by their supervisors. The percentage of trainees able to perform five consecutive sets of correct measurements in the control group and in each SBE subgroup were compared (II).

RESULTS

The study included 61 trainees (39 SBE and 22 controls). Comparisons between groups showed no significant difference in the quantitative assessment of skill enhancement (difference in the pre- and post-internship OSAUS score: 1.09 ± 0.87 in the SBE group and 0.72 ± 0.98 in the control group) (I). Conversely, the predefined acceptable skill level was reached by a significantly higher proportion of trainees in the 'early' SBE subgroup (74%, compared with 30% in the control group, P<0.01)(II).

CONCLUSIONS

The quantitative assessment does not support the existence of long-term benefits from SBE training, although the qualitative assessment confirmed SBE helped to raise the minimal level within a group when embedded in an 'early' stage of a practical course.

[Skills assessment for the practice of fetal ultrasound biometry: Prospective validation of the OSAUS METHOD score]

OBJECTIVES

To develop and validate a customized variant for fetal biometry of the generic OSAUS score (Objective Structured Assessment of Ultrasound Skills) METHODS: The 5-points OSAUS METHOD grid was elaborated by defining five target skills specific to fetal biometry for each thematic item of the generic score. The level of skills of 43 trainees was prospectively assessed during an ultrasound examination by using this grid. The results of the "novice" level group (experience<10 ultrasounds) were compared to those of the "intermediate" level group (experience≥10 ultrasounds) (I). The reached/non-reached skills ratio within the different items composing the score allowed the identification of priority areas of improvement (II). Previously published distribution and actual distribution of ratings according to the generic pass/fail score were compared (III).

RESULTS

Median scores of "novices" (n=29) and "intermediates" (n=14) groups were statistically different, 1.87 (±0.75) and 3.31 (±0.83) (P=1.85-5), respectively and corresponded to the pre-existing experience (I). A lower ratio of reached skill allowed the identification of "documentation of the examination" item as a priority area of improvement for both groups (II). The relevance of the pass/fail score is consolidated, even if an overlap was observed between novices and intermediates groups (III).

CONCLUSIONS

The relevancy and feasibility of using OSAUS scoring method for fetal biometry are supported. In addition, the possibility of comparisons with generic OSAUS remains.

How often do we incidentally find a fetal abnormality at the routine third-trimester growth scan? A population-based study

BACKGROUND

Third-trimester scans are increasingly used to try to prevent adverse outcomes associated with abnormalities of fetal growth. Unexpected fetal malformations detected at third-trimester growth scans are rarely reported.

OBJECTIVE

To determine the incidence and type of fetal malformations detected in women attending a routine third-trimester growth scan.

STUDY DESIGN

This was a population-based study of all women with singleton pregnancy attending antenatal care over a 2-year period in Oxfordshire, UK. Women who had a viable singleton pregnancy at dating scan were included. Women had standard obstetrical care including the offer of a routine dating scan and combined screening for trisomies; a routine anomaly scan at 18 to 22 weeks; and a routine third-trimester growth scan at 36 weeks. The third-trimester scan comprises assessment of fetal presentation, amniotic fluid, biometry, umbilical and middle cerebral artery Dopplers, but no formal anatomic assessment is undertaken. Scans are performed by certified sonographers or clinical fellows (n=54), and any suspected abnormalities are evaluated by a team of fetal medicine specialists. We assessed the frequency and type of incidental congenital malformations identified for the first time at this third-trimester scan. All babies were followed-up after birth for a minimum of 6 months.

RESULTS

There were 15,244 women attending routine antenatal care. Anomalies were detected in 474 (3.1%) fetuses as follows: 103 (21.7%) were detected before the anomaly scan, 174 (36.7%) at the anomaly scan, 11 (2.3%) after the anomaly scan and before the third-trimester scan, 43 (9.1%) at the third-trimester scan and 143 (30.2%) after birth. The 43 abnormalities were found in a total of 13,023 women who had a 36 weeks scan, suggesting that in 1 out of 303 (95% confidence interval, 233-432) women attending such a scan, a new malformation was detected. Anomalies detected at the routine third-trimester scan were of the urinary tract (n=30), central nervous system (5), simple ovarian cysts (4), chromosomal (1), splenic cyst (1), skeletal dysplasia (1), and cutaneous lymphangioma (1). Most urinary tract anomalies were renal pelvic dilatation, which showed spontaneous resolution in 57% of the cases.

CONCLUSION

When undertaking a program of routine third-trimester growth scans in women who have had previous screening scans, an unexpected congenital malformation is detected in approximately 1 in 300 women.

Guidelines for minimal report in gynaecologic sonography: Are they useful for emergency department resident physicians?

OBJECTIVES

This study aimed to evaluate the impact of Collège National des Gynécologues et Obstétriciens Français (CNGOF) guidelines on the minimal sonographic reports generated by emergency department resident physicians.

MATERIAL AND METHODS

This prospective observational study was conducted in the gynaecologic emergency unit of a teaching hospital from November 2016 to May 2017. We analysed sonographic reports generated by residents during gynaecological emergencies before and after training on the minimal report standards. An analysis of the evaluated items was carried out. We also compared residents according to their specialities and seniority.

RESULTS

A total of 240 reports were analysed, 120 before and 120 after the training. Half of the reports concerned women with an early pregnancy while the others concerned women with negative hCG. All residents significantly improved their practice after the training, as shown by the increase in ratings of the evaluated items (38 % before training vs 44.8 % after, p < 0.01). General practitioners had greater improvement (48.1 % of evaluated items), whereas older residents reported fewer items before or after the training (43.5 %) than younger residents. Finally, all residents improved their practice with a conclusion that followed the guidelines in 92.5 % of cases (versus 68.3 % before the training; p < 0.01).

CONCLUSION

Training on the CNGOF minimal sonographic report guidelines significantly improved the emergency sonographic reports generated by residents. Wider dissemination of this training, particularly to young residents, would probably improve the quality of sonographic reports performed at gynaecological emergencies.

Evaluation of adenomyosis after gonadotrophin-releasing hormone agonist therapy using ultrasound post-processing imaging: a pilot study

Objective

We explored a method for the quantitative sonographic analysis of myometrial texture using computer-aided image analysis software to assess outcomes following treatment with gonadotrophin-releasing hormone (GnRH) agonist for adenomyosis in women with infertility.

Method

Data for patients with ultrasound images of the myometrium obtained at Taipei Medical University Hospital from 1 September 2018 to 5 April 5 2019 were analyzed. Only 10 patients with 20 ultrasound images matched the eligibility criteria. The images were divided into pre-treatment (n = 10) and post-treatment images (n = 10) and quantitative grayscale histograms were obtained from the ultrasound images using publicly available ImageJ computer-aided image analysis software. We analyzed the differences between the pre- and post-treatment images using the Mann–Whitney test and compared the results with outcomes assessed by serum CA-125 levels.

Results

Image analysis of the grayscale histograms revealed significant differences between before and after treatment. The classification of the myometrium pre-treatment and post-treatment was similar using CA-125 and histogram grayscale analysis.

Conclusion

Computer-aided image analysis of grayscale histograms of the myometrium obtained from ultrasound images is an alternative method for assessing myometrial conditions after GnRH agonist treatment in patients with adenomyosis.

Prior authorization and its impact on access to obstetric ultrasound

Prior authorization is a process requiring health care providers to obtain advance approval from a payer before a patient undergoes a procedure for the study to be covered. Prior authorization was introduced to decrease overutilization of ultrasound procedures. However, it has led to unanticipated consequences such as impeding access to obstetric imaging, increased administrative overhead without reimbursement, and contribution to physician frustration and burnout. Payers often use intermediary radiology benefit management companies without providing specialty-specific review in a timely manner as is requisite when practicing high-risk obstetrics. This article proposes a number of potential solutions to this problem: (1) consider alternative means to monitor overutilization; (2) create and evaluate data regarding providers in the highest utilization; (3) continue to support and grow the educational efforts of speciality societies to publish clinical guidelines; and (4) emphasize the importance of practicing evidence-based medicine. Understanding that not all health plans may be willing or able to collaborate with health care providers, we encourage physicians to advocate for policies and legislation to limit the implementation of prior authorization within their own states.

Prospective assessment of reproducibility of three-dimensional ultrasound for fetal biometry

PURPOSE

To compare fetal ultrasound measurements performed by two observers with different levels of experience and evaluate the potential contribution of the use of three-dimensional (3D) ultrasound on repeatability, reproducibility and agreement of two-dimensional (2D) and 3D-derived measurements.

MATERIALS AND METHODS

Two observers (one senior and one junior) measured head circumference (HC), abdominal circumference (AC) and femur length (FL) in 33 fetuses (20 to 40 weeks of gestation). Each observer performed two series of 2D measurements and two series of 3D measurements (i.e., measurements derived from triplane volume processing). Measurements were converted into Z-scores according to gestational age. Variability between the different series of measurements was studied using Bland-Altmann plots and intra-class correlation coefficients (ICC).

RESULTS

Agreement with the 2D measurements of the senior observer was higher in 3D than in 2D for the junior observer (systematic differences of -0.4, -0.2 and -0.8 Z-score vs. -0.1, -0.1 and -0.6 for HC, AC and FL on 2D and 3D datasets, respectively). The use of 3D ultrasound improved junior observer repeatability (ICC=0.94, 0.88, 0.90 vs. 0.94, 0.94 and 0.96 for HC, AC and FL in 2D and 3D, respectively). The reproducibility was greater using the junior observer 3D datasets (ICC=0.75, 0.60 and 0.45 vs. 0.79, 0.89 and 0.63 for HC, AC and FL, respectively).

CONCLUSION

The use of 3D ultrasound improves the consistency of the measurements performed by a junior observer and increases the overall repeatability and reproducibility of measurements performed by observers with different levels of experience.

Semiautomatic Fetal Intelligent Navigation Echocardiography Has the Potential to Aid Cardiac Evaluations Even in Less Experienced Hands

OBJECTIVES

To investigate the interobserver and intraobserver variability and corresponding learning curve in a semiautomatic approach for a standardized assessment of the fetal heart (fetal intelligent navigation echocardiography [FINE]).

METHODS

A total of 30 stored spatiotemporal image correlation volume data sets of second-trimester fetuses were evaluated by 3 physicians with different levels of expertise in fetal echocardiography by using the FINE approach. Data were analyzed regarding the examination time and proper reconstruction of the diagnostic cardiac planes. The completions and numbers of correct depictions of all diagnostic planes were evaluated by a blinded expert (time t0). To determine interobserver and intraobserver variability, the volumes were reassessed after a 4-week training interval (time t1).

RESULTS

All operators were able to perform the investigation on all 30 volumes. At t0, the interobserver variability between the beginner and both the advanced (P = .0013) and expert (P < .0001) examiners was high. Focusing on intraobserver variability at t1, the beginner showed a marked improvement (P = .0087), whereas in advanced and expert hands, no further improvement regarding proper achievement of all diagnostic planes could be noticed (P > .999; P = .8383). The beginner also showed improvement in the mean investigation time (t0, 82.8 seconds; t1, 73.4 seconds; P = .0895); nevertheless, the advanced and expert examiners were faster in completing the examination (t1, advanced, 20.9 seconds; expert, 28.3 seconds; each P < .0001).

CONCLUSIONS

Based on our results, the FINE technique is a reliable and easily learned method. The use of this semiautomatic work flow-based approach supports evaluation of the fetal heart in a standardized and time-saving manner. A semiautomatic evaluation of the fetal heart might be useful in facilitating the detection of fetal cardiac anomalies.