Informed Consent, Image Recording and ISUOG Basic Training Informed Consent, Image Recording and Report Writing Reem S. Abu-Rustum, Lebanon

Learning Objectives At the end of this session, you will: Know when you should obtain informed consent for an ultrasound examination, & how to do it Be able to record images of ultrasound scans & know how to store them digitally Know how to write a report describing the ultrasound findings of an obstetric scan

Key Points Informed consent should always be obtained before performing any ultrasound examination Abnormalities detected during a scan should be documented, using digital media or photos in the patient’s file A thorough report should describe the results of an ultrasound scan The report’s conclusion should indicate any action to be taken by the clinician as follow-up to the scan

Informed Consent Check patient name & ID Describe the purpose of the examination to the patient Inform the patient about how the examination will be performed Inform the patient of possible other findings detected during the examination Receive oral or written acceptance of the examination from the patient

Example: Screening for Trisomy 21?

Indications: Obstetrical Scan To confirm pregnancy To evaluate a suspected ectopic pregnancy To define the cause of vaginal bleeding To evaluate pelvic/abdominal pain To determine gestational age To diagnose multiple pregnancy To confirm viability/cardiac activity To guide a prenatal diagnosis procedure To discover or assess fetal abnormality To measure the nuchal translucency To measure the cervical length To measure fetal biometry Many others, especially in the second & third trimesters

Why Have a Report? To document the findings for other health care providers caring for the patient To have an understandable report for those not proficient in reading ultrasound images For you, if your memory is not as good as you may think For the health care record and its many uses

What Should Be Measured ? Only measure what is relevant (remember in 3 planes) - too many measures are confusing Measure and describe abnormalities, and take pictures

What Each Image Should Include Patient name & other identifying information Facility identifying information Date of ultrasound examination Image orientation Details of ultrasound machine settings *provided automatically (frequency, power, scale) Label of image structure *if not obvious or to identify a particular structure

Image Recording Ideally all findings should be recorded – either on a digital medium or on paper in patient files Images should as a minimum include all abnormal findings

Report and Image Storage Hard copies of all images should be stored Prints, photocopies, dvd, electronically A report should go in the patient’s chart A report should be sent to the provider if preferred The sonographer should keep a report at their facility

Terminology Ultrasound in Obstetrics & Gynecology: A Practical Approach. Abuhamad et al 2014

Terminology Shape: e.g. round, irregular contour Contents : e.g. septations, papillary projections Acoustic shadowing Acoustic posterior enhancement Demarcation relative to other organs +/- capsule, thin / thick adherent / mobile

What the Report Should Include – Early Pregnancy Date Patient’s name & medical number TA, TV or both Presence of chaperone Confirmation of intrauterine location presence of heart pulsations Singleton / twin if twin, number & chorionicity Any abnormal findings Comments / recommendations Signature & status

What the Report Should Include – Dating Date Patient’s name & medical number Confirmation of fetal heart activity Fetal biometry US assigned gestational age & US EDD Any abnormal findings Comments / recommendations Signature & status ISUOG Practice guidelines for performance of the routine mid-trimester fetal ultrasound scan. 2011.

What the Report Should Include – Anomaly Scan Date Patient’s name & medical number Transabdominal, transvaginal or both, presence of chaperone Confirmation of fetal heart activity Gestational age, as calculated from previous US dating Fetal biometry (HC, BPD, AC, FL, PH, TCD) Anatomical survey, describing any abnormal findings Placental site relative to internal cervical os Amniotic fluid volume Comments / recommendations Signature & role

Anatomical Survey ISUOG Practice guidelines for performance of the routine mid-trimester fetal ultrasound scan. 2011.

Anatomical Survey ISUOG Practice guidelines for performance of the routine mid-trimester fetal ultrasound scan. 2011.

What the Report Should Include – Growth scan Date Patient’s name & medical number Transabdominal, transvaginal or both, presence of chaperone Confirmation of fetal heart activity Gestational age, as calculated from US EDD Fetal biometry (HC, BPD, AC, FL, EFW) Placental site relative to internal cervical os Amniotic fluid volume Comments / recommendations Signature & role

What the Report Should Include – Growth scan

What the Report Should Include – Growth scan

What the Report Should Include – Growth scan

What the Report Should Include – Growth scan

What the Report Should Include – Growth scan

Other Information Specific ultrasound examination requested Name of health care provider & contact information Relevant clinical information +/- ICD code Approach of ultrasound transabdominal / transvaginal Comparison with prior studies Urgent report/finding call relevant party & report who was called with time and date

AIUM Recommendations There should be a permanent record of the ultrasound examination & its interpretation Images of all relevant areas, both normal & abnormal, should be recorded in a retrievable format Retention of the ultrasound images & report should be consistent both with clinical needs & with relevant legal & local health care facility requirements

Dating & Growth Challenge

Case 1 BPD 49.5mm HC 185.0mm AC 155.0mm FL 34.5.0mm Gestational age = ?

Case 1 BPD 49.5mm HC 185.0mm AC 155.0mm FL 34.5mm Gestational age = 20w5d

Case 2 BPD 73.0mm HC 272.0mm AC 240.0mm FL 53.0mm Gestational age = ?

Case 2 BPD 73.0mm HC 272.0mm AC 240.0mm FL 53.0mm Gestational age = 29w0d

Case 3 BPD 41.0mm HC 152.0mm AC 127.0mm FL 27.5mm Gestational age = ?

Case 3 BPD 41.0mm HC 152.0mm AC 127.0mm FL 27.5mm Gestational age = 18w2d

Case 4 Which fetus is breech – A or B?

Case 4 Fetus A BPD 88.0mm HC 325.0mm AC 295.0mm FL 65.0mm Gestational age = 36w2d

Case 4 Fetus B BPD 80.0mm HC 325.0mm AC 295.0mm FL 65.0mm Gestational age = 36w2d

Which Fetus is Breech? Fetus A Fetus B

Review Questions List 3 things to be included in an obstetric ultrasound scan report Should ultrasound images be stored? Who should get a copy of the report?