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

2. 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

3. 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

4. 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

5. Example: Screening for Trisomy 21?

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. 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

15. 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

16. 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

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

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

19. 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

20. What the Report Should Include – Growth scan

21. What the Report Should Include – Growth scan

22. What the Report Should Include – Growth scan

23. What the Report Should Include – Growth scan

24. What the Report Should Include – Growth scan

25. 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

26. 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

27. Dating & Growth Challenge

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

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

31. Case 2
BPD 73.0mm
HC mm
AC mm
FL 53.0mm
Gestational age = ?

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

34. Case 3
BPD 41.0mm
HC mm
AC mm
FL 27.5mm
Gestational age = ?

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

37. Case 4
Which fetus is breech – A or B?

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

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

42. Which Fetus is Breech?
Fetus A
Fetus B

43. 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?