Don't Ultrasound Scan your Baby without Cause are the recommendations by Dr. Sarah Buckley
Ultrasound Scans- cause for concern
By Sarah Buckley
When I was pregnant with my first baby in 1990, I decided against having a scan. This was a rather unusual decision, as my partner and I are both doctors and had even done pregnancy scans ourselves- rather ineptly, but sometimes usefully- while training in GP Obstetrics a few years earlier.
What influenced me the most was my feeling that I would lose something important as a mother if I allowed
someone to test my
baby. I knew that if a minor or uncertain problem showed up, (this is not uncommon) that I would be
obliged to return again and
again, and that after a while, it would feel as if my baby belonged to the system, and not to me.
In the years since then I have had three more unscanned babies, and have read many articles and research
papers about
ultrasound. Nothing I have read has made me reconsider my decision. Although ultrasound may sometimes
be useful when
specific problems are suspected, my conclusion is that it is at best ineffective and at worse
dangerous when used as a
‘screening tool’ for every pregnant woman and her baby.
Ultrasound past and present
Ultrasound was developed during WWII to detect enemy submarines, and was subsequently used in the steel
industry. In July
1955 Glasgow surgeon Ian Donald borrowed an industrial machine and, using beefsteaks as controls, began
to experiment with
abdominal tumours which he had removed from his patients. He discovered that different tissues gave
different patterns of
‘echo’, leading him to realise that ultrasound offered a revolutionary way to look into the previously
mysterious world of the
growing baby (Wagner 1995).
This new technology spread rapidly into clinical obstetrics. Commercial machines became available in
1963 (De Crespigny
1996) and by the late 1970’s ultrasound had become a routine part of obstetric care (Oakley 1986). Today,
ultrasound is seen as
safe and effective and scanning has become a rite of passage for pregnant women in developed countries. Here
in Australia, it
is estimated that 99% of babies are scanned at least once in pregnancy - mostly as a routine prenatal
ultrasound (RPU) at 4 to 5
months.
However, there is growing concern as to its safety and usefulness. UK consumer activist Beverley Beech
has called RPU “the
biggest uncontrolled experiment in history” (Beech 1993), and the Cochrane Collaborative Database- the
peak scientific
authority in medicine-concludes that “…no clear benefit in terms of a substantive outcome measure like
perinatal mortality
[number of babies dying around the time of birth] can yet be discerned to result from the routine use
of ultrasound.” (Neilson
1999).
This seems a very poor reward for the huge costs involved. In 1997-8, for example, $39 million was
paid by the federal
government for pregnancy scans- an enormous expense compared to $54 million for all other obstetric
medicare costs. This
figure does not include the additional costs paid by the woman herself.
In 1987, UK radiologist H.D.Meire, who had been performing pregnancy scans for 20 years, commented,
“The casual
observer might be forgiven for wondering why the medical profession is now involved in the wholesale
examination of
pregnant patients with machines emanating vastly different powers of energy which is not proven
to be harmless to obtain
information which is not proven to be of any clinical value by operators who are not certified as competent
to perform the
operations.”(Meire 1987). The situation today is unchanged, on every count.
The 1999 Senate Committee report, ‘Rocking the Cradle’ recommended that the cost-benefit of routine
scanning, and of current
ultrasound practices, be formally assessed. Recommendations were also made to develop guidelines for
the safe use of all
obstetric ultrasound, as well as for the development of standards for the training of ultrasonographers
(see below). So far, none of
these recommendations have been implemented (Senate Committee 1999).
What is Ultrasound?
The term ‘ultrasound’ refers to the ultra-high frequency soundwaves used for diagnostic scanning: these waves travel at 10 to 20 million cycles per second, compared to10 to 20 thousand cycles per second for audible sound (De Crespigny 1996). Ultrasound waves are emitted by a transducer (the part of the machine that is put onto the body), and a picture of the underlying tissues is built up from the pattern of “echo” waves which return. Hard surfaces such as bone will return a stronger echo than soft tissue or fluids, giving the bony skeleton a white appearance on the screen.
Ordinary scans use pulses of ultrasound which last only a fraction of a second, with the interval between
waves being used by the
machine to interpret the echo that returns. In contrast, doppler techniques, which are used in specialised
scans, fetal monitors
and hand-held fetal stethescopes (‘sonicaids’) feature continuous waves, giving much higher levels of
exposure than ‘pulsed’
ultrasound. Many women do not realise that the small machines used to listen to their baby’s heartbeat
are actually using doppler
ultrasound, albeit with low dose parameters.
More recently, ultrasonographers have been using vaginal ultrasound, where the transducer is placed
high in the vagina, much
closer to the developing baby. This is used mostly in early pregnancy, when abdominal scans can give
poor pictures. However,
with vaginal ultrasound, there is little intervening tissue to shield the baby, who is at a vulnerable
stage of development, and
exposure levels will be high. Having a vaginal ultrasound is not a pleasant procedure for the
woman; the term ‘diagnostic rape’
was coined to describe how some women experience vaginal scans.
Another recent application for ultrasound is the ‘nuchal translucency test’, where the thickness of the skin fold at the back of the baby’s head is measured at around 3 months; a thick ‘nuchal (neck) fold’ makes the baby more likely, statistically, to have Downs syndrome. When the baby’s risk is estimated to be over 1 in 250, a definitive test is recommended. This involves taking some of the baby’s tissue by amniocentesis or chorionic villus sampling. Around 19 out of 20 babies diagnosed as ‘high risk’ by nuchal translucency will not turn out to be affected by Down’s syndrome, and their mothers will have experienced several weeks of unnecessary anxiety. A nuchal translucency scan does not detect all babies affected by Down’s syndrome.
Information gained from Ultrasound
Ultrasound is mainly used for two purposes in pregnancy- either to investigate a possible problem at any stage of pregnancy, or as a routine scan at around 18 weeks.
If there is bleeding in early pregnancy, for example, ultrasound may predict whether miscarriage is
inevitable. Later in pregnancy,
ultrasound can be used when a baby is not growing, or when a breech baby or twins are suspected. In
these cases, the
information gained from ultrasound can be very useful in decision-making for the woman and her carers.
However the use of
routine prenatal ultrasound (RPU) is more controversial, as this involves scanning (or ‘screening’)
all pregnant women in the hope
of improving the outcome for some mothers and babies.
The timing of routine scans (18 to 20 weeks) is chosen for pragmatic reasons. It offers a reasonably
accurate due date- although
dating is most accurate at the early stages of pregnancy, when babies vary the least in size- and the
baby is big enough to see
most of the abnormalities that are detectable on ultrasound. However, at this stage, the EDD (expected
date of delivery) is only
accurate to a week either side, and some studies have suggested that an early examination, or calculations
based on a woman’s
menstrual cycle, can be as accurate as RPU. (Olsen and Clausen, 1997; Kieler et al, 1993).
And while many women are reassured by a normal scan, RPU actually detects only between 17% and
85% of the 1 in 50 babies
that have major abnormalities at birth (Ewigman 1993, Luck 1992). A recent study from Brisbane showed
that ultrasound at a
major women’s hospital missed around 40% of abnormalities, with most of these being difficult or impossible
to detect (Chan
1997). Major causes of intellectual disability such as cerebral palsy and Down’s syndrome are unlikely
to be picked up on a
routine scan, as are heart and kidney abnormalities.
When an abnormality is detected, there is a small chance that the finding is a ‘false positive’, where
the ultrasound diagnosis is
wrong. A UK survey showed that, for 1 in 200 babies aborted for major abnormalities, the diagnosis on
post-mortem was less
severe than predicted by ultrasound and the termination was probably unjustified. In this survey, 2.4%
of the babies diagnosed
with major malformations, but not aborted, had conditions that were significantly over or under-diagnosed
. (Brand 1994).
There are also many cases of error with more minor abnormalities, which can cause anxiety and repeated
scans, and there are
some conditions which have been seen to spontaneously resolve. (eg see Saari-Kemppainen 1990).
As well as false positives, there are also uncertain cases, where the ultrasound findings cannot be
easily interpreted, and the
outcome for the baby is not known. In one study involving women at high risk, almost 10% of scans were
uncertain. (Sparling
1988) This can create immense anxiety for the woman and her family, and the worry may not be allayed
by the birth of a normal
baby. In the same study, mothers with “questionable” diagnoses still had this anxiety 3 months after
the birth of their baby.
In some cases of uncertainty, the doubt can be resolved by further tests such as amniocentesis.
In this situation, there may be up
to two weeks wait for results, during which time a mother has to decide if she would terminate the pregnancy
if an abnormality is
found. Even mothers who receive reassuring news have felt that this process has interfered with their
relationship with their baby
(see Brookes, 1995).
As well as estimating the EDD and checking for major abnormalities, RPU can also identify a low-lying
placenta (placenta
praevia), and detect the presence of more than one baby at an early stage of pregnancy. However, 19
out of 20 women who have
placenta praevia detected on an early scan will be needlessly worried: the placenta will effectively
move up, and not cause
problems at the birth. Furthermore detection of placenta praevia by RPU has not been found to be safer
than detection in labour.
(Saari-Kemppainen, 1990). No improvement in outcome has been shown for multiple pregnancies either;
the vast majority of
these will be detected before labour, even without RPU (MIDIRS 1995).
The American College of Obstetricians, in their guidelines on routine ultrasound in low-risk pregnancy,
conclude “In a population
of women with low-risk pregnancies, neither a reduction in perinatal morbidity [harm to babies around
the time of birth] and
mortality nor a lower rate of unnecessary interventions can be expected from routine diagnostic ultrasound.
Thus ultrasound should be performed for specific indications in low-risk pregnancy.”(ACOG 1997).
Biological effects of Ultrasound
Ultrasound waves are known to affect tissues in two main ways. Firstly, the sonar beam causes heating of the highlighted area by about 1 degree celsius. This is presumed to be non-significant, based on whole-body heating in pregnancy, which seems to be safe up to 2.5 degrees celsius (Am Inst of Ultrasound Medicine Bioeffects Report 1988)
The second recognised effect is cavitation, where the small pockets of gas which exist within mammalian
tissue vibrate and then
collapse. In this situation “…temperatures of many thousands of degrees celsius in the gas create a
wide range of chemical
products, some of which are potentially toxic. These violent processes may be produced by micro-second
pulses of the kind
which are used in medical diagnosis….” (Am Inst of Ultrasound Medicine Bioeffects Report 1988) The significance
of cavitation
effects in human tissue is unknown.
A number of studies have suggested that these effects are of real concern in living tissues. The first
study suggesting problems
was a study on cells grown in the lab. Cell abnormalities caused by exposure to ultrasound were seen
to persist for several
generations (Liebeskind 1979). Another study showed that, in newborn rats, (who are at a similar stage
of brain development to
humans at 4 to 5 months in utero), ultrasound can damage the myelin that covers nerves (
Ellisman 1987), indicating that the
nervous system may be particularly susceptible to damage from this technology.
A 1999 animal study by Brennan and colleagues, reported in New Scientist (June 12 1999), showed that
exposing mice to
dosages typical of obstetric ultrasound caused a 22% reduction in the rate of cell division,
and a doubling of the rate of
aptosis, or programmed cell death, in the cells of the small intestine.
Mole (1986) comments “If exposure to ultrasound… causes death of cells, then the practice of ultrasonic
imaging at 16
to 18 weeks will cause loss of neurones [brain cells] with little prospect of replacement of lost cells…The
vulnerability
is not for malformation but for maldevelopment leading to mental impairment caused by overall reduction
in the number of
functionning neurones in the future cerebral hemispheres.”
Studies on humans exposed to ultrasound have shown that possible adverse effects include premature ovulation
(Testart 1982),
preterm labour or miscarriage (Lorenz, 1990; Saari-Kemppainen 1990), low birth weight (Newnham, 1993,
Geerts 1996), poorer
condition at birth (Thacker 1985; Newnham, 1991), perinatal death (Davies 1992) dyslexia (Stark 1984),
delayed speech
development (Campbell, 1993) and less right-handedness (Salvesen 1993: Kieler 1998a, Salvesen
1999, Kieler 2001). Non
right-handedness is, in other circumstances, seen as a marker of damage to the developing brain (see
Odent 1998, Keiler
2001). One Australian study showed that babies exposed to 5 or more doppler ultrasounds were 30% more
likely to develop
intrauterine growth retardation (IUGR)- a condition that ultrasound is often used to detect. (Newnham,
1993)
Two long-term randomised controlled trials, comparing exposed and unexposed childrens’ development at
8 to 9 years old,
found no measurable effect from ultrasound. (Salvesen 1992, Kieler 1998b) However, as the authors
note, intensities used today
are many times higher than in 1979 to 1981. Further, in the major branch of one trial, scanning time
was only three minutes
(Salvensen 1993). More studies are obviously needed in this area, particularly in the areas of Doppler
and vaginal ultrasound,
where exposure levels are much higher.
A further problem with studying ultrasound’s effect is the huge range of output, or dose, possible
from a single machine. Modern
machines can give comparable ultrasound pictures using a lower, or a 5000 times higher dose (Meire 1987),
and there are no
standards to ensure that the lowest dose is used. Because of the complexity of machines, it is difficult
to even quantify the dose
given in each examination (Taylor 1990). In Australia training is voluntary, even for obstetricians,
and the skill and experience of
operators varies widely.
A recent summary of the safety of ultrasound in human studies, published in May 2002 in the prestigious
US journal
Epidemiology concluded “….there may be a relation between prenatal ultrasound exposure and adverse outcome.
Some of the
reported effects include growth restriction, delayed speech, dyslexia, and non-right-handedness associated
with ultrasound
exposure. Continued research is needed to evaluate the potential adverse effects of ultrasound exposure
during pregnancy.
These studies should measure the acoustic output, exposure time, number of exposures per subject, and
the timing during the
pregnancy when exposure(s) occurred.” (Marinac-Dabic 2002).
The UK consumer organisation AIMS has produced a booklet Ultrasound Unsound? , originally
published in 1993 and recently
updated. This very comprehensive publication, which I highly recommend, includes a form that pregnant
women undergoing
ultrasound can ask their carers to fill out. You can make your own form based on the information as
below, or obtain the booklet
from
www.birthinternational.com.au
My Baby’s Ultrasound Exposure Record
- The following procedure requires the use of ultrasound……..
- This is necessary to obtain the following information ……
- To my knowledge, there is no current alternative method available to obtain this information that carries less risk to ……. …….(mother’s name)
Signature (doctor or midwife)………………………… Date …………..
.
The ultrasonographer is asked to specify
- Manufacturer and model of ultrasound equipment……
- Date of last calibration………..
- Type or combination of types of ultrasound used……………..
- Intensity of exposure (W/cm sq or mW/cm sq)
- Time commenced………..Time Completed……….
- Duration of exposure…………….
- Name of hospital or clinic……………..
- Carried out by………………
- Qualifications………………… Position………………….
Signature………………. Date…………….
Women’s experiences of Ultrasound
Women have not been consulted at any stage in the development of this technology, and their experiences and wishes are presumed to coincide with, or be less important than, the medical information that ultrasound provides. For example, supporters of RPU presume that early diagnosis and/or termination is beneficial to the affected woman and her family. However the discovery of a major abnormality on RPU can lead to very difficult decision-making.
Some women who agree to have an ultrasound are unaware that they may get information about their baby
that they do not want,
as they would not contemplate a termination. Other women can feel pressured to have a termination, or
at the least feel some
emotional distancing from their “abnormal” baby (Brookes, 1995). Furthermore, there is no evidence that
women who have
chosen termination are, in the long term, psychologically better off than women whose babies have died
at birth; in fact, there are
suggestions that the opposite may be true in some cases (Watkins 1989). And when termination has
been chosen, women are
unlikely to share their story with others and can experience considerable guilt and pain from the knowledge
that they themselves
chose the loss (MIDIRS 1996).
When minor abnormalities are found- which may or may not be present at birth, as discussed above- women
can feel that some
of the pleasure has been taken away from their pregnancy.
Women’s experiences with ultrasound and other tests used for prenatal diagnosis (eg amniocentesis) are
thoughtfully presented
in the book ‘The Tentative Pregnancy' by Barbara Katz Rothman. The author documents the heartache that
women can go
through when a difficult diagnosis is made-for some women, this pain can take years to resolve.She suggests
that the large
numbers of screening tests currently being offered to check for abnormalities may make every woman feel
that her pregnancy is
'tentative' until she receives reassuring results.
To my mind, ultrasound also represents yet another way in which the deep internal knowledge that a mother
has of her body and
her baby is made secondary to technological information that comes from an ‘expert’ using a machine.
Thus the ‘cult of the
expert’ is imprinted from the earliest weeks of life.
Furthermore by treating the baby as a separate being, ultrasound artificially splits mother from
baby well before this is a
physiological or psychic reality. This further emphasises our cultures favouring of individualism over
mutuality and sets the scene
for possible- but to my mind artificial- conflicts of interest between mother and baby in pregnancy,
birth and parenting.
Conclusions and recommendations
I would urge all pregnant women to think deeply before they choose to have a routine ultrasound. It is not compulsory, despite what some doctors have said, and the risks, benefits and implications of scanning need to be considered for each mother and baby, according to their specific situation.
If you choose to have a scan, be clear about the information that you do and do not want to be told.
Have your scan done by an
operator with a high level of skill and experience (usually this means performing at least 750 scans
per year) and say that you
want the shortest scan possible. Ask them to fill out the form, or give you the information, as above,
and to sign it.
If an abnormality is found, ask for counselling and a second opinion as soon as practical. And remember
that it's your baby,
your body and your choice.
References
American College of Obstetricians and Gynecologists (ACOG) Routine Ultrasound in Low-Risk Pregnancy. In:ACOG Practice Patterns- Evidence-Based Guidelines for Clinical Issues in Obstetrics and Gynecology. Number 5 August 1997
Association for Improvements in the Maternity services (AIMS)- AIMS UK. Ultrasound Unsound? AIMS Journal vol 5 no 1, spring 1993. The updated version is available from www.birthinternational.com.au
American Institute of Ultrasound Medicine Bioeffects Report 1988. J Ultrasound Medicine 7S1-S38. Sept 1988
Beech BL. Ultrasound- unsound? Talk at Mercy Hospital, Melbourne, April 1993
Brand IR, Kaminopetros P, Cave M et al. Specificity of antenatal ultrasound in the Yorkshire region: a prospective study of 2261 ultrasound detected anomalies. Br J Obstet Gynaecol 1994. Vol 101, no5. pp 392-397
Brookes, A. Women’s experience of routine prenatal ultrasound. Healthsharing Women: The newsletter of Healthsharing Women’s Health Resource Service. Vol 5, no’s 3 & 4. Dec 1994- March 1995.
Campbell JD et al Case-control study of prenatal ultrasonography in children with delayed speech. Can Med Ass J 1993 vol 149 no 10 pp1435-1440
Chan FY. Limitations of Ultrasound. Paper presented at Perinatal Society of Australia and New Zealand 1st Annual Congress, Freemantle 1997
Davies J et al. Randomised controlled trial of doppler ultrasound screening of placental perfusion in pregnancy. Lancet 1992;340:1299-1303
De Crespigny L, Dredge R. Which Tests for my Unborn Baby, Revised Edition. Oxford University Press, Melbourne 1996.
Ellisman MH, Palmer DE, Andre MP. Diagnostic levels of ultrasound may disrupt myelination. Experimental Neurology 1987 vol 98 no 1 pp78-92
Ewigman BG, Crane JP, Frigoletto FD et al. Effect of prenatal ultrasound screening on perinatal outcome.RADIUS study group. N Engl J Med . 1993 vol 329, no 12, pp821-7
Geerts JGM, Brand E, Theron B. Routine obstetric ultrasound in South Africa: cost and effect on perinatal outcome- a prospective randomised controlled trial. Br J Obstet Gynaecol 1996. Vol 103. pp501-507
Kieler H, Axelsson O, Nilsson S, Waldenstrom U. Comparison of ultrasonic measurement of biparietal diameter and last menstrual period as a predictor of day of delivery in women with regular 28 day cycles. Acta-Obstet-Gynecol-Scand, 1993 vol 75 no 5 pp 347-9
Kieler H, Axelsson O, Haguland B, et al. Routine ultrasound screening in pregnancy and the children’s subsequent handedness. Early Hum Dev 1998 , vol 50 no 2, pp233-245
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Kieler H, Cnattingius S, Haglund B et al. Sinistrality- a side-effect of prenatal sonography: A comparative study of young men.Epidemiology 2001:12 (6):618-23
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Liebeskind D, Bases R, Elequin F et al. Diagnostic ultrasound: effects on the DNA and growth patterns of animal cells. Radiology 1979 vol 131, no1, pp 177-184
Lorenz RP, Comstock CH, Bottoms SF, Marx SR. Randomised prospective trial comparing ultrasonography
and pelvic
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Marinac-Dabic D, Krulewitch CJ, Moore RM Jr. The safety of prenatal ultrasound exposure in human studies.
Epidemiology 2002
May; 13(3 Suppl):S19-22
Meire HB. The safety of diagnostic ultrasound (commentary). Br J Obstet Gynaecol 1987 vol 94, pp1121-1122
MIDIRS. Informed Choice for professionals leaflet no 3. Ultrasound screening in the first half of pregnancy: is it useful for everyone? MIDIRS and the NHS centre for Reviews and Dissemination. 1996
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New Scientist Shadow of doubt 12 June 1999, p23
Newnham J, Evans SF, Michael CA et al. Effects of frequent ultrasound during pregnancy: a randomised controlled trial. Lancet 1993, vol 342, no 8876, pp887-91
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Odent M. Where does handedness come from? Primal Health Research Quarterly 1998, vol 6 no 1.
Olsen O et al. Routine ultrasound dating has not been shown to be more accurate than the calendar method. Br J Obstet Gynaecol 1997, Vol 104 No 11 pp1221-2
Rothman, Barbara Katz. The Tentative Pregnancy: Amniocentesis and the Sexual Politics of Motherhood. (2nd ed) Pandora 1994
Saari-Kemppainen A, Karjalainen O, Ylostalo P et al. Ultrasound screening and perinatal mortality: controlled trial of systematic one-stage screening in pregnancy. The Helsinki ultrasound trial. Lancet 1990 vol 336, no 8712. pp 387-391
Salvesen KA, Bakketeig LS, Eik-nes SH et al. Routine ultrasonography in utero and school performance at age 8-9 years. Lancet 1992, vol 339 no 8785 pp 85-89
Salvesen KA, Vatten LJ, Eik-nes SH et al. Routine ultrasonography in utero and subsequent handedness and neurological development. BMJ 1993: vol 307 no 6897 pp159-64
Salvesen KA, Ein-nes SH et al. Ultrasound during pregnancy and subsequent childhood non-right handedness- a meta-analysis. Ultrasound Obstet Gynecol 1999; 13(4) 241-6.
Sparling JW, Seeds JW, Farran DC. The relationship of obstetric ultrasound to parent and infant behavior. Obstet Gynecol 1988 vol 72 no 6. pp 902-7
Senate Community Affairs Reference Committee. Rocking the Cradle- A Report into Childbirth Procedures. Commonwealth of Australia 1999
Stark CR, Orleans M, Havercamp AD et al. Short and long term risks after exposure to diagnostic ultrasound in utero. Obstet Gynecol, 1984, vol 63 pp 194-200
Taylor KJW A prudent approach to ultrasound imaging of the fetus and newborn. Birth 1990. Vol 17 no 4, pp218-223
Testart J, Thebalt A, Souderis E, Frydman R. Premature ovulation after ovarian ultrasonography. Br J Obstet Gynaecol, 1982, vol 89, no 9, pp 694-700
Thacker SB. Quality of controlled clinical trials. The case of imaging ultrasound in obstetrics: a review. Br J Obstet Gynaecol, 1985 vol 92, no 5, pp 437-444
Wagner M. Ultrasound; More harm than good? Mothering magazine Winter 1995
Watkins D. An alternative to termination of pregnancy. The Practitioner,1989, vol 233 no 1472,pp990, 992.
____________________
First published in Nexus magazine, vol9, no 6, Oct-Nov 2002,
Copyright Dr Sarah Buckley
_________________________________
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