Worried About Too Many Ultrasounds

[SurpriseBub]

Do the scan- I definitely would in your shoes. The knowledge you and your care providers will get is way more valuable than the fear of any risk... Don't fret on the decision. Hoping all looks good for you

 

[Feronia]

Could you ask what they are checking for and what would be the course of action if a problem is found with his bladder? If the answer is "nothing" and they can find out in some way after birth, maybe avoid it. But if the scan can help change a course of action in any way, then I'd do it.

 

[Larkspur]

For all of you saying "my baby turned out just fine," sure it's easy to say that -- we don't know the long-term effects of ultrasound and it's impossible to know what sort of effect, if any, they have already had on your baby. They haven't been thoroughly studied since the late 80's and early 90's, and they've changed in strength since then. What we do know is that in animal studies, they cause tissue to heat up (bone more than fluid and tissue) and can cause cell migration. So obviously they CAN have detrimental effects on your baby, but assessing these effects is extremely difficult. Just about every medical organization has advised against too many scans -- especially 3d/4d novelty scans -- and says you should ONLY do one in the event that there is a medical indication. Otherwise, ultrasounds do not improve health outcomes and should be avoided.

I'd just like to speak to this comment because I think it's unnecessarily alarmist, especially for a mother-to-be who is already anxious. Below, I've paraphrased a very informative comment that I came across in the course of my reading about this subject. It summarises the key concerns better than I can!

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A Lancet study from 1993 did come back with results suggesting there may be a link between ultrasound and IUGR. But the scientists behind the Lancet study kept studying the same group of children up to the age of 8. Their final report, issued in 2004, concluded: “There were no significant differences indicating deleterious effects of multiple ultrasound studies at any age as measured by standard tests of childhood speech, language, behaviour, and neurological development.”

The animal studies you refer to were by a scientist named Pasko Rakic on the effect of ultrasound on the neurologic development of fetal mice. But in those studies, the mice were exposed to ultrasound continuously for up to 7 hours, and at intensities far greater than those used in human diagnostic ultrasounds. Rakic himself warned, “It would be very wrong if women stopped having medically indicated ultrasounds because of this. Our study in mice does not mean that use of ultrasound on human fetuses for appropriate diagnostic and medical purposes should be abandoned.”

As for the suggestion it may be linked to autism, this is based on the work of a scientist called Michael Casanova, who has hypothesized that ultrasound may be a contributing factor to autism. He made this hypothesis in an article published in a journal called Medical Hypotheses. The stated objective of this journal is “to give novel, radical new ideas and speculations in medicine open-minded consideration, opening the field to radical hypotheses which would be rejected by most conventional journals.” In other words, it publishes interesting ideas before they have been fully investigated.

In short, there's no reason to panic at all. Suggestions that ultrasound are linked to autism or developmental delays are speculative at best. The prudent choice at this point would be to have the ultrasound.

 

[redneckhippy]

I emailed my MW and reminded her about how many scans I've had (I was still seeing a RE in the first trimester, so I thought she might not be aware) and she wrote back that she still thinks the benefits outweight any potential risks. I did ask her to call me today, so I can clarify what the plan of action is if the ultrasound today does show the bladder is distended and also clarify the advantage of confirming this via ultrasound vs when he's born (since he's due in less than a week), but I do trust her judgement, so if she feels it's important I will get it. Sigh, I thought we would out of the woods on Friday and I was feeling better about everything and now I have another ultrasound coming and something to worry about.

 

[redneckhippy]

Well I spoke with my MW and she feels it is important to confirm as it would change the plan of action if baby's bladder is still not emptying, plus would change follow up care after he's born, so looks like I'm going back in today for yet another ultrasound.

 

[Feronia]

Larkspur, I never once mentioned autism and I am familiar with the study and how it was conducted. My midwives gave me an entire binder of research on ultrasounds and I read through the whole thing when I was making my decision. What I was saying was against non-medically indicated ultrasounds (e.g. dating ultrasounds when you have regular cycles or know your ovulation date, 3D/4D novelty scans, other scans "just to see baby," and even 20-week scans without medical indications).

I have absolutely nothing against scans that are done when a problem is suspected. So when the researcher said "It would be very wrong if women stopped having medically indicated ultrasounds because of this" I completely, 100% agree.

Overall, my point was in response with people saying that ultrasounds absolutely don't have any effect on the baby. The fact that these effects happen in animal studies, albeit using longer periods of time with amplified waves, means that smaller, less-known effects are possible but extremely difficult to study -- especially long term. Does that mean we should avoid all ultrasounds? No, absolutely not. It just means that we should be wary of them when they aren't absolutely needed.

In the OPs case, if there's a course of action that would change based on the discovery of the distended bladder, then I would do the scan for sure. It sounds like your midwives confirmed that care would change, so don't feel guilty about doing a follow up exam!

 

[Larkspur]

Larkspur, I never once mentioned autism and I am familiar with the study and how it was conducted. My midwives gave me an entire binder of research on ultrasounds and I read through the whole thing when I was making my decision. What I was saying was against non-medically indicated ultrasounds (e.g. dating ultrasounds when you have regular cycles or know your ovulation date, 3D/4D novelty scans, other scans "just to see baby," and even 20-week scans without medical indications).

I know you didn't mention autism but the OP did, and the animal study you mentioned is the basis for the supposed autism hypothesis.

Anyway, I'm glad you agree that medically indicated ultrasounds are the sensible choice. I can't say I understand why you brought up such a highly speculative study in a thread that's not at all about "novelty scans" (I would definitely not call the 20-week scan unnecessary but that's by-the-by) but I'm glad everyone is on the same page that the OP does not need to feel anxious about medically indicated scans.

 

[Feronia]

I know you didn't mention autism but the OP did, and the animal study you mentioned is the basis for the supposed autism hypothesis.

Anyway, I'm glad you agree that medically indicated ultrasounds are the sensible choice. I can't say I understand why you brought up such a highly speculative study in a thread that's not at all about "novelty scans" (I would definitely not call the 20-week scan unnecessary but that's by-the-by) but I'm glad everyone is on the same page that the OP does not need to feel anxious about medically indicated scans.

I brought it up in response to the several posters saying things along the lines of "I had a lot of scans and my baby turned out just fine." That is not a good reason to justify a scan to someone else for reasons I've pointed out. I don't recall reading anything about suspecting autism, and I wouldn't go so far as to claim scans cause anything at all. The fact is we just don't know.

A statement put out by AIUM: "The American Institute of Ultrasound in Medicine (AIUM) and the US Food and Drug Administration (FDA) believe that the use of ultrasound without a medical indication is inappropriate and contradicts the responsible practice of medicine.
...

Although there are no confirmed biological effects on patients at the present time, the possibility exists that such biological effects may be identified in the future. Therefore, the AIUM recommends that ultrasound should be used only when the patient's physician indicates that it will provide medical benefit to the patient."

The 20-week scan is routine and does not improve outcomes UNLESS there are problems suspected or the woman is high-risk in any way, so for low-risk women with healthy pregnancies, yes it is non-medically indicated.

I know a lot of this is beside the point, but the general culture around here is ultrasound heavy. I don't think what the OP is doing is unnecessary though, and I apologize if my comments seem out of place since they are directed towards other posters more than the OP.

 

[laodicean]

The 20-week scan is routine and does not improve outcomes UNLESS there are problems suspected or the woman is high-risk in any way, so for low-risk women with healthy pregnancies, yes it is non-medically indicated.

I would like to see the published evidence that it doesn't improve outcome, because in my experience as a medical professional, it does.

Having recently been present at the birth of an anecephalic baby whose parents had refused the 20wk ultrasound, I can say that a lot of heartbreak could have been avoided.

Plus I have a couple of friends whose babies were diagnosed with problems that couldn't have been picked up at the 12wk dating scan that required either immediate surgical intervention following birth or birth in a tertiary centre to reduce complications, that would have been classed as low-risk if it wasn't for the 20wk scan.

Also, the NHS is stingy to a fault; if it could save itself a fortune by ditching the 20wk scan because it doesn't improve outcome, it would of have by now. The fact it hasn't leads me to suspect that you're simplifying the issue.

 

[kit10grl]

I was low risk in second pregnancy until scans discovered issues. These issues would have resulted in my child suffocating at birth and is she had survived that we would have also missed a heart condition. The 20 week scan is used as preventative medicine, it saves lives. I think its pretty dangerous to rule out a routine scan as not neccesary. Like PP said if the NHS didnt think it was neccesary they would do away with it in a money saving effort as it costs a fortune to provide it as a service.

 

[Feronia]

I would like to see the published evidence that it doesn't improve outcome, because in my experience as a medical professional, it does.
...

Also, the NHS is stingy to a fault; if it could save itself a fortune by ditching the 20wk scan because it doesn't improve outcome, it would of have by now. The fact it hasn't leads me to suspect that you're simplifying the issue.

Okay I know this is going off topic, but I didn't just make this up, lol. Though I've since returned the binder of ultrasound research my midwives gave me, I still have one document that lists studies. The main one cited is this one, but I know it's been replicated.
"Effect of Prenatal Ultrasound Screening on Perinatal Outcome" Bernard G. Ewigman, James P. Crane, Fredric D. Frigoletto, Michael L. LeFevre, Raymond P. Bain, Donald McNellis, and the RADIUS Study Group N Engl J Med 1993; 329:821-827, September 16, 1993.

In this study, they randomized over 15,000 low-risk women to 2 groups: one group got the 20-week scan as well as a third trimester scan, and another group ONLY got ultrasounds if a medical indication came up (and for the vast majority of women in this group, that meant no scans since they were low risk). Then they looked at outcome defined as fetal death, neonatal death, or neonatal morbidity such as intraventricular hemorrhage.

Here are the results: "The rate of adverse perinatal outcome was 5.0 percent among the infants of the women in the ultrasound-screening group and 4.9 percent among the infants of the women in the control group (relative risk, 1.0; 95 percent confidence interval, 0.9 to 1.2; P = 0.85). The rates of preterm delivery and the distribution of birth weights were nearly identical in the two groups. The ultrasonographic detection of congenital anomalies had no effect on perinatal outcome. There were no significant differences between the groups in perinatal outcome in the subgroups of women with post-date pregnancies, multiple-gestation pregnancies, or infants who were small for gestational age."

So while there are certainly times when it does find a problem that can be addressed during pregnancy or directly out of birth, usually there are signs of problems to begin with. Occasionally there aren't, that's true, but the statistics don't reflect a difference in outcome. This was a very difficult decision for me to make during pregnancy, but after reviewing the evidence I was comfortable skipping all routine scans.

 

[Monzter79]

My midwife told me that ultrasounds are VERY safe according to the available studies. I trust her, big time! She did say that many practices (her opinion) over-utilize US, and it impacts healthcare costs in a detrimental way. I can see that point since my previous practice would've taken a picture at every routine appointment. Health-wise however, she is confident in the safety of US.

I just wish the medical community would do a better job of tackling the issue of ethics regarding studies in the fields of maternal/fetal medicine and pediatrics. The available information (or lack of!) leaves a lot to be desired.

Empirical evidence (unlike morals, politics, anecdote etc) destroys the ability for controversy to distract in conversations where the common interest of ALL parties is just doing what's best for their children. I find it really unfortunate. Especially for moms like our OP who is dealing with more than her share of anxiety as a result.

Thinking of you redneckhippy.

 

[felix555]

I think there is a time and place for listing the dangers of ultrasounds if you believe there are any. I think this thread is probably not that time or place given the OP is already worried and made it clear this is a medically necessary US and not a fun scan to get some cute 3d shots to see if her baby has daddy's nose.

 

[laodicean]

"Effect of Prenatal Ultrasound Screening on Perinatal Outcome" Bernard G. Ewigman, James P. Crane, Fredric D. Frigoletto, Michael L. LeFevre, Raymond P. Bain, Donald McNellis, and the RADIUS Study Group N Engl J Med 1993; 329:821-827, September 16, 1993.

1993? That's an incredibly old study. Actually prehistoric - if a doctor told me they were still practicing medicine the way they were practicing it 20yrs ago, I'd tell them to get the f**k out my hospital and come back when they'd got a another medical degree.

I will read the study and properly critique it when I get the chance, but without looking at it I would say that a) it's obsolete, since it's 22yrs old b) ultrasound technology has improved significantly in 22yrs, and things we were missing then we're picking up now c) treatment of complications has also improved significantly, and things that would have resulted in neonatal morbidity / mortality 22yrs ago are now treatable and survivable with improved quality of life outcomes. Want proof of that? To quote the Office of National Statistics for the UK, In 2012 the infant mortality rate was 4.0 deaths per 1,000 live births, the lowest ever recorded in England and Wales, and compares with an infant mortality rate of 4.2 deaths per 1,000 live births in 2011 and 10.8 deaths per 1,000 live births in 1982.

I'm sure the specific data for '93 is available somewhere on the internet, but rest assured, it was definitely higher than 4 per 1000.

I'm afraid that you've quoted the ultrasound literature equivalent of leeches, and I would say as a result haven't made as informed a decision as you would have wished with regards to your antenatal care.

Edited to add: Seriously, I started studying medicine in 2000. So much of what I was taught as a medical student is now obsolete and thrown by the roadside. I started practicing as a doctor in 2007; I can't even begin to list the number of things that have changed in that time, even just in the sphere of radiology. I used to have to carry around packets of X-rays and scans for patients; now they're all digitally recorded and can be manipulated on screen to tease out the tiniest details. When I first started using ultrasound, I'd get a grey fuzzy picture that gave me a vague idea of what I was looking at. The machines we have now would have blown 2007 Me's socks off - image quality has improved beyond measure.

So to use a study from 1993 - SEVEN YEARS before I started studying my profession, (I was 12 and still in school, and I believe I still wanted to be a fighter pilot at that point) to back up your assertion that 20wk scans make no difference to outcome is honestly shocking. I would be laughed out of the room if I presented a paper at a journal club that was 5yrs old, let alone 22yrs.

 

[Feronia]

redneckhippy, how did it go today?

Empirical evidence (unlike morals, politics, anecdote etc) destroys the ability for controversy to distract in conversations where the common interest of ALL parties is just doing what's best for their children. I find it really unfortunate. Especially for moms like our OP who is dealing with more than her share of anxiety as a result.

I agree, it is unfortunate that there is a lack of empirical evidence on things like this. The problem is that it's incredibly difficult (if not impossible) to accurately study the effects of ultrasounds in an ethical way on pregnant women and their babies, and I think it's also unethical to study on animals -- especially since these type of studies don't accurately replicate human physiology and the conditions where the technology is used. Everything I've read on the topic concludes that there is no concrete evidence that ultrasounds are unsafe, but this isn't a proof that they are safe -- it's just an absence of evidence and there is still the possibility that they might be found to be unsafe in various ways in the future. And THAT is why every medical organization, the FDA, and imaging organizations say that they shouldn't be used unless there is medical indication, because medical indication outweighs any unknown risks.

 

[Feronia]

"Effect of Prenatal Ultrasound Screening on Perinatal Outcome" Bernard G. Ewigman, James P. Crane, Fredric D. Frigoletto, Michael L. LeFevre, Raymond P. Bain, Donald McNellis, and the RADIUS Study Group N Engl J Med 1993; 329:821-827, September 16, 1993.

1993? That's an incredibly old study. Actually prehistoric - if a doctor told me they were still practicing medicine the way they were practicing it 20yrs ago, I'd tell them to get the f**k out my hospital and come back when they'd got a another medical degree.

I will read the study and properly critique it when I get the chance, but without looking at it I would say that a) it's obsolete, since it's 22yrs old b) ultrasound technology has improved significantly in 22yrs, and things we were missing then we're picking up now c) treatment of complications has also improved significantly, and things that would have resulted in neonatal morbidity / mortality 22yrs ago are now treatable and survivable with improved quality of life outcomes. Want proof of that? To quote the Office of National Statistics for the UK, In 2012 the infant mortality rate was 4.0 deaths per 1,000 live births, the lowest ever recorded in England and Wales, and compares with an infant mortality rate of 4.2 deaths per 1,000 live births in 2011 and 10.8 deaths per 1,000 live births in 1982.

I'm sure the specific data for '93 is available somewhere on the internet, but rest assured, it was definitely higher than 4 per 1000.

I'm afraid that you've quoted the ultrasound literature equivalent of leeches, and I would say as a result haven't made as informed a decision as you would have wished with regards to your antenatal care.

Geesh, as I said, that was only one study I read and the only one I have access to at the moment considering I returned the more comprehensive research I had to my midwives. I did not based my entire decision on one study. Yes, it's not a recent study, but it was pretty comprehensive. I wouldn't say that it's the equivalent of leeches. I'm involved in a interdisciplinary medical discussion group (only as a student viewer since I'm not a medical professional myself yet), but they frequently quote studies from over 20 years ago if there's nothing to go off of since. There should be, certainly though. The neonatal mortality rate was on the 15,000 women in the study, not the general UK. The study was also done in the US. The mortality rate was around 5% for both groups -- no difference -- not 4 in 1,000.

Anyway, while I look to see if I can find some of the other studies I read, do you have a link to any studies that show that the 20-week scan does improve outcomes? Anecdotal evidence doesn't work for this.

 

[zorak]

OP - How did your scan go?

 

[laodicean]

Geesh, as I said, that was only one study I read and the only one I have access to at the moment considering I returned the more comprehensive research I had to my midwives.

Sorry, so you didn't do a full literature search when coming to this conclusion? You had a folder of evidence that someone else gave you? I strongly recommend to you, since you are a student, that you don't fall into the trap of other people's selection bias. How do you know they didn't leave out any papers that they disagreed with the conclusions of?

Unfortunately, even scientists have an agenda. And scientists are just people, so will often not publish data that proves the status quo, because that's not going to get placed in a good journal and improve their CV.

The neonatal mortality rate was on the 15,000 women in the study, not the general UK. The study was also done in the US. The mortality rate was around 5% for both groups -- no difference -- not 4 in 1,000.

Those two statistics are completely unrelated; not least because infant mortality and neonatal mortality are different things.

I was quoting the 10.8 / 4 in 1000 numbers to prove that my assertion that, in the UK (which has has routine 20wk ultrasounds for a couple of decades), infant mortality has fallen between 1982 and 2012, likely due to a number of reasons of which improved antenatal screening is just one and of which the significance is undefined.

Anyway, while I look to see if I can find some of the other studies I read, do you have a link to any studies that show that the 20-week scan does improve outcomes? Anecdotal evidence doesn't work for this.

You're the one that's making an assertion that goes against what other people consider to be true, and so you're the one that has burden of proof. HOWEVER, because this piqued my interest and I'm insomnia ridden, I refer you to the 2008 NICE (National Institute of Clinical Excellence) Guidance for Antenatal screening for low-risk women in the UK. It was reviewed in 2014, and it's findings have been confirmed and it's advice will remain unchanged for now.

https://www.nice.org.uk/guidance/cg62/evidence

Pages 134-179 specifically look at the evidence for various types of ultrasound examinations in pregnancy, and determine from the evidence available whether or not any difference is seen, and from that whether it should be a routine part of the NHS's low-risk antenatal screening programme.

I'll leave you to read it (they list all the studies that they have looked at in order to come to the conclusions that they have), but of second trimeter screening their conclusion is clear:

"There is high-level evidence that routine, rather than selective, ultrasound in early pregnancy before 24 weeks enables better gestational age assessment, earlier detection of multiple pregnancies and improved detection of fetal anomalies with resulting higher rate of termination of affected pregnancies. There is no good-quality evidence on long-term outcomes for women and their children."

So, we're picking more fetal anomolies, and whilst there's no evidence of improved long-term outcome, there's also no evidence of worsened long-term outcome due to fetal exposure of ultrasound waves.

After that, the question just remains: do you want to find out about your baby's tetraolgy of Fallot at 20wks so that you can give birth in a tertiary centre with on-site neonatal cardiac services, or when they come out blue and not breathing at district hospital or at your home birth?

20wk ultrasounds prove that most low-risk pregnancies are low risk pregnancies. I'd rather not find out mine was one of the minority of high-risk pregnancies when it was too late to do anything about it.

 

[Feronia]

Sorry, so you didn't do a full literature search when coming to this conclusion? You had a folder of evidence that someone else gave you? I strongly recommend to you, since you are a student, that you don't fall into the trap of other people's selection bias. How do you know they didn't leave out any papers that they disagreed with the conclusions of?

There's no need to be condescending. I read through the research they gave me (my midwife is a top researcher in the field and has been practising for over 30 years, so I do trust her) and I also did my own research since I worked at a large university and had access to the medical database. I've been through grad school so I have at least a basic understanding of reviewing studies. I've only taken the pre-medical courses since switching fields, so that's what I mean about being a student in my chosen field.

I haven't been able to find anything as comprehensive as the 1993 study, and I certainly think it should be replicated now that ultrasound imaging has changed. However, I don't see why the burden of proof is on me considering that most medical recommendations have been to avoid routine ultrasounds, and that includes the 20-week scan considering it's offered to all women regardless of risk status in most countries.

"There is high-level evidence that routine, rather than selective, ultrasound in early pregnancy before 24 weeks enables better gestational age assessment, earlier detection of multiple pregnancies and improved detection of fetal anomalies with resulting higher rate of termination of affected pregnancies. There is no good-quality evidence on long-term outcomes for women and their children."

The thing is, I agree with those statements based on everything I've read, but they aren't talking about outcome (which apparently nobody has looked at since 1993)? Improved detection of fetal anomalies is obvious, and for people who would terminate for certain things, it could be vital information. Like you've quoted, ultrasounds are useful for terminations. The scenarios you are giving below that are extremely rare so I wouldn't make a decision based on hyperbolic examples. The 1993 study didn't look at detection of fetal anomalies, it looked at outcome, and since neither of us could find anything more recent about mid-pregnancy routine ultrasounds improving outcomes for low-risk women, then I guess we will have to wait for more research that replicates what the 1993 study did.

Ultrasounds also give TONS of false positives that end of stressing women out. (E.g. oh, your baby might have a kidney problem that we wouldn't be able to address in utero anyway. Let's do more scans every few weeks just to monitor it. Oh, turns out it's nothing.) I've seen those sorts of scenarios happen far, far more often than situations where care would change as the result of a diagnosis (like the hyperbolic ones you're talking about). So I still think it's best to avoid routine ultrasounds without any medical indication. And where there is a medical indication, I TOTALLY support getting a scan, because that's where outcomes have been shown to be altered.

 

[SarahBear]

Ahhhh. My MW just called (8 PM at night) and said that although they told her when they called her after my ultrasound they said everything was good, but on the report she got today it said the baby's bladder was distended (I do remember her mentioning during the ultrasound that his bladder was full the whole time, which was like 45 min) so she wants me to come in tomorrow for ANOTHER scan. I'm so stressed about this. I don't want another scan, but of course if there is a problem, I don't want to ignore it. I'm 39 weeks 1 day, so I'm praying maybe he will come tonight and solve the problem for me. I just don't know what to do.

Make sure to ask lots of questions before agreeing. What would they look for on another ultrasound? What would they do with their findings? Is there a difference in outcome if you wait until birth to address it? What likely would have happened if it hadn't been caught on the last ultrasound? Sometimes when you start asking questions that don't assume that the doctor's recommendation is the best or only option, you find that there are in fact other viable options. Sometimes not, but it's worth asking tons of questions in order to be sure. Hope I made sense; I'm writing from my phone.