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Ultrasounds – Risks, Benefits, and Ethical Considerations

Submitted by Sally Dear-Healey, PhD, PPNE, CCE(BWI), Doula(BWI)

Years ago, X-ray was the diagnostic procedure of choice in pregnancy but today we understand more about the harmful effects of radiation so ultrasound is used as a safer alternative.  What we do know today is that every medical procedure has inherent risks known and unknown.  Therefore it is not wise to perform any procedure except if the known risks are higher than the risks of not doing anything.  However, instead of progressing cautiously and limiting exposure, more and more doctors/OB practices order repeated ultrasound scans for most of their patients/clients.

Ultrasounds are a form of electronic fetal monitoring that have become a normalized part of mainstream obstetric practice.  In fact, practically every pregnant woman in the U. S. will have at least one ultrasound scan during her pregnancy and most will have electronic fetal monitoring during their labor and delivery.  These women tend to be influenced by popular magazines, social media,  internet medical media, mainstream pregnancy books, news articles, and oftentimes friends and family members that purport that ultrasounds are necessary to ensure the safety and healthy development and birth of their baby. This article reviews a sampling of the issues, concerns, and benefits related to ultrasounds.

There are multiple issues and problems associated with the routine use of ultrasounds in pregnancy:

  • Most women today don’t question the procedure or educate themselves on its risks and benefits. Even if they have, few feel they have the right or ability to refuse the test(s).
  • Doctors may not have the time or knowledge to educate their patients about the risks and benefits of the procedure.  However, all women have a right to informed consent and should be encouraged to ask any questions they may have.
  • The number of scans is an issue. Instead of one ultrasound, many women have multiple ultrasounds over the course of their pregnancy in addition to “routine” scanning during labor and delivery (Electronic Fetal Monitoring and Dopplers are forms of ultrasound).
  • The integrity of the scanning machine, the length of the scan time, as well as interpretations of the results can be problematic.
  • “Gender reveal” parties based on the result of these scans are becoming more common and some parents have even purchased their own ultrasound machines so they can track the development of their unborn baby.
  • The financial cost of these scans is a significant concern for individuals and for the health care industry overall.  The average cost of an ultrasound in the U.S. is $250 – $300 without insurance.

Thirty years ago, there were concerns about ultrasound based on animal research, as in 1984, Doris Haire’s article in the Journal of Nurse-Midwifery titled “Fetal effects of ultrasound: A growing controversy,” which cited Dr. Melvin E. Stratmeyer, of the Center for Devices and Radiologic Health (CDRH), as saying “Increasing concern has arisen regarding the fetal safety of widely used diagnostic ultrasound in obstetrics,”  but to this day concerns about such things as neuromuscular development, anomalies, and genetic alterations have not been substantiated on animals or humans. In 1985, ACOG (The American College of Obstetrics and Gynecology) issued a technical bulletin that stated, “No well-controlled study has yet proved that routine scanning of all prenatal patients will improve the outcome of pregnancy.”

As a long-time birth worker, and having taught classes in human development and child and family studies for over two decades, I share their collective concerns and argue that, even though it has been thirty-five years since Haire’s article came out, we have yet to fully understand or appreciate the long-term impacts of prenatal ultrasound exposure.  Yet, there is research out that can be drawn upon to make an educated decision.

Nyborg (1987) writes, “Alterations to cell membrane structure have been reported by a number of investigators.  Some alterations include increased density of microvilli and ruffles in cell membrane following exposure that may alter growth characteristics” and “The persistence of a hereditable disturbances in cell motility after ultrasound exposure is especially important and investigations need to be conducted to determine if these effects occur in vitro” (256).

Sarah Buckley, MD, is also very clear about ultrasounds, stating that “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. […] Treating the baby as a separate being, ultrasound artificially splits mother from baby well before this is a physiological or psychic reality.  This further…sets the scene for possible but to my mind artificial conflicts of interest between mother and baby in pregnancy birth and parenting” (as quoted in West, 2015).

In 2000, Professor Ruo Feng, of the Institute of Acoustics, Nanjing University, who holds a PhD in physics and has published over 186 scientific papers summarized human studies of prenatal ultrasound and suggested five points of protection.  They are:

  • Ulltrasound should only be used for specific medical indications.
  • Ultrasound, if used, should strictly adhere to the smallest dose principle, that is, the ultrasonic dose should be limited to that which achieves the necessary diagnostic information under the principle of using intensity as small as possible and the irradiation time as short as possible.
  • Commercial or educational fetal ultrasound imaging should be strictly eliminated and ultrasound for the identification of fetal sex and fetal entertainment imaging should be strictly eliminated.
  • Avoid ultrasound in the first trimester of pregnancy. If unavoidable, minimize ultrasound.  Even later, during the 2nd or 3rd trimester, limit ultrasound to 3-5 minutes for sensitive areas, e.g. fetal brain, eyes, spinal cord, heart and other parts,
  • For every physician engaged in clinical ultrasound training, their training should include information on the biological effects of ultrasound and ultrasound diagnostic dose safety knowledge (West, 2015).

In terms of benefits, diagnostic ultrasound may be useful where there is a true medical need, although it is reasonable to conclude from the evidence that many of these conditions auto-correct themselves prior to the birth.  It could also be argued that for the mother who has experienced baby loss, either during a pregnancy or shortly after birth, seeing and hearing her unborn child may help to alleviate stress and anxiety in a subsequent pregnancy, which could also positively influence the well- being of the baby due to decreased cortisol levels.  On the other hand, scanning too much can actually create stress.  Jeffrey Ecker, M.D., chief of the department of obstetrics and gynecology at Massachusetts General Hospital, notes that “It’s important to have a specific question you are trying to address.  If by chance someone thinks they see something off, it can cause unnecessary worry” (Miller, 2016).  According to an article in the Journal of Ultrasound Medicine (2012), Miller et al. report that “Safety information can be scattered, confusing, or subject to commercial conflicts of interest.”

While some of the research presented is dated, it is widely acknowledged that very little has changed, and we still don’t have definitive answers.  If you do decide to have a prenatal ultrasound, it is wise to do the following:

  • Limit the number of scans
  • Have the procedure done by an operator with a high level of skill and competence
  • Have the shortest scan possible.
  • Be clear about what questions you have and be sure to ask them.
  • Most important, remember that it’s your baby and your choice.

 

References

  • American College of Obstetricians and Gynecologists (ACOG). (1985). Diagnostic Ultrasound in Obstetrics and Gynecology.  Technical Bulletin No. 63; October.
  • Haire, D. (1984). Fetal effects of ultrasound: A growing controversy. Journal of Nurse-Midwifery; Vol. 29, No. 4.
  • Mendelsohn, R. Dr. Robert Mendelsohn on Pregnancy and the Dangers of Ultrasound. https://www.youtube.com/watch?time_continue=208&v=YfaUQCp6L1s
  • Miller, D., Smith, N., Baily, M. Czarnota, G., Hynynen, K, Makin, I. (2012). Overview of therapeutic ultrasound applications and safety considerations. Journal of Ultrasound Medicine: 31(4):623-34.
  • Miller, K. (2016). This is How Many Ultrasounds You Actually Need During Pregnancy. Self.com https://www.self.com/story/this-is-how-many-ultrasounds-you-actually-need-during-pregnancy
  • Nyborg, W. L. (1987). Research Priorities in Ultrasound.  In: Repacholi, M.H.. Grandolfo, M., Rindi, A. (Eds.). Ultrasound. Springer: Boston.
  • West, J. (2015).  “50 Human Studies in Utero, Conducted in Modern China Indicate Extreme Risk for Prenatal Ultrasound A New Bibliography.”  Harvoa.org