ultrasounds: potential harm vs. potential benefits

[saritajoy]

So... I have been debating whether to post this or not... but have decided to do so since I think it is interesting and important for every pregnant mama to consider. The last thing I want to come across as is preachy, and hope that no one will interpret this as anything but sharing of my own experience and genuine concern over something that rarely questioned in prenatal care. I also don't want to inspire fear in anyone, just to encourage caution.

I have the strong opinion that ultrasounds are extremely over-used in pre-natal care. With my first pregnancy I was set against any ultrasounds, but my midwife did recommend getting one at about 20 weeks to confirm healthy baby, placenta and uterus, which we did and were happy with. Of course the lovely side-benefit being that the gender can usually be determined by that time which we opted to find out. We were planning to do the same with this pregnancy.

Due to bleeding I had last Monday, I made an appointment for Monday (4 April) for an ultrasound.  (On Monday the 28th I went to the hospital where I was given a super quick ultrasound to check and the baby was there and moving!  Thank God!!!  The diagnosis given for the bleeding was placental detachment.)  The ultrasound this coming Monday is a change of plans from 20 weeks to 12 weeks... I talked to my midwife about it extensively today and again, I am so reassured that she is right in line with dp and my perspectives and she is exactly the right fit for my prenatal care and labor and birth experience.  I have to say that I am also very flattered; my midwife said that I am probably the most informed woman she has ever had in her care... much of that I believe is due to my training as a doula!

 

I truly hope that each of you feel as blessed and happy with your choice of prenatal care as I do.

My midwife asked me why we wanted an ultrasound and I said to check the placenta... and yes, to just be reassured by getting another glimpse of the baby and know that he or she is fine. We talked about potential effects on the baby. She said that studies have not been conclusive, but we do know that ultrasounds are irritating to the baby and may have negative neurological effects. Her response to my reasoning for scheduling the ultrasound for Monday was that I have thought about the potential harm vs. potential benefits and that is important. She feels it would be good to verify what the hospital doctors told me about the placental detachment. Specifically she trusts the private doctor who will do the ultrasound (and supports the midwifery model) whereas she said she cannot rely on what the public hospital doctors diagnosed and said; there are simply too many people who handled my case and thereby too much margin for error. My midwife also noted that unlike many more hippy-type midwives, she does believe in ultrasounds to help with the treatment of pregnant women when it is medically warranted and/or to know ahead of time if there is any abnormality with the baby, placenta or uterus. She also mentioned that the doctor might be able to also do a scan with a fetal monitor and with that detect any uterine contractions. If we find them, then it will be a good indication to continue with medication to relax the uterus and try to prevent the contractions.

I would never want to tell any of you what to do with your own prenatal care, but I can say that my personal skepticism of ultrasounds came from my extensive reading and training to be a doula. I would recommend that you read this article to learn more about potential risks of ultrasounds (but take it with "a grain of salt"): http://www.unhinderedliving.com/pultra.html Also if you want to read further you may want to start with books by Henci Goer (recommended on the above web link).  I own "The Thinking Woman's Guide to a Better Birth" and found it enlightening with a lot of other solid research about common interventions during labor and delivery.

[JJ'sMom]

I think the same way as you.

I have one ultrasound at about 20 weeks to check the location of the placenta as the midwives require that for a safe home birth. I also decline the doppler heartbeat every appointment as just have them use a fetoscope after 20 weeks. It has worked for us well. 

(Okay, I do allow one doppler heartbeat to confirm pregnancy at about 12 weeks.....)

Good links and information.

Julia

[~pi]

Nice post.

Thank you for taking the time to share this info.

I definitely agree that the risks and benefits of any procedure need to be considered. I suspect most of us who have already had an u/s have underlying risk factors that make the benefits outweigh any risks, but I agree that it's an important consideration to keep in mind going forward.

I know that when I was pregnant with DS and had u/s regularly, especially at the end of the pregnancy, it was very clear that he didn't like them. He always tried to move as far away from the source as possible, and got very agitated.

[emmaegbert]

my midwife for #2 (who had been doing homebirths for 19 years and was extremely experienced!) said, basically (I'm paraphrasing here): "an ultrasound can find something important, an ultrasound can miss something important, and an ultrasound can 'find' something that isn't there at all." Potential risks of the ultrasound itself aside, I think that third piece is a risk of its own (and IIRC that is Henci Goer's point about some of the testing too)- I've seen that in various IRL friends of mine- lots and lots of worry, and sometimes further interventions (themselves not without risk) that turned out to be for naught. I also know (IRL) major things that were not identified by U/S. That same MW was comfortable with me having u/s if I really wanted it, and certainly if there was any indication of a problem or concern. But her approach was so different than the mainstream, and yes, I do wonder why so many routine U/S are done. Back when my mom was pregnant with my sister, and they were very new, her OB (who was an old guy) said, "since we have the machine, we use it" but he sort of laughed about it and said that for most of his career they did fine delivering babies without it. 

[DomerJen]

Originally Posted by emmaegbert 

I do wonder why so many routine U/S are done.

For "routine" u/s, doctors can bill for it, insurance will pay for it, and the patient doesn't see it come out of pocket directly, so the "costs" are invisible to the individual policy holder.

I'm pro-u/s for the 20w scan (esp for myself, as it gives me the reassurance that there is a healthy baby and placenta placement for a HB), and for the NT scan if you are willing to continue w/ testing if warranted, but "dating" u/s* in the beginning and especially "weight checks" in late pg are a waste of $$.

* Full disclosure, my HMO did a dating u/s for us at 8w this time as a standard procedure and I did not say no. ;)

[nicolian]

Originally Posted by DomerJen 

For "routine" u/s, doctors can bill for it, insurance will pay for it, and the patient doesn't see it come out of pocket directly, so the "costs" are invisible to the individual policy holder.

I'm pro-u/s for the 20w scan (esp for myself, as it gives me the reassurance that there is a healthy baby and placenta placement for a HB), and for the NT scan if you are willing to continue w/ testing if warranted, but "dating" u/s* in the beginning and especially "weight checks" in late pg are a waste of $$.

* Full disclosure, my HMO did a dating u/s for us at 8w this time as a standard procedure and I did not say no. ;)

I remember with DS1 I had a late u/s and was told he was 'approximately 7 pounds, give or take 5 pounds.' Um.
 

[lilacvioletiris]

I hadn't thought that an ultrasound would irritate the growing baby but it makes sense.  I am off the mind to just have the 20 week ultrasound mainly because I don't want to pad a doctor's pockets for a likely unnecessary test.  I would like to know the gender of my baby if possible and I am leaning toward a homebirth if my husband and I can find a provider.

[StephandOwen]

Originally Posted by nicolian 

I remember with DS1 I had a late u/s and was told he was 'approximately 7 pounds, give or take 5 pounds.' Um.
 

That's hilarious! I did not have any ultrasounds after 20 weeks with ds, but by feeling him through the belly everyone (midwife, doctor, nurses, etc) were all guessing he'd be around 6-7 pounds. When he was born just a tiny bit shy of 9lbs they were all shocked

[brennan]

I really do agree that they are over used.  However, I will never not get one, in fact I will always have 2.  I lost a previous pg in the 2nd trimester to something that could have been detected at 12 weeks (an EXTREMELY rare deformity).  And while I wouldn't have terminated I would have liked to have known and be prepared for the loss (I was 21, it was my first pg, I thought I was invincible).  Plus I am now hyper paranoid and I feel that I need to see the baby at 12 weeks to know that everything is okay.  We keep them short and not for entertainment, but its something that I feel that I need.  We don't do any other u/s (we also do the 18-20 week, but other than that none) and don't do any for entertainment purposes and don't find out the sex.  

[akind1]

With DS, I saw hospital CNMs. I had a u/s at 12 weeks because the midwife thought my uterus felt a little large for dates, one at 22 weeks for anatomy, etc. At that u/s we could get neither a good picture of his face or heart due to his position, so it was repeated at 28 weeks.  I went over my "due date" and so to check on him I had two BPPs  - I felt that these were necessary to make sure he was still good in there so everyone - me included - was comfortable allowing him more time to come.

I switched practices after his birth - which ended up being a c-section after a failed induction at 41+6 - because immediately after his birth the CNMs felt I wouldn't be a good VBAC canidate because I didn't go into labor on my own with DS within their timeframe. The new practice is all OB's and they do a routine ultrasound at the first visit. DH and I rolled our eyes, but allowed it, and I am glad we did. by that u/s dates, they measured me a week behind where I knew I was - I am happy to have a little extra cushion in the timing for this baby to arrive. We will do the 20 week scan because placental placement is a concern of mine, and yes, we do want to know the sex. Beyond that, I don't really see the necessity. I do think it is overused and also kind of scary they are using the same technology for non-invasive liposuction and are also doing tests regarding its use in male sterilization.

at any rate: OP thanks for the info,  more information is a good thing.

[emmaegbert]

well, of course in the end I also have to trust my midwives to advise me on all this- and we all end up in that situation, where at some moment we just have to either accept or reject the recommendations of our care providers. What I found when I had #2 (planned HB, vs #1 planned birth center birth w/ midwives) was that the HBMW really discussed the risks and benefits and reasons for various tests, and she really asked ME to take responsibility for making the choices about what to do (she would advise, but not tell me what to do), while IME the more mainstream practices just said, "now its time for ABC" and you can always ask why, and you can decline them, but its not usually presented as a choice.

I am not sure yet if I'll do a 20w U/S or not. I didn't do an early "dating" U/S this time b/c I don't have health insurance worked out yet- DomerJen I expect you're right that part of it is something docs can bill for that patients don't really perceive as an expense... when I had to consider paying out of pocket for it, a "dating" u/s did seem quite silly- I know when my LMP was, and even though I had them with my previous two pregnancies, its not like I had any more precise prediction of when I would give birth! (38w2d for #1, 40w4d for #2)

Of course the risk/benefit calculation seems quite different if there is any reason to suspect a problem. I had an episode of v heavy bleeding early in my pregnancy w/ #1 and had my first u/s after that. Everything was fine but it was certainly warranted in that case I believe.

[saritajoy]

Beautiful to see all your conscientious and careful thoughts on the subject. 

Our ultrasound was totally normal today!  Went a little long for our preferences; dp reminded the OB that we wanted to keep it short.  The doctor did say that he disagreed with the hospital doctors about the cause of the bleeding I had a week ago.  In his professional opinion there was absolutely no sign of any problem with the placenta, but there was a space in the uterine lining that looked to him like it would be the site of bleeding and said that I might have a little more but shouldn't worry about it. 

Wow... I'm just floored that different doctors can see (or choose to see) what they want to.  Makes me go back to being more trustful of myself and my body and my instincts, really!  I am glad to have had the ultrasound today to rule out any deformities and problems with the placenta though.     

[AlexisT]

I have a little bit of a different perspective, I think, because I didn't have my first in the US. I'm not at all sure the 20wk is about billing. It's the only one the NHS is required to offer. That's a little bit of politics (imagine the outcry if you were never entitled to an ultrasound) but even if it's imperfect, it finds enough problems enough of the time for the benefit to outweigh the risk.

Also, for some of these ultrasounds, they're not done by the OB anyway--they refer you to someone else. An NT scan/1st tri screen, for example, can only be done by a certified center. I checked, and none of the regular OB practices in my area can do one--you need to be referred to either the maternal-fetal specialists or one radiology place.

It's important not to generalize about ultrasounds, too. A dating u/s isn't necessary if you have regular cycles, but may be a good idea for a surprise pregnancy. Early u/s can give invaluable peace of mind to a woman who has had previous losses. A 36 week scan to guess the weight isn't very useful, but serial ultrasounds to track growth in a woman at risk for IUGR are much more useful (a pattern over time is more significant than a single estimate, which has significant room for error).

My OB didn't tell me which tests to do--the nurse sat down at my intake appointment and gave me a list of the things they offered, with information on each. I don't know how they'd react to a normal, low risk woman refusing everything (I know how they'd react to me doing that, but I'm a bad example in this case) but I certainly wasn't pushed to do the NT scan or quad screen.

I'm coming at this from the other end. I had a bunch of u/s initially because this pregnancy was from fertility treatment following miscarriage, and will get more because I have high blood pressure (I'm also very difficult to palpate). I had multiple growth scans with my first. It's important to remember that for those of us at risk for problems, ultrasound is an important and useful tool.

[saritajoy]

Originally Posted by AlexisT 
It's important to remember that for those of us at risk for problems, ultrasound is an important and useful tool.

Absolutely!  I hope it never sounded like I was suggesting anything to the contrary.  I was pointing out that for low-risk pregnancies it may be a good idea to minimize ultrasound use.  I know that the standard practice here in Costa Rica is to do an ultrasound each month... and while they measure the baby, in my opinion it is more gratuitous just to see the baby and it would be so much better to just do 1 or 2 strategic ultrasounds instead.