Integrating Early Pregnancy Ultrasound Training into the Medical Home Kara Cadwallader, MD Family Medicine Residency of Idaho Honor MacNaughton, MD Rebecca Simons, MD, MPH Beth Israel Residency in Urban Family Practice, New York

Objectives List indications for and benefits of use of early pregnancy ultrasound in the family medicine setting Describe techniques for teaching and evaluating competency of early pregnancy ultrasound skills Discuss barriers and potential solutions to integrating early pregnancy ultrasound training into a family medicine residency

Background Pregnancy ultrasound is common need in family medicine office, yet few family physicians offer office-based ultrasound Benefits include cost, continuity, access Several studies support accuracy of prenatal ultrasounds provided by family physicians Though the need for early pregnancy ultrasound is common and the procedure is readily performed and taught by family physicians, only 1 in 8 family doctors currently provides the service in the office. Benefits to offering the service within the medical home include improved continuity and increased access to timely and patient-centered care during the management of potentially sensitive problems such as first trimester pregnancy bleeding, early pregnancy loss or unintended pregnancy. References: Dresang LT, Rodney WM, Dees J. Teaching prenatal ultrasound to family medicine residents. Fam Med 2004;36(2):98-107. Dresang LT, Rodney WM, Rodney KM. Prenatal ultrasound: a tale of two cities. J Natl Med Assoc. 2006 Feb;98(2):167-71. Brunader R. Accuracy of prenatal sonography performed by family practice residents. Fam Med 1996;28(6):407-10. Keith R, Frisch L. Fetal biometry: a comparison of family physicians and radiologists. Fam Med 2001;33(2):111-4.

Indications for Ultrasound Establishing gestational age Evaluation of first trimester bleeding or pain Ectopic pregnancy Threatened abortion / early pregnancy failure IUD localization Determining completion of abortion (spontaneous and induced) Evaluation of abortion complications (hemorrhage, pain, fever) What setting do you work in? Experience with US? Do you have an US machine in your office? Any other uses for ultrasound? Photo release obtained for all photos used in presentation

“Limited” Ultrasound What does this mean? Coding and reimbursement Liability When to refer for complete ultrasound “Limited Ultrasound” includes evaluation and documentation only of: -Pregnancy location -Gestational dating -Viability -# gestations -Placental location (in second trimester) Patients need to be informed with verbal or written consent that during a limited ultrasound exam you are evaluating only these parameters and not evaluating for any other pelvic pathology. Suspicion of any abnormalities or evaluation of anything beyond the above, needs referral for complete ultrasound. CPT code: 76815 – limited ultrasound, pregnant uterus, real time with image documentation, transvaginal Lower reimbursement than complete ultrasound, of course

Teaching Techniques Didactics Workshops with paid models Lectures On-line teaching sites CD-ROMs Reading Workshops with paid models Supervised scanning Hand-on-hand Online Teaching Tools: 1) National Abortion Federation: Ultrasound Imaging in Early Pregnancy—CME course: http://www.prochoice.org/education/cme/online_cme/m4ultrasound.asp 2) Goodman, S., M. Wolfe, et al., Eds. (2007). Early Abortion Trainer’s Workbook. San Francisco, CA., UCSF Bixby Center for Reproductive Health Research and Policy. Chapter 3 and Chapter 11. www.teachtraining.org/Workbook.html Reading Materials:  1) Goldstein, S. R., F. R. M. Jacot, et al. (1999). Documenting Pregnancy and Gestational Age. A Clinician's Guide to Medical and Surgical Abortion. M. Paul, E. S. Lichtenberg, L. Borgatta, D. A. Grimes and P. G. Stubblefield. Chapter can be found on-line at : http://www.prochoice.org/education/resources/textbook.html   2) Deutchman, M., M. F. Reeves, et al. (2007). Ultrasound in Abortion Care Workbook, Affiliates Risk Management, Inc. Planned Parenthood Consortium of Abortion Providers.    3) Fleischer, A. (2004). Sonography in Gynecology and Obstetrics. New York, MacGaw Hill.

Teaching Logistics What service will be offered / taught? Limited vs complete ultrasound, anatomic survey, BPP, placental location, fetal presentation? Where / when in residency curriculum? Taught by whom? Taught to all residents? As with the introduction of any new service, considering and discussing the following logistical issues with key stakeholders beforehand will make implementation run more smoothly: 1) What services will be offered and taught? -Limited vs complete ultrasound, anatomic survey, BPP, placental location, fetal presentation? 2) Where / when in residency curriculum? -OB or gyn rotations, procedure clinics, didactic workshop, 3) Taught by whom? FM, radiology, ultrasound tech, OB, MFM Will any or all FM faculty be trained? 4) Taught to all residents? -elective or required training -just those interested in prenatal or abortion care

Evaluating Competency Documented supervised scans How many? Competency checklists Written exams Compare to FM attending, radiology or OB/GYN scans Clinical outcomes: compare to delivery date or Dubowitz scores - In studies of family physician competency with didactics followed by supervised scanning, b/w 20—70 supervised scans. -IUAM, ACOG, & ACR: 1993 recommendation: 200 scans over 3 years (but no competency outcomes to support this recommendation!) Reference: Dresang LT, Rodney WM, Dees J. Teaching prenatal ultrasound to family medicine residents. Fam Med 2004;36(2):98-107.

Competency Checklists TRAINING SKILLS Beginner Competent Comments INTERPERSONAL SKILLS Introduces self to patient and establishes rapport Explains sonogram procedure to client, and routinely asks about LMP, latex allergy, etc. Pays attention to patient comfort Uses appropriate language to discuss ultrasound findings in presence of patient Solicits and answers patient questions appropriately CLINICAL SKILLS Selects and prepares ultrasound probe properly for use Uses keyboard and screen functions properly Keeps uterus in center of screen, zooming as needed Systematically identifies uterus in longitudinal and transverse views, taking appropriate images Systematically scans across pelvis (to help rule out anomalies, masses, twins), requesting help as needed. Measures gestational sac in at least 2 planes Finds and identifies yolk sac Identifies fetal pole and cardiac activity Measures CRL in longest view (without limbs or yolk sac) Assures location of pregnancy is intrauterine Perform post procedural or post medical abortion US to establish no evidence of IUP Ensures transducer(s) cleaned between exams MEDICAL KNOWLEDGE Knows discriminatory levels Able to name key characteristics of pseudo vs. true gestational sac (identify if possible) Accurately calculates GA when only sac seen Accurately calculates GA by CRL Knows when to switch to BPD measurement, and elements of an optimal BPD measurement There are many competency-based evaluation tools that exist. One sample competency checklist: http://www.teachtraining.org/evaluation/ultrasoundeval.doc

Teaching Areas Proper set-up (patient and machine) Consent, communication, patient education Physics and orientation of images Systematic scanning Location of pregnancy Measuring gestational age Determining viability Determining completed abortion

Proper Set-Up Selects and prepares ultrasound probe for use Ensures probe is cleaned before use Uses keyboard and screen functions properly Labels images with name, MRN, date, location

Communication Introduces self, establishes rapport Explains procedure to client, asks about LMP, latex allergy, etc. Pays attention to patient comfort, allows for self-insertion of probe Uses appropriate language to discuss findings with patient How do you discuss ultrasound in the presence of or with patients: -Discuss, in advance, with the patient what they want to know or see (e.g. Multiple gestations, do they want to look at screen in real-time, do they want a copy of pictures) -Discuss, in advance, with the trainee the use of language to describe the ultrasound results (e.g. use of the term “embryo” vs “baby” especially with unintended pregnancy, patient-centered language to describe a non-viable pregnancy) -As with teaching other procedures, discuss in advance how many ultrasounds the trainee has previously done, what they want to focus on with this ultrasound, want they want to do vs. have the trainer do (e.g. discuss results with patient, use ultrasound keyboard, take measurements), develop a signal for when help from the trainer is needed

Physics and Orientation How do you teach trainees orientation? CD-ROM Didactic sessions Real time or patient models Many ways to teach physics and orientation; usually takes learners multiple iterations before they “get it”. Trying explanations using different modalities is particularly helpful for teaching these skills.

Orientation – Longitundinal Abd

Orientation – Transverse Abd

Orientation – Longitundinal Vag

Orientation – Transverse Vag

Systematic Scanning Technique Identifies normal landmarks (bladder, uterus, cervix, endometrial stripe, ovaries, cul-de-sac) Keeps uterus in center of screen, zooming as needed Systematically identifies uterus in longitudinal and transverse views Systematically scans across pelvis (to help rule out anomalies, masses, twins) Captures and prints appropriate images Every scan (limited ultrasound) should include visualization of: -Bladder -Uterus in longitudinal and transverse view -Cervix -Endometrial stripe -Ovaries -Cul-de-sac

Bladder in transvaginal ultrasound should, by convention, always be seen in top left of screen. Uterus to right of bladder

Anteverted uterus and cervical canal in longitudinal view (sometimes called sagittal or papaya view) Fundus to left, cervix to right Endometrial stripe in midline, continues along cervical canal Small sonolucent fluid collection towards fundus

Transverse (or coronal) view of uterus Thick endometrial stripe in center

Identifying all appropriate structures with a systematic scan will help to reduce possibility of mistaking an ectopic pregnancy or other structure for an intrauterine pregnancy. In this picture: Adnexa with ectopic in tube

Bladder, top left Anteverted uterus with thin endometrial stripe, no IUP. Fluid in cul-de-sac (sonolucent collection, layering “behind” uterus on right of screen) Empty uterus with fluid in the cul-de-sac highly suggestive of ectopic pregnancy

Twin gestation: another reason for scanning through entire uterus before honing in on gestational sac.

Location of Pregnancy Knows discriminatory levels Able to name key ultrasound characteristics of pseudosac vs. true gestational sac (FEEDS mnemonic) Captures sac in longitudinal view Scans adnexae for masses and cul-de-sac for fluid To demonstrate competency at documenting intrauterine pregnancy a trainee should: Know discriminatory levels Be Able to name key ultrasound characteristics of pseudosac vs. true gestational sac (FEEDS mnemonic) Capture sac in longitudinal view surrounding by myometrium on all sides– to ensure intrauterine (not ectopic, cornual, bowel, etc) Scan adnexae for masses and cul-de-sac for fluid

FEEDS mnemonic Normal gestational sac is: Fundal Elliptical in 2 planes Eccentric to endometrial stripe Double ring sign - Decidual reaction Size >4mm or grows 1 mm/day Significance of yolk sac Normal gestational sac is: Fundal Elliptical in 2 planes Eccentric to endometrial stripe Double ring sign - Decidual reaction Size >4mm or grows 1 mm/day The presence of the yolk sac is the only thing that can definitively differentiate a true gestational sac from a pseudosac

Case 1 WS is a 32 yo G1P0 who presents with a positive UCG from home. She has no idea when her last period was, maybe 3-5 weeks ago. She isn’t sure what she plans to do. She wants to know how far along she is before discussing options.

Pseudosac vs small gestational sac without yolk sac What would you want trainee to realize here? Use of FEEDS mnemonic

Pseudosac vs early gestational sac Gestational sac should be visible on transvaginal ultrasound when bHCG level reaches ~1500-2000 and on abdominal ultrasound at a bHCG of ~5000. These are known as the discriminatory levels.

Tiny GS, no yolk on transvaginal ultrasound What would you want learner to “realize” in this circumstance?? -normal GS? -feeds pneumonic -need for quants?

Tiny GS, no yolk sac

Case 2 FY is a 37 year old woman who presents to the office with lower abdominal pain, worsening over several days. Her pregnancy test is positive, and she explains that she has missed some birth control pills in the last couple of packs. The pain is fairly severe when you examine her, more on the right than left. She has no fever, no vaginal discharge, no urinary symptoms.

Ruptured ectopic, free fluid

Adnexa -Ectopic in tube

Determining Gestational Age Measures mean sac diameter in 3 planes Finds and identifies yolk sac Accurately calculates GA when only gestational sac (+/- yolk sac) seen Identifies fetal pole and cardiac activity Measures CRL in longest view (without limbs or yolk sac) Accurately calculates GA by CRL Knows when to switch to BPD measurement, and elements of an optimal BPD measurement Measures mean sac diameter in 3 planes Finds and identifies yolk sac Accurately calculates GA when only gestational sac (+/- yolk sac) seen Identifies fetal pole and cardiac activity Measures CRL in longest view (without limbs or yolk sac) Accurately calculates GA by CRL Knows when to switch to BPD measurement, and elements of an optimal BPD measurement

Case 3 PM is a 20 yo G6P2 who presents to the office with an LMP of about 5-6 weeks. She would like to know her due date.

Gestational sac with yolk sac, no embryo To date pregnancy need to measure gestational sac (without yolk sac) in three dimensions (in two planes).

Gestational sac with yolk sac, no embryo First measurement

Gestational sac with yolk sac, no embryo Second and third measurements, in a different plane Gestational age in days= 30 + mean gestational sac diameter ((H+W+L)/3)

Case 4 KO is a 41 yo G3P2. She thinks she has missed 2 periods. She is wants to know she can have a medication abortion.

Gestational sac, yolk sac, embryonic fetal pole Crown rump length (CRL) = longest axis of embryonic pole, measured without including yolk sac or limb buds Once embryonic pole is visible, the CRL is the most accurate measurement of gestational age Gestational age in days = 42 + CRL Many ultrasound machines are programmed to automatically calculate gestational age using the Hadlock formula which may provide slightly different dates than the above formula. It is important to use consistent dating calculations throughout your department and other departments (e.g. OB, radiology) when dating for prenatal care to avoid conflicting measurements.

Gestational sac, yolk sac, embryonic fetal pole Crown rump length (CRL) = longest axis of embryonic pole, measured without including yolk sac or limb buds Once embryonic pole is visible, the CRL is the most accurate measurement of gestational age Gestational age in days = 42 + CRL

The most accurate time for a dating ultrasound to establish EDC for prenatal care is ~8-9 weeks LMP. Gestational sac, yolk sac, embryonic fetal pole Crown rump length (CRL) = longest axis of embryonic pole, measured without including yolk sac or limb buds Once embryonic pole is visible, the CRL becomes the most accurate measurement of gestational age Gestational age in days = 42 + CRL

Case 5 SR is a 17 year old who has irregular periods, with an LMP ~3 months ago. She has had some spotting and nausea.

Later in the 1st trimester and in the 2nd trimester an abdominal ultrasound may be easier to capture appropriate images.

BPD (biparietal diameter) becomes more accurate than CRL for gestational dating at ~12 weeks.

Determining Viability Knows red flags for early pregnancy failure No yolk sac by 13mm gestational sac (43 days) No cardiac activity by 5mm CRL (47 days) No embryonic pole by 49 days No change in ultrasound over 1-2 weeks Identifies fetal cardiac activity

Case 6 TR is a 29 yo G4P1 with an LMP of about 6 weeks. She has had a bit of spotting over the last several days, no significant cramping.

Large gestational sac (48mm), no yolk, no CRL with some debris in the sac No yolk sac by 13mm gestational sac (43 days) is red flag for non-viable pregnancy Consistent with anembryonic pregnancy

Large GS 33mm MSD and yolk sac, giving gestational age of 75 days, but no embryonic pole No embryonic pole by 49 days is red flag for non-viable pregnancy Again, consistent with anembryonic gestation

Fetal cardiac activity should be present when CRL reaches 5-7mm (47-49 days). Absence of FH (fetal heartbeat) in above sonogram would be consistent with early pregnancy failure.

Documenting Completed Abortion Establishes that there is no evidence of pregnancy following induced or spontaneous abortion Describes expected sonographic findings associated with post-abortion complications

Case 7 KS is a 30 yo woman one week s/p medication abortion with mifepristone and misoprostol at 8 weeks 4 days gestation. She had heavy bleeding and cramping for several hours after using the misoprostol and is now using two pads /day. She reports resolution of pregnancy symptoms, is having minimal cramping and no fever.

Post medication abortion, uterus in longitudinal view, retroverted uterus (fundus to right, cervix to left) Post completed abortion (induced or spontaneous) you should see absence of the gestational sac and either: Heterogeneous echogenic debris Thickened endometrial stripe Thin edometrial stipe -thickened stripe is not pathologic! -”treat the patient not the sono”

Transverse view of uterus with thickened endometrial stripe

Case 8 JL is a 40 year old healthy woman who presents to the office because she cannot feel her Paragard IUD strings. No IUD strings are visible on speculum exam.

Paragard IUD properly positioned at uterine fundus Paragard on sono—easy to see Mirena on sono—not so easy to see

Paragard IUD in transverse view

Barriers to Implementation? Barriers to implementation vary depending on setting, but may include: Cost of ultrasound Training faculty Turf conflict with other specialties (OB/GYN, radiology) Space in curriculum Liability Credentialing Cleaning equipment

Resources Competency Checklists Ultrasound Written Quiz Online Teaching Tools Documentation of Ultrasound Form Policy and Procedure for Cleaning Ultrasound Probe Cleaning Vaginal Probe Poster Resource List   Implementing a Basic Course in Early Obstetrical Ultrasound in the Family Medicine Residency Program STFM National Conference: May 1, 2008 E. Figueroa MD, E. Godfrey MD, MPH, J. Banks MD, S. Goodman MD, MPH (Revised 2009 by Honor MacNaughton MD, Kara Cadwallader MD, Rebecca Simons MD, MPH) Starting up ultrasound services in your primary clinic is feasible, but additional aspects should be considered. These aspects include: Know lay of the land: Find out whom else at your hospital is doing ultrasounds. Inquire about the forms they use to document ultrasound, policies they already have in place. Departmental partnerships: Partner with the departments who are already doing ultrasound and find out what they think of family medicine implementing ultrasound into the clinic. How can the addition of family medicine adding ultrasound to their clinical services add and enhance the services being offered at the hospital? Sometimes a privileging process will be recommended. Developing Volume for training: To ensure an adequate volume for training to competency consider partnering with outpatient radiology, maternal-fetal medicine or a high volume abortion clinic. Workshops with paid models are another option for providing high volume experience in a controlled setting. Supply list: Make a list of supplies that need to be ordered in addition to the ultrasound Probe covers (consider ordering from CIVCO @ www.civco.com) Ultrasound gel Cidex for disinfecting (see below) Ultrasound paper Disinfecting ultrasound probes: Know the OSHA rules or other standards you must abide by when disinfecting ultrasound probes. Be aware that some hospitals have been very strict with this requiring 30 minute soaks between patients. Rules may differ at your institution. Sample poster with protocol: http://www.teachtraining.org/officepractice/VaginalProbePoster.doc Documentation: Have a system in place as to how ultrasounds will be documented in the clinic and filed in the record. Sample form: http://www.reproductiveaccess.org/mva/ultrasound_form.htm Training Courses: Be prepared to attend one or several training courses and work closely with a willing preceptor in your area prior to initiating ultrasound services. Have a plan in place to train other faculty so that residents have adequate supervision. See attached list. Protocol for Clinical Setting: Create a protocol for the clinic, i.e. applying for privileging, indications for contacting a privileged attending, ultrasound use and care, etc. Resident Supervision: Create a description of teaching opportunities for resident in the primary care clinic. Make the parameters for teaching clear. Provide the resident and other teaching faculty with a proficiency checklist. Sample competency checklist: http://www.teachtraining.org/evaluation/ultrasoundeval.doc Quality Assurance: Consider partnering with perinatal ultrasonographers to implement a QA program. One program could entail the tracking of ultrasounds done for dating in the family medicine center with ultrasounds that are done later in pregnancy. Do the dates compare? Another idea could include a second reader in perinatalogy or radiology every quarter or so. Coding: There are many codes that can be used in the clinic. Google “ACR obstetrical ultrasound coding and the Radiology Report” for a good overview of CPT codes. Most frequently used codes: ICD: V22.2 – pregnancy uncertain dating CPT: 76817 – ultrasound pregnant uterus, real time with image documentation, transvaginal CPT: 76816 – ultrasound, pregnant uterus, real time with image documentation, transabdominal, limited follow-up CPT: 76815 – limited ultrasound, pregnant uterus, real time with image documentation, transvaginal On-Line Resources: American Institute of Ultrasound in Medicine: www. aium.org, 800-638-5352 Excellent resource for CME courses, practice guidelines (see Female Pelvis or Obstetric) Radiologic Society of North America (RSNA): www.rsna.org, 800-272-2920 Good resource to find additional educational materials for ultrasound training Reading Materials: Goldstein, S. R., F. R. M. Jacot, et al. (1999). Documenting Pregnancy and Gestational Age. A Clinician's Guide to Medical and Surgical Abortion. M. Paul, E. S. Lichtenberg, L. Borgatta, D. A. Grimes and P. G. Stubblefield. Chapter can be found on-line at : http://www.prochoice.org/education/resources/textbook.html Deutchman, M., M. F. Reeves, et al. (2007). Ultrasound in Abortion Care Workbook, Affiliates Risk Management, Inc. Planned Parenthood Consortium of Abortion Providers. Goodman, S., M. Wolfe, et al., Eds. (2007). Early Abortion Trainer’s Workbook. San Francisco, CA., UCSF Bixby Center for Reproductive Health Research and Policy. Chapter 3 and Chapter 11. www.teachtraining.org/Workbook.html Fleischer, A. (2004). Sonography in Gynecology and Obstetrics. New York, MacGaw Hill. Ultrasonography in Obstetrics and Gynecology, 4th Ed. Callen, P.W. editor. W.B.Saunders Co., 2000 On-Line Educational Materials: National Abortion Federation: Ultrasound Imaging in Early Pregnancy—CME course: http://www.prochoice.org/education/cme/online_cme/m4ultrasound.asp Ultrasound Courses: University of Illinois at Chicago, Department of Family Medicine. Introduction to Obstetrical Ultrasound for Primary Care. 3-hour evening course available several times per year. Course Instructor: Dr. Evelyn Figueroa, efigueroa914@yahoo.com University of Wisconsin at Madison, Department of Family Medicine. Prenatal Ultrasonography: A workshop for physicians, nurse practitioners and physician assistants. Contact Dr. Anne-Marie Lozeau, alozeau@wisc.edu Institute for Advanced Medical Education. Fetal and Women’s Ultrasound. Two-day conference including practice sessions. www.iame.com Bowman Gray School of Medicine, Center for Medical ultrasound, Wake Forest University, Winston Salem, NC 919-748-4505 or 800-277-7654 Thomas Jefferson University Hospital, Division of Diagnostic Ultrasound, Philadelphia, PA 215-955-8533. National Procedures Institute. They offer obstetrical ultrasound training every once and a while. www.NPInstitute.com References: Dresang LT, Rodney WM, Dees J. Teaching prenatal ultrasound to family medicine residents. Fam Med 2004;36(2):98-107. Dresang LT, Rodney WM, Rodney KM. Prenatal ultrasound: a tale of two cities. J Natl Med Assoc 2006 Feb;98(2):167-71. Brunader R. Accuracy of prenatal sonography performed by family practice residents. Fam Med 1996;28(6):407-10. Keith R, Frisch L. Fetal biometry: a comparison of family physicians and radiologists. Fam Med 2001;33(2):111-4. AAFP Position Paper on FM Provision of diagnostic OB/GYN ultrasound: http://www.aafp.org/online/en/home/policy/policies/u/ultrasonography.html

Wrap Up Questions? Feeback? Thank You!