VAIL, COLO. -- The "limited" ultrasound examination as defined by the American College of Obstetricians and Gynecologists presents a legal minefield for obstetricians at a time when litigation involving ultrasound is increasingly common, Dr. Richard L. Berkowitz said during a conference on obstetrics and gynecology sponsored by the University of Colorado.
"ACOG is our union, our club. ACOG is out there trying to help us, trying to help people who take care of pregnant women from getting creamed in court. But I think this document, which was designed to help us, is in fact incredibly counterproductive," said Dr. Berkowitz, who is professor and chairman of ob.gyn. at Mount Sinai School of Medicine, New York.
That's because performing a limited ultrasound exam as described in ACOG Technical Bulletin No. 187 can place a physician at odds with the 1990 American Institute of Ultrasound in Medicine--American College of Radiology guidelines for performance of the antepartum obstetrical ultrasound examination. And it is clearly this AIUM-ACR document, not the bulletin, that is viewed by the courts as the standard of care, he said.
"When you go to court, the plaintiff's lawyer is going to be holding up that AIUM-ACR document and saying it's the standard of care for a radiologist who does an ultrasound exam. He'll ask, 'Do you as an obstetrician really believe that you can use the same equipment on the same type of patient and have a completely different standard?'
"And the answer is no," Dr. Berkowitz said.
ACOG distinguishes between the limited ultrasound exam and the basic exam, which provides information about placental location, amniotic fluid volume, gestational age, a survey of fetal anatomy and maternal pelvic organs, and other features.
A limited examination is "appropriate and desirable," according to ACOG, in the assessment of amniotic fluid volume, fetal biophysical profile testing, ultrasound-guided amniocentesis, external cephalic version, confirmation of fetal presentation, location of the placenta in antepartum hemorrhage, and confirmation of fetal life or death.
In contrast, the AIUM-ACR guidelines state that a limited exam is acceptable only in clinical emergencies or as a follow-up to a complete basic ultrasound exam.
So a stand-alone limited exam would be perfectly appropriate under AIUM-ACR guidelines to confirm fetal life or death when an obstetrician is considering doing a crash Cesarean section or to localize the placenta in a case of antepartum hemorrhage, because these are emergencies.
But under the AIUM-ACR guidelines, a physician scanning a patient for any reason in a nonemergent situation--to assess amniotic fluid volume, for example, or to perform fetal biophysical profiling--needs to obtain and properly document all the information that's part of the basic ultrasound exam, unless that's been done previously.
That's how to stay out of medicolegal trouble with ultrasound, he stated at the meeting.
"There's a guy at our hospital who did an amniocentesis at his office in which he used ultrasound only to see where to put the needle. He got back a normal karyotype and later delivered a baby that had holoprosencephaly [absence of a midline structure in the brain that's evident starting in the first trimester]. I think the settlement was $2.5 million," Dr. Berkowitz recalled.
Misconceptions abound regarding the AIUM-ACR guidelines' call for a fetal anatomic survey as part of a basic exam in the second or third trimester.
Here, physicians aren't being asked to diagnose any particular anatomic defect. They're just being asked to look at the various organs and see whether they look all right.
"If you do that, you will pick up lots and lots of cases where things aren't right. And you then can refer that patient for a targeted or a level 2 exam," the ob.gyn. explained.
Adequate documentation of the basic exam includes a written report of the findings to be included in the medical record, regardless of whether the scan was done in the office, on the delivery floor, or in the ER.
It should include key biometric measurements and anatomic findings, along with pictures of any abnormalities detected during the exam, according to Dr. Berkowitz.
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