Am Fam Physician. 2005;72(11):2362-2364
Case Scenario
During a prenatal visit, a woman says: “What do you think about me getting a video of my baby from a three-dimensional ultrasound store at the mall? By the way, they want a note from you saying it is okay for them to perform the scan.” How should the physician approach this request?
Commentary
The quality and detail of ultrasonography has advanced to the point of providing easy-to-interpret, striking fetal images, especially with newer three-dimensional (static) and four-dimensional (real-time three-dimensional) imaging. It is natural for pregnant women and their families to be excited about the unborn baby and to be intensely interested in sharing an ultrasound image. Three-dimensional ultrasound images also may provide an even greater opportunity for positive mother-infant bonding, because they are easier to see and understand than traditional two-dimensional imaging.1
Approximately 10 years ago, nonmedical services began to offer patient-requested ultrasound scans for keepsake photographs and videos. These services are not regulated or standardized. Many require that the woman receive prenatal care and written permission from a physician before the ultrasonography is performed. Controversy exists about the propriety, safety, and legality of these services.
Governmental and professional organizations have weighed in on the issue. The U.S. Food and Drug Administration’s (FDA’s) statement about fetal “keepsake” videos raises concerns about the safety and legality of nonmedical ultrasonography.2 For example, the FDA says that prolonged exposure of the fetus to ultrasound energy “cannot be regarded as completely innocuous,” and “exposing the fetus to ultrasound with no anticipation of medical benefit is not justified.”2 It also concludes that creating fetal keepsake videos from ultrasound images is “an unapproved use of a medical device,” and those who perform ultrasonography scans “without a physician’s order may be in violation of state or local laws or regulations.”2
The American Institute of Ultrasound in Medicine (AIUM) has a “prudent use” statement,3 which is endorsed by the American College of Obstetricians and Gynecologists, that strongly discourages the nonmedical use of ultrasonography. An AIUM patient information sheet stating this position is available online athttp://www.aium.org/patient/entertainment/handout.pdf.
New York state legislators have proposed a ban on ultrasonography for entertainment purposes, citing data showing that four-dimensional ultrasound equipment can emit eight times more energy than the machines commonly used in medical settings.4
Even those who perform nonmedical ultrasound scans routinely offer wide-ranging disclaimers telling women that non-medical ultrasonography should not replace prenatal care from their doctors.
The popularity of keepsake ultrasound scans may represent some degree of failure of traditional medical imaging services. In medical settings, the sonographer is commonly prohibited from explaining the results of the scan to the patient, who must then wait for days or weeks to get the results from the physician who ordered the scan. Family members may be barred from attending the ultrasound appointment to avoid congestion in the radiology department. The patient may or may not receive still pictures or video to take home. Therefore, it is not surprising that patients crave a more open, friendly, and informative experience. Patients’ needs may be better met if physicians who provide prenatal care are trained to perform their own ultrasound scans, allowing them to share the experience with the patient and her family and to teach and answer questions.5
Concerns about nonmedical ultrasonography include: (1) the possibility that non-medical ultrasonography will fail to identify a problem with the baby, falsely reassuring the patient and her family; (2) the possibility that nonmedical ultrasonography will result in a false-positive result, creating unnecessary patient anxiety and follow-up testing; and (3) the significant cost ($75 to $300 per scan), which is not covered by insurance.6
If a patient asks about nonmedical ultrasonography, several counseling points may be helpful. If the woman is adamant about having the scan, the physician should emphasize the importance of using a properly trained sonographer. The best documentation for nonphysician ultrasound training is the American Registry for Diagnostic Medical Sonography (ARDMS) (to verify sonographer credentials through the ARDMS, go tohttp://www.ardms.org/statusverification/index.htm).
Although ultrasonography is assumed to be safe, physicians can inform patients that ultrasound scanning applies mechanical energy to the fetus, especially in sophisticated techniques such as color Doppler and three- and four-dimensional scanning.
The physician also can tell the patient that nonmedical scans are expensive and are not covered by health insurance. In addition, some fetal positions, maternal obesity, and later gestational age diminish the detail seen on the scan. If the woman wants the ultrasound scan to make sure the baby is healthy or to know the gender of the baby, medical ultrasonography can meet these needs. Most insurance companies cover one, if not two, routine prenatal medical ultrasound scans.
Physicians who do not perform their own ultrasound scans should choose a sonographer who takes the time to communicate with patients during the scan and who offers images for patients to keep. Thermal prints are an excellent option, and they only cost a few cents each. This may decrease the demand for nonmedical scans.
MARK DEUTCHMAN, M.D., Professor, Department of Family Medicine at the University of Colorado Health Sciences Center, Denver, Colorado