Organ-specific learning curves of sonographers performing first-trimester anatomical screening and impact of score-based evaluation on ultrasound image quality

Abstract

Introduction First-trimester anatomical screening (FTAS) by ultrasound has been introduced in many countries as screening for aneuploidies, but also as early screening for fetal structural abnormalities. While a lot of emphasis has been put on the detection rates of FTAS, little is known about the performance of quality control programs and the sonographers’ learning curve for FTAS. The aims of the study were to evaluate the performance of a score-based quality control system for the FTAS and to assess the learning curves of sonographers by evaluating the images of the anatomical planes that were part of the FTAS protocol. Methods Between 2012–2015, pregnant women opting for the combined test in the North-Netherlands were also invited to participate in a prospective cohort study extending the ultrasound investigation to include a first-trimester ultrasound performed according to a protocol. All anatomical planes included in the protocol were documented by pictures stored for each examination in logbooks. The logbooks of six sonographers were independently assessed by two fetal medicine experts. For each sonographer, logbooks of examination 25-50-75 and 100 plus four additional randomly selected logbooks were scored for correct visualization of 12 organ-system planes. A plane specific score of at least 70% was considered sufficient. The intra-class correlation coefficient (ICC), was used to measure inter-assessor agreement for the cut-off scores. Organ-specific learning curves were defined by single-cumulative sum (CUSUM) analysis. Results Sixty-four logbooks were assessed. Mean duration of the scan was 22 ± 6 minutes and mean gestational age was 12+6 weeks. In total 57% of the logbooks graded as sufficient. Most sufficient scores were obtained for the fetal skull (88%) and brain (70%), while the lowest scores were for the face (29%) and spine (38%). Five sonographers showed a learning curve for the skull and the stomach, four for the brain and limbs, three for the bladder and kidneys, two for the diaphragm and abdominal wall and one for the heart and spine and none for the face and neck. Conclusion Learning curves for FTAS differ per organ system and per sonographer. Although score-based evaluation can validly assess image quality, more dynamic approaches may better reflect clinical performance.

A Learning Curve for First-Trimester Anatomy Ultrasound in Obese Patients

“…Abu-Rustum et al [5] focused on cardiac imaging, finding that 75 scans were needed in patients with BMI 17.7-32.3 kg/m 2 . Their study required many more cardiac views for a complete scan, which may account for their longer learning curve compared to this report [4,5]. Sripilai-pong et al [7] published a learning curve with median BMI 31.3 ± 4.9 kg/m 2 for one operator and BMI 31.7 ± 5.6 kg/m 2 for a second operator.…”

“…Bardi et al [4] investigated the learning curve of firsttrimester anatomy ultrasound in a population with BMI 24.8 kg/m 2 ± 3.7. Their learning curve was longer than this one, which may reflect the exclusive use of high-end ultrasound equipment in the parent trial (only 40% of scans in Bardi et al [4] used high-end equipment, which facilitates the first-trimester exam). Abu-Rustum et al [5] focused on cardiac imaging, finding that 75 scans were needed in patients with BMI 17.7-32.3 kg/m 2 .…”

“…A learning curve of 50-100 scans has been previously published for first-trimester ultrasounds, with some organ systems requiring up to 200 scans and improvement continuing for years into practice [3][4][5][6]. However, the body mass index (BMI) of patients in these studies is either not reported [3] or is relatively lean [4,5]. The learning curve in obese women is unclear.…”

First‐trimester screening strategies: A balance between costs, efficiency and diagnostic yield

“…Importantly, due to the strong association between fetal defects and major chromosomal abnormalities, it is recommended to perform invasive testing when a structural anomaly is diagnosed 39 . Thus, a detailed anatomical examination in the late first trimester has the potential to further increase the detection rates of chromosomal abnormalities, including some that are not detectable by NIPT alone 40,41 …”

“…39 Thus, a detailed anatomical examination in the late first trimester has the potential to further increase the detection rates of chromosomal abnormalities, including some that are not detectable by NIPT alone. 40,41…”