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1042 PART IV Obstetric and Fetal Sonographycredentialing in NT do not demonstrate compliance with therecommended use of the TI in monitoring acoustic output. 177An easy way to reduce exposure is to reduce the TI and MI,using the appropriate controls, and/or reduce the dwell time.he 1999 statement of the British Medical Ultrasound Society,reconirmed in 2009, declares 178 :For equipment for which the safety indices are displayedover their full range of values, the TI should always be lessthan 0.5 and the MI should always be less than 0.3. Whenthe safety indices are not displayed, T max should be less than1°C and MI max should be less than 0.3. Frequent exposureof the same subject is to be avoided.he British Medical Ultrasound Society has strict recommendationsfor maximum allowed exposure time (T max ), dependingon the TI (Table 29.1).Miller and Ziskin 57 demonstrated a logarithmic relationshipbetween exposure duration and temperature elevation in producingharmful bioefects in animal fetuses. For temperatures below43°C, the exposure time necessary for every 1°C increase intemperature was decreased by a factor of 4. Using a maximum“safe” exposure time of 4 minutes for a temperature elevationof 4°C, based on these calculations, the following maximalexposure times are allowable with no apparent obvious risks:128 minutes at 1°C, 64 at 2°C, 16 at 3°C, and only 4 minutes at4°C. Precautions are, naturally, of particular importance in earlygestation 179,180 and for Doppler exposure. 181General recommendations from major professional organizationsfollow. It is strongly recommended to consult various safetystatements published on these organizations’ websites. 182-1921. A diagnostic ultrasound exposure that produces a maximumin situ temperature rise of no more than 1.5°C abovenormal physiologic levels (37°C) may be used clinicallywithout reservation on thermal grounds. 1932. A diagnostic ultrasound exposure that elevates embryonicand fetal in situ temperature above 41°C (4°C above normaltemperature) for 5 minutes or more should be consideredpotentially hazardous. 193,194 In this regard, maternal temperatureelevation (e.g., from viral disease) should be consideredbecause body temperature of the fetus will also beincreased above normal. 48TABLE 29.1 Duration of ObstetricUltrasound as a Function ofThermal IndexThermal Index (TI)Recommended Upper Limit0.7 60 min1 30 min1.5 15 min2 4 min2.5 1 minModiied from British Medical Ultrasound Society (BMUS) SafetyGroup. Guidelines for the safe use of diagnostic ultrasoundequipment. Ultrasound. 2010;18:52-59. 1783. he risk of adverse efects is increased with the duration ofexposure (dwell time). 1954. Based on available information, there is no reason to withholdscanning in B-mode for medical indications. he riskof thermal damage secondary to heating appears to be negligible.1935. M-mode ultrasound appears to be safe and not to causethermal damage (Fig. 29.5). 486. Spectral Doppler ultrasound may produce high intensities,and routine Doppler examination during the embryonicperiod is rarely indicated. 1967. hree-dimensional (3D) and four-dimensional (4D) ultrasoundare based on two-dimensional (2D) B-mode imagingwith multiple 2D planes obtained and assembled (reconstructed)into a volume. Hence the exposure is really toB-mode and is, most likely, safe. Time of exposure has to bewatched to avoid long episodes of scanning to obtain the“ideal” 3D volume (Fig. 29.6).8. Education of ultrasound operators is crucial; the responsibilityfor the safe use of ultrasound devices is shared betweenthe users and the manufacturers, who should ensurethe accuracy of the output display. 1969. he AIUM advocates the responsible use of diagnosticultrasound and strongly discourages the nonmedicaluse of ultrasound for “entertainment” purposes. he useof ultrasound without a medical indication to view thefetus, obtain a picture of the fetus, or determine the fetalgender is inappropriate and contrary to responsiblemedical practice. Ultrasound should be used by qualiiedhealth professionals to provide medical beneit to the patient.2810. Examinations should be kept as short as possible and withas low MI and TI outputs as possible, but without sacriicingdiagnostic accuracy. Follow the as low as reasonably achievable(ALARA) principle. 197CONCLUSIONDiagnostic ultrasound has been used in medicine in general andobstetrics and gynecology in particular for more than half acentury. No conirmed biologic efects have been described inpatients as a result of exposure to diagnostic ultrasound. Suchefects, however, have been described in animals, oten at exposurelevels higher than, but also occasionally equivalent to, those usedin clinical practice. Epidemiologic information available is fromstudies performed on instruments with acoustic output muchlower than current machines. Oten, exposure data are insuicientand number of subjects too small. Furthermore, “no reportedefects” does not mean “no efects,” and such biologic efects maybe identiied in the future. Prudent use of ultrasound in fetalscanning, following the ALARA principle, is therefore recommended.Based on known mechanisms, there is no contraindicationto the use of B-mode, M-mode, 3D/4D, and color Dopplerultrasound, when clinically indicated. However, special precautionis necessary when applying pulsed Doppler ultrasound, particularlyin the irst trimester.
CHAPTER 29 Bioeffects and Safety of Ultrasound in Obstetrics 1043FIG. 29.5 M-Mode Tracing, Obtained With Low TI (0.3) and MI (0.8).FIG. 29.6 Multiplanar Images and Three-Dimensional Reconstructed Volume With Low TI (0.1) and MI (0.9).REFERENCES1. Abramowicz JS. Ultrasound in reproductive medicine: is it safe? In:Stadtmauer LA, Tur-Kaspa I, editors. Ultrasound imaging in reproductivemedicine. New York: Springer; 2014. p. 3-16.2. Abramowicz JS. Beneits and risks of ultrasound in pregnancy. SeminPerinatol. 2013;37(5):295-300.3. Dewhurst CJ. he safety of ultrasound. Proc R Soc Med. 1971;64(9):996-997.4. Donald I. he safety of using sonar. Dev Med Child Neurol. 1974;16(1):90-92.5. Hellman LM, Dufus GM, Donald I, Sunden B. Safety of diagnostic ultrasoundin obstetrics. Lancet. 1970;1(7657):1133-1134.6. Lele PP. Safety and potential hazards in the current applications of ultrasoundin obstetrics and gynecology. Ultrasound Med Biol. 1979;5(4):307-320.7. Meyer RA. Diagnostic ultrasound: hazardous or safe? Appl Radiol.1982;11(5):71-74.8. Kremkau FW. Biological efects and possible hazards. Clin Obstet Gynaecol.1983;10(3):395-405.9. Brown BS. How safe is diagnostic ultrasonography? Can Med Assoc J.1984;131(4):307-311.10. Wells PN. he prudent use of diagnostic ultrasound. British Institute ofRadiology presidential address 1986. Br J Radiol. 1986;59(708):1143-1151.11. Reece EA, Assimakopoulos E, Zheng XZ, et al. he safety of obstetricultrasonography: concern for the fetus. Obstet Gynecol. 1990;76(1):139-146.12. Salvesen KA, Eik-Nes SH. Is ultrasound unsound? A review of epidemiologicalstudies of human exposure to ultrasound. Ultrasound Obstet Gynecol.1995;6(4):293-298.13. Abramowicz JS. Ultrasound in obstetrics and gynecology: is this hottechnology too hot? J Ultrasound Med. 2002;21(12):1327-1333.14. Marinac-Dabic D, Krulewitch CJ, Moore Jr RM. he safety of prenatalultrasound exposure in human studies. Epidemiology. 2002;13(Suppl.3):S19-S22.15. Church CC, Miller MW. Quantiication of risk from fetal exposure todiagnostic ultrasound. Prog Biophys Mol Biol. 2007;93(1-3):331-353.
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viiiContributorsOlga R. Brook, MDAs
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xContributorsChristy K. Holland, Ph
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xiiContributorsRupa Radhakrishnan,
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xxiiContentsVOLUME IIPART IV Obstet
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xxivVideo ContentsVideo 12.8 Angiog
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xxviVideo ContentsVideo 26.20 High-
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xxviiiVideo Contents42 Fetal Measur
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2 PART I Physicsphysics. he amplitu
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4 PART I Physics× ms×FIG. 1.4 Ult
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6 PART I Physicsθ 1 = 20°Tissue A
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8 PART I Physicssignature. Broad-ba
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10 PART I PhysicsFIG. 1.13 B-Mode I
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12 PART I PhysicsIn these transduce
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14 PART I PhysicsFIG. 1.17 Tissue H
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16 PART I PhysicsKey Points of Ultr
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18 PART I PhysicsA - Normal liverv
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20 PART I PhysicsFIG. 1.27 Reverber
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22 PART I Physics-0 dBUncorrected-0
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24 PART I Physicsθ = 0°cos θ = 1
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26 PART I PhysicsABFIG. 1.38 Color
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28 PART I PhysicsChanges in Doppler
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30 PART I PhysicsABFIG. 1.44 Wall F
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32 PART I PhysicsABCDFIG. 1.46 Alia
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CHAPTER2Biologic Effects and Safety
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36 PART I PhysicsPressurePulse repe
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38 PART I PhysicsUltrasound imaging
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40 PART I Physicsacoustic power and
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42 PART I PhysicsFIG. 2.6 Acoustic
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44 PART I PhysicsThe AIUM Statement
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46 PART I Physics1. Current ultraso
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48 PART I PhysicsEPIDEMIOLOGYWith a
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50 PART I Physicscontrols whether t
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52 PART I Physics70. Hwang JH, Tu J
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54 PART I PhysicsA B 5 μmFIG. 3.1
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56 PART I Physicsstudies with Levov
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58 PART I Physicsabdominal organs.
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60 PART I PhysicsHarmonic B-Mode Im
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62 PART I PhysicsFIG. 3.9 Contrast-
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64 PART I Physicsdramatic manifesta
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66 PART I Physics5 µmFIG. 3.15 Fra
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68 PART I Physicsplatelet lysis), n
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70 PART I PhysicsEnhancement1 2 3 4
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72 PART I Physics46. Hamilton MF, B
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PART TWO: Abdominal and Pelvic Sono
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76 PART II Abdominal and Pelvic Son
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100 PART II Abdominal and Pelvic So
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ABFIG. 5.20 Microabscesses in Two P
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ABFIG. 6.32 Distal Cholangiocarcino
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CHAPTER7The PancreasThomas Winter a
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CHAPTER8The Gastrointestinal TractS
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ABFIG. 8.16 Lymphadenopathy in Two
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A B CD E FG H IFIG. 8.23 Inlammator
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FIG. 8.56 Gastrointestinal Stromal
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CHAPTER9The Kidney and Urinary Trac
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Remnant ofpronephrosMesonephrosBMes
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CHAPTER11The Adrenal GlandsChristin
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CHAPTER12The RetroperitoneumRaymond
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CHAPTER13Dynamic Ultrasound of Hern
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CHAPTER14The PeritoneumAnthony E. H
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CHAPTER15The UterusDouglas Brown an
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CHAPTER16The AdnexaRochelle Filker
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692 PART III Small Parts, Carotid A
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CHAPTER20The Parathyroid GlandsBonn
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*** *FIG. 21.8 Terminal Ductolobula
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CHAPTER22The ScrotumDaniel Sommers
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CHAPTER23Overview of Musculoskeleta
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CHAPTER25Musculoskeletal Interventi
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ABCDFIG. 25.15 Biceps Tendon Sheath
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CHAPTER27Peripheral VesselsMark E.
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ABFIG. 27.29 Chronic Deep Venous Th
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1000 PART III Small Parts, Carotid
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e2APPENDIXUltrasound Artifacts: A V
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FIG. A.18 Comet-Tail Artifact. On c
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e12APPENDIXUltrasound Artifacts: A
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I-2 IndexAcetabulumdescription of,
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I-4 IndexAnemiafetal, hydrops from,
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I-6 IndexAttenuationcoeicient, 36of
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I-8 IndexBlood low. See also Cerebr
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I-10 IndexBreast(s) (Continued)thic
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I-12 IndexCat-scratch disease, pedi
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I-14 IndexChorion laeve, 1465-1466C
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I-16 IndexContrast agents (Continue
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I-18 IndexCyst(s) (Continued) Cyst(
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I-20 IndexDoppler ultrasound (Conti
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I-22 IndexEndocardial cushion(s), 1
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I-24 IndexFibroma(s) (Continued)par
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I-26 IndexGerminal epithelium, 565G
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I-28 IndexHematoma(s) (Continued)pe
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I-30 IndexHoloprosencephaly (HPE) (
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I-32 IndexImplants, breast (Continu
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I-34 IndexJaundice (Continued)bile
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I-36 IndexLipomyelocele, closed spi
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I-38 IndexMammary ductsnormal sonog
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I-40 IndexMolar pregnancy. See Hyda
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I-42 IndexNonrhizomelic chondrodysp
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I-44 IndexPancreas (Continued)percu
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I-46 IndexPeritoneum (Continued)tum
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I-48 IndexPosterior fossa (Continue
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I-50 IndexPyloric musclehypertrophy
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I-52 IndexSample volume size, Doppl
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I-54 IndexSpectral broadening, in D
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I-56 IndexSuperoanteromedial ridge,
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I-58 Indexhrombosis (Continued)of s
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I-60 IndexTrisomy 18 (Edwards syndr
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I-62 IndexUrinary tract, pediatric
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I-64 IndexWalker-Warburg syndromeco
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DIAGNOSTICULTRASOUND
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DIAGNOSTICULTRASOUND5TH EDITIONCARO
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ABOUT THE EDITORSCarol M. Rumack, M
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ContributorsviiCONTRIBUTORSJacques
Page 1163 and 1164: ContributorsixPeter M. Doubilet, MD
Page 1165 and 1166: ContributorsxiAna P. Lourenco, MDAs
Page 1167 and 1168: ContributorsxiiiWendy hurston, MDAs
Page 1169 and 1170: In memory of my parents, Drs. Ruth
Page 1171 and 1172: PrefacexviiPREFACEhe ith edition of
Page 1173 and 1174: AcknowledgmentsxixACKNOWLEDGMENTSWe
Page 1175 and 1176: ContentsxxiCONTENTSVOLUME IPART I P
Page 1177 and 1178: Video ContentsxxiiiVIDEO CONTENTS4
Page 1179 and 1180: Video Contentsxxv19 The Thyroid Gla
Page 1181 and 1182: Video Contentsxxvii33 The Fetal Fac
Page 1183 and 1184: Video Contentsxxix52 The Pediatric
Page 1185 and 1186: DIAGNOSTICULTRASOUND
Page 1187 and 1188: PART FOUR: Obstetric and Fetal Sono
Page 1189 and 1190: CHAPTER 28 Overview of Obstetric Im
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CHAPTER 31 Chromosomal Abnormalitie
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ABCDFIG. 31.12 Sonographic Findings
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CHAPTER32Multifetal PregnancyMary C
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CHAPTER 32 Multifetal Pregnancy 111
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ABFIG. 32.5 Sonographic Findings Se
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CHAPTER33The Fetal Face and NeckAna
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CHAPTER 33 The Fetal Face and Neck
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ABCDFIG. 33.13 Hypertelorism With E
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ABCDFIG. 33.16 Dacryocystocele. (A)
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ABCDEFFIG. 33.24 Unilateral Complet
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CHAPTER 34 The Fetal Brain 1167impo
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CHAPTER 34 The Fetal Brain 1169cmAB
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CingulatePOCalcarineAB21 wkCD25 wkI
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CHAPTER 34 The Fetal Brain 1173FIG.
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CHAPTER 34 The Fetal Brain 1175LTAR
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CHAPTER 34 The Fetal Brain 1177CC12
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CHAPTER 34 The Fetal Brain 1179SPEC
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CHAPTER 34 The Fetal Brain 1181ABCD
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CHAPTER 34 The Fetal Brain 1183asym
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CHAPTER 34 The Fetal Brain 1185FIG.
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CHAPTER 34 The Fetal Brain 1187Cere
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CHAPTER 34 The Fetal Brain 1189loba
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CHAPTER 34 The Fetal Brain 1191ABCF
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CHAPTER 34 The Fetal Brain 1193ABCF
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CHAPTER 34 The Fetal Brain 1195spor
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ABCCCDEFFIG. 34.24 Type 2 Lissencep
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CHAPTER 34 The Fetal Brain 1199ABFI
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CHAPTER 34 The Fetal Brain 120120 w
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CHAPTER 34 The Fetal Brain 1203Ultr
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CHAPTER 34 The Fetal Brain 1205ABCD
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VSSABHHPHCDEFFIG. 34.35 Intracrania
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CHAPTER 34 The Fetal Brain 1209VABC
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CHAPTER 34 The Fetal Brain 1211Huma
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CHAPTER 34 The Fetal Brain 1213121.
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CHAPTER 34 The Fetal Brain 1215221.
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CHAPTER 35 The Fetal Spine 1217ABCF
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CHAPTER 35 The Fetal Spine 1219L1S3
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CHAPTER 35 The Fetal Spine 1221FTFT
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CHAPTER 35 The Fetal Spine 1223FIG.
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CHAPTER 35 The Fetal Spine 1225TABL
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CHAPTER 35 The Fetal Spine 1227Feta
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CHAPTER 35 The Fetal Spine 1229MMAB
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ABCDEFFIG. 35.15 Skin-Covered Myelo
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CHAPTER 35 The Fetal Spine 1233diic
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CHAPTER 35 The Fetal Spine 1235CCSC
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CHAPTER 35 The Fetal Spine 1237chon
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CHAPTER 35 The Fetal Spine 1239BSCT
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CHAPTER 35 The Fetal Spine 124162.
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CHAPTER36The Fetal ChestDorothy Bul
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CHAPTER 36 The Fetal Chest 1245seco
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CHAPTER 36 The Fetal Chest 1247TABL
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CHAPTER 36 The Fetal Chest 1249Left
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CHAPTER 36 The Fetal Chest 12511ABC
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CHAPTER 36 The Fetal Chest 1253ABCF
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CHAPTER 36 The Fetal Chest 1255cent
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CHAPTER 36 The Fetal Chest 1257Left
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CHAPTER 36 The Fetal Chest 1259ABCD
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CHAPTER 36 The Fetal Chest 1261RTLT
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CHAPTER 36 The Fetal Chest 1263ARig
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CHAPTER 36 The Fetal Chest 12659. B
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CHAPTER 36 The Fetal Chest 1267107.
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CHAPTER 36 The Fetal Chest 1269204.
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CHAPTER 37 The Fetal Heart 1271TABL
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CHAPTER 37 The Fetal Heart 1273TABL
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CHAPTER 37 The Fetal Heart 1275Plac
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CHAPTER 37 The Fetal Heart 1277ADop
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CHAPTER 37 The Fetal Heart 1279LVRV
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CHAPTER 37 The Fetal Heart 1281RARV
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CHAPTER 37 The Fetal Heart 1283RARV
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CHAPTER 37 The Fetal Heart 1285Norm
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CHAPTER 37 The Fetal Heart 1287RVLV
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CHAPTER 37 The Fetal Heart 1289RVTA
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CHAPTER 37 The Fetal Heart 1291LVRA
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CHAPTER 37 The Fetal Heart 1293Aspl
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CHAPTER 37 The Fetal Heart 1295PLVL
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CHAPTER 37 The Fetal Heart 1297HR-L
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CHAPTER 37 The Fetal Heart 129951.
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CHAPTER 38 The Fetal Gastrointestin
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UrogenitalsinusMesonephrosMesonephr
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CHAPTER 39 The Fetal Urogenital Tra
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CHAPTER 40 The Fetal Musculoskeleta
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CHAPTER 41 Fetal Hydrops 1413ABFIG.
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ABCDFIG. 41.2 Ascites. (A) Fluid ou
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CHAPTER 41 Fetal Hydrops 1417A B CD
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CHAPTER 41 Fetal Hydrops 1423later
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CHAPTER 41 Fetal Hydrops 1427CHABCH
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CHAPTER 41 Fetal Hydrops 1429Monoch
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CHAPTER 41 Fetal Hydrops 1431feedin
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CHAPTER 41 Fetal Hydrops 1433TABLE
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CHAPTER 41 Fetal Hydrops 1435sampli
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CHAPTER 41 Fetal Hydrops 1437Predel
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CHAPTER 41 Fetal Hydrops 143973. Ma
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CHAPTER 41 Fetal Hydrops 1441169. I
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CHAPTER42Fetal Measurements: Normal
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CHAPTER 42 Fetal Measurements 1445F
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CHAPTER 42 Fetal Measurements 1447T
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CHAPTER 42 Fetal Measurements 1451p
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CHAPTER 42 Fetal Measurements 1453d
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CHAPTER 42 Fetal Measurements 1455A
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CHAPTER 42 Fetal Measurements 1459A
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CHAPTER 42 Fetal Measurements 14618
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CHAPTER 42 Fetal Measurements 14631
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CHAPTER43Sonographic Evaluation oft
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CHAPTER 43 Sonographic Evaluation o
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CHAPTER44Cervical Ultrasound and Pr
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CHAPTER 44 Cervical Ultrasound and
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PART FIVE: Pediatric SonographyCHAP
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CHAPTER 45 Neonatal and Infant Brai
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CHAPTER46Duplex Sonography of the N
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CHAPTER 46 Duplex Sonography of the
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CHAPTER47Doppler Sonography of the
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CHAPTER 47 Doppler Sonography of th
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CHAPTER 48 The Pediatric Head and N
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CHAPTER 49 The Pediatric Spinal Can
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RA B CDEFGFIG. 49.27 Neuroblastoma
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CHAPTER50The Pediatric ChestChetan
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CHAPTER 50 The Pediatric Chest 1703
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CHAPTER 51 The Pediatric Liver and
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ABCFIG. 51.39 Hepatosplenomegaly. W
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CHAPTER52The Pediatric Urinary Trac
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CHAPTER 52 The Pediatric Urinary Tr
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TABLE 52.4 Mean Total Renal Volumes
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CHAPTER53The Pediatric Gastrointest
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CHAPTER 53 The Pediatric Gastrointe
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CHAPTER 54 Pediatric Pelvic Sonogra
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CHAPTER 55 The Pediatric Hip and Ot
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ABCDFIG. 55.13 Normal and Dislocate
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CHAPTER 56 Pediatric Interventional
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ABCFIG. 56.15 Access for Drainage o
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APPENDIXUltrasound Artifacts: A Vir
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APPENDIX Ultrasound Artifacts: A Vi
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IndexAAA anastomoses. See Arterial/
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Index I-3Adnexa (Continued)transvag
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Index I-5Arrays, transducer, 11-12A
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Index I-7Bioefects (Continued) Biop
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Index I-9Brain, neonatal/infant (Co
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Index I-11Carcinoma(s) (Continued)
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Index I-13Cervix (Continued)for sym
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Index I-15Color Doppler ultrasound
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Index I-17Cystic artery, 194promine
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Index I-19Diabetes mellituschronic
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Index I-21Echinococcal disease (Con
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Index I-23Exudate ascites, 506-507E
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Index I-25Gallbladder (Continued)ad
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Index I-27Gyriabnormalities of, in
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Index I-29Hernia(s). See also Diaph
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Index I-31Hyperechoic tissue, in br
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Index I-33Internal jugular vein (IJ
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Index I-35Kidneys, pediatric (Conti
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Index I-37Liver transplantation (Co
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Index I-39Mesentery, small bowel, 5
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Index I-41Nasal bone, fetal (Contin
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Index I-43Orbits, fetal (Continued)
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Index I-45Patau syndrome. See Triso
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Index I-47Pleural efusionsfetal, 12
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Index I-49Prostate (Continued)thera
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Index I-51Renal transplantation (Co
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Index I-53Shunt(s) (Continued) Skel
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Index I-55Splenic vein (Continued)t
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Index I-57Testis(es) (Continued)cys
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Index I-59Transcranial Doppler (TCD
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Index I-61Umbilical cord, 1481-1487
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Index I-63Vein of Galen (Continued)
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