Objective: To evaluate the quality of first trimester ultrasound examinations in patients consulting in the gynecology and obstetrics department at the University Teaching Hospital Yalgado Ouedraogo (UTH-YO) of Ouagadougou. Method: Our study took place from January 1st to March 31st 2017, in the department of Obstetrics and Gynecology of the University Teaching Hospital Yalgado Ouedraogo of Ouagadougou. This was a descriptive study on the records of the first trimester ultrasound of pregnancy, with analysis of the iconography. We used the criteria of the Technical Committee of Fetal Echography (TCFE) of France to analyse all the ultrasound reports brought by the patients. Results: Two hundred reports were collected in three months. In terms of ultrasound identification, only 2 reports out of 200 mentioned the brand and date of first circulation and 4 specified the type of device. The study of the quality of the appointment showed that only 52% of the ultrasounds had been performed at the right time, between 11SA - 14SA of amenorrhea. For the nuchal translucency quality, we rated by the Herman score, 41.67% of the scores were of “unacceptable” quality and only 58.33% were of “acceptable” quality we did not achieve “excellent” quality. The analysis of the biparietal diameter (BIP) cuts revealed that 1/4 only anatomical cuts had been well made. Analysis of the cranio caudal length (CCL) cuts showed that only 14.58% of the CCLs had been well done. Elements of early morphology had been explored to less than 5%. Conclusion: The results revealed the acceptable quality of the NC measurements, but a small proportion of NC achieved. The quality of the ultrasound, morphological analysis and biometrics period is not very acceptable.
The performance of the first quarter morphological examination has been the subject of numerous publications with a constant annual increase for 5 years. For the sonographer, it is a question of identifying the fetuses at risk within a generally healthy population. Ultrasound from the first trimester is a powerful screening tool made available to the obstetrician [
From an obvious public health perspective, it is clear that these acts should be carried out according to minimum quality criteria, in order to avoid worries, costs and additional examinations on healthy fetuses. This quality approach should also make it possible to concentrate efforts on fetuses that deserve more specific diagnostic tests. Given the large number of actors in antenatal surveillance, harmonisation of practices, especially in the context of resource-limited countries, seems justified so that each outcome can be interpreted in the same way. Sonographers themselves, faced with a heavy workload, should provide themselves with the means of self-control in order to encourage self-criticism, a guarantee of the constant improvement of medicine, which is by no means an exact science [
In our country, obstetrical ultrasound has experienced great growth, but the lack of control and standardization of the reports gives free rein to each operator to analyse in the fetus the elements he considers useful and to formulate his own reporting model. This could lead to many disparities in reporting. Through this study, we propose to analyze in a more detailed way the quality of first trimester ultrasound examinations of pregnancy seen in patients having consulted in the gynecology and obstetrics department of the University Teaching Hospital Yalgado Ouedraogo (UTH-YO) of Ouagadougou, Burkina Faso.
Our study took place from January 1st to March 31st, 2017 in the obstetrical gynecology department of the University Hospital Yalgado OUEDRAOGO (UTH-YO). This was a cross-sectional study with descriptive purpose on the second trimester pregnancy ultrasound reports that the patient brought with them during their consultation. We did the analysis of the iconographies looking at both the morphologic and the biometric settings. To achieve our objectives, we conducted our study in a hospital setting, hence the choice of the UTH-YO maternity department. We were interested in all pregnant women at the consultation or in delivery and the labor room who were in possession of their second trimester ultrasound report. The calculated sample size was 140 ultrasound scans was calculated according to the formula: n = (Z1 − α/2) 2 × P × (1 − P)/i2. Thus, the final size of the sample is 140 ultrasounds. To increase the power of the study, we corrected n = 200 ultrasounds reports. The patients included in our sample met the following criteria:
- patient of childbearing age,
- patient carrying a pregnancy beyond the second trimester,
- patient seen in the department of obstetrics and gynecology during the study period,
- patient with a second trimester ultrasound of pregnancy report done by a practitioner other than those involved in the study.
We did not include in our study the ultrasounds performed on twin pregnancies as well as on stopped pregnancies. We collected the ultrasounds reports from the patients received in the Gynecology and obstetrics department after a presentation on the objectives of the study. We used a standardized collection sheet as a data collection instrument.
After the collection of the ultrasounds reports and especially the iconographies were analyzed by three people including 3 doctors holding the National Inter-University Diploma (NIUD) in gynecological and obstetrical ultrasound in France. It must be said that before the study began, the attending physicians in charge had held about ten training sessions with the entire study group. During this mini training, the different images and recommendations of the Technical Committee of Fetal Echography (TCFE) on first trimester (T1) ultrasound were the subject of extensive exchanges to put everyone on the same level. The data were captured and analyzed on a microcomputer using the Epi info software version 7.1.4.0. The tables and graphs were produced in Excel and Word 2013 (
The oral informed consent of the gestants was obtained prior to the start of this investigation. To ensure confidentiality in this study, no sonographer or structure name to identify a health professional was mentioned on a data collection sheet. The data will be used exclusively to make recommendations for the harmonization of the practice for the benefit of pregnant women. We also got the approval of the Ethics Committee on Research.
We used the Herman score (
Interprétation | Unacceptable | Insufficient | Acceptable | Excellent |
---|---|---|---|---|
Score | 1 ou 0 | 3 ou 2 | 7 à 4 | 9 ou 8 |
to evaluate the quality of the CCL and BIP. We considered acceptable control when for an item analyzed, the completion rate exceeded 50% and not very acceptable when it was less than 50%.
The average age of the pregnant women was 29 years with extremes of 19 and 45 years. The 25 - 29 age group was the most represented. In our study sample 3/4 of the patients came from the city of Ouagadougou. Housewives were the most represented. Also, 146 patients (73%) reported having used a modern method of contraception. High blood pressure was the most common medical history. One in four patients reported no medical or surgical history.
The distribution of ultrasounds reports according to the quality control of identification was summarized in
The analysis of the item identification of the patient was acceptable for surnames, given names and age. For the item Sonographer, it was acceptable for
Identification elements | Number | Percentage % |
---|---|---|
1-Patient | ||
Last Name | ||
- Yes | 200 | 100.0 |
- No | 00 | 00.0 |
First Name | ||
- Yes | 200 | 100.0 |
- No | 00 | 00.0 |
Age | ||
- Yes | 136 | 68.0 |
- No | 64 | 32.0 |
2-Sonographer | ||
Last Name | ||
- Yes | 180 | 90.0 |
- No | 20 | 10.0 |
First Name | ||
- Yes | 180 | 90.0 |
- No | 20 | 10.0 |
Qualification | ||
- Yes | 146 | 73.0 |
- No | 54 | 27.0 |
Adresse | ||
- Yes | 94 | 47.0 |
- No | 86 | 43.0 |
3-Ultrasound scanner | ||
Date of start up | ||
- Yes | 2 | 1.0 |
- No | 198 | 99.0 |
Brand Name | ||
- Yes | 2 | 1.0 |
- No | 198 | 99.0 |
Type | ||
- Yes | 4 | 23.0 |
- No | 196 | 98.0 |
surname, first name, qualification and not acceptable for address (47%). For the item Ultrasound scanner, it was not acceptable for the date of commissioning, brand and type (≤50%).
The distribution of ultrasound examinations according to the quality of the period during which they were performed has been presented in
Only 48% of ultrasounds were performed in the ideal gestational interval 11 - 14 GA. The quality of the implementation period was therefore not acceptable (≤50%).
➢ Quantity of biometrics elements
The distribution of the ultrasounds iconography according to the presence or not in the report in the various elements of biometry and dating has been presented in
Biometric element information was mentioned in less than 50% of the cases for items such as BIP, nuchal translucency and number of required images. The quality of the biometry and dating was acceptable for the LCC and not acceptable for the BIP, the nuchal translucency (NT) and the number of images.
➢ Quality of the pictures supplied
• Nuchal translucency quality control (Herman’s score)
・ Major criteria of Herman’s score
The distribution of ultrasounds according to the results of the assessment of Herman’s major criteria has been presented in
Out of 26 nuchal translucency clichés, the major criteria were observed in less than 50% for all the items. Compliance with the major criteria was of an unacceptable quality.
・ Herman’s minor score criteria
The distribution of ultrasounds according to the results of Herman’s assessment of minor criteria has been presented in
Out of 26 nuchal translucency clichés, minor criteria were observed in more than 50% for amnion recognition (acceptable). For the zoom and the position of the head, it was respected in less than 50% of the cases (not acceptable).
・ Herman score results
The results of the overall qualitative analysis of ultrasound scans according to Herman’s criteria were represented in
Of the 26 nuchal translucency images analyzed, nearly half were judged unacceptable by Herman’s score.
Period of implementation (GA) | Number | Percentage (%) |
---|---|---|
11 - 14 | 96 | 48.0 |
9 - 10 | 30 | 15.0 |
6 - 8 | 74 | 37.0 |
Total | 200 | 100.0 |
Biometrics elements | Number | Percentages (%) |
---|---|---|
LCC | ||
- Provided | 64 | 66.7 |
- Not Provided | 32 | 33.3 |
BIP | ||
- Provided | 44 | 45.8 |
- Not Provided | 52 | 54.2 |
Nuchal translucency | ||
- Provided | 26 | 27.1 |
- Not Provided | 70 | 72.9 |
The 3 pictures | ||
- Provided | 20 | 20.8 |
- Not Provided | 76 | 79.2 |
Elements of major criteria | Staff | Percentages (%) |
---|---|---|
Strict sagittal plan | ||
- Yes | 12 | 46.1 |
- No | 14 | 53.8 |
Skin continuity | ||
- Yes | 8 | 30.8 |
- No | 18 | 69.2 |
Calipers in place | ||
- Yes | 2 | 7.7 |
- No | 24 | 92.3 |
Elements of minor criteria | Number | Percentage (%) |
---|---|---|
Sufficient zoom | ||
- Yes | 6 | 23.0 |
- No | 20 | 76.9 |
Recognized or remote amnios | ||
- Yes | 16 | 61.5 |
- No | 10 | 38.5 |
Neutral position of the head | ||
- Yes | 10 | 38.5 |
- No | 16 | 61,5 |
Scores | Frequencies | Percentages (%) |
---|---|---|
Unacceptable (0 et 1) | 12 | 46.1 |
Insufficient (2 et 3) | 00 | 00.0 |
Acceptable (4 - 7) | 14 | 53.8 |
Excellent (>7) | 00 | 00.0 |
Total | 26 | 100.0 |
• Quality control of biometry and dating by BIP and CCL
・ The BIP
The analysis of the cuts showed that 77.3% of the BIP cuts are not of good quality. Therefore the quality of the BIP cuts is not acceptable.
・ The CCL
The distribution of the CCL sections according to the recommended measurement parameters has been shown in
Analysis of the cuts showed 85.4% of LCC cuts are not of good quality. Therefore the quality of LCC cuts is not acceptable.
• Quality control of early morphology
The distribution of patients according to morphology analysis was presented in
Information on morphological elements was not acceptable as it was mentioned in less than 50% of cases.
➢ Quality control of other elements of the report
The results of the overall qualitative analysis of the ultrasounds according to the other morphological elements were represented in
Information on the vitality elements of the embryonic and maternal appendices was acceptable as it was mentioned in more than 50% of cases.
According to Coquel [
・ Before 11 weeks, the measurement of the thickness of the NT is difficult because of the small size of the embryo.
・ After 14SA, measurement is made difficult by the difficulty of obtaining in the same plane the cephalic pole and the trunk of the embryo.
・ The choice of an upper limit of 13 weeks + 6 days of amenorrhea also meets the need to be able to perform a medical interruption of pregnancy in the first trimester in case of pathology meeting the criteria of the law in force in the corresponding country.
Benchmarks | Number | Percentage (%) |
---|---|---|
Axial plane | ||
- Yes | 44 | 100.0 |
- No | 00 | 00.0 |
Symmetrical cut | ||
- Yes | 20 | 45.4 |
- No | 24 | 54.6 |
Thalami and v3 visible | ||
- Yes | 15 | 34.1 |
- No | 29 | 65.9 |
The 3 landmarks | ||
- Yes | 10 | 22.7 |
- No | 34 | 77.3 |
Benchmarks | Staff | Percentages (%) |
---|---|---|
Strict sagittal cuts | ||
- Yes | 10 | 33.3 |
- No | 22 | 66.7 |
Calipers well placed | ||
- Yes | 9 | 28.6 |
- No | 23 | 71.4 |
Head in neutral position | ||
- Yes | 8 | 23.8 |
- No | 24 | 76.2 |
The 3 parameters | ||
- Yes | 5 | 14.6 |
- No | 27 | 85.4 |
Fetal morphology | Number | Percentage (%) |
---|---|---|
Appearance of the contour of the skull | ||
- Yes | 4 | 4.2 |
- No | 92 | 95.8 |
Attendance of the four members | ||
- Yes | 4 | 4.2 |
- No | 92 | 95.8 |
---|---|---|
Four members each with 3 member segments | ||
- Yes | 4 | 4.2 |
- No | 92 | 95.8 |
Exploration of the anterior abdominal wall | ||
- Yes | 4 | 4.2 |
- No | 92 | 95.8 |
Exploring the centre line | ||
- Yes | 2 | 2.1 |
- No | 94 | 97.9 |
Anatomical and functional structures | Number | Percentages (%) |
---|---|---|
Vitality Cardiac activity | ||
- Yes | 92 | 95.8 |
- No | 4 | 4.2 |
Spontaneous mobility | ||
- yes | 64 | 66.7 |
- No | 32 | 33.3 |
Heart Rate | ||
- Yes | 50 | 58.1 |
- No | 46 | 47.9 |
Embryonic appendices Appearance of the placenta | ||
- Yes | 62 | 64.6 |
- No | 34 | 35.4 |
Amniotic volume | ||
- Yes | 50 | 58.1 |
- No | 46 | 47.9 |
Exploring maternal appendices | ||
- Yes | 74 | 77.1 |
- No | 22 | 22.9 |
In our study, only 48% of ultrasounds were performed in the ideal gestational interval. The quality of the implementation period was therefore not acceptable. This result could be explained by the lack of rigour of the practitioners on the date of realization. In Cameroon Moifo et al. [
The latest generation cameras allow detailed morphological exploration through image quality and a reduction in the frequency of false positives and false negatives [
• Quantity control
An acceptable proportion of ultrasounds had provided CCL (66.7%) but the proportion of ultrasounds that had provided BIP and NT was not acceptable at 45.8% and 27.1% respectively. Benacerraf [
・ Quality control
• Nuchal translucency
After evaluation of the 26 nuchal translucency clichés we realized that the proportion of clichés of “unacceptable” quality i.e. with a score of Herman < 2 was 41.67%. The non-application of the measurement criteria by sonographers could explain our figures. Moifo et al. [
• Quality control of dating and biometrics by CCL and BIP
Analysis of the 32 cranio-caudal length measurements showed that 33.33% of the cuts were made on a strict sagittal plane. Fetal head was neutral in 23.81% and calipers were well placed in 28.57% of cases. Therefore among 48 CCL images, only 14 cuts were of good quality (14.58%). We are not satisfied because the NT cannot be interpreted without a good CCL. It has been shown that the threshold used for the definition of nuchal hyperclarity is not fixed and varies according to the CCL [
• Quality early morphology
This is the role of the very first morphological examination that has focused all the attention of ultrasound specialists on the first trimester ultrasound over the past five years. This examination makes it possible to diagnose acrania, abdominal wall abnormalities and many lethal forms of malformative syndrome at this term [
The results revealed the acceptable quality of the NT measurements, but a small proportion of NT achieved. Our study also revealed the unacceptable quality of the ultrasound, morphological analysis and biometrics period. At the end of our work new questions appear, why is there a significant gap between the observed quality of ultrasound and that prescribed by the literature? What may be the impact on the prognosis of pregnancy?
The authors declare no conflicts of interest regarding the publication of this paper.
Adama, O., Astrid, N.O.N., Natacha, L.B., Smaila, O., Amelie, N., Aline, T.S., Alexis, S.Y., Francoise, M.T., Charlemagne, O.M., Ali, O. and Blandine, T.B. (2018) Quality Control of First Trimester Ultrasound Examinations in the Gynecology and Obstetrics Department of the University Teaching Hospital Yalgado Ouedraogo (UTH-YO) of Ouagadougou, Burkina Faso. Open Journal of Obstetrics and Gynecology, 8, 1399-1413. https://doi.org/10.4236/ojog.2018.813141