Testing telediagnostic obstetric ultrasound in Peru: a new horizon in expanding access to prenatal ultrasound

Abstract

Background Ninety-four percent of all maternal deaths occur in low- and middle-income countries, and the majority are preventable. Access to quality Obstetric ultrasound can identify some complications leading to maternal and neonatal/perinatal mortality or morbidity and may allow timely referral to higher-resource centers. However, there are significant global inequalities in access to imaging and many challenges to deploying ultrasound to rural areas. In this study, we tested a novel, innovative Obstetric telediagnostic ultrasound system in which the imaging acquisitions are obtained by an operator without prior ultrasound experience using simple scan protocols based only on external body landmarks and uploaded using low-bandwidth internet for asynchronous remote interpretation by an off-site specialist. Methods This is a single-center pilot study. A nurse and care technician underwent 8 h of training on the telediagnostic system. Subsequently, 126 patients (68 second trimester and 58 third trimester) were recruited at a health center in Lima, Peru and scanned by these ultrasound-naïve operators. The imaging acquisitions were uploaded by the telemedicine platform and interpreted remotely in the United States. Comparison of telediagnostic imaging was made to a concurrently performed standard of care ultrasound obtained and interpreted by an experienced attending radiologist. Cohen’s Kappa was used to test agreement between categorical variables. Intraclass correlation and Bland-Altman plots were used to test agreement between continuous variables. Results Obstetric ultrasound telediagnosis showed excellent agreement with standard of care ultrasound allowing the identification of number of fetuses (100% agreement), fetal presentation (95.8% agreement, κ =0.78 (p < 0.0001)), placental location (85.6% agreement, κ =0.74 (p < 0.0001)), and assessment of normal/abnormal amniotic fluid volume (99.2% agreement) with sensitivity and specificity > 95% for all variables. Intraclass correlation was good or excellent for all fetal biometric measurements (0.81–0.95). The majority (88.5%) of second trimester ultrasound exam biometry measurements produced dating within 14 days of standard of care ultrasound. Conclusion This Obstetric ultrasound telediagnostic system is a promising means to increase access to diagnostic Obstetric ultrasound in low-resource settings. The telediagnostic system demonstrated excellent agreement with standard of care ultrasound. Fetal biometric measurements were acceptable for use in the detection of gross discrepancies in fetal size requiring further follow up.

Testing telediagnostic right upper quadrant abdominal ultrasound in Peru: A new horizon in expanding access to imaging in rural and underserved areas

“…In our experience, 8 hours is sufficient to teach and reinforce a RUQ VSI protocol, including training on the telediagnostic system [15]. Individuals without prior imaging experience or medical training can perform VSI effectively; the only true requirements involve the ability to hold the probe and follow simple instructions [15][16][17][18]. In general, a VSI examination with the RUQ protocol is usually performed within 10 minutes or less.…”

Artificial Intelligence in Obstetric Ultrasound: An Update and Future Applications

“…Since obstetric ultrasound remains unavailable in many developing countries and rural areas, telemedicine/telediagnostic service can increase access to diagnostic obstetric ultrasound in low-resource setting. It had been proved to have excellent agreement with standard of care ultrasound (56). In obstetrics and gynecology education, VR is becoming a new way of simulation-based ultrasound training, which significantly improves learning efficiency and knowledge retention in fetal ultrasound teaching [such as recognizing fetal brain anomalies on ultrasound imaging (57) or studying fetal development (58)].…”

No sonographer, no radiologist: New system for automatic prenatal detection of fetal biometry, fetal presentation, and placental location

“…In VSI, the operator requires no significant medical background or technical ultrasound skill. Individuals have been shown to learn VSI after a few hours of training, and no significant ultrasound experience or anatomical knowledge is required [ 7 , 8 , 18 – 20 ]. A VSI protocol consists of a series of ultrasound probe sweeps over the target region demarcated by easily recognized external body landmarks.…”

“…This VSI protocol is based on eight sweeps of the ultrasound probe which constitute a full volumetric examination of the pregnant abdomen. Obstetric VSI has previously demonstrated excellent agreement with standard of care ultrasound performed by a radiologist [ 8 ].…”

“…We propose that this barrier to ultrasound access may be overcome in a locally sustainable and resource-conscious way through the use of standardized scanning protocols combined with artificial intelligence obviating the need for an interpreting provider and an experienced sonographer. Prior studies demonstrate that individuals without prior ultrasound training (non-specialists) can obtain diagnostic imaging for placental position, fetal presentation and number, and amniotic fluid volume using volume sweep imaging (VSI) [ 7 , 8 ]. Different fetal and placenta positions and their significance are illustrated and described in Figs 1 and 2 .…”