Portal de Periódicos da CAPES

Parallel universes

2004; Wiley; Volume: 24; Issue: 7 Linguagem: Inglês

10.1002/uog.1808

1469-0705

S. Campbell,

Primary Care and Health Outcomes

ISUOG is an unusual Society in that it was founded by some of the foremost luminaries practicing and teaching in 1990. It was, in a way, their contribution to worldwide education in our specialty. Figures such as Hansmann, Kurjak, Wladimiroff, Eik-Nes and Platt didn't need a society to make them famous. This is different from many medical organizations where the fame of the institution is greater than that of the office-holders, who gain status from their association with the institution. Eventually, these minor functionaries begin to delude themselves that their opinions are important, they gain political and even academic credibility for their views, and worst of all they suppress the true original voices within their specialty. This was never the situation with ISUOG, whose founding fathers established the principle of supporting and sponsoring talent from every country. The first World Congress in London is still remembered by all who participated because it was a true gathering of all the talents. We took huge financial risks (and indeed made a small loss) by flying in a very international faculty from all parts of the world but the quality of the meeting made it all worthwhile. I hope these principles are cherished in the future. I say this because I am concerned about what appears to be two disturbing trends which may undermine these principles. The first is that financial success has become an overriding priority for the World Congress. This, you may feel, is a laudable objective, but surely not when vital speakers are left at home because an invitation might dent the profits. The second is that the Scientific Committee which chooses the program for our World Congress is not representative of our international membership, which I feel has led to a lack of balance in some of the sessions. While I accept that the meetings in Paris and Stockholm were outstanding successes, there are warning signs that need to be addressed to ensure our Society remains truly international and does not descend into a club culture. From the perspective of the Journal there is very little I can add to Larry Platt's inspiring and (for me) touching Editorial of January of this year. Yes, the Journal has made extraordinary progress over the past 14 years and on impact factor we are up with the big boys, being equal with the British Journal of Obstetrics and Gynaecology and closing in fast with the American Journal. One of the main signs of success of any peer-reviewed journal is when leading researchers submit their best work to it as first choice and there is increasing evidence that this is happening with the White Journal. Some of this may be related to the enormous explosion in new technology outlined by Larry in his Editorial, which many of the conventional journals find difficult to evaluate and put into perspective. This gives our Journal the image of being in the vanguard of advance, the journal people turn to when they want to know ‘what's new’. This explosion in technology should give us some pause for thought, however. Are there two parallel universes developing in our specialty, one in which a few luminaries fly around the world exchanging ever more exotic images of ever more complex diagnoses to an admiring audience which is then beamed back to a very different alternative universe where patients are rushed through at 15-minute intervals and there is satisfaction if a good four-chamber view is obtained? And even within the so-called tertiary units a huge disparity in ultrasound expertise is developing. Let me tell you an anecdote which to me illustrates the problem as I see it. I am now in private practice and as part of my routine for every obstetric examination I perform uterine artery Doppler. I have always recommended this and am disappointed that virtually no centers perform routinely what is the simplest, quickest and most valuable screening test for pre-eclampsia/IUGR. I performed this test on a primigravid woman at 23 weeks who had previously had a normal screen in her own hospital and found that she had large bilateral notches in the uterine arteries. The fetus was of normal weight and fetal Dopplers were normal so, as she was attending a London teaching hospital with tertiary fetal medicine, I sent the report to them with the expectation that they would give her advice on what symptoms to look for, changes in lifestyle and even some preventive therapy such as antioxidants, aspirin etc. None of this transpired, so, not surprisingly, the lady was admitted at 27 weeks with severe pre-eclampsia. They managed to control her blood pressure and then performed an umbilical artery Doppler which showed absent end-diastolic flow and arrangements were made for an emergency Cesarean section. Fortunately for the patient, the Cesarean Section was postponed because of pressures on the neonatal unit, which gave me the opportunity to repeat the fetal Dopplers. These showed that although the umbilical artery PI was high, there was no evidence of cardiac decompensation as the ductus venosus PI was less than 0.5. Indeed, compensatory circulatory changes had not even kicked in as the middle cerebral artery PI and thoracic aorta PI were normal. Yes, the fetal weight was on the 5th centile, but there was no need to deliver a fetus at a gestational age which would have severely compromised its chances of survival. To cut the story short, twice-weekly ultrasound monitoring showed continuing growth of the fetus just below the 5th centile and although compensatory circulatory changes were evident from 30 weeks there was no change in the ductus venosus PI and the pregnancy was continued until 33 weeks (6 weeks after the original decision to deliver!) when Cesarean section was performed for maternal indications. The parents have a beautiful and bright little boy but I rather doubt if this would have been the case if the original decision had stood. Surely in this day and age obstetricians should realize that the umbilical artery is a placental vessel and reflects only indirectly the fetal condition. Furthermore, the umbilical artery PI is one of the most variable of Doppler parameters, because, as was pointed out by Neil Sebire in this Journal, the umbilical artery PI in IUGR is affected by vasoconstriction in the arteries in the stem villi, which can alter even over a few minutes. Surely also they should know that while it is acceptable to deliver a fetus after 34 weeks on the basis of absent end-diastolic flow in the umbilical artery or centralization of the fetal circulation, evidence of decompensation should be demonstrated before delivery is contemplated before 32 weeks as this can add precious potentially life-saving weeks to the age of the infant at birth, making all the difference to survival. In terms of long-term morbidity there is no current evidence that compensated hypoxemia constitutes a risk, although prolonged acidemia almost certainly does; that is why frequent monitoring of the ductus venosus is so important, because a high PI is diagnostic of acidemia. Measurement of the ductus venosus PI should therefore be a prerequisite skill in anyone professing to be a maternal–fetal specialist, and yet how many can do this? I don't think that in adult medicine a physician would survive very long in practice if he/she did not know how to diagnose heart failure in their patient yet this is precisely what we fail to do in our fetal patient if we do not assess the pulsatility of the ductus venosus. Color Doppler has been around for over 20 years and still I would reckon less than 5% of fetal medicine centers use this modality to its full potential. We must remember that if what we do is not translated to everyday practice, our research will become less and less relevant. To some extent it is we in the rarefied universe of the expert who are to blame, and I believe that I have been one of the worst sinners in this regard, rushing ahead with what I believed (and still believe) were important and self-evident advances without glancing backward to see if anyone was following. And frequently those in the alternative universe were not following, because the people who were responsible for their training were the minor functionaries I described above. Only one of us spotted the problem. It is in this regard that the contribution of Kypros Nicolaides in bridging the gap between the two universes has been truly phenomenal. Single-handedly (and despite opposition from the reactionary institutions I described earlier) he has made The Fetal Medicine Foundation the foremost organ for training, certification and audit in fetal medicine in Europe not just for elite fetal medicine specialists but for sonographers as well. And even in the USA the influence of The FMF is being felt, with programs for audit and training being adopted by the Society for Maternal-Fetal Medicine (SMFM) and co-operating societies which are similar to those formulated by Kypros. The FMF has focused audit and training on the first-trimester scan but surely this should now be extended to Doppler, for there is now an abundance of literature showing the clinical value of uterine and fetal Dopplers in everyday clinical practice. I would like to think this could be accomplished by ISUOG but it will require leadership just as resolute and committed as has been shown by Kypros; and we will have to move fast, because now we are expecting people to learn the complexities of 3D scanning. Nothing exemplifies the parallel universe scenario more clearly than does 3D ultrasound. I regard myself as being proficient in this modality and have even produced a small book for the lay public to show them how their embryo/fetus changes both behaviorally and physically throughout gestation. To some extent I have modified my views expressed in my Editorial of 2000. Indeed, in next month's issue I and my colleagues from Cambridge describe the advantages of 3D in the diagnosis of cleft palate. However, despite what the Phillips advertisement implies, 3D ultrasound is not easy and if a relatively simple technique such as Doppler ultrasound causes difficulties in the alternative universe, how indeed is 3D going to be properly utilized? Of course, the demonstration of the baby's features and behavior which I enthusiastically endorse and which is patient-driven will soon be part of the standard scan but the advantages of 3D scanning are more than this. I recently sat at the feet of two of the greatest exponents of 3D scanning, Bernard Benoit and Greg DeVore, who dazzled me with applications of 3D ultrasound which even I did not exploit. The new spatio-temporal image correlation (STIC) technology with the ability to retrospectively view the anatomy of the beating heart from all planes, with and without color flow, and to slow the rate down to identify even the smallest ventricular muscular septal defect; the Inversion 3D mode, which facilitates visualization of vascular anatomy and allows us to measure the volume of obstructions whether it be ventriculomegaly or a hydrosalpinx; B-flow, which literally provides an angiogram in real time of the fetal cardiac circulation even as early as 14 weeks; and all those different surface rendering algorithms which enhance the visualization of surface, internal and bony abnormalities of the fetus—how are these to be assimilated into the everyday practice of the alternative universe? Recently I heard a lecture by Beryl Benacerraf, ever one of our most original thinkers, who presented a scenario of how 3D ultrasound might be used in the future in our alternative universe. She asked her sonographers to carry out as part of their standard screening scan five volumes irrespective of the position of the fetus encompassing the head, thorax, abdomen, face and lower extremities, respectively. The volume acquisition and subsequent analysis took 6.6 min, half the time required for the standard screening scan, with a similar ability to detect fetal anatomical structures and all without any need to talk to the prospective parents! A nightmare scenario indeed for those of us who believe in the role of ultrasound as a means of strengthening the doctor–patient relationship and the parental antenatal bonding process. However, what her study demonstrated was the potential of 3D volume scanning as a means in the future of narrowing the gap in levels of expertise between different practitioners of antenatal ultrasound. I said at the outset that these would be random thoughts but let me draw some of these observations together. Treasure your Society and its Journal for together they are one of the most innovative and progressive forces for education and academic thought in obstetrics and gynecology. Make sure the Society is run as a democratic international institution and that speakers are invited to speak at the World Congress not because they are friends of members of the Scientific Committee but because they are the best, most thought-provoking researchers in the business. Treasure those who work selflessly for your Journal, like Sarah Hatcher, who cares about every contributor and every statement, table, statistic, sentence, word and full stop that appears in its pages. Make sure that ISUOG looks after both our parallel universes, not just those clever exponents of the latest technology but the sonographers, midwives and private practitioners out there in the field who need not only training but certification and audit such as has been initiated by Kypros Nicolaides at The Fetal Medicine Foundation. Without this there will be no trickle-down effect and the two universes will never converge. Make Doppler your first goal, then think about 3D. The Boeing jet is hovering over the vast featureless suburbs of LA, my computer is unplugged and I am on batteries now. So it is time for me to finish. I thank all of you for granting me the privilege of being your President and Editor-in-Chief. I have enjoyed it immensely. I apologise if some of you have felt I have been somewhat autocratic over the past 14 years but, in the early years of a journal, decisions have to be made speedily and opportunities created as well as seized. The Journal will now be more democratically run and under Yves Ville's leadership I am certain it will progress from strength to strength. In Larry Platt the Society has a president of vision, energy and strong sense of fairness. I am hopeful that, under his leadership, progress will be made in raising standards in scanning for the benefit of our patients. Now I will join my colleagues in the alternative Universe where I will continue to do what I enjoy doing best, scanning. And I will follow the advice encompassed in Hamlet's dying words, ‘the rest is silence’.