Tuesday, June 22, 2010

Ultrasounds in Women of Size, part 1

Recently, a commenter asked about ultrasounds in women of size, and I'd like to briefly address that here and then refer folks to the very in-depth article I have on the topic over at my regular website

Remember, if you don't see your question answered here on this blog, I do have my http://www.plus-size-pregnancy.org/ website that covers a lot of these topics in far more detail, complete with research references. The two sites are meant to be complementary.  If you don't see an answer here, be sure to check out my main website.

[Normally, I'd answer the commenter's question on the page of the original post, but I can't easily figure out which post that is.  If there is some way on Blogger to know which post a comment goes to once approved, please let me know!  Otherwise I end up having to go back through zillions of posts trying to figure it out.  I make a best-guess stab at it and if I can't find it easily, I give up.]

Ultrasounds in Women of Size - General Information

Ultrasounds in women of size can be more difficult to do than in women of average size, but most of the time they are quite doable and most women of size get an adequate ultrasound result. 

It is true that extra adipose tissue on the abdomen CAN make it harder to get a completely accurate ultrasound "picture" so the task is definitely harder in fat women. Because of this, it is possible to sometimes "miss" a problem in women of size that might be caught in a smaller woman.  In particular, research shows that it is particularly difficult to get complete evaluations of the fetal heart in women of size. To a lesser degree, there can be difficulties with visualizing the fetal spine, the cranio-facial system, the fetal kidneys/urinary system, and the mother's ovaries.

Therefore, it's not uncommon for the ultrasound report to note the mother's obesity and whether there were any problems completely visualizing anything.  Don't take such comments personally; it's simply CYA for the ultrasonographer, in case something turns up later that was not noted in the ultrasound report.

Simply noting adiposity on a report is not fat-phobia; it's for liability purposes, not to make you feel badly.  However, berating you about your fatness, telling you that they'll never get a decent picture because you are so fat, or treating you roughly with the justification that it's "harder" to get good images because of your fatness is fat-phobic treatment. 

It's not just what they say, but how they say it, the intent behind saying it, and how they treat you.  Most women of size have unremarkable ultrasound experiences, but now and then some do experience fat-phobic treatment and that is never acceptable.

Transvaginal vs. Transabdominal Ultrasounds

There are two methods typically used for ultrasound in pregnancy:
  • Transvaginal ultrasound
  • Transabdominal ultrasound
In the beginning of pregnancy, fetal structures are particularly difficult to see via abdominal ultrasound in most women, regardless of size, so most women have transvaginal procedures if they have ultrasounds in their first trimester. 

To do a transvaginal ultrasound, doctors take a long cylindrical ultrasound transducer, cover it with a condom, and put it inside the woman's vagina where they can move it around as needed. This gets the ultrasound closer to the fetus, there is less intervening tissue to impede transmission, and it therefore improves the quality of the images.

Transvaginal ultrasounds are common in the first trimester of pregnancy in women of all sizes.  They are usually done in order to date the pregnancy more accurately and/or to tell if the pregnancy is viable.

In the second trimester, doctors usually switch to transabominal ultrasounds in most patients, which are commonly used to look for any problems with fetal structure (birth defects) and to check placental placement.

However, because it is more difficult to visualize the fetus adequately in women of size, doctors may still need to use transvaginal ultrasounds in women of size early in the second trimester (especially women with a lot of abdominal adiposity) in order to get a clearer picture.  By the end of the second trimester, however, doctors are usually able to get adequate images via transabdominal ultrasounds, even in women of very large size.

These are the main differences between ultrasound in women of average size and women of increased size. However, most of the time, reasonably adequate images are obtained and the procedure is very similar, regardless of size.

Possible Problems To Be Aware Of

Although ultrasounds usually go just fine with women of size, there are some possible problems to be aware of.  The first we already discussed; doctors may need to use transvaginal ultrasounds longer in women of size, and the quality of images can be decreased, regardless of the method.

Another problem women of size sometimes encounter is that doctors and ultrasound technicians may press extra hard on women of size to try and compensate for less-clear images. (This has happened to me...ouch!)

Sometimes pressing firmly does help get a better image, but pressing extremely hard can also cause more problems than it solves by distorting the image that they do get.  There have been women of size who have been misdiagnosed with birth defects due to the ultrasound tech pressing too hard.

One woman wrote to me about her experience with this; the ultrasound tech pressed extremely hard, despite her protestations, and they got a devastating diagnosis.
Jessica's Story (paraphrased): I had an ultrasound at 18 weeks. I was told my weight made it impossible to scan the baby, and they saw encephaly [Kmom note: Hydrocephaly?] on the scan. They told me he was going to have a grossly misshapen head and that I'd need a c-section. They sent me to a high-risk OB. He saw the scan and said, "Wait a minute, you're pushing too hard! Do a vaginal!" They did the vaginal and there was our rascal, safe and sound, the right size, and no deformity. I was sore for a week after the abdominal scan, the transducer hurt so bad.

What happens when they push too hard is they distort and add artifact to what they can't see, and the baby looks deformed to their measurements.
If you are told that your baby has deformities or other problems based on an ultrasound scan and they seemed to be pushing pretty hard, ask for the scan to be repeated with a transvaginal scan or by a perinatologist (who usually has the most advanced equipment). Although it is uncommon for images to be distorted from too-strong pressure, it has happened, and should be ruled out as a cause before making a final diagnosis.

Although more firm pressure may be needed on women of size, you should NOT have to endure pain during an ultrasound. If you experience this problem, let the tech know that he/she is hurting you. Let them know that you realize that doing an ultrasound on a heavy person can be more difficult, but suggest that they try more gently at first and only increase pressure if needed. Remind them that if the results they get are suboptimal, there is always the option of a transvaginal ultrasound instead. If they don't listen, then end the session and ask for another session at another time with someone who will listen to and respect your concerns and discomfort.

Improving Image Quality in Women of Size

If your doctor or ultrasound tech is having difficulty getting an adequate image on you, there are several ways to improve image quality in a woman of size. 

For example, often just coming back for another ultrasound in a few weeks is enough to "see" everything more clearly. The baby is older, the uterus has lifted up out of the pelvis a bit more, and the baby may be in a better position the second time. These factors can be very important. 

Research shows that just waiting a few weeks is usually enough to get adequate ultrasounds in most women of size.  Probably the best alternative is simply to wait until 18-20 weeks to do an ultrasound at all in women of size, since after that point, most scans are able to get adequate results. 

Requesting that a follow-up ultrasound be done on a more powerful machine in a center that specializes in prenatal ultrasound may also improve results as well. Not all ultrasound machines are of equal quality; the ones in a doctor's office tend to be the least effective.  Furthermore, it can be very helpful to see someone who specializes in prenatal ultrasound for a living, because they often have the best skills in how to elicit clearer images. 

There are also several other refinements that can be done if the technician has difficulty resolving the images adequately. First, if you have a large "apron" (saggy belly), pull it up and hold it back so the transducer can go underneath/below it. This reduces the amount of adipose tissue the transducer has to go through and can therefore improve the image.  Don't be embarrassed if you are asked to do this; your body is simply your body, lots of people of all sizes have droops and sags in various bits, and it's not that uncommon in diagnostic tests to have to pull and push things this way and that a bit. Be matter-of-fact about it and just do it. It really can help.

Turning on your side and putting the transducer on the side may also help clarify the images, especially if the baby's position is less than optimal, or if there are multiple babies inside.

Another technique they can use to clarify images later in pregnancy is to put a vaginal transducer inside your belly button. Some research has reported success with this, especially with visualizing the fetal heart.

Rosenberg (1995) reported on their experience using transvaginal probes in the belly buttons of obese women to help improve ultrasound resolution. 19 of the 25 cases involved incomplete imaging of the fetal heart. Techs filled the women's belly buttons with ultrasound transmission gel, and then a transvaginal probe was inserted into the belly button. This improved image resolution and resulted in satisfactory heart images in 18 of the 19 women with incomplete fetal cardiac reports. All told, 24 of the 25 heavy women (96%) were able to have a 'complete fetal survey' using this technique.

Remember also that not all problems with ultrasound imaging result from fatness.  If the baby is in a poor position or if the placenta is anterior (in the front), this can decrease the accuracy and clarity of the images.  Technician skill and the power of the ultrasound machine can also impact results.

So although it's true that ultrasound accuracy is definitely lessened in women of size as a group, it's difficult to know whether the problem in any particular scan is due to adiposity or any one of many other factors.  Don't take it as a personal indictment if there is a problem with your scan; be aware of the possible problems, know the possible fixes, and consider trying again in a few weeks if you feel it's really important to have a complete scan. 

Coming Soon: Do Women of Size NEED Extra Ultrasound Scans? What are the pros and cons of having ultrasounds?


Anonymous said...

My father-in-law is an OB and my mother-in-law is his sonographer. So, both times my wife was pregnant we got to have as many ultrasounds as we wanted (which is AWESOME!!!)

One thing I didn't see mentioned was that it is a LOT easier to see if somebody lifts your belly (or panus, in creepy medical lingo) and they do the ultrasound on your waist beneath your belly.

Because of our circumstances, we were able to experiment more for the best results. But you'll need someone to hold up your belly while this is done. My wife could hold her own belly up if I wasn't, but it was difficult for her to stay in that position.

All that being said, I'm guessing that a lot of sonographers might not be comfortable pointing this out because it might be awkward to say "Hey, lift up your belly." But we had no problem getting images of our first daughter and the only problem with had with our second was that she never wanted to face the screen.

So, if you're having trouble try lifting your belly and scanning underneath.


Unknown said...

I'm glad you addressed this - I heard an editorial on NPR about doing ultrasounds on fat patients, and the person who wrote the editorial had a definite patient-blaming slant to it, with a side order of blaming obesity for rising medical costs ("lose weight already so that we can do ultrasounds clearly and stop costing taxpayers so much money in missed diagnoses"). It's nice to see someone put the onus on the doctors to be creative, rather than their patients to lose weight.

nopinkhere said...

Thankfully, I never had a problem with this. But I had all my ultrasounds at the perinatologist's office where I was referred by my midwife. I'm happy to know some techniques for the future if needed.

Raine @ Mama Rants said...

One thing I noticed was that it seemed to show much more in the ultrasound when I drank a lot of water beforehand, but I wonder how many women skip eating or drinking beforehand because they know they'll have to weigh and possibly be berated for it if the number on the scale has risen more than the doctor thinks it should.

Well-Rounded Mama said...

Atchka, I did actually mention the lifting the belly thing, in the section on improving image quality. You're right, this really can help sometimes.

Raine, you're right that drinking more water ahead of time can help, at least for abdominal ultrasounds. However, sometimes you have to wait a while for the ultrasound and then all the extra water can be miserable! So while I encourage women to drink more than usual before an u/s, they should know they don't have to push it to the point of discomfort.

Laura said...


I am very very heavy and have been worried about how well ultrasounds may work for me.

I had my 20 week ultrasound last week. Although the doctor was not reallyhappy with the clarity of the images, I believe she was able to see most of what she was looking for. She said that everything she could see looked fine but there were some things that she was unable to visualize. She asked me to come back in 3 weeks for a follow up ultrasound. I am worried that she will still be unable to see whatever she couldnt see last time. I am also worried that if the pictures werent clear she may have missed issues that may have been caught in a thinner woman. I have had all the various blood tests for chromosonal issues and everything came back fine. Does anyone know if the blood tests are pretty accurate?

Also what can I do to help increase the possibility of getting good images at the next ultrasound? Anything I can do besides drinking lots of water?

One more thing has anyone gone to one of those proffessional 3d/4d ultrasound places? I was wondering if I might have better results with a 3d/4d ultrasound.

Well-Rounded Mama said...

Laura, although it's harder on average to see every structure perfectly in women of size, usually just waiting a few weeks is enough to resolve MOST issues. Your doctor knew this when she asked you to come back for another ultrasound in a few weeks. That should likely resolve MOST issues.

The blog post had a few ideas for improving images if they continue to be a challenge, such as turning on your side, using a vaginal ultrasound probe in your belly button area, having you drink even more water, etc.

Are the blood tests accurate? Well, no tests are 100% accurate.....NONE. Are they reasonably accurate? Yes, especially the versions that look at more than one hormone marker.

However, prenatal blood tests are less accurate in women of size.....how accurate the LATEST tests are in women of size is not clear (I've seen no recent research on the latest versions in women of size). We know that the earlier tests had a high margin of error in women of size; I haven't seen any data about the latest tests in women of size, but what I've heard from various sources is that they are not terribly accurate in women over 250 lbs.

However, remember that the chances of something being wrong with your baby are very small, and even more small once you add in ultrasounds and good results on the blood tests. No one can promise that there aren't any problems, but chances of a major problem being missed after all that are probably pretty small. I wouldn't spend much time worrying about it.

Go do your next ultrasound if that would reassure you...that will probably resolve most or all of your image issues.....but if not, remember that the chances of an undetected problem are small after all that and not worth a lot of worry time.

Laura said...


Thanks for the reply. I will do my best not to worry. :-) Im only 26...so hopefully age is on my side. Plus although im very heavy I have always been healthy and surprisingly active...although right now ive been feeling pretty tired..lol

Once again thanks for the reply and also for creating such a wonderful site! The info I have gotten from this site is priceless! Thank you so much!

Anonymous said...

First off, I'm sorry if this post is a little all over the place but I am so happy to have a place to discuss this concern and have a lot to be heard about!

THANK YOU SO MUCH for this post. I am approximately 295 pounds and about 19 weeks pregnant. I had an ultrasound two days ago and have been experiencing a lot of soreness and pain in my abdomen post ultrasound. Though I told the technician (a young woman who had been doing this for two years) that she was hurting me several times, she was polite and apologized (and certainly did not seem intentionally discriminatory in any way, and I am very sensitive to fatphobia in medical care) she did continue to press really hard. The ultrasound took about an hour and a half so I think the length and the pressure combined to create the soreness. I do think it's totally possible she was "compensating" for my size by increased pressure and that it's reasonable to write a letter of concern about this to the facility in which I received the ultrasound. I think awareness and dialog are healthy tools for sorting out misinformation and to benefit those that come after me.
I am loathe to cry fatphobia or discrimination without evidence so reading that some of the most common problems in ultrasound due to size such as an accurate view of the heart, the cranio-facial structure, and spine, brought me comfort. Those are the exact three things the technician had difficulty with and I was asked to reschedule for a few weeks from now. My ultrasound also dated me a little earlier (18 weeks, 3 days) than I had been tracking with my midwives based on my LMP. She also could not determine the sex ("genitals" really) of the fetus, which is far less important to me than any of those other things. I would love a boy/girl/intersex/trans child equally the same. And I really didn't want to have more than one ultrasound because I have read studies that suggest that ultrasounds can cause problems in cell growth, but since my friend had a child with an extreme cleft palate/lip and my mom also had a cleft palate as did my other friend's daughter,this combined with the increased risk for spina bifida in women of size does make me convinced enough to get the second ultrasound. Truthfully, I'm happy to have another peek at the nether regions but mostly because even as we dress our daughter gender neutral a lot and didn't tell anyone she was a girl before she was born (we found out at 20 weeks with her)I might need some more boy clothes if it's a boy. I draw the line at putting boys in dresses before they can make that choice for themselves.

Cindy said...

I had my 20 week scan yesterday and experienced the technician pushing too hard, so hard that she broke my skin. My husband noted that I was bleeding and the tech laughingly apologized. I am thinking about filing a complaint but I'm not sure if i'm overreacting. She said baby was low in my pelvis, and I understand she had to press hard, but there was no consideration of making sure I wasn't hurt especially when she kept pushing into my broken bleeding skin.

Anonymous said...

@Cindy - Not okay! I had a tech do that in 2005 with my 1st. Not only was I in pain & had trouble walking for a couple weeks, but I got a BAD diagnosis! I was told I had little to no amniotic fluid & my baby probably wouldn't survive :(. Thankfully I was referred to a specialist, they redid the scan, any my little girl was fine. I was told pushing to hard can distort the image giving a false diagnosis & causing undue stress. Before I filed a complaint I thought about how I would feel if this happened to someone else. Good Luck with everything :)

Due w/#3 11/2014

Unknown said...

My friend just found out that she's pregnant, and we're all so excited to see the first ultrasound. To be honest, I had no idea that there were so many different ways that someone could do their ultrasound. We're hoping that everything will look fine, and I was wondering if any mothers had any advice on which ultra sound to get. I've heard there are 3D ones, and I was wondering if anyone has had one of those?

Sara Welsh | http://www.cherishedmemoriesultrasound.com/

momofjohnjr said...

Monday was my first dr. Appt. & for multiple reasons I have found a new one. Just past 9 weeks the Dr had me hold my stomach and kept pressing hard and insisted I was Not that far along...but the thing is I'm positive about my lmp. The thing is with the child before this one he used a transvaginal but this one was external. He didn't even order labs and my new dr. Can't see me til almost my 12th week. I've been worried about the size of the baby because I'm not getting enough sleep but isn't it quite possible it's because he did not do an internal??

momofjohnjr said...

Btw...this is #4.

Unknown said...

7 weeks have had 2 ultrasound vaginal as well they keep saying they see sac but no baby can this be because of my weight

Well-Rounded Mama said...

Deloris, more likely it is because you are only 7 weeks along. More adipose tissue can indeed make it harder to see in an ultrasound, but often it is difficult at 7 weeks in women of many different sizes. Also depends on where baby is implanted, the skill of the ultrasound tech, and many other factors. Yes, it's possible that perhaps there is a sac but no baby but more likely it's just that things are too early to see clearly.

Chances are you will see things just fine with a bit more time and at that point you will know what is going on. Don't let anyone rush you into any actions without more data from further along.

Kate from BC said...

I just went through a horrendous ultrasound for my 20 weeks ultrasound. It started with " did you gain all this weight from pregnancy, or is this your normal weight?" This is my third baby and I've never experienced this kind of abuse before. During the first ten minutes i asked her what she was doing because she was digging into my hip bone and she replied that she didn't have time to explain everything she does during an ultrasound. I basically laid there like a piece of meat on a slab crying while she continued to molest my belly. I'm still crying about the loss of what's suppose to be a magical 20 week ultrasound.

Margarita said...

I'm fat and I've had 3 early ultrasounds, there was no problem seing the baby and taking all the measures. I would ask that someone else does the ultrasound or go somewhere else.

Susana said...

"This is my third baby and I've never experienced this kind of abuse before."
I'm very sorry to read about this. No one, not you not any woman should go through what you went through here Kate.

I will really like to know that clinic or what doctor did you go to so that I never ever go there and end up like you.

Jade Brunet said...

I appreciate this information provided about ultrasounds and women of size. I did not know that ultrasounds were slightly more difficult to perform with these women than with those of average size. It is harder to determine possible problems and see detail. It is a good idea to discuss this problem with a doctor to learn of other potential options such as a transvaginal ultrasound or a transabdonimal ultrasound. It is amazing to know that with technology, these concerns can be resolved.

Jade Brunet said...
This comment has been removed by a blog administrator.
Anonymous said...

Today, currently 23 weeks, I had an additional ultrasound as they told me I had not drank enough water the first time @ 19 weeks. The tech took about 10 minutes and told me to wait for the Dr. to come in to talk. When the Dr. came in, the first thing she said was "that because you are so obese we can't get a good look at the organs. The reason for this follow up appt was to get the images we need and determine if there are any serious birth defects because this is the last week you would be able to terminate the pregnancy." I was so taken aback by her demeanor and frankness all I could say was "OK". She then proceeded to say that she had referred to some of her colleagues to see what they would do in this situation and that the options would be to get an MRI and be seen by a cardiologist. This is my 3rd child, my youngest just turned 1 last month and I’m 5'8 320 pds with no issue prior. >positive vibe- at least she didn’t call me morbidly obese.