Abstract
This issue of the Journal of Diagnostic Medical Sonography is about women’s health. According to data from the Centers for Disease Control and Prevention, 1 in 1900, the life expectancy for women of all races in the United States was 48.3 years. In 2014, it was 81.3 years, an increase of 33 years in 114 years. Women are statistically living longer, and yet early research in our country was primarily focused on men.
In 1918, cardiovascular disease (CVD) was the leading cause of death for both genders (more frequently in men), with much of the research data obtained from men. In the 1970s, CVD deaths began to decline for the total population; however, for women, the total deaths from CVD began to increase. In 1997, the American Heart Association released a study revealing that a majority of women (93%) did not realize that CVD was their utmost health threat and then created a campaign called “Take Wellness to Heart” to raise awareness about women’s health disease. 2 This online campaign eventually led to the “Go Red” program to reduce risk factors, coronary heart disease, and stroke.
Meanwhile, the U.S. government decided that research was important for children and human health. Beginning in 1962, Congress established a new National Institute of Health, the National Institute of Child Health and Human Development (NICHD), and in 1986, the Maternal-Fetal Medicine Units (MFMU) Network was established within the NICHD to respond to the need for well-designed clinical trials in maternal-fetal medicine and obstetrics. According to the MFMU website (www.nichd.nih.gov/research/supported/mfmu), “The aims of the network are to reduce maternal, fetal, and infant morbidity related to preterm birth, fetal growth abnormalities, and maternal complications and to provide the rationale for evidence-based, cost-effective obstetric practice.” Network studies have included randomized clinical trials, cohort studies, and registries. Clinical sites at U.S. universities and hospitals, along with the NICHD, are developing research studies, enrolling participants, and analyzing the data. Throughout the years, there have been prospective publications in the New England Journal of Medicine that have resulted from MFMU research. A few of these publications include the following:
“The Length of the Cervix and the Risk of Spontaneous Premature Delivery” 3 was published in 1996. This article’s findings “found an inverse relationship between the length of the cervix as measured by sonography during pregnancy and the frequency of preterm delivery.” In addition to women with a history of a preterm birth benefiting from a second trimester vaginal ultrasound of the cervix, many low-risk women will routinely undergo a transvaginal ultrasound screening to determine cervical length during their anatomy or detailed examination—a direct result of this publication.
The rate of cesarean delivery had increased from 5% of all deliveries in 1970 to 26% in 2002. This led to the publication in 2004 of “Maternal and Perinatal Outcomes Associated With a Trial of Labor After Prior Cesarean Delivery.” 4 This prospective cohort 4-year study of women was important, as this research study of women with a singleton gestation and a history of cesarean delivery included 17,898 women who attempted a vaginal delivery and 15,801 women who underwent elective repeat cesarean delivery without labor. This study found that a “trial of labor after a prior cesarean delivery is associated with a greater perinatal risk than is elective repeated cesarean delivery without labor,” but the risk is small. Most importantly, as a result of this study, women can be counseled with statistical information about their future choice for delivery after a cesarean section.
Gestational diabetes mellitus has been rising in the United States and occurs in 1% to 14% of all pregnancies. In 2009, “A Multicenter, Randomized Trial of Treatment for Mild Gestational Diabetes” 5 was published. A total of 958 women were randomized to either a treatment group (dietary intervention, self-monitoring, and insulin therapy, if necessary) or a control group, which received usual prenatal care. The results of this study revealed a reduced risk of fetal overgrowth, shoulder dystocia, cesarean delivery, and hypertensive disorders but did not significantly reduce the frequency of stillbirth or perinatal death.
Obstetric sonographers have witnessed policy and guideline changes throughout the years in consensus statements from the American Institute of Ultrasound in Medicine, the American Congress of Obstetricians and Gynecologists (ACOG), and the Society for Maternal-Fetal Medicine (SMFM). The ACOG and SMFM have also updated Practice Bulletins based on these large network studies.
In 1993, the Women’s Health Initiative, through a National Institutes of Health branch, the National Heart, Lung, and Blood Institute, began a “long-term national health study that focused on strategies for preventing heart disease, breast and colorectal cancer, and osteoporotic fractures in postmenopausal women. These chronic diseases are the major causes of death, disability, and frailty in older women of all races and socioeconomic backgrounds.”
According to their website (www.whi.org), the Women’s Health Initiative enrolled more than 160,000 postmenopausal women between 50 and 79 years of age in one or more randomized clinical trials evaluating the effects of hormone therapy, dietary modification, calcium, and vitamin D supplementation or in an observational study. The first phase of this study concluded in 2005, and extension studies will continue the follow-up of all women enrolled through 2020. Results from this ground-breaking research have impacted how healthcare providers prevent and treat postmenopausal disease. To date, the Women’s Health Initiative has published more than “1,400 articles and approved and funded 289 ancillary studies.”
In the mid- to late 1970s, ultrasound articles began to appear in the literature on the evaluation of breast tissue. Two significant breast ultrasound articles were published in the journal Radiology with a grant from the National Cancer Institute (www.nih.gov/about-nih/what-we-do/nih-almanac/national-cancer-institute-nci), which is a part of the National Institutes of Health: “Ultrasound Mammography: A Comparison With Radiographic Mammography” 6 and “Ultrasound Analysis of 104 Primary Breast Carcinomas Classified According to Histopathologic Type.” 7
Both articles utilized two water-path ultrasound machines that used large-aperture 3 MHz transducers. With women lying in a prone position, the breast tissue was submerged in warm water and evaluated two ways: with the breast tissue hanging dependently and with the breast tissue compressed toward the chest wall. Results revealed that water-path scanners could diagnose benign and malignant disease in a symptomatic population. Ultrasound descriptors were discussed for the different types of malignancies that had variable ultrasound characteristics. This technique was not viewed as a screening examination for breast malignancy. Today, breast ultrasound examinations are primarily performed to evaluate a mass detected by a physician during a physical examination or to characterize a mass seen on mammography if it is a solid or fluid-filled mass.
Enjoy this issue of the Journal of Diagnostic Medical Sonography dedicated to women’s health.