A Future World Ultrasound lets physician 'listen' to growing fetus

THE BALTIMORE SUN

A bevy of bellies assembles daily in the Village of Cross Keys to await his scrutiny. Some are puffy, others downright mountainous. All are gobbed with goo.

Dr. Roger Sanders looks through the taut tummy skin at males flailing tiny arms, females floating contentedly, twins wrestling. Transducer in hand, he can perceive a being the size of a pinhead, just 2 1/2 weeks after conception. By the time it triples in size to 3 millimeters in length, Dr. Sanders can detect the motion of a heart beating, if not see the muscle itself.

He bears witness to the evolution of the brain and spine and the formation of all major organs within two months of conception. He watches as the fetus hiccups, sucks, flinches and grasps -- determining if it's content or in distress, assessing if it's growing or dying.

Daily, Dr. Sanders peers into the secluded water world of the unborn.

This week, he is directing an international conference on fetal anomalies at the Hyatt Regency at the Inner Harbor, where more than 500 health-care providers will explore and debate the latest research in genetics, prenatal testing, sonography, ethics and neonatology.

Dr. Sanders is the sole physician in the Baltimore area (and one of 40 nationwide) to devote his private practice exclusively to the use and development of ultrasound. (While the bulk of his practice is dedicated to obstetrics, he does perform other diagnostic ultrasound tests.)

At the Ultrasound Institute of Baltimore, as he charts the progress of fetuses, Dr. Sanders nurtures an exclusive medical sub-specialty, the product of the union of maternal-fetal medicine and ultrasound. He is a radiologist admittedly trespassing on obstetric turf.

"I'm doing much more in the way of counseling, of amniocentesis and of managing fetal anomaly cases," he says. "It's an emerging specialty."

His niche, though, is not without controversy.

Obstetric procedures such as amniocentesis and the management of obstetric patients are best left to obstetricians, says Dr. Sharon Dooley, chairman of the Committee of Obstetrics, Maternal and Fetal Medicine for the American College of Obstetricians and Gynecologists.

A turf war may be raging between obstetricians and radiologists, but not at the University of Maryland, where Dr. Sanders is a valued member of the team of specialists who manage high-risk pregnancies.

"There are a handful of people in the country who have the tremendous expertise in a broad base of knowledge that Roger does," says Dr. David A. Nagey, an obstetrician-gynecologist and director of Maternal-Fetal Medicine at the University of Maryland Hospital.

Dr. Sanders says he feels a duty to inform and educate his patients as he shows them real-time images: cinematic scenes of the workings of their bodies. Television monitors in the ceilings of his private office allow patients to follow along as he talks through their exams: "The baby has a full head of hair"; "The two cysts I detected last time on the brain have resolved themselves."

"I feel strongly the patient should be kept in the picture as the diagnostic routine goes on," says Dr. Sanders. "There are some doctors who still cling to the idea that they [and not I] should be the ones to talk to the patient about any sort of news. I've lost referrals because I tell patients what's going on, what I'm thinking. But I think doctors [who don't] are behind the times."

Even worse than being old-fashioned is being inept, and according to Dr. Sanders, "There's a lot of lousy ultrasound going on out there."

Diagnostic medical sonographers (technicians) are tested for proficiency and accredited, but there is no similar qualifying exam or board certification for physicians. Any physician with access to the technology can hang out a shingle and proclaim himself an ultrasonologist, he says.

No one was practicing ultrasound in Maryland 22 years ago when Dr. Sanders arrived at Johns Hopkins from Oxford University in his native England, where he had done "primitive" ultrasound studies of the head. He was the first in this state to use the technology, on both humans and animals.

Learning from dolphins

Having scanned polar bears, monkeys, tigers and apes, he was for a while the official zoo ultrasonologist -- until he realized he was terribly allergic to the animals he was scanning. One case involved an orangutan with a problem pregnancy for which he prescribed bed rest.

The animals from which Dr. Sanders learned the most are dolphins: They depend on ultrasound for communication, emitting high-frequency sounds from their nostrils and receiving them back on bony detectors on their skulls.

In ultrasound testing, the echoes of sound ultimately are translated into black, white and gray images, which, by their shape, position, size and brightness, Dr. Sanders recognizes either as viable organs or anomalies.

"I see an enormous number of normal babies, although I'm sure I see more abnormal babies than anyone else in this area," he says. "It does get to me now and again, but it's an intellectual exercise, which is very interesting.

"I guess I don't think of them as little people [as much as] I think of them as problems or dilemmas. I'm constantly trying to think about what's going on, what's going to happen."

Despite his tendency to depersonalize the subjects of his studies, he describes pregnancy losses at nine to 10 weeks as "particularly devastating -- perhaps because it's the time when they're just becoming viable individuals."

As the father of 19-year-old Nicolette and 13-year-old Nigel, he empathizes with the countless anxieties of parents-to-be.

"I must admit I was constantly sneaking a look" when his children were in the uterus, he said. "They had a lot of examinations, at least one a month."

The technology of 20 years ago was much less informative, however. He could see the outline of the pregnancy -- the head and the trunk -- but not much internal detail. The images were black and white; gray scales, which allow for subtler findings, didn't come about until 1973. There were only static images; real time became available in 1975 and wasn't widely used until 1980.

An area of study that excites Dr. Sanders involves using ultrasound as an alternative to more invasive prenatal tests. He is convinced the number of amniocentesis procedures performed could be cut. (Amniocentesis, in which a long hollow needle is used to extract amniotic fluid, poses some risk of miscarriage; ultrasound does not.)

Dr. Sanders, 56, is the editor of Ultrasound Quarterly, founder of the professional society for radiologists in ultrasound and author of a dozen books and many articles about the subject. But he plans to leave all that behind for a while. In the next five years, he hopes to pack a very large black bag and make a six-month house call to a tropical country, just him and his ultrasound machine. He would use it "in ways you wouldn't dream of using it in this country," he said, "because there are other technologies" available here.

Curiosity and altruism

A mixture of curiosity and altruism motivates him: "I think it would be beneficial if someone tried to use this modality in its highest possible way and took the technology to its potential.

"And I'm a Quaker, and I thought this would be a way of doing something constructive for civilization."

Dr. Sanders imposes on patients neither philosophy nor faith but rather offers all the information available to enable them to make and live with the gravest of decisions.

When something is lethal

"The key is it's terribly important to know if something is lethal," he said. "It makes the decision enormously easier for everyone. You've got to go to the absolute end to try to establish that.

"I want to expand the idea that there are situations where you can be 100 percent confident using ultrasound that the anomaly syndrome is lethal. There are probably at least a dozen different ones."

Some of what confronts Dr. Sanders is horrendous: babies with missing brains and twisted limbs. But most findings are subtler. For that reason, he relies on insight, odds and hunches as much as technical expertise. A little luck helps, and so does a lot of patience as he lies in wait for precious glimpses at the fetal face (a droopy, down-turned mouth could indicate an abnormality), as he stalks hard-to-photograph kidneys (if too bright, it could mean serious problems) and as he anticipates tiny fingers flashing by.

"Finger position is terribly critical," he said. "In certain chromosomal anomalies, they overlap in a fashion that you just can't take a still picture of. Unless you're looking at them [real-time], you can't recognize the overlapping. It's hard to pick it up."

Ironically, it was when he was searching for the most delicate of clues that he captured the least subtle of images.

His patient, a schoolteacher, had been exposed to a common childhood disease that posed a serious risk to her developing fetus.

"We didn't know when the infection might manifest in the fetus," Dr. Sanders said, "so she came in every week for 10 weeks."

The two played a waiting game, watching to see if and when something awful would begin to happen to the baby.

Finally, when it seemed as though the incubation period was over and everything appeared to Dr. Sanders to be intact, the baby took matters into her own hands, quite literally. Leaving nothing to chance (and perhaps celebrating the last of the tiresome photo shoots), she gave Dr. Sanders a victorious, in utero thumbs-up, as if to say, "I'm OK."

THE SANDERS FILE

Born: June 17, 1936, England.

Education: University College, Oxford, 1956-1960; University of Oxford Clinical Medical School, 1960-1964.

Occupation: Medical director, Ultrasound Institute of Baltimore, Cross Keys; clinical professor, diagnostic radiology and obstetrics, University of Maryland Hospital.

Resume: 1968, admitted as member of the Royal College of Physicians; 1976, president and founder, Society of Radiologists in Ultrasound; 1982, Presidential Award, American Institute of Ultrasound in Medicine; 1986-1990, professor of radiology and professor of urology, Johns Hopkins Hospital; 1987-present, editor, Ultrasound Quarterly.

Projects: Directing an international medical conference, "Structural Fetal Anomalies, the Total Picture," May 25-28 at the Hyatt Regency Baltimore.

Research interests: "I've been working on an attempt to try and decide when fetuses are first able to feel things, based on ultrasound -- when you first see movements that are purposeful. At 12 weeks, the movements seem random, fishlike, without any cohesive purpose; by 16 weeks, they sometimes try to grasp the amniocentesis needle."

Family: Wife, Barri; children Nigel, 13, and Nicolette, 19.

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