Routine Anomaly Scan Ilse Erasmus

Routine Anomaly Scan Timing: 18 – 23 weeks Costs about R 230 – 00

RCOG Guidelines October 1997 Timing of sonars Best Acceptable Less Accept Dating 8-10 10-20 24 Viability >7 Twins Anytime Chorionicity 8-12 13-15 Fetal anomaly 18-20 NT 8-15* 15-16* 18-20*

Routine Anomaly Scan Waste of resource to request routine anomaly scan in the late second or 3rd trimester Waste of resource to request growth scan in 3rd trimester in the absence of an early sonar

Routine Anomaly Scan Indication in SA cost considerations??? Routine late bookers High risk Previous fetal/ neonatal anomalies Previous IUD AMA Maternal: disease index pregnancy / history of Medication Congenital anomalies

Routine Anomaly Scan Cochrane Database Radius?!? Reduction in post term inductions Twin Pregnancies Radius?!?

Routine Anomaly Scan Screening? 1/55 babies born with major anomaly Structural anomalies > single gene defects UK Fetal anomalies = 15% of perinatal deaths and 15% of deaths in first year of life

Routine Anomaly Scan Screening? Six objectives Reassurance that baby is apparently normal Or the identification of: Non –viable anomalies Anomalies associated with high morbidity and long term handicap Fetal conditions with the potential for intrauterine therapy Fetal conditions requiring postnatal investigation and/ or therapy Parental preparation

Routine Anomaly Scan Screening? Lethal anomalies – anencheph, BRA, thanatophoric dwarfs High morbidity and long term handicap – NTD, cardiac,aneuploidy Potential intrauterine therapy – RH, Parvo,TTS Fetal conditions requiring postnatal investigation and/ or therapy – renal, facial cleft Parental preparation

RCOG Guidelines October 1997 Detection Rates for Specific anomalies Anomaly <24w Sensitivity Specificity Anencheph/Enc 87 – 100% (>95%) 99 – 100% Intracranial Path 27 – 100% (70%) Renal Agenesis 75 - 100% (85%) Cystic Lung 0- 100% (100%) Cardiac Major 4 – 77% (47%) 98 – 99% CD hernia 0 – 100% (40%) Exomphalos 0 – 100% (>95%) Gastroschisis 0 –100% (66%) 0 - 100% Muscuoloskeletal 0 –100% (50%)

RCOG Guidelines October 1997 Detection Rates for Specific anomalies Anomaly < 24 Sensitivity Specificity Spina Bifida 69 – 100% (78%) 99 – 100% Major Renal 26 – 100% (60%)

RCOG Routine sonar in Pregnancy July 2000 6 year Scottish Study Booking scan only % Minimum standard scan % Anencheph 97 100 ( better) Spina Bifida 61 92 (better) Major cardiac (hypoplastic LV) 14 61 (better) CD Hernia 30 62 (better) Gastroshcisis 86 100 (better) Exomphalos 45 92 (same) Major renal Renal agenesis 76 85 (better)

RCOG 2000 July Minimum standard for a 20 week anomaly scan Gestational age BPD, HC, FL, AC

Measurments

RCOG 2000 July Minimum standard for a 20 week anomaly scan Gestational age BPD, HC, FL, AC Fetal Normality Head shape and internal structures CSP, Cerebellum, Ventricular size at atrium (<10mm) Spine longitudinal and transverse Abdominal shape and content at the level of the stomach

RCOG 2000 July Minimum standard for a 20 week anomaly scan Renal Pelvis (<5mm AP) Longitudinal axis – abdominal thoracic appearance (diaphragm/bladder) Thorax at level of 4ch cardiac view Arms – 2 x 3 long bones + hands (not counting fingers) Legs - 2 x 3 long bones + feet (not counting toes)

RCOG 2000 July Minimum standard for a 20 week anomaly scan

RCOG 2000 July Optimal standard for a 20 week anomaly scan The above plus: Cardiac outflow tracts Face and lips

RCOG 2000 July Marker scans Not considered “routine” Isolated markers of dubious value Increased overall detection rate increase from 51% - 55% but FPR from 1/2332 to 1/188!!!!! (Boyd PA Lancet 1998) Two or more markers significant Screening using maternal age, age + NT, age+ serum will identify 50 – 80% So marker scan as screening in unscreened population unlikely to be of use

RCOG 2000 July Marker scans “Markers” CPC Ventriculomegaly(>10mm at atrium) Echogenic bowel(equivalent to bone density) Head shape Nuchal skinfold thickness(>5mm at 20 weeks) CM Cleft lip Echogenic intracardiac focus

RCOG 2000 July Marker scans Dilated renal pelvis(>5mmAP) Short Femur/Humerus Talipes Sandal gap Clinodactyly Clenched hand Two vessel cord

RCOG 2000 July Marker scans Other risk factors Maternal age > 35 Serum screening results Nuchal translucency at 11 – 14 weeks

Standard views Pilu, Nicolaides CD - ROM ISUOG Standards

Standard views Intrauterine Amount of fetuses Cardiac activity Placental Position, Appearance Cord vessels Liquor

Standard views Head and Brain

Standard views Face

Standard views Face

Standard views Spine

Standard views Heart

Standard views GIT

Standard views Limbs

Anomaly scan Skull & Brain Normal and abnormal

Anomaly scan Face Normal and abnormal

Anomaly scan Spine Normal and abnormal

Normal Spine

Abnormal Spine

Anomaly scan GIT Normal and abnormal

Anomaly scan Heart Normal and abnormal

Anomaly scan Kidneys Normal and abnormal

Anomaly scan Limbs Normal and abnormal