Fetal Anomaly Scan Guidelines

Dr Mary Moran

• National

• United Kingdom

• International

• Implications

National Survey 2016

• Prof Keelin O’Donoghue

(Principal Investigator; Consultant Obstetrician &

Gynaecologist; Senior Lecturer, University College Cork)

• Fetal anomaly ultrasound is offered:

> universally to all women in 7/19 (37%) units

> selectively to some women in 7/19 (37%) units

> not offered at all in the remaining 5/19 (26%)

units

• Universal first trimester ultrasound, performed in a dedicated ultrasound department by a suitably qualified sonographer, is offered to 47% of women nationally

• Universal first trimester ultrasound, performed in a dedicated ultrasound department by a suitably qualified sonographer, is offered to 47% of women nationally

• Universal first trimester ultrasound, performed in a dedicated ultrasound department by a suitably qualified sonographer, is offered to 47% of women nationally

National IUGR Guideline

Key Recommendation 1

• A comprehensive medical and obstetric history should be taken from every patient booking for antenatal care, ideally prior to 14 weeks gestation, to assess risk factors for fetal growth restriction (FGR). In addition, assignment of estimated date of delivery (EDD) should occur at this visit based on menstrual history or, more appropriately, on dating ultrasound

Key Recommendation 6

• Every woman should undergo a comprehensive evaluation of the fetal anatomy (by a sonographer or clinician who is experienced in ultrasound) between 20 and 22 weeks gestation to rule out structural abnormalities and to assess for soft markers as a sign of chromosomal abnormalities. Referral to a fetal medicine specialist should occur as per local protocol

National Multiple Pregnancy Guideline

Key Recommendation 1

• Where multiple gestation is identified on ultrasound examination, chorionicity should be assigned at the earliest opportunity. This is best achieved before 14 weeks gestation

Ireland 2016

• “Psychologically, the late diagnosis made it impossible to process or prepare for what lay ahead”

• “We feel it’s a major part of having a late diagnosis, that the heartbreak and pain is made so much harder by the constraint of time. At that late stage it forces you to deal with the shock and grief in a way that you may not normally do”

• “We had to take in the diagnosis, the fatal outcome, breaking the news to everyone we know, becoming parents, a sick child, the death of a child and a funeral and go home and close the door on an empty nursery”

• “Nobody is capable of processing all that in four weeks, and it is this that I struggle to deal with to this day”

• “Heartbreak made worse by the shortness of time”

• “No inkling of fate that awaited”

• “If we had had a 20-week scan, we would have had more time to come to terms with it”

February 2017

• 36% of women did not get foetal anomaly scan

• Professor of Obstetrics at UCC and Consultant Obstetrician at Cork University Maternity Hospital Louise Kenny said we are providing "inadequate care" to mothers and babies, "which impacts upon clinical outcomes, sometimes with devastating consequences.“

(Oireachtas Health Committee)

• Usually performed between 19-22 weeks' gestation, the main purpose of the fetal anomaly scan is to screen for structural foetal abnormalities to facilitate prenatal diagnosis of a wide-range of conditions.

• Professor Kenny said: "Without nationwide access to anomaly scans, we continue to provide inadequate or inappropriate care to mothers and babies, which impacts upon clinical outcomes, sometimes with devastating consequences."

• She cited the example of babies with undiagnosed structural anomalies such as cardiac defects being born outside centres of paediatric surgery and will require emergency ex-utero transfer to Dublin immediately after birth

• "For some babies, this will significantly decrease their chance of survival. In other cases, an absence of ultrasound means that the opportunity of in utero foetal therapy will be missed and babies will die of potentially treatable conditions."

• She added: "A lack of ultrasound also has detrimental effects on maternal health. Women will continue to have unnecessary caesarean sections and other interventions for infants who cannot survive.”

• "Families will continue to be deprived of prenatal palliative care, to enable them to prepare for their baby's death. Obstetricians will continue to deal with unexpectedly bad outcomes at sometimes extremely complicated deliveries

• "We are expected to explain to parents how a major anomaly, normally clearly visible on routine ultrasound, was not diagnosed and to assist parents in dealing with the aftermath of a traumatic delivery and either unexpected bereavement or unanticipated illness or disability."

International Guidelines

• Gestational Age

• Equipment

• Images and Measurements

• Documentation / Report

• When to repeat scan

• Sonographer/Clinician qualifications

• Audit /QA

NHS/FASP (18-20+6/40)

American Institute for Ultrasound in Medicine

Australian Society Ultrasound Medicine (18-22/40)

• Each practice should develop a protocol on the procedure to be followed when an abnormality is detected. This protocol should include guidelines for the immediate care of the patient and how the referring doctor will be informed

ISUOG (18-22 weeks)

Qualifications will vary country to country. For optimal scans: • trained in the use of diagnostic ultrasongraphy

and related safety issues • regularly perform fetal ultrasound scans • participate in continuing educational activities • have established appropriate referral patterns for

suspicious or abnormal findings • routinely undertake quality assurance and control

measures

ISUOG Cardiac Scanning Guidelines

Issues

• Range of gestations and views

• First trimester Screening

• Scans performed in private clinics by staff not qualified to a high level / Patients opting for 3D scans

NB

• Upskilling of Sonographers

• Registration

• CPD

References

• AIUM (2013). AIUM Practice Parameter for the Performance of Obstetric Ultrasound Examinations.

• ASUM (2014). Guidelines for The Mid-Trimester Obstetric Scan (D2).

• HSE/Institute Obs & Gyn (2014). Clinical Practice Guideline No 29: Fetal Growth Restriction- Recognition, Diagnosis and Management.

• HSE/Institute Obs & Gyn (2012). Clinical Practice Guideline No 14: Management of Multiple Pregnancy. ISUOG (2013).

• ISUOG Practice Guidelines (updated): sonographic screening of the fetal heart. Ultrasound Obstet Gynecol 2013; 41: 348–359.

• NHS (2015). Fetal Anomaly Screening Programme; www.gov.uk/topic/population-screening-programmes

• Salomon et al (2010). Practice guidelines for performance of the routine mid-trimester fetal ultrasound scan. Ultrasound Obstet Gynecol/ www.isuog.org