Ultrasound
Screening
July 2000
Supplement to Ultrasound Screening for Fetal Abnormalities
CONTENTS
Membership of the Working Party
1. Introduction
2. The Early Pregnancy Scan
3. The "20 week" Anomaly Scan
4. Standards
4.1 Quality of information
given to patients, and its explicitness
4.2 Setting and timing
4.3 Care and support for women
undergoing screening
4.4 Record keeping
4.5 Computer-based records
4.6 Quality and Audit
5. Assessment of screening programmes
6. Training
7. Equipment
8. References
Appendix 1 Baseline fetal anomaly scan
Appendix 2 Ultrasound Screening for
Aneuploidy Guidance for the professional
Appendix 3 Patient information leaflet -
Your ultrasound scan
Appendix 4 Potential detection rates based
on screening strategy
MEMBERSHIP OF THE WORKING PARTY
Professor M J Whittle FRCOG (Chair)
Professor of Fetal Medicine, University of Birmingham Head,
Academic Department of Obstetrics and Gynaecology
Dr L S Chitty MRCOG
Consultant in Genetics and Fetal Medicine University College
Hospital, London
Professor J P Neilson FRCOG
Department of Obstetrics & Gynaecology University of Liverpool
Dr I M Shirley FRCR
Consultant Radiologist The Hillingdon Hospital, Uxbridge
Dr N C Smith FRCOG
Consultant Obstetrician & Gynaecologist Aberdeen Maternity
Hospital
Professor Y G Ville MD
Professor, Head of Obstetrics & Gynaecology University of
Paris-Ouest
Mr M P Wyldes MRCOG
Consultant in Obstetrics & Gynaecology Birmingham Heartlands
Hospital
Acknowledgments
The Working Group gratefully acknowledges contributions from
Dr P Chudleigh
Siemens Senior Lecturer in Clinical Ultrasound Faculty of Health,
South Bank University, London
Professor T Marteau
Department of Psychiatry & Genetics Guy's Hospital with St
Thomas', London
Professor K Nicolaides
Director, Harris Birthright Research Centre for Fetal Medicine
King's College Hospital, London
Professor C Rodeck
Professor of Obstetrics and Gynaecology University College, London
Dr S Russell
Consultant Radiologist St Mary's Hospital, Manchester
Professor P Soothill
Chairman, Joint Committee RCR/RCOG
Royal College of Radiologists
National Screening Committee
1. INTRODUCTION
The 1997 Report of the Royal College of Obstetricians and
Gynaecologists Working Party on Ultrasound Screening for Fetal
Abnormalities(1) identified that one of the problems
with screening scans was the variable way in which they were
conducted throughout the country. There are no clear guidelines
about what should, or should not, be examined. Sonographers are
trained to look at all structures; however local resources, such
as the quality of ultrasound equipment and the time available for
each examination, may dictate exactly what is examined, certain
structures being more readily sought than others. As a result
there can be a lack of clarity about the content of the
examination which can lead to confusion for both ultrasonographer
and patient. A supplementary Working Group was convened in 1998 to
produce a standard format for a 20 week anomaly screening scan.
The Group agreed that a two-stage ultrasound examination programme
was acceptable, and a recent survey (unpublished) from the Joint
Committee of the Royal College of Obstetricians and Gynaecologists/Royal
College of Radiologists indicates that probably at least three
quarters of the units in the country use such a programme. This
paper provides recommendations for the two-stage scan programme:
an initial scan performed at booking and the second at or around
20 weeks' gestation. The role of anomaly scanning in the later
first/early second trimester has not been established although
research in this area continues.
2 The Early Pregnancy Scan
2.1 The first scan in early pregnancy, referred to as a
booking scan, is undertaken ideally before 15 weeks. The purpose
of this scan should be to establish:
- gestational age accurately
- viability
- fetal number, and in multiple pregnancies the chorionicity/amnionicity
- detection of gross fetal abnormalities
Randomised studies(2) suggest that at least one
routine scan in pregnancy to confirm gestational age confers
benefit, especially in reducing the need for intervention for
post-maturity. If serum testing is to be used as a method of
screening for Down syndrome, accurate knowledge of gestational age
is essential(3).
2.2 The Procedure. Before 13 weeks, gestational age can
be accurately assessed from the measurement of crown rump length.
However, from 13 weeks crown rump length should not be used
because the fetus becomes increasingly flexed making the
measurement unreliable. As an alternative bi-parietal diameter,
and/or head circumference should be used; some units include femur
length measurement.
2.3 The early scan can usually be performed abdominally
but, on occasion, a vaginal scan is necessary.
2.4 As far as scanning for nuchal translucency is
concerned, current evidence suggests that this is an effective way
of determining babies at risk of Down syndrome and is best
performed between 10-14 weeks. Whether it is preferable to serum
testing remains to be decided and it is most likely that a
combination of serum testing and nuchal translucency measurement
will produce the highest sensitivity for the lowest false positive
rate. However, whether or not nuchal translucency screening is
introduced is a funding issue for individual Trusts. The
Department of Health is awaiting the report of the Serum, Urine
and Ultrasound Screening Study (SURUSS) before it decides on its
position with regard to funding nationally.
3 The "20 week" Anomaly Scan
3.1 In units in which a booking scan is not performed,
the "20 week" scan provides dating information and
diagnosis of multiple pregnancy. The majority of non-viable
pregnancies will be lost before the scan at twenty weeks.
3.2 The twenty week anomaly scan is to reassure the
woman that her baby appears to have no obvious structural
abnormalities. Lack of explicitness about which structures have
been examined may lead to confusion. The literature provides a
range of detection rates and therefore individual units should
provide their own figures to inform women undergoing the "20
week" scan. Recent data(4) from one unit would
suggest that about 50% of significant abnormalities will be
identified by a screening scan. The value of identifying fetal
abnormalities at this stage is that it offers parents options.
Some, probably the majority, for serious lesions, will elect to
terminate the pregnancy. Those couples who choose to continue the
pregnancy have the opportunity to prepare themselves through
discussions with health care personnel and self-help groups,
whilst attendants can ensure appropriate care during pregnancy and
following delivery.
3.3 The objectives of the ultrasound examination should
be made as explicit as possible to women and their partners to
enable them to opt for, or opt out of, having a scan. For example,
women who do not wish to be informed of a risk of aneuploidy may
consider not having a scan at all.
3.4 A national standard for a routine ultrasound anomaly
scan is recommended by the Working Group. This would provide
parameters for sonographers, choice of options for women and
provide purchasers with indications of how much screening could be
accomplished within the available resources. For example, an
individual Trust could make a clear decision that it does not have
the resources for ultrasonographers to examine cardiac outflow
tracts. A clear indication of what could, and what could not, be
achieved with screening will remove a wide area of uncertainty and
would alleviate anxieties for both women and sonographers.
3.5 The Working Group propose that a "20 week"
scan should be to a minimum standard, which should be made clear
to the woman in the form of a leaflet. If a unit considers it
cannot deliver scans to this minimum standard then the "20
week" scan should be abandoned. Under these circumstances the
woman should have a single scan in pregnancy to establish the
objectives outlined in paragraph 2.1. If the equivalent of a
"20 week" scan is desired the woman should be referred
to an appropriate unit.
3.6 The Procedure
3.6.1 The minimum standard for a "20 week"
anomaly scan Gestational age can be established by measurement of
bi-parietal diameter, head circumference and femur length. The
inclusion of abdominal circumference would be optional.
Fetal Normality
- Head shape + internal structures cavum pellucidum cerebellum
ventricular size at atrium (<10 mm)
- Spine: longitudinal and transverse
- Abdominal shape and content at level of stomach
- Abdominal shape and content at level of kidneys and
umbilicus
- Renal pelvis (<5 mm AP measurement)
- Longitudinal axis - abdominal-thoracic appearance (diaphragm/bladder)
- Thorax at level of 4 chamber cardiac view
- Arms - three bones and hand (not counting fingers)
- Legs - three bones and foot (not counting toes)
3.6.2 The optimal standard for the "20 week"
anomaly scan If resources allow, the following could be added to
the features in 3.6.1:
- Cardiac outflow tracts
- Face and lips
It is likely that the "optimal scan" will only
improve the detection of cardiac abnormalities and clefts. Recent
evidence(5) seems to demonstrate above average
detection of fetal cardiac abnormality in areas which have most
likely been influenced by a training programme for
ultrasonographers started at Guy's Hospital some years ago(6).
However, ensuring the outflow tracts are intact takes additional
time and may require the woman to return for a further check in
15% of cases; an additional 9% may need another review(7).
3.7 A checklist for the baseline fetal anomaly scan is
included as Appendix 1.
3.8 Guidance on screening for aneuploidy for the
professional is included in Appendix 2.
3.9 Markers
The use of markers to identify the fetus at risk of aneuploidy has
been used in an erratic way. Markers may be seen during a routine
scan and when isolated are of dubious value(8),
especially when women have already been screened for Down syndrome
(either by nuchal translucency or maternal serum testing). One
study suggested that the use of markers increased the overall
detection of abnormalities from 51% to 55% but increased the false
positive rate from 1 in 2332 to 1 in 188(4). Two or
more markers may be significant and will need to be discussed with
the woman. The Working Group believes that a scan specifically
undertaken to screen for these markers would not be regarded as
routine, and therefore falls outside its remit.
4. Standards
4.1 Quality of information given to patients, and its
explicitness
Clear, written advice should be given to women prior to their scan
(see Appendix 3). The advice should indicate the nature and
purpose of the scan (ie the structures examined) together with the
detection rate for defined, common conditions. Preferably locally
derived detection rates should be indicated. Women should receive
a report that they understand and information could be provided in
a format such as in Appendix 1.
4.2 Setting and timing
4.2.1 The ultrasound examination should be undertaken in
an area/room designed for the purpose. About 20 minutes should be
allocated for the whole investigation including introduction and
documentation.
4.3 Care and support for women undergoing screening
4.3.1 Every department undertaking screening scans
should have at least one individual trained in counselling in the
area of prenatal diagnosis and screening.
4.3.2 Wherever screening for fetal abnormalities is
undertaken, it should be possible for the woman to discuss issues
about screening with a named midwife/counsellor with particular
interest/expertise in the area.
4.3.3 A quiet room should be available for the use of
the trained counsellor to talk to women who need to receive and
understand bad or troublesome news about their baby.
4.3.4 Discussion of the implications of a suspicious
scan should occur with an obstetrician within 24 hours (or one
working day). If indicated, referral to a tertiary centre with
maternal fetal medicine specialists and other relevant
practitioners should be possible within 72 hours (or two working
days). If referral to a tertiary centre is not possible within
this time limit then at least an explanation about the need for
referral should be given.
4.3.5 Women should receive written details about their
scan result and, whenever possible, information concerning the
type of fetal abnormality present.
4.3.6 There should be a mechanism in existence whereby
the woman with an abnormal scan can be followed up and supported.
4.4 Record keeping
4.4.1 All scans should be carefully documented and
archived. The use of hard copy for routine normal scans has major
cost implications. However when abnormalities are found, or when
specific structures are seen which may appear suspicious, hard
copy or preferably video recordings are recommended.
4.4.2 Accurate record keeping is needed to ensure that
pregnancy outcome is recorded with sufficient detail to ensure
that feedback is comprehensive.
4.4.3 Depending on workload, the employment of
appropriate support staff/clerks to maintain high standards of
record-keeping is recommended.
4.5 Computer-based records.
It is desirable that all units work towards developing
computer-based records. Unfortunately a number of different
systems exist which are unlikely to be compatible. At the very
least the system used should be capable of being used in
combination with the hospital information system.
4.6 Quality and Audit
4.6.1 Every unit should audit its results with respect
to the detection of fetal abnormalities on an annual basis. The
results of the audit should be included in the information
provided to women, for example in a patient information leaflet.
4.6.2 A high standard of perinatal pathology with
feedback to the ultrasound department is an essential element of a
screening service. The continual monitoring of results in terms of
accuracy of diagnosis is mandatory.
5 Assessment of screening programmes
The monitoring of the screening process and its ability to pick
up abnormalities can only be achieved through regional anomaly
registers. The following issues are important:
- to establish the detection rates for the main anomalies. (For
an example of an audit undertaken in Scotland(9)
see Appendix 4.)
- to audit the standards of measurements that are made to
ensure that these are being undertaken correctly and with an
acceptable accuracy.
- to know the referral rates to tertiary units. This gives two
types of information; firstly about the ability of peripheral
units to detect abnormalities and secondly whether units are
excessively referring cases which when reviewed are found to
be normal. Unnecessary referrals, described in the earlier
document(1) as a temporary false positive, can be a
source of great anxiety to patients.
6 Training
6.1 Sonography is not recognised as a specialty by the
Health Act 1999, so there is no obligation for sonographers to be
registered to practise. There is currently no statutory
requirement for ultrasound practitioners to receive accredited
training.
6.2 Many sonographers will have achieved a postgraduate
certificate or diploma in clinical ultrasound. Well-established
programmes leading to these qualifications are available in a
number of universities in the United Kingdom and the courses are
accredited by the Consortium for the Accreditation of Sonographic
Education (CASE). Members of the consortium include the British
Medical Ultrasound Society, the College of Radiographers, the
Royal College of Midwives and the United Kingdom Association of
Sonographers.
6.3 To achieve and attain CASE accreditation an
individual course must demonstrate that both its academic and
clinical teaching programmes and its assessment methods are
sufficiently rigorous to ensure that successful students are safe
to practise in the ultrasound areas for which they have studied.
Current postgraduate education certificates/diploma training
programmes in obstetric ultrasound are designed with the provision
of a safe, accurate and efficient screening service for fetal
abnormality in mind.
6.4 There is a need for practical competence tests at
Trust level. The Working Group recommends that local departments
monitor standards and keep checks on them.
6.5 Trusts should have a process for retraining and
updating as required but at present there is little provision for
this in Trust budgets. Clinical governance provides a facilitating
mechanism.
6.6 Medical staff who undertake ultrasound scanning for
fetal abnormalities should ideally, and increasingly, hold the
Advanced Certificate of Ultrasound Training which is issued
following a 300 hour course held in centres recognised by the RCOG/RCR.
Skills should be maintained by performing detailed scans in at
least one and preferably two sessions a week.
6.7 Medical staff should not undertake scans of any sort
if they have not been specifically trained.
7 Equipment
7.1 A scan to perform a fetal structural survey demands
the use of modern equipment (not more than 5 years old) of modest
sophistication. The scanner must be capable of performing the
necessary measurements and should provide good image quality. As
always, regard for safety in the use of ultrasound is paramount
and minimum output should be used in accordance with the ALARA
principle - As Low As Reasonably Attainable.
8 References
- Ultrasound Screening for Fetal Abnormalities. Report of the
RCOG Working Party (1997). RCOG, London.
- Neilson JP. Ultrasound for fetal assessment in early
pregnancy. Cochrane Review. The Cochrane Library Issue 3
(1999). Oxford Update software.
- Wald NJ, Cuckle HS, Densem JW, Kennard A, and Smith D
(1992). Maternal serum screening for Down's syndrome: the
effect of routine ultrasound scan determination of gestational
age and adjustment for maternal weight. Br J Obstet Gynaecol
99 No 2, 144-49.
- Boyd PA, Chamberlain P and Hicks NR (1998). 6-year
experience of prenatal diagnosis in an unselected population
in Oxford, UK. Lancet 352, 1577-81.
- Bull C. for the British Paediatric Cardiac Association
(1999). Current and potential impact of fetal diagnosis on
prevalence and spectrum of serious congenital heart disease at
term in the UK.
- Sharland GK and Allan LD (1992). Screening for congenital
heart disease prenatally: results of a 2½ year study in SE
Thames Region. Br J Obstet Gynaecol 99, 220-25.
- Rustico MA, Benettoni A, D'Ottavio G, Maieron A,
Fischer-Tamaro I, Conoscenti G, Meir Y, Montesano M, Cattaneo
A, Mandruzzato G (1995). Fetal heart screening in low-risk
pregnancies. Ultrasound Obstet Gynaecol 6, 313-9.
- Whittle MJ (1997). Ultrasonographic "soft markers"
of fetal chromosomal defects. Editorial BMJ 314, 918.
- Smith NC and Hau C (1999). A six year study of the antenatal
detection of fetal abnormality in six Scottish health boards.
Br J Obstet Gynaecol 106, 206-212.
Appendix 1
Baseline fetal anomaly scan
Extended views
Appendix 2
Ultrasound for Screening for Aneuploidy
Guidance for the professional
Some pregnancies affected by aneuploidy will have sonographic
markers, which are listed below, but many normal pregnancies will
also have these features.
If you are scanning at 20 weeks it is very important to know
what screening has already been undertaken in your population. If
your population has already been screened using maternal age
alone, or in combination with nuchal translucency measurement or
serum screening, 50-80% of affected cases will already have been
identified, and it is therefore much less likely that a
sonographic marker will be linked to aneuploidy, most typically
trisomy 21, than in an unscreened population.
Ultrasound Checklist
Sonographic "markers" for aneuploidy Other risk
factors
Choroid plexus cyst Maternal age (> 35 yrs)
Ventriculomegaly (> 10 mm at the atrium) Serum screening
results
Echogenic bowel (equivalent to bone density) Nuchal translucency
(10-14 week scan)
Head shape
Nuchal pad (> 5 mm at 20 weeks)
Cysterna magna
Cleft lip
Echogenic foci in heart
Dilated renal pelvis (> 5 mm AP)
Short femur/humerus
Talipes
Sandal gap
Clinodactyly
Clenched hand
Two vessel cord
Appendix 3
Your Ultrasound Scan
Please read this carefully
As part of your antenatal care we are offering to do a scan of
your pregnancy.
The first scan will be done at your antenatal visit. It is to
check how many weeks pregnant you are, that there are not twins
and that the baby is doing well. Usually the scan will be through
your abdomen and you should have a full bladder. Sometimes the
scan will be done through the front passage (vagina) but the
ultrasonographer will talk to you about this if it proves
necessary.
A second scan, done at about 20 weeks, is to check that your
baby is normal. Most babies are healthy, but sadly some have
problems which could be serious. If you really do not wish to know
if the baby has an abnormality, it may be best to decide not to
have this scan. If you do decide to have a scan we will assume
that you wish to know about anything that we find.
The scan will involve you lying down on a couch, and a trained
scan operator putting scan gel and then the scan head onto your
abdomen. This will give images on the screen which allow
measurements of the baby and give moving pictures. These can be
quite difficult to see clearly, but the scan operator will try to
ensure that all is well.
About half of the major abnormalities which cause serious
difficulties will be seen on a scan and half will not be
seen. This means that even if your scan is normal there is a small
chance that your baby will still have a problem.
Below is a list of different types of congenital abnormality,
and how likely scanning is to identify each problem.
Problem |
What the problem is |
Chance of being seen |
Spina bifida |
Open spinal cord |
90% |
Anencephaly |
Absence of the top of the
head |
99% |
Hydrocephalus |
*Excess fluid within the
brain |
60% |
Major congenital heart
problems |
|
25% |
Diaphragmatic hernia |
A defect in the muscle which
separates the chest and abdomen |
60% |
Exomphalos/gastroschisis |
Defects of the abdominal
wall |
90% |
Major kidney problems |
Missing or abnormal kidneys |
85% |
Major limb abnormalities |
Missing bones or very short
limbs |
90% |
Cerebral palsy |
Spasticity |
Never seen |
Autism |
|
Never seen |
Down syndrome |
May be associated with heart
and bowel problems |
About 40% |
* Many cases
present late in pregnancy or even after birth |
The scan can sometimes tell what sex the baby appears to be,
but not always, and we would usually not do extra scans just to
identify the sex of the baby. If the scan does predict the sex of
the baby this is right about 95% of the time. The scan operator
will only tell you the sex of the baby if you, and all the people
in the scan room with you, want to know that information.
If the scan finds a problem you will be told at the time of the
scan that there is a problem, but a full discussion of the problem
may require you to come back to the hospital for a further scan
and discussion with a specialist. Most problems that need repeat
scanning are not serious and approximately 15% of scans will need
to be repeated for one reason or another.
APPENDIX 4
Potential Detection Rates based on Screening Strategy(9)
A six year study in Scotland Booking Scan Minimum
only Standard Scan
% %
Anencephaly |
97 |
100 |
Spina bifida |
61 |
92 |
Major cardiac anomalies
(Hypoplastic ventricle) |
14 |
61 |
Diaphragmatic hernia |
30 |
62 |
Gastroschisis |
86 |
100 |
Exomphalos |
45 |
92 |
Major renal tract problems
(Renal agenesis) |
76 |
85 |