 Good afternoon, everybody. Hi, Dr. Yogita Parashan, Consultant Ops and Guany at Manipal Hospital, Roarka. Give your very welcome to join for our webinar session today. It includes first trimesters screening and early anomalies can. The only anomalies can part will be presented by Dr. Gauru, who is a consultant meteorologist out here. All right, so we start with the first trimesters screening. As we all know, the safe motherhood idea, which have been now widely propagated by our government, it includes giving a good anti-natal care to all our anti-natal patients. An important objective in this anti-natal care is anti-natal, good anti-natal screening methods. Now, the aim of anti-natal care should be focused and individualized to screen the conditions which are treatable, which need constant vigilance and surveillance, and which may require urgent management, which should be able to identify such conditions. Every obstetrician and gynecologist should be aware of the recent advances and should incorporate new investigations and screening methods, diagnostic modalities and management options for early detection, counseling and treatment of the conditions. Now, we should all know what is screening. The screening is the process of identifying apparently healthy people who may be at increased risk of a particular disease or a condition. Screening does not mean that the person or the fetus is actually having or carrying that disease, but it just identify the population which is at increased risk of carrying that disease. Now, our ideal screening test, ideally, we all want it to be 100% sensitive, 100% specific. It should give 100% positive predictive value with a no-false positive and a no-false negative in which the sensitivity is basically the ability to detect individuals with presence of a target condition. Specificity is the ability to detect individuals who are completely disease free. False positive are individuals who are not carrying the disease, but somehow are detected with it. Least is the false positive, more is the test sensitive. And false negative, these are the individuals who have the disease, but they are detected free of it. The least is the false negative, more is the test specific. Now, the first trimester screening, people like to identify any anomaly in the fetus as early as possible. So the earlier, the second trimester screening and second trimester anomalies can use to be are made major factor, but we try to decrease the gestational age so that we can detect these anomalies in the first trimester itself. Now, the components of first trimester screening, it includes screening for any aneuploidy or chromosomal defects, screening for fetal structure anomaly, screening for any risk of early preeclampsia or fetal growth retardation, multi-fetal gestational screening for pulmonicity and prediction of any related complications, detection and screening for various genetic disorders and screening for preterm labor as well with the help of survival. Now, the first trimester screening, what are the important components from it? First is the maternal serum markers, which should be commonly known as dual marker. It includes the chemicals like free beta Hcg and PAPA, which is the pregnancy-associated plasma protein A. Second modality is 2D or 3D ultrasound, by which we do a mucotranslucency scan in between 11p to 13 plus six weeks. Doppler is also included nowadays and this is to detect, this gives the prediction for any early onset preeclampsia and future fetal growth retardation in which we see if there is any diastolic notching in the neutrin artery. This combines screening, including the maternal age, the mucous scan and the dual marker. It is known as combined screening method. Now, which all are the high risk group in which these animaloidies are common? First of all, if the maternal age is more than 35 years at the expected date of birth. If there is any history of tereterin exposure, for example, tereterinic drugs like anti-epileptics, isotretinoin, asinobiters, radiations, including x-rays and CT scan. If there is any history of high-grade fever with rash, any history of exposure to medical conditions, including diabetes and thyroid. If there is any history of intake of any abortivation drugs in the first trimester, if there is any history of concern immunity or same community manage, if there is any history of pregnancy for fetal anomaly, if there is any history of previous child born with major congenital defect, mental retardation or hearing disability. We also have to look for any genetic disease in the family. Factors which are included in anepyloid screening. First of all, the maternal age. The more is the maternal age, the more is the risk of anepyloid in the fetus. Second is the fetal heart rate. As we know, the fetal heart rate is slightly higher in trisomy 21 and much higher in trisomy 13, but it is slightly lower in trisomy 18. Other others, you know, biochemistry marker, like the dual marker between moles, beta-HCT and papi. Then there is mucotranslucency scan and new ultrasound markers, which Dr. Gaurav is going to talk to you about shortly. Now, what is combined first trimester screening? It is the new non-invasive evaluation which combines maternal blood screening tests plus the ultrasound evaluation of the fetus for mucotranslucency and measles bone plus maternal age. It identifies the risk for specific chromosomal abnormalities, including down syndrome and trisomy 18 and 13. It gives a really good detection rate of as high as 93 to 96% for trisomy 21 and 75% for trisomy 18 and 13, with a very less false positive rate of just 3%. Now, what is the importance of dual marker? Dual marker is generally conducted between 10th to 13th week and sometimes few options they advise it between 9th week to 13th to 6 weeks also. It measures the level of beta-HCG and papillage. It screens the fetus with chromosomal anomalies. When we screen these fetus, this means that these fetus may be at increased risk of carrying these trisomies, but 100% detection can be done only with further testing with colonic malice sample or amniocentesis. The beta-HCG value generally falls in the range of 25,700 to 288,000 million international unit per unit between 8 to 12. And pap A value is generally more than 0.5 multiple of millions. Now, the importance of human corneal gonadotropin as risk-predictor, when it is included in dual marker screen, why it is important we all need to know. This glycoprotein is made up of two alpha and beta sublimates. The free beta sublimates, it is widely used as for screening as component of dual marker, although both alpha and beta, both sublimates increase during the first trimester, but more specific is the free beta sublimate. It increase in fetus with any priority, starting at the end of first trimester and it continues till the second trimester, making it useful for both the first and second trimester screen. The multiple of medium of free beta Hcg in any priority 21 is between 2.06 and 2.64. Now, pap A as risk-predictor, pap A or pleasant pregnancy associated plasma protein A. It was first discovered by Linn in 1974. It has a highly potent protease for insulin-like growth factor binding protein, four and five, which actually inhibits the insulin-like growth factor. Now, proteolysis acts as positive regulator of IGF availability, as they are not further able to degrade IGF factor and this insulin-like growth factor. It, as it mediates the trophoplastic invasion of decidua and modulates transport of glucose and amino acids in placenta, whenever pap A is grazed, it generally indicates the baby will be made suffer with fetal growth retardation. The low values of pap A. Insufficient since he should draw for plastic development and function, it leads to abnormal placenta secretion of main placenta protein. The measurement of pap A in first trimester of pregnancy is part of combined screening in first trimester for various chromosomopathies as further recommendation of fetal medicine foundation. This pap A generally increases as a pregnancy progresses, but the low levels of pap A, which is less than 0.4 multiple of medium in first trimester screening, they have predictive value for fetal growth retardation as we just talked. Whenever the level of pap A is low, this decreases the availability of insulin-like growth factor because of this proteolysis. And this leads to more of fetal growth retardation, pre-eclampsia, pre-machiavole, and stillbirth. As pap A has a role in trophoplastic invasion of decidua, cell mitosis and differentiation. It also has an immunosuppressive effect in placenta and inhibition of coagulation. Now we generally give it as a risk ratio. A risk ratio of one is to 10 to one is to 250, it indicates a high risk. What do you mean by that? That every 10 pregnant female in which this evaluation is being done in fetus which have the same value, the risk of the fetus, one fetus will be in every 10 fetus with the same value of pap A, one fetus will have, actually have this anomaly. So these indicates a high risk. These patients are offered prenatogenetic testing to exclude chromosomopathies. Risk ratio of more than one is to 1000. These indicates a low risk. All these three trizones, they are associated with increased maternal age, increased fetal-nucleotranslucency, and decreased serum pap A. Now the difference between all these trizones when we apply all these cleaning methods, as we see the differences, fetal-nucleotranslucency is generally higher in trizones 18 and 13 than in 21. Serum pap A is lower in trizones 18 and 13 as compared with trizone 21. And see three serum beta Hcg in trizone 21 is higher, whereas in trizones 18 and 13, it is lower. The fetal heart rate in trizone 13 is much higher compared to trizone 18 and 21. Thank you, this concludes my talk. Now, Dr. Gaurav is going to take over to discuss about early anomaly. Good afternoon, everybody. I'm Dr. Gaurav Malhotra, consultant radiology and imaging at Manipal Hospital, Swarka. Today we are going to talk about early anomaly or NT scan. Now my talk is over to cover the foreign points. Why we need an early anomaly scan. Timing of early anomaly scan. What is Nucle scan? That includes NT, NV, DVF, tricuspid regurgitation and a newer marker, intra-perial translucency. Now, this part of the talk we are going to focus today. The anatomical scan and systematic evaluation of the fetus, we are going to take care in the next lecture. And in the end, we'll see what to achieve in future. Now, need for early anomaly scan. Now we have ever changing and emerging new concepts every day. We started off earlier as an anomaly scan at 18 to 20 weeks. And then we thought that why we can't pick up the anomalies earlier than this. We started off with early anomaly scan, which is done as 11 to 14 weeks or 11 to 30 weeks, six days precisely, wherein our target is to find the life-threatening anomalies that are picked up early or at least we get some clues to anomalies so that we can do follow-up repeat scans. Now, even if I'm suspicious about a fetus at around 11 to 14 weeks, I still have a window period of four weeks before the anomaly scan. So we can repeatedly scan the patients in which we are suspicious. We started off by measuring accurate CRL and a Nucle scan. And then we moved on to the anaphytalanatomy and studying the structure defects. Now, all these, they are included in early anomaly scan. Now, early anomaly scan, it is used to predict the outcome in preeclampsia, diabetes and preterm deliveries along with a set of biochemistry correlation, which Madam has already talked about. And we actually have different prenatal screening protocols. I always start my talk with the basics thing that is the crowned lump length. It is measured in the sagittal view of the fetus in neutral horizontal position. Crown that is skin above the parietal bone and lump, skin inferior to the tip of the sacrum is measured. It should be between 45 to 84 mm for anti-scan. Ideally, it should be more than 56 mm. It is used to sanitize the biochemistry. That is a maternal serum results. Now, why I always focus on a good CRL is because that is the baseline for our serum biochemistry. If you're not getting a good CRL, our results are going to vary. Another thing, the CRL has to be in this window of 45 to 84 mm. Even if we have a CRL of 43 mm or 86 mm, we are not going to go in for a anti-scan. Now, let's see two examples. These are the two fetuses. The station is 12 weeks, six days. We do the CRL. There is adequate depth and magnification. The CRL axis is almost at a degree of 30 degrees with the horizontal. It should be as parallel to horizontal as possible. And if it is vertical or it is more than 30 degrees, we are not going to get an accurate CRL. Now, we can see very clearly the fetus is at 12 weeks, six days, and our ultrasound age is corresponding to 13 weeks, three days. Here, we have a fetus with the stationage of 12 weeks, two days, and our ultrasound age is around 12 weeks, five days. So, two to three days of variation, even with a very good CRL, is still possible. Now, let's see this example. We have a fetus in which we are measuring a CRL. It is almost vertical. The angle is almost 60 degrees. We get a CRL of 65 mm. We wait for some time around five to 10 minutes. Now, the fetus is more horizontal. And we get a CRL of 60 mm. So, you can very clearly see, this is not the right way to do, take a CRL, because we can get variation even in the same fetus. Scans done five minutes apart. There is a five mm variation of CRL. And all my serum biochemistry depends on that. The, let's talk about the timing of our dienomic cell. The timing is broadly classified into 11 to 12 weeks, 20 to 13 weeks, and 13 to 14 weeks. Now, let's see what each week has to offer. Now, in 11 to 12 weeks, NT can be measured, yes. The structural details are difficult. And the gestational age and bio-metry. If they're not corresponding with each other, then bio-metry journey may turn out to be less. And if it is less than 11 weeks, we are not going to do a proper NT scan. And we are going to send the patient back and call the patient again. The 12 to 13 weeks is the best time to do the early anomaly scan. The, there is horizontal orientation of fetus. The NT is best visualized. The structural details are good. And gestational age and bio-metry, even if they are not corresponding with each other, we still have two to three days window. And we are well within the range of doing a good NT. Hence, I always tell my Guinean people to send the patient for a NT scan in 12 to 13 weeks. In 13 to 14 weeks, there is vertically oriented fetus, which is not good for NT. The structural details are better visualized, definitely, because the fetus has grown. And gestational age and bio-metry, if they vary, it can be more. That is, it can go up to 14 weeks, three days or five days. Now, in bio-metry, we generally take two readings. One is CRL. We also take a BPD. Or a FL can also be used. So we take both the readings for an averaging effect. Oh, now what is NUCLE scan? NUCLE scan includes NUCLE transglucency, nasal bone, ductus venous flow, tricuspid reurgitation, and intracranial transglucency. NUCLE transglucency. It is a collection of fluid under the skin behind the neck of fetuses at 11 weeks to 36 days that can be measured by the ultrasound. It is measured between the CRL of 45 to 84 mm by expert ultrasonologist or sonographers. The window has to be between 45 to 84 mm. I've already stated. Now, what are the criteria for a good NUCLE anti-scan? Appropriate depth and magnification, true mid-seizure section, neutral fetal position, calipers are to be placed on-to-on or inside-to-inside, and maximum transglucency is to be measured, and thin-nucle mammary should be identified. Let's see what each and everything means. Appropriate depth and magnification means, ideally, only the fetal head, and the upper thorac should be included. A true mid-seizure section means, tip of the nasal bone should be visualized, and rectangular shape of palate should be defined. Neutral fetal position. The head is in line with the spine, and there is a clear space between the chin and the thorax. Calipers are placed on-to-on. It means it has to be inner-to-inner, and it has to be a straight line in erect position. Maximum transglucency. It is the widest part of the nuisance you measured, and a thin-nucle membrane is seen clearly. Thin-nucle membrane. It is important to distinguish between the fetal skin and the amniotic membrane. We have to fulfill all the six criteria. Now, these are two examples. Let's see if we are fulfilling the criteria. The first one is appropriate depth and magnification. The fetal head and abdomen are visualized. Yes, it has to be a true mid-seizure section. The tip of the nasal bone is visualized, and there is a pocket of fluid between the fetal chin and the thorax. Ideally, the length of this pocket should be at least equal to the rectangular shape of palate or more than that. In fact, people say that the tip of the nose and the thorax should actually make a straight line for a good amount of flexion. Then the calipers are placed onto one or inside-to-inside. In GE machines or Voluson, we have a box. We can place it over here, and it automatically gets the maximum reading. Otherwise, we have to take the maximum reading, and we know that we are going in the right direction. Thin-nucle membrane has to be well-identified, and it is to be differentiated from the anodic membrane. If we are confused, we have to wait for the to-do moment. Now, one more clue is that we should be very well able to see the Diane Keflog of the future thalamus. Now, whenever I see this section, I know that I am in the right plane. We should be able to see intra-clinic and rhinocerosensate also, which I want to talk about very shortly. The frontal process of the maxilla should not be visualized. This is the perfect way to do a proper NT scan, and we cannot compromise on any of the six points, which I have already discussed. On interpretation, the median and the 95% I led the CRL of 45 mmR, 1.2 and 2.1 mm. The respective values at CRL of 84 mmR, 1.9 and 2.7 mm. General values of 3 mmR more are to be applied cautiously. Whenever my NT goes beyond 2.5 or 3, I get really, really suspicious, and I search, actually search for the anomalies. Actually, I study anatomy, and I see all my other parameters very carefully. Normal grams at different CRL are also available. We actually have, for every CRL, we have an NT value, and we have got proper normal grams available. Now, it is increased in chromosomal abnormalities, non-chromosomal syndromes, cardiac defects, fetal anemia and hypoproteinemia, fetal infections such as torch and pyrobytes. Let's see a few examples. We can very well see the NT is increased over here. It is not looking normal. NT is basically a fluid overload. So we have to be very careful that the fetus has to be in proper position, and we are not going to increase NT if we are taking all the sections properly. Again, in this fetus, we can see there's skin edema all throughout, all over the skin edema, and NT is actually reaching 7.4 mm. So we know that both these fetuses are abnormal and immunoglobulins. Let's talk about nasal bone now. It appears at a CRL of 42 mm. The ultrasound transducer should be parallel to the nose, or equal sign should be visualized. That means a top line is skin, the bottom is a nasal bone, and the third line is the cartilaginous tip of the nose should be seen. We have to be very careful that the ecogenicity of the nasal bone should be more than the skin overlying it. We have to see the presence or the absence of nasal bone, and even if we are seeing a nasal bone, we have to mention if it is normal or hyperplastic. A normal value of nasal bone is around 3 mm for the first semester. I have just taken this example to show you how nasal bone looks like and what is equal to sign. This is the tip of the nose. This is the skin overlying it, and this is the nasal bone proper. So we have to see this is equal to, we have to see the cartilaginous tip of the nose as well. This is the proper section where we can see all the three things and we can actually see is equal to sign. The presence or the absence or the normal versus hyperplastic nasal bone should be documented. The absence or non-ossified nasal bone is strongly linked to Down syndrome. It's a marker of other syndrome associated with mid-phase hyperplasia. Let's see two examples. Look at this example. I can see a nasal bone, yes, but then the ecogenicity of this nasal bone is not more than the overlying skin. This is an abnormally looking fetus. I'm not getting suspicious about it. Look at this NT. This is also increased. So I know that, yes, I'm dealing with the abnormal fetus. Here there is a clear that absent nasal bone seen and there is no is equal to sign seen. So I know I'm dealing with a fetus with Down syndrome, probably. Let's talk about ductus venousus clonon. Societal section of the abdomen is magnified. We put the color dropper on the area of maximum aliasing of the pyrus signal. The PW sample of the 0.5 to 1 mm is to be taken and isolation angle should be less than 30. Now DVF is basically a shunt. It is a shunt which carries the oxygen blood from the umbilical vein. The abnormal waveform is a high velocity during ventricular system called as S-way and diastone. This is called as DV with a forward flow during arterial contraction that is called the A-way. Now abnormal DV flow means the reversal of A-way flow. Abnormal DVF is associated with increased risk of Down syndrome, preeclampsia, and gestational diabetes. Now if we have abnormal ND and abnormal DVF, it is a pointer towards the cardiac anomaly. We should be very careful about it. And we have to avoid contamination. Let's see this example. It's a proper magnified view of the abdomen, straight to the view, and we can see my area of maximum aliasing. So I'm going to put my cursor over here and I put my cursor, we can see the S-way, the DV and the A-way, all have to be on the same side of the baseline. This is very important. Now abnormal DVF looks something like this. Now we have A-way which is reversal, this is A-way reversal. These are the various patterns of abnormal DVF. Now we first have an absent A-way, then we have a reversed A-way, then we have something called an M-shaped wave. All these things we are able to see once we know that how to look at the DVF every time, how to avoid contamination. Believe me, you're not going to miss A-way reversal if you are regularly and religiously doing DVF in all the patients. Let's talk about tricuspid regurgitation now. It is seen in magnified apical 4th chamber view. The PW sample across a tricuspid valve of 2 to 3 mm is put. We do not use the color Doppler because there is a lot of artifacts which are covering the tricuspid valve. Isolation angle should be less than 30 degrees to the interventive interceptor. A normal tricuspid valve flow velocity is less than 60 cm per second. In tricuspid regurgitation, the velocity is more than 60 cm per second. Now it is associated with hormones of the amuclides and cardiac defects if NT is raised. So if my NT is raised, I move on to see the DVF. I move on to see the tricuspid regurgitation. My baseline, NT is very, very important and I get really suspicious if DVF and tricuspid regurgitation are both abnormal. Let's see how it looks. Now these are two examples again which we have done. Now we can very well see that there is no waveform which is going beyond 60 cm per second. So there is no PR. You will never miss abnormal PR if you are regularly doing it. Now look at this. It is almost going up to 80 cm per second or even one meter per second. So this is how a normal waveform looks like and we have to see, we have to put a cursor properly. We have to take a line from the spine. We know which is the left ventricle. We know which is the right ventricle. And if you magnify it, you are able to get it very easily. Now let's talk of the newer marker, interclinic transfer sensor. Now it is a concept given by Robin Chui of Germany. Now, Robin Chui and Professor Nikolaus of Feetal Medicine Foundation, they published a paper in 2010 in general of Obsenkaini wherein the fourth ventricle presence as IT. They said the fourth ventricle presence is the IT between the brainstem and the coroid plexus and it's easily visible. The AP diameter of CRN, 45 mm is 1.5 mm and it's CRN of 84 mm is 2.5 mm. Now it is used for the prediction or it is a marker of the future spina bifida. The obliteration of integrated passwords NC tells us that everything is not right. Let's see these examples. Now this, I already told you, this is a future thalamus, this is a future midbrain. This black line is a future brainstem and this is a future midbrain on data. Now, this white line is the posterior aspect of the brainstem. This black thing is the intra-thaline trastocency behind which there is a coroid in the fourth ventricle. This black line again is the future system on that. And the white line in the last is the occipital bone. So this is again making an equal to sign. We have to measure this in every patient. We have to be very alert if we can see architectural distortion or if we can see loss of IT, we are heading for a future spina bifida. Let's see some other cases. Now, what do we see? We see a middle laser bone. Is it seen? Yes, okay, it can be seen. What about the IT? Yes, IT is also looking good. And what about the NT? NT is also looking okay. So is this something abnormal with the fetus? Yes, there is something abnormal. We are not able to see the rectangular shape of the palate. And this fetus later on moved on to be a calf palate. This is another case with the increased nuclear transmissivity where we cannot see the laser bone. NT is increased, it is 3.6 mm. And we are not able to see a good IT. So I know this is a fetus with a down syndrome and heading for a fetus with down syndrome. Now, this again, we did this abnormally looking fetus, not a very good section. But I know that this fetus is abnormal. When we zoomed in, we saw that there was the loss of cranial bones. There were no cranial bones. And this, all the brain matter was lying outside. So this is a acrenia exenkefeli, enenkefeli sequence. Now, we have to pick this up before the enenkefeli. Why should we wait for enenkefeli to appear? We already know about 12 to 13 weeks, we can see the cranial bones. And we should be very alert. Now see something, this is something interesting. I see it very, very common in my practice. If you see multiple lines over here, what is this? Now, we put a color and we see, oh, this is the call. Now, how to measure NT in such cases? You can see, you can take the NT proximal to this, you can take the NT test, you do it, add them, divide by two, that is one method. Or else the best is that you call the patient at another time or for the next visit. Now, this is the master himself. Let's see what future is installed. This is Robin Chewy. We attended this international webinar last week only. Now, we have indirect hints, as I told you. There is thickened NT, there is Ticus could be the agitation. There's DV reverse flow, there's abnormal cardiac access. The more than that, we should be doing Cytus, we should be doing four-chamber view in gray scale, we should be doing four-chamber color view, and we should be saying three vessel outflow view. Now, four images on the screening can detect most complex heart anomalies in the first semester. Cytus, four-chamber gray scale view. Now, this is four-chamber ventricular view. Now, if you see it, I'll just tell you the reason for this. If you see, we are standing here, our probe is here, and the blood is flowing towards our probe from this side. So this is red. And again, when the outflow rack, the blood is flowing away from our probe. So that is why there is color difference. Basically, there should be a color reversal wherever you are screening the patient. And that is what we are doing in our setup at Manupal Hospital's blocker. We are regularly following it. This is a 12-week six-day skytus. We are regularly doing this. We see the ventricles, we see the ventricular info. Our outflow racks are in blue. I know that we are safe in the cardiac aspect. I also do this. We try and see the track, the renal arteries. I know both the renal arteries are there. I know in future, probably I won't have a renal anomaly. So we are trying to be more intelligent, be more futuristic with all the scans. Now, this is three equal to sign. Now, this you won't find anywhere because I use ad coin this term. I use three is equal to an MD scan. The first one is, of course, the nasoboon is equal to. I use this. I have to see this is equal to. I won't leave my patient unless I see this. The second is equal to this intangible tracthusensis. Again, I have to see this is equal to. If I don't see it, I'll recall my patient. I'll scan the patient again and again, but I need to see this also. And third one is, of course, the tracthusensis, which we are bound to have, bound to see properly. It takes a lot of immense practice. It takes an immense patience to do, get this image. This image is very difficult to get, but then you have to get it because we are doing a proper anti scan. Again, you can see this is just a thing that the hands of the fetus are normally open in the first semester. And we can very well see this in all the patients. I thank you for your patient hearing. Thank you. Thank you all. I hope now we all are wiser as for tending to our first semester screening, including the dual marker plus the early end use cam. Thank you.