 Hi, I am Dr. Nitin Sobel and I am going to talk on anti-scan, IT and much beyond. So basically the 11 to 14 week scan which is now done almost routinely has a lot of benefits. We can date and establish curiosity if this has not already been done. Most importantly we can look out for chromosomal abnormalities, screen for congenital anomalies we used to say media but now we are looking at more abnormalities and of course we can screen for preeclampsia. So as we can see that a lot of users of 11 to 14 week scan. Putting up coreonicity in your report is very important because it makes a lot of difference in management. So that is a typically multi-coreonic pregnancy which is here of course it is a trichoreonic pregnancy, here it is a di-coreonic pregnancy and you can see the lambda spine as opposed to that here we have a monochromatic pregnancy with a very thin membrane separating between the two and we know that the management of both these are entirely different. We established a gestational age typically by looking at the CRL and we all know how to do it by measuring from the crown to the rump in its maximum dimension in a straight line. Then of course why this is important is because even at this stage we can have chromosomal abnormalities, electroploidies or for that matter trisomy 18 presenting as growth retardation or when there is a twin a difference in CRL can mean a lot of complications especially in monochromatic twins. We look at a heart rate typically what we do in our center is we look at when we look at a tricuspid valve which we will see later on at the same time we measure the heart rate again heart rate can be abnormal in certain trisomies. We look at a placenta most of the time the placenta will be covering the os we can maybe just mention that looking at cervix measuring cervix is controversial but some people want it in their report so we at least report whether the cervix is or cervix is closed. Look at a fetal well-being a jumping fetus which is a nuisance to you in the way that you are not able to take your measurements is good because it is a healthy fetus just like children running around the house whereas if you have a fetus which is just standing quiet they are not moving at all that means something is going wrong just like children who are quiet and not active. So the whole idea of looking out for chromosomal abnormalities is to pick up that odd one and this odd one in the crowd is not going to stand up easily and say oh I am that odd one so we need to do take special efforts to pick that odd one and now we know that over a period of time by looking at maternal age certain biochemical markers and of course ultrasound features like the NT nasal bone DV and tracheal speed valve regurgitation we can pick up a fetal with chromosomal abnormalities from the crowd. So a nuclear translucency as we know is a collection of fluid under the skin behind the neck in the first trimester this of course was popularized by Nikolay Nis earlier Beryl Menaceff talked about nuclear thickness in the second trimester but in the first trimester we talk of nuclear translucency. So how do you do that? I hope that the fetus gives you good position because sometimes the position is not good you just have to eat and watch and once you get the fetus in right position then you gradually zoom that particular area till you get a good nuclear translucency section where you should see the head and only the part of the upper mini astrum. So technique is very important timing typically between a CRL of 45 to 84 then of course it should be in a mid sagittal plane that means you should not see the maxilla picture should be adequately zoomed up of course very important and we should make sure that we are not looking measuring the amnion. So if the amnion is close to the fetus make sure that the fetus jumps and of course the fetus has to be in a neutral position neither to flex not to extend adequate magnification is very important and we are going to measure only the black space putting the calibers on the line between the two lines and that is a nuclear translucency. What is very important is after you have done the measurement we need to correlate it with the CRL and we can do it by using certain online applications or we can go to the FMF site and do that. So how does NT help us? It can pick up almost about 80% of fit and it tries to meet 21 and others. For example, we have an abnormal NT, we have done a CVS and we have done a counter tapping nowadays we can also do a micro array because the cost of micro array is quite reasonable. We can not only pick up twice in 21 we can also pick up other trisomies, triploidies and even monosomies when you have an abnormal NT. So then of course the next marker is a nasal bone. Now remember that whenever you want to see anything good on B-mode like for example nasal bone you have to hit that at almost like 90 degrees. So if you hit the nasal bone with a good ultrasound beam at 90 degrees you will see it well and you see two lines there and of course that's the tip of the nose that's the skin and this bright line below that is the actual nasal bone and in the first trimester we typically are looking out for presence of nasal bone we need not measure it in the first trimester unlike the second trimester. And of course we look at a tricuspid valve again the picture has to be adequately zoomed, do you increase your sample size that you cover so that you cover the tricuspid valve well and that's the normal tricuspid valve with the e-wave and the e-wave and normally you might see a little regerge but it should not be more. So typically tricuspid regurgitation again is associated not only with chromosomal abnormalities but also with cardiac defects as we will see some examples later on and of course then we look at a ductus venosis. So you can go to the FMF website and look in detail how to look at ductus but you can do it in both the planes the sagittal plane as well as a transverse plane. So here are three examples of a sagittal plane usually it's very easy to identify because that's the area where the umbilical vein suddenly becomes narrow it sort of becomes a small triangle and the most important thing is at that point you see aliasing because of high velocities. So that's the transverse plane again it is scanned that's the umbilical vein and that's the ductus there and again you can see here in a transverse plane that's the heart there of course and you can see aliasing or lighter shades of color there telling us that that's the point to sample it and make sure that your sweep speed is high because you want to spread out the wave because you want to differentiate between the S between the S wave the D wave and the A wave. So it is not enough to look at DV subjectively now we also do the PI and the reason why we do a PI is because if you do a complete course in FMF of ductus venosis the nasal bone etc you can go to the site and enter your PI values of ductus venosis along with NTN. This is what all of you should be doing now and then you get a risk a calculator risk with DV which in for example in this case is normal one in one from the background is in fact the digestive risk is much better this is an artifact this is not a reversal the A wave is here whereas here we see a reversal of A wave and we see the PI is high and typically the digestive risk has become high in fact people say that if you do this well this is probably as good as doing or adding biochemical markers so I would urge all of you to complete the FMF course get a certification if you have not and not only a basic certification but including all the markers of trisomase that's very important. So typically when you see multiple things like an abnormal NT with a pulsatile DV or an abnormal NT with a tricuspid regurgitation and a pulsatile DV and or an absent nasal bone then you have hit your target and the chances that you will see something wrong either on kerotimping or the microarray are very very high and that's what you should be doing now typically the scene is that you have an abnormal NT the kerotimper the microarray is normal what do we do that after that so it's very important to follow up this fetal heteron and I do an early animal scan maybe 14-16 weeks look out for cardiac anemones look out for skeletal dysplasia, diaphragmatic hernias, etc. if the nuclear fold persists maybe rule out infection if everything is fine and the nuclear fold thickness or the NT disappears that's good enough if it persists then of course look out for other syndromes and inform the parents that there is a 10% risk of evolution to hydrops and penny and death but if it disappears and all your tests are normal the outcome is going to be quite normal and the baby will be as good as anyone else in the general population this is a very important thing for counseling okay so what we do again is we not only look at the ultrasound features but also combine the biochemical markers that is the double markup free beta and then you can get an adjusted risk for example here we are looking at ultrasound booking up the biochemical markers we have an adjusted risk which is very low and here we have an adjusted risk which is very high of 1 in 165 so after you have calculated the the effective list of the adjusted risk what we need to do is look at the value so typically the risk is very high say 1 in 50 or 1 in 100 you need to do an invasive test if the risk is very low say about 1 in 1000 then of course you should just repeat a routine target scan maybe at 18 weeks of gestation but if the risk is intermediate that is between 1 in 100 or say up to 1000 then you have now an option of doing an NIPT so that's a good subset of patients where we have an intermediate risk where you we are not sure whether you should do an invasive test at the same time you don't want to take any chances this is a group where you can subject them to NIPT now we expect to do a lot of structural we expect to see a lot of structures in the first trimester and we can follow the ISWAQ guidelines for the structures but we can go one step beyond that as well so starting with the head the ISWAQ guidelines expect us to make sure that the head is present the cranial bones are seen the midline fox is seen and the corad plexus fill up the ventricles but it is also a good idea to mature the biparital diameter and this of course is because a small BPD can be a clue towards diagnosis of spinal myofidium so again make sure that the corad plexus fill up the ventricle this is again very important because now you can pick up ventricle megalin in the first trimester though the criteria are not very well defined there are a lot of articles which talk about various ratios of the corad plexus in militia the ventricles etc as one example of a ventricle megalin this is a normal of course corad plexus then of course comes the most important thing which is the intracranial translucency so in the same anti-section which we already have taken we can see that there are three sonolucent areas here the first of course is the brainstem the second is the IT which is actually the fourth ventricle and this one is of course the system of magna and then these three black spaces have white lines here of course we have the outline the brainstem the roof of the fourth ventricle the corad plexus and the occipital bone so typically if you look at these three that is the brainstem the IT and the system of magna you typically have a ratio of 3s to 2s to 1 that means as you move from top to down you have a slight decrease in size and this can be very important in picking up either an IT obliteration or an IT increase in the size of the IT so this is very important to look at when you do an IT scan so typically for example here is an example where the intracranial translucency is obliterated the brainstem looks very prominent so that's the sign of neural tube defect and here again we can also take what is known as a brainstem to brainstem occipital distance and typically this increases in open neural tube defects so that's the brainstem size and that's the brainstem to the occipital distance because as we know that the because of amnon kary 2 this herniation of posterior structures and the brainstem this distance will increase. We can also look at the maxilo occipital line that is from the palate you draw a line to the occipit and under the normal circumstances the junction between the thalamus and the midbrain lies above this line but wherever there is a herniation of the posterior structures this junction actually goes down this line and that's another sign of open neural tube defect. Now it's very important not only to look at BPD but take a complete axial sweep so we go from the top look at the fox go to the coronaplexus and go further posterior and also look at the posterior fossa and just like what you see in a sagittal plane the similar structures are seen in the posterior fossa so again here we have your brainstem we have your IT or the fourth ventricle and the cisterna magna and this view can again be very very important in picking up posterior fossa abnormalities at an early stage. So when you are taking a BPD one step down you can see the cerebral pedicules and the actiniductive sylvias we can measure the distance between the actiniductive sylvias and the occipital bone and typically again in spina bifida what you see is parallel cerebrals and the actiniductive sylvias is pushed towards the or is moved towards the occipit or sometimes it can get obliterated. So these are all indirect spines or signs of spina bifida or open neural tube defect and Dr Praveen has basically had put up all these together and has described almost 13 signs of spina bifida in the first time which one can easily look at. So that's the summary basically we have an IT obliterated increased distance say parallel cerebrals, actiniduct shifted down or not seen almost and of course then you need to look at for direct signs of spina bifida or open neural tube defect. We can have rarely an increase in the size of IT. So as we said that as you go from year to year we have a ratio of 3 to 2 is 1 year we see that the IT is increased and if you look very closely in the posterior fossa you can almost appreciate that there is like a cystic structure and this was a dandy worker picked up in the first trimester. So an increased IT look out for posterior fossa abnormalities. Then we look at the face and the neck. Neck of course we just glance besides the NT look at the neck whether it's normal and in the face we look at the profile of course of the face and easel bone which we have talked about. We can look at this of course and of course we can also look at the mandible. So the ISWA guidelines also talk about looking at eyes and lens. So what we can do is again in the same axial plane which we took earlier for the head we can go down we can look at the orbits and we can go further down and look at the alveolar range of the maxilla. So we can appreciate that's in fact 13 weeks plus fetus when you can see both the eyeballs as well as the lens in the first trimester in the NT scan. So we can also look at the lips and try and look at a nose lip view. This can be difficult and picking up cleft lips is very very difficult in the NT scan. The other marker which we look out for typically which is very useful in picking up cleft palates is the retro nasal triangle. So we take a coronal sweep again go to the sort of nose lip and then sweep down and we can see the retro nasal triangle with the palate forming the bain the nasal bones at the top and the margins of the maxilla. So we have three planes which can help us in picking up cleft palate. One is of course your the basic NT scan view which is a sagittal view. Here we look out for two signs. One is make sure that the interrupted maxillary line sign make sure that this line is not interrupted and the second is a superimposed line. So what is superimposed line Dr. Lakshmi has described this from India herself from India and if you look at this very carefully the palette you see that there are two sort of lines one on the top and the one which is the basic palette and this area here is actually formed by the VOMO and then VOMO bone and this she has labeled as a superimposed line that means this VOMO is superimposed on the palette. So what happens is if there is a cleft in the palette basically what you see is a single line or absent superimposed line sign as she called it and what you see is basically only the VOMO and see we will see an example of that. In an excel plane we can also look at the continuity of the alveolar range because this is the same plane which we try in the second trimester of course you do not see the eula at this stage and then make sure that the retro nasal triangle is also intact. So this plane three planes help us in picking up the planet. So the maxillary gap sign of course was described by Rabichoi some years back and is reliable but it has been challenged by some people and what Dr. Lakshmi is described as superimposed line which is basically the VOMO superimposed on the palette and line but typically when you have for example a cleft in the palette what you see is only the VOMO bone and this is she has labeled as absence of the superimposed line sign. So she has two or three articles both in the ISVAC journal as well as in the AIUM journal which I would urge you to read and in fact she has talked in our forum also earlier and written several articles which you can actually go on the net and see to pick up cleft lip palette in the first trimester. So this is just one example where you can see that there is a gap in the maxillary line and there is not only a cleft palette there is also a cleft lip and of course this features also had a diaphragmatic hernia and we have done most of the scan either with the transfer channel probe or with the high frequency probe. So we will come to this point a little later. Typically when you look at a retro nasal triangle there is a gap here which is known as a mandibular gap. If the mandibular gap is absent that could be a clue towards diagnosis of mycopnithia. So we have one more thing which we can pick up with the help of the retro nasal triangle. Then of course look at the spine itself both in all three planes that is the sagitti plane, the coronal plane and of course the transverse field make sure that the overline skin is intact. So besides looking in the indirect science it is also very important to look at the spine itself. When you look at a chest make sure that we have symmetrical lung fields there is no effusion or any mass you can pick up diaphragmatic hernias in the first trimester also when you see something odd happening in the chest. Then coming to the heart of course very important what you should do which all of us can do of course is take a sweep which we are very familiar with in the first trimester. So when you take a sweep very often it is very difficult to decide the side of the fetus or the lie of the fetus in the first trimester because the fetus is moving but if you take a sweep and you can see that the stomach and the heart are on the same side the axis of the heart is on the left side and the heart grossly has a good size then you have done a good job. So that is the stomach and the heart on the same side that is the aorta on the same side and at least you know the decided of the fetus is normal. So one thing we should do is take a sweep and then of course nowadays with high frequency probes and even with basic probes you can see the four chambers and you can see the interventricular septum well if you hit it perpendicularly and then of course it is a good habit to switch on color and again look at the four chambers and flow so we can just sort of make sure that your settings are correct and we can see the flow across the tricuspid and endometrial valve and then of course we can go up just like in the second trimester and I take a three we track your view again with the help of color Doppler and or power Doppler whatever and this is very often referred to as a tick sign in the first trimester. So we are picking up more and more of cardiac anemones typically the ones which we pick up are things like interventricular septum defects things like hyperplastic left heart and of course we can also pick up outflow anemones here for example we had a extremely small aorta we had a small left ventricle with a large cystic agroma and this was a fetus with turners so here we have a fetus who has who had a fellow seal as well and you can see that there is the right ventricle and you can see a large aorta coming from there and a small pulmonary artery so that was a dorb so a very important thing is is the rule of transvaginal scans so whenever you suspect something you should do a transvaginal scan I will go one step further and I would say that whenever you finish your anti scan always put in a transvaginal probe and try and pick up as many and you might pick up something more what you may not have seen on transvaginal scan and sometimes the fetus position is good you can do almost like a complete target scan. Look at the abdomen make sure that the stomach is present in the left upper quadrant make sure that the bladder is seen and you see two umbilical arteries so all these things can be seen kidneys can be seen in fact this is a 12 weeks four days fetus we can see in both the kidneys with high resolution clones a little bit of renal pelvis there and we are seeing also the renal arteries at 12 weeks and four days of gestation we can pick up gross renal anomalies and bladder abnormalities of course megasis this can be picked up at this stage as well. Abdominal wall very important make look at the contour of the fetus make sure the abdominal wall is intact again look at the chord insertion which is very very important to pick up on phallus yield and make sure that again then there are two umbilical arteries so that's a chord insertion in the in the abdominal wall and of course the most common thing we see in the first time is to our phallus yield these are the same fetus who had also a DORB look at extremities in fact it is very easy to look at extremities in the first semester because you get overall glimpse of the picture in the second trimester very often one of the limb is sort of hiding behind the baby so make sure that you see four limbs and each of the limb has four as three segments in fact you are able to see the hands and the hands also very well in most of the fetus and you can also see the extremities again you can make sure that the three segments are there and that this angle between the tbfibular and the foot is good so this can be done and we can pick up anomalies typically for example fita with reduced movements or skeletal displays at this stage so that's an example of her skeletal displays are picked up at an early stage the other important role of anti scan is of course looking at the uterine artery to pick up or predict early onset preeclampsia and hypertension so again the fmf guidelines give us an idea about how to go about looking at the uterine artery one can do trans abdominally or one can do trans vaginally so typically what we do is look at the cervix at the internal loss and then move gradually to the right or the left this can be trans as I said trans abdominally or trans vaginally but most of the times we do it trans abdominally then of course identify the uterine arteries as they cross the ilac and try and get one full segment of the uterine arteries where it is straight and then get a waveform of the uterine arteries so we look at both the right and the left uterine artery and what we are looking out for is the mean PI so we no longer look at the pre-rastolic notch etc we are looking at mean PI and most of the times the machine is going to calculate the mean PI for us directly so we do have charts for but for all practical purposes a mean PI above 2.3 or 2.4 is considered as high in the first trimester and there can be a little difference when we do a trans vaginal approach so here's an example of a trans abdominals scan where the mean PI is high 3.0 at 11 weeks and 2 days and she later on add a pre-eclampsia so we can also predict pre-eclampsia maybe in a better way by combining uterine artery Doppler the mean arterial pressure of the mother and we see the biochemistry so in this we can add PLGF again people say that PLGF probably doesn't have much of value we can predict the same thing by using only free beta agent PAPA and uterine artery Doppler but if you add PLGF maybe there could be a little improvement in your p-coprate or P-eclampsia here for example we have done a biochemical marker and an empty scan with the mean arterial pressure and uterine artery PI and we have we see that the risk of pre-eclampsia in this case is high and sure the risk of trisomy 21 was also very very high so we can combine these things together so as it is we do double marker so we can ask the lab to we have to give the so basically a mean arterial pressure again has to be calculated so we give the pressure ring as per the FMF guidelines to the lab along with the requisition form and then we can get the calculated risk so in summary one section we can see so many things and I think if you look at value for money or for whatever the value of this at this scan the utility is tremendous and all we need to do is keep our eyes open and we can help the mother in several ways thank you so much for your kind attention.