 Good morning members of the faculty and delegates. My name is Dr. Vidheya Rameshti. I'm a third year radiology resident at Maharishi Markandeshwar Institute of Medical Sciences. So the topic of my paper that I'll be presenting today is first trimester fetal echocardiography limitations and its expected clinical values. So let's look at how we're going about this paper. So fetal echo, as we all know, has always been scanned routinely from 20 to 24 gestational weeks to determine the presence of congenital heart diseases. However, recently there's a growing research interest to develop an earlier approach to diagnose major structural cardiac anomalies at earlier gestations. As we know, early diagnosis and treatment is always better to prevent any problems in future. So we try to diagnose in the first trimester which is aided by upgrading in the frequency of sonographic waves produced from abdominal and vaginal probes and other image enhancing features have been integrated to display fetal structures in a detailed manner as early as age gestational weeks. So congenital heart diseases as we know are considered challenging cases and it requires a multidisciplinary management approach by a radiologist, an obstetrician and a neonatologist. Therefore, early diagnosis could further enhance and improve clinical outcomes by permitting establishment of suitable and safe circumstances during delivery. So even in those cases that could be corrected by cardiac surgery, early intrauterine diagnosis could allow early preparation for life saving surgical approaches. So the aim of our study is that we try our best to assess congenital anomalies as early as possible so that an early abortion can be done or an early treatment can be done. So the aim is to evaluate the capability to visualize fetal cardiac structures within the first trimester from as early as 10 gestational weeks and to elucidate and explain the value of using color Doppler in visualization of cardiac structures within early gestation. So the methods that were gone about as we chose study subjects of approximately 150 out of which 44 were twin gestations and they were assessed in a routine in a systematic manner between 11 to 13 gestational weeks and what we did is we performed these scans again at 18 gestational weeks so that we could compare and contrast the studies and see how much of a difference it makes. So the research study was conducted at the antinatal radiology department at our super speciality hospital, the sonographic machine that was used was Philips affinity 50. So transabdominal scanning was done using an either 4.5 megahertz array or a 7 megahertz array and gestational ages were obtained either by LMP or by the early sonographic scan that is a dating scan and the CRL was obtained from all of these. So what was the methodology that was used? So using transabdominal imaging the transducer has been situated just about the pubic symphysis. The plane of imaging was oriented in a manner to be behind the pubic bone and we adjusted our game to be about 80 hertz so that we could visualize the cardiac anatomical structures. So what are the structures that we want to look at? The four chambers, the great vessels and the arches and the four chamber imaging mainly involves the tricuspid and the mitral valves and both the great arteries with display of great vessels and the aortic and ductile arches and the IVC and the pulmonary veins. So the three vessel imaging permitted assessment of the arc position, size and latency. So Gyatel plane evaluation of the arches supplied valuable sonographic data and findings as regards the arc size and the flow and also what we did is we tried to compare 2D studies and Doppler studies and we also assessed the thermolytics and the mechanical index, all of these were recorded. So now if you have a look at this, the four chamber view could be assessed as early as 12 gestational weeks. So figure A shows us on a 2D imaging and figure B shows us on a color Doppler. So here what we did is in a 13 week gestation pregnant female, we assessed left ventricular outflow tract by 2D imaging and on figure B we can see that right ventricular outflow tract could be assessed by 2D and by color Doppler and this was in a patient who was as early as 11 gestational weeks. So in this image a normal systematic bino arterial connection was made by both 2D and color Doppler imaging in a 12 week gestation. Here we tried to assess in this image the iotic arch in a case of a 13 week gestation. So now let's look at what were the results that we obtained from this. So first of all like I mentioned about we did a systematic review starting at 10 gestational weeks 11, 12, 13 and we repeated it at 18 gestational weeks. So first of all the four chamber view gave us excellent results. At 10 gestational weeks we could assess it in 94% of the patients but by 12 and 13 gestational weeks we could assess in 100% of patients. Then we saw the cardiac axis. At 10 gestational weeks we could see it in 74% of the patients and it reached 100% by the 12 and 13 gestational weeks. Ventricular inflow also gave us excellent results close to 100%. The next thing that we tried to assess were the IVC pulmonary veins and left and right outflow tracts. IVC was something that gave us a bit of a difficulty because on 2D in just 12.9% of the patients we could assess it whereas on color Doppler there was a drastic improvement in 88% we could assess it. Then coming to the pulmonary veins, pulmonary veins it was extremely difficult to assess it by 2D it could not be seen in any patients at all by the 10th to 12th weeks but by 18th weeks we could assess it in 29% of the patients but with the help of color Doppler by 12 gestational weeks we could assess pulmonary veins in 9.3% of the patients and right and left outflow tracts gave us decent results that is by color Doppler by 12 gestational weeks we could assess in 95% of the patients. Then the crossing greater arteries this gave us not very good results because only in 22.7% of the patients we could see via 2D but via color Doppler we could see it in 53% of the patients and by 13 gestational weeks we could see it in 96% of the patients. Iotic arch also could be visualized in almost 93% of the patients via color Doppler by 12 gestational weeks and ductile arch also we could assess in 95% of the patients. So what did we conclude by this? The current research study findings have interestingly revealed that color Doppler in comparison to 2D in observation of IVC, pulmonary veins and right and left outflow tracts, crossing of great arteries, Iotic arch, ductile arch all of these could be assessed in a very systematic manner in the first trimester. So what we noticed and this is color Doppler tremendously helped us. So the color with increasing amounts of rate like for example it could be assessed in just 4% by the eighth week but it increased by 13% by the 10th week and almost as high as 80% in the 13th week. So in our study that was done at 13 gestational weeks color Doppler surprisingly did not show much comparison to that of 18 weeks it showed us almost the same result. So prior research studies were also done more than a decade ago which revealed and displaced a full eco examination of the fetal heart and the research studies that have been done recently also there are excellent results that have been obtained with respect to first trimester scanning especially color Doppler. So a small percentage of gestation cardiac sonographic evaluation could be possible from 10 gestational week as sonographic researchers were in harmony with the current situation study findings which have revealed that the real challenge was actually in the pulmonary vein that was a disappointing study because the pulmonary vein could not be assessed very well and only in 50% it was successful. So in conclusion the first trimester fetal echo is an outstanding scan that helps us in detecting the structural cardiac anomalies and it is greatly helpful for diagnosing but we also need to keep in mind medical problems like diabetes mellitus and we need to think about the ethnic factors the race and other important things but we got a positive result at the end of this time. Thank you.