1. The Scan ‘Menu’ Trish Chudleigh Advanced Practitioner Manager Cambridge University Hospitals

2. Rationale for the Scan Menu to provide consistency in the scan procedure to specify measuring techniques to define the range of anatomical structures to be assessed to provide the minimum assessment that should be undertaken

3. The NHS FASP Anomaly Screening Service population pre-screened & low risk for Down’s (or declined screening) examination focused towards optimising perinatal management pathways addresses 11 selected conditions Includes target detection rates incorporates annual audit

4. Key Ultrasound Features gestational age 18 +0 – 20 +6 weeks - change from ~20 weeks - no need to recall if scanned ‘early’ appointment time 30 minutes - times currently vary from 10-30 mins, 61% 20mins - underpins clinical importance of examination - supports extension of scanning time to incorporate additional views & measurements

5. Key Ultrasound Features six specified images recorded & stored - allows audit of examination’s quantitative & qualitative components at local level - valuable tool for confirming quality single further scan only, at 23 weeks if first assessment incomplete - when quality compromised by ↑BMI,fibroids, abdominal scarring, fetal position ‘allows’ an incomplete screen

6. Key Ultrasound Features range of normal variants extended to include previous ‘markers’, with exception of ↑nuchal fold (Tri 21) outflow tracts & coronal lips included fingers, toes, carrying angles, profile not screened normal renal pelvis increases to 7.0mm

7. Eleven Auditable Conditions ConditionDetection rate (%) Anencephaly98 Open spina bifida90 Cleft lip75 Diaphragmatic hernia60 Gastroschisis98 Exomphalos80 Serious cardiac abnormalities50 Bilateral renal agenesis84 Lethal skeletal dysplasia60 Edward’s syndrome (Trisomy 18)95 Patau’s syndrome (Trisomy 13)95

8. Scan Menu – ‘tick list’ AreaViews 1, 2Head and neckHC (Chitty) + suboccipito-bregmatic 3FaceLips coronal 4-7Chest4ch, both outflow tracts, lungs 8-12AbdomenAC, cord insertion, kidneys, bladder 13-14SpineSagittal & transverse, skin covering 15-19LimbsFL, metacarpals & metatarsals x 2 20-21Uterine cavityAmniotic fluid, placenta position noted

9. Scan Menu – fetal biometry HC Chitty et al Br J Obstet Gynaecol 1994 101:35-43 AC Chitty et al Br J Obstet Gynaecol 1994 101:125-131

10. Scan Menu – fetal biometry FL Chitty et al Br J Obstet Gynaecol 1994 101:132-135 small measurements compared to dating scan (significantly less than 5 th centile on national charts) - refer

11. Scan Menu – images & diagrams

12. Scan Menu – other measurements ISUOG Guideline. Ultrasound Obstet Gynecol 2007;29:109-116 Goldstein et al. Am J Obstet Gynecol 1987:156:1065-9 atrium >10.0mm – refer nuchal fold >6.0mm - refer

13. Scan Menu – tick list & referral echogenic bowel (with density equivalent to bone) – refer renal pelvic dilatation (AP measurement > 7.0mm) - refer

14. Scan Menu – tick list limbs femur – length (one leg only) hands – metacarpals (right & left) feet – metatarsals (right & left)

15. Scan Menu – uterine cavity amniotic fluid – subjective volume placenta – visible & position noted

16. Scan Menu – six images measured HC & atrium 12 measured TCD (+ NF)) 3 measured AC 4 measured FL 5 sagittal spine including sacrum & skin covering 6 coronal lips & nasal tip

17. Conclusions implementation of national programme should shift emphasis of routine anomaly scan from ‘markers’ to ‘requiring referral’ and from aneuploidy to perinatal management. adopting scan menu should extend diagnostic capability of anomaly scan rather than diminish it the scan menu provides an exciting challenge for all health professionals involved along pathway & an opportunity for many sonographers to develop & extend their range of skills