Fetal anomaly ultrasound screening - GOV.UK

Fetal anomaly ultrasound screeningObstetrics and Gynaecology > Antenatal care > Fetal anomaly screening

Published: 24-Mar-2015 Valid until: 31-Mar-2016 Printed on: 26-Jun-2015 © Map of Medicine Ltd This care map was published by England. A printed version of this document is not controlled so may not be up-to-date with the latest clinicalinformation.

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R

18 +0 to 20+6week fetal anomalyultrasound screening

Go to NIPE

Fetal anomalysuspected/detected

No abnormalitysuspected/detected

Go to NIPE

Discuss options

Screening declinedScreening accepted

Diagnostic testingaccepted

Diagnostic testingdeclined

Go to NIPE

Continue withpregnancy

Termination ofpregnancy

Go to NIPE

Refer as appropriatefollowing local policy

Fetal anomalyconfirmed

Offer follow up support

Follow up at delivery




This document is excluded from the Open Government Licence. Images and content are subject to copyright; All rights reserved ©Map of Medicine Limited 2015 and © Public Health England 2015.



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1 18 +0 to 20+6 week fetal anomaly ultrasound screening

Quick info:Scope: Fetal anomaly ultrasound during pregnancy, based on current service specification and FASP national standardshttp://www.fetalanomaly.nhs.uk/specificationhttp://www.fetalanomaly.screening.nhs.uk/standards Out of scope: Screening for Down’s, Edwards’ and Patau’s syndromes in the first trimester using the combined screening strategy. Definition:The Fetal Anomaly Screening Programme (FASP) recommends the offer of a mid-pregnancy scan which is undertaken between18+0 to 20+6 weeks of pregnancy to screen for major fetal anomalies. The examination should be undertaken in accordance withthe requirements of the FASP guidance - base menu and fetal cardiac protocol (www.fetalanomaly.screening.nhs.uk/standards)Some women may choose not to be screened or only for some conditions and it is important that this choice is respected.The 18+0 to 20+6 weeks ‘base menu’ specifies measuring techniques and defines the anatomical structures to be assessed. Thispromotes consistency in the examination. The fetal anatomy to be examined are:

• head circumference demonstrating HC measurement and measurement of the atrium of the lateral ventricle

• suboccipito-bregmatic demonstrating measurement of the transcerebellar diameter

• coronal view of lips with nasal tip

• abdominal circumference demonstrating AC measurement

• femur length demonstrating FL measurement

• sagittal view of spine including sacrum and skin covering.

Cardiac views specified:

• Situs/Laterality

• Four-Chamber: Transverse section of the thorax including a complete rib and crux of the heart

• Aorta/Left Ventricular Outflow Tract: This view shows the outflow tract of the left ventricle

• Pulmonary/Right Ventricular Outflow Tract: This view shows the outflow tract of the right ventricle only or the

• Three-Vessel View (3VV): This view shows the outflow tract of the right ventricle including the pulmonary artery

• The 3 vessel and trachea view (3VT): a transverse view of the fetal upper mediastinum; it depicts the main pulmonary artery indirect communication with the ductus arteriosus, the transverse aortic arch and the superior vena cava.

Incomplete screeningA single repeat scan must be offered and completed by 23+0 weeks gestation in cases where the image quality of the firstexamination is compromised by one of the following:

• Increased maternal body mass index (BMI)

• Uterine fibroids

• Abdominal scarring

• Sub-optimal fetal position

The woman should be rescanned on the same day or offered a new appointment according to local clinical assessment.If the first examination is sub-optimal and the sonographer is suspicious of a possible fetal abnormality, a second opinion should besought and this should be recorded. Where an adequate assessment of the fetal anatomy remains compromised after the repeatscan, the woman should be told that the screen is incomplete and this should be documented.

2 Screening accepted

Quick info:


http://www.fetalanomaly.nhs.uk/specification

http://www.fetalanomaly.screening.nhs.uk/standards



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The main structures to be assessed at the 18+0 to 20+6 week scan are defined. Abnormalities of these structures can indicate anumber of specific conditions - 11 conditions are specified. Other conditions may be detected using this ultrasound screening test,but there are insufficient data to confidently predict the standard which should be achieved. These conditions are chosen because they indicate the baby may die shortly after birth, conditions that may benefit from treatmentbefore birth, to plan delivery in an appropriate hospital/centre and/or to optimise treatment after the baby is born and have detectionrates (DR) which exceed 50%.(Fetal Anomaly Ultrasound Screening Programme Study: Literature Survey June 2007 Bryant L, Fisher A and Vicente F SocialResearch and Regeneration Unit A University of Plymouth Centre) The conditions screened for and target detection rates:

• Anencephaly 98%

• Open spina bifida 90%

• Cleft lip 75%

• Diaphragmatic hernia 60%

• Gastroschisis 98%

• Exomphalos 80%

• Serious cardiac anomalies includes the following 50%:

• Transposition of the Great Arteries (TGA)

• Atrioventricular Septal Defect (AVSD)

• Tetralogy of Fallot (TOF):

• Hypoplastic left heart syndrome (HLHS)

• Bilateral renal agenesis 84%

• Lethal skeletal dysplasia 60%

• Edwards’ syndrome (Trisomy 18) 95%**

• Patau’s syndrome (Trisomy 13) 95%**

**Detections rates will be reviewed following implementation of screening as part of the combined screening strategy The ultrasound scan appointment should incorporate pre-scan counselling, the ultrasound examination, post-scan counselling andreporting. The time allocation for appointments to meet these requirements for a singleton pregnancy is a minimum of thirty (30)minutes and for a multiple pregnancy is forty five (45) minutes.

3 Screening declined

Quick info:Women who wish to have a fetal anomaly ultrasound scan, but do not wish to be informed if abnormalities are found, should beadvised that all significant findings seen on scan will be reported and therefore should consider not having fetal anomaly ultrasoundscreening.

4 Fetal anomaly suspected/detected

Quick info:The woman is informed at the time of the scan by the sonographer/midwife/clinician and the discussion includes:

• to have no further investigations

• accept referral for a further scan/investigation i.e. to a second sonographer/obstetrician/fetal medicine department as per localprotocol. The result should be recorded in the health record/IT system.

Discussion should include sufficient information to ensure that the woman is aware of the purpose, benefits, limitations andimplications of undergoing further investigations. Refer as appropriate and follow local policy




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Women with a suspected or confirmed fetal abnormality should be seen by an obstetrician with an interest in fetal medicine in a localunit within 3 working days or if a referral to a tertiary unit is required, by a fetal medicine sub specialist in a fetal medicine centrewithin 5 working days of the referral being made.

5 No abnormality suspected/detected

Quick info:All women should be notified of their scan findings at the time of the screen. The results should be documented in the health record/IT system.

6 Follow up at delivery

Quick info:A mechanism should be in place to alert the practitioners providing subsequent care (including the newborn physical examination).Pregnancy outcome is obtained for audit purposes.



9 Discuss options

Quick info:Some fetal anomalies will be confirmed by scan alone others will require prenatal invasive diagnostic testing.The midwife/clinician and mother discuss the options available:1. to have no further testing2. to have diagnostic test - ultrasound3. to have an invasive diagnostic test. This test should be available within three working days of woman receiving the screening testresultDiscussion should include sufficient information to ensure that the woman is aware of the purpose, benefits, limitations andimplications of undergoing a diagnostic test.Following further scan/investigation the possible outcomes are:

• No anomaly identified: all women should be notified of their scan findings at the time of the screen. The results should bedocumented in the health record/IT system and the pregnancy outcome obtained.

• Anomaly suspected/identified: the woman is informed at the time of the scan. The sonographer/midwife/clinician and motherdiscuss the findings and the two options available:

1. Declines further management: Decision is recorded in the health record. The woman continues with pregnancy and outcomeis obtained. A mechanism should be in place to alert the practitioners providing subsequent care (including the newborn physicalexamination).2. Accepts referral to either an in-house consultant with fetal anomaly/ultrasound experience or a fetal medicine unit (FMU)depending on the condition suspected and local protocol.

10 Diagnostic testing accepted

Quick info:If diagnostic testing is accepted consent is obtained and the woman's decision is documented in the healthcare records. All providersshould have a written pathway for communicating results. The process for communicating results should be discussed and agreedwith the woman before the procedure. Where prenatal invasive diagnostic testing (PND) is accepted discussion should includesufficient information to ensure that the woman is aware of the purpose, benefits, limitations and implications of undergoing adiagnostic test.




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PND is performed in accordance with Royal College of Obstetricians and Gynaecologists (RCOG) and National Institute for Health &Care Excellence (NICE) guidelineshttps://www.rcog.org.uk/globalassets/documents/guidelines/gt8amniocentesis0111.pdf Note: PND for a multiple pregnancy should be conducted at a tertiary fetal medicine unit due to the specialised nature of theprocedures and the increased risk of miscarriage:

• where the indication for undertaking PND is a suspected fetal anomaly the sample is sent to the cytogenetic laboratory for fullkaryotype

• local protocols should be in place between the laboratory and maternity service to log receipt of a fit for purpose sample, dealwith incomplete information on the request form, or any unacceptable samples that require repeat specimens. This should bedone as soon as practicable to ensure timely processing of samples and all requests should be tracked until completed.

11 Diagnostic testing declined

Quick info:If diagnostic testing is declined, this should be recorded in the health record and the woman offered on-going support throughout thepregnancy.If further investigation is declined the woman continues with her pregnancy and the pregnancy outcome is obtained for auditpurposes. A mechanism should be in place to alert the practitioners providing subsequent care (including the newborn physicalexamination).

12 Fetal anomaly confirmed

Quick info:The woman is given the opportunity to discuss the results with health professionals who are knowledgeable about the identified fetalanomaly. This will include the offer of a termination or continuing support throughout pregnancy.



14 Continue with pregnancy

Quick info:If the woman chooses not to undergo termination and continues with her pregnancy a referral to appropriate paediatric and supportservices should be made.A pregnancy outcome should be recorded and a mechanism should be in place to alert the practitioners providing subsequent care(including the newborn physical examination)A local protocol should be in place for reporting and appropriate referral of any babies born with a suspected/confirmed fetal anomalywho were not identified in the antenatal period, to allow review of the screening pathway.

15 Termination of pregnancy

Quick info:If termination of pregnancy is accepted, this should be undertaken in line with the Abortion Act 1967 and RCOG guidance https://www.rcog.org.uk/en/guidelines-research-services/guidelines/the-care-of-women-requesting-induced-abortion/


Quick info:


https://www.rcog.org.uk/en/guidelines-research-services/guidelines/the-care-of-women-requesting-induced-abortion/

https://www.rcog.org.uk/en/guidelines-research-services/guidelines/the-care-of-women-requesting-induced-abortion/



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A mechanism should be in place to alert the practitioners providing subsequent care (including the newborn physical examination).Pregnancy outcome is obtained for audit purposes.


Provenance: Fetal Anomaly Ultrasound

Provenance

It is important that each care map is referenced in line with Map of Medicine guidelines.

Classification

When creating or updating each care map you will need to use the following classification,

please note not all classification may be applicable;

[G] – guideline [M] – meta – analysis [S] – systematic review [A] – randomised controlled trail [B] – non-randomised prospective study [C] – retrospective study [Q] – cost or decision analysis [P] – performance measures or policy documents [E] – practice based information (expert opinion)

ID Reference

Royal College of Obstetricians and Gynaecologists (RCOG), Supplement to Ultrasound Screening for Fetal Abnormalities. RCOG, 2000, [E, G, P]

Service specification No.16 NHS Down’s Syndrome Screening (Trisomy 21) Programme, November 2013[G, P]

National Institute for Health and Clinical Excellence (NICE), Antenatal care: routine care for the healthy pregnant woman guideline 62. 2010. NICE. [E, G, P]

Public Health England, service specification number 17, NHS Fetal anomaly screening programme, November 2013 [G, P]


Provenance: Fetal Anomaly T21, T18/T13

Provenance

It is important that each care map is referenced in line with Map of Medicine guidelines.

Classification

When creating or updating each care map you will need to use the following classification,

please note not all classification may be applicable;

[G] – guideline [M] – meta – analysis [S] – systematic review [A] – randomised controlled trail [B] – non-randomised prospective study [C] – retrospective study [Q] – cost or decision analysis [P] – performance measures or policy documents [E] – practice based information (expert opinion)

ID Reference

Royal College of Obstetricians and Gynaecologists (RCOG), Supplement to Ultrasound Screening for Fetal Abnormalities. RCOG, 2000, [E, G, P]

Service specification No.16 NHS Down’s Syndrome Screening (Trisomy 21) Programme, November 2013[G, P]

National Institute for Health and Clinical Excellence (NICE), Antenatal care: routine care for the healthy pregnant woman guideline 62. 2010. NICE. [E, G, P]

Public Health England, service specification number 17, NHS Fetal anomaly screening programme, November 2013 [G, P]


Antenatal Screening – Working Standards: National Down’s Syndrome Screening Programme for England (2007) [G, S, P]

Contributors

The following individuals have contributed to this care map:

Name of Screening Programme: NHS Fetal Anomaly T21, T18/T13 Screening Programme

Contributor Name Job Title Conflicts of Interest

Annette McHugh Programme Manager, NHS

Fetal Anomaly Screening

Programme

None

Nadia Permalloo National Quality Assurance

Manager

Antenatal & Newborn Screening

Programmes (FASP, NHSP &

NIPE)

None

Sue Tucker Antenatal & Newborn Screening

coordinator

The Great Western Hospital

Swindon

None


National Ultrasound Guidance and Standards: 18+0-20+6 week fetal anomaly scan’ Fetal Anomaly screening Programme 2010 [G, S. P] Contributors

The following individuals have contributed to this care map:

Name of Screening Programme: NHS Fetal Anomaly Ultrasound Screening Programme

Contributor Name Job Title Conflicts of Interest

Annette McHugh Programme Manager, NHS

Fetal Anomaly Screening

Programme

None

Nadia Permalloo National Quality Assurance

Manager

Antenatal & Newborn Screening

Programmes (FASP, NHSP &

NIPE)

None

Sue Tucker Antenatal & Newborn Screening

coordinator

The Great Western Hospital

Swindon

None


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