Fetal Radiology

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Fetal Radiology

27 Jun, 2 PM

[Music] good evening i'm your host for the evening dr winston thomas from the hospital threshold we will start off today's evening of learning uh with two speakers today uh the theme of today's topic is vital radiology of course but we will be looking into how to develop a fetal medicine department in the department of radiology in teaching hospitals that would be the theme of today's talk we'll have dr shafi uh who will be uh starting off uh with that uh who will initiate with that topic and dr sumiya nasrullah will uh lead on from there to talk about early pregnancy and then we shall have a panel discussion on the same topic as well so uh without any further ado i'd uh invite dr shafi ku who is the consultant from armc threshold is also a consultant at elite medical mission and over to you sir [Music] hi good evening everybody my topic is just an introduction for a series on fetal radiology and most of us are doing a lot of scans a lot of pregnancy scans etc so why the city charter thought we we should give an introduction as well as a proper guidance to start a full-blown fetal medicine or at least primary step towards developing a fetal medicine of fetal radiology departments in our own utilizing our limited resources or what are available so these are the basic fetal medicine specialist services ultrasonography of course the equipment everything that we are all acquainted with and we are all familiar with uh basic minimum requirement of a better ultrasonography machine is from mediocre to higher end so most of us are using the higher end in the teaching hospitals and in periphery we will be using a mediocre machine but minimum requirement is a mediocre machine that we can do almost all the works with and maybe a little more effort than a hiring machine but the patients don't want to know i mean usually they don't care about the machine if whatever things happen to them if something we missed uh we can't claim that i have done it in a lower machine because they expect a similar service from all the places uh so that comes the equipment part the department then comes the pre-test and post-trust cards counseling part so pre-test what we are going to do with the patient and you have to explain in most of the time what especially in the first remastered period like ntnb scan that or 11 to 14 weeks then you have to explain why you are doing this scan whether they are aware of this three-month scan and what are the test additional to it you have to do in the case of first trimester scans like combined screening or pregnancy i mean pih screening etc and posters counseling means uh whatever you have discovered in or whatever you have interpreted in that particular scan so that you have to explain to them and in current area common scenario what a radiologist can do and up to what extent that is acceptable to the reference clinician that is what we we should see in coming sections and third is genetic counseling genetic counseling is all the from first time strong words uh you can see a lot of genetic abnormalities are happening and for that only we are screening the features for at least four three down syndrome etc and another part of genetic counseling is already happen that they must have terminated the pregnancy and they have to plan a new i mean next pregnancy they need i need a genetic counseling or what are the recurrence rates etc they want to know from the fetal medicine specialist or fetal medicine specialist in that area we have to be knowledgeable to explain to them whether this will be recurring this condition will be recurring again you can do a donor program or whatever available the treatment available for that baby or in the next pregnancy and of course next uh one of the additional or important part is invasive procedures invasive procedures mainly i will come to that point later so ultrasonography and counseling the first important part is adequate training adequate training means we are already we have already trained in ultrasonography so additionally we have to be trained in such a way that we can perform the all the fetal ultrasound in proper guideline manner that is more important so next point is that one that is stick to the guidelines of international uh associations like isog and fetal medicine foundations so what you have to do is the guidelines of each trimester should be followed it is given in their website very clearly what all things you have to do in each trimester and proper image planes and phased image should be obtained because this is important in case you want to get accredited or you want to reevaluate the images later so proper image planes is a must in fetal medicine and that freeze image should be stored for future references especially when the patient come back for the trimester scan whether you are not seeing any structure and you want to be sure that you are not visiting that anomaly scan itself so you can always refer back to that those images and see that you have properly scan the patient by i mean by following all the guidelines like checklists although whatever things it is available with you with the guidelines so next is form of id need to be obtained for each first time spam second trimester this is not a compulsory requirement but all the labs and all these softwares are based on the algorithm of fetal medicine foundation so you need to get an id or accredited by sms to get use that software itself some software's like ashtray and or they will automatically check your status on the fatal medicine foundation websites so that is a added advantage to you because you can get all the like software with pro version and light version you will get all the access to that software's uh full capacity with fm of id otherwise you may be stuck with some point you may not get all the algorithm risk calculations or those things from the software but indian based software's like sauna parent there is no need of an fm of trading but the some labs working in indian scenarios like perkin elmer and lifestyle they may need an sms id from you to give you a result otherwise they they will say like they have to code to your images for uh accreditation or improper evaluation so you may need to get to give those images also if you have an example id they will assume that you have audited your images already and this is the important part i want to because all those things that i have said is very easy and this is easily available communication nobody can be talk to you like our experience can be taught to anybody you have to develop yourself or by closely associated with your colleagues or closely associated with your peers you have to develop a communication skill that is more important that each test should be explained to the pregnant woman as someone needed because they will ask a lot of questions to you so each test what is its importance because you will be stuck at some point like the patient comes to you for anomaly scan that you have done an empty scan previously but they have not done an ftcs like combined screening when they ask you i mean when you ask them like uh you have not done a thesis because they may say to you that no my doctor didn't tell me to do an fpcs so you will be stuck because you have to have a there is no priority risk available there and you will be you have to do additionally ask the patient to play waterproof screening for genetic counseling so each test should be explained to the pregnant woman as and when needed but at the same time should not terrorize the patient because that is a major complaint from clinicians that my equation has been devised by you by explaining all the tests that is there but so communication communicate with the patient in a friendly manner and first trimester the something say you should always see us or decide as a fetal radiologist or fetal medicine specialist sample should be sent to standard labs and you should identify those snaps now you should not wait for the clinician to identify those slabs because as a fetal radiologist you should have an upper hand that the this sample that ftcs samples or your amnesia this is sample or your genetic sample nipt samus whatever it may be should be sent to the labs decided by you that you should identify those standard labs many labs are available but some are accredited and according to the standard guidelines of this previously mentioned associations and tests should be offered to our respective office previously it was like our cog guidelines so those guidelines are this combined string were offered only to above 35 now it is offered to all the patients because the syndrome syndromic syndromes are distributed across all the ages so the test should be offered irrespective of the age and you should tell them that it is a screening test that should be explained like it is not a definitive test all those things you should clearly mention in the report as well as you should uh explain to the patients the order this should be seen in the department itself before dispatching the patient which means radious must see the result then only he can take a decision so whether it is a normal lower risk it's okay fine but when the result came as a high risk then only you can instruct the patient to go undergo another test like invasive trust or an apt if you don't see that report the patient will go somewhere else and come back after some time where you may not be able to do invasive procedures as easy so that is very important and another thing is you may have done an empty with a lower risk but the result came back as a slightly higher than your calculated low risk so in that case also you have to counsel the patient for invasive tests or contingency tests etc like quadruple later all those things so communicate in each test time is very important this sample uh test result we used to get in rmc that is it also includes placental growth factors for pah that is just for a reference and this is our test request for prenatal screening in first trimester so again is for reference you have to follow all those things like history patient previous history of eclampsia eutron artery everything that will be discussed later in this series uh for each trimester and dr sumaya will elaborate on early pregnancy also later uh this is one area where above 40 years mothers you can directly offer some tests other than ftcs or you can bypass all those tests that you should be aware of it and that you should update your knowledge and tell the patients for bypassing the ftcs and do another test like an ipd or invasive procedures etc that is occupation because counseling means the patients should be able to take a decision on the screening tests and they should be aware that such a confirmation tests are available they should not sue you on regarding that you are you didn't tell them the tests available at present maybe future litigations will come that the doctor didn't tell you the investigation this much of investigations were available that time i could not do so he is responsible he is negligent uh litigations may come you know people are nowadays are more informed through searching they come towards you after searching all this google and all these things and all and they will ask you all those things and proper charts you should explain all this invasive procedure whatever maybe you should explain with charts and diagrams even videos available will be very helpful for them and all the consent forms should be obtained from the patient including pnd defense this availability of an atp and apt should be in front of our respective mothers because they will search because nobody wants an invasive procedure right to it so we offer them an apt as well in including in the investigation available and always document take proper consensus and all the tests and counseling are subject to pndt laws and for anomalies and device nothing but anomaly scan greatest counselling may not be needed because they have already done an empty scan and posters communication is a must in all cases i believe because you can tell the patient your baby is fine is enough for them to reassure in all cases and in positive cases you can explain if possible and you have to classify it as a lead they learn only there is all those things and you can write in your report because as a radiologist many a time you cannot take decision of your own so you need to communicate with the clinician always and you have as a team you have to take decisions so better you have to do in verbal as well as in writing in the reports other fetal medicine specialists they usually may be writing in their reference letters only may not write in the report itself so if any animal is formed they have to be phosphate communicated in a proper way in writing a simple verb and you can communicate with the clinician also because writing and giving a guidance to the clinician also will help them to reach to counsel the patient from their side always ready to get a second opinion and re-evaluate second opinion you know better and re-evaluation means within the period of mtp all those things you can plan a re-evaluation and even if that normally present in re-evaluation you can ask for a second opinion that sort of algorithmic approach you should always apply to anonymity scans not only anomaly scans even empties all those things you can apply that law and basic feed electrode to be done in all cases basic feed electro including the output right so those things you should do in differ as soon as opinion is concerned and you should not hesitate to do fetal accusing even in a basic machines because if the window is proper you can do basically like in our machines the role of pre you know step by step evaluation utilization of checklist approaches highly recommend utilization of checklist approach is very useful i have seen because all these checklists are given in the ucog website and if you want i will share it in the group of what i am using in my irc if our fatal medicine department in the group i will share this pdf so you teach your typist or your transcriptionist the what or you should take when i tell the anatomical parts in addition i used to label the anatomical parts in the ultrasound machine itself not to miss anything of course it may take time but it will save you in the future it will save you from any litigations so checklist approach is very important in all the scans especially in np and anomaly schemes uh growth and subsequent scans this also or scan to be done according to guidelines there are a lot of guidelines from us you know this is eog even radiology our own iria has put forward a lot of guidelines and growth and subsequent scans and ph also or some directions going on so all scans to be done according to guidelines and you need to mention a conscious fetal anatomy evaluation even in growth scan you should not write this not an anomaly scan in growth stance it is there is no verb you should write that it is not an anomaly scan it is only a growth scan and not mentioning any fatal anatomy you should mention fate line item whether you are not seen it or not it's not it's fine because of unfair positions advanced gestational is by fine but you should not write this i have not seen any anatomy in the growth scan you should be very careful about it because for almost all clinicians knows it there is a supreme court verdict also um three radiologists have been accused of negligence because they have done all these three radiologists have seen the case at different times but they have all missed the anomalies so you should be very careful about it and doppler to be done when needed growth chart and pressure groups are about growth percentages are very important and very useful because at times the clinicians say feel it is an iugr but with personalized you can follow okay this is small for gestation or full blown iugr and you can instruct and you can [Music] continue the pregnancy without any fear and uh posters counseling is needed in all cases uh to decide for our termination suggestion of zero as i already said this baby is fine maybe in a fluration of the patient at times you can suggest a follow-up what is available to you or you can suggest determination say about 34 weeks no need to further continue the pregnancy you can suggest determination so that will be discussed because the clinician's point is may be different if we suggest determination or if we suggest some drugs medications uh this is uh multiple pregnancy and rs negative or there's a separate clinic like entity in your own fetal radiology department and our cases should be properly followed in every month and need more attention to monochromatic varieties but that is one of the important thing you should do in the early itself that the korean city and diamond city should be mentioned in the report a lot of times we can see that there is nothing has been written just in gestation is written on the report so now the gynacer and the obstetricians are more aware of the core ethnicity and its complications and amniocity so they will send back the patient and the patient will be running here and there so all those guidelines are given so you should mention all the score unicity amnesty everything in your report and more attention to monochromic varieties because more sense of a dtts and always ready for any intervention like laser radio frequency ablation and reduction transfusion etc uh and use of dedicated software must be encouraged especially in multiple pregnancies the discordance is very is an important factor and standard protocols to identify feature in india as well as this dedicated software vivia the volume should be transduced and anemic features so dedicated softwares are very useful in this fetal medicine department compared to general radiology and he is another clinic like entity because already some directions won they're doing a wonderful job and advanced like teaching hospitals or where they have enough funds and or you can do an extended first trimester combined screening including personal growth factors they will give you the risk at 37 weeks and you can instruct the patient to start on aspirin uh genetic counseling as i told the additional permission from bndt and my cases may need to be cancelled after termination may be because after that abortless you can do an autopsy and karyotyping and instruct the patient for planning for the pregnancies and also need to be offered to parents and child together at times the pediatric child need to be stereotyped or genetically mapped all those things need to be done and need to be affiliated with a with a good genetic class good genetic lives are many now nowadays and inborn is also a very good idea if in amala or jubilee you can ask for setting up a genetic lab it is useful not only to the city medicine department it's useful in a variety of variety of scenarios and separate genetic geneticist is more favorable she or he can do better counseling than you there are a lot of websites available that linga will be sharing in the group so that with that with the help of that website you can directly counsel the patients as well a lot of conditions are given in that website and based on that you can counsel the patient to plan the pregnancies or what is happening in this pregnancy etc and you should always aware of the late uh on certified only source that i forgot to mention the pizza and anyways you have two minutes two minutes one or two minutes that's all uh invasive procedures i don't need to i am not going into the elaborate uh description of it so this should be available and last one laser and rf ablation is not feasible to maintaining the department better you hire a laser and our fabrication for rent then they will bring to you all these equipments and you arrange a vital medicine specialist or fatality obviously specialist that you can do laser and diversity and do it the above information is the basic minimum requirement in a federal department i can be further expanded with resources like more and more fun comes you can upgrade to better machines etc but foremost thing is adequate training and updating knowledge that is very important and take home messages adequate training identify the center of excellence for training mastering communication that you have to do with your colleagues or you have to train yourself and good wrap with other fetal medicine specialists that is the future teamwork uh because you will get help from transfusion space operations all those scenarios you can ask for their help and somebody even fetal radiology somebody from other centers can come and do the transfusions and celebrations etc good ripple acid fetal radiologists we have some limitations so you have to have a good rapport with the bt departments and paid address as well in periodics you can do wonders uh like a lot of anomalies you can follow up in the post-natal video you can only do that and all those cheap displays here so those things a radiology service is much needed because usually the fetal medicine department itself is called maternal fetal medicine so it includes mothers fetus and failure to learn and it's better to have a good fetal medicine association affiliations so that you can attend their uh constant webinars or updates uh take a membership in ioc which is a very wonderful addition to your career and i think i rush through it but it's just as an introduction i think i think i covered almost 50 what i expected to do thank you sir i think you have quite in that brief time possible you have uh covered it in quite extension extensively particularly to general radiologists a couple of points that i felt was quite nice was that even though you can always up skill into a fatal medical radiologist but you as a general radiologist you can always follow guidelines for my isu og fmf and id can help you with the software's like astr alexa said and improving on your communication skills uh i think that is something personal you can always develop that and if you if you can communicate well you can even choose the labs that you can send your reports you can offer additional like pleasantly growth factor can be additionally council most uh when colleges don't add that those extra tests i think those are the some good points sir is added and wonderful slide to sum it up in the end thank you very much sir thank you for your time next i invite dr sumiya nazrullah dr sumiya is a from home tough she is trained in threshold now she is a consultant at armc and iv ivf fertility clinics in calicut she will be talking to us on early pregnancy with some interesting cases to follow up over to you sumiya good evening everyone i am dr sumiya i would like to thank iria for giving me an opportunity to speak in such a district platform with such renowned speakers today i will be speaking about early pregnancy and with the short time provided i am just going to brush through the important findings in normal and abnormal early pregnancy so what is the need for a first trimester ultrasound evaluation what do we do what all should we look for we should look for the location of pregnancy the structure of pregnancy viability the number of gestational sacs and dating of pregnancy so the image acquisition a transfer channel scan is the optimal way to uh image in the first trimester and use of different modalities like 3d ultrasound will increase the diagnostic accuracy so first coming to the location of our pregnancy the first point is that we should always confirm whether the pregnancy is intrauterine or extra uterine location normally the implantation is in the fundal endometrium usually in a paracentric location and within the decidua here we can see that then the endometrial stripe can be clearly seen and within the endometrial stripe is a gestational sound now the importance of locating the pregnancy is that we should always look for abnormal implantations in that the first one is a low implantation a gestational sac seen in the lower portion of the uterus or closer to the cervix is defined as a low implantation by definition the lower uterine segment does not develop until later in pregnancy but if the gestational sac is located in the tissue just superior to the external cervical cause we can call it as a low implantation now the significance of identifying a low implantation is that it could be a miscarriage process a cervical ectopic pregnancy or even a cesarean scar pregnancy all of which may carry significant morbidity and mortality the next abnormal location would be an abnormally eccentric gestational fact that is the embryo is implanted in the lateral angle of the uterine cavity but just medial to the utero tubal junction it is not within the tube but just medial to the uterus junction and only a very thin myometrium that is less than one centimeter of myometrium is surrounding the gestational stack the presence of a circumferential endometrium surrounding the gestation is diagnostic of intraordinate it is not an ectopic gestation it is an enzyme trend gestation but it is just implanted abnormally in the lateral angle so when we see an abnormally eccentric location we should consider angular pregnancy angular pregnancy is when the implantation is within the endometrial cavity but towards one corner second one would be a corner pregnancy coronal pregnancy we call it as cornell when a normal intrauterine implantation but in an anomalous unicorn like bicone weight or septate uterus then a possibility would be displacement of the sac by a large uterine leo myoma or other myometrial masses or even a focal myometal contraction at the time of scary now the significance is that we should always be able to distinguish whether it is an angular pregnancy or a cornell pregnancy versus an industrial ectopic pregnancy angular pregnancies and corneal pregnancies will have a surrounding thick endometrium and if this diagnosis can be made in the first trimester we can always have an expectant management because the pregnancy outcomes are generally good most commonly complications occur in the third trimester as pre-term labor or fetal malpositions particularly in congenital neutron anomalies now what is an interstitial ectopic pregnancy this is when implantation occurs within the proximal tubal segment within the muscular uterine wall that is lateral to the uterotuber junction and there is only a very thin layer of myometrial layer surrounding the corionic stack which is usually less than five millimeter and in such cases intervention is warranted at the time of diagnosis because it is usually associated with significant morbidity including spontaneous abortion uterine rupture etc so that is the significance of confirming the location of a pregnancy we should look whether it is intraoperating extraordinary whether it is abnormally eccentric or whether it is a low implantation now coming to the structure of a pregnancy what are the things we should look for a gestational sac a yolk sac embryo and cardiac activity so the gestation sac is the first sign of an early pregnancy on ultrasound it is defined as an echogenic accent eccentric echogenic ring with analog center the threshold for sac visibility is usually four weeks in a transvaginal scan and five weeks in a trans abdominal scan and the beta xcg levels for the sap to be seen is usually in a tvs when the the sac is seen when the beta hcg is more than 1800 and via transabdominally we can see when the beta cg is more than 6000 now the mean sag diameter is used to date an early pregnancy before the embryo is visible that is between four to six weeks of gestation and the sap grows approximately one millimeter in diameter per day when the mean sap diameter that is in a trans abdominal ultrasound when the main sac diameter is 20 millimeter a yolk sac should be visible and when it is more than 25 millimeter a fetal pole should be visible lack of a yolk sac is not a definitive indication of pregnancy failure once an embryo can be identified within the gestational sac a crl should be used instead of mean sac diameter for dating of a pregnancy now in the first trimester when we visualize only a sac that is there is no embryo or yogurt sac we should determine whether it is an actual intrauterine pregnancy or a pseudo gestational sac a pseudo gestational sac is basically intra cavitary fluid a small amount of intrauterine fluid in the setting of a positive pregnancy test and abdominal pain could be a pseudo gestational second ectopic pregnancy so a sewerage gestations are it is usually irregular shape it has pointed edges sometimes filled with debris and centrally located within the endometrial cavity and it displaces the anterior and posterior myometrium endometrium and the important point is that there is no yolk sac visible within the connection now how do we distinguish a true sac from a pseudo gestational snack a true sac is normally eccentric in location it is embedded within the endometrium rather than centrally within the uterine cavity and if a yolk sac is seen then it is unequivocal evidence of a gestational sac now when this only the sacristy what are the signs that determine whether it is an early pregnancy or not there are two important signs these are the intradecedual sign and the double deceiver sac side the intra-residual sign is when an echogenic rim we see an echogenic rim with an anechoic center and this echogenic rim is the trophoplastic tissue this is embedded in the thickened silver and is eccentric located on one side of the uterine cavity and this is the intradisabled sign the double decedent side is when we see two concentric rings surrounding an anechoic gestational sac and these concentric rings consist of the deceiver parietalist which lines the uterine cavity and the residual capsularis which lines the gestation sac if a double residual sucks iron is present it is highly suggestive of an intrauterine pregnancy but it may be absent in many cases and absence does not define a pseudo gestational sac now that was about the gestational sac early pregnancy science now coming to the yolk sac yolk sac is the first anatomical structure identified within the gestational sac visualization for yoghzak is useful in distinguishing and a intrauterine pregnancy from a pseudo gestational sac a decedeable cyst or an an embryonic pregnancy because a yolk sac is seen only in a intrauterine pregnancy it appears this is a circular thick walled echogenic cream with an anechoic center it is seen within the gestational sac but outside the amniotic membrane it appears at five weeks and it stays in 12 weeks a yolk sac should be seen on pas when the mean sag diameter is 20 millimeter or at a gestational age of seven weeks and on tvs when the means at diameter is eight to ten millimeter or a gestational age of 5.5 weeks visualization of multiple yoga sacs it is the earliest sign of a polyaminotic pregnancy the yolk sac is measured from the inner rim to the inner dilator in a normal early pregnancy the diameter of the yolk sac should usually be less than six millimeter and the shape should be nearly spherical a yolks are more than six millimeter is suspicious of a failed pregnancy but not diagnostic the yolk sac floats freely into coronary cavity but outside the amniotic cavity and after 12 weeks the amniotic sac will compress it against the chorion corianic cavity mold and so identification of a yolk sac is difficult after 12 weeks the embryo is seen as an echogenic tickering of the yolk sac it is usually seen at five to six weeks through a trans abdominal scan before 10 weeks we call the conceptus as an embryo and after 10 weeks we call it as a fetus the embryo grows at around one millimeter per day and all embryos of crl more than seven millimeter should demonstrate a cardiac activity so now about the solar anatomic development through the early pregnancy at five to six weeks usually a thin gold yolk sac appears the embryonic pole may appear adjacent to the yolk sac and a cardiac figure may be seen the heart rate is about 80 to 100 beats per minute at six to seven weeks the embryonic pole the yolk sac and the cardiac activity are always present and the heart rate increases to 130 beats per minute at seven to eight weeks the fetal head is relatively larger in relation to the trunk and the links appear as limbs appear as short hypoechoic outgrowths the hypoechoic brain cavities can be seen and the fetal heart rate increases from 130 to 160 beats per minute at eight to nine weeks the brain cavities are easily seen as large and according areas in the head these as you can see the diane kephlon means centriphalan and the rhombone teflon the choroid plexus may become visible and the spine is usually seen as two echogenic parallel lines a fluid filled stomach may be visible as a small hyperbolic area on the left side of the upper abdomen and physiological gut transmission may be identified as an aquagenic area in the umbilical cord at the abdominal insertion now at nine to ten weeks the lateral ventricles and the chloride plexus are predictable the cerebellar hemispheres are easily detectable but the spine is still characterized by two echogenic parallel lines during week 9 the heart rate reaches a maximum of 175 am i audible still during week 9 the heart rate reaches a maximum of 175 beats per minute and the mid gut herniation is now a large hyperechoic mass in the umbilical cord at the abdominal insertion by 10 to 12 weeks the fetus develops a human appearance the head is relatively large ossification starts at 11 weeks with the occipital bone and then ossification of the spine becomes apparent the heart rate slows down to 165 beats per minute at the end of 11 weeks anatomical details of the heart become obvious and mid gut herniation is clearly delineated at 10 weeks and it returns to the abdominal cavity during 11 weeks fetuses more than 12 days do not demonstrate any sign of midfield habitation and its presence it will be an omphalocele stomach is always visible at 11 weeks and the yolks at swings now the cardiac activity cardiac activity is seen as soon as the embryo is visible there is a rapid increase in heart rate between six to nine weeks followed by a decline after 10 weeks if the fatal heart rate is less than 100 beats per minute or more than 180 beats per minute in the first trimester it is associated with an increased rate of spontaneous abortion and the scan should be repeated after one week for viability of the fetus now coming to number of fetuses what is corionicity what is amniocity and what is zygosity so chorionicity refers to the type of placentation or the number of functioning plasma does so if there are two different plasmas we call it as a dicorioric pregnancy if there is a single plasma single shared plasma we call it as a mono coriani pregnancy what is amnioticity the number of amnions or the inner membranes that surround the baby in a multiple pregnancy is the amniocity so a pregnancy with one amnion that is if all the babies are sharing a single amniotic sac it is called monoamniotic pregnancies with two amnionese are diagnotic three amnionese are tri-amniotic and so on so here we can see that in the first picture there are two placentas so this is a dichorionic religion c and there are two amniotic stacks so it is diametric so this is a dicorionic and a diamondic pregnancy in the second picture we can see that there is only a single shared plasma both the fetuses are sharing a single plasma so this is a monochromatic pregnancy but both of them are in two separate sucks so it is a diet amniotic monochorionic diagnosis pregnancy again in the third picture we can see that both of them are sharing a single plaster and sharing a single sac so this is a mono choreonic monoamniotic pregnancy what is digosity zygosity refers to the type of conception that is the number of fertilized doma that resulted in a multiple pregnancy this can be determined only by dna analysis in a dizygotic multiple pregnancy there is independent fertilization of two over and so dizygotic twins are always dicorionic and die amniotic and they have different genetic makeup and are discordant for anomalies in a monozygotic multiple pregnancy there is fertilization of a single ovum which then separates into two so there is similar genetic makeup and the risks are also concordant for aneuploidies the time at which the separation occurs will determine the chorionicity and amnesity of the pregnancy if the cleavage occurs between one to three days that is at the modular stage we get a dicorionic diaminotic pregnancy if the cleavage occurs at days four to eight at the blastocyst stage we get a monochorionic diagnotic pregnancy if it cleaves at the 8 to 13 at the implanted blastocyst stage we get a monochorionic and monoamniotic pregnancy and if it cleaves later between days 13 to 15 we get a conjoined twin now ultrasound diagnosis of coronicity the ideal time to determine choreonicity is the first trimester the gestational sag visualizing the early pregnancy is created by the korean so the number of gestations are is equal to coronicity of the pregnancy so in a dicorionic twin pregnancy there will be two complete and separate gestational sacs and in a monochromatic in pregnancy there will be a single room of chorionic tissue which creates a single gestational sac how is the diagnosed up to seven up to seven to nine weeks the amniotic is very thin and it may not be detectable so in this scenario the amnioticity is equal to the number of yolk sacs if there are two yolk sacs it is suggestive of a die amniotic twin and one yolk sac will suggest a mono-amniotic wind but the amnioticity must always be verified in full of examinations now this ultrasound images image shows two thick corionic sacs there are two embryos and is entirely in two sacs so this is a dicorionic die amniotic during pregnancy in this image we can see that there are two different embryos but there is only one thick chorionic sac surrounding both the embryos so this is a monochorionic pregnancy but each embryo is surrounded by a stone amnion and each amniotic cavity has its own yolk sac so this should be a die amniotic pregnancy so it is a mono chorionic diamnotic twin pregnancy in most of the cases the number of the oxalic responds to the amniocity of the pregnancy in this case there is only one thick echogenic chorion there is only one sac so it is a monochorionic pregnancy we can see that there is a very thin amnion with both embryos inside the single amniotic sac and there is only a single yolk sac and this finding is consistent with a monochorionic monoamniotic twin again an initial ultrasound which was taken at five weeks five days showed a single chorionic sac so it is a monochorionic queen pregnancy there were two embryos each with its own yolk sac and there was no visible intervening membrane in between so this we can conclude as a mono chorionic diamond because we are seeing two yolk sacs now again for our confirmation a follow-up ultrasound was done at 11 weeks which showed the thin membrane separating the two amniotic sac and thus confirming the diagnotic nature of the pregnancy so early in gestation a thin membrane may be the below may be below the limits of resolution for an ultrasound and it may not be visualized but if there is presence of two yolk sacs with its own embryo this is more suggestive of a diagnosis now a dicorionic di diamniotic versus a monochorionic diamiotic at 10 to 14 weeks of gestation that is if the glass and eye is entirely located in two locations that is if one sec the plaster is located anteriorly and if in the other side it is located posteriorly we can easily identify that it is a dicorionic gestation but in some cases it may be a fused dicorionic plasma both the placenta may appear anteriorly or both may appear posteriorly and we are not able to distinguish whether it is a fused plaster or it is a single plasma so in such cases we make use of the twin peak sign or the lambda sign that is in a dicorionic twist always there is a thick membrane separating the tubulins and this thick membrane is composed of two chorions and two amnions there will be two chorions and two amnions and usually the thickness of the membrane is more than two millimeter the chorionic tissue extends from the placenta to the base of the thick membrane and this creates the twin peak sine or the lambda sine this helps establish the true chorionicity even when there is a single placental mass in monochronic diameter means we can see only a thin membrane which is less than two millimeter composed of only two layers of ammonia which separates the monochorion entrance the amnion aborts the placenta but there is no intervening chorion and this creates the t site so in monochorionic twins we see only a very thin membrane and there is t sign whereas dicorionic twins we can see a thick membrane more than 2 mm with lambda sine so in a dicorionic diagnotic gestation there are 2 sacs 2 placenta there will be yolk sac there is a thick intervening membrane with twin peaks i or lambda sign in a mono or any pregnancy there is only a single sac one placenta two yolk sacs there will be a thin membrane separating the two fetuses and there will be t side in a monochorionic mono amniotic gestation there is only one sac one placenta one yolk sac there is no inter twin membrane and sometimes an entangled cord may be seen now how do we classify a triplets in the first image we can see that there is a single shared placenta there are three fetuses but within a single amniotic sac so this single placenta it is monocoryonic and single sack so it is more amniotic monochorionic monoamniotic triplets in the second picture we can see that again a single plasma so it is mono chorionic but there are two sags so one fetus endurally it has its own different sac and two fetuses share a common sack so since there are two sacs this is diamond so this is a monochorionic diagnotic triplex and in the third case again there is a common placenta but there are three fetuses within three different sacs so it is a monochronic triaminotic triplets in the second case we can see that there are two placentas so it is dicorionic but again two amniotic sacs only so it is dichoryonic diamiotic and in this case again two plus and r so it is dichoryonic and there are three amniotic sacs so it is a dichoryonic triamniotic gestation triplets in the third case there are three separate placentas three different amniotic stacks so this is the trichorionic dry amniotic triplets here in this image we can see that there are three different sags there are three different embryos and there are three different yolk sacs with thick indoor twin membranes so this is a dry corionic triamniotic triplet in this case again we can see that there are three embryos but there are only two sacs so this is dicorionic the single embryo on the right side is seen in a separate coronic sac and again on the left side we can see that there are two embryos with separate amniotic sacs and thin amniotic membrane between them so this is a dicorioric triangle triplet now the significance in assessing chorionicity and amniocity is that after 14 weeks it is difficult to assess choreography and animal city it should be best assessed in the first trimester scan itself monochromatic twin pregnancies share one placenta so they are more prone for the hemodynamic complications such as 22 in transmission syndrome twin anemia polycythemia sequence twin reversed arterial perfusion sequence demise of a core twin brain embolization syndrome etc it helps in the risk assessment discord and fatal anomalies genetic counseling invasive procedures as well as management of 22 transmission syndrome and selective fgr so that was about multiple pregnancies now coming to dating of a pregnancy we date a pregnancy to establish an accurate gestational age and to assign the edd for appropriate follow-up frequencies as well as for the optimal assessment of fetal growth later in pregnancy so that we can uh early identification of fgr and to provide appropriate obstetric care so from 5 to 9 weeks we use the mean sat diameter that is when the embryo is not visible once the embryo is seen or from 6 to 12 weeks we use crn for dating of a pregnancy and this is the most accurate after 12 weeks we use the head circumference a correctly measured crl is the most accurate means of estimating a gestational age we have to obtain a true unflexed longitudinal section of the fetus the end points are the ground that is the top of the head and the run rum that is the end of the trunk which is clearly defined place the calipers correctly on these end points and measurements are taken once the spine is visible it can be used as a guide for assessing the true fetal length any degree of flexion of the fetal spine will underestimate the crl when linear calipers are used examination of the fetus with full length of its spine position directly anteriorly or posteriorly enables us to assess any degree of flexion if the fetus is obstinately curled that is even after a long time we there are only three choices either again sit and wait so that the fetus gets to be in a good position neutral position or we can measure the flex length using non-linear measurement or again the third measurement is linear calipers can be used to measure the parts of the feeders that are in straight sections and then we can again add them together if the gestational age matches the ultrasound biometric age then we assign edd by lmp and once the edd is assigned do not change the edd in subsequent scans a re-dating of a pregnancy is done when there is a discrepancy between the edd calculated by mmb and that we get by ultrasound care should be taken when radiating a pregnancy especially in the third trimester because there might be other reasons for a fetus to be small like fetal growth restriction now what are the guidelines uh for regulating our pregnancy if it is i'm talking only about the first trimester relating when it is less than 14 weeks if the pregnancy is less than nine weeks and the discrepancy is more than five days we need her pregnancy between nine to fourteen weeks we redate a pregnancy only if the discrepancy is more than seven days i'll give you an example suppose a patient comes to you with lmp first january 2022 the edd by lmp is 7th october 2022 so the gestational age by lmp was seven weeks five days but by crl we are getting only a gestational age of six weeks six days so in this case discrepancy is six days so according to this table when the when the gestation is less than nine weeks and the discrepancy is more than five days we should re-date the pregnancy so here in this case it is less than nine weeks the discrepancy is six weeks so again we should give a corrected edd by usg a second case in which the lmp is 15th january and the edd we got is 21st october the gestational age by lmp was 12 weeks and 5 days and by crl was 12 weeks 0 days so here the discrepancy is 5 days now between 9 to 14 weeks we read the pregnancy only if the discrepancy is more than 7 days so in this case the discrepancy is only 5 days there is no need to redate the pregnancy we can do follow-up scans and monitor the interval growth once a radiating is done always mention the corrected ada in the report and in the subsequent scans enter the corrected edd and not the lmp do not change the edd in subsequent scans and make the mother aware about the difference and stress the importance of carrying the previous reports for the subsequent scans that was all about normal pregnancy now we are coming to abnormal sonography which includes an empty gestational sac a failed early pregnancy pregnancy of unknown viability unknown location ectopic pregnancy subcorionic hemorrhage miscarriage and gestational trophoblastic disease an empty gestation sac can be due to a number of causes like an embryonic pregnancy a very early intravenous pregnancy a pseudo gestations are with an ectopic pregnancy or a gestational trophoblastic disease an an embryonic pregnancy is when it's a form of failed early pregnancy where the gestational fat will develop but the embryo does not form an an embryonic pregnancy is diagnosed when the main sac diameter is more than 13 millimeter with no yolk sac or the mean set diameter is more than 18 millimeter with no embryo or we see an empty sac beyond 38 days of gestation and there is no interval growth a failed early pregnancy or an embryonic device is when the death of the embryo occurs before 20 weeks of gestation and the most common cause of embryonic death is a chromosomal abnormality so what are the ultrasound findings diagnostic of a pregnancy failure when we see a crl embryo with crl more than seven millimeter but there is no cardiac activity it is pregnancy failure a mean sac diameter is more than 25 millimeter still no embryo is seen that is pregnancy failure again if the initial scan showed a gestational fat with without a yolk sac and again we are doing a repeat scan after two weeks if again there is no embryo with a heartbeat then it is a sign of failure of pregnancy again if the initial scan showed a gestational sac with the oak sac and the scan is repeated after 11 days still there is no embryo then it is a pregnancy failure so these are the conditions for diagnosing a pregnancy failure now embryonic device is when the crl is more than 7 mm and there is no cardiac activity or the crl is less than 7 mm but there is no cardiac activity on the initial scan and again no cardiac activity or interval growth on a repeat scan done more than 7 days later or cessation of a previously documented cardiac activity of the embryo irrespective of the crm now we call it as a pregnancy of uncertain viability when the crl is only six mm we don't see a cardiac activity or the main sack diameter is only 20 mm and there is no fetal power these are findings only suspicious of a pregnancy failure we can't clearly define it as a frequency failure in that case we do a follow-up after 7 to 14 weeks to assess the pregnancy for viability now pregnancy of unknown location is when there is no intrauterine or extra uterus act visible the possibilities are it could be a very early intravenous pregnancy a very early failed pregnancy could be an ectopic pregnancy or an abdominal pregnancy nothing to ectopic pregnancy ectopic pregnancy is implantation of a developing blastocyst at a site other than the endometrium there can be extra uterine ectopics as well as intrauterine ectopics 95 percent of the cases it's often it is a tube electrode that is in the topic uh pregnancy is located in the fellow printer the others could be ovarian ectopics or abdominal ectopics which are very rare and there's only less than one percent then intrauterine ectopics could be an interstitial ectopic a colloidal topic or a cervical ectopic the ultrasound examination should be performed both trans abdominally and transfer generally the tas component will provide a wider overview of the abdomen whereas the tv is important for diagnosing for diagnostic sensitivity now the most common is the tube electrode the ultrasound findings will be an empty uterine cavity with no evidence of an intrauterine pregnancy sometimes a small pseudo gestational start will be seen as i mentioned earlier it is just an intra cavity fluid collection and a thick echogenic endometrium will be seen there may be a simple or complex agnexil cyst or mass the tubal ring sign that is an echogenic ring that surrounds the unruptured pregnancy the ring of fire sign that is peripheral vascularity of that natural mass on color or pulse doppler there will be a gestational sag in that mixer with yolk sac or sometimes even the fetal pole and cardiac activity can be seen in case of analytic token gestation and there will be flea fluid or hemo peritoneum in the pouch of darkness but this image shows that echogenic ring ah that surrounds an under absorbed tropic pregnancy this is the tubal ring sign and this is the ring of fire sign where there is peripheral vascularity of that mixture mass on color or pulse doppler examination now in the first image we see that the endometrial cavity can be seen there is no interruption gestation a small fluid collection is seen within the endometrial cavity there is an addiction mass which is separately visualized from the ovary on color doppler the ring of fire vascularity can be seen and there is flea fluid near the impact so so in the setting of an elevated beta cg these features will represent an ectopic pregnancy again in the first image we see that the endometrium is thickened there is no indirect run gestation sag there is a thick walled and textured sac and excel cyst which is separate from the ovary and on careful examination we can see that there is a yolk sac as well as a small fetal core with cardiac cavity so there is a this is a live ectopic station now interstitial ectopic pregnancy this is a gestation that gets implanted in the most proximal part of the fallopian tube which is within the myometrium it is an uncommon site for tectopic pregnancy the ultrasound features include a empty uterine cavity that is the endometrium can be seen separately and the sarc is seen separately from the lateral edge of the uterine cavity and the surrounding myometrial layer we have only very surrounding thin biometric layer which is less than five millimeter and the industrial line sign that is an echogenic line that runs from the endometrial stripe to the gestational sac in this case we can see that there's a retroverted uterus the endometrial cavity is empty there is no gestational cycle seen the gestational sac is seen in the left or neural region separate from the endometrium there is a thin echogenic line extending from the endometrium to the gestational sac and the minimal myometrial thickness around the gestational sac is only 1.7 millimeter this is the second case where the sac can be seen separately from the endometrial cavity this is the endometrial cavity which is thickened but there is no endometric there is no sag within the sac is seen separately from the endometrial cavity of heat is with cardiac activity seeing yoxin then this is a 3d image which illustrates that the sac is entirely separate from the endometrial cavity there is only a thin intervening biometric band and a thin myometrial mantle so the significance is that this interstitial ectopic has the potential to grow to larger sizes than standard tubal ectopic pregnancies at the time of presentation because the surrounding myometrium will hold it longer so the mobility and mortality is higher because of a later presentation and associated complications the uterine myometal rupture tends to occur by the second trimester and there is a greater tendency for massive hemorrhage now about angular pregnancy this is not an ectopic pregnancy but it is just an eccentrically located sac which is implanted in the lateral angle of the uterus it is entirely within the endometrial cavity but just it is in the lateral angle and medial to the uter tubal junction most often there is sufficient endometrium and biomaterial surrounding the sac double section may be seen as usual in any in-driven pregnancy now the confirmation when we have a doubt whether it is an angular pregnancy or an interstitial ectopic an mri should be done and we can see that in an angular pregnancy the sac is surrounded by a d2 hyperintense endometrium whereas in industrial pregnancy the sack is surrounded by only by a t2 hypo indians myometrium now cornwall ectopic pregnancy this is reserved for pregnancy in women with a uterine anomaly that is a pregnancy is located in a communicating or non-communicating rudimentary one of a unique coronary uterus or its intrauterine location in the lateral half of a septate subsupdate or a biconvid uterus the sac is often found laterally in the uterus and can resemble an interstitial pregnancy but the sac is actually located medial to the interstitial tube to diagnose a coronal pregnancy it is necessary to first identify the uterine anomaly so a 3d ultrasound or an mri should be done to clearly depict the uterine malformation and the exact location of the sac there is increased incidence of miscarriage free term delivery abnormal fetal eye and cesarean delivery in a conventional again in this image there is a trans abdominal sagittal section of the uterus you can see the endometrial cavity is empty and separate gestational sac is seen from the uterus surrounded by biomedium and 3d images we can see that this is a right unicorn uterus and the gestational sac is located in the left rudimentary horn cervical pregnancy is when uh implantation occurs within the endocervical canal that is the gestational sac is seen within the cervix the endometrial stripe will be normal there is no sac within and as the fetus expands within the cervix there will be a hourglass or a figure of eight appearance of the uterus and the fetal heart can be detected below the internal cause it should be differentiated differentiated from an incomplete abortion in an incomplete abortion usually the cervical horse is open the gestational sac is irregular in contour and not adhering to the cervix this can be confirmed by sliding sign that is when we manipulate a transducer prop we can also manipulate the gestational sac and cardiac activity may be detectable in a cervical pregnancy with visible embryo which will not be present in an incomplete emotion ovarian pregnancy usually the gestational fact is seen within the ovary rarely a live features may be seen and always care should be taken to differentiate it from the corpus luteal cyst with serial four of ultrasound and beta ecg levels heterotopic pregnancy is when there is both intra uterine and extroverted pregnancies occurring simultaneously detection of an ectopic pregnancy may be delayed because in the presence of a intrauterine pregnancy if you don't look for it properly if you don't examine that mixer then we can miss the ectopic gestation so along with the introverted pregnancy for complex adnexal mass is seen with a gestational sac or embryo it is a heterotopic pregnancy now a scar pregnancy is when the sac is implanted in the scar tissue of a previous cesarean section it can result in uterine rupture and life-threatening hemorrhage on ultrasound registration sag is seen at the scar site at the antero inferior edge of the neutron cavity in case it is difficult to distinguish with the ultrasound we can always use an mri again this is a transvaginal image we can see a small oval fluid collection in the region of the anterior lower uterine segment the uterine wall is extremely thin anteriorly which increases the chance for a wall dehiscence and this is a typical cypher cesarean scar ectopic pregnancy and this is not a cervical infection because we can see the cervical canal clearly and it is empty again another image which shows the caesarean scar ectopic the bladder is seen on the right side the uterus uterus is seen divulging into the bladder the sac is located in the lower uterine segment away from the endometrial stripe as well as av from the cervix that is about ectopic now coming to subcorionic hemorrhage this is bleeding beneath the chorionic membranes that enclose the embryo due to partial detachment of the quranic membranes from the walls of the uterus it is usually a chronic connection with elevation of the quranic membranes and depending upon the time elapsed it can be appearance will be variable if it is acute it can be hyper acrylic and it may not be able to distinguish from the quadratic membrane if it is subacutely chronic there will be decreasing echogenicity with time now if it a sub coordinate hemorrhage can be considered small if it is less than 20 percent of the size of the sac and if it is large if it is more than 50 to 66 percent of the site large homeotomors by size that is more than 50 of the sac or volume more than 50 ml has a bad prognosis coming to miscarriage it is a spontaneous or natural termination of a pregnancy before 20 weeks of gestation after 20 weeks it is fatal that we call it as fetal death in utero causes could be an embryonic pregnancy chromosomal anomalies embryonic anomalies neutron anomalies teratogens maternal diseases placental abnormalities or trauma their types are miscarriage threatened miscarriage inevitable miscarriage incomplete or complete miscarriage now we call it as a missed miscarriage when there is a non-viable fetus without any symptoms of miscarriage that is the patient does not have any symptom the patient does not have an abdominal pain there is no bleeding pv but on ultrasound we see that we see a fetal pole with crl of more than seven millimeter and there is no cardiac activity there is a small and irregular gestational sac and the cervical horse is closed management is according to the patient preference we can either wait for a spontaneous expulsion or we can terminate the pregnancy with medical or surgical management threaten miscarriage is when the woman pregnant woman presents with spotting mild abdominal pain contractions etcetera in the first 20 weeks of gestation when we do an ultrasound we can see a normal life in driving gestation with cardiac activity the cervix is closed there may or may not be a sub coronary hemorrhage again here we go for an expected management management because this can either carry on as a normal pregnancy or it can progress to an inevitable or complete miscarriage if cervical dilatation occurs now features suggestive of a poor outcome are fetal bradycardia that is less than fhr less than 80 beats per minute a small or irregular gestational sac crl less than five millimeter a large and calcified yolks at more than seven millimeter a large subchorionic hemorrhage more than two third of the gestational sac abnormally large amniotic cavity or absent or per decedent reaction now inevitable miscarriage is when the patient has symptoms cramping and bleeding is present but the cervix is dilated the products of consumption are not yet expanded but miscarriage is unavoidable on ultrasound a sat may be seen low within the uterus or intracervical condensed may be present at the time of examination and feature cardio category may or may not be present incomplete miscarriage is again when the cervical horse is open there is partial passage of the products of consumption ultrasound appearance may be variable ranging from visible fetal parts to mass of mixed echogenicity in the endometrial stripe on cervical canal complete miscarriage is diagnosed when all the products of consumption has passed the recession of vaginal bleeding ultrasound shows a thickened endometrial lining there is no evidence of a gestational sac or retained products of consumption now retain products of consumption is when there is persistence of glass center or fetal tissue in the uterus following delivery termination frequency or a miscarriage it can be suspected when the endometrial thickness is more than 10 mm following a dilatation and cure attach or a spontaneous abortion there will be echogenic or heterogeneous material within the endometrial cavity if increased vascularity is present within the contents or the myometrium this variants medical or surgical evacuation if there is no vascularity and there is no invasion of myometrium then the contents may excel spontaneously we can do it if there is hypo or anochoic contents this is usually non vascular clots now coming to gestational trophoblastic disease there are two types one is the high dietary form mold and second one is the gestational trophoblastic neoplasia which includes an invasive mold a choriocarcinoma and a plastinocyte trophoplastic tumor in all forms of gestational trophoblastic disease the maternal serum beta ecg values are markedly elevated except in case of a plus single cytophobic tumor where it is less so a high dietary form there is a complete mode and a partial mode a complete mole is formed when there is no maternal dna and but this empty egg is fertilized by a sperm and there is duplication of the sperm dna so there is no maternal dna there are two sets of pattern and dna and as there is no maternal dna there is no fetus formed in case of a partial mole usually the fetus is seen because one set of maternal dna that is a haploid egg is fertilized by two sperms two haploid sperms so there are two sets of pattern and dna and one set of maternal dna so an abnormal fetus may be seen findings in a complete mole there is an enlarged uterus there is no fetal part the intrauterine mass has multiple cystic spaces which gives a classical snow storm or a bunch of grape appearance and there is no involvement of the myometrium again here we can see that there is an enlarged uterus distance of the uterine cavity by a cogenic material with numerous small irregular cystic spaces this is a classical bunch of appearance and there is no identifiable feature tissue and color doppler shows areas of increased vascularity in a partial mode there is usually an enlarged placenta relative to the size of the uterine cavity with cystic changes there is a small abnormal or deformed fetuses present so in a complete mold there is no fetal parts and in a partial mold usually some abnormal fetal parts will be present again this is a image showing a distorted gestational sac with a large uterus multiple cystic areas within the endometrium or the placenta and a fetal pore colour doppler shows no cardiac pulsations which indicate a non-viable pregnancy both the ovaries will be enlarged and bilateral thick luteinizes will be present in case of a molar pregnancy high digestivity for more is a pre-management condition with 16 percent of complete and 0.5 percent of partial modes undergoing transformation into malignant forms such as invasive mole choreocaroma or a plastinocytophoblastic tumor so an invasive mole when a complete or a partial mole invades the myometrium this is called an invasive mold it is a locally invasive non-metastasizing neoplasm it may invade the parameter tissue and blood vessels a choriocarcoma is a highly vascular metastasizing neoplasm fifty percent arise from a complete high dietary for more 25 percent from a normal pregnancy and 25 percent following a miscarriage or a chronic pregnancy early and extensive vascular invasion results in metastasis even when the primary tumor is quite small a placental cyclophobic tumor is the rarest form with an uncertain biological behavior it arises from the glass center implantation site and it can occur following a normal pregnancy abortion or a high dietary form all but most commonly occurs from an anticipated normal pregnancy generally it's a slow growing tumor with a tendency for local and lymph node metastasis before distal metastasis occurs and in contrast to other forms of gestational prophylactic diseases this will produce only very small amount of beta fcg so sonographically all these three conditions are indistinguishable from each other it is seen as non-specific focal heterogeneous muscles with a myometrial epicenter there is invasion of the myometrium mass may be hypo or hyper complex or multicystic it may show unaccurate spaces which represents hemorrhage necrosis or vascular species more extensive disease may appear as a heterogeneously enlarged uterus with low belated contour or a large pelvic mass which may extend to involve other pelvic organs persistent roper blasting neoplasia is presumed to be invasive mold unless there is presence of metastasis such as choriocarcinoma both invasive mole and chloroplast are usually treated with chemotherapy but placental cyto for trophoblastic tumor is chemo resistant and often requires hysterectomy so although invasive mold choreocarcinoma and plastinocytoplastic tumor are indistinguishable sonographically a diagnosis can be strongly suggested that is a flare central cytophobalistic river because there will be only a very low levels of beta cg when compared to the other two conditions on color doppler a molar pregnancy will show high velocity low impedance waveforms due to high degree of arterial invasion arterial venous shunts are often associated with neovascularization within the invasive biometal mass and this will result in a chaotic vasculature with color aliasing and loss of vascular discreteness so here we can see that this is the enlarged uterus distance of the uterine cavity by a cogenic material with small irregular cystic spaces within and areas of ill definition with a myometrium this indicates biometal ignition and on color doppler we can see that there is a mosaic pattern of uh color signal within the cystic spaces which represents turbulent flow and increased vascularity within the myometrium which such as myometrial invasion again another image which shows a complex solid cystic mass in the uterine fundus with myometrial epicenter there are anachroics genus structures in the adjoining myometrium and colour doppler shows turbulent flow and spectral analysis reveals the abnormal vasculature thank you thank you thank you very much dr sumiya i think that was a fantastic comprehensive uh and run-through of the first trimester imaging no one could have done it better very thorough on the crucial concepts very smart slides and very good images thank you so much so we will now move on to the panel discussion i invite our esteemed panelists our very own doctor richard matthew our state secretary and the crusader for quality fetal imaging across india dr barajandar nair our professor from jupiter medical college dr betsy principal and hsod gynecology at amla medical college and dr sumiya also will be joining his panelist i invite dr sheffie to moderate this session over to you dr shetty thank you all right good evening actually supposed to moderate good evening all okay okay sorry okay good evening uh dr balendra and i have to leave because of some personal issues okay the theme for our panel discussion is setting up of fetal radiology division in teaching hospitals the pros and cons um my first question is to dr bexy is there a need for specialized fetal radiology medicine services in medical colleges why definitely yes it is because of three reasons because we are talking about medical college that is first for educational purpose both for undergraduate and postgraduate educational purpose especially with the new curriculum that is competency based medical education you know like radiology has become an integral part of cpma so for undergraduate education pg education definitely we know that second thing is these medical colleges are supposed to be referral centers and of course then there are some problems where when there are some doubts from the peripheral centers definitely we have to solve the uh problem for them and third is research because medical colleges we have good research committees and then ethics committees and many of the researchers especially related to fetal radiology can be conducted only in places where good institutional ethics committees are there i think we should have fetal radiology units in medical colleges okay thank you madam dr richo what is your opinion on this yes sir i perfectly agree with doctor what dr betsy has said it's high time that all radiology departments and medical colleges have this particular division of fetal radiology and fetal medicine the radiology currently has got some 15 sub-specialties among which the diagnostic radiology and interventional radiology is now slowly coming into all the medical colleges intervention but fetal radiology is still fetal radiology and fetal medicine is still not um coming in a big way even though there is a great need at the referral hospital level and also for the teaching and also for those post graduates who are coming out from those institutions if they are not trained properly because india is a country which has got nearly three crows of pregnancies it's a huge number that is and those pregnancies require at least two or three scans in during their pregnancy means we need to have trained people who are doing quality scans uh and in in uh most of this time the pgs that are coming out will have to work we have to do fetal imaging and if they are not trained in a proper way if they are currently some of the institutions in our country the pgs in radiology haven't got any exposure to fetal image so that's a sad reality that we have to really understand and those postgraduates have come out with flying colors from those institutes are finding it difficult even to diagnose an nnk file so such situations we have to avoid and all medical colleges were the postgraduate degree radiology degree is the post graduation radiology is the there should be a fetal radiology department in the fetal medicine department to improve the quality of radiology services for as far as the obstetrics imaging is concerned that's a must and it is high time the radiologist has to come together and do that unfortunately what has happened is maybe somewhere between 2000s the radiology's focus has more grown and gone into ct and mr and there has been considerable development in other subspecialties like neuro radiology msk and all those things and much of our senior faculties were engrossed in those and this being a modality of fetal radiology which requires more of a physical involvement rather than sitting in a image waiting a room they they might have purposefully avoided or might have given it to the obstetric department or might not have given sufficient attention to that but it is high time that they themselves have to realize the post graduates they have taught and coming out from their institutions are finding it extremely difficult they will have to go and go for a fellowship or get trained for another one year or two year in some centuries where field imaging is being done so but this can be very well integrated again i'm emphasizing the point india is a country which has got three crow pregnancies and all the radiologists who are coming out will have to do most of them 90 percent will have to do some kind of heat imaging work during their initial five years of their practice before they decide to suspect become an expert in some kind of specialty whether it's a neuroradiology or all these things so fetal radiology has to be in the integral part but there is a mindset problem right now for which my solution is the hiv is the head of the department so whoever is in charge has to entrust an associate professor and assistant professor to start the department because 15 subspecialty none of the actuaries are going to be a mastery not unfortunately they are very reluctant to realize understand realize that or admit that that's a sad reality okay thank you sir i also admitted with your opinion [Music] we are talking of developing a highly specialized fetal radiology division in a teaching hospital so what are the practical issues on setting up a specialized fetal radiology medicine division in a medical college and what are its solution again to a doctorate yes uh see the one of the major problems that i already told it's a mindset problem because and that mindset problem is reflected is projected in a way that we have got huge volumes so huge volumes of work in all other subspecialties we don't have enough staff strength and not so only solution i am recommending is for interventional radiology and fetal radiology here the hrd's has to delegate that work to either an associate professor an assistant professor to take the lead in that is hivs cannot be a master of all fetal radiology and interventional radiology in all the departments so that is one way but apart from that mindset problem if that can be solved another thing is post graduate radiology education exams if you look at it is there a long case in the offsetting image is there a short piece in upsetting imaging how many spotters have you seen i've been conducting the crest pg courses for the last 10 years absolutely nothing if the student is not having anything for the next time how will they learn there is no incentive for them to learn but when they come out of after passing this thing the next day they get a job and the first first day they will have to do 10 of obsidi cases they're finding it extremely difficult and the angry barriers has been kept very high by the fetal medicine experts in the sense if you want to get a good nuclear translucency without any this thing you will take hour one hour at least for that but you need constant training to get it so the gap is so huge that's what the radiologist has to understand if you really want to do a quality fetal imaging fetal radiology feature medicine work currently the curriculum the training as especially the structure and cost process based training in the medical college is not sufficient is not providing them the competency based training they are not skilled enough to do that so they they have to be mentored in such a way delegated in such a way with the proper guide to do these things and when they come out even some advanced training also may be required for interventions because basically all these working 90 percent of the fetal work it's basically imaging genetics biochemistry and all these things are only coming as part of the world cups 90 percent the pivotal role is played by imaging but radiologists are not giving sufficient attention to that even then there is another big divide amongst radiologists that those who are practicing ultrasound are one group there's a practice in ct and mr and another group seen even in shafi's presentation today he has not mentioned about fetal mri why fetal mri is an integral part of fetal radiology and that is a modality that can solve a lot of issue problems especially the structural anatomies in relation with neuro cns and chest and all those many of the other systems also so a fetal radiology department fetal radiology of intermediate department in the radiology department division in a radio department should train their young residents to solve a structural anomaly or evaluate a structural anomaly with the help of ultrasound hello doppler 3d 4d and also with mri and also fetal interventions those there are excellent radiology departments in the throughout the country which are doing very good vascular and non-vascular interventions why can't they do fetal interventions fatal interventions are nothing when compared to the kind of work most of them are doing there is again a mindset problem there and that comes right from the top because nobody wants to take the responsibility there so my suggestion is delegate it to somebody who is interested in your department to start an interventional or a fetal radiology medicine rather than the achiods taking the lead of this starting it and managing it and if most of the chores [Music] ultrasound imaging they will be into neuro radiology they will be into msk most of them will be i am openly admitting you i have not i don't have any idea about what you're talking about especially with fatal imaging is concept because i not done much so delegate it that is the only way out i think i have given a few suggestions but there can be and again the major problem is called quantity of work most of the medical colleges has and to have a quality work the kind of guidelines that is currently being accepted and practiced by the fetal medicine experts if they want to implement it at the medical college level for the volumes that they have the waiting period will be more or the staff strength has to be increased for which i am sure principal dr betsy and all will support them in a kind way that is important alligation is very important for department to develop that's the only way to do it many many hrds because last 40 years most of the radiological modalities have developed in the last 40 years and people who were very good at conventional and even ultrasound they may not be good at cpu or mr people who are good at secure mri they might not have maybe not be very good at conventional or there are very few radiologists who are good at all these modalities so it is a reality that everyone has to admit and whether you're holding a post or not listening there are 15 sub-specialities in radiology and you cannot be a master of all the 15 sub-specialties that is a reality that all radiology actually has to admit and delegate it to some smart assistant professors or associate process who has got a passion to work on it that is the only way the radio departments can have uh interventional radiology and fatal radiology with them otherwise they will lose it the pathetic significant situation is those pgs who come out with gold medals and all with apps without any idea about fetal or intervention are also are in a very difficult situation when they come out to practice they get a job for 2.5 lakhs or three lakhs and they can't they find it difficult to do some of the basic uh feet imaging and they cut a sorry figure with the obstetricians or referring physicians it is also important to include it in the curriculum as a main life but exams that has it has to be a part of a short case or a long piece or something one case was given as obstetric for all the students but later that short case was stopped and the examiner started bringing the films because they feel that they have to spend a lot of time on one one case by doing ultrasound adam the problem is our exams are not checking their competence yeah so now i feel that this should be kept as a long case or a short case for the students so that students will have an energy for doing it and they will come out with beautiful colors also i feel that should be implemented in all the medical colleges and all the institution that a 1k should be in abstracts give them a case and see the examiners should see the way they are approaching it yeah while they are doing the scans yeah that will give an idea yeah so that kind of a competency based uh training and um examination is not there our structure and process systems are the basic problems you know we will try to do it because with this we can do it i think there is a new curriculum that is coming up yeah coming up yeah actually nmc has already put up in their website actually yeah yeah competence is expected out of post graduates in various departments yeah that's good so we will try to include this in the exam as madam said yeah we should and one more thing i wanted to highlight is the prioritization the clinical priorities in india has not been sufficiently addressed by neither by the fetal radiology nor by the fetal meds because fetal medicine and knowledge mostly developed in the west their priorities are being uh brought here and but that is one of the core uh what is one of the reasons when this subjection project was introduced we realized that preeclampsia and fetal growth restriction which contributes to its major contributor to perinatal death in india it is totally being ignored because our pregnancy scans are concentrating only on structural anomalies look at whether i have missed an anomaly and more much more on chromosomal markers so much of my attention and technique training and everything is for to get an nt where a preeclampsia screening or an fgr screening with the combined screening i have totally not not done pregnancy scans ideally has got three components one is an anomaly or structural evaluation along with that the chromosomal markers will come second is growth evaluation there are growth abnormalities that causes major damage major amount of casualty to the perinatal death perinatal morbidity then the fetal maternal environment so these two are integral part of our scans are of the clinical priorities in india which the west doesn't have they've got only two to three percent of prayer clams here they've got only two to three percent of fatal growth restriction so if you can't blame them in a guideline come from this they are not paid much attention to that because for them what causes more death there what causes more countability there is still congenital anomalies and chromosomal anomalies so that if you straight away trans translate into the indian circumstances and practicing it you're spending quite a bit of time on chromosomal markers and evaluation structural anomalies of course we have a lot of structural anomalies but if you compare the numbers say for example down syndrome one in 700 in india when out of the 2.7 crore or three crore pregnancies in india it is translated it into numbers it comes to 38 000 40 000 but the 63 percent causes of perinatal deaths in india is due to prematurity and intra pattern complications of which fetal growth restriction preterm births and the preeclampsia are a major contributor that number will be somewhere around 5x so you understood it's 10 times that screening is not being done next screening is not being given priority even by the fetal medicine departments fetal medicine experts also not giving doing it 11 to 14 week scan ideally has got four components one it's a dating scan second second priority should in india should it should be re-eclampsia and fgr screen third should be structural anomaly screen and fourth should be evaluation of chromosomes all the four should be done but if you look at the clinical priorities in india this is the one two three and four but what happens is that most of the institution uh even though they have a center for doing the opg scans but they don't have a genetic lab close by that's a major issue which is coming to all the institutions so we should this who can take care of there are enough facilities which can do the genetic this thing right now that is not the major issue we have to majority of the work is radiology and the combined screening with biochemical markers and radiology itself and only in the sequential this thing the high risk is there some patients will have to undergo the amniocentesis and genetic evaluations of all those it's not that all patients will have to go for that the one more area we have to concentrate is on fetal mri that we have to develop our experience and competency in the fetal mri yeah i have a suggestion as we used to do outreach program breast imaging i want to do an outreach program on fatal radiology also that will be very good for the residents as well as the junior faculties i think we can start norwegian yes yes program yeah we can yeah especially when we have got youngsters like dr sumiya doing excellent talks we got a young stream of radiologists coming up yeah we can do that okay dr betsy i have a question to you what is your opinion on radiologists communicating with patient about outcomes and next step in management in verbal as well as in variety i have to be very very diplomatic because i'm sitting with my radiology colleagues i would have answered very differently in an obstetric platform actually i'll just tell the mind of the obstetrician not my personal opinion uh generally obstetricians don't like radiologists uh talking to the patient about the report like what next and what are the complications uh especially because these patients will be going back to the obstetrician with the scan report immediately immediately uh maybe one maximum or not two days only delay will be there and if you have very told like like uh you have to go back to the obstetrician immediately they'll definitely some way they'll come back to us so i'll just tell an example for example uh nuclear transfers nt you have done and say it is on the higher risk side but we have got other options before we do we have got the combined test and we have got other options before we counsel them so that part always obstetricians would like to take care what to do next or maybe uh like um pre-eclampsia patient would have actually done a given steroids and we might be ready to terminate when you will be documenting like a doppler's borderline review after one week we'll be ready to terminate because that one week is not going to add anything to the baby with a good nico setup so in such situations definitely we would like to counsel the patient maybe you can write please correlate clinically and all you can do there's no harm in that but i'm talking the mind of the observation not my personal opinion and another thing i just want to tell you especially in this platform some things like we always like we are worried about such reports especially a loop of cod around the neck uh that i've told our ideologies they have stopped writing but many times when we see that the patients would have read the report before coming to us and even if we try to tell them it's absolutely normal nothing to worry will monitor you during labor they are absolutely terrified they feel that it is something very dangerous so some some things like that we would very like would appreciate if you can avoid writing in the report and counseling part okay you can do your part i heard dr schefe telling all that and how to counsel everything i heard all that and even you were talking about the genetic labs and sending samples and all that but generally obstetricians feel that it is their arena thank you okay madam uh next question is also related to this is it acceptable that fetal radiologist instructing the patient to take aspirin or any medication aspirin definitely yes with all the literature pouring as dr richard was telling now our concept is um we call it an inverted pyramid in the antenatal we call it inverted pyramid we more concentrate on 11 to 14 weeks cat in 11 to 14 weeks can if you feel that the pi is about the 95th percentile you can confidently say aspen because our society also believes that we have to give low-dose aspirate but that 11 to 14 only but if the same report you report with the anomaly scan after 16 weeks there's no point in uh starting aspirin that's only thing if you say at 11 to 14 we have no objection but beyond 16 weeks it's not going to do any benefit otherwise we don't mind you telling asthma because we also do the same thing okay madam i have one more question to you uh what about the most information you need from a radiologist doing uh first trimester second trimester or third trimester scans okay i think uh dr ridge already answered that first trimester i'll just repeat your as i was mentioning about the dating the structural part of it and the chromosomal anomaly but again i want to highlight on like uterine artery pi because let's see inverted pyramid that means we want to concentrate more here we want to uh distinguish between high risk and lowest patients this lowest patients can actually reduce the number of antenatal visits by but high risk patient rather than the routine care they have to go in for the disease specific care we are talking here about preeclampsia we are losing many mothers even in the state of kerala we are losing many mothers as well as more babies because of preeclampsia and of course intrauterine growth restriction and all the other things so we want to pick up these two things as dr rijo rightly pointed out this is a must thing in all the 11 to 14 weeks and you're all doing nt you're all doing dating you're all doing structure but this is a thing we want because that is a golden opportunity to start aspiring at that point of time it has been proven well beyond doubt that this low dose has been at this point of time is going to help our patients second thing is in the anomaly scan anomalies can also you're beautiful you're doing the structure part of it i'm not going to comment on that but again the dopplers if you comment on dopplers there even if we have missed the boat in the first place we have not started aspirin but we will be concentrating on them we'll be calling them more frequently bp checking i'm very sorry to say that bp checking even in medical colleges there can be mistakes i believe i will trust only my people i won't trust any other person's bp so at least such patients i can check bp on my own and make sure that they're going not going for hypertension and maybe more frequent growth scans because they are high risk for fetal growth restriction and in the third trimester we have now actually all unexplained fatal demise the term unexplained fatal demise was a worrisome problem for all of us but now with the 35 to 36 week scan which all of us are doing just for doppler's sake especially to pick up the late onset iugr there again the doppler doppler means there we are more concentrating on the umbilical artery and the mca doppler and sd ratios and the cpr that's the proplusion ratio but again a small bird on uterine artery doppler might see the other part may be more for the fetal prognosis but a small comment on the uterine repi might warn us okay these patients also might develop late onset pre-eclampsia so these are the mustache means i'm not mentioned what you already do but these are the additional things which have come into picture maybe that during the last couple of years okay madam dr richo how much time ideally you should spend for each trimester scans and the advantage of spending time on the scans so the time you spend for a scan in any trimester depends on the kind of equipment that you have the kind of experience that you have in the kind of expertise that you have and how systematically you are doing your scans so if it is a first trimester scan say for example 11 to 14 week scan as i already mentioned i personally take this force areas it's basically a dating scan it's uh i do the pre-eclampsia and fgr screening so my staff is trained to take the material history and also they do the mean arterial pressures they take the systolic and diastolic bps from both arms twice and give it to me and then the online i take the uterine artery doctor pi and the mean pis then they do the online calculation give me the risk whether it's a screen positive or a screen negative for fgr as well as for pre-eclampsia and i also do a uh the nt and nv uh just stress scan uh and also do a structural evaluation uh for uh so all these things is i stay time usually for n to get the proper np it may be more otherwise for rest of the things it doesn't take much time and coming to the second trimester why i'm saying that the there are four components it's not just your experience expertise alone that meant your equipment resolution also matters if you are doing it everything with a very low resolution equipment you're going to you're not seeing most of the things so the equipment also matters and your expertise and experience matters and how systematically you are doing these scans also matters so the there lies the problem the systematically doing it is something that has to come as part of a training from your medical college or from your fellowship from your mentors this is one area where the medical colleges has to train them systematically according to the guidelines according to uh the say for the second trimester if you look at it what are the four components three components that i am looking at one is a general assessment general assessment of the uterus the number of heaters and the dire features and the placenta like cervix adnexa all these things then it comes to the biometric then it comes to the structural assessment from a cns head to toe so this secret systematic assessment especially the structural assessment is something that we we should train our youngsters to do that if you and document it also so if you miss in sometimes you see head and then immediately you go to the spine then immediately then see the kidney then if you're not following that proper methodology you're likely to miss one or two organs and that is where you will some sometimes land up in an abnormal for chamber you something that you already missed you might have the most of the time whatever people assume and they will think that okay i've already seen it or this might be normal and that is where uh you make yourself an ass out of you and me dr sheffield is there any advantage of doing 4d scan for 12 to 14 weeks time actually i usually don't do four discounts for 12 to 11 to 14 weeks time because it is horrible more or less it is depends on the 2d scan only all the measurements all the doctors everything is for 2d scans as registrars said high resolution machines high resolution 2d images what you all need in 11 to 14 weeks scan including your structural equalities at times there are reports of people are using 3d scanning for getting the proper empty images but i don't think and i don't recommend to do depending on 4d or 3d scans for getting all those entries and these uh getting the operators and all those things but you can use that 3d pro for a better resolution that is there but i don't recommend for 3d scans in 11 to 14 days in anomaly scans and all those things you can do if you find an anomaly you can additionally evaluate the same anomaly 3d or 4d that depends on the cases not all cases see the 3d and 4d you should not consider it as something additionally that has come because in this in your ctmr this is multiplayer imaging is part of that you are not thinking about it it is something that you have to apply when you have got a problem to evaluate or more information is needed you can use 3d and 4d at any point of time there is nothing but we don't use 3d don't use 4d android i don't agree with that if there is a structural problem that i see and i want more information and i got a good equipment it's not that that resolution has to be good and i got the expertise to do it get it either in trans abdominal transfer channel i always try to get a 3d or 4d image try to get the multiplanar image but fundamental requirement is i should have the knowledge of the multiplanar imaging to understand what is going on without that just for the namesake if i am doing it is just a gimmick but you have to understand the 3d and 4d in the right perspective that imagine in this ct and mri multiplanar imaging is giving you more more and more information yeah but by then you are oriented more towards the coronal plane more towards the sagittal plane more towards axillary 3d and 4d is actually multiplanar imaging and reformat nothing more than that so you have to utilize it if you have abnormalities that needs more workup more information and more understanding if you can you can definitely use it that's the way i use it okay dr richard dr sumanya if every first trimester scan dating scan should be supplemented by tbs for accurate dating what's your opinion there it is not an absolute must but i will tell that a tvs is always better than a tas because one thing it is a very good resolution we can identify everything and even early fatal anomalies even less than 10 weeks if it has a generalized edema around the fetus or something abnormally cranial or not we can identify with the genius so it is not an absolute must but if you have the time and expertise i would recommend that a tvs is always the best okay thank you dr samaya we exceeded our time you know what there is something let me add on to what sumiya said there is a mental block for most of the radiologists especially in the medical colleges to do tbs so they say we got a lot of volume we don't have the time it takes a lot of a lot of time but what sumiya said is correct the resolution of tvs is superb it adds on especially in gynec imaging and first try master imaging tvs has to be an integral part of you wherever you if you want if you got any confusion the tvs has to be done and most of the time you've seen tvs will throw up something very something that you might not have even imagined in the transabdominal scans similarly in for your prostate evaluation also see the kind of resolution that we get for translating prostate the same thing happens here for transvaginal but radiolas majority of them has got a mindset problem especially those working in the larger institutions they are not willing to do transvaginal scans uh because either like inciting the lack of time or the volumes but dbs gives you superb resolutions and really really helps in your diagnosis it is true that radiologists are a bit hesitant to do devious but sometimes you will end up in trouble too yeah so just to add on uh to a point just putting an id across uh there is uh can you hear me the recent supreme court and various court rulings against radiologists particularly at the 11 to 14 and anomaly scans isn't it not a requirement to consolidate our reports along with the serological parameters so it also comes down to who counsels the patient we also take the owners of risk is actually shared between the gynecologists and the radiologists so we can't really absolve ourselves by giving a structural report rather it has to be a comprehensive report at the time of inception of the report itself so it shouldn't i'm just putting it across should we hold back the structural report integrated with the serology report and give a complete risk analysis in the end which is standardized to interpret across all platforms so a gynecologist who gets the report uh will have standardized yeah so this is the risk ratio this is the next algorithmic approach like how dr shafi said we should go with the so there is no second question on uh if if this is the risk factor this is the approach to take so there is no discordance on who talks to the patient what so shouldn't that be the ultimate evolution of our report rather than split these reports into structural report and then so most times what happens is i never get to see the triple market reports for my 11 to 14 weeks gently with the structural report and this is gone uh this goes and it gives me an additional check if i get these reports back and if we can you know systematically do that we can get it's an additional check i can even recall the patient take a look if the parameters are a little bit abnormal and it also gives a double check for the gynecologist as well so in case they feel that you know serology parameters are little uh uh you know aloof and they can send the patient back for a restructuring evaluation all this it will not will this not help the patient better this is just a thought across actually what happens is uh when we get the serology report usually from the labs when we get the astrology report they will do this risk by the time we get the report they would have already had this nt or nb and then the combined test and then they will give a final report so it is not a problem for us because they are coming back with the risk we can just counsel with the report what they what they bring back from the um i mean from the lab from your point of view if it is not the same center many i think many radiology centers do that they do the scan they do the combined test and then they get the report by the time they come back with ultrasound report the risk is also there some centers are already doing that but i don't think medical colleges are doing but labs are doing others the private centers are great so for us it is not an issue always they come back with the risk so we have to just uh i mean counsel them depending on the risk what to do next okay shall we wind up yeah okay dr sheffie and dr samaya enlighted us with this information on setting up a red red petal radiology division in a teaching hospital and regarding the um sonological features of early pregnancy uh thank you dr betsy dr richow for joining with us and for contributing the panel discussion uh thanking netflix the platform provider dr vishali doctor ramit shannoy and ayari kerala for uh providing this opportunity and the platform okay thank you all state thank you

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IRIA Kerala in association with the Thrissur City Chapter brings to you an interactive panel discussion. Dr. Shephy KU will be talking about the developing fetal medicine division in the radiology department of a teaching hospital and Dr. Sumiya Nazrulla will be elaborating more about early pregnancy. Join us LIVE to participate and to clear your doubts about Fetal Radiology.

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