Tricuspid Valve Regurgitation during NS screening

Role of Tricuspid Valve Regurgitation

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TR assessment is performed during the 11–13 weeks + 6 days scan, especially in cases with increased NT or other risk indicators.

Technique

1. Obtain an apical four-chamber view of the fetal heart using color Doppler.

Normal fetal four-chamber heart view

Four-Chamber View Evaluation

• Proper visualization of both atria and ventricles.
• Symmetrical size of the left and right chambers.
• Normal insertion of atrioventricular valves (TV and MV).
• Clearly defined interventricular septum (IVS), indicating no obvious septal defect.
• Spine (Sp) visible, ensuring proper orientation.
• Correct situs (left/right alignment), confirmed by L and R markers.

Section structure
1. IVS - Interventricular Septum
2. LV - Left Ventricle
3. RV - Right Ventricle
4. LA - Left Atrium
5. RA - Right Atrium
6. MV - Mitral Valve
7. TV - Tricuspid Valve
8. Ao - Aorta
9. PV - Pulmonary Vein (or Pulmonary Valve, depending on context)
10. Sp - Spine
11. L / R - Left / Right side markers of the fetus

2. Ensure the fetus is still and the heart rate is between 120–160 bpm.

3. Use a small Doppler gate over the tricuspid valve.

4. TR is identified as a reverse flow jet into the right atrium during systole

Interpretation

Normal (No TR): No significant reverse jet seen during systole (No regurgitation or brief regurgitation < 60 cm/s)
Abnormal (TR Present): Reverse jet lasting ≥ half of systole with velocity ≥ 60 cm/s(Regurgitant jet > 60 cm/s, duration > 50% of systole)
TR Indicates: TR is abnormal in ~50% of trisomy 21 cases or major cardiac anomalies
Note: TR alone is not diagnostic. It is a supplementary marker to be interpreted with other first-trimester screening results.

Forehead-to-Nasal Tip Ratio

Forehead-to-Nasal Tip Ratio

Fronto-Maxillary Facial (FMF) Angle

• Definition: Angle between the line along the upper surface of the maxilla and the line along the frontal bone.
• Normal Range: ~76–83° at 11–13⁺⁶ weeks
• Clinical Relevance: Helps assess facial disproportions or micrognathia
• Increased FMF Angle: Associated with Down syndrome (Trisomy 21)
• How to Measure:
  • Mid-sagittal view of the face
  • One line: along the upper aspect of the maxilla
  • Second line: tangential to the frontal bone
  • Measure the angle between these two lines

Forehead-to-Nasal Tip Ratio

• This is a relatively rarely used soft marker assessed during first-trimester NT (Nuchal Translucency) screening.
• It is a craniofacial ratio calculated on a mid-sagittal plane ultrasound image using two linear measurements:
• Forehead Length: From the leading edge of the frontal bone to the nasion (root of the nose).
• Nasal Tip Length: From the nasion to the nasal tip.
• Formula: Forehead-to-Nasal Tip Ratio = Forehead Length / Nasal Tip Length

Fronto-Maxillary Facial FMF Angle

FMF Angle

• Definition: Angle between the line along the upper surface of the maxilla and the line along the frontal bone.
• Normal range: ~76–83° at 11–13+6 weeks
• Purpose: Helps assess facial disproportions or micrognathia
• Increased FMF angle: Associated with Down syndrome (Trisomy 21)
• How to Measure:
  • Use mid-sagittal view of the face
  • Draw one line along the upper aspect of the maxilla
  • Draw a second line tangential to the frontal bone
  • Measure the angle between these two lines

Anatomical Assessment of the Fetal Profile

Fetal Profile

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The fetal profile refers to the mid-sagittal view of the fetal head and face, showing the alignment and appearance of:

• Forehead
• Nasal bone
• Nasal tip
• Upper and lower lips
• Maxilla and mandible
• Chin (mentum)

Diagnostic clue for Abnormalities

• Flattened forehead or Vertical, or bulging forehead: Trisomy 21 or early signs of syndromes
• Ensure neutral fetal position: Prevent measurement and shape distortion.
• Optimize grayscale settings: Clear visualization of frontal bone and contour.

Amniotic fluid volume measuring mathod

Amniotic fluid volume

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Amniotic fluid volume (AFV) is not routinely measured quantitatively as part of the screening. However, qualitative assessment of amniotic fluid is still done, and significant abnormalities may be noted.

Points about AFV during NT Screening

1. Amniotic Fluid Volume Evaluation
Amniotic fluid is not measured using AFI (Amniotic Fluid Index) or MVP (Maximum Vertical Pocket) during the first trimester. Instead, a subjective or qualitative assessment is typically performed. The sonographer ensures adequate amniotic fluid surrounds the fetus for proper NT visualization. Any significant findings like oligohydramnios (too little fluid) or polyhydramnios (too much fluid) are reported if noted.
2. When is Quantitative AFV Measurement Done?
Quantitative AFV assessment usually begins around 20 weeks during the anomaly scan. It is measured using either:

• AFI – Four-quadrant technique (used in singletons).
• MVP – Maximum Vertical Pocket method (especially in twin pregnancies).

3. Clinical Significance
Although rare, abnormal fluid volume in the first trimester may suggest early rupture of membranes, fetal anomalies, or chromosomal abnormalities. Suspicious findings require follow-up evaluation and possibly genetic counseling.

3D AFV measurement

1. 3D Volume Acquisition
A 3D transducer captures a complete volume of the amniotic sac using a transabdominal or transvaginal approach depending on fetal position.
2. VOCAL Method (Virtual Organ Computer-aided AnaLysis)
Most common method for calculating 3D fluid volume:

1. Freeze the 3D image.
2. Manually or semi-automatically trace the amniotic fluid in rotating planes (every 15° or 30°).
3. The software reconstructs and displays the calculated AF volume in mL.

Normal AFV Values

Gestational Age (weeks)
11 weeks – ~30–35 mL
12 weeks – ~40–50 mL
13 weeks – ~60–70 mL

Note: While 3D AFV measurements provide promising data, normal ranges are not yet standardized for routine clinical use. Follow-up is essential if abnormalities are suspected.

Nasal Bone (NB) Measuring Method During

Step-by-Step Nasal Bone Measurement Method

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Nasal Bone (NB) Measuring Method During First NT screening

• NB is assessed between 11 weeks 0 days and 13 weeks 6 days (CRL: 45–84 mm).
• The midsagittal plane of the fetal face should be used – same as for NT measurement.
• The fetal head must be in a neutral position, not flexed or extended.
• The ultrasound image should be magnified so that the fetal head and upper thorax fill the screen.
• The nasal bone appears as a bright echogenic line under the skin line of the fetal nose.
• The NB is assessed as either present, absent, or hypoplastic (underdeveloped).
• The insonation angle should be 45° to the nasal bridge to avoid false absence.
• Calipers are placed on the outer edges of the echogenic nasal bone line (if measured).
• Multiple images should be taken and the best one used for documentation.

Nasal Bone (NB) Assessment Criteria

Plane: True mid-sagittal view of the fetal profile (same as NT view)
Fetal: Position head in neutral position, no flexion or hyperextension
Zoom: Fetal head and upper thorax should occupy at least 75% of the image
Magnification: Maximize to clearly visualize nasal bridge and skin
Image Quality: High-resolution grayscale with appropriate gain (to avoid under/overexposing bones)

Landmarks for NB

• Skin line (top)
• Nasal bone (middle, shorter and more echogenic)
• Tip of the nose (hard palate or nasal tip) (bottom)

CRL vs Nasal Bone Length Reference

CRL (mm)	Approx. Gestational Age (weeks+days)	Expected NB Length (mean ± SD)	Range (approx.)
45–54 mm	~11w0d to 11w6d	1.4 ± 0.2 mm	1.1 – 1.8 mm
55–64 mm	~12w0d to 12w6d	1.7 ± 0.2 mm	1.3 – 2.1 mm
65–74 mm	~13w0d to 13w6d	1.9 ± 0.2 mm	1.5 – 2.3 mm
75–84 mm	~14w0d to 14w6d	2.1 ± 0.2 mm	1.7 – 2.5 mm

short or absent nasal bone

1. Trisomy 21 (Down Syndrome)
Absent nasal bone is seen in up to 60–70% of fetuses with Down syndrome.
Short nasal bone is also commonly associated.
Particularly significant when seen between 11–14 weeks (first trimester).

2. Other Chromosomal Abnormalities
May also be seen (less commonly) in:
- Trisomy 18 (Edwards syndrome)
- Trisomy 13 (Patau syndrome)
- Turner syndrome

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NB Length Percentile Calculator

Gestational Age (weeks): Nasal Bone Length (mm):

NT measuring mathod

Measuring mathod

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• Gestational Age: Ideally between 11 weeks 0 days to 13 weeks 6 days.
• Crown-Rump Length (CRL): Between 45 mm and 84 mm.
• Fetal Position: Midsagittal plane of the fetus with neutral head position—not flexed or hyperextended.
• Magnification: The fetal head and thorax should fill at least 75% of the image.
• Caliper Placement: Measure the maximum lucency at the back of the fetal neck—inner-to-inner margins of the nuchal space.
• Image Settings: High contrast and clear resolution. Amniotic membrane should be distinguishable from the NT space.
• Number of Measurements: Take at least 3 measurements and record the highest consistent one.
• Exclude: Do not include the amnion or fetal skin in the measurement.

Step-1: Preparation for the Scan No special preparation is needed, but a full bladder may help improve image clarity. The scan is typically abdominal, but in some cases, a transvaginal ultrasound may be used for better visualization.
Step-2: Performing the Ultrasound The sonographer places an ultrasound probe on your abdomen (or inserts a transvaginal probe if necessary). The baby is positioned in a mid-sagittal view (side profile). The image is magnified to ensure accurate measurement.
Step-3: Measuring the Nuchal Translucency The sonographer identifies the fluid-filled space at the back of the baby’s neck. Using calipers, the maximum thickness of this translucent (fluid-filled) area is measured. The measurement is taken three times, and the largest reading is recorded for accuracy.
Step-4: Interpreting the NT Measurement Normal NT thickness: Typically less than 3.0 mm. Increased NT thickness: Over 3.5 mm may indicate a higher risk of chromosomal abnormalities like Down syndrome (Trisomy 21), Trisomy 18, or congenital heart defects.
Next Step: NT measurement is combined with maternal age, blood test results (PAPP-A, β-hCG), and other factors to estimate the risk of chromosomal abnormalities. This combined screening helps determine if further diagnostic testing (e.g., NIPT, CVS, or amniocentesis) is recommended. If the NT is increased, further testing (such as NIPT, CVS, or amniocentesis) may be recommended.

What If NT is High?

If the Nuchal Translucency (NT) measurement is higher than normal (typically >3.5 mm), it does not mean the baby definitely has a problem, but it may indicate an increased risk for certain conditions.
Possible Implications of High NT
1. Chromosomal Abnormalities

• Down syndrome (Trisomy 21)
• Edwards syndrome (Trisomy 18)
• Patau syndrome (Trisomy 13)
• Turner syndrome (Monosomy X)

2. Structural Anomalies

• Congenital heart defects (most common)
• Diaphragmatic hernia
• Skeletal dysplasias

3. Genetic Syndromes

• Noonan syndrome
• Other single-gene disorders

4. Poor Pregnancy Outcome (in some cases)

• Miscarriage
• Fetal death
• Intrauterine growth restriction (IUGR)

Steps After High NT

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1. Chromosomal Abnormalities

• Down syndrome (Trisomy 21)Edwards syndrome (Trisomy 18)
1. Detailed Ultrasound (including fetal anatomy and heart evaluation)
2. First-Trimester Combined Screening (NT + PAPP-A + free β-hCG)
3. Non-invasive Prenatal Testing (NIPT) – analyzes fetal DNA in maternal blood
4. Diagnostic Testing (if indicated)

• Chorionic Villus Sampling (CVS) at 11–13 weeks
• Amniocentesis after 15 weeks

Step-by-Step NT Scanning Technique

NT Scanning Technique

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Step-1. Patient Preparation

Ask the mother to have a partially filled bladder (optional).
Position her comfortably in the supine or slightly tilted position.

Step-2. Transducer Placement

Use a transabdominal probe (3.5–5 MHz).
In early gestations or with unfavorable views, a transvaginal probe (5–9 MHz) may be used.

Step-3. Aligning the Fetus in a True Mid-Sagittal Plane

Introduction: Importance of accurate nuchal translucency (NT) & CRL measurement.
Role of mid-sagittal alignment in reducing errors and improving screening sensitivity.
Key anatomical landmarks:
a). Nasal bone
b). Tip of the nose
c). Rectangular palate
d). Diencephalon
e). Fourth ventricle
f). Nuchal membrane
i). Sonographic Criteria for Mid-Sagittal Alignment
The fetal head and thorax must be in a neutral position (neither hyperextended nor flexed).
The echogenic tip of the nose should be visible.
The rectangular shape of the palate must be clearly seen.
The translucent diencephalon and fourth ventricle (intracranial translucency) should be visible.
ii). Technique for Achieving Alignment
Maternal Preparation: Empty bladder (if transvaginal), partially full bladder (if transabdominal).
Probe Orientation: Align the transducer parallel to the fetal body axis.
Adjusting Fetal Position: Use gentle abdominal pressure or ask the patient to change position.
Zoom & Focus: Enlarge the image so that the fetal head and upper thorax occupy at least 75% of the screen.
iii). Common Errors and How to Avoid Them
Off-axis images: May mimic the midline but lack key structures (e.g., missing nasal bone).
Fetal movement: Wait for stillness or reattempt alignment.
Incorrect flexion/extension: Identify and correct before measuring NT.
iv). Visual Aids and Examples
Annotated ultrasound images showing:
a). Correct mid-sagittal plane
b). Incorrect off-midline planes
Diagrams highlighting critical landmarks
v). Clinical Implications of Incorrect Alignment
Risk of inaccurate NT measurement
False positives/negatives in screening for chromosomal abnormalities

Step-4. Optimize the Image

Zoom in until the fetal head and upper thorax fill at least 75% of the screen.
Use grayscale only (do not use Doppler).
Adjust gain and focus to enhance bony structures like the frontal bone.

Step-5. Differentiation of Structures

In NT screening, one of the most important steps is correctly identifying and distinguishing the NT space from adjacent anatomical structures.
Grayscale ultrasound imaging provides the necessary contrast to make these distinctions clearly and accurately.
Grayscale imaging helps differentiate the nuchal translucency from:
- Amnion (the thin membrane surrounding the fetus)
- Fetal skin
- Subcutaneous tissues
- Umbilical cord if nearby
Avoids misidentifying thickened amnion or skin folds as increased NT.
Why Structural Differentiation Matters:
Accurate NT measurement depends on visualizing only the fluid space behind the fetal neck.
Misidentification can lead to false-positive or false-negative risk assessments for chromosomal abnormalities.
Using grayscale imaging only for NT measurement:
- No Doppler
- No color overlays
- No power Doppler

Introduction of NT Screening

NT Screening

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Nuchal translucency (NT) screening is a prenatal test performed during the first trimester of pregnancy, usually between 11 and 14 weeks, to assess the risk of certain chromosomal abnormalities in a fetus, particularly Trisomy 21 (Down syndrome), Trisomy 18 (Edwards syndrome), Trisomy 13 (Patau syndrome) or Turner syndrome (Monosomy X).

How the NT screening works

1. NT screening is most effective when combined with:

• Maternal age.
• Biochemical markers
• Additional ultrasound markers (nasal bone, ductus venosus, tricuspid flow)

2. Ultrasound: An ultrasound is used to measure the thickness of the fluid-filled space at the back of the baby's neck. This is done while the baby is still in the early stages of development.
3. Blood Test: A blood test is often done at the same time to measure the levels of certain substances in the mother's blood (such as free beta-hCG and PAPP-A). These measurements, combined with the NT measurement, help calculate the risk of chromosomal conditions.
4. Risk Assessment: NT screening does not diagnose chromosomal abnormalities but provides a risk assessment based on the fluid measurement, the blood test results, and the mother's age. A higher-than-normal NT measurement can indicate an increased risk, but it does not mean the baby has a condition.
5. Follow-up Tests: If the NT screening shows a higher risk, it may lead to further diagnostic testing, such as amniocentesis or chorionic villus sampling (CVS), which can provide definitive results regarding genetic conditions. The goal is to provide a risk estimate, not a diagnosis, and to help guide decisions for further testing like NIPT or invasive testing.

why NT screening is important?

Nuchal Translucency (NT) screening is important because it is a non-invasive, early screening test used to assess the risk of chromosomal abnormalities and structural anomalies in the fetus during the first trimester of pregnancy (typically between 11 to 13+6 weeks of gestation)
1. Early Detection of Chromosomal Abnormalities

• Measures the fluid-filled space at the back of the fetal neck (NT).
• Increased NT is associated with:
• Trisomy 21 (Down syndrome)
• Trisomy 18 (Edwards syndrome)
• Trisomy 13 (Patau syndrome)
• Turner syndrome (Monosomy X)

2. Identifies Risk for Structural Abnormalities

• Enlarged NT may also indicate:
• Congenital heart defects
• Diaphragmatic hernia
• Body stalk anomaly
• Other syndromic conditions (e.g., Noonan syndrome)

3. Combined with Biochemical Markers

• NT measurement is often combined with:
• Serum markers (PAPP-A, free β-hCG)
• Maternal age
• This combination improves the detection rate (>90%) for Down syndrome with a low false-positive rate (~5%).

4. Safe and Non-Invasive

• NT scan uses standard ultrasound—no radiation or risk to the fetus.
• Provides critical early information without invasive procedures.

5. Guides Further Testing

• Abnormal NT results may prompt:
• Non-invasive prenatal testing (NIPT)
• Fetal echocardiography
• Chorionic villus sampling (CVS) or amniocentesis for genetic diagnosis

Twin reversed arterial perfusion (TRAP) Sequence (Acardiac twin)

TRAP Sequence

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Figer-1

📄 Report Sample Line- Reversed arterial perfusion Acardiac twin
Twin pregnancy, monochorionic monoamniotic (confirmed by T-sign and absence of intertwin membrane).
Pump Twin (Twin A):
Live intrauterine fetus with active cardiac pulsations. Biometry corresponds to gestational age: [23w 2D]. No signs of hydrops fetalis. Normal fetal anatomy visualized. No structural anomalies detected.
Acardiac Twin (Twin B):
Amorphous soft tissue mass noted with ill-defined cephalic and truncal structures. No cardiac activity. No identifiable fetal heart, brain, or organized thoracoabdominal structures. Grossly malformed with absent cranial vault and rudimentary limbs. Color Doppler shows reversed arterial flow in the umbilical artery supplying the acardiac twin. Blood flow entering the acardiac twin from the pump twin confirms reversed perfusion.
Doppler Findings:

• Umbilical artery Doppler (Pump Twin): Normal resistance indices
• Middle cerebral artery (MCA) Doppler (Pump Twin): Normal
• Ductus venosus flow (Pump Twin): Normal
• Reversed flow in umbilical artery (Acardiac Twin): Present
• Cardiac activity in Acardiac Twin: Absent (No independent cardiac activity)

Conclussion: 📋

• TRAP Sequence / Acardiac Twin Identified
• Viable Pump Twin with Normal Doppler Parameters
• No current evidence of cardiac strain or hydrops in the pump twin

Recommendation: Serial ultrasound monitoring every 1–2 weeks to evaluate growth of acardiac twin and strain on pump twin.

Fetus papyraceus

Fetus papyraceus

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Figer-1

📄 Report Sample Line- Fetus papyraceus
The presence of a flattened, compressed, and mummified fetal remnant adherent to the uterine wall or fetal membranes, consistent with fetus papyraceus. The demised twin appears markedly reduced in size with loss of amniotic fluid, absence of cardiac activity, and echogenic overlapping of fetal parts, suggestive of intrauterine fetal demise occurring in the second trimester. The surviving co-twin appears structurally normal and viable at the time of scan.No vascular flow is detected within the demised fetus on color Doppler imaging.


Conclussion: 📋 Findings are consistent with fetus papyraceus – a mummified, compressed fetus resulting from intrauterine fetal demise of one twin, in the second trimester. The surviving twin appears structurally normal and viable. No signs of immediate complications are observed in the co-twin at the time of scan.
Recommendation: Recommend close serial ultrasound monitoring of the surviving fetus for growth, well-being, and possible complications.Consider Doppler studies of the umbilical artery, middle cerebral artery, and ductus venosus in follow-up scans.

Intracranial fetus-in-fetu

Intracranial fetus-in-fetu

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Figer-1

📄 Report Sample Line- Intracranial fetus-in-fetu
A well-encapsulated, echogenic intracranial mass with vertebral and limb-like structures suggestive of intracranial fetus-in-fetu is noted, causing mild mass effect on adjacent cerebral structures.


Conclussion: 📋 Findings are suggestive of an intracranial fetus-in-fetu, characterized by a well-organized parasitic twin within the fetal cranial cavity.
Recommendation: Fetal MRI recommended for further anatomical assessment.

Intra-abdominal fetus in fetu

Intra-abdominal fetus in fetu

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📄 Report Sample Line- Intra-abdominal fetus in fetu
a well-circumscribed intra-abdominal mass containing organized fetal structures, including a head, vertebral column, limb buds, and partial axial skeleton. The lesion shows partial calcifications and cystic areas consistent with a diagnosis of intra-abdominal fetus in fetu. No independent cardiac activity is identified within the mass. The heterogeneous mass located in the left hypochondriac region, below the diaphragm of fetus, and pushing the left kidney downwards


Conclussion: 📋 Findings are consistent with an intra-abdominal fetus in fetu, characterized by the presence of a well-organized fetal-like mass within the abdominal cavity, containing axial skeletal elements and limb structures. No independent cardiac activity is noted within the mass. This rare congenital anomaly should be differentiated from teratoma.
Recommendation: Further imaging with MRI or CT is recommended for detailed anatomical assessment

Living oropharyngeal fetus in fetu

Living oropharyngeal fetus in fetu

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Figer-1

📄 Report Sample Line- Living oropharyngeal fetus in fetu
Shows a well-defined, partially developed fetal structure located within the oropharyngeal region of the host fetus. The mass demonstrates organized axial skeletal elements, including a vertebral column, limb buds, and cranial structures, consistent with a parasitic twin. Notably, there is evidence of vascular perfusion and cardiac activity within the mass, indicating a rare “living” oropharyngeal fetus in fetu.


Conclussion: 📋 Findings are consistent with a rare case of "living" oropharyngeal fetus in fetu, characterized by the presence of a partially developed parasitic twin within the oropharyngeal region of the host fetus. The presence of organized fetal parts and detectable cardiac activity within the mass confirms its viability. This condition poses a significant risk of airway obstruction at birth and may be associated with feeding and craniofacial developmental complications.
Recommendation: Fetal MRI is recommended for detailed anatomical mapping, particularly to assess

Parapagus conjoined twin

Parapagus conjoined twin

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Figer-1

📄 Report Sample Line- Parapagus conjoined twin
Shows a monochorionic, monoamniotic twin pregnancy. There are two distinct heads, visualized in close proximity and oriented side-by-side. Below the neck, there is fusion of the thorax, abdomen, and pelvis, forming a single, laterally fused trunk. Findings are consistent with Parapagus conjoined twins, characterized by lateral fusion of the fetal bodies with a shared pelvis and lower abdomen. Two heads are visualized side-by-side with a single contiguous thoracoabdominal trunk. Four upper limbs and variable number of lower limbs are noted. Internal organ sharing is suspected, particularly in the gastrointestinal and genitourinary systems.


Conclussion: 📋 Parapagus conjoined twins with significant lateral body fusion. Shared thoracoabdominal organs likely; further imaging and multidisciplinary evaluation recommended

Thoracopagus Conjoined twin

Thoracopagus Conjoined twin

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Figer-1

📄 Report Sample Line- Thoracopagus Conjoined twin
Shows a monochorionic, monoamniotic twin gestation with evidence of conjoined twins. The fetal trunk shows a single heart shared between the two twins and fused liver The fetuses are joined at the anterior thorax, consistent with thoracopagus. Both fetuses have distinct heads and spines, and demonstrate fused upper thoracic structures, including the sternum and chest wall. Conjoined thoracopagus twins


Conclussion: 📋 Findings consistent with thoracopagus conjoined twins
Recommendation: Fetal MRI to further evaluate the extent of thoracic and abdominal organ.

Ureteric calculus ultrasound case study

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Case Study
Ureteric calculus

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Clinical History: The patient is a [36]-year-old [Male] presenting with acute onset of sharp, colicky lower abdominal pain,
Figer-1

📄 Report Sample Line- Ureteric calculus
Ureter appears dilated and shows A hyperechoic structure is noted within the ureter, measuring approximately [12.2 mm]. with posterior acoustic shadowing, consistent with calculuc.


Conclussion: 📋 Ureteric calculus
Recommendation: KUB X-Ray.