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1.Pregnancy Dating

1. The Significance of Precise Gestational Dating
•    How first-trimester dating influences fetal growth patterns.
•    Common mistakes in misclassifying growth restrictions due to incorrect dating.
•    The effects of inaccurate gestational age estimation on clinical choices.
2. First Trimester Dating: The Best Approach
•    Crown-Rump Length (CRL) – The Most Reliable Method
o    Reasons why CRL outshines Mean Gestational Sac Diameter (MSD).
o    Ideal gestational age estimation occurs between 7-10 weeks (with ±5-7 days accuracy).
o    Frequent CRL measurement mistakes and tips for avoiding them.
•    When Should You Reassign Gestational Age in the First Trimester?
o    Guidelines from ACOG/AIUM/SMFM regarding gestational age reassignment.
o    Gestational Age Cutoff Chart (when to confirm or reassign dates).
3. Second Trimester Dating & Growth Monitoring
•    Why Second Trimester Dating Isn’t as Reliable?
o    Increased variability in fetal growth.
o    Key biometric parameters: Head Circumference (HC) & Corrected Biparietal Diameter (BPD) as the most dependable indicators.
o    BPD errors caused by fetal head compression in breech positions.
•    How to Avoid Gestational Age Reassignment in the Second Trimester?
o    When to look for fetal growth restrictions (FGR) versus genuine dating errors.
o    OFD/BPD ratio for spotting unusual head shapes.
o    Utilizing corrected BPD.
4. Third Trimester Dating: The Least Trustworthy Method
•    Reasons third-trimester gestational age estimation can be unreliable.
o    Estimation errors may reach up to 30 days.
o    Risks of incorrectly redating a fetus with growth restrictions.
•    When is redating in the Third Trimester Justified?
o    Only when discrepancies exceed 21 days (according to ACOG guidelines).
o    The emphasis should shift to monitoring growth rather than adjusting gestational age.
5. Misclassification of Fetal Growth Restriction (FGR)
•    Iatrogenic FGR – A Mistake That Can Be Prevented
o    How incorrect dating may lead to misclassifying a healthy fetus as growth-restricted.
o    Case Study: A fetus wrongly classified as FGR due to inaccurate dating.
o    Adjusting the estimated due date (EDD) to prevent unnecessary interventions.
6. Suboptimally Dated Pregnancies
Definition: Any pregnancy lacking a confirmed first-trimester ultrasound before 22 weeks.
•    Clinical Management:
o    Avoid making elective delivery decisions based on estimated gestation.
o    Requires regular growth scans every 3-4 weeks.
o    Higher chances of misdiagnosing fetal size issues.
7. Special Considerations: Dating Twin Pregnancies
•    Chorionicity & Its Effect on Dating:
o    Differences between DCDA (Dizygotic Twins) and MCDA (Monozygotic Twins).
o    The timing of embryo splitting plays a role in determining chorionicity.
•    Which Twin’s CRL Should You Use for Dating?
o    Always opt for the larger CRL to prevent misclassifying FGR in one twin.
8. Assisted Reproductive Technology (ART) Pregnancy Dating
•    IVF Dating Is More Accurate Than Using LMP
o    For fresh embryo transfers, the transfer date equals the Date of Conception (DOC).
o    For frozen embryo transfers (FET), adjust the DOC by considering the embryo’s developmental stage.
o    Correcting gestational age for Day 3, Day 5, or Day 6 blastocyst transfers.
•    Essential Documentation for IVF Pregnancies
o    Always record the ART conception date instead of LMP.
o    Ensure proper dating adjustments using ultrasound machine settings.
9. Learning Through Cases & Clinical Implications
o    Real-world clinical examples showing errors in fetal dating.
o    The impact of incorrect dating on fetal weight classification and FGR diagnosis.
o    How to accurately adjust gestational dating in ART and twin pregnancies.

Key Takeaways from the Lecture
✔ First-trimester CRL remains the gold standard for dating—keep it consistent.
✔ Avoid redating in the second and third trimesters unless there are significant discrepancies.
✔ Use corrected BPD for breech pregnancies and twin situations.
✔ For ART pregnancies, always base gestational age on the embryo transfer date.
✔Suboptimally dated pregnancies need regular scans, not adjustments in gestational age.
✔Inaccurate dating can result in iatrogenic FGR—ensure a precise first-trimester assessment to prevent this.

 

             2. ECTOPIC PREGNANCY

•    Getting to Know Ectopic Pregnancy  
o    What it is and how we classify it  
o    Rising numbers, especially with ART  
o    Factors that increase risk and hurdles in diagnosis  
•    Updates on Standardized Terminology (ESHRE 2024)  
o    Terms we’re no longer using: Cornual, Angular, Chronic Ectopic, Fimbrial, Tubal Miscarriage  
o    New terms introduced: Normally Sited Pregnancy (NSP), Residual Ectopic Pregnancy (REP)  
o    Different Types of Ectopic Pregnancy  
    Extrauterine Ectopic Pregnancy:  
•    Tubal Ectopics:  
o    Interstitial Ectopic – High chance of rupture; identified through the Interstitial Line Sign  
o    Isthmic Ectopic – Early rupture risk because of a narrow lumen  
o    oAmpullary Ectopic – The most common type (around 70%)  
o    Ovarian Ectopic – Detected using the Bagel Sign  
o    Abdominal Ectopic – Rare but poses significant risks  
    Uterine Ectopic Pregnancy:  
o    Cesarean Scar Pregnancy (CSP) – Associated with placenta accreta spectrum (PAS)  
o    Cervical Ectopic Pregnancy – Recognized through Doppler vascularity & Sliding Sign  
o    Intramural Pregnancy – Located within the myometrium, resembling a fibroid  
    Heterotopic Pregnancy (Related to ART)  
o    Having both intrauterine and ectopic pregnancies at the same time  
o    Increased risk for IVF patients → Always take a close look at the adnexa  
•    Pregnancy of Unknown Location (PUL)  
o    93% continue to develop into normal pregnancies  
o    Only 7% turn out to be ectopic → Needs monitoring  
o    Be cautious with early methotrexate treatment  

    Sonographic Signs of Ectopic Pregnancy  

    Important diagnostic signs discussed:  
o    Interstitial Line Sign – Indicates interstitial ectopic pregnancy  
o    Bagel Sign – Suggests ovarian ectopic pregnancy  
o    Tubal Ring Sign – Observed in tubal ectopic pregnancies  
o    Ring of Fire on Doppler – Shows increased trophoblastic blood flow  
o    Sliding Sign – Helps distinguish cervical ectopic from a potential abortion  
o    Claw Sign – Differentiates between corpus luteum and extraovarian ectopic   
o    Minimal Residual Myometrium Thickness – Crucial for Cesarean Scar Pregnancy  
    ESHRE 2024 Guidelines on Terminology & Classification  
•    Discarding terms like Cornual, Fimbrial, and Angular pregnancies  
•    New terminology approach:  
o    NSP (Normally Sited Pregnancy)  
o    Extrauterine Ectopic  
o    Residual Ectopic Pregnancy (previously known as chronic ectopic)  
    Approaches to Management  
•    Step-by-step method for diagnosing and treating ectopic pregnancy: 
o    Early detection with TVS + Doppler  
o    Importance of tracking β-hCG levels  
o    Choosing between methotrexate and surgical options  
o    Managing CSP, Heterotopic, and Interstitial Ectopics
    Learning Through Cases & Interactive Q&A  
o    Real-life ultrasound examples  
o    Guided analysis of imaging results  
Common diagnostic challenges and tips to overcome them

 3. Prenatal Diagnosis: Chorionic Villus Sampling (CVS) and  Amniocentesis

1. Getting to Know Prenatal Diagnosis  
o    The significance of prenatal screening and diagnostic methods  
o    Understanding Invasive vs. Non-Invasive Prenatal Testing (NIPT, CVS, Amniocentesis, Cordocentesis)  
o    Why and when to opt for invasive testing  

2. Exploring Invasive Prenatal Testing – Techniques & Reasons  
•    Chorionic Villus Sampling (CVS)  
o    Comparing Transabdominal and Transcervical approaches  
o    Steps involved in the procedure and best practices  
o    Benefits of early genetic diagnosis  
•    Amniocentesis  
o    When is the best time and what are the procedural guidelines?  
o    Techniques for collecting samples and necessary precautions  
o    Common reasons for testing and genetic strategies  
•    Cordocentesis (PUBS – Percutaneous Umbilical Blood Sampling)  
o    Reasons for fetal blood sampling  
o    Potential risks and limitations  

3. Diagnosing Genetic & Chromosomal Abnormalities Before Birth  
•    Common Chromosomal Disorders & Ultrasound Markers  
o    Trisomy 21 (Down Syndrome) – Key markers like nuchal translucency, absent nasal bone, short femur/humerus
o    Trisomy 18 (Edwards Syndrome) – Indicators such as strawberry skull, clenched hands, cardiac defects  
o    Trisomy 13 (Patau Syndrome) – Signs like holoprosencephaly, polydactyly, and facial anomalies  
o    Turner Syndrome (45, X0) – Features including cystic hygroma and coarctation of the aorta  
o    Confined Placental Mosaicism (CPM) – When to confirm with amniocentesis  
4. Identifying Structural Abnormalities in Prenatal Scans
•    Neural Tube Defects (NTDs) – Such as Spina Bifida, Anencephaly, and Encephalocele
•    Congenital Diaphragmatic Hernia (CDH) – Interventions like FETO  
•    Congenital Heart Defects – Conditions like Tetralogy of Fallot and Hypoplastic Left Heart Syndrome  
•    Gastrointestinal Issues – Including Duodenal Atresia, Omphalocele vs. Gastroschisis
•    HydropsFetalis and Fetal Infections (TORCH panel)  
5. Special Points to Consider in Prenatal Diagnosis  
•    Twin Pregnancies – Considerations for CVS & Amniocentesis  
•    Prenatal Diagnosis in Cases of Maternal Infections (HIV, HBV, HCV)  
•    Understanding Rhesus Status & Administering Anti-D Immunoglobulin  
•    Managing Complications & Risks in Invasive Procedures

 4. Early Pregnancy; Sonoembryology : Normal and Abnormal and Early Preg Failure : Diagnostic criteria and prognosticating factors

1. Getting Started with Early Pregnancy Evaluation
•    The significance of transvaginal ultrasound (TVS) in the early stages of pregnancy.
•    Essential diagnostic measurements to consider (MSD, CRL, Yolk Sac).
•    How serial beta-hCG testing helps assess the viability of the pregnancy.
2. Understanding Early Pregnancy Loss and Diagnostic Guidelines
•    Anembryonic Pregnancy (Blighted Ovum)
o    When MSD is 25 mm or more but there's no visible fetal pole.
• Embryonic Demise (Missed Miscarriage)
o    When CRL is 7 mm or greater without any cardiac activity.
• Subchorionic Hematoma (SCH) and Its Effect on Pregnancy Viability
o    How the size of the hematoma can influence pregnancy outcomes.
3. Abnormal Blood Flow in Early Pregnancy
•    Enhanced Myometrial Vascularity (EMV) versus Arteriovenous Malformation (AVM)
o    The differences in Doppler signals, underlying causes, and treatment approaches.
o    Gutenberg's classification of retained products of conception (RPOC) according to vascular characteristics.
o    A step-by-step management plan for EMV (expectant care, surgery, or interventional options).
o    Potential risks and complications associated with uterine artery embolization (UAE).
4. Gestational Trophoblastic Disease (GTD) and Hydatidiform Moles
•    Comparing Complete and Partial Molar Pregnancies
o    Genetic distinctions (46, XY versus 69, XXY).
o    Ultrasound findings (Snowstorm appearance compared to Swiss cheese pattern).
o    The risk of developing Gestational Trophoblastic Neoplasia (GTN).
•    Monitoring and Managing GTD
o    The crucial role of beta-hCG tracking.
o    How to distinguish it from persistent trophoblastic disease.

5. First Trimester Scan Guidelines (11-14 Weeks Anomaly Scan)
•    Screening for Aneuploidy  
o    Evaluating NT, nasal bone, ductusvenosus flow, and tricuspid regurgitation  
o    Identifying Trisomy 21, Trisomy 18, Trisomy 13, and Monosomy X  
o    Different screening guidelines for single and twin pregnancies  
•    Fetal Structural Issues  
o    Neural tube defects: Anencephaly, spina bifida, iniencephaly
o    Distinguishing between Omphalocele and Gastroschisis
o    Congenital diaphragmatic hernia (CDH)  
o    Skeletal conditions: Club hand, polydactyly, and caudal regression syndrome  
•    Complications in Twin Pregnancies  
o    Determining chorionicity: Lambda vs. T-sign  
o    Predicting Twin-to-Twin Transfusion Syndrome (TTTS)  
o    Understanding Twin Reversed Arterial Perfusion (TRAP) sequence  
•    Abnormalities of the Placenta and Uterus  
o    Vasa Previa – Early detection via cord insertion mapping  
o    Placenta Accreta Spectrum (PAS) – Sonographic indicators in high-risk cases  
•    Cardiac Concerns in the First Trimester  
o    Tetralogy of Fallot (TOF) – Features like overriding aorta and narrowing of the pulmonary artery  
o    Hypoplastic Left Heart Syndrome (HLHS) – Notable signs include a single AV stripe and reversed aortic flow  
•    Predicting Preterm Labor
o    Assessing cervical length and utilizing new biochemical markers  
•    Tips for NT Scan & Screening Accuracy  
o    Best practices for imaging, measurement techniques, and diagnostic protocols  
o    Learning from cases of misdiagnosed NT scans and their impact on clinical outcome

 

6. 11–14 Week Aneuploidy Screening

•    Basics of Aneuploidy Screening:  
o    What first-trimester screening is and why it matters  
o    The significance of detecting Trisomy 21 (Down Syndrome)  
o    Understanding screening methods: Balancing risk assessment with diagnostic accuracy  
•    Chromosomal Abnormalities & Ultrasound Indicators:  
o    Trisomy 21 (Down Syndrome) – NT, missing nasal bone, reversed ductusvenosus, tricuspid regurgitation  
o    Trisomy 18 (Edwards Syndrome) – Omphalocele, clenched hands, heart defects  
o    Trisomy 13 (Patau Syndrome) – Holoprosencephaly, facial clefts, extra fingers  
o    Turner Syndrome (45X0) – Cystic hygroma, hydropsfetalis, heart issues  
o    Triploidy (69,XXX / XXY / XYY) – Enlarged NT, molar placenta, intrauterine growth restriction  
•    Important Ultrasound Indicators in Aneuploidy Screening:  
o    Nuchal Translucency (NT) Measurement: Standard methods, common mistakes, and clinical importance  
o    Nasal Bone (NB) Evaluation: The role of absent or underdeveloped NB in identifying aneuploidy  
o    DuctusVenosus (DV) Doppler: Reversed A-wave and its link to chromosomal disorders  
o    Tricuspid Regurgitation (TR) Doppler: Early signs of heart issues and congenital heart disease predictions  
o    Intracranial Translucency (IT) & Open Spina Bifida: Indicators for neural tube defects  
•    Identifying Congenital Heart Disease (CHD) in the First Trimester:  
o    Atrioventricular Septal Defect (AVSD) – Frequently seen in Trisomy 21  
o    Hypoplastic Left Heart Syndrome (HLHS) – Small left ventricle condition  
o    TruncusArteriosus – A single great vessel anomaly  
o    Aberrant Right Subclavian Artery (ARSA) – A marker indicating aneuploidy  
•    Neural Tube Defects (NTDs) & Posterior Fossa Irregularities:  
o    Open Spina Bifida – Recognizable by the ‘Crash sign’ & IT disappearance  
o    Dandy-Walker Malformation – Enlarged IT & cyst in the posterior fossa  
o    Occipital Encephalocele – Differentiating from open NTDs  
•    Soft Markers & Doppler Assessments:  
o    Importance of preeclampsia screening and uterine artery Doppler  
o    New markers emerging: Ophthalmic artery Doppler  
•    FMF Certification & Image Evaluation Guidelines:  
o    Criteria for submitting Nasal Bone, DV, and TR data  
o    Common mistakes that lead to rejection  
o    Technical specifications for achieving successful certification

       7 First Trimester Neurosonogram

•    Basics of Aneuploidy Screening:
o    What first-trimester screening is and why it matters
o    The significance of detecting Trisomy 21 (Down Syndrome)
o    Screening concepts: Balancing risk assessment with diagnostic assurance
•    Chromosomal Abnormalities & Ultrasound Indicators:
o    Trisomy 21 (Down Syndrome) – Key markers include NT, absent nasal bone, reversed ductusvenosus flow, and tricuspid regurgitation
o    Trisomy 18 (Edwards Syndrome) – Notable signs are omphalocele, clenched hands, and heart defects
o    Trisomy 13 (Patau Syndrome) – Indicators like holoprosencephaly, facial clefts, and polydactyly
o    Turner Syndrome (45X0) – Associated with cystic hygroma, hydropsfetalis, and heart issues
o    Triploidy (69,XXX / XXY / XYY) – Features include a thick nuchal translucency, molar placenta, and intrauterine growth restriction
•    Important Ultrasound Indicators in Aneuploidy Screening:
o    Nuchal Translucency (NT) Measurement: A standardized method, common pitfalls, and its clinical importance
o    Nasal Bone (NB) Evaluation: The role of absent or underdeveloped nasal bone in detecting aneuploidy
o    DuctusVenosus (DV) Doppler: Reversed A-wave and its link to chromosomal abnormalities
o    Tricuspid Regurgitation (TR) Doppler: Early signs of heart dysfunction and potential congenital heart disease prediction
o    Intracranial Translucency (IT) & Open Spina Bifida: Indicators for neural tube defects
•    Identifying Congenital Heart Disease (CHD) in the First Trimester:
o    Atrioventricular Septal Defect (AVSD) – Commonly seen in Trisomy 21
o    Hypoplastic Left Heart Syndrome (HLHS) – Characterized by a small left ventricle
o    TruncusArteriosus – A condition with a single great vessel anomaly
o    Aberrant Right Subclavian Artery (ARSA) – A marker indicating potential aneuploidy
•    Neural Tube Defects (NTDs) & Posterior Fossa Abnormalities:
o    Open Spina Bifida – Recognized by the ‘Crash sign’ and obliteration of the IT
o    Dandy-Walker Malformation – Noted for a large IT and the presence of a posterior fossa cyst
o    Occipital Encephalocele – Differentiating from open NTDs
•    Soft Markers & Doppler Assessments:
o    The importance of preeclampsia screening and uterine artery Doppler studies
o    New emerging markers: Ophthalmic artery Doppler    
•    FMF Certification & Image Assessment Guidelines:
o    Criteria for submitting Nasal Bone, DV, and TR images
o    Common mistakes that can lead to rejection
o    Technical requirements for achieving successful certification
 

      8 First Trimester Evaluation of Fetal Heart

1. Introduction to First-Trimester Heart Checkups
o    Why it's crucial to assess the fetal heart early on
o    Guidelines from ISUOG and FMF for first-trimester heart screenings
o    The importance of Transabdominal (TA) and Transvaginal (TVS) ultrasound
o    Using a pattern-based method to spot early congenital heart defects (CHD)
2. Systematic Approach to Cardiac Assessment
•    Analyzing the Four-Chamber View 
o    Evaluating cardiac position, axis, and size
o    Assessing the proportions of atrial and ventricular chambers
o    Checking the ventricular inflow tract (mitral & tricuspid valves)
•    Interpreting the Three-Vessel and Trachea (3VT) View 
o    Identifying the normal crossover of major arteries
o    Spotting any unusual vessel positions and size differences
3. Common Congenital Heart Defects (CHDs) and Their Early Indicators
•    Conotruncal Anomalies: 
o    Tetralogy of Fallot (TOF)
o    Double Outlet Right Ventricle (DORV)
o    Transposition of the Great Arteries (TGA)
o    TruncusArteriosus
•    Left-Sided CHDs: 
o    Hypoplastic Left Heart Syndrome (HLHS)
o    Coarctation of the Aorta
•    Right-Sided CHDs: 
o    Pulmonary Atresia with Intact Ventricular Septum (PA-IVS)
o    Tricuspid Atresia
o    Ebstein’s Anomaly
•    Arch Abnormalities & Vascular Rings: 
o    Right Aortic Arch & Double Aortic Arch
o    Aberrant Left Subclavian Artery (ALSA) & Vascular Rings
•    Other Notable Findings: 
o    Pericardial & Pleural Effusions
o    Cardiac Diverticulum & Its Importance
4. Advanced Doppler Techniques & Enhancements
o    Assessing flow direction for confirming CHDs
o    Differentiating between pericardial effusion and pleural effusion
o    The significance of spectral Doppler in evaluating regurgitant flow
5. Learning Through Cases & Recognizing Patterns
o    Step-by-step diagnosis of intricate CHDs using actual case examples
o    The role of follow-up scans in the first trimester (16-week re-evaluation)


  9. First Trimester Evaluation of the Fetal Spine

1: Introduction & Importance of Early Spinal Screening  
o    Traditional anomaly scans at 18–22 weeks compared to 11–14-week screenings.  
o    Why is early detection so important? It opens doors for genetic counseling and    reproductive options.  
2: Grasping Normal Spinal Development  
o    Spine Embryology – The creation of the neural tube, vertebrae, and spinal cord.  
o    Fetal Spine Anatomy – Understanding the cervical, thoracic, lumbar, sacral, and coccygeal segments.  
3: Open vs. Closed Spina Bifida  
o    Understanding Open Spina Bifida – Issues like CSF leakage and brainstem traction.  
o    Types of Open Spina Bifida – Meningocele, Myelomeningocele, and Myeloschisis.  
o    Difficulties in Identifying Closed Spina Bifida – Lack of secondary brain signs.  
4: Ultrasound Indicators for Early Detection  
o    Intracranial Translucency (IT) and Fourth Ventricle Evaluation.  
o    Brainstem-to-Occipital Bone (BSOB) Ratio and Brainstem Thickening.  
o    Maxillo-Occipital Line Displacement and the Parallel Cerebral Peduncles.  
o    The Choroid Bar Sign and Its Importance in Detecting Spinal Defects.  
5: Advanced Axial & Coronal Plane Indicators  
o    The Crash Sign – Midbrain Displacement Against the Occipital Bone.  
o    Aqueduct-to-Occipital Bone Distance Measurement.  
o    Dried Lateral Ventricles in cases of Open Spina Bifida.  
o    Identifying Posterior Masses and Direct Visualization of Spinal Defects.  
6: Other Spinal Anomalies in the First Trimester  
o    Kyphosis & Scoliosis – Issues like Hemivertebra and Vertebral Segmentation Defects.  
o    Caudal Regression Syndrome – Including Sacral Agenesis, Megacystis, and Limb Defects.  
o    Diastematomyelia – The Split Cord Anomaly and Early Identification through Coronal Views.  
o    Body Stalk Anomaly – Severe Scoliosis with a Short or Absent Cord.  
o    OEIS Complex – Omphalocele, Exstrophy, Imperforate Anus, and Spinal Defects.  
7: Practical Steps for First Trimester Spinal Screening  
o    A Step-by-Step Guide to Examining the Brain & Spine.  
o    Transabdominal vs. TransvaginalSonography – When should we opt for TVS?  
o    Direct Spine Evaluation – Finding the Best Fetal Positioning.  
o    Differentiating Open Spina Bifida from Other CNS Abnormalities.  
8: Clinical Cases, Insights & Key Takeaways  
o    Real-Life Case Studies & Imaging Illustrations.  
o    Contrasting Findings from the First and Second Trimester.  
o    Tackling Challenges & Exploring Future Opportunities in Early Spinal Imaging.

 

10. First Trimester Evaluation of the Fetal Face

The significance of evaluating the fetal face during the first trimester
•    How the face develops in embryology
•    Guidelines from ISUOG and FMF for screening facial features in the first trimester
•    Essential imaging perspectives:
o    Mid-sagittal view
o    Retronasal triangle view
o    Axial and coronal views
•    Assessing the nasal bone and its importance in detecting aneuploidy
•    Understanding the frontomaxillary facial angle and its uses
•    Examining:
o    Forehead and overall facial profile
o    Nose and its tip
o    Lips along with primary and secondary palates
o    Mandible and chin    
o    Orbits and spacing between them
External ears
•    Notable sonographic indicators:
o    Maxillary gap sign
o    Superimposed-line sign
o    Premaxillary protrusion
o    Crash sign
o    Gibbus deformity
•    Signs of cleft lip and palate: how to detect and confirm using specific planes
•    Checking for micrognathia and retrognathia
•    Associated syndromes and conditions:
o    Alobarholoprosencephaly
o    Open spina bifida
o    Pierre Robin Sequence (PRS)
o    -Trisomy 21, 18, and 13
o    Goldenhar syndrome
o    Treacher Collins syndrome
o    Epignathus (oropharyngealteratoma)
o    Femoral hypoplasia–unusual facies syndrome
o    Amniotic band syndrome
•    The contribution of 3D ultrasound in evaluating facial structures
•    Helpful advice on when to follow up on borderline or subtle observations
•    A recap of best practice protocols and a structured approach to scanning

            11. Genetics in Fetal Medicine

•    Introduction to Genetics in Fetal Medicine  
o    Why it matters during every trimester  
o    Insights for radiologists during counseling
•    Understanding Genetic Terms and DNA Structure  
o    Overview of genes, alleles, chromosomes, and base pairs  
o    Difference between genotype and phenotype, exons and introns  
•    Exploring Types of Genetic Abnormalities  
o    Numerical issues: Trisomies, Monosomy, Triploidy
o    Structural issues: Deletions, duplications, insertions, translocations, and ring chromosomes  
•    Microdeletion and Microduplication Syndromes  
o    Conditions like DiGeorge, Williams, and Prader-Willi syndromes  
o    Copy Number Variants (CNVs)  
•    Single Gene (Monogenic) Disorders  
o    Categories: Autosomal dominant, recessive, X-linked  
o    Distinction between de novo and inherited mutations  
o    Examples: Achondroplasia, Marfan syndrome, Sickle Cell disease, Duchenne Muscular Dystrophy  
•    Screening Approaches  
o    First-trimester combined screening (NT, nasal bone, DV, TR + biochemistry)  
o    Second-trimester quadruple test  
 Non-Invasive Prenatal Testing (NIPT) – methods, accuracy, and limitations  
•    Diagnostic Techniques  
o    Karyotyping – banding techniques, resolution, and limitations  
o    FISH – quick probe-based detection  
o    QF-PCR – fast testing for aneuploidy using STRs  
o    MLPA – probe-based detection of CNVs and genes  
o    Chromosomal Microarray (CMA) – high-resolution genome-wide CNV analysis  
o    Sanger Sequencing – standard gene sequencing method  
o    Next Generation Sequencing (NGS) – including Whole Exome and Whole Genome Sequencing  
•    Variants of Uncertain Significance (VOUS)  
o    How to interpret them, study inheritance, and assess clinical importance  
•    Clinical Workflow: Choosing the Right Test  
o    Decisions based on ultrasound findings, screening outcomes, patient history, and phenotype  
o    Diagnostic decision trees and flowcharts to guide choices  
o    Importance of DNA storage and sequential testing for unresolved cases

12. Understanding Aneuploidy Risk Assessment from an Imaging Perspective

1.    Conceptual Foundation  
o    What is aneuploidy and why is it important?  
o    How risk varies with maternal and gestational age  
o    Insights into fetal demise trends across different aneuploidies  
2.    The Imaging Approach  
o    The role of ultrasound in chromosomal screening  
o    Understanding hardware versus software (structural versus chromosomal insights)  
o    Introduction to soft markers as visual indicators for chromosomal risk  
3.    Screening Strategies  
o    What exactly is a screening test? (Comparing a priori risk to adjusted risk)  
o    How ultrasound helps fine-tune risk from dual markers/NIPT  
o    Limitations of screening: it’s not just a simple “Yes/No,” it’s about “Probability”  
4.    First Trimester Markers  
o    Nuchal Translucency (NT) – methods, interpretation, and implications  
o    Absent Nasal Bone – criteria for echogenicity and views required  
o    DuctusVenosus Flow – significance of a reversed A-wave  
o    Tricuspid Regurgitation – techniques, velocity cut-offs, and their importance  
5.    Case-Based Management of Increased NT  
o    Follow-up decision tree at 14–16 and 20–22 weeks  
o    Links with genetic syndromes and structural anomalies  
o    Case examples like cystic hygroma, jugular sacs, hydrops, and triploidy
6.     Second Trimester Genetic Sonogram  
•    The 9 Soft Markers:  
o    Ventriculomegaly
o    Absent/Hypoplastic Nasal Bone  
o    Increased Nuchal Fold  
o    ARSA (Aberrant Right Subclavian Artery)  
o    Echogenic Bowel  
o    Hydronephrosis
o    Short Humerus
o    Short Femur  
o    EIF (Echogenic Intracardiac Focus)  
7.    Marker Interpretation and Likelihood Ratios  
o    LR⁺ and LR⁻ based on meta-analysis  
o    How to determine composite risk from imaging markers  
o    Excluding short humerus in likelihood ratio calculations  
o    Effect of positive markers compared to all negative markers (7.7× risk reduction)  
8.    Common Pitfalls and Diagnostic Pearls  
o    Telling apart ARSA from an Azygos vein  
o    Confirming nasal bone with the retronasal triangle technique  
o    Managing duplicated renal pelvis and understanding hydronephrosis thresholds  
o    Real-life examples: heart anomalies (AVSD, HLHS), omphalocele, cystic placenta  
9.    Strategic Integration with Other Tests  
•    What to do in various scenarios:  
o    Intermediate risk based on FTS  
o    No prior screening completed  
o    Post-NIPT results (whether positive or negative)  
•    Knowing when a genetic sonogram is crucial and when it’s not necessary  
10.    Philosophical Takeaway  
o    The need for careful interpretation of soft markers  
o    The value of observation: “Even in the normal, there’s plenty to learn”  
o    The changing role of fetal imaging in precise perinatal care

13. Caesarean Scar Pregnancies and Placenta                                Accreta Spectrum

•    The study of how common Cesarean Scar Pregnancy (CSP) really is
•    How to identify CSP through ultrasound and tell it apart from low implantation
•    Understanding the impact of niche and residual myometrial thickness (RMT)
•    Different types of CSP classification (Type 1, 2, 3 based on UCL and SL)
•    The sliding sign, peritrophoblastic flow, and comparing transverse and sagittal approaches
•    Using Color Doppler imaging to evaluate CSP
•    How CSP can develop into Placenta Accreta Spectrum (PAS)
•    The histological foundation: Nitabuch's layer and the decidual interface
•    Classifying PAS: accreta, increta, percreta
•    Key grayscale ultrasound indicators:
o    Absence of a clear zone
o    Thinning of the myometrium
o    Bulging of the placenta
o    Bladder wall interface (= sign)
•    Color Doppler indicators of PAS:
o    Connecting vessels
o    Lacunar feeder vessels
o    Increased blood flow under the placenta
•    Key differences between PAS and third-trimester placental lakes
•    Common ultrasound challenges: probe pressure, PRF settings, and obesity factors
•    The Placenta Accreta Index (PAI - 2014) and the updated PAS scoring model for 2023
•    The value of MRI in assessing PAS
•    The critical role of early detection and teamwork in management

 14. First Trimester Anomalies Other                       Than CVS and CNS

•    Review of non-CNS and non-CVS issues during the first trimester
•    Examination of the fetal face and neck: looking for cleft palate, jugular lymphatic sacs, and cystic hygroma
•    Investigating thoracic conditions: including diaphragmatic hernia, pleural effusion, ricardial effusion, and pulmonary agenesis
•    Assessing abdominal wall issues:
o    Omphalocele
o    Gastroschisis
o    Pentalogy of Cantrell
o    Bladder and cloacalexstrophy
•    Identifying gastrointestinal concerns: such as cloacal malformations, enteric and hepatic cysts, and GI atresias
•    Looking into genitourinary anomalies:
o    Megacystis and LUTO (posterior urethral valve, urethral atresia)
o    Renal dysplasia, agenesis, and cross-fused ectopia
o    Meckel-Gruber syndrome
•    Checking umbilical and venous anomalies:
o    Single umbilical artery (SUA)
o    Missing ductusvenosus (DV) and unusual UV-IVC connections
•    Noting skeletal abnormalities and dysplasias:
o    Polydactyly, ectrodactyly, acheiria, symbrachydactyly
o    Radial ray defect, clubfoot, iniencephaly, osteogenesisimperfecta, and short rib-polydactyly syndrome
o    Sirenomelia, sacral agenesis, and limb reduction defects
•    Conducting functional assessments:
o    Fetal movement analysis
o    Diagnosis of FADS (FetalAkinesia Deformity Sequence)
•    Gaining clinical insights:
o    The importance of NT, NB, DV, TR in screening for anomalies
o    The evolving importance of the first trimester for targeted anomaly scans
o    When and how to monitor evolving or borderline anomalies

   16. Ultrasound Evaluation of Multiple              Pregnancies in the First Trimester and                            Risk Assessment
•    The increasing occurrence and importance of twin pregnancies
•    Types of twins: Dizygotic versus Monozygotic
•    How the day of embryonic splitting affects chorionicity and amnionicity
•    Evaluating chorionicity: Using Lambda versus T-sign, membrane thickness, and common pitfalls
•    Strategies for dating both spontaneous and IVF twin pregnancies
•    Understanding CRL and NT discordance: definitions, implications, and early signs of complications
•    What to do when chorionicity is uncertain: always prioritize safety
•    Thorough evaluation of amnioticity through sac visualization, yolk sacs, and membranes
•    MCMA twins: dealing with cord entanglement, delivery planning, and ruling out conjoined twins
•    Learning through case studies on conjoined twins (like craniopagus, thoracopagus, parapagusdicephalus)
•    Identifying diagnostic Doppler signs and prognosis in TRAP sequence (acardiac twin)
•    Twin-to-Twin Transfusion Syndrome (TTTS):
o    Understanding its pathophysiology
o    Quintero staging system
o    The significance of bladder visibility, MVP, and Doppler changes
o    Treatment options like laser ablation and serial amniocentesis
•    The classic presentation of a “stuck twin”
•    Distinguishing between amniotic fluid discordance and early TTTS
•    Selective IUGR (sIUGR) in monochorionic twins:
o    Gratacós classification (Type I–III)
o    Prognosis based on Doppler findings and sudden demise risk
•    Twin AnemiaPolycythemia Sequence (TAPS):
o    Understanding its pathophysiology
o    The importance of MCA Doppler for diagnosis
o    Differences in placental echogenicity
•    Genetic screening for twins: limitations of NIPT, specific risk assessments, and guidance for invasive testing
•    Professional advice on how to label and document twin pregnancies
•    Key takeaways on the importance of vigilance, monitoring frequency, and a systematic approach

 17. First Trimester Screening for Preeclampsia     and Fetal Growth Restriction (FGR)
•    The significance of screening for preeclampsia (PE) and fetal growth restriction (FGR) in India
•    Current statistics on maternal and neonatal mortality in the country
•    Understanding why preeclampsia is more critical than congenital anomalies in the Indian context
•    A brief look at the Samrakshan initiative by IRIA
•    An introduction to the two-stage disease model of preeclampsia
•    Comparing normal and abnormal placentation through spiral artery remodeling
•    Factors influencing preeclampsia, including:
o    Maternal characteristics
o    Mean Arterial Pressure (MAP)
o    Uterine artery Pulsatility Index (PI)
o    Biochemical markers like PLGF, PAPP-A, and sFLT-1
•    How to use the FMF calculator for personalized risk assessment
•    Understanding ethnic-specific benchmarks for the Indian population (1 in 150 for PE)
•    Examples showing how PE and FGR can be overlooked without combined screening
•    The role of aspirin (150 mg at night) and insights from the ASPRE trial
•    Is late initiation of aspirin (16–18 weeks) beneficial?
•    Guidelines for understanding screen-positive and negative results
•    Using the Doppler technique for uterine artery PI, mean PI, and gestation-specific analysis
•    Why the notch method is no longer utilized in predicting PE
•    Findings from Samrakshan research indicating a decrease in maternal mortality, neonatal mortality, FGR, and preterm births
•    Screening protocols for twin pregnancies: how applicable are they?
•    Helpful tips for reporting what to include in PE/FGR screening results
•    Counseling for compliance regarding aspirin use
•    An invitation to become part of the Samrakshan Movement
•    A heartfelt tribute to Dr.KyprosNicolaides, the visionary behind the Fetal Medicine Foundation