Obstetric fetal anomaly scan checklist

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CHECKLIST REPORT FOR 18-24 FETAL ANOMALY SCAN

Name: Date of Birth:

Medical Record Number:

Comment:…………………………………

…………………………………………………………………..……………

LMP (dd,mm,yyyy)
EDC (dd,mm,yyyy)
Gestational age (weeks, days)

Tick the box, use comment lines, do not hesitate to mention if scan is suboptimal.

General Abdomen and pelvic scan:

Maternal urinary bladder full and allows optimal scan

Normal Maternal liver and gall bladder

Normal Maternal right kidney

Normal Maternal left kidney

No abnormality noticed in maternal abdomen scan

Normal Uterus

Normal right adnexa

Normal left adnexa

Comment:

Obstetric Scan:

I. Extra-fetal structures:

Placental Site:

Fundal
Fundal Anterior
Fundal Posterior
Not reaching the fundus but > 1 cm from the cervix
Placenta < 1 cm from the cervix and not more than 2.5cm of placental tissue covering the cervix
More than 2.5 cm of the placenta covering the cervix

Comment:

Umbilical cord insertion

Eccentric insertion into placenta
Marginal insertion
Velamentous insertion suspected
3 vessels identified in TS

Comment:

Amniotic Fluid:

Adequate for optimal scan
Above average
Reduced

Comment:

Uterine cervix

Cervical length more than 2.5 cm
Cervical length less than 2.5 cm
Suboptimal assessment of the cervix

Comment:

II. Fetal Biometry

LMP GA in weeks

Measure	Value	Weeks
BPD
HC
FL
AC
EFW

III. Fetal Anomaly scan:

1- Fetal Head (Trans-Thalamic, Trans-cerebellar and Trans-ventricular views):

Skull bones complete
Falx cerebri seen
Posterior horn of lateral ventricle <10mm
Cavum Septum Pellucidum seen
Structures both sides of midline checked
Cisterna Magna <10mm
No Cranial Cysts
Nuchal fold <6mm
Upper lip - Palate
Orbits and Nose

Comment:

2- Fetal chest and heart Chest TS – LS and 3 cardiac views):

Normal axis and position of the heart (same side of stomach)
4 chambers seen
Aorta and MPA arise from relevant ventricles
Intact Inter-ventricular septum
Intace Atrioventricular septum
No cyst or masses in the chest
Normal rhythmic FHR

Comment:

3- Abdoment (TS and LS views):

TS Abdominal wall intact
Site of UC insertion checked
Stomach bubble seen
Kidneys checked
Urinary bladder seen
Diaphragm seen
No abnormal cysts or masses seen
External genitalia checked

Comment:

4- Spine (Sagittal – Para-sagittal and TS views)

3 sets of rosettes form the vertebral column
No masses or cysts bulging
Lower limb movement seen

Comment:

5- Limbs

4 limbs seen
3 bones seen in every limb
Feet properly oriented
Limb movement checked

Comment:

Overall comment

Scan is satisfactory, low risk for gross anomalies
Scan is suboptimal
Refer for Level III scan
Other:

Name

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