FMF Certificate of competence in measurement of the facial angle The findings of recent studies suggest that fetuses with

trisomy 21 have a flat profile because the maxilla (upper jaw) is small and set back. This produces a wide angle in a line drawn over the palate and between the maxilla and the forehead (facial angle). Measurement of the facial angle at 11-13 weeks improves the performance of screening for trisomy 21 by maternal age and fetal NT.

Protocol for measurement of the fetal facial angle y The gestational period must be 11 to 13 weeks and six days. y The magnification of the image should be such that the fetal head and thorax occupy the whole image. y A mid-sagittal view of the face should be obtained. This is defined by the presence of the echogenic tip of the nose and rectangular shape of the palate anteriorly, the translucent diencephalon in the centre and the nuchal membrane posteriorly. Minor deviations from the exact midline plane would cause non-visualization of the tip of the nose and visibility of the zygomatic process of the maxilla. y The facial angle should be measured between a line along the upper surface of the palate and a line which traverses the upper corner of the anterior aspect of the maxilla extending to the external surface of the forehead, represented by the frontal bones or an echogenic line under the skin below the metopic suture that remains open.

Clinical application of fetal facial angle measurement The fetal facial angle decreases with CRL and is wider in fetuses with trisomy 21 than in chromosomaly normal fetuses. It is essential that in adjusting the risk for trisomy 21 using the measurement of the facial angle the software takes into account the fetal CRL. The FMF software firstly calculates a risk based on maternal age, fetal NT and maternal serum free -hCG and PAPP-A. If the risk is more than 1 in 50 and and the facial angle is within the normal range the risk does not change. If the risk is 1 in 50 to 1 in 1,000 and the the facial angle is within the normal range the risk is usually reduced. If the facial angle is above the bormal range the risk is always increased.

Protocol for the assessment of the ductus venosus y The gestational period must be 11 to 13 weeks and six days. y The examination should be undertaken during fetal quiescence. y The magnification of the image should be such that the fetal thorax and abdomen occupy the whole image. y A right ventral mid-sagittal view of the fetal trunk should be obtained and color flow mapping should be undertaken to demonstrate the umbilical vein, ductus venosus and fetal heart. y The pulsed Doppler sample volume should be small (0.5-1.0 mm) to avoid contamination from the adjacent veins, and it should be placed in the yellowish aliasing area. y The insonation angle should be less than 30 degrees. y The filter should be set at a low frequency (50-70 Hz) so that the a-wave is not obscured.

The sweep speed should be high (2-3 cm/s) so that the waveforms are spread allowing better assessment of the a-wave. When these criteria are satisfied, it is possible to assess the a-wave and determine qualitatively whether the flow is positive, absent or reversed.

Clinical application of ductus venosus flow findings The incidence of reversed ductus venosus a-wave is related to NT and CRL as well as aneuploidy, being more common when the NT is high and the CRL is low. Therefore it is not possible to give simple numbers by which the presence of normal flow will reduce the risk for trisomy 21 and the presence of reversed a-wave will increase the risk. The FMF software firstly calculates a risk based on maternal age, fetal NT and maternal serum free -hCG and PAPP-A. If the risk is more than 1 in 50 and ductus venosus flow is normal the risk does not change. If the risk is 1 in 50 to 1 in 1,000 and the ductus venosus flow is normal the risk is usually reduced. If there is reversed awave the risk is always increased. In addition, there is an increased risk for cardiac defects and therefore such patients should have a follow up specialist fetal cardiac scan.

Protocol for the assessment of tricuspid flow y The gestational period must be 11 to 13 weeks and six days. y The magnification of the image should be such that the fetal thorax occupies most of the image. y An apical four-chamber view of the fetal heart should be obtained. y A pulsed-wave Doppler sample volume of 2.0 to 3.0 mm should be positioned across the tricuspid valve so that the angle to the direction of flow is less than 30 degrees from the direction of the inter-ventricular septum. y Tricuspid regurgitation is diagnosed if it is found during at least half of the systole and with a velocity of over 60 cm/s, since aortic or pulmonary arterial blood flow at this gestation can produce a maximum velocity of 50 cm/s. y The sweep speed should be high (2-3 cm/s) so that the waveforms are widely spread for better assessment. y The tricuspid valve could be insufficient in one or more of its three cusps, and therefore the sample volume should be placed across the valve at least three times, in an attempt to interrogate the complete valve. Clinical application of tricuspid flow findings The incidence of tricuspid regurgitation is related to NT and CRL as well as aneuploidy, being more common when the NT is high and the CRL is low. Therefore it is not possible to give simple numbers by which the presence of

normal flow will reduce the risk for trisomy 21 and the presence of tricuspid regurgitation will increase the risk. The FMF software firstly calculates a risk based on maternal age, fetal NT and maternal serum free -hCG and PAPP-A. If the risk is more than 1 in 50 and tricuspid flow is normal the risk does not change. If the risk is 1 in 50 to 1 in 1,000 and the tricuspid flow is normal the risk is usually reduced. If there is tricuspid regurgitation the risk is always increased. In addition, there is an increased risk for cardiac defects and therefore such patients should have a follow up specialist fetal cardiac scan.

FMF Certificate of competence in measurement of uterine artery PI The Fetal Medicine Foundation has now established software for the calculation of risk for preeclampsia. The software is provided free of charge to those who comply with the FMFregulation of NT screening and have demonstrated competence in the Doppler assessment of the uterine arteries at the 11-13 weeks scan. Preeclampsia, which affects about 2% of pregnancies, is a major cause of perinatal and maternal morbidity and mortality. Routine antenatal care has evolved with the aim of identifying women at high-risk for subsequent development of preeclampsia. The likelihood of developing preeclampsia is increased by a number of factors in the maternal history, including Afro-Caribbean race, nulliparity, high body mass index and personal or family history of preeclampsia. However, screening by maternal history may detect only about 30% of those that will develop preeclampsia for a false positive rate of 5%. A more effective method of screening for preeclampsia is provided by measurement of the uterine artery pulsatility index (PI) at 11-13 weeks' gestation in combination with maternal history, blood pressure and serum PAPP-A and placental growth factor (PLGF). For a false-positive rate of 5% it has been estimated that the new combined method of screening can predict 90% of preeclampsia requiring delivery before 34 weeks and 45% of late preeclampsia. There is extensive evidence that it is early rather than late preeclampsia which is associated with an increased risk of perinatal mortality and morbidity and both short-term and long-term maternal complications. Identification of women at high-risk for preeclampsia during the first trimester could potentially improve pregnancy outcome because intensive maternal and fetal monitoring in such patients would lead to an earlier diagnosis of the clinical signs of the disease and the associated fetal growth restriction and avoid the

development of serious complications through such interventions as the administration of antihypertensive medication and early delivery. It is imperative that, as for the NT scan, sonographers undertaking risk assessment of preeclampsia by examination of the uterine arteries must receive appropriate training and certification of their competence. Requirements for Certification in measurement of uterine artery PI The requirements for certification are: 1. FMF certification in the measurement of nuchal translucency. 2. Attendance of the internet based course on the 11-13 weeks scan. 3. Submission of a logbook of 3 images demonstrating color flow mapping and waveforms of the uterine artery at 11-13 weeks. Protocol for first-trimester measurement of the uterine artery PI y The gestational age must be between 11 weeks and 13 weeks and six days. y Sagittal section of the uterus must be obtained and the cervical canal and internal cervical os identified. Subsequently, the transducer must be gently tilted from side to side and then colour flow mapping should be used to identify each uterine artery along the side of the cervix and uterus at the level of the internal os. y Pulsed wave Doppler should be used with the sampling gate set at 2 mm to cover the whole vessel and ensuring that the angle of insonation is less than 30. When three similar consecutive waveforms are obtained the PI must be measured and the mean PI of the left and right arteries be calculated.