Anomaly scan: The Indian dilemma

A patient came to me recently for an obstetric scan at 39 weeks of gestation. She already had anomaly scan (at 19 weeks) from one of the prominent fetal medicine expert in city. Later, he had two scans before coming to me. Fortunately, all the scans were normal. As I first focused my probe at the cranium to measure BPD and HC parameters, I saw enlarged occipital horns bilaterally, measuring 2.5 cm each - colpocephaly. Well, then other things started unfolding, as corpus callosum was not well visualized and paralleling of lateral ventricles was seen. I reviewed the images of previous scans. Although, it seemed evident on later two scans, anomaly scan images were ambiguous. In fact, it was mentioned to review for fetal skull at 24-26 weeks.

Either the fetal medicine specialist had a foresight, or he was playing safe. If anomaly scan was done by expert hands at 24-26 weeks, it would have been conclusive enough. Indian dilemma is - Medical termination of pregnancy can only be done before 20 weeks. Obstetricians are bound to send patient to rule out anomalies before 20 weeks, and sonologist still struggles to see things, which has not yet developed. I personally have missed cleft lip in anomaly scan, which I later picked up incidentally during interval growth scan at 30 weeks. But, our mindset in those scans, is just to calculate the fetal weight, check the placental location and cervix. We ourselves are assured of anomaly scan, if the report was normal.

My suggestions:
To the radiologist: Please double check all the anomalies during 28-30 weeks scan (Always recommend in the reports too).
To the obstetrician: Please classify the anomaly scans as a) Gross anomaly scan (19 weeks) b) Detailed anomaly scan (26 weeks).
To the government authority: Please amend the law accordingly.

Because you said so!

Gone are the days, when clinical acumen held the key to diagnosis. A requisition slip, earmarking a good bunch of diagnostic tests are handed over to the patients. And then, you will receive a call from the clinician, as soon as patient reaches you. While you are still scratching your head to come to a final diagnosis, whatever earliest words you told him, will be put in case sheet. Patient will be dispatched with that diagnosis, and you are still in dilemma. Its just too late before you finally prepare your report.

I remember one of the incidences my colleague shared recently. Patient presented with acute scrotum. He was not even examined by surgeon and sent directly to the radiologist. Radiologist saw a large hypoechoic testes, with some vascularity within. He was still having probe in one hand and phone in another. He told the same on phone, and said...looks like epididymo-orchitis. Surgeon immediately sent him home, with few antibiotics. Radiologist was still reviewing the images, and somehow could not differentiate, finally wrote in the report- ?torsion testes ?epididymo-orchitis. When he called back the surgeon, it was a loud screaming voice from the other end, "I sent him because you said so! What kind of radiologist you are, if you cannot differentiate the two?". The buck didn't stop there and radiologist was fired few days later.

I had many similar experiences, and learnt overtime to speak diplomatically, and reserving my diagnosis till the end. It would be much better in faith of healthcare, if the ball stays in clinician's court for most of the time. Radiologist should be taken as aid in diagnosis, and not as decision-makers. We should not get call from the gynecologists, like "Should we deliver her now?". How would we know?