Radiology

Review Article
Australasian Radiology (2007) 51, 324329

Management options for echogenic intracardiac focus and choroid plexus cysts: A review including Australian Association of Obstetrical and Gynaecological Ultrasonologists consensus statement
M Bethune1,2,3
1 3

Ultrasound Department, The Royal Womens Hospital, 2Department of Medical Imaging, The Mercy Hospital for Women and Melbourne Ultrasound for Women, Melbourne, Victoria, Australia

SUMMARY
Echogenic intracardiac focus and choroid plexus cysts are common findings at the midtrimester ultrasound. These findings have been linked with an increased risk of Down syndrome and trisomy 18. Most fetuses with these findings will, however, not have chromosomal abnormalities, especially when these findings are isolated. Patients experience considerable anxiety when informed of these findings and require extensive counselling in order to minimize anxiety not only about aneuploidy but also about the structure and development of the heart and brain. Although early studies showed an association with aneuploidies, several recent studies have cast doubt on this association. Many of the early studies were carried out in high-risk populations or in populations that had not had the benefit of other screening tests. Many Australian and New Zealand patients will access screening tests designed to detect these aneuploidies before presenting for a midtrimester ultrasound. Patients who have been screened by nuchal translucency, maternal serum screening or some combination of the two will already have had most cases of Down syndrome and trisomy 18 detected, and any soft marker found will almost certainly be a false positive. It is time to rethink the management of these markers. Recent evidence indicates that if these markers are found in isolation in an otherwise low-risk pregnancy, then there is minimal or no increase in the risk of Down syndrome or trisomy 18: these markers should be considered normal variants.The Australian Association of Obstetrical and Gynaecological Ultrasonologists consensus statement on these markers is included. Key words: Down syndrome; fetus; prenatal screening; soft marker; ultrasound.

INTRODUCTION
Midtrimester soft markers have been in use for many years. Despite the large volume of literature on this topic, controversy rages as to the significance of some of these markers. Echogenic intracardiac focus (EIF) and choroid plexus cysts (CPC) are two markers that were the subject of discussion at the 2005 Australian Association of Obstetrical and Gynaecological Ultra-

sonologists (AAOGU) annual conference. A consensus statement was drafted and unanimously endorsed by those present at the meeting. This article explains the reasoning behind the consensus statement. This article aims to review the current literature relating to these markers in an attempt to provide evidence-based guidance on the managements of fetuses found to have one of these markers.

M Bethune MB BS, FRANZCOG, DDU, COGU. Correspondence: Dr Michael Bethune, c/o Melbourne Ultrasound for Women, Level 1/62, Lygon Street, Carlton, Vic. 3053, Australia. Email: bethunes@gmail.com Submitted 29 June 2006; accepted 15 January 2007. doi: 10.1111/j.1440-1673.2007.01716.x

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MANAGEMENT OF EIF AND CPC

This article addresses isolated markers only. A fetus with a structural abnormality and a soft marker should be treated as for the structural abnormality, the soft marker is incidental. It follows from this statement that if the fetal anatomy has not been clearly visualized, then one cannot be sure that the soft marker is isolated, and it may be necessary to repeat the ultrasound scan in 12 weeks or refer the patient to a tertiary obstetric hospital or specialist obstetric ultrasound centre for a second-opinion scan. It is important that the patient is aware that the repeat scan is being carried out because of suboptimal images and not because of a soft marker identified at the scan. Soft markers may be reported by imaging specialists because of the fear that failure to report might lead to potential for litigation if the pregnancy is subsequently found to be affected by Down syndrome. Although there is a valid argument that it is the role of the midtrimester ultrasound to highlight potential problems for the pregnancy, one must always be mindful of the well-established medical principle primum non nocere (first do no harm). Almost 10 years ago, an editorial was published in the British Medical Journal entitled Ultrasonic Soft Markers of Fetal Chromosome Defects, Detecting Them May Do More Harm Than Good.1 Whittle argued that there are significant consequences/costs involved with detecting soft markers. After finding a marker the patient must be offered counselling which should be detailed and of high quality. He further stated that there would be fetal losses due to consequent further testing. Whittle suggested that before soft markers are introduced into standard practice, the costs must be justified by the benefits to women. This warning has not been heeded. The detection and reporting of a soft marker causes a range of consequences. It invokes anxiety in the patient; this anxiety can reach clinically significant levels in comparison with control groups. The patient then requires further counselling, usually initially by the imaging specialist or sonographer in the ultrasound room. Counselling may also be sought from their referring obstetrician or general practitioner and, if available, a geneticist or genetic counsellor. This requires a significant investment in time and counselling skills. Some of the patients will proceed on to further tests, which are expensive and require specific training and expertise. Unfortunately, some patients undergoing invasive testing may miscarry. Amniocentesis is not without risk, although the original randomized control trial showed a 1% risk of miscarriage,3 a more recent review of almost 70 000 procedures showed a procedure related a loss rate of 1 in 166 (0.6%).4 Few studies have evaluated the difficult issue of what to do with patients who have had screening before presenting for a midtrimester ultrasound. Many Australian and New Zealand patients will have nuchal translucency (NT) and/or maternal serum screening (MSST) performed. Most of the Down syndrome fetuses will be detected by these screening tests, mak2

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ing it highly likely that any EIF or CPC found in these previously screened patients will be a false positive. In one study of almost 17 000 women, none of the fetuses with isolated EIF in a previously screened population (NT or MSST) were affected by Down syndrome.5 Bayes theorem can be used to sequentially modify a patients risk. Likelihood ratios are generated and used to calculate a new risk from the patients previous risk. The advantages of this technique are multiple. It is not necessary to embark upon a detailed discussion about the nature of the soft marker, instead the patients are told their original risk (age or based on previous screening) and is then given their new risk. If the new risk is less than 1:250, then the patient can be considered to be at low risk for aneuploidy and need not consider amniocentesis (1:250 is the current cut-off for the midtrimester serum screening test). There is little increase in the falsepositive rate as only those patients who enter the high-risk group need be offered further investigation. Emotive statements such as there is a cyst in the brain, there is a spot on the heart are avoided. Before discussing each marker individually, one must consider the occasional fetus who presents with both an EIF and a CPC (but no other finding). These are markers for independent conditions. Echogenic intracardiac focus is associated with trisomy 21 not trisomy 18. Choroid plexus cyst is associated with trisomy 18 but not with trisomy 21, and it has a likelihood ratio of 1.0 for trisomy 21.6 Consequently, a fetus with both these findings should be independently assessed for each finding as outlined below.

ECHOGENIC INTRACARDIAC FOCUS

Echogenic intracardiac focus was originally described as a normal variant7 and has been shown to be microcalcifications within the papillary muscle.8 It is a common finding in normal fetuses (35% of the normal population), has been shown to cause no functional heart defect and is not considered to be associated with an increased risk of structural heart abnormalities.9 The papillary muscles are often visible as echogenic spots in the ventricle, they must be as bright as the adjacent ribs to be considered an EIF, and consequently false positives are common (Fig. 1). Reducing the intensity gain to ensure that the focus does not fade out before the ribs is an important test to minimize false positives (Fig. 2).10 There have been case reports that have suggested that multiple EIF or foci in the right ventricle are believed to be of greater significance.11 One of the early studies to show an association with Down syndrome concluded that 5% of normal fetuses and 18% of fetuses with trisomy 21 had an EIF. There were, however, only four Down syndrome fetuses with EIF in this study, and only two of these were isolated EIF; all fetuses were high-risk

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M BETHUNE
Two recent studies have cast further doubt on the significance of isolated EIF. These two studies were carried out in low-risk patients and showed an isolated EIF in only 1 of 626 Down syndrome fetuses.20,21 Both studies concluded that isolated EIF was not a marker for Down syndrome in low-risk patients (21 839 total patients). A third recent study showed 176 cases of EIF;22 there were three trisomies within this group. Two of the trisomies had other abnormalities visible on ultrasound. Only a single trisomy was found in the 141 isolated EIF patients; this occurred in a 38-year-old patient. The authors concluded that for patients younger than 35, an isolated EIF does not increase the risk of aneuploidy.22 Despite appropriate counselling, 30% of the patients younger than 35 years of age opted to have an amniocentesis, indicating a significant potential for fetal loss.22 An analytical model of patients younger than 35 years of age having an amniocentesis for isolated EIF has been carried out; the authors assumed a likelihood ratio of 4.0. It was calculated that 485 amniocentesis were required to diagnose one fetus with Down syndrome; that is, up to 2.8 miscarriages of normal fetuses would occur for every Down syndrome fetus detected.23 Few studies have looked at soft markers in patients who have had previous screening; one study that addressed this issue looked at almost 17 000 pregnancies, all mothers were offered NT or MSST. There were no cases of trisomy 21 in the group of patients who had isolated EIF (144 cases, 1% of the total).5 A recent meta-analysis of 11 studies24 involving almost 52 000 pregnancies and over 300 Down syndrome fetuses showed that although there was an increased risk of Down syndrome with an isolated EIF, the increased risk is minimal and the authors argue[s] further against the use of isolated or even combined EIF for guiding the decision for amniocentesis . in otherwise low-risk women.24 A summary of the evidence to date would indicate that although early studies provided evidence supporting the introduction of EIF as a marker for Down syndrome in high-risk patients, more recent studies have cast doubt about the role of this marker in unselected or low-risk populations.

Fig. 1. An EIF in the left ventricle (note it is as bright as the adjacent rib). 19 weeks gestation, normal outcome.

Fig. 2. This echogenic spot disappears with reduced gain before the ribs it should not be considered to be an EIF. 18 week pregnancy, normal outcome.

fetuses (older than 35 or abnormal serum screen).12 There have also been isolated case reports associating this finding with trisomy 13, but almost all of these fetuses will have other detectable abnormalities at the midtrimester ultrasound.13 I could only identify one reported case of trisomy 18 in a review of the literature, although this case was mentioned in more than one review.
10,14

Recent studies have shown a difference in the prevalence of EIF between ethnic groups, the original study found that 30% of Asian women had a fetus with an EIF (although there were only 46 Asian fetuses in the study group). Ethnic variation of this marker has been confirmed in recent larger studies.16,17 Several recent studies have cast doubt on the significance of EIF. Two casecontrol studies showed an increased likelihood ratio for Down syndrome, but in each case, this was not statistically significant with confidence intervals crossing 1 (group of Nyberg et al.: likelihood ratio 1.5, 95% CI 0.63.6,
19 18 15

CHOROID PLEXUS CYSTS

Approximately 13% of the normal population will have CPC identified within the fetal head at the midtrimester ultrasound (Fig. 3).25 It has been suggested that CPC should not be reported unless they are greater than or equal to 5 mm in maximum dimension; cystic spaces within the choroid less than this size should be considered mottled choroid and are unlikely to be significant.26,27 The CPC are not associated with an increased risk of trisomy 21, with a likelihood ratio of 1.06. They have, however, been associated with trisomy 18; approximately

group of Bromley et al.: likelihood ratio 1.4, 95% CI 0.64.3 ).

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This position statement not surprisingly sparked considerable debate, and a dissenting opinion was published in the same journal 1 month later.36 The dissenting authors believed that it was paternalistic not to share a potential modification of a patients risk with that patient.

CONCLUSION: HOW SHOULD WE MANAGE EIF AND CPC?

The literature to date leaves us in doubt about how to proceed after the identification of isolated EIF or CPC at the midtrimester ultrasound. One option would be to treat these markers the same as the other soft markers and to modify the previous risk by appropriFig. 3. Large bilateral choroid plexus cysts. 18 weeks pregnancy, normal outcome.

ate likelihood ratios to generate a new risk. The suggested likelihood ratios are 2.8 times the background risk of trisomy 21 for an isolated EIF (95% CI 1.55.5) and nine times the background rate of trisomy 18 for an isolated CPC.30 This approach

3050% of fetuses with trisomy 18 have been shown to have CPC.28 The vast majority of these fetuses will, however, have additional abnormalities, with an estimated 80% of trisomy 18 fetuses having detectable structural abnormalities at the midtrimester ultrasound.29 The detection of CPC has been estimated to increase the background rate of trisomy 18 by a factor of 9 times (likelihood ratio = 9).30 A recent study showed a similar likelihood ratio of 7.09.31 Recent studies have raised doubt about the significance of isolated CPC. Coco and Jeanty looked at almost 13 000 unselected patients, and there were 366 isolated CPC, and none of these fetuses were affected by trisomy 18.32 Another study reviewed 38 prenatally detected trisomy 18 fetuses, although 50% showed CPC, none were isolated; all of these fetuses had multiple other abnormalities.33 A recent study reported on almost 50 000 patients34 including 50 in trisomy 18 fetuses. The authors reported 1060 cases of isolated CPC with normal hand appearances; none of these fetuses were affected by trisomy 18. There were, however, three trisomy 18 fetuses with clenched hands and CPC as the only findings. This shows the importance of assessing appropriate hand movement (fingers open) in all midtrimester ultrasounds.34 The Journal of Ultrasound in Medicine recently published an editorial position paper written by and supported by many of the major researchers in obstetric and gynaecological ultrasound.35 The editors stated that isolated CPC (with normal hands in particular) or EIF did not increase the risk of aneuploidy, consequently these findings do not need to be discussed with the patient.35 They contended that these findings could be considered to be a normal variant. The authors also reminded the reader that it is not the role of the midtrimester scan to assess the risk of aneuploidy unless the patient specifically consents to this as there are other more accurate methods available (screening or diagnostic).

is supported by much of the early literature in this field and ensures that each patient receives an individualized risk assessment at the end of the ultrasound. This approach is based on the premise that the patient has a right to know any material risk. This would involve alerting each and every patient as to the presence of an EIF and a CPC. This requires a lengthy explanation and counselling, which is expensive in terms of time and skills required to counsel patients. The report conclusion could be in a form similar to Table 1. This approach would involve notifying every patient of the new risk, but focussing on the risk rather than on the ultrasound finding: ideally minimizing patients anxiety about holes/cysts in the head or problems with the heart. Significant anxiety cannot be avoided in all cases, and some low-risk patients may request amniocentesis on the basis of the finding and subsequent anxiety, and this will potentially cause more miscarriages of unaffected fetuses than detected Down syndrome fetuses. This may also adversely affect patients perceptions of the remainder of the pregnancy (medicalizing the pregnancy). Patients may request further ultrasound scans later in the pregnancy to reassure themselves that the heart or brain is in fact developing appropriately.

Table 1. A possible format for reporting EIF or CPC found at a routine midtrimester ultrasound An ultrasound soft marker (EIF/CPC) has been noted. The presence of this isolated soft marker has no clinical or functional significance to this fetus and does not need review. This marker has been shown to slightly increase the risk of aneuploidy from a prior risk of 1 in xxx to a new risk of 1 in xxx. This remains in the low-risk category. CPC, choroid plexus cyst; EIF, echogenic intracardiac focus.

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This approach also ignores the fact that recent studies have cast doubt on the relevance of these two markers in low-risk women. It may not be advisable to take a test with a known good detection rate (e.g. approximately 90% for the combined first trimester screen) and then modify the generated risk by the results of a test with a very poor (and unknown) detection rate. An alternative approach would be to decide not to report isolated EIF or CPC in low-risk women. This approach implies that these findings can be ignored as normal variants, provided that adequate views have been obtained of all structures and the in particular the fingers are seen to open and are not clenched. Not reporting EIF and CPC is contrary to the early established literature in high-risk patients but implies that likelihood ratios generated in high-risk patients are not necessarily applicable to low-risk patients. It relies on the principle that management should not be based on unproven and possibly unreliable tests as there is a growing body of evidence casting doubt on the role of EIF and CPC in the detection of aneuploidies. This approach is not paternalistic if one takes the view that there is insufficient good evidence of a link between these markers and aneuploidy on the basis of recent studies involving unselected and low-risk patients. This approach is supported by 22 leading American subspecialists in a recently published consensus opinion.35 Not reporting isolated EIF and CPC has been endorsed by the AAOGU in their recent consensus statement (Appendix I).
15. 14. 13. 12. 11. 10. 9. 8. 7. 6. 5.

M BETHUNE
Thilaganathan B, Olawaiye A, Sairam S, Harrington K. Isolated fetal echogenic intracardiac foci or golf balls: is karyotyping for Downs syndrome indicated? Br J Obstet Gynaecol 1999; 106: 129497. Smith-Bindman R, Hosmer W, Feldstein VA, Deeks JJ, Goldberg JD. Second-trimester ultrasound to detect fetuses with Down syndrome. JAMA 2001; 285: 104455. Schechter AG, Fakhry J, Shapiro LR, Gewitz MH. In utero thickening of the chordae tendinae. A cause of intracardiac echogenic foci. J Ultrasound Med 1987; 6: 6915. Brown DL, Roberts DJ, Miller WA. Left ventricular echogenic focus in the fetal heart: pathological correlation. J Ultrasound Med 1994; 13: 61316. Simpson JM, Cook A, Sharland G. The significance of echogenic foci in the fetal heart: a prospective study of 228 cases. Ultrasound Obstet Gynaecol 1996; 8: 2258. Wax JR, Mather J, Steinfeld JD, Ingardia CJ. Fetal intracardiac echogenic foci: current understanding and clinical significance. Obstet Gynecol Surv 2000; 55: 30311. Bromley B, Lieberman E, Shipp TD, Richardson M, Benacerraf BR. Significance of an echogenic intracardiac focus in fetuses at high and low risk for aneuploidy. J Ultrasound Med 1998; 17: 12731. Bromley B, Lieberman E, Laboda L, Benacerraf BR. Echogenic intracardiac focus: a sonographic sign for fetal Down syndrome. Obstet Gynecol 1995; 86: 9981001. Lehman CD, Nyberg DA, Winter TC III, Kapur RP, Resta RG, Luthy DA. Trisomy 13 syndrome: prenatal ultrasound findings in a review of 33 cases. Radiology 1995; 194: 217222. Sepulveda W, Cullen S, Nicolaidis P, Hollingsworth J, Fisk NM. Echogenic foci in the fetal heart: a marker of chromosomal abnormality. Br J Obstet Gynaecol 1995; 102: 4902. Shipp TD, Bromley B, Lieberman E, Benacerraf BR. The frequency of the detection of fetal echogenic intracardiac foci with respect to maternal race. Ultrasound Obstet Gynecol 2000; 15: 4602. Rebarber A, Levey KA, Funai E, Monda S, Paidas M. An ethnic predilection for fetal echogenic intracardiac focus identified during targeted midtrimester ultrasound examination: a retrospective review. BMC Pregnancy Childbirth 2004; 4: 12. Tran SH, Caughey AB, Norton ME. Ethnic variation in the prevalence of echogenic intracardiac foci and the association with Down syndrome. Ultrasound Obstet Gynecol 2005; 26: 15861. Nyberg DA, Souter VL, El-Bastawissi A, Young S, Luthhardt F, Luthy DA. Isolated sonographic markers for detection of fetal down syndrome in the second trimester of pregnancy. J Ultrasound Med 2001; 20: 105363. Bromley B, Lieberman E, Shipp TD, Benacerraf BR. The genetic sonogram: a method of risk assessment for Down syndrome in the second trimester. J Ultrasound Med 2002; 21: 108796. Coco C, Jeanty P, Jeanty C. An isolated echogenic heart focus is not an indication for amniocentesis in 12,672 unselected patients. J Ultrasound Med 2004; 23: 48996. Anderson N, Jyoti R. Relationship of isolated fetal intracardiac echogenic focus to trisomy 21 at the mid-trimester sonogram in women younger than 35 years. Ultrasound Obstet Gynecol 2003; 21: 3548. Bradley KE, Santulli TS, Gregory KD, Herbert W, Carlson DE, Platt LD. An isolated intracardiac echogenic focus as a marker for aneuploidy. Am J Obstet Gynecol 2005; 192: 20218.

ACKNOWLEDGEMENTS
The author would like to thank Associate Professor Lachlan deCrespigny, Principal Fellow, Department of Obstetrics and Gynaecology, The University of Melbourne, for reviewing the manuscript. The author would also like to acknowledge the staff of the medical imaging and perinatal departments of the Mercy Hospital for Women for their advice and feedback during the development of protocols to manage soft markers. The comments of Dr Susan Walker, Department of Perinatal Medicine, were particularly helpful.
19. 18. 17. 16.

REFERENCES
1. Whittle M. Ultrasonic soft markers of fetal chromosome defects, detecting them may do more harm than good. BMJ 1997; 314: 918. Watson MS, Hall C, Langford K, Marteau TM. Physiological impact of the detection of soft markers on routine ultrasound scanning, a pilot study investigating the modifying role of information. Prenat Diagn 2002; 22: 56975. Tabor A, Philip J, Madsen M, Bang J, Obel EB, NorgaardPedersen B. Randomised controlled trial of genetic amniocentesis in 4606 low-risk women. Lancet 1986; 1: 128793. Seeds JW. Diagnostic mid trimester amniocentesis: how safe? Am J Obstet Gynecol 2004; 191: 60715.

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23. Caughey AB, Lyell DJ, Filly RA, Washington AE, Norton ME. The impact of use of the isolated intracardiac focus as a screen for Down syndrome in women under the age of 35 years. Am J Obstet Gynecol 2001; 185: 10217. 24. Sotiriadis A, Makrydimas G, Ioannidis JPA. Diagnostic performance of intracardiac echogenic foci for Down syndrome: a meta-analysis. Obstet Gynecol 2003; 101: 100916. 25. Benacerraf BR, Harlow B, Frigoletto FD Jr. Are choroid plexus cysts an indication for second-trimester amniocentesis? Am J Obstet Gynecol 1990 162: 10016. 26. Chitty LS, Chudleigh P, Wright E, Campbell S, Pembrey M. The significance of choroid plexus cysts in an unselected population: results of a multicenter study. Ultrasound Obstet Gynecol 1998; 12: 3917. 27. Walkinshaw S, Pilling D, Spriggs A. Isolated choroid plexus cyststhe need for routine offer of karyotyping. Prenat Diagn 1994; 14: 6637. 28. Bromley B, Lieberman R, Benacerraf BR. Choroid plexus cysts: not associated with Down syndrome. Ultrasound Obstet Gynecol 1996; 8: 2325. 29. Nyberg DA, Kramer D, Resta RG et al. Prenatal sonographic findings of trisomy 18: review of 47 cases. J Ultrasound Med 1993; 12: 10313. 30. Choong S, Meagher S. Management of choroid plexus cysts in the mid-trimester. Aust NZ J Obstet Gynecol 1999; 39: 711. 31. Ghidini A, Strobelt N, Locatelli A, Mariani E, Piccoli MG, Vergani P. Isolated fetal choroid plexus cysts: role of ultrasonography in establishment of the risk of trisomy 18. Am J Obstet Gynecol 2000; 182: 9727. 32. Coco C, Jeanty P. Karyotyping of fetuses with isolated choroid plexus cysts is not justified in an unselected population. J Ultrasound Med 2004; 23: 899906. 33. Yeo L, Guzman ER, Day-Salvatore D, Walters C, Chavez D, Vintzileos AM. Prenatal detection of fetal trisomy 18 through abnormal sonographic features. J Ultrasound Med 2003; 22: 58190. 34. Bronsteen R, Lee W, Vettraino IM, Huang R, Comstock CH. Second-trimester sonography and trisomy 18: the significance of isolated choroid plexus cysts after an examination that includes the fetal hands. J Ultrasound Med 2004; 23: 2415. 35. Filly RA, Benacerraf BR, Nyberg DA, Hobbins JC. Choroid plexus cysts and echogenic intracardiac focus in women at low risk for chromosomal anomalies. J Ultrasound Med 2004; 23: 4479. 36. Doubilet PM, Copel JA, Benson CB, Bahado-Singh RO, Platt LD. Choroid plexus cysts and echogenic intracardiac focus in women at low risk for chromosomal anomalies the obligation to inform the mother. J Ultrasound Med 2004; 23: 8835.

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APPENDIX I Australian association of obstetrical and gynaecological ultrasonologists consensus statement

Soft markers at the midtrimester anomaly ultrasound

There are effective prenatal screening tests available for chromosomal abnormalities (including Down syndrome) with detection rates of up to 90%. The second trimester ultrasound has a much lower detection rate and is therefore not intended as a Down syndrome screening test. Recent studies have cast doubt as to the significance of some ultrasound findings as markers for chromosome abnormalities. These markers are: echogenic intra-cardiac focus; mild renal pelvis dilatation; and choroid plexus cyst(s). The detection of one of these markers in a routine mid-trimester ultrasound is a warning sign to ensure that the ultrasound examination is of sufficient quality to reliably check for structural abnormalities, and in particular that the hands are not clenched. If one of these markers in isolation is found in an otherwise low risk patient then it may be considered to be a normal variant and does not necessitate further discussion or investigation. Mild renal pelvis dilatation should still be reported due to its association with paediatric renal problems.

This consensus statement was ratified unanimously at the recent annual scientific meeting of the AAOGU (Launceston, November 2005) and is planned for review on a regular basis.

Members present and endorsing this statement

Dr Michael Bethune, Dr Danny Challis, Dr Rebecca Chalmers, Dr Fung Yee Chan, Dr Jackie Chua, Associate Professor Lachlan de Crespigny, Dr Andrew Edwards, Dr Bev Hewitt, Dr Victor Hurley, Dr Louise Kornman, Dr Valeria Lanzarone, Dr Andrew McLennan, Dr Stanley Ng, Dr Debbie Nisbet, Dr Emily Olive, Dr Sofie Piessens, Dr John Phillips, Dr Gary Pritchard, Dr RB Richardson, Dr Alistair Roberts, Dr Amanda Sampson, Dr Karen Shand, Dr Sashi Siva, Dr Paul Shekleton, Dr John Smoleniec, Dr Mark Teoh, Dr Stephanie The, Dr Debbie Wass, Dr Sue Walker, Dr Susan Winspear and Dr Nicole Woodrow.

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