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Announcements and latest updates

Right Decision Service newsletter: September 2024

Welcome to the Right Decision Service (RDS) newsletter for September 2024.

1.Business case for permanent provision of the Right Decision Service from April 2025 onwards

This business case has now been endorsed by the HIS Board and will shortly be submitted to Scottish Government.

2. Management of RDS support tickets

To balance increasing demand with available capacity and financial resource, the RDS team and Tactuum are now working together to  implement closer management of support tickets. As a key part of this, we want to ensure clear, timely and consistent communication with yourselves as requesters.  

Editors will now start seeing new messages come through in response to support ticket requests which reflect this tightening up and improvement of our processes.

Key points to note are:

2.1 Issues confirmed by the RDS and Tactuum teams as meeting the critical/urgent and high priority criteria will continue to be prioritised and dealt with immediately.

Critical/urgent issues are defined as:

  1. The Service as a whole is not operational for multiple users. OR
  2. Multiple core functions of the Service are not operational for multiple users.

Example – RDS website outage.

Please remember to email ann.wales3@nhs.scot and his.decisionsupport@nhs.scot with any critical/urgent issues in addition to raising a support ticket.

High priority issues are defined as:

  1. A single core function of the Service is not operational for multiple users. OR:
  2. Multiple non-core functions of the Service are not operational for multiple users.

Example – Build to app not working.

2.2 Support requests that are outwith the warranty period of 12 weeks since the software was originally developed will not be automatically addressed by Tactuum. The RDS team will consider these requests for costed development work and will obtain estimate of effort and cost from Tactuum for priority issues.

2.3 Support tickets for technical issues that are not classified as bugs will not be automatically addressed by Tactuum. The definition of a bug is ‘a defect in the software that is at variance with documented user requirements.’  Issues that are not bugs will also be considered for costed development work.

The majority of issues currently in support tickets fall into category 2 or 3 above, or both.

2.4 Non-urgent requests that require a deployment (i.e a new release of RDS) will normally be factored into the next scheduled release (currently end of Nov 2024 and end of Feb 2025) unless by special agreement with the RDS team.

Please note that we plan to move in the new year to a new system whereby requests all come to an RDS support portal in the first instance and are triaged from there to Tactuum when appropriate.

We will be organising a webinar in a few weeks’ time to take you through the details of the current support processes and criteria.

3. Next scheduled deployment.

The next scheduled RDS deployment will take place at the end of November 2024.  We are reviewing all outstanding support tickets and feature requests along with estimates of effort and cost to determine which items will be included in this deployment.

We will update you on this in the next newsletter and in the planned webinar about support ticket processes.

4. Contingency arrangements for RDS

Many thanks to those of you who attended our recent webinar on the contingency arrangements being put in place to prevent future RDS outages as far as possible and minimise impact if they do occur.  Please contact ann.wales3@nhs.scot if you would like a copy of the slides from this session.

5. Transfer of CKP pathways to RDS

The NES clinical knowledge pathway (CKP) publisher is now retired and the majority of pathways supported by this tool have been transferred to the RDS. Examples include:

NHS Lothian musculoskeletal pathways

NHS Fife rehabilitation musculoskeletal pathways

NHS Tayside paediatric pathways

6. Other new RDS toolkits

Include:

Focus on frailty (from HIS Frailty improvement programme)

NHS GGC Money advice and support

If you would like to promote one of your new toolkits through this newsletter, please contact ann.wales3@nhs.scot

To go live imminently:

  • Focus on dementia
  • NHS Lothian infectious diseases toolkit
  • Dumfries and Galloway Adult Support and Protection procedures
  • SIGN guideline – Prevention and remission of type 2 diabetes

 

7. Evaluation projects

We have recently analysed the results of a survey of users of the Scottish Palliative Care Guidelines toolkit.  Key findings from 61 respondents include:

  • Most respondents (64%) are frequent users of the toolkit, using it either daily or weekly. A further 25% use it once or twice per month.
  • 5% of respondents use the toolkit to deliver direct patient care and 82% use it for learning
  • Impact on practice and decision-making was rated as very high, with 80% of respondents rating these at a 4-5 on a 5 point scale.
  • Impact on time saving was also high, with 74% of respondents rating it from 3-5.
  • 74% also reported that the toolkit improved their knowledge and skills, rating these at 4-5 on the Likert scale

Key strengths identified included:

  • The information is useful, succinct, and easy to understand (31%).
  • Coverage is comprehensive (15%)
  • All information is readily accessible in one place and users value the offline access via mobile app (15%)
  • Information is reliable, evidence-based and up to date (13%)

Users highlighted key areas for improvement in terms of navigation and search functionality. The survey was very valuable in enabling us to uncover the specific issues affecting the user experience. Many of these can be addressed through content management approaches. The issues identified with search results echo other user feedback, and we are costing improvements with a view to implementation in the next RDS deployment.

8.RDS High risk prescribing (polypharmacy) decision support embedded in Vision and EMIS primary care E H R systems

This decision support software, sponsored by Scottish Government Effective Prescribing and Therapeutics Division,  is now available for all primary care clinicians across NHS Tayside. Board-wide implementation is also planned for NHS Lothian, and NHS GGC, NHS Ayrshire and Arran and NHS Dumfries and Galloway have initial pilots in progress. The University of Dundee has been commissioned to evaluate impact of this decision support software on prescribing practice.

9. Video tutorials for RDS editors

Ten bite-size (5 mins or less) video tutorials for RDS editors are now available in the “Resources for providers of RDS tools” section of the RDS.  These cover core functionality including Save and preview, content page and media management, password management and much more.

10. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Wednesday 23rd October 4-5 pm
  • Tuesday 29th October 11 am -12 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

 

Mild Ventriculomegaly on Antenatal Ultrasound (916)

Please report any inaccuracies or issues with this guideline using our online form

Fetal ventriculomegaly is a common finding on antenatal ultrasound and is defined as an atrial measurement of ≥ 10mm of the posterior horn of the lateral ventricle (1). It can be further subdivided into mild 10-12mm, moderate 13- 15mm and severe >15mm (2). It has a prevalence of approximately 1% (3). Ventriculomegaly has a range of causes; normal variation, aneuploidy, genetic syndromes, primary brain structural abnormalities, congenital infections, cerebrovascular accidents and intracranial haemorrhage. Prognosis and corresponding counselling of the parents is dependent on the cause of the ventriculomegaly, the antenatal progression and any co-existing abnormalities(4). It is therefore vitally important to look for  any underlying aetiologies and co-existing CNS and non-CNS abnormalities in order to present the parents with the most relevant and accurate information.

Diagnosis

Accurate measurement of the ventricles is important in both defining ventriculomegaly and also assessing progression. The fetal head should be scanned in the axial plane at the level of the frontal horns and the cavum septum pellucidum (CSP) (the same level at which a head circumference is taken), at an appropriate magnification that the head fills the screen. The callipers should be placed at the internal margins of the atrial walls at the level  of the parietal occipital groove and the glomus of the choroid plexus, perpendicular to the axis of the ventricle.

Although the distal ventricle is always easier to see than the proximal one because of reflection of the ultrasound beams from the fetal skull, both ventricles should be checked; ventriculomegaly is unilateral in 50-60% cases and bilateral in 40-50% (5).

Ultrasonography

Once ventriculomegaly has been diagnosed, there should be a detailed, sonographic evaluation of the neuroanatomy by a medical sonographer. Whether this is by transabdominal or transvaginal ultrasound will depend on the preference of the patient, the sonographer and the fetal position.

Other, non-CNS structures should also be carefully assessed including fetal biometry looking for evidence of growth restriction, the heart and any markers of intrauterine infection.

Testing for genetic disorders

Parents should be offered invasive, diagnostic testing and chromosomal microarray (CMA). 

Between 0-5% (2, 5) of fetuses with apparently isolated m i l d ventriculomegaly will have an underlying abnormal karyotype, most commonly Trisomy 21 and a further 10-15% will have abnormalities found on CMA.  

Testing for fetal infection

Congenital infections, most commonly cytomegalovirus (CMV), toxoplasmosis, parvovirus and Zika have been associated with mild ventriculomegaly in around 8% of cases (5). Parents should be offered tests for CMV, toxoplasmosis and parvo virus (regardless of history of known exposure or symptoms). Women with mild fetal ventriculomegaly who have been to a Zika area and not yet tested should be offered a test.

Fetal MRI

Fetal MRI (fMRI) can be a useful adjunct to ultrasound if the relevant radiological expertise and technology is available. The additional information will depend on the size of the ventricles as well as the quality of the original ultrasound and the level of expertise in the practitioner. The chance that fMRI will find important, clinically relevant additional brain abnormalities not picked up on ultrasound varies in the literature from 1-14% with the most recent studies putting the figure at 5-6% (5). The most common abnormality picked up on fMRI after being missed on ultrasound is agenesis of the corpus callosum.

Women wishing to have a fetal MRI, to look for additional brain abnormalities that may affect the prognosis, after appropriate counselling should be referred to fetal medicine department for review.

  • The fetal medicine department will arrange the MRI
  • Fetal medicine will review again after MRI to discuss results.
  • Thereafter the patient will go back to their own unit, unless otherwise indicated and delivery will be planned in their own unit.

Follow up antenatal ultrasound examinations

There are no data on optimal timings of follow up assessments once a diagnosis has been made. A suggested pragmatic approach would be 4-weekly assessments. Progression of ventriculomegaly is an important prognostic indicator; evidence suggests that 5% progress during pregnancy (5).

Delivery

The timing and mode of delivery should be planned as per normal obstetric indications. An alert should be placed on the electronic BadgerNet record to ensure that neonatologists are made aware of the antenatal diagnosis.

Cord bloods should be taken with parental consent for chromosomal analysis and congenital viral infections from those infants who didn’t have antenatal testing.

Postnatal follow up should be arranged by the neonatologists prior to discharge from hospital.

Prognosis

Most of the statistics quoted in the literature are based on whether the ventriculomegaly is apparently isolated or not; true isolation will only be able to be confirmed postnatally. Neurodevelopmental delay in case of isolated unilateral mild or moderate ventriculomegaly is thought to be 6% (5); in bilateral isolated ventriculomegaly this rises to 8-12% (7). This may not be dramatically higher than the background population risk. Long-term prognosis also depends on associated findings and the positive results of any investigations. 

Parents should be offered antenatal counselling by paediatricians to discuss prognosis and postnatal care in greater detail. A patient information leaflet from ISUOG and a link to further information is below.

Further information

Melchiorre, K & Bhide, Amarnath & Gika, Artemis & Pilu, G & Papageorghiou, A.T. (2009). Counseling in isolated mild ventriculomegaly. Ultrasound in Obstetrics & Gynecology

Patient Information:

ISUOG. Ventriculomegaly
"This leaflet is to help you understand what Ventriculomegaly is, what tests you need, and the implication of having been diagnosed with Ventriculomegaly for you, your baby and your family."

Editorial Information

Last reviewed: 01/04/2021

Next review date: 01/04/2024

Author(s): Rachel Bradnock.

Approved By: Obstetrics Clinical Governance Group

Document Id: 916

References
  1. International Society of Ultrasound in Obstetrics and Gynecology Education Committee. Sonographic examination of the fetal central nervous system: guidelines for performing the ‘basic examination’ and the ‘fetal neurosonogram’. Ultrasound Obstet Gynecol 2007; 29: 109 – 116.
  2. Society for Maternal-Fetal Medicine (SMFM): Fox NS et al. Mild Fetal Ventriculomegaly: diagnosis, evaluation and management. SMFM Consult Series 45 2018.
  3. Pilu G, Hobbins JC. Sonography of fetal cerebrospinal anomalies. Prenat Diagn 2002; 22: 321 – 330.
  4. Scala C, Familiari A, Pinas A, Papageorghiou T, Bhide A, Thilaganathan B, Khalil A. Perinatal and long-term outcomes in fetuses diagnosed with isolated unilateral ventriculomegaly: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2017; 49: 450–459
  5. Griffiths PD, Brackley K, Bradburn M, et al. Anatomical subgroup analysis of the MERIDIAN cohort: ventriculomegaly. Ultrasound Obstet Gynecol 2017;50:736-44.
  6. RCOG/RCM/PHE/HPS Clinical Guidelines. Zika Virus Infection and Pregnancy. Updated Feb 2019.
  7. Pagani G, Thilaganathan B, Prefumo F. Neurodevelopmental outcome in isolated mild fetal ventriculomegaly: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2014; 44: 254 – 260.