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Brittani Schwartzkopf, RDMS (Guest): Hi, I'm Brittani Schwartzkopf. I'm a Registered Sonographer with BJC Med Group.

Heather Lopez, MD (Guest): Hi, I'm Dr. Lopez and I'm a board eligible OBGYN with Missouri Baptist BJC Medical Group.

Melanie Cole (Host): Well, the 20 week ultrasound is here. The one that most parents look forward to through the whole first half of their pregnancy. The 20 week ultrasound often gives parents a detailed look at exactly how their baby is developing and allows them to see how much their baby has grown in the first half of pregnancy.

Welcome to Mom Docs, the podcast from St. Louis Children's Hospital. I'm Melanie Cole. So, today we're talking about this 20 week ultrasound and Dr. Lopez, before we get into it, set the table for us a little bit. What are some of the more important tests that a pregnant woman has during her pregnancy? Kind of just give us a quick overview.

Dr. Lopez: So, some of the important tests before you get to that 20 week ultrasound is your initial obstetric labs. So, these are the initial labs that we're going to obtain at your first visit; looking to make sure moms aren't anemic, you know, we always screen also all of our moms for STDs. So, those are some of the biggest things that we go over with moms before their anatomy ultrasound. Also talking to them about what's called genetic testing, asking moms that they want to be screened for genetic testing for their baby. That's how a lot of moms these days actually find out, you know, if they're having a boy or girl before their anatomy ultrasound, where back in the day, we used to wait until that 20 week ultrasound, which we're going to talk about in a minute to find out that gender of your baby.

Host: What an exciting time. Boy, I told you off the air, I just loved being pregnant. So, Dr. Lopez, tell us a little bit about the 20 week ultrasound. Why is this so important?

Dr. Lopez: The 20 week ultrasound is so important, as this is kind of taking snapshots of your baby and looking at the entire anatomy. So, the ultrasound actually can take anywhere from 45 minutes to an hour and we're looking at all the important parts. So, we're actually looking at the brain, looking at important parts in the brain, like the cerebellum.

We're looking at your baby's heart to make sure we're not seeing any fetal anomalies or holes in the heart. We're looking at your baby's spine to make sure we're not seeing any holes in the back of the spine, which is known as spinal bifida. So, it's a really important exam to kind of make sure that everything anatomically looks good.

Host: And Brittani, you're the sonographer. Tell us a little bit about your role in this. What are you doing? I mean, Dr. Lopez just gave us a brief overview of what's important about this ultrasound, but you tell us a little bit about how it works.

Brittani: Sure. So, I would say as a whole, most sonographers would agree that during the anatomy scan, during the survey you take about 42 to 50 images and each image is basically ruling out a genetic or structural defect. Some can be isolated and some can be linked to a genetic defect. So, it's nice to have also the genetic screening on board, while some people opt out of it; it also is another piece of the puzzle. So, we can combine that with the ultrasound. So as she said, I look at pretty in detail, parts of the brain, midbrain, hindbrain, there's three parts to look out on the spine even down to, I have a lot of people say, oh, there's five toes where we actually look at the shape of the feet and we look at the bones and the pinky and things like that. So, it's a pretty detailed ultrasound. We also look at mom's ovaries to make sure she's not growing anything extra special during the pregnancy. We look at the placental placement. A lot of moms come in and they say that they can't feel the baby. And sometimes they have a placenta that could be in the front of the uterus. So, they wouldn't then feel the baby till closer to around 22 weeks. So, it's a pretty in-depth study, but each picture is taken to rule out a malformation, every photo.

Host: So, Brittani then what does the baby look like at 20 weeks pregnant?

Brittani: Most babies between 18 and 20 weeks, that's usually when I get them for their anatomy scan, they're usually between 200 and 400 grams in size. So, that's approximately eight to 12 ounces, so to speak. So, they're pretty small still. They all really look the same, obviously with respect to the gender.

So, that's why we do the scan at that time. You know, obviously at the end of the pregnancy, when you do scans, you do for are they a long, skinny baby? Are they a short, chunky baby? So, the genetics really take on shape after about 35 weeks or so. So, that's why obviously all babies are born at different sizes. But the anatomy scan, they're all really all the same. Everyone should be around the 50th percentile.

Host: And that's when, if you want to, you can find out the sex of the baby.

Brittani: Yes, of course. Like Dr. Lopez said, also the genetic testing that is done early in the pregnancy that will often determine the gender of the baby through blood work. We also like to match that to what we see on the ultrasound.

Host: Dr. Lopez, tell us a little bit about how to prepare and what you tell women, because you know, it can be a scary time. That ultrasound, that particular one as Brittani just described can show you anomalies. And we're not sure what we're looking at, right? The lay person, but for you docs, how do you prepare your moms-to-be for what they're going to see or these possible complications?

Dr. Lopez: Yeah, it can be scary. I just actually went through this with my husband. I'm currently 37 weeks pregnant and it's our first baby. And I remember being really excited for my anatomy ultrasound. The difference is that I know exactly what I'm looking at, where my husband's point of view going in was that he was very nervous for the ultrasound. You know what if we see an anomaly, what if our baby has a heart defect? Where do we go from there? so, it kind of put things in a different perspective for me. So, I tell moms, 20 week ultrasound should be exciting. It's when, a lot of moms are seeing the gender for the first time, seeing actually the baby look like a baby, which is really exciting.

And you have your spouse normally coming with you. So, I tell people first thing going in, you thinking, I want them to think about getting good pictures of their baby. We do, do 3D images of their baby's face. So, they're always getting good ultrasounds to put on their refrigerator. So, trying to take off that nervousness for them. I tell them to prepare for about 45 minutes to an hour, or sometimes even longer, you know, if the baby is not cooperating for Brittani our ultrasonographer. These babies are little and they're moving all over the place in there. And sometimes it can be hard for her to get some images. I also tell them, don't be afraid to tell, Brittani, if for some reason they're laying on their back too long and they start to feel lightheaded or dizzy.

Sometimes that can happen and Brittani is pushing on the uterus in a certain way to make sure she gets that perfect image. So, make sure you're talking to your ultrasonographer. Sadly, I also let people know, everyone always wants our sonographer to walk them through everything. And Brittani does a great job of that, but also Brittani's job is to really be focused and really make sure she gets the images that we need to make sure we're not seeing any fetal anomalies. So, Brittani, sometimes it's really quiet during that ultrasound because she's so focused on getting those 40 to 50 images.

And I tell people, after Brittani finishes everything, she then kind of writes up the case and like prints out all the images and brings them down to me. And then Brittani and I discuss them together. And then I go in the room and talk to the patient about it. So, that can sometimes be intimidating to know having all these images taken. You don't know what you're looking at and then have to go and wait in a room for me to come in the room. Really all that Brittani can really tell you as an ultrasonographer is the gender of the baby. So, that's hard on her too. Cause if she sees something. So, to get a good image of it so I can see it also, but she also is not legally allowed to tell a patient like, oh, there is a hole in the heart or things like that.

So yeah, having anatomy ultrasound is exciting, but it also can be very scary. And so I try to calm our patients down and things like that and let them know that as soon as you're done with Brittani, we're going to talk and go through all the images together.

Host: So, you really make them feel at ease with that wait time. Nobody likes waiting for any of these kinds of results. And Brittani, how many ultrasounds does a woman have during the pregnancy? And, and just tell us a little bit about your experience. Women want to chat, but as Dr. Lopez says, you have to be very focused and there are a lot of things that you can't tell the woman except for the sex. So, how many ultrasounds and tell us what it's like doing what you do.

Brittani: It varies depending on if you're in a high risk department or if you are in a low risk department, which is basically the general population. High-risk imaging is a little different, so ideally, there's a first trimester ultrasound, usually around eight weeks. Then there's an ultrasound sometimes between 11 weeks and 13 weeks, which is also to look at a specific area on the baby called the nuchal translucency.

Some of that has been weeded out over the years as genetic testing has evolved, with the blood work, but we can look at the baby's neck between 11 and 13 weeks and see if there's any suspicion for potential cardiac defect down the road. And also, this little area, if it's greater than three millimeters, we can then do a further workup for genetic testing. Let's say if someone's insurance didn't cover that blood work, we now have a reason then to submit for that blood work. If we have an elevated risk for just an example, trisomy 21.

In a low-risk environment, it would really just be your first viability scan, which is that eight week scan. And then, typically your anatomy scan at 20 weeks. Subsequent scans after the anatomy scan are based on our findings, really. Sometimes we couldn't get everything. So, in four weeks we follow up to complete the anatomy scan or it really is just depending on the doctor's discretion, actually.

What she sees fit to order in the future is really where it goes from there. I personally have about 10 years and background in high-risk imaging. So, I worked most of my career in maternal fetal medicine. I have just now made my way to the low risk side of things, which is a little more relaxed, just in nature, but I essentially scan my patients the exact same way as I did when I worked in high risk.

Dr. Lopez: And all that in here, just to go off of Brittani. So, talking about ultrasounds, Brittani's correct. In a low risk mom, we usually just do two ultrasounds, so that viability ultrasound at 8 to 10 weeks, when mom's first presenting to establish care for her pregnancy. And then we do the anatomy ultrasound, usually between 18 and 22 weeks.

The next time that I would get an ultrasound, if someone became high risk. So, if they had chronic hypertension, they were diagnosed with gestational diabetes, things like that. Lots of moms always ask me, like, how do I know if I'm low risk? If my baby's growing appropriately? Well, every time you come to the OBGYN, we're measuring from your pubic bone all the way to the top of the uterus and that actually in centimeters should equal your gestational age.

So, say I have a mom that comes in who's 35 weeks and I'm measuring her belly and she's measuring exactly 35 weeks. Her baby is measuring right on. It tells me the baby has good growth, where if I'm measuring a mom, who's 35 weeks and her baby is measuring 37-38 weeks. That makes me think, okay, is baby bigger, or does mom have extra fluid around the baby?

So, that would kind of prompt me then to obtain an ultrasound to make sure we're not missing anything.

Host: Well, it certainly is such an exciting time. And Dr. Lopez, congratulations to you. What a very fun time for you. So, I'd like to give you the last word here. What you tell moms, you're an OBGYN. You deal with this every single day, well really both of you do. What do you tell moms to give them hope, reassure them, but really get them excited and jazzed up for that 20 week ultrasound?

Dr. Lopez: Thank you for also, um, congratulations for me, I'm super excited about having our baby soon. I usually tell moms, these are pictures that you're going to have for the rest of your life of your baby. And these are pictures that you're going to go home and bring on your fridge and people are going to post on their Instagram and their Facebook and things like that.

Like I said earlier, try to get rid of that nervousness for moms about coming in and looking at their baby and looking at all the parts. And I explain to them you're going to be looking at things on the screen and you're not going to have any idea what they are. And I said, that's okay, that's our job.

That's our job to go through these images and look at them with our ultrasonographer and source things out. So I said, the part that I want you to focus on is how cute your little baby is in there. Moving around, wiggling around. It's an exciting time when you know, we have a couple that comes in and it's their first baby, second baby, third baby. Seeing them laying there together, holding hands, watching their baby move on the screen. Brittani in our office has a beautiful new ultrasound. And we have a big screen TV where moms and dads can actually watch everything that Brittani's doing on the live screen, which is awesome. So, it's very interactive for them. So, I try to tell them, I know that Brittani is going to be quiet and she's doing her job and focusing and things like that. And I say, I just want you to focus on how cute your little baby is in there, wiggling around. And then we'll sit down and talk about the images together.

Host: As we said, how exciting and thank you ladies, both for joining us today and really sharing your expertise for moms-to-be listening that are like, okay, I got that ultrasound coming up. I'm going to learn the anatomy of my baby and the sex if they want to. And so it's really a very exciting time. And thank you again. For more advice and articles check out the mom docs website at children'smd.org. That concludes another episode of Mom Docs with St. Louis Children's Hospital. If you found this podcast informative, please share on your social media, your social channels, and be sure to check out all the other interesting podcasts in our library. I'm Melanie Cole.