The level II anomaly scan, also called the TIFFA scan (targeted imaging for fetal anomalies), is the most detailed routine scan of pregnancy. It is usually done between 18 and 22 weeks, when the baby’s organs are large enough to be seen clearly and there is still time for further tests or a second opinion if needed.
The scan follows a structured checklist based on ISUOG guidance, so every important part of the baby is examined in turn: brain, face, spine, heart, chest, abdomen, kidneys, bladder and limbs, along with the placenta, cord, fluid and, where relevant, the cervix. Major structural conditions affect about 2 to 3 in every 100 babies, and this scan is designed to find most of them.
Dr. Devang Patel trained in maternal-fetal medicine and 3D ultrasound at Fernandez Hospital, Hyderabad. At Divine Women’s Hospital, Gota, the scan is performed and reported by the consultant who looks after your pregnancy, so any finding is explained and planned for in the same visit.
What the anomaly scan is for
The anomaly scan looks at how each part of the baby has formed. Its main aim is to identify structural conditions such as spina bifida, cleft lip, serious heart defects, kidney problems or a defect in the abdominal wall, so that you can be counselled and the birth can be planned around the baby’s needs.
It also checks the baby’s growth against the dates, where the placenta lies, the amount of fluid, the cervix where relevant and the number of vessels in the cord. In most pregnancies it provides real reassurance that the baby’s anatomy looks normal.
The organ-by-organ checklist
- Head and brain: skull shape, the ventricles (fluid spaces), cerebellum, cisterna magna and midline structures
- Face: upper lip and profile, looking in particular for cleft lip, and the eye sockets
- Spine: alignment and skin covering from neck to tail, in long and cross-sectional views
- Heart: position, four chambers, both outflow tracts, and the three-vessel and trachea views
- Chest and diaphragm, stomach position, abdominal wall at the cord insertion, and bowel
- Both kidneys, the renal pelvis and the bladder
- Arms, legs, hands and feet, including the long bones of each segment and the position of the feet
- Biometry: head circumference, abdominal circumference and femur length
- Placenta position, cord vessels and insertion, and amniotic fluid
- Cervical length and uterine artery Doppler where indicated
How likely it is to detect different conditions
Detection depends on the type of condition, the baby’s position and your body build. Some conditions are seen in almost every case, others are much harder. The figures below are typical ranges from published studies for a careful mid-trimester scan.
| Condition | Typical detection at 18–22 weeks | Comment |
|---|---|---|
| Anencephaly | Over 95% | Usually already seen at the NT scan |
| Open spina bifida | About 90% | Head signs (lemon and banana) help |
| Abdominal wall defects | About 90–98% | Gastroschisis and exomphalos |
| Major heart defects | About 50–80% | Higher with outflow tract views; fetal echo adds more |
| Cleft lip | About 70–80% | Isolated cleft palate is rarely seen |
| Kidney conditions | About 80–90% | Some dilatation appears only later |
| Limb reduction defects | About 50–70% | Fingers and toes are hard to count reliably |
Why the timing matters
Before 18 weeks the heart and parts of the brain are small and harder to assess. After 22 weeks the bones become denser and cast shadows, and the time available for further testing becomes shorter. Booking within the window, ideally at 19 to 20 weeks, gives clear views with time to spare.
Timing also matters legally. Under the MTP (Amendment) Act 2021, termination for a substantial fetal abnormality beyond 24 weeks needs the approval of a state medical board. A scan at 18–22 weeks leaves room for further tests, counselling and a considered decision if a serious condition is found.
If the baby is lying in a position that hides an important view, you may be asked to walk, change position or come back later the same day or within one to two weeks. This happens in a fair proportion of scans, particularly with a raised body mass index, and does not mean anything is wrong.
Soft markers: small findings that are usually harmless
A soft marker is a minor variation seen in many healthy babies, such as a bright spot in the heart (echogenic focus), a choroid plexus cyst in the brain, mildly dilated kidneys or a single umbilical artery. On their own, with a low-chance earlier screening result, most change the overall risk very little.
Choroid plexus cysts, for example, are seen in about 1 to 2% of babies and usually disappear by 28 weeks without any effect on the brain or development.
A few markers carry more weight, such as a thickened nuchal fold, an absent or small nasal bone, or mildly enlarged brain ventricles. In these cases further counselling, NIPT or a diagnostic test may be offered. You will be told plainly whether a finding matters.
An isolated soft marker after a low-chance NT or NIPT result rarely needs invasive testing.
If a structural finding is seen
You will be told what the finding is, how certain the diagnosis is, and what it could mean for the baby before and after birth. Some findings, such as mild kidney dilatation, are monitored and often resolve. Others, such as a cleft lip, are treatable after birth with surgery, and the baby can usually feed with support in the meantime.
A few findings are serious and may affect the baby’s survival or long-term health. In these situations you are given time, written information and, where you wish, a second opinion, so that any decision is made calmly and within the time frames allowed by Indian law.
Depending on the finding, next steps may include a fetal echocardiogram, genetic testing by amniocentesis with microarray, an MRI in selected brain conditions, repeat scans, and a meeting with the neonatologist or paediatric surgeon. Where needed, delivery is planned at a centre with the right specialist support.
What the scan cannot do
No scan finds every condition. Some heart defects, bowel blockages, brain changes and skeletal conditions only develop or become visible later in pregnancy, and many genetic conditions, including autism and most learning difficulties, cannot be seen on ultrasound at all.
Ultrasound images also depend on conditions on the day. A normal report means no major structural problem was seen, not that every possible condition has been excluded.
After the scan: follow-up and future pregnancies
Most women need no further scan for the anatomy after a normal anomaly scan. A repeat is advised if a view was incomplete, if the placenta was low-lying (rechecked at about 32 weeks), if a marker such as mild kidney dilatation needs follow-up at 28–32 weeks, or if your pregnancy is high risk and needs growth scans in the third trimester.
If a structural condition was found, the chance of it happening again depends on the cause. Many isolated conditions, such as a single heart defect or cleft lip, carry a recurrence chance of around 2 to 5%, while genetic conditions may carry up to 25% or more. Folic acid at 5 mg before the next pregnancy is advised after a neural tube defect, and a pre-pregnancy visit allows a plan with an early scan at 12–16 weeks.
At Divine Women’s Hospital, the anomaly scan report becomes part of your pregnancy file, so the consultant who sees you at later antenatal visits and in labour already knows the findings.
A note on the PCPNDT Act
Pre-natal sex determination is prohibited in India under the PCPNDT Act. The sex of the baby is not detected or disclosed at any scan.
Your care, step by step
- Book for 18–22 weeksYour appointment is timed from the dating scan. Bring earlier scan reports, NT and NIPT results and prescriptions.
- History reviewYour history, medicines and earlier results are checked so any specific concerns are targeted during the scan.
- Systematic scanEach organ system is checked in order using a structured checklist, usually over 30 to 60 minutes.
- ExplanationImages are reviewed with you and any finding is explained in plain language, in Gujarati, Hindi or English.
- Report and planYou receive a written report, and any further scan, echo or test is booked before you leave.
When to book a visit
- You are 18 to 22 weeks pregnant (every pregnancy should have this scan)
- Your NT, double marker or NIPT result was higher chance
- You have diabetes, or took medicines such as anti-epileptics in early pregnancy
- A previous baby had a structural condition
- An earlier scan suggested a finding that needs a closer look
- You and your partner are blood relatives
Warning signs - get same-day care
- Vaginal bleeding of any amount in the second trimester
- A gush or steady trickle of fluid from the vagina
- Regular tightenings or period-like cramps before 37 weeks
- Severe headache, blurred vision or sudden swelling of the face and hands
- Fever above 38 °C with abdominal pain
Labour and emergency care are available 24 × 7. Call the hospital and come in directly.
Myths and facts
Myth: A 3D or 4D scan is more thorough than the anomaly scan.
Organs are assessed and measured in 2D. 3D is an add-on for specific questions, such as the face or spine, not a replacement.
Myth: The anomaly scan can confirm the baby has no genetic problem.
Many chromosomal and genetic conditions look normal on ultrasound. Screening and diagnostic genetic tests answer that question.
Myth: Being asked to come back means something is wrong.
A repeat visit is usually because the baby was lying in an awkward position, which is very common.
Myth: Too many scans can harm the baby.
Medically indicated scans, done within standard ultrasound safety settings, have no proven harmful effect on the baby’s development.
Frequently asked questions
What is the difference between a level I and level II scan?
A level I scan checks heartbeat, size, position, placenta and fluid. A level II scan adds a systematic organ-by-organ assessment of the baby’s structure, and is recommended for every pregnancy at 18–22 weeks.
What is the right week for the anomaly scan?
Between 18 and 22 weeks. Around 19 to 20 weeks often gives a good balance of clear views and time for any follow-up tests.
Is the anomaly scan the same as a TIFFA scan?
Yes. TIFFA stands for targeted imaging for fetal anomalies and is another name for the detailed mid-pregnancy anomaly scan.
Can the anomaly scan detect Down syndrome?
Not reliably. Some babies with Down syndrome show markers or heart differences, but around half look normal on scan. NT screening or NIPT, and CVS or amniocentesis, are the reliable routes.
What is an echogenic focus in the heart?
It is a small bright spot in a heart chamber, seen in about 3 to 5% of healthy babies. On its own, after low-chance screening, it is considered a normal variant and does not affect heart function.
What does a low-lying placenta on the anomaly scan mean?
At 20 weeks the placenta is often near the cervix and usually moves up as the uterus grows. A repeat scan at about 32 weeks checks its position.
Is a full bladder needed for the anomaly scan?
No. A full bladder is not needed and can make you uncomfortable during a longer scan. Eat normally before you come.
Can I bring my husband or family?
Yes, one support person is welcome in the scan room. If possible, arrange for young children to stay at home so you can concentrate on the explanation.
Can the anomaly scan be done at 24 weeks?
Yes, a detailed scan can still be done, though bones cast more shadows and some views are harder. Under the MTP (Amendment) Act 2021, decisions after a serious finding have time limits, so booking within 18–22 weeks is wiser.
Will I need another scan later?
Not always. Further scans are advised for growth concerns, placental position, fluid, a finding that needs follow-up, or a high-risk pregnancy.