Around week 20, your baby is roughly as long as a banana, and the organs are developed enough to be looked at closely on ultrasound. Here you can read what is checked at the 20 week anomaly scan, how it differs from a routine ultrasound, when health insurance in Germany pays for it, how reliable the results are and what happens if something is found.
What is an anomaly scan?
The detailed anomaly scan is a thorough ultrasound in which the unborn baby's organs are examined step by step. Other names are 20 week scan, mid-pregnancy scan, detailed anatomy scan, level 2 ultrasound, fetal anomaly scan or second trimester screening. In the language of the German maternity guidelines (Mutterschafts-Richtlinien), it is called a further differential diagnostic ultrasound examination (G-BA 2026).
The scan is done by obstetricians and gynaecologists who specialise in prenatal medicine, usually with a level II or III qualification from the German Society for Ultrasound in Medicine (DEGUM). They often work in prenatal diagnosis practices or perinatal centres.
When is the 20 week scan done?
Usually between weeks 20 and 22 of pregnancy, and some practices scan from week 18. Earlier, some organs are still too small. Later, the bones make the view worse and there is less time left for further tests. The due date calculator shows your current week, and the pages on week 20 and week 21 show what happens during this time.
Ultrasound scans in pregnancy: what happens when
- 1st basic ultrasoundweeks 9 to 12 · Insurance pays (DE)
- First trimester screeningweeks 11 to 14 · Usually self-pay (DE)
- 2nd basic or extended basic ultrasoundweeks 19 to 22 · Insurance pays (DE)
- Detailed anomaly scanweeks 20 to 22 · Insurance pays if medical reason (DE)
- 3rd basic ultrasoundweeks 29 to 32 · Insurance pays (DE)
Insurance pays (DE)Insurance pays if medical reason (DE)Usually self-pay (DE)
Book an appointment early, ideally right after your first scan. Specialist practices are often booked up weeks in advance.
Basic ultrasound, extended ultrasound or anomaly scan?
In routine antenatal care in Germany, you are entitled to one basic ultrasound in each trimester with your gynaecologist: in weeks 9 to 12, 19 to 22 and 29 to 32. For the second one, you can choose between the basic ultrasound and the extended basic ultrasound. Health insurance pays for both (G-BA 2026).
| Basic ultrasound | Extended basic ultrasound | Detailed anomaly scan | |
|---|---|---|---|
| When | weeks 19 to 22 | weeks 19 to 22 | usually weeks 20 to 22 |
| Who | your gynaecology practice | gynaecology practice with an extra qualification | specialist, usually DEGUM II or III |
| What | head, abdomen and thigh bone measured, position of the placenta | also head and brain ventricles, cerebellum, neck and back, heart with four chambers, abdominal wall, stomach, bladder | all organs systematically, including the face, heart valves and major vessels, kidneys, arms, legs, umbilical cord, often Doppler |
| Duration | a few minutes | a little longer | about 30 minutes or longer |
| Cost in Germany | health insurance | health insurance | health insurance if there is a medical reason, otherwise you pay |
So the extended basic ultrasound is a smaller organ check. The detailed anomaly scan goes much further: it looks at each organ specifically, with better equipment and more time.
Anomaly scan: what do they check?
The scan follows a fixed scheme, as described by the international professional society ISUOG (Salomon 2022):
- Head and brain: shape of the skull, brain ventricles, cerebellum, midline
- Face: lips and upper jaw, to detect a cleft lip and palate, eye sockets, profile
- Neck and spine: vertebrae in long and cross section, skin over the back, to detect spina bifida
- Chest and lungs: size, diaphragm
- Heart: position, size, four chambers, heart valves, where the major vessels leave the heart, heart rhythm
- Abdomen: stomach, bowel, liver, abdominal wall with the umbilical cord insertion
- Kidneys and bladder
- Arms, legs, hands and feet
- Umbilical cord: number of vessels
- Placenta and amniotic fluid: position of the placenta, amount of amniotic fluid
- Growth: head circumference, abdominal circumference, thigh bone length, estimated weight
Depending on the reason for the scan, a Doppler scan of the blood vessels and a measurement of the cervix may be added. The baby's sex can usually be seen clearly. Say at the start whether you want to know or not.
What happens at the appointment
- Talk: your medical history, the reason for the scan, information about the examination. You decide what you want to know.
- Ultrasound over the bump: you lie on a couch and gel is put on your tummy. If the baby is in an awkward position, you may be asked to move around a little, have a drink or go for a short walk.
- Discussion: the doctor explains the results to you straight after the scan. You get a report for your gynaecology practice and your maternity record (Mutterpass).
Bring your maternity record and earlier results. A full bladder is usually not needed, but check with your practice beforehand. Most practices are happy for you to bring someone with you.
When does health insurance pay for the anomaly scan?
In Germany, statutory health insurance pays for the detailed anomaly scan if there is a medical reason. Under the maternity guidelines, this means an increased risk of malformations or illness in the baby because of (G-BA 2026):
- abnormal or unclear findings in an earlier ultrasound
- abnormal lab results
- inherited conditions or malformations, or ones that run in the family
- harmful influences in pregnancy, such as certain medicines or infections
- as an alternative to amniocentesis or chorionic villus sampling
Diabetes, twins or more, or a high-risk pregnancy are also common reasons for a referral. Your gynaecologist writes the referral.
Without a medical reason, the anomaly scan is a self-pay service in Germany (IGeL). A report by the German Press Agency quoted 200 to 300 euros (dpa 2019). The price is based on the German fee schedule for doctors and varies by practice and effort. The practice must tell you the cost in writing beforehand (Verbraucherzentrale). Some health insurers voluntarily cover part of it, so ask before your appointment.
Private health insurance in Germany often pays for the anomaly scan, depending on your plan.
How reliable is the anomaly scan?
No ultrasound finds everything. Some malformations are clearly visible, such as spina bifida or a missing top of the skull. Others, such as small heart defects, malformations of the hands and feet or conditions that only develop later, are missed more often. How well the scan works depends on the baby's position, the amount of amniotic fluid, the abdominal wall, the equipment and the experience of the person scanning (G-BA 2026).
Two kinds of error are possible: a finding looks abnormal although the baby is healthy, or the ultrasound looks normal although the baby has a malformation. According to international figures, about 1 in 100 pregnant women can expect a wrong result (G-BA 2026).
Congenital heart defects are the most common malformations: about 9 in 1,000 babies are born with a heart defect, which is just under a third of all major congenital malformations (van der Linde 2011). An experienced eye is especially worthwhile for the heart, because some heart defects need treatment straight after birth.
As far as we know today, ultrasound does not harm you or your baby (G-BA 2026).
What happens if something is found?
Most scans are normal. If something shows up, it does not automatically mean your baby is ill. Often these are small findings, called soft markers, which are usually harmless and often disappear. Possible next steps:
- Follow-up ultrasound after a few weeks
- Ultrasound of the heart (fetal echocardiography) by specialists
- Blood test for trisomies (NIPT) or amniocentesis, if a genetic cause is possible
- Counselling with paediatricians, paediatric surgeons or clinical geneticists
- Planning the birth in a perinatal centre so your baby can be treated straight away
In Germany, if a finding is abnormal, you are entitled to detailed medical counselling and free psychosocial counselling at a pregnancy counselling centre. You do not have to make any decision straight away.
Anomaly scan: yes or no?
You have the right to decline some or all ultrasound scans, or not to be told certain results (G-BA 2026). In favour of the anomaly scan: some malformations can be treated better if they are known before birth, and the birth can then be well planned. Many parents are reassured by a normal result. Against it: abnormal or unclear findings can cause worry and lead to difficult decisions.
A helpful question is: what would I do with the result? Talk about it with your midwife or doctor and, if you like, with a counselling service.
Early anomaly scan and first trimester screening
An early organ scan is already possible between weeks 12 and 14, often together with first trimester screening. This includes measuring the nuchal translucency to estimate the risk of trisomies. In Germany, this test falls under the Genetic Diagnosis Act and requires special counselling beforehand (G-BA 2026). It does not replace the anomaly scan around week 20, because many organs are still too small at that stage. First trimester screening can also be used to calculate the risk of pre-eclampsia.
After fertility treatment or a pregnancy over 40, many practices recommend the anomaly scan, but you do not automatically get a referral for it.
Frequently asked questions
Should I have an anomaly scan?
That is your decision. If there is a medical reason, it makes sense and is paid for. Without a reason, it can give extra reassurance, but it does not find every malformation (G-BA 2026).
When is the anomaly scan done?
Usually between weeks 20 and 22, and in some practices from week 18.
What happens at the 20 week scan?
At the basic ultrasound, the head, abdomen and thigh bone are measured and the position of the placenta is checked. The extended basic ultrasound also looks at the brain, back, heart, abdominal wall, stomach and bladder (G-BA 2026). The detailed anomaly scan examines all organs thoroughly.
What happens at the third scan?
At the third basic ultrasound in weeks 29 to 32, the head, abdomen and thigh bone are measured, and the baby's position and heartbeat are checked (G-BA 2026).
How long does the anomaly scan take?
Usually about half an hour, sometimes longer if the baby is in an awkward position.
Does the 20 week scan hurt?
No. The ultrasound probe is moved over your bump, which can feel a little uncomfortable when it presses.
Can you see the baby's sex at the anomaly scan?
Usually yes. Say beforehand whether you want to know.
Can the anomaly scan detect Down's syndrome?
Not reliably. Some babies with trisomy 21 (Down's syndrome) show signs on ultrasound, but many do not. A blood test or amniocentesis is more reliable.
Sources
Guidelines and fact sheets
- Mutterschafts-Richtlinien mit Merkblatt zum Ultraschall (German maternity guidelines with ultrasound information leaflet), Federal Joint Committee (G-BA), as of 2026
- Salomon LJ, Alfirevic Z, Berghella V et al.: ISUOG Practice Guidelines (updated): performance of the routine mid-trimester fetal ultrasound scan, Ultrasound Obstet Gynecol 2022;59:840-856
- 20-week screening scan, NHS
- Was kosten Individuelle Gesundheitsleistungen (IGeL)?, Verbraucherzentrale
- Vorsorgeuntersuchungen: Der Blick auf das Ungeborene, dpa, 24.10.2019
Studies
