Antenatal ultrasound cannot detect all congenital Anomalies: Clinical limitations, India-specific barriers, and medicolegal perspectives.

Background: Antenatal ultrasound is central to prenatal screening, enabling early detection of many congenital anomalies. However, its diagnostic accuracy is limited, especially for subtle, complex, or late-onset fetal abnormalities. In India, additional systemic, infrastructural, and legal factors further restrict its effectiveness. Objectives: To review the diagnostic limitations of prenatal ultrasound, highlight India-specific barriers to anomaly detection, and examine medico-legal perspectives, including landmark court rulings on alleged negligence. Methods: This article synthesizes global and Indian data on anomaly detection rates, analyzes categories of commonly missed anomalies, and reviews relevant Indian legal cases, including Supreme Court judgments. The policy implications of the PCPNDT Act are also critically discussed. Results: Ultrasound detects 50-70 % of major anomalies in ideal settings, but many conditions-such as cardiac defects, skeletal dysplasias, orofacial defects ( Cleft lip, Cleft palate etc) and limb abnormalities-remain undiagnosed. India-specific challenges include operator variability, delayed antenatal care, equipment disparities, and regulatory hurdles under the PCPNDT Act. Indian courts consistently require expert testimony to establish negligence and have ruled in favor of clinicians when standard protocols were followed. Conclusion: Missed anomalies on antenatal ultrasound typically reflect known technical and systemic limitations, not medical negligence. Indian jurisprudence has set a clinician-protective precedent when standard care is provided. Counseling, documentation, and legal awareness remain key to mitigating risk. Policy reforms should promote ethical ultrasound use while safeguarding both patient access and provider protection.