Raj Sonography &\nX- Ray Clinic, Baiju Choraha, Nayapura, Guna, Madhya Pradesh, India. <\/p>\n\n\n\n
Short Title:<\/strong> Trimester Specific\nColour Doppler Study<\/p>\n\n\n\n *Corresponding\nAuthor: Lalit K Sharma, MD, Raj Sonography & X- Ray Clinic, Baiju Choraha,\nNayapura, Guna, Madhya Pradesh, India E-mail : drlksharma_guna@yahoo.co.in<\/a><\/strong><\/p>\n\n\n\n Keywords: Doppler\nUltrasound, Pre-eclampsia, Fetal Growth Restriction, Delay, Perinatal Care Established Facts and Novel Insights<\/strong><\/p>\n\n\n\n Established Facts<\/strong><\/p>\n\n\n\n Novel Insights <\/strong><\/p>\n\n\n\n Introduction: India has a high\nperinatal mortality rate that can be attributed in part to the models of delay\ninfluencing perinatal care. Integrating Colour Doppler Studies with routine\ntrimester specific ultrasound exams can help reduce delays optimizing perinatal\ncare <\/p>\n\n\n\n Case Presentation : A pregnant\nwoman presenting at 12 weeks of gestation was identified as being at high risk\nfor preterm preeclampsia (PE) and started on low dose aspirin 150mg once daily\nat bedtime to be continued till 36 weeks or delivery or onset of PE, whichever\nis earlier. At 32 gestation weeks, she was identified with Stage 1 fetal growth\nrestriction (FGR) based on Doppler studies and advised weekly follow up. At 35 gestation weeks, Doppler studies\nindicated Stage 3 FGR and early onset fetal acidemia. The woman was referred to\na tertiary care center for immediate childbirth and delivered a live baby\nweighing 1700 gms by a cesarean section.<\/p>\n\n\n\n Discussion\/Conclusion. Colour Doppler studies helped optimally initiate low dose aspirin early in the 1st<\/sup> trimester. Colour Doppler studies 3rd<\/sup> trimester helped the early identification of FGR and\u00a0 initiate weekly follow up as opposed to routine follow up after 4 weeks, \u00a0\u00a0identify early the progress to stage 3 FGR and fetal acidemia\u00a0 and recommend immediate childbirth.\u00a0\u00a0 This fetus may not have survived if the routine schedule for ultrasound exam during the 3rd<\/sup> trimester was followed. <\/p>\n\n\n\n <\/strong><\/a>Introduction<\/strong><\/p>\n\n\n\n India has a high perinatal mortality rate, 36\nper 1000 pregnancies, as reported by the National Family Health Survey-4\n(NFHS-4) of India .[1] NFHS-4 reported a still birth rate of 0.7% and a\nneonatal mortality rate of 30 per 1000 live births in India, and a birth weight\n<2500 grams in 18.2% of live births.[1] \nPreterm births and low birth\nweight are the major causes (41.77%) of neonatal deaths in India.[2] The\nmaternal mortality ratio in India was reported as 130 per 100,000 live births\nin 2014-16 [3]. The NFHS-4 reported that only 58.6% pregnant women had at least\none antenatal care visit in the 1st trimester of pregnancy and only 61% of all\npregnancies had received at least one ultrasound exam during pregnancy.[1] <\/p>\n\n\n\n Thaddeus and Maine introduced the Three Delays\nframework, in 1991, to describe obstacles that lead to maternal death [4].\nMaternal death can result from the delay: (1) to seek appropriate medical help\nfor an obstetric emergency; (2) to reach an appropriate obstetric facility; and\n(3) to receive adequate care at the facility. [5,6,7,8,] Pacagnella, et al, critiqued\nthe Three Delays model for its inability to consider underlying factors that\ncontribute to maternal death and lack of consideration for preventative care\nthat reduces maternal mortality [6]. A fourth delay related to community\nfactors [6,9] was recommended as an addition to the 3 delay model.<\/p>\n\n\n\n In this case, we discuss the impact of\nintegrating colour Doppler Studies with routine trimester specific ultrasound\nexams on the 4 delay model and illustrate how it may help reduce perinatal mortality\nin India. <\/p>\n\n\n\n Case Report<\/strong><\/p>\n\n\n\n A pregnant woman presented to us at 12 weeks of\ngestation for routine 1st<\/sup> trimester ultrasound exam. The woman was\nscreened using a combined screening protocol [10] that incorporated clinico-demographic\ndetails like age, parity, body mass index, family history of PE, history of PE\nin previous pregnancies, inter-pregnancy interval, use of assisted reproductive\nconception, comorbid conditions especially diabetes mellitus, chronic\nhypertension, systemic lupus erythematosus and anti-phospholipid syndrome. Two\nreadings of the systolic and diastolic blood pressure in both arms were taken\nsimultaneously using validated digital instruments and determination of the\nmean arterial pressure was done using a standardized protocol. Ultrasound scan\nfor dating of pregnancy and fetal biometry was done through a transabdominal\napproach, and Colour Doppler study of the right and left uterine arteries and\ndetermination of the mean uterine artery PI was carried out. A sagittal section\nof the uterus was obtained and the cervical canal and internal cervical os were\nidentified. Subsequently, the transducer was gently tilted to the side in the\nmidline and colour flow mapping was used to identify each uterine artery along\nthe side of the cervix and uterus at the level of the internal os. Pulsed\u2010wave\nDoppler was used with the sampling gate set at 2 mm to cover the whole vessel\nand care was taken to ensure that the angle of insonation was less than 30\u00b0.\nWhen three similar consecutive waveforms were obtained, the Uterine artery PI\nwas measured and the mean Uterine Artery PI of the left and right arteries was\ncalculated. Biochemical markers were not assessed. <\/p>\n\n\n\n The woman was determined to be at high risk for\nthe development preterm PE based on the combined screening protocol algorithm [10]\nand is used globally to determine risk estimates for preterm PE based on a\npriori risk factors and based on a 1 in 150 cutoff. The risk calculator is\navailable free of charge at\nhttps:\/\/fetalmedicine.org\/research\/assess\/preeclampsia. Consistent with current\nevidence based recommendations for the management of pregnant women at high\nrisk for preterm PE, the woman was advised low dose aspirin at 150mg once daily\nat bedtime to be continued till 36 gestation weeks.<\/p>\n\n\n\n The pregnant woman was initially reluctant to\nstart low dose aspirin but started the schedule after repeated counselling in alignment\nwith the managing obstetrician. She was advised follow up Doppler and\nultrasound exams at 22, 26 and 30 weeks of gestation but did not come for the\nfollow up exams. After repeated telephonic contact and counselling over the\ntelephone, she came for the repeat ultrasound exam at 32 weeks. <\/p>\n\n\n\n Doppler and ultrasound exams at 32 weeks showed\na live fetus with Stage 1 FGR. The estimated fetal weight (EFW) was 1 centile\nand Abdominal circumference was 11th<\/sup> centile. Umbilical Artery\nDoppler PI was 96th<\/sup> centile, the middle cerebral artery Doppler PI\nwas 1 centile and the Cerebro-Placental ratio was 1 centile. She was advised\nweekly follow up for repeat exams and monitoring of the health of the fetus. The pregnant woman and her family were\nreluctant for weekly exams but provided consent after counselling. The status\nof the fetus remained unchanged till 34 weeks of gestation. <\/p>\n\n\n\n At 35 weeks of gestation, Doppler study showed absent end diastolic velocity\nin the umbilical artery and EFW 0 centile with normal liquor. The Ductus\nVenosus was explored and the PI was 99th<\/sup> centile. The\nclinico-demographic and Doppler parameters were assessed using the Barcelona\nalgorithm available online and the fetus was determine to have progressed to\nStage 3 FGR with early acidemia. <\/p>\n\n\n\n She was advised administration of antenatal corticosteroids for fetal maturity and\nreferral to a tertiary care center for immediate delivery. The family were\nreluctant to plan for immediate childbirth but agreed after repeated\ncounselling and explanation of the Doppler study findings. <\/p>\n\n\n\n Communication was established with the managing\nobstetrician at the tertiary care center and details of the Doppler and\nultrasound exams were shared. A caesarean section was done for immediate\nchildbirth and a live baby weighing 1700 grams was delivered. The child was\nlive and healthy a week after delivery. <\/p>\n\n\n\n Discussion<\/strong><\/p>\n\n\n\n This case highlights the importance of using a\ncombined screening protocol to estimate the risk for preterm preeclampsia and\nfetal growth restriction in the 1st trimester integrating colour Doppler\nstudies with routine ultrasound exam. In the 3rd<\/sup> trimester, the\nintegration of colour Doppler studies aids in the early identification and\nmonitoring of the progress of FGR guiding decision making pertaining to\nchildbirth. This case highlights the impact the screening, staging, and\nmonitoring protocols and the potential impact of the 4 delay model on perinatal\nmortality rates.<\/p>\n\n\n\n The three delay model of Thaddeus and Maine [4]\nidentified the three delays as a) delay to seek care, b) delay to reach help\nand c) delay to receive adequate help. The fourth delay [6,9] was added later\nand identified as related to community factors. The four delays, in isolation\nor in combination, contribute significantly to maternal death and are usually\ninterlinked. Previous studies have reported that most maternal deaths occur due\nto the 1st<\/sup> delay (seeking care), however, the third delay (to\nreceive adequate help) is the most significant.[11] Studies have also\nemphasized the need to consider multiparous women, women with little or no\neducation and accessibility of services for the poor and the \u201cdistance-decay\u201d\nphenomenon in reaching services.[8] Studies have shown that pregnant women\nin vulnerable settings often lacked a certain awareness of their healthcare\nneeds and relied on their partner\u2019s\/husband\u2019s and\/or mother\u2019s advice regarding\nseeking care. [12] The four delay model is built on a framework is underpinned\nby Social Constructivism and overlaps with theories of empowerment,\nparticipatory communication, social change, socio-ecology and public health. <\/p>\n\n\n\n The first to fourth delays are influenced by\nthe socioecological determinants including knowledge, age, economic status, and\nsocial support. [9] The resources of the family and the community and its\nengagement and willingness to allocate or reallocate resources can also impact\nthe delays. [9] These also include the availability of human and natural\nresources, transport facilities and good roads within the community and the infrastructure to\naccess them. Family and Community resourcefulness also plays a role in the\nsocioecological determinants of maternal health. <\/p>\n\n\n\n The integration of a combined screening\nprotocol incorporating colour Doppler Studies with routine trimester specific\nultrasound exams can help early identification of problems and partly address the\nfirst delay of seeking care as well as the 3rd<\/sup> delay of receiving adequate and appropriate help. In\nthis case, we want to highlight the importance of the fourth delay. In this\ncase, we had to repeatedly counsel the\nwoman and her family to start prophylactic low dose aspirin and to return for follow\nup exams. Despite repeated counselling on the need for follow up exams, the\nwoman missed the entire 2nd<\/sup> trimester of screening. Several rounds\nof counselling were required for the woman to return for the 3rd<\/sup>\ntrimester exam and to continue screening protocols once she was identified with\nStage 1 FGR. Part of the reluctance to continue with the screening protocols\nwas its relative \u201cnewness\u201d; other members of the family did not recollect being\nfollowed up in this manner. Additionally, the woman looked healthy externally\nand hence there was a reluctance to believe something may affect the fetus and\na doubt whether commercial considerations were overriding the recommendations\nfor follow up exams. Once stage 3 FGR was identified, the woman had to be\nreferred to a tertiary care facility approximately 180 kms away, necessitating\nthe family to allocate resources for transport and stay. Fortunately, the\nfamily was convinced and made the effort to reach the tertiary care center. We\ndiscussed the case with the obstetrician at the tertiary care center\nemphasizing on the Doppler findings suggestive of early acidemia setting in and\na decision for immediate childbirth by a cesarean section after clinical\nexamination was made.<\/p>\n\n\n\n The\nroutine schedule for 3rd<\/sup> trimester ultrasound at 32 weeks, when\nfetal biometry and growth is normal, is to recommend a follow up screening\nafter 4 weeks. In this case, the fetus biometrics were normal but Doppler\nidentified the early onset of FGR. This\nallowed the initiation of a weekly follow up protocol that helped early\nidentification of the progress to stage 3 FGR. [13] The baby was delivered\nbefore the 36th<\/sup> week when the routine follow up may have been\nscheduled if recommendations were based without integrating colour Doppler\nfindings. It is possible that this fetus may not have survived till then or may\nhave developed neonatal consequences from acidemia.<\/p>\n\n\n\n This case highlights that integrating colour Doppler Studies with routine trimester specific ultrasound exams as part of a combined screening protocol can positively influence the delays influencing perinatal outcomes. Repeated counselling and communication with the pregnant woman, her family and other stakeholders in her health care is essential to ensure optimal <\/a>care.<\/a> Raj Sonography & X- Ray Clinic, Baiju Choraha, Nayapura, Guna, Madhya Pradesh, India. Short Title: Trimester Specific Colour Doppler Study *Corresponding Author: Lalit K Sharma, MD, Raj Sonography & X- Ray Clinic, Baiju Choraha, Nayapura, Guna, Madhya Pradesh, India E-mail : drlksharma_guna@yahoo.co.in Keywords: Doppler Ultrasound, Pre-eclampsia, Fetal Growth Restriction, Delay, Perinatal Care Established Facts and […]<\/p>\n","protected":false},"author":1,"featured_media":2899,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[16],"tags":[],"class_list":["post-2897","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-case-reports"],"_links":{"self":[{"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/posts\/2897","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2897"}],"version-history":[{"count":8,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/posts\/2897\/revisions"}],"predecessor-version":[{"id":2991,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/posts\/2897\/revisions\/2991"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/media\/2899"}],"wp:attachment":[{"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2897"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=2897"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=2897"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
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\nAbstract<\/strong><\/strong><\/p>\n\n\n\n
<\/strong><\/p>\n\n\n\nReferences <\/h6>\n\n\n\n