{"id":2901,"date":"2019-11-14T01:06:19","date_gmt":"2019-11-14T01:06:19","guid":{"rendered":"http:\/\/cms.firststepmart.com\/?p=2901"},"modified":"2019-11-17T04:29:06","modified_gmt":"2019-11-17T04:29:06","slug":"importance-of-colour-doppler-studies-in-the-3rd-trimester-of-pregnancy-for-early-identification-of-fetal-growth-restriction","status":"publish","type":"post","link":"https:\/\/fetalradiology.co.in\/?p=2901","title":{"rendered":"Importance of Colour Doppler studies in the 3rd trimester of pregnancy for early identification of fetal growth restriction."},"content":{"rendered":"\n<p><sup>1<\/sup>Raj\nSonography &amp; X- Ray Clinic, Baiju Choraha, Nayapura, Guna, Madhya Pradesh,\nIndia.&nbsp;<\/p>\n\n\n\n<p><strong>Short Title:<\/strong> Colour Doppler Study for FGR<\/p>\n\n\n\n<p>*Corresponding Author: Lalit K Sharma, MD, Raj\nSonography &amp; X- Ray Clinic, Baiju Choraha, Nayapura, Guna, Madhya Pradesh,\nIndia E-mail : <strong><a href=\"mailto:drlksharma_guna@yahoo.co.in\">drlksharma_guna@yahoo.co.in<\/a><\/strong><\/p>\n\n\n\n<p>Keywords: Doppler Ultrasound, Fetal Growth Restriction, Perinatal Care&nbsp;<br><\/p>\n\n\n\n<p><strong>Established\nFacts and Novel Insights<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Established\nFacts<\/strong><\/li><\/ul>\n\n\n\n<p>Prenatal\nidentification of small-for-gestational age (SGA) babies results in a reduction\nof adverse perinatal outcomes and stillbirth.<\/p>\n\n\n\n<p>Most\ninstances of avoidable stillbirth are related with a failure to detect SGA in\nthe antenatal period<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Novel\nInsights<\/strong><\/li><\/ul>\n\n\n\n<p>Integrating colour Doppler studies with 3rd trimester ultrasound exams can help early identification of FGR. Doppler studies of the Cerebro-Placental ratio and mean Uterine Artery PI combined with estimates of fetal weight\u00a0 provide better risk estimates of FGR than isolated umbilical artery Doppler studies <strong><br> <br> Abstract<\/strong><\/p>\n\n\n\n<p>Introduction: Fetal\ngrowth restriction (FGR) and Small for Gestational Age (SGA) babies are major\ncauses for preterm births and low birth weight, and consequently perinatal\nmortality in India. Integrating colour Doppler Studies with routine 3<sup>rd<\/sup>\ntrimester ultrasound exams can help early identification of FGR and guide\nmanagement<\/p>\n\n\n\n<p>Case presentation: <\/p>\n\n\n\n<p>We present two cases\nwith the same gestational age (34+6 weeks) and almost similar estimated fetal\nweight percentiles (18<sup>th<\/sup> and 19<sup>th<\/sup>) respectively . All\nDoppler indices were normal for one fetus while the other fetus showed abnormal\nDoppler indices for &nbsp;mean Uterine artery\nPI, Middle Cerebral artery, Cerebro-Placental ratio and Umbilical artery PI. The\nfetus with abnormal Doppler indices was classified as Stage 1 FGR and\nrecommended weekly follow ups while the other fetus with similar estimated\nfetal weight percentiles and normal Doppler was recommended follow up as per\nroutine schedules.<\/p>\n\n\n\n<p>Conclusion: The onset of\nStage 1 FGR was picked up only by the integration of colour Doppler studies and\nwill have been missed if only estimated fetal weight was considered.<\/p>\n\n\n\n<p><strong>Introduction<\/strong><\/p>\n\n\n\n<p>India has a high perinatal mortality\nrate.[1] Preterm births and low birth weight are major drivers of the high\nperinatal mortality rate in India. [1] Fetal growth restriction (FGR) is a\nmajor cause for preterm births and low birth weight in India and consequently\nperinatal mortality. [1]\n\n\n\n<p>&nbsp;Detection of FGR is important as these fetuses\nhave poor perinatal outcomes in the short term including perinatal death, fetal\ndistress and neurological injury and long term implications on health during\nadulthood. [2-7] Early identification and staging of FGR helps customize follow\nup schedules and appropriate planning regarding the timing and mode of\nchildbirth and subsequent neonatal care. Colour Doppler studies have a very\nimportant role in the management of FGR. We will discuss the importance of each\nof these parameters in this case presentation.<\/p>\n\n\n\n<p><strong>Case Report\/Case Presentation<\/strong><strong><\/strong><\/p>\n\n\n\n<p>The important details of the two\ncases are summarized in Table-1.<\/p>\n\n\n\n<p>Table-1: Comparison of important Doppler\nand clinical parameters of the two cases in the 3<sup>rd<\/sup>&nbsp; trimester<\/p>\n\n\n\n<table class=\"wp-block-table\"><tbody><tr><td>\n  &nbsp;\n  <\/td><td>\n  Case 1\n  <\/td><td>\n  Case 2\n  <\/td><\/tr><tr><td>\n  GA\n  <\/td><td>\n  34 +6 weeks\n  <\/td><td>\n  34+ 6 weeks \n  <\/td><\/tr><tr><td>\n  Mean\n  Uterine Artery PI\n  <\/td><td>\n  0.99\n  <\/td><td>\n  0.91\n  <\/td><\/tr><tr><td>\n  Mean\n  Uterine artery PI Centile\n  <\/td><td>\n  69\n  <\/td><td>\n  50\n  <\/td><\/tr><tr><td>\n  Middle Cerebral\n  Artery &nbsp;PI\n  <\/td><td>\n  1.20\n  <\/td><td>\n  1.47\n  <\/td><\/tr><tr><td>\n  Middle Cerebral\n  Artery Centile\n  <\/td><td>\n  1\n  <\/td><td>\n  8\n  <\/td><\/tr><tr><td>\n  Cerebro-placental\n  Ratio\n  <\/td><td>\n  1.21\n  <\/td><td>\n  1.61\n  <\/td><\/tr><tr><td>\n  Cerebro-placental\n  Ratio Centile\n  <\/td><td>\n  1\n  <\/td><td>\n  17\n  <\/td><\/tr><tr><td>\n  Umbilical\n  Artery PI\n  <\/td><td>\n  1.38\n  <\/td><td>\n  0.68\n  <\/td><\/tr><tr><td>\n  Umbilical\n  Artery Centile\n  <\/td><td>\n  100\n  <\/td><td>\n  82\n  <\/td><\/tr><tr><td>\n  Estimated\n  Fetal Weight Centile\n  <\/td><td>\n  19\n  <\/td><td>\n  18\n  <\/td><\/tr><tr><td>\n  Inference\n  <\/td><td>\n  Stage 1 FGR\n  <\/td><td>\n  Normal\n  fetus\n  <\/td><\/tr><\/tbody><\/table>\n\n\n\n<p><strong>Discussion<\/strong><\/p>\n\n\n\n<p>This Case presentation aims to\nhighlight several learning points and to discuss the importance integrating\ncolour Doppler Studies with routine 3<sup>rd<\/sup> trimester ultrasound exams .\nThe non integration of colour Doppler studies and reliance only on fetal\nbiometry and estimated fetal weight will have led us to miss the diagnosis of\nStage 1 FGR. This will have limited the opportunity to closely monitor progress\nand potential deterioration in this case. <\/p>\n\n\n\n<p>Late-onset FGR represents the\nmajority (70-80%) of FGR and has a low association with PE. Placental disease\nmay be minimal or mild and the umbilical artery (UA) Doppler may be normal in\nalmost all cases.[8]. However, these cases may show a high association with\nabnormal Cerebro-placental (CPR) values and Middle Cerebral Artery (MCA)\nPI&lt;5, which suggests advanced brain vasodilation suggesting chronic hypoxia,\nmay occur in 25% of late FGR [8]. Although advanced signs of fetal\ndeterioration with changes in the DV are usually not visible in late onset FGR,\nthere remains the possibility of acute fetal decline, fetal distress and\nneonatal acidosis.[9] Late FGR may be unpredictable in its course and can cause\nsevere injury or death without observable late-stage signs as in early FGR\npossibly explained by a very low tolerance of term fetuses to hypoxia, the more\nfrequent presence of uterine contractions at term, and even rapid placental\nfunction failure.[9]\n\n\n\n<p>Umbilical Artery Doppler <\/p>\n\n\n\n<p>Traditionally, the umbilical artery (UA)\nDoppler studies have been relied on to consider a diagnosis of FGR. Meta\nanalysis have provided evidence that UA Doppler can improve mortality rates and\nperinatal outcomes in FGR. [10]&nbsp;However, UA fails to identify mild\nplacental disease that make up the majority of early-onset cases and almost all\nlate-onset FGR. &nbsp;Additionally, SGA, considered to have a &nbsp;normal UA pulsatility index (PI), includes a significantly\nlarge proportion of fetuses with worse perinatal outcomes than normally grown\nfetuses. UA Doppler provides both diagnostic and prognostic information. The\nprogression of UA Doppler patterns to absent or reverse end-diastolic flow\ncorrelates with the risks of injury or death. UA Doppler in high-risk\npregnancies improves perinatal outcomes, with a 29% reduction (2-48%) in\nperinatal deaths [10]. Absent or reversed end-diastolic velocities maybe found on\naverage 1 week before the acute deterioration and may be found in nearly 40% of\nfetuses with acidosis.[11] <\/p>\n\n\n\n<p>Middle Cerebral Artery (MCA) Doppler<\/p>\n\n\n\n<p>MCA provides information about vasodilation\nin the brain, which is a surrogate marker of hypoxia. MCA PI &lt;5th centile is\nassociated with adverse perinatal and neurological outcome and is useful for\nthe identification [8] and prediction [12,13] of adverse outcome among\nlate-onset FGR, independent of UA Doppler. The risk for emergency caesarean section\nfor fetal distress is six times higher in fetuses with abnormal MCA PI compared\nwith SGA fetuses. &nbsp;Late FGRs with\nabnormal MCA PI are also at higher risk for poorer neurobehavioral competence\nat birth and at 2 years of age [12,14].<\/p>\n\n\n\n<p>Cerebroplacental Ratio (CPR)<\/p>\n\n\n\n<p>The CPR is a diagnostic index that improves\nthe sensitivity of UA and MCA &nbsp;as increased\nplacental impedance (UA) is often combined with reduced cerebral resistance\n(MCA). The CPR may already be decreased when the UA or MCA show mild changes that\nare still within normal ranges [15,16]. Abnormal CPR is present in about 25% of\nlate SGA fetuses before delivery and is associated with a higher risk of\nadverse outcome at induction. An abnormal CPR predicts neurobehavioral problems\nat 18 months of age [17]. The anterior cerebral artery-CPR rather than the\nMCA-CPR shows a stronger association, indicating a differential impact of\nregional alterations in cerebral blood flow impedance on development that is\nconsistent with findings in early FGR [18,19].<\/p>\n\n\n\n<p>Ductus Venosus (DV) Doppler<\/p>\n\n\n\n<p>DV is a strong predictor of the\nshort-term risk of fetal death in early-onset FGR. DV flow waveforms become\nabnormal only in advanced stages of fetal compromise [20] and there is a good\ncorrelation of abnormal DV waveform with late-stage acidemia [21]. Absent or\nreversed velocities&nbsp; are associated with\nperinatal mortality independent of GA at delivery [22], with a risk ranging\nfrom 40 to 100% in early-onset FGR [23]. An abnormal DV is an indication to\nrecommend delivery at any GA after completion of steroids. A DV above the 95%\ncentile is associated with higher risks but not as consistently as when atrial\nflow is reverse. Abnormal DV precedes the loss of short-term variability (STV)\nin computerized cardiotocography (cCTG) in a about 50% of cases and is abnormal\n48-72 h before the biophysical profile (BPP) in about 90% of cases [20]. Thus,\nabnormal DV provides a better indication for delivering fetuses in critical\nconditions at very early gestational ages.<\/p>\n\n\n\n<p>Aortic Isthmus Doppler<\/p>\n\n\n\n<p>The aortic isthmus (AoI) Doppler\nreflects there relation between brain impedance and systemic vascular systems\nand is associated with increased fetal mortality and neurological morbidity in\nearly-onset FGR [24]. Reverse AoI flow indicates advanced deterioration.<\/p>\n\n\n\n<p>There is no evidence to support the\nuse of traditional fetal heart rate (FHR) monitoring or \u2018non-stress tests&#8217; in\nFGR fetuses and false positive rates are very high. A main limitation of\nconventional CTG is the subjective interpretation of the FHR. cCTG evaluates\nSTV of the FHR, an aspect that subjective evaluation cannot assess and is\nsensitive to detect advanced fetal deterioration providing a value similar to\nDV reverse atrial flow for the short-term prediction of fetal death.\nBiophysical Profile(BPP) is calculated by combining ultrasound assessment of\nfetal tone, respiratory and body movements, with amniotic fluid index and a\nconventional CTG. However, a high false-positive rate (50%) limits the clinical\nusefulness of the BPP [25]. A meta-analysis [26] showed no significant benefit\nof BPP in high-risk pregnancies. Consequently, whenever Doppler expertise\nand\/or cCTG are available, the incorporation of BPP in management protocols of\nFGR is questionable.<\/p>\n\n\n\n<p>Currently, the best test to\ndifferentiate FGR from SGA is the Doppler cerebroplacental ratio (CPR). CPR reflects\neven mild increases in placental resistance with mild reductions in fetal brain\nvascular resistance and correlates better with adverse outcome [14]. The\nuterine artery Doppler PI (UtA PI) can be abnormal even if UA Doppler is normal\nand predicts a poorer outcome in small fetuses. A very small EFW &lt;3<sup>rd<\/sup>\npercentile is another predictor of poor outcome. Fetuses with an EFW &lt;3<sup>rd<\/sup>\npercentile &nbsp;have a much higher risk of\nadverse perinatal outcome irrespective of the CPR and UtA Doppler indices [27].\nThe risk of adverse perinatal outcomes is increased when any one of CPR, UtA PI\nor EFW &lt;3<sup>rd<\/sup> percentile is abnormal. A recent study reported that\nthe risk of caesarean section for fetal distress or neonatal acidosis was 8% in\ncontrols, 11% when all three parameters &nbsp;CPR,\nUtA PI or EFW &lt;p3 were normal and 36% when any one if these was abnormal [28].<a> <\/a><br><\/p>\n\n\n\n<p><strong>References <\/strong><\/p>\n\n\n\n<ol class=\"wp-block-list\"><li>International Institute for Population Sciences (IIPS) and ICF. 2017. National Family Health Survey (NFHS-4) 2015-16: India. Mumbai: IIPS\u00a0<\/li><li>Lindqvist PG, Molin J: Does antenatal identification of small-for-gestational age fetuses significantly improve their outcome? Ultrasound Obstet Gynecol 2005;25:258-264.<\/li><li>Gardosi J, et al: Maternal and fetal risk factors for stillbirth: population-based study. BMJ 2013;346:f108.<\/li><li>Richardus JH,  Graafmans WC, Verloove-Vanhorick SP, Mackenbach JP; EuroNatal  International Audit Panel; EuroNatal Working Group. Differences in perinatal mortality and suboptimal care between 10 European regions:  results of an international audit. BJOG. 2003 Feb;110(2):97-105.\u00a0 <\/li><li>Larroque B, Bertrais S, Czernichow P, L\u00e9ger J. School difficulties in 20-year-olds who were born small for gestational age at term in a  regional cohort study. Pediatrics. 2001 Jul;108(1):111-5.<\/li><li>Crispi F, Bijnens B, Figueras F, Bartrons J, Eixarch E, Le Noble F,      Ahmed A, Gratac\u00f3s E. Fetal growth restriction results in remodeled and      less efficient hearts in children. Circulation. 2010 Jun      8;121(22):2427-36. doi: 10.1161\/CIRCULATIONAHA.110.937995.\u00a0 <\/li><li>Verkauskiene R, Figueras F, Deghmoun S, Chevenne D, Gardosi J,      Levy-Marchal M. Birth weight and long-term metabolic outcomes: does the      definition of smallness matter? Horm Res. 2008;70(5):309-15.<\/li><li>\u00a0Oros      D, Figueras F, Cruz-Martinez R, Meler E, Munmany M, Gratacos E.      Longitudinal changes in uterine, umbilical and fetal cerebral Doppler      indices in late-onset small-for-gestational age fetuses. Ultrasound Obstet      Gynecol. 2011 Feb;37(2):191-5. <\/li><li>Figueras F, Eixarch E, Meler E, Iraola A, Figueras J, Puerto B, Gratacos E. Small-for-gestational-age fetuses with normal umbilical artery Doppler have suboptimal perinatal and neurodevelopmental outcome. Eur J Obstet Gynecol Reprod Biol. 2008 Jan;136(1):34-8. <\/li><li>Alfirevic Z, Stampalija T, Gyte GM: Fetal and umbilical Doppler ultrasound in high-risk pregnancies. Cochrane Database Syst Rev 2010:CD007529.<\/li><li>Ferrazzi E, Bozzo M, Rigano S, Bellotti M, Morabito A, Pardi G, Battaglia FC, Galan HL. Temporal sequence of abnormal Doppler changes in the peripheral and central circulatory systems of the severely growth-restricted fetus. Ultrasound Obstet Gynecol. 2002 Feb;19(2):140-6. <\/li><li>Eixarch E, Meler E, Iraola A, Illa M, Crispi F, Hernandez-Andrade E, Gratacos E, Figueras F. Neurodevelopmental outcome in 2-year-old infants who were small-for-gestational age term fetuses with cerebral blood flow redistribution. Ultrasound Obstet Gynecol. 2008 Dec;32(7):894-9. <\/li><li>Hershkovitz R, Kingdom JC, Geary M, Rodeck CH. Fetal cerebral blood flow redistribution in late gestation: identification of compromise in small fetuses with normal umbilical artery Doppler. Ultrasound Obstet Gynecol. 2000 Mar;15(3):209-12. <\/li><li>Oros D, Figueras F, Cruz-Martinez R, Padilla N, Meler E, Hernandez-Andrade E, Gratacos E. Middle versus anterior cerebral artery Doppler for the prediction of perinatal outcome and neonatal neurobehavior in term small-for-gestational-age fetuses with normal umbilical artery Doppler. Ultrasound Obstet Gynecol. 2010 Apr;35(4):456-61. <\/li><li>Gramellini D, Folli MC, Raboni S, Vadora E, Merialdi A. Cerebral-umbilical Doppler ratio as a predictor of adverse perinatal outcome. Obstet Gynecol. 1992 Mar;79(3):416-20. <\/li><li>Arbeille P, Maulik D, Fignon A, Stale H, Berson M, Bodard S, Locatelli A. Assessment of the fetal PO2 changes by cerebral and umbilical Doppler on lamb fetuses during acute hypoxia. Ultrasound Med Biol. 1995;21(7):861-70. <\/li><li>Roza SJ, Steegers EA, Verburg BO, Jaddoe VW, Moll HA, Hofman A, Verhulst FC, Tiemeier H. What is spared by fetal brain-sparing? Fetal circulatory redistribution and behavioral problems in the general population. Am J Epidemiol. 2008 Nov 15;168(10):1145-52. <\/li><li>Figueroa-Diesel H, Hernandez-Andrade E, Acosta-Rojas R, Cabero L, Gratacos E. Doppler changes in the main fetal brain arteries at different stages of hemodynamic adaptation in severe intrauterine growth restriction. Ultrasound Obstet Gynecol. 2007 Sep;30(3):297-302. .<\/li><li>\u00a0Dubiel M, Gunnarsson GO, Gudmundsson S: Blood redistribution in the fetal brain during chronic hypoxia. Ultrasound Obstet Gynecol 2002;20:117-121.<\/li><li>Baschat AA, Gembruch U, Harman CR: The sequence of changes in Doppler and biophysical parameters as severe fetal growth restriction worsens. Ultrasound Obstet Gynecol 2001;18:571-577.<\/li><li>Hecher K, Snijders R, Campbell S, Nicolaides K. Fetal venous, intracardiac, and arterial blood flow measurements in intrauterine growth retardation: relationship with fetal blood gases. Am J Obstet Gynecol. 1995 Jul;173(1):10-5. <\/li><li>\u00a0Schwarze A, Gembruch U, Krapp M, Katalinic A, Germer U, Axt-Fliedner R. Qualitative venous Doppler flow waveform analysis in preterm intrauterine growth-restricted fetuses with ARED flow in the umbilical artery&#8211;correlation with short-term outcome. Ultrasound Obstet Gynecol. 2005 Jun;25(6):573-9. <\/li><li>Baschat AA, Gembruch U, Weiner CP, Harman CR. Qualitative venous Doppler waveform analysis improves prediction of critical perinatal outcomes in premature growth-restricted fetuses. Ultrasound Obstet Gynecol. 2003 Sep;22(3):240-5. <\/li><li>Fouron JC, Gosselin J, Raboisson MJ, Lamoureux J, Tison CA, Fouron C, Hudon L. The relationship between an aortic isthmus blood flow velocity index and the postnatal neurodevelopmental status of fetuses with placental circulatory insufficiency. Am J Obstet Gynecol. 2005 Feb;192(2):497-503. <\/li><li>Miller DA, Rabello YA, Paul RH: The modified biophysical profile: antepartum testing in the 1990s. Am J Obstet Gynecol 1996;174:812-817.<\/li><li>Alfirevic Z, Neilson JP: Biophysical profile for fetal assessment in high risk pregnancies. Cochrane Database Syst Rev 2000:CD000038.<\/li><li>Savchev S, Figueras F, Cruz-Martinez R, Illa M, Botet F, Gratacos E. Estimated weight centile as a predictor of perinatal outcome in small-for-gestational-age pregnancies with normal fetal and maternal Doppler indices. Ultrasound Obstet Gynecol. 2012 Mar;39(3):299-303.<\/li><li>Figueras F, Savchev S, Triunfo S, Crovetto F, Gratacos E. An integrated model with classification criteria to predict small-for-gestational-age fetuses at risk of adverse perinatal outcome. Ultrasound Obstet Gynecol. 2015 Mar;45(3):279-85. <\/li><\/ol>\n","protected":false},"excerpt":{"rendered":"<p>1Raj Sonography &amp; X- Ray Clinic, Baiju Choraha, Nayapura, Guna, Madhya Pradesh, India.&nbsp; Short Title: Colour Doppler Study for FGR *Corresponding Author: Lalit K Sharma, MD, Raj Sonography &amp; X- Ray Clinic, Baiju Choraha, Nayapura, Guna, Madhya Pradesh, India E-mail : drlksharma_guna@yahoo.co.in Keywords: Doppler Ultrasound, Fetal Growth Restriction, Perinatal Care&nbsp; Established Facts and Novel Insights [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":2903,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[16],"tags":[],"class_list":["post-2901","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\/2901","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=2901"}],"version-history":[{"count":5,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/posts\/2901\/revisions"}],"predecessor-version":[{"id":2984,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/posts\/2901\/revisions\/2984"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/media\/2903"}],"wp:attachment":[{"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2901"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=2901"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=2901"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}