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Optimizing Fetal Outcomes through Fetal Imaging

Mar 21 | 3:30 PM

Abnormal umbilical artery Doppler and EFW <3rd centile is strongly and consistently associated with adverse perinatal outcomes. If a problem is detected early via fetal imaging techniques, the physician can significantly improve the clinical outcomes for the fetus. Let's hear from Dr. Prathima Radhakrishnan, the first Indian to get a Diploma in Fetal Medicine from the Fetal Medicine Foundation, UK, about how physicians can optimize fetal outcomes using the cutting-edge imaging techniques available. Join us live to hear from a passionate advocate for the cause as she takes us deep into the topic of fetal imaging!

[Music] so on behalf of netflix i talked to pazzi extend a warm welcome to all of you doctors in the audience we're extremely thrilled to have you here with us tonight tonight with us we have with us among amongst us dr pratima radha krishnan who is director and consultant in fetal medicine at bangalore fetal medicine center and also advisor in the department of genetics and fifi medicine committee the karnataka state obstetrics gynecology association international women's day 2022 focused on breaking the bias for a brighter tomorrow and dr prathama is a shining example for the cause in 2010 she became the first indian to acquire the prestigious diploma in fetal medicine from fetal medicine foundation in the uk dr pratima is immensely passionate about methods of early screening diagnosis and fetal therapy and every day on a daily basis educates and encourages more and more doctors to specialize in this field we are beyonce to have you with us here tonight mom and thank you so much for joining us thank you mr queen thank you so much we're so happy to have you here ma'am just thank you looking forward to learning from you right i hope so thank you very much dr kazi and it's been really nice liaising with you for the last few days and that's like very pleasant yeah and uh it's it's uh you know i've been talking to computers from people i moved to computers and now it's a bit awkward talking to my phone clearly but anyway i hope uh this helps uh people uh there okay so without much ado let me just start my presentation yeah it's a very very broad topic you know optimizing fetal outcomes to feed limiting you know don't know where to start and where to end but i've just brought you a gist of what uh you know i'm you know personally passionate about some things which are really really close to my heart and um of course uh there's much much more to this than what i'm presenting in the next few minutes really so we know to optimize antenatal care the most important uh things is to detect fetal anomalies structural and chromosomal anomalies check for uh develop check for problems associated with pleasantly insufficiency primarily for eclampsia and feeding growth restriction and of course try and assess uh for preterm delivery and prematurity and again scan is the main modality and hopefully by reducing all you know by by helping us in these three areas we should be able to reduce the perimeter mortality and morbidity and of course fetal scanning has come a long long way in the last several years now to optimize fetal outcomes to make get the best outcomes of the pregnancy it is extremely important to keep some basics in mind first we need to screen and diagnose early for feeding problems we need to combine parameters because you cannot have just uh you know say that only scans a number we need to combine various parameters whether it is in the scan or whether it is the history whether it is measuring blood pressure whether it is checking for you know blood tests etc so various parameters have to be combined and of course the early detection will lead to early intervention and hopefully that will change the course of the pregnancy or the complication and finally the timing of the delivery should be such that we should be able to get the baby out at the optimum time not too early but not too late as well to optimize the outcome for the mother and the pain so here is the first whole question and i'd really like you to answer this and i will give you about you know 30 seconds 45 seconds to answer this go on which is the best scan to take the pregnancy head circumference at 16 17 weeks bpt at 20 to 22 weeks crl at 10 to 12 weeks or estimated fetal weight at 18 to 20 weeks so go ahead quick i think we have a clear winner here seems that way yes we do i think i think people have done excellent i really wonder whether you need my next two three slides at all really okay so those of you got it uh you know right crl cl crown grump length is the best uh measurement and at you know in the early pregnancy 10 to 12 weeks i don't go earlier than 10 weeks primarily because the variation is very small and very small variations also can cause big variations in the gestational agent therefore 10 to 12 13 weeks crl is the best uh method to date the pregnancy and this falls within plus minus five days and of course the early pregnancy scan is very important to date the pregnancy to control viability because parents want to know what's happening is the baby there they be alive heartbeat and they get really excited when they see multiple pregnancies good to check for multiple pregnancy well ahead of time involved in a lot of you know vast number of pregnancies that looking at the heartbeat and a baby that has appropriately grown to the gestational it is very reassuring and of course when there is recurrent pregnancy losses we do weekly reassurance scans and this is shown to improve the pregnancy outcomes scientifically not just for reason scientifically because that builds a positive attitude for the mother and it is work supposedly works very good for the uh continuation of pregnancies including other things as well but reassurance scans are very very important okay so no it is not the ppd we must also remember that when you measure the head circumference the abdominal circumference and the vpd it is subject to lot more variations so the best time to treat a pregnancy is early pregnancy before uh 12 weeks now though in india about half a million children are born with intellectual malformations and majority of and of course majority of them are related to genetic or chromosomal liberations as well and this includes palestinian sickle cell disease and yes of course down syndrome does is the most commonest non-inherited form of uh chromosomal abnormality in our population as well now the purpose of the first trimester scan as deciphered from as put forth by the international society of ultrasound and obesity that is the eyes walk and fmf you know is to confirm the viability of the pregnancy measure the crown rampling properly according to the standardized guidelines confirm gestational age and if there are multiple pregnancies this is the right time to consume the periodicity screen for chromosomal abnormalities detect structural abnormalities early and finally screen for preeclampsia and ct growth restriction and this is done between 11 to 13 plus six weeks and the crl corresponding to 45 to 84 millimeters now when you're screening for abnormalities they're taking a number of parameters and that would be the crown drum length the neutral translucency and the nasal bone and when we uh take to do the screening only using the nuclear translucency the accuracy or the detection rate was about 75 to this is improved further by adding a nasal nasal bone to the to the to the measurement and when you add serum biochemistry that is the beta lcg paper and now we have introduced plgf as well this accuracy is improved to 92 percent the cell free fatal dna that is an nipt has got a 99.6 percent accuracy for i down talk about that a little bit later and of course when we do an invasive procedure it's almost confirmatory now why i say 99.999 because nothing in life is 100 and occasionally there can be either the you know uh selective growth of certain self that may not entirely reflect the uh reflect the fetic but to be honest for all practical purposes uh invasive testing is the confirmatory test because uh you know that's the best as it gets and that is the whole standard indeed now invasive testing and primarily there are two invasive tests chorionic village sampling where we sample the placenta and amniocentesis where we sample them and when we take samples from the amniotic fluid and because it is an invasive procedure it does carry a small risk of miscarriage and studies meta-analysis have shown that in trained hands there is no difference in the risk of miscarriage whether you perform a cvs or amniocentesis and this is called the procedure related risk of uh pregnancy loss and that is less than 0.5 percent of 0.3 percent one and 300 approximately now when we get the results after uh of the karyotyping it looks something like that on the left is a normal karyotype that means you have two sets of uh 23 chromosomes uh and that is a normal karyotype and when you have extra chromosomes more or less that's called an aneuploidy and then this is a typical example of trisomy 21 then if you notice the chromosome number 21 in the lower most uh column the lowest row there are three chromosome number 21 instead of two now when they say trisomy 21 that is that three chromosomes tries to be 21 and this is most likely uh this is a free or a spontaneous trisomy 21 and this is the most common form of downs now in the next you can see this is a translocation down syndrome where it looks the chromosome number 21 here there are two copies here but there is an extra chromosome number 21 which is gone and sitting on uh chromosome number 14 so this is a translocation type of down syndrome and of course when there is a translocation type of down syndrome the risk of recurrence is many times higher so why is it important to know that when it was a previous down syndrome what type of trisomy 21 it was whether it was a spontaneous trisomy 21 whether it was a mistake down syndrome or whether it was a transformation down syndrome primarily because the risk of recurrence will vary depending upon what type of down syndrome it was that means if it was a mistake price only 21 the risk of recurrence is extremely low whereas it is a trisomy 21 the risk of recurrence is one percent higher in subsequent pregnancies and in the those cases you don't necessarily need to check the parental uh karyotype whereas if it's a translocation dance then you must check the parental uh karyotype because the risk of recurrence will vary that the father of the mother is carrying the transportation and of course there will be occasional where both of them will not be carrying and it's just a spontaneous mutation and in those cases also the risk of recurrence will be extremely low so the type of trisomy 21 is very important and this brings us to the fact that it is very important to investigate these pregnancies properly now i've got the next poll question and i want you to answer this which is associated with increased glucose translucency cardiac defects and employees anomalies all of the above right so go ahead so dr pyle gupta vishal kumar everybody's need to think of pb options yep so that's that's winning the game today isn't it again as clear winner it seems like good yeah so i'm talking to a very elite audience i think they already know everything and they're eager to learn more ma'am definitely well i hope that yes yes ma'am so most of our doctors seem to have voted for option d excellent and that is the right answer so when in the first trimester scan you find there's an increased nuclear translucency what do we do next right now this is something that uh you know as obstetricians as radiologists and we all need to know how to follow up these pregnancies we must remember that even with increased local translucency majority of the babies will be normal right but as the neutral translucency increases the chances of finding an abnormality will increase and the most common abnormality is a chromosomal abnormality so when the chromosomal abnormality is excluded then you are looking at other structural abnormalities primarily cardiac defects skeletal problems genetic syndromes etc and you are basically systematically you have to go looking for these abnormalities and uh excluding them and if once you have excluded the major defects the baby you have got a live baby and you have got a chromosomally normal baby at 20 weeks and the nuclear translucency is gone back to normal that is less than six of the anomaly scan then the chances of having a healthy live baby is excellent and now with the advent of the micro array testing in the samples this has gotten even better in terms of excluding chromosomal and some genetic abnormalities so when you find a baby with increased local translucency that is definitely not an indication for termination but it is an indication that you have to go through systematically excluding abnormalities and come 20 weeks you have a chromosomally normal babies actually normally translucency has gone back to normal you can be quite reassured okay so uh let us just uh quickly go through what is if this is not absolutely hard and fast rule but this could be a good guide to start off with that when you have an increase in the translucency which is defined as above the 90th centil for the crl we can we can divide it into two groups and 95th to 99th centil or above 3.5 millimeters which is 99th nd is centim increased it may be reasonable to offer an uh cell free dna testing rather than an invasive test and definitely an invasive test if it's more than 3.5 that is the 99th percentile and in those cases you will need to uh do an early anomaly scan a video echo even earlier if possible and of course many times you may need to repeat the scan because not everybody is very used to doing an early anomaly scale at 16 centimeters now in this group of women also what is recommended now is to do a microarray than just karyotype okay now the next very important aspect of the first trimester scan particularly is the assessment of the baby's anatomy now we must understand the baby is fully formed by 12 11 leaks the head body two hands to lexis all form and therefore we go through a systematic approach looking at the head the stomach the spine the neck and the eyes the hands the bladder the legs uh the heart examination also has done well for insertion and all this will be hugely reassuring because vast majority of the babies as we know are normal but if you can confirm that or you can ensure that it is progressing normally in the first trimester that gives a huge amount of reassurance to vast majority of the women which is a very very important aspect of the fetal uh scan as well now we did a study way back in 2018 2010 uh which is why which is where i got my diploma really uh looking at screening for major fetal defects at 11 to 15 weeks and we found by good systematic scanning over 50 of the major structural problems can be detected in the first trimester and this of course you know ten years down the line will be even better now by having introduced many other uh aspects of uh you know of assisting the features in the first trimester so uh we also looked into the nine com uh nine uh abnormalities that will always be present in the first trimester and we found that when these when you look out for these nine abnormalities the detection rate is much much better almost hundred percent in the first trimester so those of you who are doing the first trimester scan or even if you make sure that you have this list of nine and ensure that you're excluding this in every baby you're already doing a very good job right so we're just going to go through the first video if you could kindly play the first video right and this is the crl empty has it started yes ma'am okay so the first time is this scan is a you know looking at the fetal heart activity so you are confirming that the proper crl measurement is taken and from the head to toe with the baby in the neutral position and that's extremely important and you can see the space below the baby's neck uh also helps us to understand that the baby is not too flexed or not too extended now to optimal optimize your neutral translucency measurement it's also important to work under less pain so you reduce your gain as it's happened in this image and measure it on to on uh at the back of the neck with good magnification and of course in this baby we can see the nasal bone very nicely as well right so this people this is the way this is the most important image that you have to procure in the first trimester scan good magnification baby in neutral position perfect with sagittal view nasal bone is seen and you measure the nuclear translucency on to on okay we have got a second video also so we can play the second video too so the second video is looking at the anatomy of the fetus starting now yes so that's again the baby in a good position and but to be honest uh for the anomaly scan you don't really need the baby to be in a good position so that's the baby's head the bright white structure of the skull and you can see a very nice midline and those uh white spaces which are the correct plexus fills the cell ventricle and that's how they look the butterfly structure is brain and this excludes the three major structural problems that you have of the target nine which is the arcrania and kepler seal and holocaust and there so that is an extremely important uh image there okay so as we move a little bit down you can see the posterior fossa of the brain as well and just making sure that there is no large gaps in there and i will come back to that in a few in a slide or two go down further you can see the heart is pointing to the to one side and you see the stomach bubble which is a black space also on the same side and further down the baby turns around and you can see a nice fine there right from the top to the bottom and it's filling in nicely a little bit down you can see a hypoechoic area which is the ladder okay and you can switch on the color to ensure to see the umbilical arteries uh abutting the bladder and that's how you know for sure that's the bladder so going further down you see the thigh bones the knees and the two little feet and two little feet and that is also very important because if you need to examine all the three segments of the leg uh of all the uh of all the extremities so which is the uh lower and the upper extremities so i think the video has slowed down a little bit there isn't so uh coming to the um uh you know the other things that you can do potentially you can do in the first time it's of course this is a lot of new data there and just in the one single image of the uh nuclear translucency image that you just saw you could actually look at the maxilla to check for the maxillary gap you can look at the intrapreneur lucency to check for the uh screening for spina bifida and the bspsop ratio which will also uh when it is reversed will show that there is a higher probability of posterior fossa abnormalities so if you can just play video three it is a short video the same empty image that we saw earlier what we are trying to measure here is the intracranial after measuring the nuclear translucency we would be measuring the intracranial translucency uh which is normal in this fetus and below that is the systema magna and then you would go to the brain stem and brainstem occipital bone bone measurement which will uh show that uh look for posterior force abnormalities and then you can very clearly see the maxilla and there are no gaps in the maxilla and that will confirm that uh well confirmations that will indicate that the baby does not have clips of the hard palate so there are a lot of other things also that you can see in this one single image of neutral translucency and therefore this image would be almost magical for uh the parents and for the uh examining doctors of course right okay so i've got another poll question for you so tell me corianicity and amnionicity is best determined at 24 to 26 weeks 11 to 15 weeks 8 to 9 weeks 30 to 33 months most of our doctors have voted for 11 to 14 weeks yeah that's absolutely correct it's 11 to 15 weeks because amnioticity can be a bit difficult at eight nine weeks because some particularly when it is more amniotic uh sorry diamniotic because we may not necessarily uh see the amniotic membrane very well and therefore call it a mono uh chorionic mono amniotic so that's not okay so the answer the correct answer is 11 to 14 weeks okay so let's move on why 11 to 14 weeks the best time to assess the quadrionic um uh chorionicity is because when at eleven to twelve eleven to fourteen weeks we almost always see the lambda sign or the t sign and the lambda sign which indicates the one on the top in the right in the top image with the green color uh circle on it is the lambda sign and the presence of the lambda sign has gotten over 99 accuracy to confirm that it is a dicorionic dicorionic placenta and if the lambda sign is absent as in the uh as in the image with the yellow circle in it then that is a monochorionic twin pregnancy and why is it important to check whether it is monochorionic or diaphorionic because obviously the pregnancy the management of the entire pregnancy would depend on whether it is a monocoryonic or a diagonal and secondly if you find discordant anomalies then you have to sort out the possibility of feeding reduction and the earlier you do that better because the risks associated with fetal reduction primarily of miscarriage uh is much less than it is done before 16 weeks than uh performing production after 16 weeks okay now the other thing we published last year was a paper on how in the first trimester by looking at the crl abdominal circumference due to translucency we could majorly impact um or majorly predict the probability of complications and of course like anything else when you use a combination of factors particularly of disorder nuclear transverse and synthesis current ac you can predict complications associated with monopoly on acidity that is twin twin transmission syndrome selectivity growth restriction single iufd as early as uh 11 to 14 months and this would help the parents a great deal in making some important decisions and of course uh plan the care appropriately as well okay so with that i'm going to move on to the second trimester scan and of course there are a whole bunch of guidelines that one needs to follow in what all you can do in the second trimester or what always the recommendations use iso has its own guidelines sweethearts and foundation has its guidelines and it is very important that we follow the guidelines and ensure that we have complete uh complete documentation of the images and which is also according to the pcp entity requirement and apart from the biometry we have to make sure that we look at uh look for all anomalies in the second trimester as well and generate a proper report and of course anytime software based reports will would be useful and also you need to ensure that it is saved the images are saved and uh proper sentinels and charts are given along with your scan report so this is a proper complete anomaly scan report which of course should include uh you know the basic minimum that would be the growth the fetal biometry the anatomy according to the fetal medicine foundation eyes or whatever you want to follow screening for aneuploidy is looking for soft markers in the second trimester screen for preeclampsia feeding growth restriction by checking the uterine artery doppler and finally screen for pre-term birth by measuring the cervical limb and pressure please transfer generally but you know this will actually complete your second trimester scan and it is very important to go through uh each one of them because that is what is uh you know that will what what will determine the follow-up for this pregnancy also okay so now i've got another poll question for you go on the best time to screen from eternal period best time to screen for maternal preeclampsia is 24 to 26 weeks 11 to 14 8 to 9 30 and i have actually emphasized on the word scream [Music] man by popular choice here most of our doctors have voted for option b saying that 11 14 weeks that obviously seems my favorite as well because i seem to have all the answers to directed towards the yes 11 to 14 weeks yes see the thing is you need to understand whenever we screen for a condition whenever we screen for a condition we should have an appropriate intervention or a treatment to be able to change the course of the disease now this is the basic definition of screening right and that is why i kept on emphasizing on the word screen although the detection of preeclampsia will be very good at 30 to 23 weeks little less at 24 to 26 weeks but the closer you are to a disease the better you will be able to you know predict that condition but when we talk about screening we have to think about not just saying the woman is at increased risk or induced risk but we should also be able to offer her an intervention that will hopefully change the course of the disease that's why i emphasized on the words three so for that your 11 to 14 weeks is the best and how do we do that we combine we combine the history of the mother whether she's had any previous uh pre institute of previous preeclampsia or you know she is a primary we check the mean uh we check her blood pressure we calculate the mean rtl pressure and again there are specific guidelines and how to do it properly we do an ultrasound scan to measure the uterine artery pi and of course adding the blood values particularly plgf in the first trimester especially much later of course along with the uh and combine all this information will help us to uh improve the prediction of pre-eclampsia much better and of course you need to use as much resources that is available and implement it correctly and this of course is going to go a long way in health economics as well because we know create landshare is still one of the most common uh complications in pregnancy and secondly it is still one of the highest contributors in the terminal mortality and perimeter mortality and okay now at 11 to 13 plus six weeks we identify women who are at high risk based on maternal factors lean artery pressure uterine artery ti and placenta growth factor and the one who are found to be at increased risk for preeclampsia we give them prophylactic aspirin 150 milligrams in the night and continue to 36 weeks and this has shown to reduce the risk of preeclampsia so the way we satisfy assist the risk put them into high risk or low risk and high risk by definition would be a char a risk of more than 100 probability will get aspirin from 12 to 36 weeks and this is according to the asper study okay now we screen them again at 20 to 24 weeks the ones who are at low risk okay the ones who are at lowest we screen them again at 20 to 24 with this we can estimate the patient's specific risk plan the subsequent management but here aspirin is not going to help as much because aspirin is best used before 16 weeks right and again measuring the mean rt pressure nutrient artery pulsatility index and probably estrogen also our increase in tlgf is decreased and this will also help to improve the detection of create lamps again you stratify them into low risk and highest the highest will continue monitoring them much closely you have an intermediate risk which is between 100 to 1 500. if it's a low risk then let them go ahead but if it is an intermediate risk you will bring them back at 32 weeks and then reassess them but if it's a low risk fuel basis then at 36 that's the way that 3d medicine foundation recommends to manage them right now at 30 to 34 weeks what do you do you again you do the same things really you check the mean rd pressure you look at the uterine artery here uh the estimate is increased plgf is decreased and therefore you can have a reversal of this ratio and uh here the uterine artery doppler has got a small role and as the pregnancy advances the biochemical markers become stronger whereas the uh biophysical markers like the uterine artery doppler becomes less uh predictive again if it's a low risk your essence then at 36 weeks if it's highest then you monitor them much more closely right and the final assessment at 35 to 37 weeks and the same thing if it's low risk your weight delivery benefits highest you consider delivery early so that you avoid the possibility of developing significant free eclampsia so in this way you can kind of systematically uh go about assessing for even late early onset and late concept day labs for early onset requirements still the first trimester screen is the best whereas for the late uh on separate eclampsia we will need to continue monitoring them from twitch to after 20-22 weeks as well now as per study which i uh showed that more than 75 percent of case of freedom preeclampsia and nearly 40 of term preeclampsia can be predicted in the first trimester itself and in this group of women is where we would give the aspirin 150 milligrams in the highest group which is the risk more than 100 and now iso also recommends that this must be done and this will help to prevent the development of severe preeclampsia for you know in a big in a really big way okay and that also is the algorithm which is given by iso which you can you know go to the website and so that takes me to the next poll question the third trimester scan check should include biometry of the baby doppler of the umbilical artery female anomalies check all of the other and by a clear margin it would be awesome i think i've got a fantastic audience here i really love it we're getting it all right absolutely i agree with you uh the field uh uh the third trimester stand and i like to call it the feeling growth of the fetal well-being scan must include all of them a good survey check the presentation check the the placenta the you know the amniotic fluid look take the biometry about hcacfl and uh you know an amniotic fluid index the umbilical artery the middle cerebral artery and the ductus venous doppler will act as your baseline the uterine artery doppler will also be helpful and of course do not forget to look for anomalies which can be detected in the third trimester as well so just doing the biometry and saying that growth is okay is not enough look for anomalies also in the third trimester and of course don't forget your growth charts plot them on the chance so by definition feeding growth restriction is a fetus which has not reached its growth potential and this can be compared only on a growth chart and of course there are various reasons why it can happen and we need to look out for these reasons and also i would like to highlight that the terminologies has become very specific now we call them appropriate for gestational age small for gestational aids large registration age or city growth restriction and that two categories early onset which is detected before 32 weeks late onset after 32 months we are done away with the terminologies like symmetrical asymmetrical etcetera etcetera so please don't use any of them we'll just go with the early onset late onset aga sga lga and fgr and of course putting the doppler and the ctg together in a baby that is growth restricted will help us will guide us and this is the another uh guidelines that is come out in the last couple of years on management of fgr uh in um you know according to the doppler and the synthetic of the managers and when i say ctd it is not the regular city it is the computer so therefore primarily in our country we will be managing them based on the top lane right now doppler and obstetrics has come a long long way where we use doppler pretty much in every fetal scan for some reason or the other apart from pt growth restriction structural abnormalities what is pre-eclampsia twin pregnancy complications fetal anemia has you know doppler has really revolutionized the uh detection and treatment of fitting and therefore it must be used uh you know liberally doppler must be used in pregnancy liberally of course judicially there's no doubt about it anything you do you should be judicious about it but don't miss out on taking the aid of doppler to improve your diagnosis and make it even better okay so that takes me to the next and this is the last question i promise is the selfie dna an ipt or nips must be offered to all pregnant mother only when the entity is increased only when there is a fetal abnormality mother seeking further accuracy is training again by popular choice most of our doctors have voted for option d okay good perfect yes i mean cell free dna you can't really offer to all pregnant mother because it's still an expensive test i would you would like to do it but you cannot really practically when there is a fetal anomaly you will not offer nipg because for fetal anomaly you are not looking just for just for a down syndrome you're looking for other abnormalities as well of course d is the right answer because some others will not be completely satisfied with one uh you know screen accuracy of screening uh that is limited in the androids want to see for the non-invasive methods to improve the detection rate and in those ones also you will use uh nipt now obviously there are clearly advanced you know indications and contraindications indications you already already know but contraindication is something that you must definitely keep in mind if there are abnormalities that you see on the scan it is ideal not to offer an ipg and tell them very clearly why you are not offering it has not been validated in triplet frequencies and of course when you are doing uh you know when you're doing an invasive for other genetic disorders like sma thalassemia etc in those cases there's no point doing uh now when there is a banishing twin the most vanishing twin is made basically the twin pregnancy where one baby has died and one baby is alive and we know that most common cause of uh uh of fetal death in neutral is actually aneuploid right so if you do an iptv that there is a vanishing twin then it may falsely uh tell us that the current pregnancy that is alive also could be uh having the chromosomal and certainly in micro deletions it's not being validated yet and therefore you would not use it now following a cell free dna test there are three types of results that you will get one you will get a screen positive well majority of the cases let's look at majority that's the green line screen negative result this is reassuring unless you find some other structural abnormality later on pregnancy but largely it's very reassuring but screen positive result if it's a screen positive result you should still do uh an amniocentesis because you could you know the cells which come from the selfie dna are not strictly fitted are mixed cells from the placenta and from the fetus and sometimes you can have what we call as a placental mosaicism or a confinement system where the placenta is carrying abnormal cells and the fetus could be normal and therefore it is very important to do an amniocentesis in these cases now occasionally you can get a no call or no result because if the amount of cells are very few and remember when i showed the carrier type of tries uh of christopher 21 looked at the chromosome number two very tiny and therefore you may not be able to uh see uh you know you may not even know the test may not detect uh significant number of uh chromosome number 21 if the fetal fraction is very low so in these cases also if it's a no call or no result we must you know do an invasive i prefer invasive test of course some labs will say repeat the test and to be honest when you repeat the test the chances of failure is ten times higher than if you uh you know that than the first time itself so i generally do not like to repeat uh in my page okay so and then you can get false positive results and false negative results false negative results are extremely rare if you choose your cases very carefully ah whereas positive cases are not uncommon particularly when you have uh you know screen positive for sex chromosomal and employees and two things very important to keep in mind whenever when you are doing nipt it's important to get a written consent and you need to fill the pcp entity form as well because it has got a potential to detect the gender of the fetus and therefore you must uh fill in the f form uh it's not an invasive acid you are not entering the eutron uterus so you don't need the g form but you certainly need to fill in the f form and you write exactly what it is and of course it should be nippy should be done in centers which are approved by the district appropriate advantage right iso came up with the statement consensus statement regardless of cell free dna testing the first trimester scan is magnitude so that it's not going to replace the scan and it must be interpreted in relation to the a primary risk and the fetal function if there is a structural anomaly it is better to do a carrier typing or a microarray and of course the failed cell free dna test also shows that there is an increased risk of anomalies and therefore you need to you need to follow up these pregnancies properly and abnormal selfie dna uh or will build warrants to do amniocentesis and sometimes every serious their sentences is predictable accuracy of the cell treaty and end-to-end testing is the twin pregnancies is possible and is much better now it's more validated because if there is a screen negative um cell free dna test then it's unlikely that both or either of the babies is affected whereas a screen positive will not be discriminatory it will just tell you that there's one baby is affected and one baby is on and that will be positive and you'll have to now micro deletions as i already mentioned it's not validated and of course understand that nipt should be interpreted in context with the scan so i hope i'm able to bring some clarity that optimizing fetal scans uh fiddle outcomes is not only fitting emerging it is a combination of history taking ct uh you know patient demographics fetal imaging and then finally the blood tests and putting all of them together to be able to uh get the uh you know proper uh output for the baby so that the baby can be triaged well in the beginning of the pregnancy itself so that you know the high risk pregnancies highest mothers and high risk feeders will have more specialist care uh rather than uh the rather than everybody and this is what is the new protocol well it's not so new anymore uh but what kepler's nicolitis my professor has been promoting for all these years the screening and diagnosis of to optimize the pregnancy must happen earlier and earlier sooner than soon so with that i conclude my talk thank you very much uh for giving me this opportunity thank you doctor i'm sure i speak for everyone in the audience here that that was incredibly informative and we're truly grateful to be here just giving the audience a couple of minutes to drop in your questions sure sure uh there's a question asking uh is it necessary to take a consent yes it is well it's ideally yes because taking a consent means you have explained to the patient uh properly you could take a verbal consent that's good enough and also in quantity document that you have given all this information because you know the retention power for many of these people who are in pregnancy for them particularly when they're very anxious is actually very reasonable right so it's always better to take a written consent pcp entity form must be filled it is not out of control it must be true so can we start aspiring and rpl as soon as we diagnose the pregnancy see rbl is a different recurrent pregnancy loss is a different you know different condition when i am saying 150 milligrams of aspirin is based on the study on the as per study which actually screened women and categorized them into high risk and lowest in rbl usually what we use is 75 milligrams if i'm not mistaken and uh that's that's the dose for recurrent pregnancy loss and that's generally started as soon as you discover that you are that the woman is pregnant we do split uh is it mandatory well split is good it's a good guide uh but it's not you know it's difficult to do it in our country so i think it's uh you know till the time it's more freely available we'll have to go with what we have you know because we are come from a kind of limited resources uh section uh should we perform nt scan if crm is less than 84 while by a lengthy fetus is 14 weeks well 84 millimeters is more accurate so you you know you can do the risk assessment from 45 millimeters to 84 millimeters even if it is uh 14 weeks plus two three days because that's what the media is so the free time foundation risk assessment software goes by the crl and not by the gestational age so that's that cut off of nd measurement there is no cutoff for nd measurement nt measurement is taken as the 95th centimeter and you have to look at the uh charts uh because the nd measurement will change according to the cr it's a range composed and increased empty means above the 95th century we've actually published a paper of 14 000 pregnancies in uh january 2020 uh in the jokey where we have measured 14 000 pregnancies np and crl and it's there uh available online as well so please go there and look it up and that gives you uh it the 95th and the 99th central uh for uh nd for each and every crl from 45 to 84 millimeters it's under with dr paul and myself we have published this paper can we recalculate crl at 70.5 and 12.5 i think it is not um unreasonable to recalculate the dates and i would always confirm it fb scam right so uh you i i even if i'm saying so for example if i see a patient at eight weeks and i'm not sure it's measuring seven weeks plus minus i always tell them i calculate the time for them to come for the empty scan correctly and then at the empty scan is when i will confirm the dates and see whether it corresponds with my previous scan measurement okay calculate the adv crl is good enough you don't need a bp if you have a good crm like the images that i showed you then i think that's perfect can we recalculate more than eight percent i mean generally there is more than five days discrepancy i tend to be calculated thank you very much thank you so my much and i really enjoyed being likewise doctor i hope uh the audience has benefited even if they get one message from this entire presentation my day is done yeah thank you so much dr pratima it is wonderful having you here thank you so much

BEING ATTENDED BY

Dr. Murtuza Zozwala & 919 others

SPEAKERS

dr. Prathima Radhakrishnan

Dr. Prathima Radhakrishnan

Director & Consultant in Fetal Medicine at Bangalore Fetal Medicine Centre (BFMC), Consultant Fetal Medicine at IMA fetal care centres in Bangalore

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dr. Prathima Radhakrishnan

Dr. Prathima Radhakrishnan

Director & Consultant in Fetal Medicine at Ba...

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