Fetal medicine -

what an obstetrician
should know
 KERALA FEDERATION OF

Content
OBSTETRICS & GYNECOLOGY

JOURNAL
Fetal medicine -
06 RELEVANCE OF GENETIC
TESTING IN PREGNANCY
Dr Anusmitha Andrews
what an obstetrician

07
should know INVERTING THE PYRAMID
OF ANTENATAL CARE-
President Academic IDENTIFICATION OF
Dr. Aswath kumar Dr. Reji Mohan PREGNANCIES WITH BAD
Secretary Adolescent
OBSTETRIC OUTCOME
Dr. Anitha Joseph
Dr. Venugopal M. Dr. Mini Balakrishnan
Vice President Reprod.Health
Dr Hariprasad
Joint Secretary
Dr.Shyjus P
Dr. Fessy Louis
Oncology
Dr. Jeena Baburaj
10 SCREENING FOR DOWN
SYNDROME - THE FACTS
Dr Pio James J, Dr. Asha Biju
Treasurer Research

13
Dr. Bindu M Dr. K.U. Kunjimoideen FIRST TRIMESTERS
Journal Editor Medicolegal Committee SCAN- A NECESSITY, NOT A
Dr. Parvathy Deth Dr. Subhash Mallaya FORMALITY
Liaison Officer PPMD / EMOCALS- D Dr Pio James J, Dr Sindhu P
Dr. V. Rajasekharan Nair Dr. Neetha George

15
EMOCALS- N DOPPLER IN FETAL
Dr. Deepthy M. GROWTH RESTRICTION
Committee Chairpersons Quality Standards Dr. Jyothi Mancheri
Mat. Fetal Med. Dr. Vasanthy Jayaraj
Dr. K. Ambujam O.R.R.T
CRMD
Dr. Paily V.P
Dr. Raji Raj
MDMNSR
Dr Lekshmi Ammal
18 INTERVENTIONS IN COMPLICATED
MONOCHORIONIC TWINS TO
IMPROVE OUTCOME
Dr.Rinshi Abid Elayedatt,
KFOG Head Quarters: Dr. Vivek Krishnan
TOGS Academia, East Sooryagramam,
Thrissur- 680 005, Kerala
Ph: 0487 2320233 | kfogsecretary@gmail.com
www. kfogkerala.com

2 KFOG Journal | April - June 2023 smritidesign.com

 Presidents
message
’

Dr. Aswath kumar

KFOG President

Dear Colleagues and Friends, I would like to express

my sincere gratitude to
G reetings from the Kerala
Federation of Obstetrics
and Gynaecology (KFOG)!
Dr. Parvathy Deth, the editor
of the KFOG journal, for
her commendable work in
“The big secret in life is that bringing out this edition. I
there is no big secret. Whatever also appreciate the efforts of
your goal, you can get there the editorial board, reviewers,
if you are willing to work” and authors for their valuable
- Oprah Winfrey contributions.
It gives me immense pleasure I hope you will enjoy reading
to present to you the first this edition of the KFOG
edition of the KFOG journal journal and provide your
for the year 2023. This journal feedback and suggestions for
is a platform for sharing further improvement.
our knowledge, experience
Thank you.
and research in the field of
obstetrics and gynaecology. Dr. Aswath Kumar,
President, KFOG

KFOG Journal | April - June 2023 3

 Secretarys
MESSAGE
’

Dear Colleagues,
Greetings from KFOG. Hope all of the enthusiasm and effort put into the
you and family are doing well. Every articles.
new editor brings new energy new I also wish to encourage members of
ideas and refreshing inputs into the KFOG to contribute in large numbers
KFOG JOURNAL. articles for the future editions of the
Congratulations to Dr Parvathy on journal.
taking up the new assignment with After a hiatus there will be print
great zeal and enthusiasm. version of the journal and I am
The theme of this journal focused sure it will be appreciated by many .
Dr Venugopal on Fetal medicine is very relevant Best wishes and happy reading.
Secretary, KFOG to day to day practice and I wish to Dr Venugopal
congratulate each contributor for

4 KFOG Journal | April - June 2023

Editors Note ’
fter a long hiatus due to

A covid, KFOG is back with a

printed version of Journal.
Since its a new beginning, I
thought of starting it in fetal stage-
Fetal medicine from an obstetrician’s
perspective what all to know. Im
immensely indebted to KFOG for
believing me and handing over me this
huge responsibility. My special thanks
to Dr Aswath Kumar, Dr VenuGopal,
and Dr Fessy Louis for being my
three pillars of support. I would like
to express my gratitude to each of the
authors for sending me the articles
with the best content, special thanks
to Dr Pio James for coordinating it.
Last but not least - CIMAR & FETAL
LOUNGE, for making this a reality.
I hope this journal will be an academic
enlightenment for each one of you.

Dr. Parvathy Deth

Editor,
KFOG Journal

KFOG Journal | April - June 2023 5

 RELEVANCE OF Dr Anusmitha
GENETIC TESTING Andrews
Consultant in Fetal Medicine

IN PREGNANCY Lifeline Hospital, Adoor.

F
or many decades, prenatal genetic testing was
offered to pregnant women in certain specific These days, Next-generation sequencing has been
situations. Traditional karyotyping was used to identify causative genes in many Mendelian
offered to women at increased risk for chromosomal disorders. These include panel tests and Whole exome
abnormalities , based on aneuploidy screening sequencing ( WES ). WES in prenatal testing has the
using maternal age, serum marker testing, ultrasound potential to provide a more precise genetic diagnosis
or a combination of these. Chorionic villus sampling .However since the data is under validation for benefits
(CVS) with DNA analysis was offered to couples at / pitfalls , it is ideally not recommended for routine
high risk for a fetus with dominant or recessive genetic use for prenatal diagnosis .
condition. Another situation is karyotyping after the
Most forms of prenatal diagnosis require invasive
diagnosis of fetal structural anomalies on ultrasound
procedures for fetal-sample collection and therefore,
examination.
although considered safe, these procedures involve
Nowadays prenatal diagnosis plays an essential a small risk of fetal loss. The most widely used non
role in obstetrical care, and with proper planning, it invasive test or aneuploidy screening methods are
is a boon for obstetricians and prospective parents combined first trimester screening and second
.Prenatal testing has become more sophisticated with trimester quadruple test .The introduction of cell-
improved level of resolution . free fetal DNA has revolutionized prenatal diagnosis
and fetal medicine. It can be offered as a primary
FISH and Qf PCR are targeted tests which detect
first trimester screen , positive first trimester screen
aneuploidies of chromosomes 13,18 , 21 and sex
, presence of ultrasound markers of aneuploidy in
chromosomes with a turnaround time of 2 – 3 days
second trimester and in cases of previous child with
. Traditional Karyotype has been superceded by
T21 with a detection rate of 99.7 % for T21 .However ,
chromosomal microarray which identifies copy number
a proper pretest and posttest counseling is necessary.
variants . Karyotype may not identify chromosomal
imbalances of < 10 Mb whereas Microarray can detect The birth of a child with intellectual disability or a
submicroscopic deletions and duplications (20-200 genetic abnormality is traumatic to the family. Hence
Kb ). CMA identifies all abnormalities that Karyotype determining genetic diagnosis prenatally, helps us
can offer , except for low level mosaicism and balanced to counsel the family about possible fetal outcomes,
translocations . However , the result has to be management options and recurrence risks. Therefore,
interpreted carefully since some copy number variants it is important for the obstetrician to be aware of the
may be present in normal individuals also . Moreover genetic conditions, and to use appropriate testing
diagnosis of monogenic or single gene disorders is .Referrals to genetic healthcare providers may be done
beyond the scope of Karyotype and CMA . in order to obtain a specific diagnosis.

6 KFOG Journal | April - June 2023

 INVERTING THE PYRAMID Dr. Anitha Joseph
OF ANTENATAL CARE-
MD, DNB, Fellowship in
Fetomaternal Medicine

IDENTIFICATION OF PREGNANCIES Fetal Medicine Specialist

The Fetal Lounge,

WITH BAD OBSTETRIC OUTCOME Kottayam

T
raditionally, , the third trimester has been This concept was inspired by the success of first
considered the most important of all trimesters trimester ultrasound screening for fetal aneuploidy
with recommendations that surveillance using nuchal translucency (NT) and the realisation
be more frequent and focussed on this trimester that increased NT can be a marker for other fetal
when most complications arise. The first trimester abnormalities. With time, more ammunition was
was deemed a period of helplessness. Then came added to the screening armamentarium. What
a seminal paper in 2011 by Kypros Nicolaides in seemed a dream in 2011 is more a reality now.
which he challenged this notion and proposed a Here’s a look at what has worked and at what the
radical different approach to antenatal care. He future might hold.
suggested that instead of waiting for complications First trimester estimation of gestational age
to occur, a more proactive and pre-emptive attitude
Determining the gestational age is one of the
be adopted; that 11-14 week of pregnancy be used
most early and vital steps in obstetric practice
as a window of opportunity for screening and early
which influences almost every obstetric decision.
diagnosis of major pregnancy complications.
Measurement of CRL in the first trimester yields
This would entail using a multi-pronged the most accurate assessment of gestational age
approach (history, maternal characteristics, particularly when the CRL falls between 30 and 84
ultrasound, and laboratory investigations) to assess mm.
the risk status of every pregnancy and use that
Screening for aneuploidies
information to plan further antenatal care i.e., high
risk pregnancies are directed towards specialist Fetal aneuploidies, trisomy 21 in particular, are
care while low risk pregnancies are followed up at major contributors to perinatal morbidity/ mortality
less frequent intervals. As illustrated below, the late and long-term disability. First trimester combined
first trimester thus becomes the base of the pyramid screening incorporating maternal age and history,
upon which the rest of pregnancy care is built. gestational age, NT measurement, PAPP-A and
KFOG Journal | April - June 2023 7
free beta-hCG has become the preferred screening
modality worldwide due to its high detection rate transvaginal assessment was a part of the protocol.
(90% for trisomy 21, about 95% for trisomies 13 and Conditions like acrania, alobar holoprosencephaly,
18), low false positive rate and cost-effectiveness. limb body wall complex can always be diagnosed
The performance can be improved further by adding at 11-14 weeks; other conditions like open neural
on ultrasound markers like nasal bone, ductus tube defects can be diagnosed with careful scrutiny;
venosus Doppler, tricuspid regurgitation and other others like agenesis of corpus callosum still evade
serum markers like PLGF and AFP. detection at this period of gestation.
In the past decade, NIPT has emerged as a challenger Early diagnosis of fetal aneuploidies/ anomalies
to the combined test because it offers a higher provides the opportunity for early termination of
detection rate (>99% for trisomy 21) for a much pregnancy which is preferable to midtrimester
lower false positive rate (0.1%). The one significant termination.
argument against it being used for universal
Assessment of multiple gestations
screening is the cost. Most centres prefer to use it in
special situations like advanced maternal age or in Multi-order pregnancies are at increased risk for
the intermediate risk group (contingent screening). perinatal morbidity and mortality; this risk is most
Many laboratories have also included screening for influenced by chorionicity. Monochorionic fetuses
common microdeletions in their portfolio, but these are at double the risk for perinatal mortality than
haven’t been validated satisfactorily. their dichorionic counterparts. First trimester is
the best time to determine the chorionicity based
It should be remembered that above mentioned
upon which, an appropriate plan to monitor and
tests are all screening tests; screen positive patients
manage these pregnancies can be chalked out. In
should undergo a diagnostic test like CVS or
addition, large differences in the NT of two fetuses
amniocentesis before concluding that the fetus is
or discrepancy in DV flow patten could be early
affected.
signs of TTTS and could serve as further tools to
Screening for structural anomalies triage multi-order pregnancies.
The understanding that increased NT is Screening for preeclampsia and FGR
also associated with structural defects (cardiac
anomalies, CDH, omphalocele etc.) led to an Recent years have seen a renewed interest
attempt to diagnose fetal structural anomalies in screening for conditions which arise out of
during the 11-14 weeks scan. Recent data suggest abnormal placentation. First trimester presents
that the detection rate for fetal anomlies is around a unique window of opportunity in this regard
50%. Higher detection rates can be achieved when as any intervention to prevent preeclampsia or
8 KFOG Journal | April - June 2023
FGR must be initiated before 16 weeks ie before birth before 34 weeks by 35-40%. In those with
the second wave of placentation is complete. history of preterm birth, early elective cerclage may
be planned if the 11-13 weeks scan demonstrates
Screening based on maternal characteristics
no major fetal abnormality. Alternatively, these
and history alone identifies <50 % of women at
patients may be placed on 2 weekly surveillance and
risk for preeclampsia which is unsatisfactorily.
cerclage may be placed when cervical length is <2.5
Throwing mean arterial pressure, mean uterine
mm. Both strategies reduce the risk of preterm birth
artery PI and serum PlGF into the mix predicts
before 34 weeks by 25%. Serial cervical assessment
about 90% of early PE (<34 weeks), 75% of
starting at 14 weeks is also recommended in women
preterm PE (<37 weeks) and 45% of term PE
with history of other risk factors like unicornuate
(≥37 weeks), at screen positive rate of 10%.
or septate uterus. In twin gestations with cervical
Treatment with low-dose aspirin (150mg length of <2.5mm, vaginal progesterone may reduce
at bedtime) from 12- 36 weeks of gestation the risk PTB at <34 weeks by up to 30%.
effectively reduced the incidence of preeclampsia
Other areas of interest
before 37 weeks by 60%. With good compliance,
reduction rates of 75% can be achieved. Screening for SGA without preeclampsia,
gestational diabetes mellitus and fetal macrosomia
Timely administration of low dose aspirin
have shown some promise and it is likely that
also reduces the incidence of FGR which
algorithms and protocols will be available for the
translates into lower healthcare cost related
prediction of these conditions too in the near future.
to prematurity and neurodevelopmental
disability. To conclude, while there may be disagreements
regarding the number of visits proposed by
Screening for preterm labour
Nicolaides, there is no denying that the late first
Prematurity is the leading cause of neonatal trimester gives us the opportunity to get many things
deaths globally. As most spontaneous preterm right early on and provides a foundation upon which
births occur in women without history of previous the right plan of management can be constructed.
preterm birth, screening based on history alone is However, the uptake and implementation of above-
not effective. Using a combination of cervical length mentioned screening programmes have been less
measured vaginally and obstetric history increases than satisfactory, particularly in the peripheries.
the sensitivity of screening. This in turn provides an This may be due to ignorance from both the patients’
opportunity to prevent or delay preterm birth. and the doctors’ side, non-availability of laboratory
Natural progesterone given vaginally and cerclage facilities, relatively expensive nature of the tests
are the two strategies currently proven to prevent and social/religious factors. But whatever be the
preterm births. In asymptomatic women with a obstacles, we should strive to give our patients the
cervical length of <2.5mm, natural progesterone best possible start on their obstetric journey. Well
200mg given vaginally reduces the risk of preterm begun is half done.

KFOG Journal | April - June 2023 9

 Dr Pio James J
Consultant in ‘SRADHA’ -
Maternal Fetal Medicine unit.
Child Development Center &
SAT Hospital, TVM

SCREENING FOR Dr. Asha Biju

DOWN SYNDROME - Consultant in Fetal Medicine,
N S Co operative Hospital,

THE FACTS Kollam

Introduction:
When we look at the prenatal prevalence of ultrasound. They live a life expectancy of 45 to 50
chromosomal abnormalities, approximately 75% years and survive with lots of medical morbidities
is contributed by Trisomy 21/13/18 of which like severe learning disability, congenital heart
50% is contributed by Trisomy 21 alone. 50% of disease, endocrinological problems, leukaemia,
Downs syndrome (DS) foetuses will look normal in Alzheimer’s disease etc.

AFP
βHCG
Micronised Estriol
Inhibin A

Cell free Fetal DNA from

maternal blood

(After 11) weeks

Table: 1

• Triple Test has a very poor sensitivity. It is obsolete and should not be offered to the patient in the current scenario
as Quadruple test with better sensitivity and similar cost is available in the second trimester
• Quadruple test is done after 15 weeks, preferably after 16 weeks or fetal BPD measures >33mm

10 KFOG Journal | April - June 2023

 The definitive diagnostic test to detect DS DS screening is an optional test that should be
antenatally is by doing foetal Karyotype. This being offered to all pregnant mothers where the resources
an invasive procedure has inherent procedure are not constraint and if it is easily available. The
related complication, which cannot be offered to all. couple can opt in or opt out from doing the test for
many reasons of their own. However it is important
Hence the importance of screening tests. The
that every mother should be offered DS screening
challenge of an antenatal screening programme is,
in pregnancy.
therefore, to identify women in whom a risk of DS is
sufficiently high to justify such an invasive test and 4. What are the components in DS screening.
to minimise the risk of miscarrying a healthy baby. The components are
1. Whom to screen? A.Pre-test counselling: During a pre-test
counselling, it is very important to explain to the
Every woman who becomes pregnant is at a risk
patient and give adequate information regarding
of delivering a DS baby. Though the risk of delivering
a DS increases with maternal age, 85% of the babies (1) What is DS and its clinical significance
with DS in the society are born to mothers who are
(2) Explain age related risk
less than 35 years of age.
(3) Explain the test - Scan + blood test
Therefore, to reduce the prevalence of DS in the
community, age should not be considered as a sole (4) Maternal factors that influence the test
criteria to offer DS screening in pregnancy. (5) Gives probability only
2. What are the screening tests available? (6) Explain false positives and false negatives
Aneuploidy screening test that are available (7) Explain screen negatives
andwidely accepted are shown in Table 1
(8) Explain screen positives - Risk cut off 1:250
First trimester combined screening: Maternal
age related risk is considered as the background risk. (9) If the screening test becomes positives, the
On this background risk, ultrasound foetal markers definite diagnosis can be established only by
and maternal serum markers are incorporated to Invasive testing – Chorionic villus sampling (11-
obtain a probability 14wks) or Amniocentesis (after 15 weeks). The
procedure, complications, turn over time, cost
Fact: of the invasive procedure should be explained.
First trimester combined test appears to be the Fact:
best option to be offered at present as it includes
both maternal and foetal markers, done in • Pre-test counselling is best done by the primary
earlier gestational age, has a good sensitivity and obstetrician seeing in the obstetric unit. On an
comparatively cheaper. Though NIPT has a higher average, it will take at least 10 -12 minutes for
sensitivity, the cost is a limiting factor. counselling each patients.

3. Is it mandatory for all pregnant mothers • In a busy OPD, alternative methods like
to undergo Downs Syndrome screening group counselling by dedicated staff, video
in pregnancy? demonstration in the OPD or information
pamphlets should be provided.

KFOG Journal | April - June 2023 11

• Couple should be clearly explained that the test 5. What is the next step once the DS
is done only for aneuploidy screening (especially screening report is available
DS) and it does not detect any other genetic,
It takes 7 to 10 days to get the report depending
morphological or metabolic problems.
upon the lab. The couple is informed to review
B. Collect maternal details with the report as soon as they receive it. Post-
test counselling should be given. Screen negative
Once the couple opt to undergo screening,
pregnancies are reassured and followed up with
the following maternal details are collected from
target scan at 18-20 weeks. Screen positive patients
the mother and provided to the lab. 1. Race 2.
are referred to a geneticist or a foetal medicine
Correct maternal DOB 3. Method of conception 4.
specialist for further counselling and confirmatory
Singleton/Twins 5. Smoking status 6. IDDM 7. H/o
test ie Chorionic villus sampling (11-14weeks) or
DS. 8 Maternal weight - BMI
amniocentesis (after 16 weeks).
Providing this information to the lab is the
6. What are the common reasons couple opt out
responsibility of the primary obstetrician. These
of DS screening OR whom are the couple the test
factors can cause variations in the maternal
is not done?
serum analytes (PAPPA, f βHCG). Hence the
above information has to be incorporated into the • Patients for religious or some other reasons, who
software, so that measurements are normalised for do not accept termination
variation for accurate risk calculation.
• Patients who are not willing for invasive test
C. Foetal and Ultrasound parameters: (confirmatory) even if risk come screen positive
The accuracy of a screening policy is highly • Couples who are ready to accept a DS baby
dependant on the accurate measurements of Crown
• Financial constraints and unavailability of the
rump length (CRL) and Nuchal translucency (NT)
test nearby.
done by a trained personnel with accreditation -
trained sonographer/foetal medicine specialist. Summary
This is because, even a 5mm error in CRL can Screening for Down syndrome is an optional
change the combined risk by 0.5 – 2.14 times. test that should be offered to all pregnant mothers
Inaccuracies in NT as small as 0.5mm will have after a pretest counselling. The couple need to be
very significant negative impact on detection rate given an informed choice to opt in or opt out of the
(decrease18%). Screening should be done only in screening. Through every point of screening, the
a structurally normal foetus. Screening should not clinician is liable to answer their queries. Each and
be performed in a foetus with an NT measurement every component of screening is very sensitive for
more than 3.5mm errors and hence accreditations, quality control and
D. Collect maternal blood for maternal standards has to be assured in each level to get the
serum markers – PAPPA and f βHCG accurate risk out of the screening test. So the ob-
stetrician is liable to know the competency of the
E .Accredited lab and quality assurance:
imageologist and the Laboratory to whom we send
The maternal details, the fetal parameters (NT, for screening. If not done under strict standards, it
CRL), maternal blood analytes normalised for will do more harm than good for the patient and the
maternal factors (PAPPA, f βHCG) – all the above attending clinician.
information are fed on an analytical platform
Screening should be done only in a structurally
or an algorithm (which is accredited) and the
normal fetus. The best screening modality available
risk is calculated. The lab should be such that it
is the first trimester combined aneuploidy screen-
assure quality control, conduct regular audits and
ing (FTS). If we miss on FTS, second trimester Qua-
calculation of the medians. If there is a shift noted in
druple test should be offered. Triple test is obsolete
the median, the lab has to recalculate and readjust
and should not be offered as a screening modality.
the medians of each components periodically for
If the couple defer screening, it is very important to
the population to come to a LR.
document it in the antenatal chart that, screening
was offered but the couple deferred testing.

12 KFOG Journal | April - June 2023

 Dr Sindhu P
Senior specialist - Fetal
medicine, Aster Medcity,
Ernakulam.

FIRST
TRIMESTERS SCAN- Dr Pio James J
Consultant in ‘SRADHA’ -

A NECESSITY, NOT A FORMALITY Maternal Fetal Medicine unit.

Child Development Center &
SAT Hospital, TVM

F
irst trimester scan is done during the 11 – 13+6 pulmonary and skeletal disorders.
weeks period. For many of us, the 11-14 wks
3. Multiple pregnancy – the most important factor
Scan is for measuring Nuchal Translucency
for the management of multiple pregnancy is
(NT) and Aneuploidy screening. However it is is
the chorionicity. Best time to do it is before 14
beyond that. If appropriately done, it can detect most
wks with a sensitivity of 100% and a specificity of
of the major aneuploidies, major anomalies, and
99.8%. If we assign chorionicity at the anomaly
define patient specific risks for most complications.
scan, we could go wrong in 14% of the cases.
At present, First trimester screening is considered Labelling of twins is also extremely important
one of the most integral part of fetal care, not only in identifying them in subsequent follow ups,
because of the earlier point of examination but especially if the twins are discordant. Since the
also due to its diagnosing potential. In the current whole pregnancy management revolves around
medical practice, no fetal care is complete without the chorionicity and labelling, it is essential to
a good quality first trimester scan. This a strong document it in writing and in the form of image
statement, however the following aspects will help for future references.
in justifying this.
4. Screening for common aneuploidies during the
Scope of First trimester scan first trimester period is well established and well
1. Crown rump length (CRL) – one of the basic accepted. The high sensitivity and specificity
measurements during the first trimester scan. is majorly contributed by the ultrasound
Helps in accurate dating which is essential to parameters like CRL, NT and NB and also
identify growth disorders and prevent still births, biochemical markers like βhcg and PAPP A.
perinatal morbidity, iatrogenic prematurity etc The first trimester screening has a sensitivity of
around 85 – 90% with a 5% false positive rate.
2. Nuchal translucency (NT)– has evolved from The quality of the whole screening program
marker for Down syndrome to being a marker depends on the quality of the first trimester
for various conditions like other chromosomal scan.
abnormalities, genetic disorders, cardiac,

KFOG Journal | April - June 2023 13

5. Screening for structural abnormalities – this major comorbidity.
First trimester scan should be able to detect
7. Screening for open neural tube defects –
anomalies like
Intracranial translucency has helped shift the
Always detectable anomalies: Anencephaly, diagnoses of Open spina bifida from second
Alobar holoprosencephaly, body stalk anomaly, trimester to first trimester.
exomphalos, gastroschisis, megacystis
Advantages of First trimester scan:
Potentially detectable anomalies: Posterior
By doing a meticulous First trimester scan, every
fossa defects, spina bifida, facial cleft, cardiac
single antenatal woman can be stratified based on
defects, renal defects, Limb defects.
her specific risk for developing maternal or fetal
With modern ultrasound equipment and the complications. Accordingly, the great majority
improved expertise of sonologists, close to 65% of antenatal women will be classified as low risk
of anomalies that used to be picked up only in in whom the number of antenatal visits could be
the second trimester are now being increasingly substantially reduced to as low as just two visits
picked up in the first trimester. It opens a whole more for the rest of her pregnancy. The small
lot of options for the parents like testing for proportion of high risk women can therefore receive
chromosomal abnormalities, getting second better, specialised prenatal care.
opinions, prognosticating the abnormality
and planning antenatal and postnatal care. All Limitations:
this can be done without worrying about the First trimester scan relies heavily on ultrasound
legal time limitations for termination in India expertise of the operator right from getting a good
due to the earlier diagnosis. The extra time CRL , a good NT, dedicated anatomical survey of
can help expectant parents to come to terms the fetus to accurately measuring uterine artery.
regarding their child’s condition and to reach However it warrants adequate training and a
an appropriate decision. learning curve for expertise. At present a dedicated
6. Screening for preeclampsia – Hypertensive first trimester scan is only available in very few
disorders in pregnancy are the second biggest centers in our state.
cause of maternal mortality in our state after Conclusion:
hemorrhage, The detection rate for preeclampsia
with maternal factors alone is very poor. The objective of a First trimester scan should
Screening for preeclampsia with a combination not be only to confirm, localization, number,
of Mean uterine PI, maternal blood pressure, viability, and dating of pregnancy. However, its
biomarkers (PAPPA and PLGF) has a sensitivity manifestations are many fold. In clinical practice,
of 90% and 75% for the prediction of early and the obstetrician should know to whom we are
preterm preeclampsia, respectively, with a sending for the first trimester scan. It should not be
10% false-positive rate. Any doubts about the prescribed for a formality to be done by a random
usefulness of screening for pre-eclampsia were imageologist. Obstetricians should be aware of the
laid to rest when the ASPRE trial performance expertise around to get the maximum benefit out
results were finally published. If screen positive, of the first trimester scan. If there is no expertise
Aspirin prophylaxis started in the first trimester around, the best way to overcome this is to get
can help to delay the onset and risk reduction of trained ourselves.

14 KFOG Journal | April - June 2023

 DOPPLER IN FETAL Dr. Jyothi Mancheri
FRANZCOG, DDU (O&G), D.G.O,
GROWTH DNB, Fellowship in Fetal Medicine
(Australia) Senior Consultant in
RESTRICTION Fetal medicine N care IVF, Calicut

D
When there is placental damage, umbilical artery
oppler studies of the various vessels have
Doppler shows a definite, chronological change.
contributed enormously in the field of
When the placental involvement is 30% or more,
obstetrics. Fetal growth restriction (FGR)
there will be increased resistance in the umbilical
contributes to 40% of all intrauterine fetal demises
artery PI. When it is >50%, absent diastolic flow
and 25% of all perinatal morbidity. If we follow
and >70% reversal in the end diastolic flow.
the standard definition of estimated fetal weight
(EFW) less than 10 percentile as the criteria for FGR When there is placental dysfunction, there will be
diagnosis, more than 2/3rd will be constitutionally fetal hypoxia, leading on to compensatory changes
small. Doppler studies of various vessels are used in the foetus like preferential shunting of blood
to improve the detection and management of to brain, heart, adrenal and spleen. There will be
pathologically growth restricted fetuses. Major decrease in blood flow to organs like kidneys, liver,
vessels studied in relation to growth restriction muscle and bowel. It will manifest as decreased urine
are uterine artery, Umbilical artery (UA), Middle production and oligohydramnios, bowel ischemia,
cerebral artery (MCA), aortic isthmus and ductus cerebral vasodilatation and low resistance in middle
venosus (DV). Other parameters, which are widely cerebral artery etc. In extremely preterm fetuses as
studied but not part of the accepted guidelines as the tolerance to hypoxia is high the compensatory
of now, are umbilical vein and cardiac function changes and the changes in the umbilical artery will
evaluation. Use of Doppler has shown 38% reduction be seen in a chronological pattern.
in overall perinatal deaths (Neilson JP et al 2005)
In late onset FGR, this pattern is not seen as near
term fetuses have minimal tolerance to hypoxia.
Even before the placental damage is 30%, fetal
Umbilical Artery :
compromise may happen. Hence we cannot rely
Umbilical artery is the much-studied vessel in on the umbilical artery Doppler changes alone to
relation to FGR. For the diagnosis, prognosis and diagnose, prognosticate or manage late onset FGR.
management of early onset FGR umbilical artery
Middle Cerebral Artery Doppler :
Doppler changes is the most widely used Doppler
parameter. MCA Doppler is mainly used in the management
KFOG Journal | April - June 2023 15
of late onset FGR. MCA vascular resistance is almost Aortic Doppler:
constant throughout pregnancy. Placental resistance
This vessel reflects the balance between the
drops with gestation hence Cerebro placental ratio
impedance of the brain and systemic vascular
(CPR), the ratio of PI of MCA to UA, increases with
systems. In hypoxic fetus due to redistribution of
gestation. As previously mentioned, when there is
blood flow, there is increased vasoconstriction and
fetal hypoxia, the preferential blood flow to the fetal
peripheral resistance and rise in RI and PI values.
brain is reflected as the low resistance in middle
In the presence of severe hypoxia, diastolic flow
cerebral artery blood flow. This will be evident
reverses. This has strong association with both
as low pulsatility index in MCA. When there is
adverse perinatal and neurological outcome. AoI
placental dysfunction, MCA PI will start dropping
precedes Ductus Venosus abnormalities by 1 week
and the umbilical PI will start increasing. CPR will
be abnormal even before the individual parameters Ductus venosus Doppler:
are abnormal; hence it is a better predictor of fetal In early onset FGR the final stage of compensation
hypoxia. In general CPR of less than 1 is considered is fetal academia. This will be reflected as the
as abnormal. When hypoxia is severe, MCA PI tends changes in the ductus venosus flow. This is part of
to rise, which reflects development of brain edema. the cardiac compromise and the final warning before
MCA Doppler is used in the Barcelona staging of fetal demise. In about 50% of cases, abnormal DV
FGR as well as in timing of delivery of fetuses with precedes absent STV in cCTG. In about 90% of cases
late onset FGR. DV flow is abnormal 48– 72 h before the biophysical
Uterine Artery : profile is abnormal. Absent or reversed velocities
during atrial contraction are associated with very
Uterine artery blood flow indices have been
high perinatal mortality Hence DV abnormality is
used as a screening tool for FGR. Uterine artery
used as the cut off for timing the delivery
pulsatility Index (PI) along with maternal blood
pressure, Serum levels of PAPP-A, PLGF, and HCG
will predict 52 % of the early onset FGR and 20% of Application of Doppler
late onset FGR. (FMF UK)
Role of Doppler in diagnosing FGR- Delphi
Mean Uterine PI of more than 2.35 in the first consensus
trimester and 1.44 in the 2nd trimester is roughly
taken as cut off for categorizing patients in to high In order to distinguish between SGA and true
risk for FGR. Increased uterine PI along with SGA is FGR apart from severe
most likely related to placental or uterine cause for smallness and poor growth velocity, UA and MCA
FGR. 3rd trimester uterine artery Doppler resistance Doppler studies are included in Delphi consensus.
has been shown to be associated with abnormal
CPR. Uterine artery Doppler PI is incorporated in Role of Doppler in staging
the Barcelona staging protocol as one of the criteria and management of FGR
for distinguishing SGA from FGR As per the Barcelona protocol Doppler parameters

16 KFOG Journal | April - June 2023

 Reference:
1. Doppler in obstetrics diploma
in fetal medicine and ISUOG
educational series
2. Update on the Diagnosis and
Classification of Fetal Growth
Restriction and Proposal of
a Stage-Based Management
Protocol. Figuros F and Gratacos
E Fetal diagn Ther 2014
3. Consensus definition of fetal
growth restriction: a Delphi
procedure, S.
J. Gordijn Ultrasound Obstet
Gynecol 2016

of umbilical, MCA, DV and uterine artery Doppler

studies will help to assess the severity of growth
restriction and plan the follow up and timing of
delivery.
Conclusion:
Doppler study of the fetal and uterine vessel
has made tremendous progress in the field of fetal
growth restriction. Before 30 weeks Umbilical
artery Doppler is used to diagnose and monitor FGR
and DV flow assessment helps to time the delivery.
After 30 weeks, UA and MCA with uterine artery
Doppler will compliment biometry in diagnosing,
monitoring and timing the delivery. FGR being the
commonest cause of unexpected fetal demise and
the diagnosis is still not 100% more work is needed
in this field to reduce the morbidity and mortality
related to FGR.

KFOG Journal | April - June 2023 17

 Dr.Rinshi Abid
Elayedatt
Amrita Institute of
Medical Sciences, Kochi

INTERVENTIONS IN Dr. Vivek Krishnan

COMPLICATED Amrita Institute of

MONOCHORIONIC TWINS Medical Sciences, Kochi

TO IMPROVE OUTCOME

INTRODUCTION stage 1 with progressive polyhydramnios, short

cervix, maternal distress or cardiac compromise in
The incidence of monozygotic twinning unlike the the recipient and Stage II, III TTTS .(figure 1)
dizygotic is stable, similar across countries, unaffected
by artificial reproductive techniques, advanced maternal (ii) TAPS is a form of chronic feto-fetal transfusion,
age or other factors. However, despite forming only characterized by inter-twin hemoglobin differences
20% of all twins, the monochorionic (MC) twins have in the absence of amniotic fluid discordances.
a higher rate of perinatal mortality due to higher risk TAPS may occur spontaneously (5%) or post
of complications secondary to their placental sharing. laser treatment for TTTS (2-13%). Even though
Additionally, the monochorionic monoamniotic intrauterine transfusion (IUT) can result in
(MCMA) which forms 5% of MC, are at further risk temporary symptomatic treatment for the donor,
of perinatal mortality due to twin related congenital the only causal treatment is fetoscopic laser
abnormalities and cord related complications. Hence, coagulation of the anastomotic vessels. (figure 2)
a timely fetal intervention in these complicated (iii) TRAP sequence seen in 2.6% of MC pregnancies,
pregnancies can result in improved neonatal survival is an acute difference in arterial pressures between
rates. twins, resulting in a unidirectional flow in the
Indication for intervention in MC Twins reverse direction. The perfusion of the acardiac
twin results in high-output cardiac failure in the
The complications unique to MC pregnancy include pump twin, which is a poor prognostic factor
Twin to twin transfusion syndrome (TTTS), Twin requiring intervention. Others include abnormal
anemia polycythemia sequence (TAPS), Twin reverse doppler indices of the pump twin and the ratio of
arterial perfusion (TRAP) sequence, monoamniotic the weight of the acardiac twin to the weight of the
pregnancy and conjoined twinning. Complications like pump twin > 0.7 (figure 3)
TTTS, TAPS, TRAP are primarily due to the abnormal
placental vascular anastomoses connecting the two (iv)Selective fetal growth restriction (sFGR), in MC twins
fetal circulations. is when one fetus has estimated fetal weight (EFW)
< 10th centile and the intertwin EFW discordance
(i) TTTS occurs due to deep arteriovenous (A-V) is > 25%. This could be structural anomalies, viral
anastomoses seen in 15% 25% of MC twins while infections, chromosomal abnormalities, or due to
clinically significant TTTS occurs only in 1% of MC. unequal sharing of the placenta and vasculature.
Untreated severe TTTS has a poor prognosis with sFGR, are classified based on the pattern of end-
a perinatal mortality rate of 90%. In those before diastolic velocity at umbilical artery doppler.
26 weeks of gestation, there is a higher risk of fetal (table 1) The survival rate in Type-I sFGR is greater
loss, and severe handicap in the surviving twin. than 90%. Type-II sFGR is associated with a higher
Indications for intervention in TTTS include, TTTS

18 KFOG Journal | April - June 2023

 1.FETOSCOPIC LASER ABLATION
Indications
1. TTTS - In stage 1 with progressive polyhydramnios,
short cervix, maternal distress or cardiac compromise
in the recipient, Stage II, III
2. In selective fetal growth restriction type 2 or 3 to
salvage both the babies
3. TRAP
This is based on the principle of interruption of inter-
risk rate of complications, (IUD of either twin is twin vascular anastomoses (the AA, AV, VV) by laser
seen in up to 29% and risk of neurological sequelae ablation under local anesthesia, using a 2 mm fetoscope
in up to 15% of cases born prior to 30 weeks). Type- with the laser machine is set at 20 - 40W power and
III sFGR is associated with a 10– 20% risk of sudden the laser is fired at short bursts of 3-5 seconds, till
death of the growth-restricted fetus, and up to 20% the anastomotic vessels are blanched following which
risk of neurological morbidity in the survivor. If all the ablated areas are connected by the Solomon’s
there is a substantial risk of fetal demise of the co- technique (equatorial laser dichoronisation), which
twin before 26 weeks, a selective termination may reduces recurrence of TTTS (seen in 14%) and post-
be considered to protect the cotwin. laser TAPS (seen in 13%)
Type-I sFGR managed expectantly have good Follow up- is weekly for 2 weeks to assess for fetal
perinatal outcome. However, fetoscopic laser anemia, presence of fetal bladders, liquor, dopplers
ablation in Type-II or -III sFGR resulted in and interval growth. Further follow up is fortnightly till
higher rate of mortality but lower morbidity than delivery between 34 to 36+6 weeks
expectant management. There is lack of evidence
on data on the outcome following selective The Eurofetus consortium randomized trial concluded
reduction in the prenatal management of sFGR. that, fetoscopic laser coagulation is more effective
Hence management of these cases should be first line treatment than serial amnioreduction
individualized based on the gestational age at for severe TTTS diagnosed before 26weeks and it
diagnosis, severity of discordance and the type of was further concluded by Cochrane review that it
Sfgr. should be considered the treatment for all stages of
TTTS to improve the neurodevelopmental outcome.
(v) Single fetal demise- can result in sudden Amnioreduction can be considered in those diagnosed
hypotension in the survivor from immediate after 26weeks.
exsanguination through the vascular anastomoses
in to the dead fetus resulting in ischemic/hypoxic
lesions in the survivor. This can result in 15% risk of
fetal death and 25% risk of neurologic handicap and
preterm delivery of 68%. In SFD before 24 weeks,
delivery is recommended. If beyond 24 weeks, the
pregnancy is best terminated on attainment of
lung maturity in the survivor. Later in gestations,
SFD could theoretically trigger coagulation defects
in the mother requiring a baseline coagulation
profile in the mother and a follow up. Anemia
in the survivor may need an intra-uterine blood
transfusion. Hence a fetal blood sampling helps
to rule out fetuses that are not anemic and hence
unlikely to develop a cerebral lesion.
Methods of fetal intervention -
The antenatal management of these complications in
MC pregnancies involves, fetoscopic laser ablation,
thus salvaging both the twins, or by selective fetal
reduction by procedures like bipolar cord coagulation,
radiofrequency ablation or interstitial laser ablation.

KFOG Journal | April - June 2023 19

2. SELECTIVE FETAL REDUCTION is monitored after the procedure by MCAPSV and
amnioreduction is considered if polyhydramnios.
“Selective termination” involves reduction of a fetus
with severe defects or one that is expected to die later c. INTERSTITIAL LASER ABLATION- of the intra-
in the pregnancy, or that would threaten the life of the abdominal portion of the umbilical cord using an
survivor. 18G 15cm large bore needle, which allows 600micron
diameter laser fiber through it to coagulate the umbilical
This is done by by bipolar cord coagulation, intra- cord vessels resulting in cessation of cardiac activity.
fetal laser ablation or radiofrequency ablation (RFA) of This procedure is done in fetuses is less than 19 weeks
the interstitial cord vessels. of gestation.
Indication: Monochorionic twins with Follow up- After the procedure, follow up is weekly
a. Discordant anomaly in one of the twins for 2 weeks and a neuro sonography of the survivor
is recommended after 4 weeks. Post procedure, the
b. Severe selective FGR- type 2 or 3 pregnancy is managed as singleton.
c. TRAP with Pump twin compromise
d. TTTS with cardiomyopathy in the recipient Outcomes following fetal intervention
a. RADIOFREQUENCY ABLATION (RFA) - This is Fetoscopic laser in severe TTTS resulted in higher
usually done between 16-24weeks of gestation using likelihood of survival of at least one twin to 28 days of
a 17G RF needle introduced to the fetal abdominal age in 76 %. And on follow up, at 6 months of age, these
cord insertion under ultrasound guidance, to cause infants had a lower incidence of cystic periventricular
coagulation of an area of 2cm diameter and a complete leukomalacia and were less likely to have neurologic
cessation of blood flow in the down- stream portion of complications. Perinatal outcome of complicated MC
the cord. twins remained same with RFA or BPC with similar
b. BIPOLAR CORD COAGULATION- is done under survival rate of 88.9% and 76.5% respectively.
ultrasound guidance using a 3mm bipolar forceps, However, RFA appeared particularly useful in sFGR
grasping the umbilical cord and coagulating with a and in those requiring selective termination later in
power set at 40W applied in short bursts of 10sec. At gestation and beyond the period of viability.
least 2 different sites on the cord are coagulated. Cotwin

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