National Fetal Growth Restriction Awareness Week 2022

Samrakshan is a national initiative of the Indian Radiological and Imaging Association (IRIA) that addresses safe motherhood and issues relating to the growing fetus and pregnant women in India. Fetal Growth Restriction (FGR) or suboptimal growth of the fetus is a major problem in India with short and long-term consequences on health. Samrakshan conducted a National Fetal Growth Restriction Awareness Week 2022 jointly organized by IRIA Preventive Radiology and IRIA Kerala in association with Journo Med and MedPiper Technologies. These were a series of educational webinars that discussed clinical practice based on actual clinical cases. 

The first educational webinar focused on two core themes- a) the “Importance of Dating the Pregnancy for FGR Detection” and b) “Is the screening for first-trimester pre-eclampsia (PE) and Fetal Growth Restriction (FGR) necessary?”

Dr Shilpa Satarkar, National Coordinator for Samrakshan welcomed the panellists and highlighted the poor perinatal statistics in India including the high maternal mortality rates Dr Rijo Mathew Choorakuttil, Founder of Samrakshan India discussed the conceptual development of Samrakshan and the initiation of the program through IRIA during the presidentship of Dr Hemant Patel. Samrakshan focused on the reduction of perinatal mortality through the integration of available, affordable, accessible technology with regular antenatal care and emphasized the importance of two of the major contributors to perinatal mortality in India- Pre-eclampsia (PE) and fetal growth restriction (FGR). Dr Rijo emphasized that India has a high magnitude of FGR and PE and attempts to reduce perinatal mortality rates in India must address both FGR and PE. Current Imaging approaches to pregnancy in India focus primarily on the detection of congenital anomalies and the focus must expand to the screening and early detection of pregnant women at risk for PE and FGR. 

The evidence from India was presented briefly to illustrate the significant changes that the Samrakshan protocols with the introduction of fetal Doppler studies, a low-dose aspirin for high-risk women and staging of FGR made on the perinatal statistics of India. The initial results of the Samrakshan program which was done in 28 districts in India and 15 states of India (published in the Indian Journal of Radiology and Imaging in 2022) were presented briefly to highlight the significant changes in the PE and FGR rates and perinatal mortality. Dr Rijo emphasized that we have evidence from our clinical practice on our population regarding the benefits of the protocols, which must be included in routine screening. He also said that the program will expand its focus to include other drivers of poor perinatal health including perinatal asphyxia, low birthweights, preterm births and stillbirths. 

Case-based panel discussions on Samrakshan Protocol for First Trimester

Panellists

The panel included several leading clinical radiology and obstetrics practitioners from India. Dr Lalit Sharma is the Joint Coordinator of Samrakshan and is a leading Radiologist from Guna, Madhya Pradesh with several decades of work in Fetal Radiology. Dr Akanskha Baghel is a Fetal Radiologist practising at Harda in rural MP and is a leader of the Madhya Pradesh Samrakshan Team. Dr Gulab Chhajer is a Fetal Radiologist from Sumerpur, Pali, Rajasthan and is a leader of the Rajasthan Samrakshan team. Dr Tejashree Patekar is a Fetal Radiologist from Nashik and is a leader of the Maharashtra Samrakshan team. Dr Yamini Mankar is a leading clinical Gynecologist from Harda who has elevated the levels of maternal care in Harda and its surrounding areas.

Key Takeaways from the case discussions

Dating of Pregnancy

Estimating a reasonably accurate expected date of delivery is an essential aspect of pregnancy care. This is important as the assessment of the normal growth of the fetus is based on the expected age of the baby which is determined by the dating process. It is preferable to estimate the date in the first trimester as the accuracy can reduce when estimated at later stages of pregnancy. The dates can be estimated based on the last menstrual period; however, this can have some errors especially as the last menstrual period may not be accurately recalled by the woman. The dates can also be assessed using an ultrasound examination in the first trimester of pregnancy, which provides a more objective assessment of the expected date based on certain structural parameters. 

Every baby has an anticipated growth potential for each week of gestational age in the womb of the mother. The accuracy of dating becomes very important as the estimation of normal or reduced or more than appropriate growth is based on the expected growth for each gestational week. If the dating is inaccurate, we might end up calling a fetus normal growth when it is undernourished or growth restricted, or we might end up calling a fetus growth restricted when it is a normal growth baby. This has consequences on the decisions around childbirth including the timing and mode of delivery and carrying a pregnancy to term. Dating is also essential as several important screening tests are to be done at certain gestational weeks for optimal results. These include screening to estimate the risk of preterm PE, FGR, screening for congenital abnormalities, and assessment of gestational diabetes amongst others. 

The case discussions highlighted these aspects of pregnancy care.

Screening for Preterm PE and FGR

Pre-eclampsia (abnormal blood pressure in pregnancy) and fetal growth restriction are major causes of fetal and maternal ill health and death. We can screen to identify the risk for pregnant women to develop these dangerous conditions. The screening can be done early during pregnancy and between 11-14 weeks of gestation. The clinical information of each woman including past pregnancies, risk factors, mean arterial blood pressure and mean uterine artery doppler indices are combined to estimate an individualized risk for each woman, The risk assessment can be done during the routine antenatal checkup at 11-14 weeks and is a painless, non-invasive process that does not take more than 5 to 10 minutes. The information is entered into a computerized online calculator and the risk for each pregnant woman can be determined. Based on the risk, the doctors will categorize women as “low risk” or “high risk” for the development of preterm PE and FGR. 

Why is this classification important? Women classified as high risk are started on low-dose aspirin 150 mg once daily at bedtime to minimize or reduce the risk of development of preterm PE and FGR. Low-dose Aspirin is more effective when started before 16 weeks and has a reduced effectiveness when started later than 16 weeks (although it can still be started at that time). Low-dose aspirin is recommended till 36 weeks of pregnancy, childbirth or development of preterm PE, whichever is earlier. 

Low-dose aspirin helps to minimize the risk of preterm PE and FGR by improving or acting on the uteroplacental insufficiency and blood flow to the uterus and thereby fetal blood flow. Low-dose aspirin is effective to reduce the transition to preterm PE in the majority of women and prevents the development of preterm PE in over 70% of high-risk women. The recommended dose for optimal benefits is 150 mg once daily at bedtime which is a low dose with minimal gastric side effects. However, it is possible that some women may not tolerate this dose. In such cases, we can consider alternating a further lower dose (75 mg or 80 mg) with 150 mg on alternate days. It is not recommended to reduce the dosage when the risk estimates change to a “low risk” later in pregnancy as the shift in risk can be due to the beneficial effects of aspirin. Current evidence suggests that low-dose aspirin does not have major side effects when used as a preventative measure in pregnancy.

Evidence from Samrakshan

The Samrakshan program of IRIA has analyzed the data of several thousands of pregnant women in India and found that the screening protocols for the identification of pregnant women at high risk for preterm PE and FGR in the first trimester are very effective. Evidence from Samrakshan has shown that more than 70% of high-risk women provided low-dose aspirin starting from the first trimester did not develop preterm PE later during pregnancy. 

Essential Points

• Make sure an accurate dating of pregnancy has been done. DO NOT CHANGE the dating once it has been done (unless there is a gross error in the estimation)
• Measure the Mean arterial blood pressure in the first trimester of pregnancy
• Measure the mean Uterine artery Pulsatility Index using a fetal Doppler test
• Estimate an individualized risk for the development of preterm PE and FGR for each pregnant woman.
• Suggest biochemical markers for those who can afford the tests and if there is a doubt about the risk estimation
• Routine antenatal assessments in the first trimester include risk assessments for congenital abnormalities. DO NOT STOP THERE. REPORT the RISK FOR PRETERM PE AND FGR as well.
• Start the high-risk pregnant woman on low-dose aspirin 150mg once daily at bedtime.

The high magnitude of pre-eclampsia and fetal growth restriction in India can be reduced significantly by incorporating regular screening for the identification of high-risk women into routine antenatal assessments between 11-14 weeks. The Samrakshan program provides evidence for the significant benefits that occur when we include risk estimations with routine first-trimester antenatal scans. The evidence has been reviewed by experts and is accepted for publication in the official journal of IRIA- the Indian Journal of Radiology and Imaging.