Author: Lalit K Sharma, MD, Raj Sonography & X- Ray Clinic, Baiju Choraha, Nayapura, Guna, Madhya Pradesh, India E-mail : drlksharma_guna@yahoo.co.in
Introduction
Guna is a district in the Gwalior Division of Madhya Pradesh with 7 tehsils and 5 blocks and 1,338 villages. The district has a population of 1,240,938 with the majority (n=928,171) residents of rural areas. There are 15 primary health centres and 1 District Hospital at Guna. The literacy rate of Guna is 65.1 and the male: female ratio is 910. The uptake of antenatal care service is suboptimal in Guna. First trimester services were utilized by 60.7% pregnant women and only 31.9% of pregnant women had at least four antenatal visits. The prevalence of anaemia among pregnant women was 55%. Folic acid consumption for more than 100 days during pregnancy was reported by 21.2% women, and 57.2% of women reported receiving postnatal care within 2 days of delivery. Most of the childbirths were institutional (90.1%) and at public health facilities (86.1%). The reported caesarean section rate was 3.9. Health checkup of the new-born baby within 2 days of birth was reported by 18.1%.
Samrakshan is a national program of the Indian Radiological and Imaging Association that aims to reduce perinatal mortality in India. The program focuses on early identification of Pre-eclampsia (PE) and Fetal Growth Restriction (FGR) with doppler integrated ultrasound-based fetal assessments at regular intervals. The 1st trimester and 2nd assessments provide every pregnant woman with a customized risk score for the possible development of preterm PE and FGR. The 3rd-trimester assessment focuses primarily on the staging and classification of FGR and integration of a stage-based protocol for childbirth management. In this manuscript, we report on the performance of the Samrakshan program delivered by Dr Lalit Sharma through the Raj Sonography & X-Ray Clinic, at Nayapura in Guna district, Madhya Pradesh from October 2019 through November 2020.
Map Locating Guna District, Madhya Pradesh
Methods
We have previously published the assessment protocols that Samrakshan utilizes to screen pregnant women. Briefly, the protocol integrates fetal doppler assessments with the routine trimester-specific ultrasound-based assessments. In the 1st trimester, this involves assessment of mean uterine artery pulsatility index (PI), assessment of mean artery pressure and the use of an online calculator to develop an individualized risk score for preterm PE and FGR for each pregnant woman. The 2nd trimester integrates fetal doppler studies of the uterine and umbilical artery to the ultrasound-based Targeted Imaging For Fetal Anomalies (TIFFA) scans and assessments of fetal environment and growth. The 3rd-trimester studies integrate fetal Doppler studies to ascertain FGR and provide stage-based management for pregnant women. A unique ID is provided for each woman and details of each visit are documented in an offline form. The details are further transcribed to an online form linked to a spreadsheet in a secure environment.
Samrakshan has several other program elements. These include education for professional peers through webinars, the publication of research based on Samrakshan data, training programs, and mentoring of peers, interdisciplinary outreach programs to professional peers including obstetricians and neonatologists, health education and awareness programs for the public and paramedical personnel.
Results
The Samrakshan program led by Dr Lalit Sharma at Guna screened 181 pregnant women in the 1st trimester, 206 pregnant women in the 2nd trimester and 313 pregnant women in the 3rd trimester. The trimester-specific details of the screening are provided below.
Table-1: First Trimester Screening of 181 pregnant women
| Characteristic | N (%) |
| Maternal Smokers | 6 (3.31%) |
| History of PE in family | 1 (0.55%) |
| Natural Conception | 179 (98.90%) |
| Nulliparous | 113 (62.43%) |
| Maternal Age >35 years | 16 (8.84%) |
| Chronic Hypertension | 7 (3.89%) |
| Type 2 Diabetes Mellitus | 1 (0.55%) |
| PE in prior childbirth | 7 (3.89%) |
| High risk for PE (1 in 150 cutoff) | 58 (32.04%) |
| High risk for PE (1 in 100 cutoff) | 37 (20.44%) |
| High risk for PE (1 in 50 cutoff) | 16 (8.84%) |
| High risk for FGR | 56 (30.94%) |
| Low Dose Aspirin Recommended | 74 (40.88%) |
| Mean Uterine Artery PI 95th percentile | 2.76 (95% CI: 2.64, 2.92) |
| Mean Uterine Artery PI 85th Percentile | 2.40 (95% CI: 2.18, 2.54) |
Table-2: Second Trimester screening of 206 pregnant women
| Characteristic | N (%) |
| Maternal Age > 35 years | 15 (7.28%) |
| Natural Conception | 205 (99.51%) |
| Nulliparous | 144 (69.90%) |
| Identified earlier (Known) as high risk of PE | 32 (15.53%) |
| Women already on low dose aspirin | 37 (17.96%) |
| Regular Compliance with Aspirin | 32 (15.53%) |
| Chronic Hypertension | 7 (3.40%) |
| Early FGR | 10 (4.85%) |
| Structural Anomaly | 2 (0.97%) |
| High risk for preterm PE | 9 (4.37%) |
Table-3: Third Trimester Screening of 313 pregnant women
| Characteristic | N (%) |
| Maternal Age >35 years | 33 (10.54%) |
| Natural Conception | 310 (99.04%) |
| Nulliparous | 238 (76.04%) |
| Women at high risk for preterm PE | 35 (11.18%) |
| Chronic Hypertension | 11 (3.51%) |
| Gestational Diabetes | 5 (1.60%) |
| Type 2 Diabetes | 2 (0.64%) |
| Mean Uterine Artery PI >95th percentile | 64 (20.45%) |
| Umbilical Artery PI >95th Percentile | 18 (5.75%) |
| Middle Cerebral Artery PI <5th percentile | 56 (18.30%) |
| Cerebro-Placental Ratio <5th percentile | 79 (25.24%) |
| Estimated Fetal Weight | |
| <3rd percentile | 45 (14.38%) |
| 3rd to 10th percentile | 37 (11.82%) |
| 10th to 50th percentile | 138 (44.09%) |
| >50th percentile | 93 (29.71%) |
| Abnormal Doppler | 123 (39.30%) |
| FGR Stages | |
| No FGR | 190 (60.70%) |
| Stage 1 FGR | 106 (33.87%) |
| Stage 2 FGR | 3 (0.96%) |
| Stage 3 FGR | 12 (3.83%) |
| Stage 4 FGR | 2 (0.64%) |
| Decelerating Fetal health | 42 (13.42%) |
| Recommended Steroids for Lung Maturity | 15 (4.79%) |
| Recommended CTG monitoring | 25 (7.99%) |
| Recommended Immediate Delivery | 48 (15.34%) |
Table-4: Childbirth outcomes of 279 women screened in the Samrakshan Program at Guna
| Parameters | |
| Mother Developed PE | 16 (5.73%) |
| Preterm PE (<37 gestation weeks) | 11 |
| Maternal Mortality | 1 |
| Fetal Growth Restriction | 94 (33.69%) |
| Stillborn | 6 (2.15%) |
| Mean (SD) birth weight at birth | 2699.40 (524.99) |
| Neonatal Mortality | 8 (2.87%) |
Table-5: Samrakshan Related Activities by Dr Lalit Sharma
| Activities | |
| Webinar -Faculty | 5 |
| Webinar -Moderator | 3 |
| Presentations | 2 |
| Research Papers | 9 |
| Outreach Programs | 8 |
| District Level Training Program | 1 |
Important Findings
- Most pregnancies are natural conception.
- Nearly 1 in 10 pregnant women are aged >35 years and approximately 75% of the pregnant women aged older than 35 years are multiparous. Elderly pregnant women are a high- risk category for fetal and maternal complications. The possibility of a targeted program to increase awareness in this subgroup exists.
- The screened population has a low prevalence of comorbidity (< 5%).
- The 1st-trimester algorithm identified 1 in 3 pregnant women as high risk for preterm PE and FGR.
- Nearly 5% of fetuses had early growth restriction in the 2nd trimester while only 1% had structural abnormalities. The 2nd-trimester screening protocol identified nearly 5% of pregnant women were identified as at high risk for preterm PE.
- An abnormal Doppler study was present in nearly 40% of 3rd-trimester pregnant women.
- The 3rd-trimester screening protocol identified nearly 1 in 4 fetuses with an estimated fetal weight less than the 10th percentile
- Approximately 15% of fetuses screened in the 3rd trimester had decelerating fetal health and were recommended immediate childbirth.
- Approximately 5% of the women who delivered had developed PE and preterm PE was more common than term PE.
- The integration of fetal doppler studies identified more fetuses at risk for adverse events.
- Lalit Sharma is leading health education initiatives at Guna to improve awareness about fetal health, wellbeing, and appropriate tests among various stakeholders at Guna. These include district health officials, doctors, ANMs, ASHA workers and the public.
- A targeted focus on elderly pregnant women can help reduce adverse events during pregnancy. These can include improved awareness about the possibility of complications in this subgroup and education about planning family sizes.
- Antenatal imaging services focus more on structural abnormalities. The preliminary data from this rural district highlight the significantly larger proportion of pregnant women at risk for pregnancy-induced hypertension and fetal growth restriction. Pre-eclampsia and Fetal Growth Restriction are major causes of fetal and maternal complications. The Radiologist can identify pregnant women at risk for these conditions early and initiate preventative therapy early in pregnancy. The integration of fetal doppler studies and the determination of a customized risk will not take additional time and can be done with the routine antenatal imaging assessments.
- Delays in accessing care and compliance with suggested recommendations remain major limitations. These can be mitigated to some extent by improved awareness and counselling.
- Shifting the paradigm to include comprehensive imaging assessments not limited to structural abnormalities can possibly significantly reduce the number of adverse events during childbirth.
- These can lead to substantial gains in perinatal and neonatal mortality statistics that utilize existing infrastructure and personnel in a more optimal manner and without much additional investment