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Risk assessment during pregnancy - sparingparents of bad surprises

Risk assessment during pregnancy, as proven globally, helps mitigate not only abnormalities in thegrowing foetus but also the advancement of non-communicable diseases in the expecting mother.

Such assessment and clinical intervention spare the anxious parents of bad surprises at birth. Thebasis risk assessment is tri-fold: very early risk assessment done in the first trimester (between 11and 14 weeks of pregnancy), bio-chemical observation which considers the composition of certainhormones in mothers blood stream which can be done either in the first trimester or mid trimester(16 to 18 weeks) and the structural scan, explained Dr. Nalinda Rodrigo, Consultant Obstetricianand Gynaecologist.

NT screening

As pointed out by Dr. Rodrigo, majority of cases where babies are born with genetic or congenitalproblems and other high risk factors can be identified through the intervention of NT screening andNasal Bone Measurement. In the case of NT screening, the fluid which is collected behind the

babys neck during formation is measured by its mucus thickness, for the purpose of identifyingvaried chromosomal make-ups such as Downs syndrome. NT which can only be measured between11-14 weeks of pregnancy can also reflect major structural defects. Although structural defects suchas cardiac problems, will not be visible at this stage, they will be represented in form of increasedmucus thickness, cited Dr. Rodrigo.

NT which is an ultrasound examination that requires no special preparation, is generally performedexternally (through the abdominal wall) and seldom an internal scan through the vagina for betterimaging of the growing foetus. A positive NT may indicate a baby with a higher risk of genetic andchromosomal problems such as Downs syndrome and also indicate a high risk pregnancy resultingwith babies of low birth weight, explained Dr. Rodrigo adding that in case of a positive result, furthertesting and closer monitoring of the pregnancy is required.

NT screening enables the identification of both lethal and non-lethal defects, latter which can bearrested with the intervention of drugs and corrective surgery. In the case of the former, theinformation elicited through screening enables to look after the next pregnancy in a more productivemanner. A very good example is continuous bleeding which is evidence of an inevitablemiscarriage. In such occurrences, the observation arrived with the aid of a NT screening will facilitatea better outcome in the next pregnancy, explained Dr. Rodrigo adding that NT screening is mostuseful for pregnant women over 35 years, those with diabetes, hyper tension and those who have

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experienced previous complicated pregnancies and those who have a history of genetic or structuraldefects within the family.

Nasal Bone MeasurementCombined with NT screening is the Nasal Bone Measurement which enables the detection of babies

with Downs syndrome. Nasal bone is one feature which appears inearly foetal life and the nasalangle between the front of the face and the upper palate which is termed fronto maxillary facial(FMF) angle, determines how flat the face could be. In case of babies with Down syndrome, thenasal bone is very short resulting in a flat facial countenance, elaborated Dr. Rodrigo.

As observed by Dr. Rodrigo, the commonest lethal genetic syndrome which can affect the growingfoetus is cardiac failure. In such identified cases of cardiac failures, a considerable accumulation ofblood can be perceived in the right side of the heart, obstructing the pumping of the same. Thereversal of blood which results in the blockage of heart valves (known as Tricuspid regurgitation) isclosely connected to liver. The changes which could occur in liver blood flow functioning is referredto as Ductus Venosus Doppler and a velocity study of blood of the foetus can help identify thisdefect, cited Dr. Rodrigo.

Structural defects

The composition of various hormones in mothers blood which are secreted by the developingplacenta is another assessment available to determine a bad pregnancy resulting in geneticallyabnormal babies. The assessment can be done between 9-13 weeks of pregnancy or a triplequadruple test can be carried out from 14-22nd week, which takes into account the concentration ofplacental hormones. This assessment helps identify about 65% of what are called bad pregnancies,pointed out Dr. Rodrigo who further said that in such cases, counseling can be offered to theparents-to-be. The main objective of such counseling, as observed by Dr. Rodrigo is to prepare theparents to accept a baby with a growth restriction or prepare the mother to manage pregnancy-induced hyper tension. Such counselling will help the expecting mother to take precautions such asregular medical supervision and better nutrition s required, he added.

High blood pressure which is considered the number one killer during pregnancy can be largelymanaged today with the advent of uterine artery blood flow assessment. Today, rather than lookingat things in the fifth month which was the standard practice, now assessment is possible even duringearly pregnancy, as early as 11th to 14th week of the pregnancy. The appearance of a notch in theblood circulation in the uterine artery will help determine hyper tension which can in turn be treatedwith small doses of aspirin, explained Dr. Rodrigo.

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The structural scan which enables the identification of cleft palate as well as cardiac defects,facilitates clinical interventions which benefit the new born child in the long run. In Sri Lanka nearly25% of the health budget is exhausted on correction of cardiac issues and preventing cardiacdefects in infancy is significant, observed Dr. Rodrigo who further said that identification of structuraldefects in pre-natal stage offers better health outcome and living outcome for the baby.

Identification of such defects is also vital in deciding the place of delivery and time of deliveryequipped with proper facilities so that clinical care can be administered in a multi-disciplinary mannerwith the involvement of expertise, he added.

Cervical length assessmentAs explained by Dr. Rodrigo, Downs syndrome is age-proportionate, thus a chance of having a babywith Downs syndrome increases with the age. A woman of 25 years having such a baby is one in2500 and a woman of 45 has a chance of ten, he explained. Trisome-18 is another medicalcondition which increases with the age of a woman and according to Dr. Rodrigo with the aid ofdeveloped ultrasonography and other related mechanisms, the velocity of the blood flow can beobserved to arrive at certain conclusions about the outcome of such feotuses.

Cervical length assessment which is another pre-natal intervention mechanism, prevents the risk ofpremature deliveries. A trans-vaginal ultrasound examination is performed to measure the length ofthe cervix or the neck of the womb. A cervical length less than 2.5 cm is identified as risky leadingto preterm of premature deliveries and to prevent prenatal losses, a cervical stitch or shirodkar stitchis placed to prevent such catastrophic events to the foetus, concluded Dr. Rodrigo.

- See more at: http://www.nation.lk/edition/health/item/976-risk-assessment-during-pregnancy-sparing-

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