World Prematurity Day

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Magnitude of problem

Around the world, 15 million babies are born prematurely (Less than 37 completed weeks) every year and one million of these will not survive due to complications of preterm birth.
Worldwide 1 in 10 babies are born premature. Sadly, prematurity is the leading cause of death in children under five.

World prematurity day is a global movement to raise awareness about premature birth and the hurdles babies and parents face every day to see their little one survive the day. Many survivors face a lifetime of disability, including learning disabilities and visual and hearing problems.

While World Prematurity Day is an opportunity to call attention to the heavy burden of deathand disability and the pain and suffering that preterm birth causes, it is also a chance to talk about Solutions.

prematurity-blog-apollo-centre-for-fetal-medicine-delhi

The 10 countries with the greatest number of preterm births1:

  • India: 3 519 100 (1 in 7)
  • China: 1 172 300
  • Nigeria: 773 600
  • Pakistan: 748 100
  • Indonesia: 675 700
  • The United States of America: 517 400
  • Bangladesh: 424 100
  • The Philippines: 348 900
  • The Democratic Republic of the Congo: 341 400
  • Brazil: 279 300

In almost all countries with reliable data, preterm birth rates are increasing.Inequalities in survival rates around the world are stark. In low-income settings, half of the babies born at or below 32 weeks (2 months early) die due to a lack of feasible, cost-effective care, such as warmth, breastfeeding support, and basic care for infections and breathing difficulties. In high-income group, almost all of these babies survive.

Addressing preterm birth is now an urgent priority for reaching Millennium Development Goal. Participation from government agencies, NGO’s and private sector is required equally for research, policy making and execution of programs to reduce the toll of preterm birth in high-burden countries like India.

Why does preterm birth happen?

Common causes of preterm birth include multiple pregnancies, infections and chronic conditions such as diabetes and high blood pressure; however, often no cause is identified. There could also be a genetic influence. Better understanding of the causes and mechanisms will advance the development of solutions to prevent preterm birth.

Solution: begins with healthy mother and good antenatal care

  • Counselling on healthy diet, optimal nutrition, personal hygiene and substance abuse
  • Contact with health care professional
  • prematurity-blog-ACFM-delhi

    • Provision of antenatal steroids
    • Essential care during child birth and postnatal period to mother and child
    • Kangaroo mother care- exclusive breast feeding and skin to skin contact
    • Antibiotics to treat neonatal infections

Optimising Use of Antenatal Corticosteroids for Fetal Lung Maturity

Author: Rachna Gupta

It is a well-known fact that antenatal corticosteroids (ACS) reduce perinatal mortalityby reducing the incidence of respiratory distress syndrome (RDS) in premature babies (1).

Cochrane review 2017 reveals that a single course of ACS significantly reduces the incidence of neonatal death by 31%. Meta-analyses have revealed significantly reduced rates of RDS, intraventricular haemorrhage (IVH), necrotizing enterocolitis (NEC), infectious morbidity, need for respiratory support, and neonatal intensive care unit admission with ACS treatment. For the mother, corticosteroid use does not increase the risk of death or chorioamnionitis, although a non-significant risk of puerperal sepsis was found (1). Maximum benefit is after 24 hours to 7 days of completed course.

Two regimes are commonly used:

  • Betamethasone 12 mg I/M 24 hourly 2 doses
  • Dexamethasone 6 mg I/M 12 hourly 4 doses.

Betamethasone is proven to be better than dexamethasone in reducing the neonatal morbidity and mortality, and cause less incidence of chorioamnionitis(1,2). However, as the betamethasone salt available in India is different from that used in international trials (3), same conclusion cannot be drawn, and either dexamethasone or betamethasone may be used depending upon availability.

There is also concern over increased prevalence of undiagnosed maternal infections in India, hence, more trials are needed on safety of use of corticosteroids. One of the trials showed increase in neonatal mortality and maternal infection with use of ACS in low-income and middle-income countries (4).

Use of ACS in late preterm babies (34 – 37 weeks) and early term (37 – 39 weeks) has been a matter of controversy so far and more data are needed to either support or refute the use of ACS in these populations. There are definite short-term benefits (mainly in reducing transient tachypnea of newborn) with some complications like neonatal hypoglycemia and unknown long-term neurodevelopmental outcomes (6).

Studies in animal models and short term studies in human beings have shown that there is increased basal level of cortisol in babies exposed to even single dose of ACS and there is aggravated response to stress (5). Barker’s hypothesis for fetal programming of adult onset of cardiovascular diseases like hypertension, stroke and diabetes also implicates exposure to ACS as a risk factor though this remains to be proven in human studies.
Repeated use of ACS has been linked with autism, neuro-developmental delay, permanent changes in limbic system, midbrain, white matter paucity, cerebral palsy, reduced head circumference, fetal growth restriction, maternal glucose intolerance. All these effects have been more widely studied in animals, and in human beings it is still a speculation, and not proven.
More than 4 repeated doses have been linked with reduced head circumference and fetal growth restriction (7).

Recommendations on basis of current literature:

  • One needs to weigh the potential risks and benefits of ACS. Between 26 – 34 weeks, the potential benefits clearly outweigh the risks and one should not hesitate to give steroids where delivery is anticipated before 34 weeks.
  • The assessment for iatrogenic or spontaneous preterm delivery needs to be more stringent and senior and more than one obstetricians should be involved in decision taking to give steroids at optimal time, so that timing is such that single course is given when delivery is expected before 34 weeks, and the estimated time to deliver is between 48 hours – 7 days.
  • High risk of imminent delivery is strictly defined as (6)

    • Preterm labour with intact membranes and at least 3 cm dilation or 75% cervical effacement
    • Preterm labour with spontaneous rupture of membranes.
    • Expected preterm delivery for any other indication either through induction or caesarean section between 24 hours and 7 days, as determined by the obstetrical provider.
  • Single course of ACS may be repeated if gestational age is less than 34 weeks, more than one week has elapsed and delivery is strictly expected between 24 hours to 7 days.
  • Between 34 – 37 weeks, there are short-term benefits with unknown long-term side effects, and lung maturity tests (like QuantusFLM) may be useful to assess the need for ACS.
  • There is not enough data to support use of ACS after 37 weeks either for planned C-section or normal delivery (8,9).
  • Elective C-section should be postponed to 39 weeks as much as possible as risk for respiratory distress keeps reducing and is minimum after 39 weeks.

References:

  • Roberts D, Brown J, Medley N, Dalziel SR, Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth, Cochrane Database Syst Rev. 2017 Mar 21;3:CD004454.
  • Baud O, Sola A; Corticosteroids in perinatal medicine: How to improve outcomes without affecting the developing brain? Semin Fetal Neonatal Med. 2007 Aug;12(4):273-9. Epub 2007 Mar 21. Review.
  • Use of Antenatal Corticosteroids in Preterm Labour; Operational Guidelines June 2014; Ministry of Health and Family Welfare, Government of India.
  • Fernando A et al; A population-based, multifaceted strategy to implement antenatal corticosteroid treatment versus standard care for the reduction of neonatal mortality due to preterm birth in low- income and middle-income countries: the ACT cluster- randomised trial; Lancet. 2015 February 14; 385(9968): 629–639.
  • Waffarn F, Davis EP; Effects of antenatal corticosteroids on the hypothalamic-pituitary-adrenocortical axis of the fetus and newborn: experimental findings and clinical considerations; Am J Obstet Gynecol. 2012 Dec;207(6):446-54-
  • Beena D. Kamath-Rayne et al; Antenatal corticosteroids beyond 34 weeks gestation: What do we do now? Am J Obstet Gynecol. 2016 Oct;215(4):423-30.
  • Michael W. Church et al;Repeated courses of antenatal corticosteroids: Are there effects on the infant’s auditory brainstem responses?NeurotoxicolTeratol. 2010; 32(6): 605–610.
  • ACOG Committee Opinion number 713, August 2017
  • NICE guideline (NG 25) Preterm labour and birth (published Nov 2015)

Anomaly Practical Exam Candidate Schedule

TIME ROOM 1 ROOM 2 ROOM 3
9:00-11:00 Amutha Chandra
Suriya Pandian
Ashish Bhalodiya Karun Wadhwa
Ananya K Ashish Talekar Jeevan Jyothi Kari
Anitha A Geeta Bhusari Kamlesh Patel
Asha Ravindran Debabrata Maitra Kanchan Mukherjee
11:00-11:15 BREAK
11:20-13:30 Neelam Jain Preeti Allum Nithya Elango
Kshitij Dhuria Nikhil Sharma Preeti Kakkar
Manasi Dabholkar Narjit Kaur Shyam Nandan Gupta
Megha Kamlapurkar Minakshi Rakholia Pavithra Vengetesh
Rinshi Saira Rajan Rachna Thadeja
13:30-14:10 LUNCH
14:15-17:15 Seneesh Kr Vikraman Hemaben Aghera Surekha B
Amita Das Shrestha Aggarwal Sushma Meda
Sandip Chavan Pankaj Rote Vibha Bansal
Saurabh Chopra Smitha Mannepalli Vishwanth Tokala
Bela Bhatt Sumati Saxena Savita Chopra
Rajendra Jain Natasha Aggarwal Ramprakash G
  • The above candidates are eligible provided they bring the proof (hard copy) of their FMF UK approval of images and subject to payment of the fees as mentioned in the brochure.
  • Kindly note that candidates will have to arrange for their own lunch on the day of the practical exams (Options available at Apollo Food Court).

FMF – UK Anomaly Certification – Theory Course and Practical Exam

Date: 29th and 30th April 2017
Venue: Auditorium, Indraprastha Apollo Hospitals, New Delhi

The Anomaly scan is considered as the most important scan in pregnancy and it is medico-legally important to perform it to the best of standards, with proper documentation of images. Enhance your skills at detecting birth defects to the standards required by the Fetal Medicine Foundation UK and the International Society of Ultrasound in Obstetrics and Gynaecology (ISUOG).
The course is useful for all those who are involved in obstetric scanning.
All Faculty are accredited by FMF-UK

The FMF-UK certified course for 18-23 weeks Anomaly will satisfy the theory requirements for the Certificationand for those who are eligible for the practical exam(ie those whose images have been approved by FMF-UK )will have a chance to appear for the Practical Assessment.

The requirements for obtaining the FMF certificate of competence in the 18-23 weeks scan are:
  • Attendance of FMF Approved Theory course (30th April 2017)
  • Online submission of a log-book of a series of images from one normal fetus to FMF-UK (it takes approximately 2 weeks for approval of images post submission to anomaly@fetalmedicine.org)
  • Demonstration to a FMF approved examiner of competence in carrying out a 18-23 weeks scan and good knowledge of the diagnosis and management of a wide spectrum of fetal abnormalities (Dr Anita Kaul, Dr Prathima Radhakrishnan are approved examiners who will be present on 29th April 2017 to conduct the practical exam)
Please Note : Only those who have already submitted the log book of images to FMF – UK and images have been approved (please contact us or visit fetalmedicine.org/training-n-certification/certificates-of-competence/the-18-23-weeks-scan or Click Here for details on submission of images) are eligible for the practical exam providing this has been done by 29th March 2017.


Additional Requirements for candidates wishing to take the practical examination in India.

I. Registration with PNDT appropriate authority (South East District, Saket, Delhi) at least 30 days in advance of the date of practical examination (29th April 2017).

Documents required for PNDT registration, to be submitted at Apollo Centre for Fetal Medicine, Indraprastha Apollo Hospital, New Delhi for getting registration for the hands-on

  • Affidavit on INR 10 stamp paper attested by notary.
    The affidavit format is available for download below
  • Copy of qualification certificates (MBBS/MD/MS) self attested.
  • Copy of DMC / MCI registration (self attested).
Programme
TIME TOPIC SPEAKER
08:00-08:30 Registration
08:30-08:40: Welcome and Introduction Dr Anita Kaul
08:45-09:45 45Central Nervous System: Normal & Abnormal views Dr Rachna Gupta
09:50-10:10 Face: Normal and Abnormal views Dr Chanchal
10:15-10:25 TEA BREAK
10:30-11:15 Normal views Dr Prashant Acharya (Paras Ahmedabad)
11:20-12:05 Abnormal views Dr Prashant Acharya
12:10-12:55 Pulmonary System: Abdominal Wall: Normal & Abnormal views Dr Prathima Radhakrishnan( BFMC Bangalore)
01:00-01:45 LUNCH BREAK
01:50-02:20 Gastrointestinal Tract: Normal and Abnormal views Dr Anita Kaul
02:25-02:55 Kidneys and Urinary Tract: Normal and abnormal views Dr Akshatha Sharma
03:00-03:40 Skeletal System: Normal and Abnormal views Dr Prathima Radhakrishnan
03:45-04:15 Second Trimester Soft markers and Risk Calculation Dr Shreyasi Sharma
04:20-05:15 Summary and Live Demo Dr Anita Kaul, Dr Prathima Radhakrishnan ,Dr Prashant Acharya

Registration Fees :
No spot registration

INR 5000/- plus 15% service tax INR 5750/-

PAYMENT OPTIONS:
Payable to “Fetal Medicine Foundation India”

1.Bank Transfer to A/c No: 03192560004661; HDFC Bank, South Extension Branch, New Delhi; IFSC Code: HDFC0000319
2. PAYTM to 8586015738
3. Post Cheque to:
Apollo Centre for Fetal Medicine,
Gate No:7, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi

Web: www.fmfindia.in
Email: anita_kaul@apollohospitalsdelhi.com.

For Queries call Himanshi on 011-29873018, 26925858, Extn:3018, 9560127575 or write to fetalmedicine@apollodelhi.com

Dr Rachna Gupta, General Secretary, FMF India: 09899294499
Dr Akshatha Sharma, Programme Coordinator : 09891494545

Register

Download PDF

Download Affidavit

FAQ

Ques 1. Who all are eligible for theory?
All those who are involved in obstetric scanning.

Ques 2. Who are eligible to appear for practical examination on 29th April 2017?
Doctors whose images have been approved by FMF-UK before 15th April, 2017 and providedthe requisite documents and affidavitfor PCPNDT registration are sent beforehand to Apollo Centre for Fetal Medicine by 29th March 2017.

Ques 3. Is it a must to get registered with Delhi Medical Council?
No, any state medical council or MCI registration will suffice.

Ques 4. What if my images are not approved before practical examination?
You can appear for theory on 30th April 2017. If your images are approved by 31st July 2017 by FMF-UK, you can appear for practical examination in Sep
2017, there will be no separate registration fee for same.

Ques 5. Will there be repeat theory course in year 2017?
No
Ques 6. Will there be repeat theory course/ practical in the year 2018 or later?
Yes, but registration fee will be separate.

Ques 7. Will I get FMF UK Certification for Anomaly if I attend only the Theory Course?
No. FMF UK Certification for anomaly can be obtained only after you have:
1). Received approval from FMF UK for the logbook of images submitted,
2). Cleared your practical exam and
3). Attended the FMF approved Theory Course

However, you shall receive a certificate of attendance for the Theory course.

Ques 8. When can we know about our eligibility for the practical exam after submitting the documents?
All those finalized for the practical exam (subject to PCPNDT approval) will be informed about their schedule for the practical exam by 15th April,2017.

Jaipur outreach programme on First trimester screening

FMFIndia’s 2017 calendar began on the festive Makar Sankranti/ Pongal/ Bihu weekend with its Jaipur outreach programme on 15th January at Orchid Women’s Hospital & Fetal Medicine Centre.

FMF-India trainers, Dr Akshatha Sharma, Dr Rachna Gupta and Dr Karuna Mandal, interacted with group of OBGYNs and sonologists from in and around Jaipur (Sikar, Kota, Alwar, Chomu, Bikaner).

The highly interactive session saw;

– Queries regarding biochemical screening and problems in patient counselling.
– Discussions on how to implement FTS protocols in remote areas, and training in first trimester scan.
– In-depth discussions on prediction & management of Fetal growth restriction, topic which is very dear to obstetricians to prevent perinatal mortality.

The live demo session covered settings of ultrasound machines and technique of scanning in various stages of pregnancy.

The registrants asked for more such programmes to be held in future which we will definitely plan.

FMF India’s Outreach programme in Kashipur

Kashipur outreach programme held on 20th Nov 2016, was conducted in association with Kashipur OBGYN society, faculty being Dr Anita Kaul, Dr Chanchal Singh, Dr Rachna Gupta and Dr Bharti Pant Gahtori.

With excellent brain storming from Dr Bharti, our local organiser, workshop was divided in two sessions. Morning session focussed on obstetricians – covering first trimester screening for aneuploidies as well as perinatal complications, diagnosis and management of fetal growth restriction and case discussions. Afternoon session focussed more on antenatal scanning skills and there was live demonstration of cases for first trimester screening, anomaly scan, fetal growth parameters and Dopplers.

There was positive feedback with this approach and we thank Dr Bharti for her efficient organising skills and hope she joins our team of trainers in the near future.

Faridabad outreach programme

Faridabad outreach programme conducted in association with FOGS by Dr Anita Kaul, Dr Rachna Gupta and Dr Nidhi Arora on 29th September, 2016 was attended by almost 100 delegates, mostly OBGYNs.

The programme was an eye opener in the sense that we need to address the learning objectives of obstetricians and sonologists differently. We realised that obstetricians are more interested in clinical and counseling aspect of scan findings rather than technique of scanning. Case based discussions were well received by the audience with active interaction. Obstetricians also clarified their doubts on management of various cases they had come across.

As a result of the feedback future programmes will be split between topics of interest to the obstetricians during the first half followed by dedicated teaching to the ultrasonologists only in the second half

Congratulations Dr Vimla Dahiya from Sonepat!

We are proud of Dr Vimla Dahiya, obstetrician from Sonepat, who after attending FMFI outreach programme held in Sonepat on 7th Feb 2016, was determined to get her FMF-UK certification, and with persistence and guidance from Dr Rachna Gupta (sec, outreach programme) obtained the certification on 7th Oct 2016. We expect more and more people to achieve this, to bring uniformity and quality to nuchal scans, which is the aim of our outreach programmes.

vimla-dahiya-certi

First trimester screening, outreach programme, Panchkula

FMFIndia conducted another successful outreach program at Paras Bliss Hospital in Panchkula on 29th May 2016.

Dr Anita Kaul ably supported by Dr Rachna Gupta, Secretary, Outreach Programme, aims to propagate the foundation’s mission of delivering high quality training of fetal diagnostic skills to medical professionals all over the country. Panchkula was the 3rd leg of Plan-2016 to cover tier-II and tier-III cities across India.

The outreach programme saw enthusiastic discussion on how to make Combined First Trimester Screening (NT with Dual marker test) feasible and universally applicable in clinics and government hospitals and the important role that obstetricians can play in ensuring Sonographers do the NT scan as per FMF UK standard. Special thanks to Dr Rashmi Bagga and Dr Alka Sehgal, for their valueable inputs and feedback, it really made the outreach worth its idea.

The programme covered all aspects of First trimester scan including combined screening, anomalies, screening for preeclampsia, multiple pregnancy, impact being enhanced with live demonstration and MCQ discussion.

The FMFIndia team is thankful to Dr Nupur Shah, Dr Rishi Mangat and the entire Paras Bliss management team for a stellar programme.