The ultrasound has come a long way; from fixing dates of delivery to picking up birth defects, it has become an invaluable diagnostic tool. A pioneer in ultrasound and foetal medicine, Dr. S. Suresh has been invited by the Royal College of Obstetricians and Gynaecologists, U.K., to be a Fellow Honoris Corsa and conferred the FRCOG in November. Here he discusses with fellow doctors, Dr. Indrani Suresh and Dr. Uma Ram, how the tool could help detect birth defects early.
Technological advances have had a huge impact on our lives, especially in the medical field. And arguably one of the biggest gainers has been the pregnant woman. In times long past, the focus was on the mother: her health, what she ate, how she felt... With the advent of the ultrasound and other such advances, the focus shifted to the baby inside the uterus leading thereby to the rise of foetal medicine.
One of the pioneers in the field of ultrasound and foetal medicine in India was Dr. S. Suresh, Director MediScan Systems, Chennai. He also played a key role in setting up a Birth Defects Registry of India, setting standards for Downs syndrome screening, introducing newborn metabolic screening and training of people in ultrasound from India and abroad. In recognition of his services in the field, he has been invited by the Royal College of Obstetricians and Gynaecologists, U.K., to be a Fellow Honoris Corsa and conferred the FRCOG in November 2010.
As Dr. Suresh, Dr. Indrani Suresh and Dr. Uma Ram discuss how the advent of the ultrasound changed the way the foetus was viewed and the range of issues that now dog foetal medicine, one realises what a crucial step this was. Excerpts from the conversation:
Advent of ultrasound
Dr. S. Suresh (S.S.): The advent of ultrasound had a significant impact on how pregnancy was viewed. Earlier the only decision was when the baby could be delivered. Any other problems were known only after birth. With the ultrasound, one started seeing things in-utero. In the initial stages, the idea was that the baby could be seen clearly only if it was big; so the first ultrasound was taken only in the third trimester. Today the first scan is done at 11-13 weeks. Serious problems are picked up early; the idea being: sooner you know the better.
Dr. Indrani Suresh (IS): Before ultrasound, the focus was on the mother; the baby was felt through mother’s stomach. Problems were always there but unsuspected. There was no means of determining birth defects through a clinical examination.
SS: Let me give you the most common example: if the mother’s abdomen was bigger than it should be the assumption was it was a twin pregnancy. But it could have been a single foetus with hydrocephalus: water in the cranial spaces. Between two babies and hydrocephalus we wouldn’t know clinically.
Dr. Uma Ram (UR): Ultrasound improved our understanding of pregnancy. Machines improved and the times when we wanted scans also shifted; 10 years ago the ideal time for first scan was the fifth month... today it is between 11 and 13 weeks.
SS: This scan has four objectives: to date pregnancy correctly, so that growth patterns can be identified as baby grows; to pick up more than 50-60 per cent of structural abnormalities; the most important is the ability to screen for Down’s syndrome; and lastly to identify multiple pregnancies.
UR: There is a flip side too. Sometimes there are too many and unnecessary scans before 11 weeks. This could lead to missing out the crucial 11-13 week scan.
Why we need to scan?
SS: The question we need to answer is: why do scans at specific points of pregnancy? One is to confirm pregnancy and whether it is inside or outside uterus. For the high risk group, those who undergo IVF for example, everyone is anxious to know if sac has implanted properly. So the early pregnancy scan is required. But for a normal conception, the first scan may be done at 11-13 weeks unless there’s bleeding , spotting or pain.
UR: This is where couples’ expectation comes in. They know that they can actually see the baby, so they ask if there’s any harm... there isn’t so long as they don’t miss the main scan.
IS: The ante natal card is very useful in such cases since all details of the pregnancy are entered there ... Monthly check ups for mother: sugars, blood pressure etc. It should also contain times for foetal check up; you know, mark it with stars or colours so that patients will be alert. As a means of creating awareness.
UR: That’s very important because here in India they tend to travel around so at the first check up, we need to tell them this is the time for scan; to tell the doctor about any allergies or any other health issue they may have.
SS: The second scan is only at 18-20 weeks or the fifth month. According to the old school, if you want just a single scan through your pregnancy this was it; the one that picked up over 90 per cent of problems. But it also creates a few problems. According to the law in our country, medical termination is allowed only till 20 weeks. If we find a problem at 18-20 weeks, we need to conduct further tests, which may take up to three weeks before the results are out. That’s 23 weeks. Supposing chromosomal abnormalities are picked up, this means the child have lifelong problems. What if the parents can’t cope? Where will they go? The National Obstetric Society FOGSI should lobby with the government to extend the law to allow medical termination up to 24 weeks.. It is justified in the case of severe abnormalities that may not be picked up early.
IS: Take the case of microcephaly, which means the brain does not develop properly. The baby will be born with strong lungs and heart and will long but the brain will not develop at all. Think of the parents’ plight.
SS: (nods vehemently) This is a problem that is diagnosed late because we wait for the head to grow and suddenly at 24-26 weeks we realise what the problem is. And imagine if this is a second pregnancy with the same problem. I strongly feel that if the government will not allow terminate a pregnancy beyond a certain point, it is the government’s responsibility to take care of the child and must provide the necessary supportive care for the rest of its life. Where is the support structure for management of anomalies? There are no designated specialised centres to take care of birth defects… parents run from pillar to post.
Of course, there are parents who terminate pregnancies even for minor abnormalities like club foot. This is easily correctible but even after extensive counselling they will insist on termination. This is because of high anxiety levels.
UR: It is also due to a very low threshold of acceptance for even minor deviance from normal; the expectation is of a “perfect” child. There are those who are very accepting some will Google everything, come back totally confused and ultimately make wrong decision.
SS: Often the couple is pushed into making a decision that may not be theirs due to pressure from elders in family and relatives.
IS: In one case when we diagnosed a heart defect, we counselled the parents that it was treatable. But the couple never came back. After three months she came to say that she had terminated the pregnancy. Both husband and wife were working and her mother/mother-in-law was supporting them financially ... “Who will take care of the baby?” was their cry. We do not have streamlined support systems for such people.
SS: There is a way to deal with this: pregnancy insurance. If the 11-13 wks scan is normal, the parents can pay a small premium to insure the baby for correctable defects that may be detected later. I can assure you more than half of the terminations won’t happen. As things progress, we will get better at finding abnormalities earlier… will face this situation every day and every life is precious. Ultrasound is not a fault finding tool but it has increased anxiety levels. After the scan the question is not ‘is everything all right?’ They ask ‘is anything wrong? Is there a defect?’
UR: They want reassurance that baby is normal. Of course, with the quality of machines and people, small things that don’t have any long-term significance are picked up but they are reported and then anxiety is generated...
SS: (smiles) The big ethical question is: should we report it knowing that it will not make a difference in long term? Say a calcified spot in the heart is just an innocuous finding and not an abnormality. But if the parents see it in the report ... (he shrugs eloquently)
UR: There was a case a few weeks ago. Before they took the baby home, the father asked if the baby should have an echocardiogram because the scan showed spot in the heart. And this despite extensive counselling. Think of those who don’t get counselling; their anxiety levels will be that much more.
SS: Terminology matters a lot. We now use the term ‘normal variant’.
Quality and training
UR: When we talk of cardiac defects, two issues crop up: expertise of sonologist; and quality of scan. Sometimes we see scans of such poor quality that there doesn’t seem to be any point in doing them even if it’s at the right time. A few weeks ago, there was this woman 35 weeks pregnant and the scan shows chromosomal abnormalities. She’d had the identical problem earlier and she’s had five scans in this pregnancy... nothing was picked up due to the poor quality of scan…
SS: Well, you have two reasons for this: exponential growth of ultrasound centres and no concomitant growth in training. There is no official training programme in ultrasound but what we need is a special diploma in obstetric ultrasound. Ultrasound should be declared as a sub specialty. The training in ultrasound during one’s PG course is a very inadequate.
Take Chennai for example: There are at least 150000 births a year. If you are looking for a good quality scan, only 15-17 is possible by a person in an eight-hour period. But we don’t have that many trained personnel.
Also, technology is ever changing. A person who did MD Radiology 15 years ago needs re-training to handle today’s machines. We need to adapt, keep ourselves updated. The mindset has to change. It’s not like it’s not possible. Online certification is available for each and every aspect of foetal care, practical training is also available… We need to think about the patient. All they want is an answer and till they get one, they will keep running around… What we need is training, quality and certification.
UR: The Foetal Care Research Centre has from the beginning focussed on training. You are a private organisation doing active patient care. So how has this insistence on training impacted your workflow?
IS: (starts laughing) If we hadn’t started training, we’d have had heavier pockets... that’s the truth... our technologists and doctors would have all been richer too.
SS: One, it’s kept us on our toes, we have had to stay aware of all the development in the field. Second is that the people who are trained by us automatically become referral centres for us when they go out into practice. We’ve had people from Aurangabad, Mumbai... all over India... and when they train others to the same standard, we are automatically reaching a larger number of people.
IS: We realised that this way we reach larger numbers; the person we train will see so many patients thereby benefiting so many others. Our objective is to train individuals who will then go out to give the same standard of care and training to others.
SS: The Foetal Medicine Foundation in U.K. is a pioneer in foetal care. They have standardised the 11-13 weeks scan and give an online certification. Doctors can take the online course and submit images of your scan. These are reviewed critically and you re given feedback on how to improve. We are the first foetal medicine centre in Asia to be recognised by the foundation. Those who go through the online course come here for the practical training and send the images to us. This has helped us to promote standardisation; to spread concept of Down’s syndrome screening. And of course with online lectures and demonstrations, I can reach so many, right from my desk here.
IS: There is a need to accept foetal care as a speciality. Now we have neonatology as a speciality for newborns. We accept that the newborn is not same as say a one or two year old... have to be handle them differently... this acceptance came after a long time. Now we have very good neonatal care. Similarly today’s foetus is tomorrow’s neonate and so we need foetal care... obstetric ultrasound is nothing but understanding the foetus...
In rural areas
SS: In a rural set up, we are in the process of taking it to the last mile. We have trained a significant number of doctors in rural areas to recognise the five most common anomalies. We want to evolve simple techniques to identify problems. Neural tube defects are the most common but by taking one picture of the head, 98 per cent of open neural tube defects can be identified. And then there are the big five anomalies; we’ll achieve quite a lot even if they spot two or three of the big five. At least we would have made a beginning.
But there is no point in having the best service in Chennai or Mumbai or Delhi... we need to get this knowledge to the deepest corners. We want to work with the government on this. The idea is to interest the doctor at the periphery to use the machine and spend time on each patient; not look upon it as another job. The availability of machines is not an issue; every PHC has at least a basic machine.
UR: The machine is only one aspect; unless you know what to see you won’t see it; training is crucial. Of course the availability of doctors and nurses at PHCs is a huge issue but, on the whole, healthcare delivery in Tamil Nadu is much better than the rest of India.
SS: We also need to look into the issue of pay. Most doctors especially obstetricians-gynaecologists cannot plan their lives. They have to drop everything and run when patients call. You need to pay them well; just calling medicine a noble profession is not enough.
With Dr. Indrani and Dr. Uma agreeing vehemently, the conference comes to a close, leaving a listener with much food for thought.