On the threshold of taking up foetal medicine with its focus on congenital heart diseases (CHD) that contribute to 23% of the total Infant Mortality Rate (IMR), Kerala is looking to break the barrier of a double-digit IMR that had refused to come down for around 15 years now.
While the jury is still out on whether Kerala has moved a step closer from 12 to 10 IMR (deaths per 1,000 live births), the State is all set to take up a 13-point agenda to reduce the IMR, of which heart defects are the target area for intervention. The focussed intervention could turn out to be a trailblazer intervention to achieve an IMR of 4-5 that is on a par with the West.
Kerala is far ahead of the national average in IMR and can afford to address these issues as many other parameters in infant care strategies had worked well to bring down the IMR drastically. However, even when the national average of IMR dropped from 80 in 2004-05 to 39 in 2013-14, the State found the going tough in its efforts to bring it down from 12 to 11. This prompted Kerala to look at the IMR more closely with technical help from the Indian Academy of Paediatrics, Kerala, pointed out Sreehari M., UNICEF consultant, Kerala.
The latest survey had placed the State’s IMR at 10, against the national figure of 35 (2016). Premature births, low birth weight, and birth asphyxia were found to contribute 32% of the total IMR in the State and it was found highly resource-limiting to tackle them. The next major chunk comprised congenital birth defects that accounted for 26% of the total IMR.
Early detection
One of the strategies of intervening in congenital heart defects is early detection, preferably during pregnancy. The first step is to make mandatory ultrasound scanning of the foetal heart.
Basic evaluation of the heart is feasible with most ultrasound equipment which are available at most centres. Advanced equipment is needed for those cases that fail to show up in such screening and, hence, those are needed only in expert and referral centres.
At present, 90% defects are missed, including complex ones. There is also lack of awareness regarding foetal heart evaluation among the public as well as practising obstetricians working at primary levels.
The National Health Mission (NHM) in Kerala is involved in capacity building with basic-level training where obstetricians and radiologists involved in basic ultrasound scans will be taught how to detect anomalies in the foetal heart. Already 300 doctors at various centres have been trained, says Dr. Sreehari, who is working closely with the government on the project.
All newborns are also to be screened for heart defects for 48 hours so that families do not find it difficult to access medical care once the problems start showing later, sometimes after 10 days.
The State government has only limited resources and expertise within the public health infrastructure. There the government has brought in the private sector too to take up paediatric cardiac surgeries as the wait list at the Sree ChitraTirunal Institute for Medical Sciences and Technology was a staggering 4,000 when the government initiated the Hridyam programme that performs free paediatric heart surgeries.
Prenatal diagnosis
In the foetal medicine update, the heart anomalies in foetuses can be detected early in prenatal diagnosis at 16-20 weeks.
According to Balu Vaidyanathan, professor and head of Foetal Cardiology, Amrita Institute of Medical Sciences (AIMS), who is coordinating the training programme in the State, there are three views that need to be taken into account: 4 chambers, outflows, and 3 vessel view.
This is a basic scan that should be done during every pregnancy. Based on the scan, it can be determined whether the foetal heart is normal or not, he said. The advantage in picking up prenatal diagnosis to identify a congenital heart defect is that it will help improve the postnatal outcomes of infants with critical but correctable heart defects, said Dr. Vaidyanathan.
Transporting the expectant mothers to a paediatric cardiac facility ensures that the baby is in a stable clinical condition before surgery and the corrective surgery can be performed without delay. Right now, transporting newborns to such facilities has had its share of casualties and morbidities. Besides, newborns transported most of the time do not present clinically stable conditions, Dr. Sreehari said. There are only a limited number of centres with expertise for foetal heart evaluation and counselling of anomalies even in the private sector and most of them are inaccessible to the common man owing to the costs involved.
The net result is that the rate of prenatal detection of even complex heart problems is low and these problems come to light only when the baby is born. This creates a great burden on the healthcare delivery system besides taking a heavy emotional and financial toll on the affected families. Prenatal diagnosis also helps the families to prepare for the delivery and the newborn heart surgery, both emotionally and financially. It could also enable the families to take the option of terminating pregnancy if the congenital heart defects do not promise good outcomes in newborn surgeries. The burden of very complex heart diseases can only be palliative care, says experts.
