Fetal Radiology and Imaging in India- Building a Path Forward

Fetal Radiology and Imaging has been making great strides in India and is carving its own niche in the field of Radiology and Imaging. We are privileged to have the opportunity to guide the specialty on its path towards sustained excellence. We are privileged to have the opportunity to seek guidance and direction from our seniors in the field of Radiology and Imaging who have set very high standards for the specialty in India.

Moving forward, we are looking at a systematic approach and dynamic framework that focuses on all aspects of Fetal Radiology and Imaging and will consider issues relevant to India

Some India Specific Statistics Relevant for Fetal Radiology & Imaging

    • Estimated 27 Million Live Births in India in 2017
    • Estimated 75,658 Live Births average per day in India in 2018  
    • 78.9% Institutional Deliveries in India (NFHS-4); 75.1% in Rural India and 88.7% in Urban India
    • Hypertensive Disorders of Pregnancy major cause of Maternal Mortality in India
    • Incidence of Hypertensive Disorders in Pregnancy: 10.08%
    • Incidence of Pre-eclampsia ranges from 8-10%
    • Incidence of Eclampsia ranges from 1-5%
    • Estimated 3.5 million premature births out of 27 million babies born every year in India
    • Prevalence of congenital malformations in newborns range from 1.9% to 2.72%
    • Approximately 6,21,000 babies born every year in India with Congenital Anomalies
    • Congenital Heart Defects most commonly Reported with prevalence of 65.86 (range 37.72-114.77) per 10,000 births
    • Prevalence of Neural Tube Defects reported as 27.44 (11.73-64.08) per 10,000 births
    • The Congenital Anomaly Prenatal Diagnosis prevalence was 10.98 per 1,000 births
    • The Congenital Anomaly Termination of Pregnancy Rate was 4.39 per 1000 births
    • Prevalence of SGA 36.5%
    • Attributable Neonatal Deaths (1000s) was 202.3 for all SGA; 126.3 for term SGA and 76 for preterm SGA
    • India has the highest neonatal death rates attributable to babies born with SGA
    • The prevalence of Intrauterine Growth Restriction is reported at 54%
    • The prevalence of Low Birth Weight Babies is 26%

We are looking at several approaches to strengthen and systematize Fetal Radiology and Imaging in India 

These include, but are not limited to,

  • Strengthening the Base of the Clinical Care Pyramid

      • This initiative will focus on skill and competency development including refresher programs focused on
        • Targeted Imaging for Fetal Abnormalities (TIFFA),
        • A systematic and organ systems based approach to evaluation of structures,
        • Fetal Magnetic Resonance Imaging and
        • Interventional Radiology Training- Amniocentesis and Guided Interventions focused on Fetal Therapy and Diagnosis
        • Synergistic Fetal Imaging
        • Developing a National Pool of Trainers and Experts in Fetal Radiology and Imaging
        • Organize at least 20 such CME programs nationwide
        • Develop a pool of trained counsellors,  including grief counselling and genetic counselling, for Fetal Radiology to interact with parents and family

  • Develop a National Pool of Trainers and Experts for Fetal Radiology and Imaging

      • A Pool of Experts and Trainers for each state and Union Territory
      • Developing Training Manuals
      • Developing Evaluation and Assessment Methods
      • Developing a State/Union Territory wide Road Map
      • Developing Program Audit tools

  • Developing India Specific Protocols and Guidelines

    • Factor in data relevant to the Indian Context
    • Evaluate use of Data derived from Caucasian populations for fetal parameters of growth and other indices
    • Develop India Specific pragmatic testing guidelines that can be applied widely and at different levels (primary, secondary and tertiary)- note biochemical tests and genetic markers are not widely available.
    • Develop India Specific Guidelines for data documentation and reporting
    • Develop India Specific Guidelines for Fetal Radiology and Imaging Counselling
    • Develop a National Registry for Fetal Abnormalities

Action Items

  1. Improved Data Documentation
    1. Data Recording or Documentation Formats adaptable to different levels of care-primary, secondary and tertiary
    2. Elements to be recorded
    3. Content to be recorded
    4. Storage of data
    5. Sharing of data to a central database- explore possibilities for anonymized data storage and sharing between members, cloud storage, upload, data protection and privacy
  2. Evaluation of Current standards used
    1. Document outcomes and related to diagnostic effectiveness
    2. Document extent of use
    3. Compare with Indian standards where applicable
    4. Use to develop India Specific Standards
      1. Focus on India specific issues first
        1. Fetomaternal Imaging Radiology Assessment Diagnostic Score (FIRADS)-India
        2. Pregnancy Induced Hypertension
        3. Preterm
        4. Congenital Abnormalities
        5. Fetal Growth
  3. Develop a Dynamic Manual for field use
    1. What investigations/tests can be applied and at what level
    2. What alternate investigations or diagnostic tests are possible
    3. Include protocols for testing, examples of outputs, documentation of results and interpretation
    4. This will have to be revisited every 3 years to make sure that content is up to date especially as the field may evolve rapidly
  4. Develop a Fetal Radiology and Counselling Guidelines
    1. Manual that provides basic clinical information to pass to clients in quantifiable terms
      1. Can include risk of adverse events
      2. Can include risk of recurrence
      3. Short and long term risk
      4. Diagnostic Effectiveness of tests
      5. Future testing guidelines
    2. FAQs or common questions that are asked during counselling
    3. Guidelines for ethical, empathetic and effective counselling (The three E approach)
  5. Develop a National Registry for Congenital Abnormalities
    1. Focus on all congenital abnormality
    2. Not restricted to live born, includes still born, terminations and early loss of pregnancy
    3. Create a documentation form to report
    4. Create a central database to store data
    5. Develop a congenital abnormality manual with a focus on providing a road map for the identification and management of congenital abnormalities

  • Academic Programs

    • Develop a specific Fetal Radiology and Imaging Fellowship Program
    • Competency and Skill Development focused on practical, hands on approaches rather than a theoretical framework
    • Develop a specific Fetal Radiology and Imaging Research Mentorship Program
      • Online Course, Self-paced with in-built assignments & assessments
        • Pragmatic, Hands on Course
        • Basic theoretical framework supplemented with plenty of “to-do” real exercises
        • Build Research Competencies- Designing Studies, Doing Studies, Analysing Results
        • Build Research Communication Competencies- Publications and Presentations
        • Should be able to do basic studies and report results effectively at end of program
      • Mandatory Dissertations Focused on a specific area of Fetal Radiology and Imaging- Dissertations have to be value additions to existing knowledge
        • Dissertation Focus on Systematic Reviews
        • Focus on Developing National Level Research Programs that Fellows join in to do their dissertations
        • Build a pool of Research Competency Building Exercises and Research Ideas focused on Fetal Radiology and Imaging
        • Develop Capacity to become TOTs in Research Competencies and Research Team Leads across different parts of the country
      • Develop Nationwide Collaborative Research Programs
        • Focused on areas of immediate large scale importance for India
          • Diagnostic Guidelines- Development, Evaluation, Implementation, Scale up, Outcome Assessment
          • PIH
          • Preterm
          • Congenital Abnormalities
          • Fetal Growth
          • Normative Standards for India
    • Develop Fetal Radiology and Imaging Ethics Guidelines
    • Build Basic Administrative competencies including leading a team, basic financial management, documentation and audits of performance
    • Build a pool of case studies and reports that be used to inform on diagnostics, interpretations, pitfalls, management

  • Build a Career Assurance Program

    • Look at three streams
      • A Diagnostic or Clinical Fetal Radiology and Imaging Cadre
      • A Research Fetal Radiology and Imaging Cadre
      • A Clinician Researcher Cadre
    • Identify Institutes for Placement
    • Develop a Larger pool of Institutes for Placement

  • Explore Synergistic Collaborations

    • Synergy with other medical specialties including basic sciences that aims to improve care for the subject as well as to improve learning for practitioners
    • Synergy with the public that aims to conduct public awareness programs and create public awareness material that highlights the importance of Fetal Radiology and Imaging

Please feel free to post constructive suggestions using the comments section below.

Dr Praveen Nirmalan

Written by Dr Praveen Nirmalan

Dr. Nirmalan did his basic medical education from Thrissur, Kerala and followed it with a PG Diploma in Ophthalmology from Aravind Eye Care System, Madurai and a Vitreo-retinal Fellowship from Mumbai. Subsequently, he completed his MPH and a Public Health Ophthalmology Fellowship from the Johns Hopkins School of Public Health in the USA. He has led community-based and clinical research in some of the top eye care institutes of India and led a clinical research program at a top tier obstetric and neonate institute as well. He has experience chairing Ethics Committees and has helped with the setting up of Institutional Review Boards. Besides mentoring clinical faculty, he has mentored DNB and PhD students through their dissertation work and research methods.


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