Screening of foetus for chromosomal abnormality

This is an ongoing debate for last one  decade :- Topic is :-Universal or Selective costly tests A) Double marker tets(serum for beta HCG & PAPP-A)  & also B) NIPT are  costly:-So the question arises “Are  NIPT or Double marker  mandatory for all ( these are  biochemical markers) -,if the NT scan is normal- This is an ongoing debate for last one  decade ?Top of Form

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 Ans:-No, Not mandatory. But better to tell your patients about the1)  options available and 2) the accuracy of each test.3)costs thereof ,Better to document in the records. Some times NT is  normal but the double marker report comes as  “high risk”= then  ,if the pt cant afford for CVS or say amniocentesis for confirmation  of chromosomal ab  not. Then what can we do? What should be our philosophy particularly who are engaged in private practice?? ? Ans:- Put in such situation we have to explain high risk requires investigation further to rule out t21 13 18 as per results. Advise amniocentesis preferably in Govt hospitals. Medical colleges where it should be affordable

 But one use his/her own judgment in practice life , & many ask for this tets Only if needed . But Dr Pal does NT routinely.

 I counsel the couple and offer d test, some choose to do..Some don't..
Some go home rethink n come back and

 NT should never be interpreted independently (NT, Double marker & NIPT all are screening tests). The first trimester screening is a COMBINED SCREENING and the total risk is calculated only after dual markers, NT, and maternal age. It does only in multiple pregnancies where the biochemical tests don't give definite results n one can rely on NT of each fetus. But still pregnancy can't be terminated for one abnormal fetus.
So dual markers are mandatory with NT

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 N according to screening guidelines, combined screening should be offer This is an ongoing debate for last one decade ed to all ANC pts. They might refuse but not offering is a medico legal issue. It  is like HIV testing –optional, .You may opt out or offer consent.  Like HIV this three screening tets must have pre test & post test counseling

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Screening tes of foetus for chromosomal abnormality-What tets when ?

Limitations of Scan at 13 weeks & 18 weeks(Anomaly-TIFA) ?? Take home message:-Scan cannot always exclude a chromosomal anomaly especially Down syndrome though may raise strong suspicion in NT scan but its detection chance at TIFA is negligible (Suspicion of Down). Quadruple marker is  +ve at 18 weeks : Now fior instance there is a  post cs case: with Q serum marker at 17 weeks is +ve. Then what nest? Straigt termination or aminoàconform by FISH then MTP at say 19 weeks. She had 2 CS earlier?? But USG level 2scan normal... should v terminate or investigate further... how?? Ans: We have to keep in mind that Q Top of Form

Ans: Q Amarker is a screening test .. One have to confirm by amniocentesis and then arrive at a firm & definitive  decision which is unquestionable.

 We should never terminate based on a blood test report and that too Triple / Q serum amylates test which are screening tets only-speaks in terms of probability-MoM! To do MTP based on Q tets more so when Scan report is normal à Its a crime against the fetus.

 Advise amino even if the scan is "normal" as a scan cannot exclude a chromosomal anomaly especially Down Syndrome. If proven abnormal then only offer termination. What is the cost of NIPT(done at 10-12 weeks )  18 k to 30k depending on the lab.

 If one dose MTP based on D marker tets and or Q marker tets without confirmation by CVS or say amnio then it may be compared to quackery à like it’s like saying "if urine sugar is positive, start Insulin" In my another case she was  already 19wks 6days......Irony is I  cannot do MTP even if amniocentesis is positiveàDelay by relatives to do amino or not and then  reports come late .In case of Q marker if +ve  1 out of 120 with such results will have DS which means 119/120 with such results will be normal. Which is 1% DS 99% normal. Sounds better now isn’t it? The chances of normal is still much higher than abnormal

Moreover the FISH for T21 result is available in 5 working days in most labs, even earlier.

 I too suggest Amniocentesis and Genetic counseling. I Dr Pal  dealt with  same type of pt 17 weeks now got it done Amino was done à which luckily was is normal -> so is now  continuing with pregnancy _To conclude à counseling to pt done and consent taken that both pros and cons for amniocentesis was explained. This(Q marker, NT, D marker , NIPT too ) are  just a screening test. Never to terminate on this. Counsel her and advise her on further testing... amniocentesis. If any one of them is +ve one and only answer is amniocentesis..but only after proper nonjudgmental  counseling

Curriculum Vitae of Prof. Srimanta Kumar Pal, Kolkata

Curriculum Vitae

PERSONAL

Name:-                  Dr. Prof. Srimanta Kumar Pal

Fathers name:             Late Dr Sudhir Ch Pal

Sex:                             Male

Date of Birth:              23-03-1945

Mobile no:-                  919333315050 /91 9635354671

Email:-                         drsrimantapal&gmail.com

Medical Registration No:                    31379(WB)

AADHAR CARD NO   :                   2735 0058 8397.

PAN:                                                   AEVPP 9256N 

Residential Address :               Block GD, Plot 207,Sector-3, Salt Lake City, Kolkata -700 106(WB):: Office Address: 152, R N Tagore Rd, Laldighi, Berhampore, Dist Murshidabad , Pin code 742 101

Degree & Training

a)      MBBS (the then Kolkata University) -1968, Stood first in First MBBS & Final MBBS in the University. (See enclosed certificate issued by Principal of N R S Medical College “Ref No 24/22/NMC/2675 dated, 10-08-1970.)

b)      Qualified DGO (1970)

c)      MS (Obstet & Gynae) in 1973 from the then Kolkata University : Stood first in both Examinations 

d)     F .A C.S  (Fellow of American College of Surgeons ( Life member since 1984)    

e)      Fellow of International College of Surgeons(since 1983)

f)       Life member  of I MA, Kolkata branch ,

g)      Life member Federation of Obstetrics & Gynaecology & Bengal Obstet Gynae Society

h)      Life member of ASAR(Indian Society of Assisted  Reproduction),

Special Academic Achievements

Advanced Training

1.      Had Laparoscopy Training for 6 weeks at Osmania MedicalColege, Hyderabad, 1973.

2.      Had MTP training at Medical College in 1974

3.      Had Training on Follicular Monitoring (USG) & IUI at Institute of Reproductive Medicine , HB block  Kolkata

4.      Government Assignment

Worked   as Senior Resident officer at N R S medical College, Kolkata, 1973-76.(W B Govt appointment )  Later promoted as  Specialist  Gynaecologist  at Basirhat Govt Hospital 1976-1980. Subsequently promoted as Addl Lecturer cum Resident Surgeon, Eden Hospitals, Medical College, Kolkata. Later worked as Sr consultant Obstet   Specialist surgeon at Berhampore District Hospital, Working from 1989 as Medical Teacher in different Medical Colleges of east Bengal up to 1996,. Later joined as Professor of Gynaecology & Obstetrics at M.G.M Medical College, Kishanganj, Bihar, India since 01-04-1996 to 31-05-2013 (Teaching experience 29 years including Undergraduate and post graduate).

5.      Other Academic Activities, while working as Professor .

Thesis guide of four MD students, MBBS, DGO & MD Examiner of different Universities of N E India since 2000-2015

Social Commitments & Attachment with different  NGO

1)      Worked with Mother Teresa   regularly during 1965-1974,

2)       Actively involved with many other Local NGO for awareness in the locality & adjoin villages, DHABAS who reside  in and around high way for prevention of HIV & other STI,

3)      Written 12 Books in different languages for HIV prevention, Contraceptives & Diseases related to interstate & intrastate migration.

4)      Regularly contributing in local periodicals , magazines of West Bengal for Birth control & Unsafe abortion .Delivered Community talk at Lioness club &  Rotary Club of the locality

5)      Presented many articles in state conferences, AICOG conferences (All India Obstetrics & Gynecology conferences since 1973). Chaired many sessions, Participated in debates as panel member/ chair person.

On Public Awareness on communicable and noncommunicable Diseases

Regular Talk in AIR, Mother Tarrasa.

Present Assignment

Director, Berhampore Fertility Clinic (WB)

Ongoing Research

1)       Ovarian volume in healthy asymptomatic women (11yrs to -70 yrs age group)–A multicentric study.

2)       Evaluation of Unexplained subfertility.

3)      The prevalence of MOTT in Laproscopy  Port

4)       Correlation of metabolic & cardiovaxcular parameters with  Ovarian USG in PCO women as par Rotterdam Criteria,

5)      Prof. Pal Is the sole administrator of two face books designed for continued medical education of young graduates(Name of the face book Pages are

                    i.            Young Gynae Group India                                         https://www.facebook.com/groups/1989447721339897/

                  ii.            Ask any questions on Female Diseases, Infertility, Pregnancy, Contraception

https://www.facebook.com/groups/364197417326132/?ref=bookmarks

                iii.            Birth Control Methods

https://www.facebook.com/Prof.S.K.Pal/?modal=admin_todo_tour

                iv.            Gynae MD & DNB Group (Post Graduate Only for distant Learning)

https://www.facebook.com/groups/1818802011757481/?ref=bookmarks

PUBLICATIONS

Had 13 publication in JIMA (by the years 1975-1992) and 32 publication in J. Obstetrics & Gynaecology of India(1975-1997). Total publications= 51. Two articles from Japan.

LIST OF PUBLICATION BY PROF. SRIMANTA KUMAR PAL

1.      Pal, S.K. and Sarkar, M. :  “Ectopic Cords”, J. Obstet. Gynaec. India 1977; 27:257-260.

2.                        Pal, S.K. and Bhattacharya, B. :  “Absolute Short Umbilical Cord”, J. Obstet. Gynaec. India, 1977;27:442-444.

3.      Pal, S.K., Sarkar, S. and Chaudhuri, S.K. :  “Thoracopagus Tetrabrachius Tetrapus”, J. Obstet. Cynaec. India, 1977;27:454-456.

4.       Pal, S.K. :  “An Approach to Rural Obstetric Problems”, J. Obstet. Gynaec. India, 1977;27:553-558.

5.      Dutta, D.C. and pal, S.K. :  “Rupture of Uterus – A Review of 74 cases”, The Antiseptic, 1977;74:684-688.

6.      Dutta, D.C. and Pal, S.K. :  “Obstrucsted Laboour – A Review of 307 cases”, J. Obstet. Gynaec. India, 1978;28:55-58.

7.      Pal, S.K. :  “Preforation of Cervix by Lippes Loop”, J. Obstet. Gynaec. India, 1978;28:885-886.

8.      Pal, S.K. :  “Paraphimosis of Clitoris”, J. Obstet. Cynaec. India, 1978;28:887.

9.      Pal, S.K. :  “Perforation of Uterus by Lippes Loop”, J.I.M.A., 1978;71:235-237.

10.  Pal, S.K. :  “Torsion of Hydrosalpinx”, J. Obstet. Gynaec. India, 1978;28:1159-1160.

11.  Pal, S.K. and Dutta, S.K. :  “Fibrothecoma of Ovary and Pregnancy”, J. Obstet. Gynaec. India, 1979;29:186-187.

12.  Pal, S.K. Chakravorty, B.N. and Bhattacharjee, S.K. :  “Foetal Ooutcome in Primarily High-Risk Pregnancies”, J.I.M.A., 1979;72:₁₅₃-157.

13.  Dutta, D.C. and Pal, S.K. :  “Obstetrical Hysterectomies in Rural Practice – A critical review of 100 consecetive cases”, J. Obstet. Gynaec. India, 1979;29:627-631.

14.  Pal, S.K. and Dutta, S.K. :  “Developmental Cyst of Vagina”, J. Obstet. Gynaec. India, 1979;29:709-710.

15.  Pal, S.K. :  “Term pregnancy with unruptured hymen”. The Antiseptic, 1979;76:486-488.

16.  Pal, S.K. and Biswas, M. :  “Scope and Limitations of local anaesthesia in abdominal sterilization – a critical review”, Current Medical Practice, 1979;23:587-591.

17.  Pal, S.K. :  “Foetus Papyraceus”, J. Obstet. Gynaec. India, 1980;30:191-192.

18.  Pal, S.K. :  “Prolapse of the placenta”, J. Obstet. Gynaec. India, 1980;30:379-380.

19.  Pal, S.K. and Dutta, S.K. : “Dystocia due to distended cloaca”, J. Obstet. Gynaec. India. 1980;30:381-382.

20.  Pal, S.K. :  “Absolute Short Cord Dystocia, J.I.M.A., 1980;74:134.

21.  Pal, S.K. :  “Prolapse of the placenta”, J.I.M.A., 1980;75:94-95.

22.  Pal, S.K. and Dutta, S.K. :  “Morbid Adhesion of Placenta”, J.I.M.A., 1980;75:163-165.

23.  Pal, S.K. and Saha, P.K. :  “Paracephalic Acardiac Monster”, J.I.M.A., 1981;76:17-18.

24.  Pal, S.K. :  “Dystocis due to Distended Foetal Urinary Bladder”, J.I.M.A., 1981;76:139-140.

25.  Pal, S.K., Purkait, D., Modak, G.C. and Dawn, C.S. :  “Surprise Dystocia”, J. Obstet. Gynaec. India, 1983;33:391-392.

26.  Pal, S.K., Purkait, D. Modak, G.C. and Dawn, C.S. :  “Pregnancy in rudimentary horn”, J.I.M.A., 1983;81:96.

27.  Chandra, S., Karmakar, S. and Pal, S.K. :  “Polymastia”, J. Obstet. Gynaec. India, 1983;33:857-858.

28.  Pal, S.K., Roychowdhury, A. and Dawn, C.S. :  “Haemoperitoneum due to rupture of a vein on the surface of a uterine fibromyoma”, J. Obstet. Gynaec. India. 1984;34:391.

29.  Pal, S.K., Chatterjee, S., Majumder, P. and Lahiri, B.C. :  “Acute abdomen in puerperium due to rupture of amoebic liver abscess”, J. Obstet. Gynaec. India, 1984;34:741.

30.  Pal, S.K. and Saha, P.K. :  “Ischiopagus Tetrabrachius Tetrapus”, J.I.M.A., 1984;82:373-374.

31.  Pal, S.K., Raha, A. and Mukherjee, K. :  “Locked Twins”, J.I.M.A., 1985;83:23-25.

32.  Pal, S.K., Abedin, S. and Dawn, C.S. :  “Torsion of Fallopian Tube in Adolescent Girl”, J.I.M.A., 1985;83:61-62.

33.  Pal, S.K., Mista, S. and Roychowdhury, N.N. :  “Rupture of uterus due to vesical calculi”, J. Obstet. Gynaec. India. 1985;35:214.

34.  Pal, S.K., Vaidanathan, S. and Roychowdhury, N.N. :  “Pregnancy following successful repair of ectopic vesicae, J.Obstet. Gynae. India, 1985;35:591-593.

35.  Pal, S.K. and Roychowdhury, N.N. :  “Postoperative Arterial Thrombosis”, Asia-Oceania, J. Obsetet. Gynaecol. 1985;11:345-347.

36.  Pal, S.K. and Roychowdhury, N.N. :  “Caesarean Hysterectomy A review of 30 cases”, J. Obstet. Gynaec. India, 1985;35:829-831.

37.  Pal, S.K. and Roychowdhury, N.N. :  “Late Recurrence of Granulosa Cell Tumouurr”, Asia-oceania, J. Obstet. Gynaecol., 1986;12:21-23.

38.  Pal, S.K. :  “Familial Congenital Adrenal Hyperplasia”, J. Obstet, Gynaec. India, 1992;42:711-12.

39.  Pal, S.K. :  “Stillbirths in Caesarean Section – A Critical Review”, J. Obstet. Gynaec India, 1992;42:616-19.

40.  Chakravorty, P. and Pal, S.K. :  “Silent Lithopaedion”, J. Obstet. Gynaec. India, 1993;443:133-34.

41.  Bhattacharyya, A.R., Pal, S.K., Bhattacharyya, A. and Sarkar, S. :  “Large Bowel Obstruction by Choriocarcinoma”, J. Obstet. Gynaec. India, 1993;43:458-59.

42.  Bhattacharyya, A.R., Pal, S.K., Bhattacharyya, A. and Sarkar, R. :  “Herniation of gravid uterus”, J. Obstet. Gynaec. India, 1993;43:450-51.

43.  Pal, S., Bhattacharyya, A.R., Mitra, A. and Som, S. :  “Uterine and Cervical Synechia following Caesarean Section”, J. Obstet. Gynaec. India, 1993;43:440-41.

44.  Pal, S.K., Bhattacharyya A.R. :  “Recurrent Hydatidiform Mole”, J. Obstet. Gynaec. India, 1993;43:445-45.

45.  Pal, S.K., Roy Choudhury, D. :  “Spontaneous Recticfication of Subacute Invesion of Uterus”, J. Obstet. Gynaec. India, 1993;43:844-45.

46.  Pal, S.K., Bhattacharyya, A.R., Bhowmick, K. and Betal, B.S. :  “Myaesthenic Crisis in Obstetric Practice”, J. Obstet. Gynaec. India, 1944;44:469-70.

47.  Pal, S.K., Bhattacharyya, A.R. and Bhowmick, K. :  “Accidental Insurauterine Electrocution – A Rare Tragedy”, J. Obstet. Gynaec. India, 1994;44:153-54.

48.  Pal, S.K., Bhattacharyya, A.R. and Bhowmick, K. :  “Issosexual True Precocious Puberty”, J. Obstet. Gynaec. India, 1994;44:335-36.

49.  Pal, S.K. and Bhattacharyya, A.R. :  “Laurence – Moon-Bradet-Biedl-Syndrome”, J.I.M.A., 1995;95:391-92.

50.  Dutta, D.C. and Pal, S.K. :  “Intrapartum Care of Rural Mothers”, Indian Medical Jurnal, 1976;70:144.

51.  Pal, S.K. :  “Anorexia Nervosa – A Review”, J.I.M.A., 1996;94:419-421.