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Dr Amit kyal - Obstetrician & Gynaecologist, Regent Court, VIP Road, Deshbandhu Nagar, Baguihati, KOLKATA (2025)

13/09/2025

Approaches for INSULIN REGIMEN IN PREGNANCY COMPLICATED BY HYPERGLYCEMIA

There are two main insulin regimens used in pregnancy:

1) Basal -bolus therapy
and
2) Split -dose (mixed) insulin regimens.

1)Basal-Bolus Insulin Regimen

The basal-bolus regimen mimics physiologic insulin secretion by providing both background (basal) insulin and mealtime (bolus) insulin coverage.

Components:
1. Basal insulin(long-acting): Controls fasting and between-meal glucose
- Options: Insulin detemir, NPH (isophane), or glargine
- Detemir /Detemir is preferred over NPH due to less hypoglycemia

2. Bolus insulin(rapid-acting): Covers mealtime carbohydrates
- Options: Insulin aspart, lispro, or glulisine
- Aspart and lispro are preferred with better safety profiles

Initiation Protocol:

1. Calculate total daily dose (TDD):
- 1st trimester: 0.7-0.8 units/kg actual body weight/day
- 2nd trimester: 0.8-1.0 units/kg/day
- 3rd trimester: 0.9-1.2 units/kg/day

2. Basal insulin:
- Start with 50% of TDD as basal insulin
- Typically given at bedtime (for NPH or detemir) or morning (for glargine)

3. Bolus insulin:
- Divide remaining 50% of TDD across 3 meals (typically breakfast, lunch, dinner)
- Initial doses: ~10-20% of TDD per meal, adjusted based on carbohydrate intake and pre-meal glucose

Titration:

- Basal insulin: Adjust based on fasting glucose targets (≤95 mg/dL)
- Bolus insulin: Adjust based on 1-hour postprandial (

12/05/2025

Approaches for INSULIN REGIMEN IN PREGNANCY COMPLICATED BY HYPERGLYCEMIA

There are two main insulin regimens used in pregnancy:

1) Basal -bolus therapy
and
2) Split -dose (mixed) insulin regimens.

1)Basal-Bolus Insulin Regimen

The basal-bolus regimen mimics physiologic insulin secretion by providing both background (basal) insulin and mealtime (bolus) insulin coverage.

Components:
1. Basal insulin(long-acting): Controls fasting and between-meal glucose
- Options: Insulin detemir, NPH (isophane), or glargine
- Detemir /Detemir is preferred over NPH due to less hypoglycemia

2. Bolus insulin(rapid-acting): Covers mealtime carbohydrates
- Options: Insulin aspart, lispro, or glulisine
- Aspart and lispro are preferred with better safety profiles

Initiation Protocol:

1. Calculate total daily dose (TDD):
- 1st trimester: 0.7-0.8 units/kg actual body weight/day
- 2nd trimester: 0.8-1.0 units/kg/day
- 3rd trimester: 0.9-1.2 units/kg/day

2. Basal insulin:
- Start with 50% of TDD as basal insulin
- Typically given at bedtime (for NPH or detemir) or morning (for glargine)

3. Bolus insulin:
- Divide remaining 50% of TDD across 3 meals (typically breakfast, lunch, dinner)
- Initial doses: ~10-20% of TDD per meal, adjusted based on carbohydrate intake and pre-meal glucose

Titration:

- Basal insulin: Adjust based on fasting glucose targets (≤95 mg/dL)
- Bolus insulin: Adjust based on 1-hour postprandial (

23/03/2025

Cervical cancer screening guidelines vary across different organizations and countries, reflecting differences in healthcare resources, disease prevalence, and population demographics. Below is a summary of the screening guidelines for cervical cancer from the American Cancer Society (ACS),U.S. Preventive Services Task Force (USPSTF),American College of Obstetricians and Gynecologists (ACOG) & World Health Organization (WHO)

1. American Cancer Society (ACS) - 2020 Guidelines
- Primary Screening Method:HPV testing alone (preferred) or co-testing (HPV + Pap smear).
- Age to Start Screening:25 years.
- Screening Intervals:
- HPV testing alone:Every 5 years (preferred).
- Co-testing (HPV + Pap smear):Every 5 years.
- Pap smear alone:Every 3 years (if HPV testing is not available).
- Age to Stop Screening:65 years (if adequate prior screening and no history of high-grade lesions).
- Special Populations:
- Individuals vaccinated against HPV should follow the same screening guidelines.
- Hysterectomy with removal of the cervix and no history of high-grade lesions: No screening needed.

2. U.S. Preventive Services Task Force (USPSTF) - 2018 Guidelines
- Primary Screening Method:HPV testing, Pap smear, or co-testing.
- Age to Start Screening:21 years
- Screening Intervals:
- 21–29 years:Pap smear every 3 years.
- 30–65 years:
- HPV testing alone every 5 years (preferred).
- Co-testing every 5 years.
- Pap smear alone every 3 years
- Age to Stop Screening:65 years (if adequate prior screening and no history of high-grade lesions)

3. American College of Obstetricians and Gynecologists (ACOG) - 2021 Guidelines
- Primary Screening Method:HPV testing, Pap smear, or co-testing.
- Age to Start Screening:21 years.
- Screening Intervals:
- 21–29 years:Pap smear every 3 years.
- 30–65 years:
- Co-testing every 5 years (preferred).
- Pap smear alone every 3 years.
- Age to Stop Screening:65 years (if adequate prior screening and no history of high-grade lesions).

4. World Health Organization (WHO) - 2021 Guidelines
- Primary Screening Method:HPV DNA testing (preferred).
- Age to Start Screening: 30 years
- Screening Intervals:
- HPV testing alone: Every 5–10 years.
- Visual Inspection with Acetic Acid (VIA): Every 3–5 years (in resource-limited settings).
- Age to Stop Screening: 50–65 years (depending on country-specific guidelines and resources).
- Special Populations:
- HIV-positive women: Start screening at age 25 and screen more frequently (every 3–5 years).

21/03/2025

The definitions of Sepsis-1, Sepsis-2,and Sepsis-3 reflect the evolution of our understanding of sepsis over time.
These definitions have been updated to improve diagnosis, treatment, and outcomes.

Sepsis-1 (1991)
- Definition:
- Sepsis was defined as systemic inflammatory response syndrome (SIRS) due to a suspected or confirmed infection.
- SIRS Criteria (at least 2 of the following):
1. Temperature > 38°C (100.4°F) or 90 beats per minute.
3. Respiratory rate >20 breaths per minute or PaCO₂ 12,000/mm³, 10% immature (band) forms.
- Limitations:
- The SIRS criteria were too broad and non-specific, leading to overdiagnosis of sepsis.
- Did not account for organ dysfunction, which is a key feature of sepsis.

Sepsis-2 (2001)
- Definition:
- Expanded on Sepsis-1 but retained the SIRS criteria.
- Introduced the concept of severe sepsis (sepsis with organ dysfunction) and septic shock (sepsis with hypotension unresponsive to fluid resuscitation).
- Severe Sepsis:Sepsis with at least one sign of organ dysfunction (e.g., hypotension, altered mental status, oliguria, etc.).
- Septic Shock: Sepsis with persistent hypotension despite adequate fluid resuscitation, requiring vasopressors to maintain blood pressure.
- Limitations:
- Still relied heavily on SIRS criteria, which remained non-specific.
- Did not fully capture the complexity of sepsis and its impact on organ function.

Sepsis-3 (2016)
- Definition:
- Sepsis is now defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.
- Key Changes:
1. Focus on Organ Dysfunction:Measured by an increase in the Sequential Organ Failure Assessment (SOFA)score of **≥2 points**.
- SOFA evaluates dysfunction in six organ systems: respiratory, cardiovascular, hepatic, coagulation, renal, and neurological.
2. Septic Shock:Defined as sepsis with:
- Persistent hypotension requiring vasopressors to maintain a mean arterial pressure (MAP) of ≥65 mmHg.
- Serum lactate level >2 mmol/L (>18 mg/dL) despite adequate fluid resuscitation.
- Simplified Screening Tool (qSOFA):
- For quick identification of patients at risk of sepsis outside the ICU:
1. Respiratory rate: ≥22 breaths/min.
2. Altered mental status
3. Systolic blood pressure : ≤100 mmHg.
- A score of **≥2** suggests a higher risk of poor outcomes.
- Advantages:
- Emphasizes organ dysfunction, which is more specific to sepsis.
- Better aligns with the pathophysiology of sepsis as a dysregulated host response.

16/03/2025

Pregnancy is a critical period that requires careful attention to the health and well-being of both the mother and the developing fetus. Following evidence-based guidelines can help ensure a safe and healthy pregnancy. Below are the **do’s and don’ts** as per general obstetric guidelines:

---
Do’s in Pregnancy

1. Prenatal Care
- Attend Regular Prenatal Visits:
- Schedule regular check-ups with your healthcare provider to monitor fetal growth, maternal health, and detect any complications early.
- Take Prenatal Vitamins:
- Folic acid (400–800 mcg/day) is essential to prevent neural tube defects. Iron, calcium, and vitamin D supplements may also be recommended.
- Get Vaccinations:
- Ensure vaccinations are up-to-date, including influenza (flu) and Tdap (tetanus, diphtheria, pertussis) vaccines during pregnancy.

2. Nutrition
- Eat a Balanced Diet:
- Include fruits, vegetables, whole grains, lean proteins, and dairy products.
- Increase caloric intake by ~300–500 kcal/day in the second and third trimesters.
- Stay Hydrated:
- Drink plenty of water (8–10 glasses/day).
- Consume Adequate Iron and Calcium:
- Iron supports increased blood volume, and calcium is essential for fetal bone development.

3. Exercise
- Engage in Moderate Physical Activity:
- Aim for 30 minutes of moderate exercise most days (e.g., walking, swimming, prenatal yoga).
- Exercise helps maintain a healthy weight, reduces stress, and improves circulation.

4. Lifestyle
- Get Adequate Sleep:
- Aim for 7–9 hours of sleep per night. Use pillows for support as the pregnancy progresses.
- Practice Good Hygiene:
- Wash hands frequently to prevent infections.
- Manage Stress:
- Practice relaxation techniques like deep breathing, meditation, or prenatal yoga.

5. Education and Preparation
- Attend Childbirth Classes:
- Learn about labor, delivery, and newborn care.
- Create a Birth Plan:
- Discuss your preferences for labor and delivery with your healthcare provider.

Don’ts in Pregnancy:

1. Avoid Harmful Substances
- No Smoking or Secondhand Smoke:
- Smoking increases the risk of preterm birth, low birth weight, and birth defects.
- No Alcohol:
- Alcohol can cause fetal alcohol spectrum disorders (FASDs), leading to developmental delays and birth defects.
- No Recreational Drugs:
- Illegal drugs (e.g., co***ne, ma*****na) can harm fetal development and increase the risk of complications.

2. Limit Caffeine
- Moderate Caffeine Intake:
- Limit caffeine to ≤200 mg/day (about one 12-ounce cup of coffee). Excessive caffeine may increase the risk of miscarriage or low birth weight.

3. Avoid Certain Foods
- Raw or Undercooked Meat, Eggs, and Fish:
- Risk of foodborne illnesses (e.g., toxoplasmosis, listeriosis).
- Unpasteurised Dairy Products:
- Risk of listeria infection.
- High-Mercury Fish
- Raw Sprouts/
- Risk of bacterial contamination.

4. Avoid Certain Medications
- Consult Your Doctor:
- Avoid over-the-counter or prescription medications without consulting your healthcare provider. Some medications (e.g., isotretinoin, ACE inhibitors) are harmful during pregnancy.

5. Avoid Excessive Heat
- No Hot Tubs or Saunas:
- High temperatures can increase the risk of neural tube defects and dehydration.
- Avoid Overheating During Exercise:
- Stay cool and hydrated during physical activity.

6. Avoid Heavy Lifting and Strenuous Activities:
- Limit Heavy Lifting:
- Heavy lifting or strenuous activities can increase the risk of injury or preterm labor.

7. Avoid Contact with Harmful Chemicals
- Limit Exposure to Toxins:
- Avoid exposure to pesticides, lead, and harmful chemicals (e.g., paint fumes, cleaning products).

16/03/2025

Looking for exceptional pregnancy care? Trust Dr. Amit kyal a compassionate and experienced gynecologist dedicated to supporting you through every stage of your pregnancy journey. With a focus on personalized care, Dr. Amit kyal offers comprehensive prenatal services, from early pregnancy monitoring to delivery and postpartum support. Using the latest evidence-based practices, he ensures the health and well-being of both mother and baby. Whether it’s routine check-ups, managing high-risk pregnancies, or answering your questions, Dr. Amit kyal is here to guide you with expertise and warmth.
Schedule your appointment today and experience the care you deserve! 🌸

13/09/2024

Early goal directed therapy ( EGDT) in sepsis :
Sepsis 6
1)Start high flow oxygen
2) Start IV fluid resuscitation- crystalloid at 30ml /hour
3) Sent sample for blood culture before starting broad spectrum antibiotic
4) Start broad spectrum antibiotic empirically
5) Serum lactate measurement
6) Strict monitoring of urinary output
( EGDT within 1 hour of diagnosis)

Apply vasopressors( Norepinephrine) for hypotension that is not responding to initial fluid resuscitation to maintain MAP > 65 mmHg
In the event of persistent hypotension or serum lactate > 4 mmol/L -
Achieve CVP of > 8 mmHg
Achieve a central venous oxygen saturation ( ScvO2) > 70% or mixed Scv02 of 65% or more

06/09/2024

Simplified method of Initiation of insulin for hyperglycaemia in pregnancy ( HIP )

There are many insulin regimens proposed for treating hyperglycemia, but the multiple daily injections (MDI) is by far the most physiological, efficient and flexible.

Here we can use basal insulin to control fasting blood sugar and bolus insulin before meals for postprandial hyperglycemia.

The total insulin dose required to achieve target glucose levels varies among individuals, ranging from 0.7 to 2 units per kg (current pregnant weight).

Insulin requirements increase with pregnancy progression.

The total insulin dose may be calculated by trimester of pregnancy and body weight: 0.7 units/kg in the first trimester, 0.9 units/kg in the second trimester, and 1.0 units/kg in the third trimester.

You have to split the total insulin dose: 50% as basal and 50% as bolus (divided into three parts for breakfast, lunch, and dinner).

Always initiate insulin with 25% of the calculated dose as we have to follow the rule of start low and go slow.

In patients with class II or Ill obesity, the initial doses of insulin may need to be increased to 1.5-2 units/kg to overcome the combined insulin resistance of pregnancy and obesity.
Therefore, when fasting glucose levels exceed 95 mg/dL, basal insulin should be initiated weight: 0.1-0.2 units/kg/day.

When postprandial blood glucose levels exceed 120 mg/dL, then bolus insulin in form of rapid-acting insulin analog (Aspart/Lispro) or regular insulin should be initiated 15 minutes before the meal.
Begin with 4-8 unit of bolus insulin as average Indian diet contains 60-100 gm of carbohydrate and 1 unit of bolus insulin is required for 10-15 gm of carbohydrates.

The bolus dose for food coverage is bolus insulin to carbohydrate ratio.

The bolus insulin to carbohydrate ratio represents how many grams of carbohydrate are covered or disposed of by 1 unit of insulin.

Generally, one unit of rapid-acting insulin will dispose of 10-15 gm of carbohydrate. This range can vary from 6-30 gm or more of carbohydrate depending on an individual's sensitivity to insulin.

TITRATION (UP/DOWN) OF INSULIN DOSE AS PER SMBG DATA :
Dose titration is based on patient blood glucose log of frequent/daily self-monitoring blood glucose (SMBG) with plasma calibrated glucometers.
Usually four daily glucose measurements are required (fasting and two hours postprandial for breakfast, lunch, and dinner with the addition of pre-lunch, pre-dinner, and 2AM measurements as needed) to optimize insulin therapy and insure timely dose increases.
There is no need of 2AM monitoring with use of long acting and rapid acting analog as they do not cause Somogyi phenomenon

Generally, 1 unit of basal analog insulin is needed to drop the fasting blood glucose by 10-30 mg/dL.

Generally, 1 unit of bolus insulin is needed to drop the postprandial blood ucose by 50 mg/dL. This drop in blood sugar can range from 30-100 mg/dL .

With this we can up titrate or down titrate the pre-breakfast, pre-lunch, and pre-dinner bolus insulin doses as per the 2 hour post-breakfast, post-lunch, and post-dinner blood sugar values to reach the target post-prandial euglycemia for each meal.

04/09/2024

MANAGEMENT OF EARLY ONSET FGR (SOGC 2023)

1)Clinicians should primarily use combination of Doppler studies ( Uterine,umbilical artery,MCA, cerebroplacental ratio, and ductus venosus Doppler) to identify and monitor early-onset (95th percentile), they should be assessed weekly using MCA and DV Doppler.
Out-patient assessments are appropriate so long as the UA changes remain stable and the DV Doppler findings are normal

4)Clinicians should consider admission to hospital for daily surveillance when highly abnormal umbilical Doppler waveforms (i.e., reversed end-diastolic flow velocities) are observed, or when absent end-diastolic flow velocities in the UA are accompanied by abnormal MCA or DV Doppler

5)Clinicians should consider admission for daily in-patient monitoring when early-onset FGR is complicated by either preeclampsia or other major comorbidities such as insulin-dependent diabetes .

6)Urgent delivery should be scheduled, irrespective of gestational age, when there is a maternal indication for delivery (e.g., severe preeclampsia complicated by uncontrolled blood pressures , HELLP ,when there is clinical evidence of placental abruption or in the presence of NST tracing abnormalities (i.e., reduced variability or repetitive late decelerations)

7)Clinicians may defer delivery until 30–32 weeks gestation in cases of reversed end-diastolic flow in the umbilical arteries and to 32–34 weeks in cases of absent end-diastolic flow, so long as DV Doppler and NST findings are normal

8)Clinicians should administer a course of corticosteroids for fetal lung maturation prior to planned preterm delivery, followed by intravenous MgSO4 on the day of delivery for fetal neuroprotection. Both medications should follow the same protocols as for pregnancies not affected by fetal growth restriction

9)Caesarean delivery is generally indicated for placenta-mediated early-onset FGR and major Doppler abnormalities in either the umbilical arteries (absent or reversed end-diastolic flow velocities) or the ductus venosus (absent or reversed a waves) so as to avoid acute fetal compromise from attempted induction of labour

10)Clinicians should provide extensive support to prospective parents making difficult decisions when the severity of early-onset fetal growth in the periviable period (23–26 weeks) presents an imminent risk of stillbirth or neonatal death

01/09/2024

Fetal growth restriction ( FGR ) - SOGC guidelines (2023)

1)It is important for clinicians to understand the differentiate between FGR & SGA because fetal growth restriction is a risk factor for perinatal morbidity and mortality, while small for gestational age is not .

2)SGA refers either to a fetus with an ultrasound-derived AC or estimated fetal weight below the 10th percentile

3)FGR describes fetal growth does not follow a normal trajectory of growth because of one or more underlying pathological conditions and is broadly categorized as either a rare early-onset disease (prevalence 0.5%–1%) prior to 32 weeks gestation, or a more common late-onset disease (prevalence 5%–10%) when diagnosed at 32 weeks and beyond (moderate).

4)The Delphi consensus ultrasound-based criteria should be used to make a diagnosis of fetal growth restriction.
These vary by gestational age, and comprise measures of fetal size, fetal growth, and abnormalities of umbilical, uterine, and middle cerebral artery Doppler (moderate).

5)Early-onset FGR is diagnosed before 32 weeks gestation. At least 1 of the following 3 criteria should be present:
1) an AC or estimated fetal weight below the 3rd percentile
2) late changes in the umbilical artery Doppler assessment (i.e., absent or reversed end-diastolic velocity) or
3) an AC or estimated fetal weight below the 10th percentile accompanied by abnormal uterine artery Doppler study (mean PI >95th percentile) or abnormal umbilical artery Doppler study (PI >95th percentile)

6)Late-onset FGR is diagnosed at or after 32 weeks gestation by either an AC or estimated fetal weight below the 3rd percentile alone or at least 2 of the following 3 criteria:
1) an AC or estimated fetal weight below the 10th percentile
2) A drop in fetal growth velocity i.e. drop in AC or EFW of > 2 quartiles or > 50 percentiles
or
3) an abnormal Doppler finding, defined as an umbilical artery Doppler PI above the 95th percentile or a CPR below the 5th percentile

7)In the first trimester, multimodal screening for fetal growth restriction is substantially more effective than clinical risk factor-based screening; however, multimodal screening is not presently recommended because of the logistical challenges to implementation

8)In the second trimester, a combination of ultrasound observations (made at the fetal anatomical ultrasound scan) may be useful for identifying pregnancies that are developing early-onset fetal growth restriction. These ultrasound features include: fetal biometry measurements more than 1 week behind gestational age, short femurs, echogenic bowel, a 2-vessel cord, and a marginal or velamentous placental cord insertion.

9)In the second and third trimesters, neither uterine artery nor umbilical artery Doppler assessments are effective in predicting fetal growth restriction in low-risk pregnancies

10)Measurement of circulating maternal PGF in either the second or third trimester is not effective in predicting fetal growth restriction in low-risk pregnancies

11)Routine symphysis–fundal height measurement has moderate sensitivity and high specificity in detecting fetal growth restriction and is an acceptable approach in clinically low-risk patients with a normal body mass index. Customization of the symphysis–fundal height chart for individual maternal characteristics and previous pregnancy outcomes may improve its effectiveness. Ultrasonography is more accurate than symphysis–fundal height measurement for the detection of FGR in patients with a body mass index >35 kg/m2, polyhydramnios, or large fibroids (moderate).

12Umbilical artery Doppler waveforms are typically abnormal in placenta-mediated early-onset fetal growth restriction and typically normal in placenta-mediated late-onset fetal growth restriction.
Umbilical artery Doppler findings may be abnormal when fetal growth restriction is due to aneuploidy (e.g., trisomy 18, trisomy 21, and triploidy) or other intrinsic fetal cause.

31/08/2024

The Society for Maternal-Fetal Medicine recommends the following approach to the evaluation and management of isolated soft markers(2021):

1)We do not recommend diagnostic testing for aneuploidy solely for the evaluation of an isolated soft marker following a negative serum or cell-free DNA screening result

2) For pregnant people with no previous aneuploidy screening and isolated echogenic intracardiac focus, echogenic bowel, urinary tract dilation, or shortened humerus, femur or both, we recommend counseling to estimate the probability of trisomy 21 and a discussion of options for noninvasive aneuploidy screening with cell-free DNA or quad screen if cell-free DNA is unavailable or cost-prohibitive

3)For pregnant people with no previous aneuploidy screening and isolated thickened nuchal fold or isolated absent or hypoplastic nasal bone, we recommend counseling to estimate the probability of trisomy 21 and a discussion of options for noninvasive aneuploidy screening through cell-free DNA or quad screen if cell-free DNA is unavailable or cost-prohibitive or diagnostic testing via amniocentesis, depending on clinical circumstances and patient preference

4) For pregnant people with no previous aneuploidy screening and isolated choroid plexus cysts, we recommend counseling to estimate the probability of trisomy 18 and a discussion of options for noninvasive aneuploidy screening with cell-free DNA or quad screen if cell-free DNA is unavailable or cost-prohibitive

5) For pregnant people with negative serum or cell-free DNA screening results and an isolated echogenic intracardiac focus, we recommend no further evaluation as this finding is a normal variant of no clinical importance with no indication for fetal echocardiography, follow-up ultrasound imaging, or postnatal evaluation

6)For pregnant people with negative serum or cell-free DNA screening results and isolated fetal echogenic bowel, urinary tract dilation, or shortened humerus, femur, or both, we recommend no further aneuploidy evaluation

7)For pregnant people with negative serum screening results and isolated thickened nuchal fold or absent or hypoplastic nasal bone, we recommend counseling to estimate the probability of trisomy 21 and discussion of options for no further aneuploidy evaluation, noninvasive aneuploidy screening through cell-free DNA, or diagnostic testing via amniocentesis, depending on clinical circumstances and patient preference

8)For pregnant people with negative cell-free DNA screening results and isolated thickened nuchal fold or absent or hypoplastic nasal bone, we recommend no further aneuploidy evaluation

9) For pregnant people with negative serum or cell-free DNA screening results and isolated choroid plexus cysts, we recommend no further aneuploidy evaluation, as this finding is a normal variant of no clinical importance with no indication for follow-up ultrasound imaging or postnatal evaluation

10) For fetuses with isolated echogenic bowel, we recommend an evaluation for cystic fibrosis and fetal cytomegalovirus infection and a third-trimester ultrasound examination for reassessment and evaluation of growth

11)For fetuses with an isolated single umbilical artery, we recommend no additional evaluation for aneuploidy, regardless of whether results of previous aneuploidy screening were low risk or testing was declined. We recommend a third-trimester ultrasound examination to evaluate growth and consideration of weekly antenatal fetal surveillance beginning at 36 0/7 weeks of gestation

12) For fetuses with isolated urinary tract dilation A1, we recommend an ultrasound examination at ≥32 weeks of gestation to determine if postnatal pediatric urology or nephrology follow-up is needed. For fetuses with urinary tract dilation A2-3, we recommend an individualized follow-up ultrasound assessment with planned postnatal follow-up

13)For fetuses with isolated shortened humerus, femur, or both, we recommend a third-trimester ultrasound examination for reassessment and evaluation of growth

Dr Amit kyal - Obstetrician & Gynaecologist

13/09/2025

12/05/2025

23/03/2025

21/03/2025

16/03/2025

16/03/2025

13/09/2024

06/09/2024

04/09/2024

01/09/2024

31/08/2024

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