The infant is born cyanotic, which becomes more intense in the next few months, because of impaired pulmonary blood flow. By the 4th to 6th weeks of life, signs of heart failure (e.g., tachypnea, dyspnea with feeding, poor weight gain, and diaphoresis) may be present in infants with increased pulmonary blood flow, which will need emergency control measures.

Auscultation will reveal a single second heart sound and a grade 2 to 3 holosystolic or early systolic murmur of a ventricular septal defect at the lower left sternal border. A systolic ejection murmur of pulmonary stenosis or a continuous murmur of patent ductus arteriosus is audible in the upper left sternal border. An apical diastolic rumble indicates increased pulmonary blood flow. Cyanosis may persist for more than 6 months resulting in clubbing of the fingers or toes on account of the reduced amount of oxygen in the blood.

• Fatigue

  Complications such as the formation of blood clots in the arteries of the lungs, strokes, complaints of fatigue, and heart rhythm abnormalities will require life style changes monitoring for infection and life-long follow-up with a cardiologist. [secure.ssa.gov]

  INCREASED PULM FLOW • Diff to diagnose • may not appear cyanotic but may present with signs of heart failure later in infancy • pulmonary plethora present with symptoms of dyspnea, fatigue, difficulty feeding, and perspiration, which are suggestive of [slideshare.net]

  These include: Rapid weight gain from retaining fluids Swelling in the abdomen Swelling in the legs, ankles, and feet Weakness and fatigue Irregular or fast heartbeat Cleveland Clinic is a non-profit academic medical center. [my.clevelandclinic.org]

• Congestive Heart Failure

  All infants presented with symptoms of cyanosis and/or congestive heart failure within a few days to 2 months after birth and died shortly thereafter. [ncbi.nlm.nih.gov]

  A heart murmur is almost always heard and congestive heart failure may develop. Symptoms of congestive heart failure in infants include rapid breathing, clammy sweating, poor feeding, and poor growth. [mottchildren.org]

  In patients with increased pulmonary blood flow and severe congestive heart failure, pulmonary artery binding is undertaken to decrease blood flow to the lungs and to facilitate treatment of congestive heart failure. [symptoma.com]

  The symptoms of congestive heart failure are fast breathing, fast heart rate, sweating with feeds and poor weight gain. [cincinnatichildrens.org]

• Pain

  Recovery was hard, not pain wise. I found out after my surgery that I have a high pain tolerance. I was sore, and my leg hurt like crazy because they cut something when they went in with the heart lung machine. [chd-uk.co.uk]

  So, four years ago I went through a terrible and painful surgery. They cut out a piece of dead tissue from my heart because it was no longer functioning. [themighty.com]

  Anxiety and pain also can change PVR to SVR ratio. Invasive hemodynamics, vasopressor and ionotropic agents thus become an integral part of management of such patient. [apicareonline.com]

  Your child's doctor will discuss pain control before your child is discharged from the hospital. [stanfordchildrens.org]

  For this child with TA, there are both early and ongoing morbidities resulting in what parents perceive to be suffering and pain for their child. [pediatrics.aappublications.org]

• Feeding Difficulties

  DIAGNOSTIC TESTING, PHYSICAL FINDINGS, AND ICD-9-CM CODING Diagnostic testing: • ECG (electrocardiogram); • Cardiac catheterization Physical findings: • Cyanosis (bluish discoloration of the skin); • Tires easily especially during feeding; • Difficulty [secure.ssa.gov]

  Many affected infants have feeding difficulties and high caloric requirements for growth, so a gastrostomy tube is often needed to maintain adequate intake. [pediatrics.aappublications.org]

• Falling

  Furthermore, although the best interests of the infant are central in decision-making, the interests of the parents, siblings, and other may also be considered. 2, 3 The American Academy of Pediatrics recognizes that most such decisions fall into a gray [pediatrics.aappublications.org]

• Dyspnea

  She did well for years until she had dyspnea, upper extremity oedema and "facial fullness". On examination she was tachycardic, hypotensive, and more desaturated than baseline. She also had facial plethora. [ncbi.nlm.nih.gov]

  Infants with increased pulmonary blood flow usually show signs of heart failure (eg, tachypnea, dyspnea with feeding, poor weight gain, diaphoresis) by age 4 to 6 weeks. [msdmanuals.com]

  Clinical manifestations include severe cyanosis, dyspnea, anoxia, and signs of right-sided heart failure. [medical-dictionary.thefreedictionary.com]

  The TA baby has bluish skin, tires easily, is underweight, has respiratory problems (tachypnea, dyspnea), drools a lot, and is at risk for aspiration pneumonia. [symptoma.com]

• Cough

  The management of a 3-month-old boy who presented with dyspnoea, fever, cough and cyanosis is presented here as obtained from Clinical records. [ncbi.nlm.nih.gov]

  These include coughing and swelling in the legs and feet, which is known as “edema.” The heart begins to form when a fetus is just 8 weeks old. Tricuspid atresia is a result of the tricuspid valve failing to develop during this period of growth. [healthline.com]

  […] disarray錯綜配列 dissection解離 distribution分布 diuresis利尿 diuretic（１）利尿　【形】　（２）利尿薬 donor artery供給血管 double shadow二重陰影〈胸部Ｘ線心陰影〉 double-outlet right ventricle (DORV)両大血管右室起始［症］ doublt productダブルプロダクト〈心拍数×収縮期血圧〉 down-sloping ST segment depression下降傾斜型ＳＴ下降 dry cough [tokyo-med.ac.jp]

• Respiratory Distress

  When the blockage is bilateral in a newborn, it produces acute respiratory distress because neonates are nose-breathers. Diagnosis is confirmed if a catheter cannot be passed through the nares. [medical-dictionary.thefreedictionary.com]

  This condition manifests with signs and symptoms of heart failure, with tachypnea or respiratory distress, poor feeding, and growth. [ncbi.nlm.nih.gov]

• Clubbed Finger

  The test can establish a strong, apical impulse and systolic murmur and thrill along the left edge of the sternum, then cyanosis, polycythemia and clubbed fingers. [remedyland.com]

• Diarrhea

  Complications may include: Irregular, fast heart rhythms (arrhythmias) Chronic diarrhea (from a disease called protein-losing enteropathy) Heart failure Fluid in the abdomen (ascites) and in the lungs (pleural effusion) Blockage of the artificial shunt [nlm.nih.gov]

  Possible Complications Complications may include: Irregular, fast heart rhythms (arrhythmias) Chronic diarrhea (from a disease called protein-losing enteropathy) Heart failure Fluid in the abdomen (ascites) and in the lungs (pleural effusion) Blockage [ufhealth.org]

  These include: Arrhythmia Chronic diarrhea (from protein-losing enteropathy) Heart failure Ascites and pleural effusion Blockage of the artificial shunt Stroke and other nervous system complications Sudden death The best strategy for care and prevention [symptoma.com]

• Hepatomegaly

  Transposed GA's -Most get pulm overcirc within a few weeks of life bc usually no obstruction to Qp bc PA is fr LV -restrictive VSD or infundibular narrowing --> obstruct Qs, and if severe--> shock -if restricted ASD/PFO, --> hepatomegaly, and decr overall [sites.google.com]

  In patients with pulmonary plethora, a physical examination would be significant for tachypnea, tachycardia, and hepatomegaly.[8] Evaluation In the era of enhanced antenatal ultrasound and fetal echocardiogram programs, the majority of these patients [ncbi.nlm.nih.gov]

• Heart Disease

  Tricuspid atresia is a type of heart disease that is present at birth ( congenital heart disease ), in which the tricuspid heart valve is missing or abnormally developed. The defect blocks blood flow from the right atrium to the right ventricle. [nlm.nih.gov]

  Tricuspid Atresia is the 3rd commonest cyanotic congenital Heart disease. It is characterized by lack of communication between the right atrium and right ventricle. [ncbi.nlm.nih.gov]

  […] of Adults With Congenital Heart Disease). [wikidoc.org]

• Cyanosis

  In contrast, with accompanying pulmonary artery or valve stenosis, pulmonary blood flow is reduced, resulting in increased cyanosis. Pulmonary obstruction occurs most often in patients with tricuspid atresia and normally related great arteries. [emedicine.com]

  • Cyanosis is minimal 23. [slideshare.net]

  Clinical Presentation: If not diagnosed in utero, tricuspid atresia commonly presents with cyanosis and a heart murmur, and the degree of pulmonary blood flow determines the timing of cyanosis. [pedclerk.bsd.uchicago.edu]

  Cyanosis, when present for > 6 months, may result in clubbing. [merckmanuals.com]

• Heart Failure

  However, her condition rapidly deteriorated and she died of sepsis and heart failure at the age of 14 days. [ncbi.nlm.nih.gov]

  Presenting signs include cyanosis or signs of heart failure. The first heart sound (S1)is single and may be accentuated. The 2nd heart sound (S2) is usually single. [merckmanuals.com]

  In patients with increased pulmonary blood flow and severe congestive heart failure, pulmonary artery binding is undertaken to decrease blood flow to the lungs and to facilitate treatment of congestive heart failure. [symptoma.com]

• Heart Murmur

  […] at the lower left sternal border (see table Heart Murmur Intensity Heart Murmur Intensity ). [msdmanuals.com]

  Pediatricians from other hospitals refer newborns to the Cardiac Center when the baby shows symptoms or signs that may indicate a heart problem, such as a blue tint to the skin or a heart murmur. [chop.edu]

  A baby with tricuspid atresia can show the following symptoms: Becoming tired easily Skin and lips that are bluish in color (cyanosis) Shortness of breath Slow growth Heart murmur (unusual heart sounds) In addition, some babies with this condition can [my.clevelandclinic.org]

  Using a stethoscope, a doctor will check for a heart murmur (an abnormal “whooshing” sound caused by blood not flowing properly), or other sounds that may indicate a heart problem. [cdc.gov]

• Tachycardia

  Atrioventricular reentrant tachycardia (AVRT) is the most common supraventricular tachycardia occurring in children. [ncbi.nlm.nih.gov]

Successful management of congenital heart disease requires close coordination of a panel of experts in pediatric cardiology, neonatology and reconstructive surgery, for optimum care of the patient. Antenatal and postnatal evaluations are important for early diagnosis and treatment. Precision diagnostic tools are available and the choice of treatment modality depends on the child's status and institutional capability.

Cyanosis is the prominent sign that there is a problem with the newborn. A heart murmur heard during physical examination indicates turbulence of blood crossing an obstructed pulmonary valve or flowing through the openings where arterial and venous blood mix. 

Confirmatory tests that are recommended:

• Chest X-ray. A routine test to visualize the disposition of the internal organs at the level of the heart, showing gross abnormality, if any, relative to TA.
• Electrocardiogram (ECG). A test to detect abnormal rhythms (arrhythmias or dysrhythmias) and heart muscle stress. 
• Echocardiogram. A procedure producing a videogram of the heart and heart valves.
• Cardiac catheterization is a surgical procedure that allows detailed visualization and evaluation of structures and functions of the heart. A small, thin catheter is inserted into a blood vessel in the groin, and into the chambers of the heart, the pulmonary artery and the aorta. Blood pressure and oxygen are measured. Contrast dye is used for maximum visibility. 

• Pericardial Effusion

  Three operations were pericardiectomy procedures carried out because of recurrent pericardial effusion. Two reoperations were successful cardiac transplantations in patients who were doing poorly because of gradual myocardial deterioration. [onlinejacc.org]

  effusion心膜液 pericarditis 心膜炎 pericardium 心膜 peripheral 末梢［性］　【形】 permeability透過性、浸透性 phonocardiogram (PCG)心音図 plateau phaceプラトー相 positron emission tomography (PET)ポジトロン放射計断層撮影[法] potential（１）潜在性　【形】　（２）電位 precordial pain前胸[部]痛 preload前負荷 premature beat [tokyo-med.ac.jp]

• Left Axis Deviation

  […] and through the VSD to the right ventricle to allow access to the lungs progressive cyanosis poor feeding tachypnea over the first 2 weeks of life holosystolic murmur due to the VSD left axis deviation on electrocardiography and left ventricular hypertrophy [en.wikipedia.org]

  Cardiomegaly and increased pulmonary vascular markings on the chest x-ray film and left axis deviation with left ventricular hypertrophy on the ECG are usually present. [ncbi.nlm.nih.gov]

  […] right ventricle and enlarged left ventricle Pathognomic findings in setting of cyanosis: Tall p-waves (indicating atrial hyperplasia) Left axis deviation LV hypertrophy ECHO: Direct visualization of the atretic tricuspid valve, atrial septal defect, [pedclerk.bsd.uchicago.edu]

  ECG characteristically shows left axis deviation (between 0° and −90°) and left ventricular hypertrophy. Left axis deviation is not usually present if there is associated transposition of the great arteries. [merckmanuals.com]

  ECG characteristically shows left axis deviation (between 0 ° and − 90 ° ) and left ventricular hypertrophy. Left axis deviation is not usually present if there is associated transposition of the great arteries. [msdmanuals.com]

• Ventricular Hypertrophy

  Cardiomegaly and increased pulmonary vascular markings on the chest x-ray film and left axis deviation with left ventricular hypertrophy on the ECG are usually present. [ncbi.nlm.nih.gov]

  […] and through the VSD to the right ventricle to allow access to the lungs progressive cyanosis poor feeding tachypnea over the first 2 weeks of life holosystolic murmur due to the VSD left axis deviation on electrocardiography and left ventricular hypertrophy [en.wikipedia.org]

  Tricuspid atresia – ECG Tricuspid atresia – ECG Right atrial overload is manifest as tall P waves in lead II and left ventricular hypertrophy with strain pattern is seen in lateral leads with tall R waves, ST segment depression and T wave inversion. [cardiophile.org]

  ECG giant (> 5mm) P waves 6 with peaked morphology in lead II exaggeration of right atrial enlargement morphology referred to as "Himalayan P waves" extreme axis deviation high left ventricular voltage (HLVV) left ventricular hypertrophy voltage criteria [radiopaedia.org]

Medical care

There are three major areas of concern in the treatment of infants with TA. These are:

• Regulating the amount of pulmonary blood flow to decrease hypoxemia or symptoms of congestive heart failure.
• Maintaining myocardial function and preserving the integrity of the pulmonary vascular bed and pulmonary vasculature for Fontan operation.
• Minimizing the risk of bacterial endocarditis and thromboembolism through routine antimicrobial prophylaxis. 

Most infants have decreased pulmonary blood flow, characterized by marked cyanosis and hypoxemia, the latter if severe may lead to acidemia and death. Prostaglandin E infusion is administered to keep the ductus arteriosus open and to increase pulmonary blood flow.       

Increased pulmonary blood flow is associated with an unrestrictive ventricular septal defect (VSD) and transposed great vessels. Infants with these defects are likely to succumb to severe congestive heart failure and should be placed on digitalis and diuretics to restrict pulmonary blood flow until surgery can be  performed.

Standard palliative procedures are at the discretion of the physician to improve the chances of survival of the patient. With reconstructive surgery, 50% may live up to adolescence. However, there is always the risk for developing complications such as polycythemia, arrhythmia, ventricular dysfunction, paradoxical emboli, stroke, brain abscess, progressive cardiac dilatation, and mitral valve insufficiency. 

Surgical care

Most infants with TA undergo reconstructive surgery on their first year of life. Depending upon the severity of the disorder, the infant is admitted to the neonatal intensive unit (NICU) and administered prostaglandin E1 for blood to circulate to the lungs via a patent ductus arteriosus.

A series of surgical procedures may be needed. If the heart is unable to pump sufficient blood into the lungs, surgery is initiated via an artificial shunt. Otherwise, the infant is sent home to prepare for the Glenn shunt or Hemifontan procedure at 4 to 6 months of age. The procedure connects veins carrying blood from the upper half of the body directly to the pulmonary artery. At this stage, the child may still be cyanotic.

In infants with decreased pulmonary blood flow, the shunt procedure connects the systemic circulation and the pulmonary circulation, via a cavopulmonary anastomosis (Glenn shunt) or from the subclavian artery to the pulmonary artery (Blalock-Taussig shunt). In patients with increased pulmonary blood flow and severe congestive heart failure, pulmonary artery binding is undertaken to decrease blood flow to the lungs and to facilitate treatment of congestive heart failure [4] [5]. 

Shunt failure, persistence of cyanosis, progression of the disease and increasing pulmonary obstruction will necessitate a third and final operation, the Fontan procedure. Otherwise, palliative treatment to alleviate symptoms should be initiated.

The Fontan operation bypasses the right ventricle by connecting the right atrium to the pulmonary artery or by creating an extracardiac cavopulmonary anastomosis with a synthetic graft. The procedure requires the following specifications: minimum age of the patient (4 years or older), normal capacity of right atrium and caval drainage, sinus rhythm, mean pulmonary artery pressure less than 15 mm Hg, mean pulmonary arteriolar resistance low, pulmonary artery-to-aorta diameter ratio more than 0.75 and previous shunt procedures should not impair the current operation.

A 3-stage Fontan pathway without cardiopulmonary bypass can been achieved in patients with a single functional ventricle and cardiac abnormalities (tricuspid atresia, pulmonary atresia with intact ventricular septum, double outlet right ventricle) [6] [7]. The procedure connects the right atrium to the systemic pulmonary artery at its point of exit or at the bifurcation of the main trunk, and closes the atrial septal defect [8] [9] [10] [11] [12] [13] [14] [15]. 

The goal of treatment is the survival of the atretic child. To achieve this, consultations among the attending physicians and with the parents of the affected child should include counselling and monitoring of the patient's progress in time. Certain prescriptions must be observed such as the use of diuretics, low sodium diet, electrolyte replacements, proper nutrition for growth and development, and limiting activities to prevent dyspnea and possible congestive heart failure. 

Prognosis is good with early recognition of the disorder, possibly of the fetus in utero and with immediate surgical intervention postnatally to repair the congenital heart defects. A series of reconstructive surgical procedures are performed at birth and later when the infant is older. With Fontan operation, the survival rate is 85% after one year and 78% after five years. The procedure eliminates cyanosis and polycythemia. Left ventricular volume overload is relieved. Patients can be expected to live longer.

The etiology of tricupid atresia remains to be elucidated. Animal experimentation has shown that mice with aberration in FOG2 gene are born with tricuspid atresia indicating possible involvement of genetic factors in humans. Further studies are needed to validate this hypothesis.

The incidence of TA in the United States is 2.9%, based on post-mortem data. Depending on the extent of impairment of cardiac function and concomitant anomalies, TA is potentially fatal if left untreated. Survivors of treatment with corrective surgery may live well into adolescence or adulthood. There is no predilection for age, ethnic origin, and gender, although more males are found with transposed great vessel defect than females. 

Tricuspid atresia is classified into three types according to the relative positions of the great vessels.These are:

• Type I, in which the great arteries are in their normal positions with respect to each other
• Type II, in which the great arteries are d-transposed; and
• Type III, the great arteries are l-transposed.

Under each of these types, blood flow from the heart to the lungs is determined by the presence or absence of ventricular septal defect (VSD) and/or pulmonary valve pathology [1] [2]. Fifteen to twenty percent of TA patients may have other cardiovascular defects which are linked to the transposition of the great vessels. For example, a persistent left superior vena cava anomaly has been observed in 15% of patients.

In patients with type I great arteries with a VSD, perfusion may take place in the lungs. Without a VSD, pulmonary blood flow is diverted through a patent ductus arteriosus, and systemic blood flow proceeds directly from the left ventricle. With type II (d-transposed great arteries), blood flows from the left ventricle to the lungs. Likewise, blood flows to the aorta from the left ventricle via the VSD and right ventricle. As for the other types of TA, the pathway of the aortic and pulmonary blood flow is determined by the size of the VSD and presence of other cardiac abnormalities.

The presence or absence of defects of the pulmonary artery affects the flow of blood in the heart in tricuspid atresia [3]. In patients without pulmonary atresia or pulmonary valve stenosis, the volume of blood flow to the lungs may still be normal with adequate oxygenation. Cyanosis is not too severe. In the presence of pulmonary pathology, pulmonary blood flow is greatly reduced and cyanosis is increased. Obstruction of pulmonary blood flow often occurs in type I TA patients whereas type II TA patients generally have unobstructed pulmonary blood flow.

In the absence of a right atrioventricular connection, venous blood from the right atrium is diverted to the left atrium via an intra-atrial route or atrial septal defect (ASD), where venous and arterial blood mix. This obligatory right-to-left shunt diminishes the saturation of oxygen in the left atrial blood, and eventually, the supply of oxygen-rich blood to the rest of the body. Systemic arterial desaturation is present in all tricuspid atresia patients because of the pooling of systemic, coronary and pulmonary venous blood in the left atrium. 

Whereas the right ventricle is degenerate, the left ventricle compensates by making up most of the ventricular mass in TA. It ejects all the venous blood (systemic, coronary and pulmonary) output and its pumping capacity is strained. Left ventricular overloading is present in all TA cases. A number of sequelae have been reported, namely: fibrosis, persistent hypoxemia, ventricular dysfunction, decreased ejection fraction, mitral annular dilatation, and mitral insufficiency. 

Congenital heart defects may be averted or minimized by conscientious antenatal care of mother and fetus in terms of proper nutrition, good hygienic practices, avoidance of exposure to infections, abstinence from unhealthy habits, and unprescribed drugs. Regular consultation with specialists is the best option.

Tricuspid atresia (TA) is one of congenital heart defects characterized by the absence or underdevelopment of the connection between the right atrium (RA) and the right ventricle (RV). This results in decreased ventricular function, thus the impairment of the passage of blood to the right ventricle and from there, to the lungs where venous blood is oxygenated. The defect is acquired in utero during the first 8 weeks of fetal development.   

The right ventricle is usually hypoplastic or underdeveloped. To compensate for the absence of an atrioventricular connection, other congenital defects may occur, like an atrial septal defect (ASD) or a ventricular septal defect (VSD). These allow mixing of oxygenated and non-oxygenated blood.

Diagnosis is based on the results of antenatal and postnatal imaging studies and presentation at birth. The newborn with TA is cyanotic, has low birth weight, shows abnormal heart sounds, has feeding and respiratory problems, and is prone to aspiration pneumonia. Early diagnosis and prompt treatment are essential. Treatment may require a series of operations to correct the defect. Those who survive these procedures may live long and be able to cope with normal daily activities. 

Risks coming from complications due to highly vulnerable status of the newborn should be taken into consideration. A multidisciplinary panel of experts (in neonatology, pediatrics, cardiology, internal medicine, and surgery) is required to ensure optimum care for the mother and the child. Prevention can best be achieved following regular consultations with the aforementioned specialists.  

Tricuspid atresia (TA) is an inborn defect of the heart in which the connection between the right atrium and the right ventricle is replaced by a solid mass of tissue instead of the tricuspid valve. The right ventricle degenerates and is unable to pump blood into the lungs via the pulmonary artery for the vital process of oxygenation. To compensate for this loss of atrioventricular connection, two other congenital anomalies develop, a passageway connecting the right and left atria called atrial septal defect (ASD) and one connecting the two ventricles, where venous (deoxygenated) and arterial (oxygenated) blood mix, called ventricular septal defect (VSD). Thus, blood that is delivered to the rest of the body is deficient in oxygen. The lungs likewise receives blood through a fetal vessel called ductus arteriosius which normally closes after birth. 

The end result of these aberrations is a cyanotic newborn (blue baby syndrome) with oxygen-poor blood. The patient might have feeding, breathing and other co-existing pathological conditions, and needs immediate remedial measures to survive. 

Tricuspid atresia affects 5 in every 100,000 live births; 20% of these patients are with other congenital defects which are likely to be the source of complications with fatal outcomes. The TA baby has bluish skin, tires easily, is underweight, has respiratory problems (tachypnea, dyspnea), drools a lot, and is at risk for aspiration pneumonia.   

TA can be detected prenatally and postnatally by routine and high precision diagnostic tools. A heart murmur may present at birth indicating an abnormal heart condition. Confirmatory tests include: ECG, echocardiogram, chest x-ray, cardiac catheterization, and MRI of the heart.

If the heart has difficulty pumping blood into the lungs and to the rest of the body, the baby may be admitted in the intensive care unit for an artificial shunt procedure within the first few days of life. This first surgery may or may not be needed, if the baby can cope with palliative treatment (oral medication) under the supervision of a pediatric cardiologist. If cyanosis and other symptoms persist, a series of reconstructive surgery may be needed. In more advanced cases, a second (Glenn procedure) and third (Fontan) operative procedure may be required a few months later and within 3 years of life, respectively. The baby should no longer be cyanotic after Fontan surgery.  

Some possible complications may occur in the course of treatment. These include:

• Arrhythmia 
• Chronic diarrhea (from protein-losing enteropathy)
• Heart failure
• Ascites and pleural effusion
• Blockage of the artificial shunt
• Stroke and other nervous system complications
• Sudden death

The best strategy for care and prevention of tricuspid atresia is compliance with early prenatal and postnatal interventions and good maternal health practices.

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