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Hot Topics in Maternal‐Fetal Medicine
Juan M. Gonzalez Velez, MD, PhDAssociate Professor
Maternal‐Fetal Medicine Department of Ob/Gyn
& RS
University of California, San Francisco
•No financial disclosures.
From: Elsevier's Integrated Pathology, 2007
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Single deepest vertical pocket or amniotic fluid index as
evaluation test for predicting adverse pregnancy outcome (SAFE
trial): a multicenter, open-label, randomized controlled trial
S Kehl, A Schelkle, A Thomas, A Puhl, K Meqdad, B Tuschy, S
Berlit, C Weiss, C Bayer, J Heimrich, U Dammer, E Raabe, M Winkler,
F Faschingbauer, MW Beckmann, M Sutterlin
Volume 47, Issue 6, Date: June (pages 674–679) 2016
Journal Club slides prepared by Dr Shireen Meher(UOG Editor for
Trainees)
Introduction• Amniotic fluid volume is an integral part of
assessment of
fetal wellbeing.• No consensus on the best method to assess
amniotic fluid
volume.• RCTs in high-risk, post-term and intrapartum women
show
that both techniques are poor predictors of adverse pregnancy
outcome.
• There is less knowledge on the usefulness of these techniques
in low-risk and term pregnancies.
SDP or AFI as evaluation testS Kehl et al., UOG 2016
Aim of the study
SDP or AFI as evaluation testS Kehl et al., UOG 2016
• To determine, in both high-risk but and low-risk pregnancies,
which technique for estimating amniotic fluid volume (AFI or SDP)
is the best test to predict adverse pregnancy outcome.
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• Study design– Multicenter, open-label RCT
• Setting– Four hospitals in Germany (July 2012 to September
2013)
• Participants– Included: women with a singleton pregnancy at
term and cephalic
presentation, presenting for delivery or pre-labor examination.
– Excluded: women with primary Cesarean section, premature rupture
of
the membranes, no ultrasound examination in the last 7 days,
structural/chromosomal fetal malformation, intrauterine fetal
death, placenta previa or any contraindication to vaginal
delivery.
SDP or AFI as evaluation testS Kehl et al., UOG 2016
Methods
• Intervention – Women randomised to AFI or SDP measurement for
estimation of
amniotic fluid volume– The diagnosis of oligohydramnios (AFI
≤5.0 cm or absence of SDP
measuring at least 2 × 1 cm) was followed by labor induction•
Primary outcome
– Postpartum admission to neonatal intensive care unit (NICU)•
Other outcomes:
– Rate of perinatal death, oligohydramnios, induction of labor
(for oligohydramnios or without specific indication), umbilical
artery pH
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ResultsBaseline characteristics
In the AFI group, fewer women had • gestational diabetes• a
previous Cesarean section
SDP or AFI as evaluation testS Kehl et al., UOG 2016
Results
SDP or AFI as evaluation testS Kehl et al., UOG 2016
• Primary outcome: postpartum admission to NICU– No significant
difference between AFI and SDP groups
4.2% (n=21) vs 5.0% (n=25); RR, 0.85 (95% CI, 0.48–1.50);
P=0.57
• Secondary outcomes with statistically significant differences–
Increased risk of diagnosis of oligohydramnios in AFI group
(9.8% (n=49) vs 2.2% (n=11); RR, 4.51 (95% CI, 2.37–8.57); P
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Results: high-risk vs low-risk pregnancies
SDP or AFI as evaluation testS Kehl et al., UOG 2016
• In low-risk pregnancies• Increased diagnosis of
oligohydramnios using AFI
9.9% vs 2.0%; RR 5.03 (95% CI, 2.39–10.58))• More labor
inductions for oligohydramnios using AFI
15.3% vs 3.9%; RR, 3.89 (95% CI, 1.84–8.27))• More cases of
arterial pH < 7.10 seen in SDP
3.5% vs 1.2%; RR, 0.34 (95% CI, 0.12–0.94))
• In high-risk pregnancies• None of the above findings were
significantly different between the
AFI and SDP groups• The only significant difference between AFI
and SDP groups was a
lower arterial pH in the AFI group (7.25 ± 0.08 vs 7.28 ±
0.07)
• Neither the AFI nor SDP technique was superior in predicting
adverse pregnancy outcome.
• Using AFI method resulted in increased diagnoses of
oligohydramnios, and subsequent induction of labor for
oligohydramnios.
• Abnormal CTG was seen more often using AFI compared to SDP
technique.
• In low-risk pregnancies, the rate of oligohydramnios was
higher with AFI compared to SDP measurement, but this was not
significantly higher in high-risk pregnancies - possibly due to
smaller sample size in the group.
• In low-risk pregnancies, an umbilical arterial pH < 7.10
was found more often when SDP technique was used. Since arterial
base excess < –12.0 and 5-min Apgar score < 7 were not
different between groups, this finding was not considered
clinically relevant.
Discussion
SDP or AFI as evaluation testS Kehl et al., UOG 2016
• A Cochrane review similarly showed – AFI method for fetal
surveillance increased the risk for induction of
labor (RR, 1.92 (95% CI, 1.50–2.46); 4 trials; 2138
pregnancies)– there was no difference between the two groups for
rate of admission
to NICU (RR, 1.04 (95% CI, 0.85–1.26); 5 trials; 3226
babies)
• The Cochrane review also found increased risk of Cesarean
section for fetal distress when AFI technique is used (RR, 1.46
(95% CI, 1.08–1.96)). This study found increased risk of abnormal
CTG but not Cesarean section.
– As there were more women with gestational diabetes and
previous Cesarean section in the SDP group, it remains possible
that Cesarean-section rate could have been higher in this study in
the AFI group if these risk factors were balanced in the two
groups.
Discussion: comparison with other studies
SDP or AFI as evaluation testS Kehl et al., UOG 2016
Conclusions
SDP or AFI as evaluation testS Kehl et al., UOG 2016
• Use of the AFI method in routine obstetric assessment resulted
in more women being diagnosed with oligohydramnios and being
induced for an abnormal amniotic fluid volume without improving the
perinatal outcome.
• The SDP method is therefore the favorable method to estimate
amniotic fluid volume, especially in a population with low-risk
pregnancies.
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Discussion points
• Should the use of AFI technique for assessment of amniotic
fluid volume be abandoned, for both low- and high-risk
pregnancies?
• What is the clinical significance of increased rate of
abnormal CTG seen with the AFI method in this study and increased
Cesarean sections for fetal distress in the Cochrane review? Could
AFI be identifying a more vulnerable population of babies?
• There is a need to explore alternative methods for amniotic
fluid volume assessment that have better correlation with adverse
pregnancy outcomes.
Future perspectives
SDP or AFI as evaluation testS Kehl et al., UOG 2016
Illustration by Alex Baker, DNA Illustrations, Inc.
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Methods
•
Multicenter, randomized, controlled, parallel‐group, unmasked trial•
Low‐risk nulliparous women between 34w0d‐38w6d•
Live singleton, cephalic fetus•
No contraindications to vaginal delivery
• No planned cesarean deliver• Low‐risk
•
No maternal or fetal condition that would be an indication for delivery
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SMFM
• It
is reasonable to offer elective IOL to low‐risk, nulliparous women at or beyond 39 weeks and 0 days of gestation. We recommend that providers who choose this approach ensure that women meet eligibility criteria of the ARRIVE trial.
•
We recommend against offering elective IOL to women under circumstances that are inconsistent with the ARRIVE study protocol unless performed as part of research or quality improvement.
•
We recommend that further research be conducted to measure the impact of this practice in settings other than a clinical trial.
www.pinterest.com/icpcare/icp‐awareness‐month‐intrahepatic‐cholestasis‐of‐pr/
Background
•
Intrahepatic cholestasis of pregnancy (ICP) is associated with adverse perinatal outcome
•
The association with the concentration of specific biochemical markers is unclear
•
Quantified the adverse perinatal effects ICP in women with increased serum bile acid concentration
•
Determined whether elevated bile acid concentrations were associated with risk of stillbirth and preterm birth
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Method • Systematic review / meta‐analysis
•
Studies that reported perinatal outcomes for women with ICP
and serum bile acid concentrations•
Inclusion criteria
•
ICP definition based upon pruritus and elevated serum bile acid concentrations, with or without raised liver aminotransferase concentrations
•
Case‐control, cohort population‐based studies and RCTs•
Minimum 30 participants | Perinatal outcomes and bile acid concentrations available
• Exclusion criteria•
Case reports, non‐cohort studies•
Selection bias such as exclusion of patient groups with poor outcomes•
‘Letters to the Editor’ without clear peer review
• Statistical Analysis•
ICP and adverse perinatal outcomes:
Random effects meta‐analysis to determine risks•
Associations between biochemical markers and adverse outcomes
•
Logistic and stepwise logistic regression, using individual patient data
Result
23 studies available for meta‐analysis
(out of 109)5,557 ICP cases |165,136 controls27 study authors provided individual patient data (5,269 ICP cases)
•
ICP and association with stillbirth (p=0.0016)•
ICP: 0.91%• Control: 0.32%• odds ratio
(OR) 1.46 (95% CI, 0.73–2.89)
• ICP was associated with higher risk:•
spontaneous preterm birth (OR 3.47) •
Iatrogenic preterm birth (OR 3.65) •
Meconium stained fluid (OR 2.60) •
NICU admission (OR 2.12)
Results
For singleton pregnancies, stillbirth risk was associated with maximum total bile acid concentration (not ALT)
Treatment with ursodeoxycholic
acid did not significantly affect this association
Results
Stillbirth prevalence
in ICP higher with total bile acids ≥100 μmol/L•
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Conclusion
• Limitations•
Possibility of incomplete data and significant number of iatrogenic PTD
•
Risk of stillbirth with ICP increases compared to a general population when serum bile acid concentrations are ≥100 μmol/L
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https://www.uabmedicine.org/patient‐care/treatments/pregnancy‐and‐congenital‐heart‐clinic
©California Department of Public Health, 2017; supported by Title V
funds. Developed in partnership with California Maternal Quality
Care Collaborative Cardiovascular Disease in Pregnancy and
Postpartum Taskforce. Visit: www.CMQCC.org for details
CA-PAMR Top 5 Causes of Death 2002-2006 (N=257)
Grouped Cause of Death, per CA-PAMR Committee
Pregnancy-Related Deaths N (%)
Cardiovascular disease 64 (25)Cardiomyopathy 42 (16)Other
cardiovascular 22 (9)
Preeclampsia/eclampsia 45 (18)Obstetric hemorrhage 25 (10)Sepsis
23 (9)Venous thromboembolism 22 (9)TOTAL 257
CVD Pregnancy-Related Mortality Rate: 2.4 deaths /100,000 live
births
Alison Young, USA TODAYUpdated 3:58 p.m. PST Mar. 6, 2019
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Objectives and Methods
•
Describe the clinical characteristics of stroke and opportunities to improve care in a cohort of preeclampsia‐related maternal mortalities in California.
•
California Pregnancy‐Associated Mortality Review retrospectively
‐•
Cohort of preeclampsia pregnancy‐related deaths CA (2002 to 2007) •
Stroke cases were identified among preeclampsia deaths•
Case summaries were reviewed with attention to clinical variables, particularly hypertension.
Results
• 54 preeclampsia pregnancy‐related deaths •
33 were attributed to stroke •
SBP exceeded 160 mm Hg in 96% of cases, and DBP was 110 or higher in 65% of cases.
•
HELLP was present in 38% (9/24) •
Eclampsia occurred in 36% of cases•
Headache was the most frequent symptom (87%) preceding stroke. •
Elevated liver transaminases were the most common lab abnormality (71%).
Conclusion
•
Stroke is the major cause of maternal mortality associated with preeclampsia or eclampsia.
•
All but one patient in this series of strokes demonstrated severe elevation of systolic blood pressure
•
Antihypertensive treatment was not implemented in the majority of cases. Opportunities for care improvement exist and may significantly affect maternal mortality.
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https://www.cmqcc.org/
Number 212 Pregnancy and Heart Disease
Presidential Task Force on Pregnancy and Heart DiseaseCommittee
on Practice Bulletins—Obstetrics. This Practice Bulletin was
developed by the American College of Obstetricians and
Gynecologists’ Committee on Practice Bulletins–Obstetrics in
collaboration with the Presidential Task Force on Pregnancy and
Heart Disease members
May 2019
-
©California Department of Public Health, 2017; supported by
Title V funds. Developed in partnership with California Maternal
Quality Care Collaborative Cardiovascular Disease in Pregnancy and
Postpartum Taskforce. Visit: www.CMQCC.org for details
CVD Assessment Algorithm For Pregnant and Postpartum Women
©California Department of Public Health, 2017; supported by
Title V funds. Developed in partnership with California Maternal
Quality Care Collaborative Cardiovascular Disease in Pregnancy and
Postpartum Taskforce. Visit: www.CMQCC.org for details
©California Department of Public Health, 2017; supported by
Title V funds. Developed in partnership with California Maternal
Quality Care Collaborative Cardiovascular Disease in Pregnancy and
Postpartum Taskforce. Visit: www.CMQCC.org for details
End-diastolicVolume & Pressure
B Type Natriuretic Peptide (BNP)
Neurohormone secreted by the cardiac ventricles in response to ventricular volume expansion and pressure overload
End-diastolicvolume & pressure
in ventricles
BNP
Pro-BNP
Inhibits renin-angiotensin-aldosterone system
Relaxes vascular smooth muscle
Increases natriuresis and diuresisImage Credit: Afshan Hameed,
MD. Used with permission
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©California Department of Public Health, 2017; supported by
Title V funds. Developed in partnership with California Maternal
Quality Care Collaborative Cardiovascular Disease in Pregnancy and
Postpartum Taskforce. Visit: www.CMQCC.org for details
BNP in Pregnancy
Pregnancy is a state of physiologic volume overload
LV wall mass and the diastolic dimensions increase
Lev-Sagie A, Bar-Oz B, Salpeter L, Hochner-Celnikier D, Arad I
and Nir A. Plasma Concentrations of N-Terminal Pro-B-Type
Natriuretic Peptide in Pregnant Women near Labor and during Early
Puerperium. Clinical Chemistry. October 2005; 51 (10):1909-10.
Katz R, Karliner JS, Resnik R. Effects of a natural volume
overload state (pregnancy) on left ventricular performance in
normal human subjects. Circulation. 1978;58(3 Pt 1):434-41.
©California Department of Public Health, 2017; supported by
Title V funds. Developed in partnership with California Maternal
Quality Care Collaborative Cardiovascular Disease in Pregnancy and
Postpartum Taskforce. Visit: www.CMQCC.org for details
BNP Levels in Normal Pregnancy
Median longitudinal BNP in 72 healthy pregnancies:
1st trimester: 19.5 pg/mL 2nd
trimester: 18.0 pg/mL 3rd trimester: 26.5 pg/mL
Postpartum: 18.5 pg/mL
No statistically significant difference was noted in BNP levels throughout pregnancy and postpartum
There is a statistically significant difference (p
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©California Department of Public Health, 2017; supported by
Title V funds. Developed in partnership with California Maternal
Quality Care Collaborative Cardiovascular Disease in Pregnancy and
Postpartum Taskforce. Visit: www.CMQCC.org for details
Key Clinical Pearls (continued)
Pregnancy or postpartum women with significant risk factors
should be counseled regarding future CVD risk.
Women with known CVD should receive pre‐
& inter‐conception counseling by an experienced perinatologist
and cardiologist.
Contraception choices should be tailored to the individual.
Provider and patient education is essential.
High index of suspicion, early diagnosis, appropriate referrals and follow up are the key elements to a successful outcome.
Hameed AB, Morton CH, and A Moore. Improving Health Care
Response to Cardiovascular Disease in Pregnancy and Postpartum
Developed under contract #11-10006 with the California Department
of Public Health, Maternal, Child an Adolescent Health Division.
Published by the California Department of Public Health, 2017.
Recommendations
•
Baseline BNP level during pregnancy in women at high risk of or with known heart disease may be helpful.
•
All pregnant and postpartum patients with chest pain:•
standard troponin testing • electrocardiogram
May 2019
Recommendations
• Avoid pregnancy severe heart disease•
ejection fraction less than 30% or class III/IV heart failure•
severe valvular stenosis• Marfan
syndrome with aortic diameter more than 45 mm, •
bicuspid aortic valve with aortic diameter more than 50 mm•
pulmonary arterial hypertension.
May 2019
Recommendations
•
Patients with known or suspected CV Dz
should proceed with further evaluation by a Pregnancy Heart Team. Patients with moderate and high‐risk cardiovascular disease should be managed
in medical centers with a multidisciplinary team.
•
All women should be assessed for CV Dz
in the antepartum and postpartum periods using the California Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum toolkit algorithm.
May 2019
-
Recommendations
•
Women with stable cardiac disease can undergo a vaginal delivery at 39 weeks of gestation, with cesarean delivery reserved for obstetric indications.
•
A postpartum follow‐up visit (early postpartum visit) with either the primary care provider or cardiologist is recommended within 7–10 days of delivery for women with hypertensive disorders or 7–14 days of delivery for women with heart disease/cardiovascular disorders.
May 2019
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Conclusions
Conclusion
•
Review the 15 things that the physicians and patients should questions from the
•
Do not use amniotic fluid index to make the diagnosis of oligohydramnios in the third trimester.
Conclusions
• It
is reasonable to offer elective IOL to low‐risk, nulliparous women at or beyond 39 weeks and 0 days of gestation.
•
Recommend against offering elective IOL to women under circumstances that are inconsistent with the ARRIVE study protocol unless performed as part of research.
•
Risk of stillbirth with ICP increases compared to a general population when serum bile acid concentrations are ≥100 μmol/L
Conclusion
•
Total bile acid concentrations of 100 μmol/L or more, delivery should probably occur by 35–36 weeks of gestation
•
UDCA for symptom relief in women with ICP however there is no reduction in stillbirth
•
Stroke is the major cause of maternal mortality associated with preeclampsia or eclampsia and timely antihypertensive treatment is key.
-
Conclusion
•
Referral to a hospital setting that represents an appropriate maternal level of care is recommended for all patients moderate to high risk cardiac conditions.
•
Patients with known or suspected CV Dz
should proceed with further evaluation by a Pregnancy Heart Team
•
It is helpful to get a baseline BNP.
•
All patients with chest pain should get an EKG and troponin.
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Don’t do an inherited thrombophilia evaluation for women with
histories of pregnancy loss, intrauterine growth restriction
(IUGR), preeclampsia and abruption.Scientific data supporting a
causal association between either methylenetetrahydrofolate
reductase (MTHFR) polymorphisms or other common inherited
thrombophilias and adverse pregnancy outcomes, such as recurrent
pregnancy loss, severe preeclampsia and IUGR, are lacking. Specific
testing for antiphospholipid antibodies, when clinically indicated,
should be limited to lupus anticoagulant, anticardiolipin
antibodies and beta 2 glycoprotein antibodies.
Don’t place a cerclage in women with short cervix who are
pregnant with twins.Women with a short cervical length who are
pregnant with twins are at very high risk for delivering preterm,
but the scientific data, including a meta-analysis of data
published on this issue, shows that cerclage in this clinical
situation not only is not beneficial, but may in fact be harmful,
i.e., associated with an increase in preterm births.
Don’t offer noninvasive prenatal testing (NIPT) to low-risk
patients or make irreversible decisions based on the results of
this screening test.*NIPT has only been adequately evaluated in
singleton pregnancies at high risk for chromosomal abnormalities
(maternal age >35, positive screening, sonographic findings
suggestive of aneuploidy, translocation carrier at increased risk
for trisomy 13, 18 or 21, or prior pregnancy with a trisomy 13, 18
or 21). Its utility in low-risk pregnancies remains unclear. False
positive and false negative results occur with NIPT, particularly
for trisomy 13 and 18. Any positive NIPT result should be confirmed
with invasive diagnostic testing prior to a termination of
pregnancy. If NIPT is performed, adequate pretest counseling must
be provided to explain the benefits and limitations.
Don’t screen for intrauterine growth restriction (IUGR) with
Doppler blood flow studies.Studies that have attempted to screen
pregnancies for the subsequent occurrence of IUGR have produced
inconsistent results. Furthermore, no standards have been
established for the optimal definition of an abnormal test, best
gestational age for the performance of the test or the technique
for its performance. However, once the diagnosis of IUGR is
suspected, the use of antenatal fetal surveillance, including
umbilical artery Doppler flow studies, is beneficial.
Don’t use progestogens for preterm birth prevention in
uncomplicated multifetal gestations.The use of progestogens has not
been shown to reduce the incidence of preterm birth in women with
uncomplicated multifetal gestations.
3
1
2
These items are provided solely for informational purposes and
are not intended as a substitute for consultation with a medical
professional. Patients with any specific questions about the items
on this list or their individual situation should consult their
physician.
Society for Maternal-Fetal Medicine
Fifteen Things Physicians and Patients Should Question
5
4
Released February 3, 2014 (1–5); February 1, 2016 (6–10) and May
1, 2019 (11–15)
* This recommendation is currently under review by SMFM
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Don’t perform routine cervical length screening for preterm
birth risk assessment in asymptomatic women before 16 weeks of
gestation or beyond 24 weeks of gestation.The predictive ability of
cervical length measurement prior to 16 weeks of gestation for
preterm birth risk assessment is limited. It should be performed,
when indicated, between 16 and 24 weeks of gestation. Routine
cervical length screening for preterm birth risk assessment in
asymptomatic women beyond 24 weeks of gestation has not been proven
to be effective.
Don’t perform antenatal testing on women with the diagnosis of
gestational diabetes who are well controlled by diet alone and
without other indications for testing.Monitoring of glucose levels
and maintaining adequate glycemic control for gestational diabetes
are paramount to decreasing adverse outcomes, including stillbirth.
If nutritional modification and glucose monitoring alone control
maternal glycemic status such that pharmacological therapy is not
required, the risk of stillbirth due to uteroplacental
insufficiency is not increased. Thus, the use of routine antepartum
testing (e.g. biophysical profile (BPP) or nonstress test (NST)) in
the absence of other co-morbidities is not indicated.
Don’t place women, even those at high-risk, on activity
restriction to prevent preterm birth.There are no studies
documenting an improvement in outcomes in women at risk for preterm
birth who are placed on activity restriction, including bed rest.
There are multiple studies documenting untoward effects of routine
activity restriction on the mother and family, including negative
psychosocial effects. Therefore, activity restriction should not be
routinely prescribed as a treatment to reduce preterm birth.
Don’t order serum aneuploidy screening after cfDNA aneuploidy
screening has already been performed. Serum biochemistry and cell
free DNA (cfDNA) are both screening tests for fetal aneuploidy.
When low-risk results have been reported on either test, there is
limited clinical value of also performing the other screen. While
serum screening may identify some aneuploidies not detected by
cfDNA, the yield is too low to justify this test if cfDNA screening
has already been performed.
Don’t perform maternal serologic studies for cytomegalovirus and
toxoplasma as part of routine prenatal laboratory studies.Routine
serologic screening of pregnant women for CMV and toxoplasmosis is
not recommended due to poor predictive value of these tests and
potential for harm due to false positive results. Serologic
screening during pregnancy for both diseases should be reserved for
situations in which there is clinical or ultrasound suspicion of
maternal or fetal infection.
8
6
7
These items are provided solely for informational purposes and
are not intended as a substitute for consultation with a medical
professional. Patients with any specific questions about the items
on this list or their individual situation should consult their
physician.
Society for Maternal-Fetal Medicine
Fifteen Things Physicians and Patients Should Question
10
9
-
Don’t recommend diagnostic testing following sonographic
identification of an isolated echogenic intracardiac focus (EIF) or
choroid plexus cyst (CPC) in women with low-risk aneuploidy
screening results.The concept of using ultrasonographic soft
markers for aneuploidy, such as EIF and CPC, was introduced in an
era that predated screening for Down syndrome based on factors
other than maternal age. Because the sensitivity of cell free
(cfDNA) screening for Down syndrome approaches 99%, the residual
risk for Down syndrome is very low in patients who have a negative
cfDNA screening test result. Given the low a priori risk, the
presence of an isolated EIF or CPC is unlikely to increase the
detection rate for aneuploidy to any measurable degree. In
addition, for a woman with an isolated EIF or CPC on a
second-trimester ultrasound in the setting of any negative first-
or second-trimester aneuploidy screening test result, a reasonable
approach is to consider the presence of the isolated finding as a
normal variant. Recent guidelines from the Society for
Maternal-Fetal Medicine state that diagnostic testing should not be
recommended to patients solely for the indication of an isolated
EIF or CPC in the setting of a negative cfDNA screening test result
or a negative first- or second-trimester screening test result.
Don’t perform serial cervical length measurement following
cerclage placement.Although progressive cervical shortening after
cerclage placement increases the risk of preterm birth, neither
overall cervical length nor the length below the stitch correlates
well with outcomes. Most importantly, there are currently no
additional treatment options for a short cervix after cerclage
(e.g., reinforcement suture does not improve outcomes). Although
there may be theoretical psychological benefits to the patient and
provider to visualize the stitch, there are insufficient data to
suggest a clinical benefit of routine post-cerclage serial cervical
length measurement.
Don’t test women for MTHFR mutations.MTHFR is responsible for
the conversion of 5,10-methylenetetrahydrofolate to
5-methyltetrahydrofolate. Genetic variant C677T and A1286C have
been associated with a mild decrease in enzymatic activity, which
in the setting of reduced folate levels has been found to be a risk
factor for hyperhomocysteinemia. Although hyperhomocysteinemia is a
risk factor for cardiovascular disease and venous thrombosis, its
cause is multifactorial and independent of the MTHFR genotype, even
in homozygotic individuals. Despite earlier (mostly case control)
studies that found an association between the MTHFR genotype and
adverse outcomes, recent studies of more robust design have not
replicated these findings. Due to the lack of evidence associating
genotype independently with thrombosis, recurrent pregnancy loss,
or other adverse pregnancy outcomes, MTHFR genotyping should not be
ordered as part of a workup for thrombophilia.
Don’t screen asymptomatic pregnant women for subclinical
hypothyroidism. Subclinical hypothyroidism (SCH) is defined as an
elevated serum TSH level in the presence of a normal free T4 level
and is found in 2% to 5% of otherwise healthy pregnant women. SCH
is unlikely to progress to overt hypothyroidism during pregnancy.
While some authorities and organizations have recommended routine
screening for all pregnant women and subsequent treatment with
levothyroxine, two recent, large (>100,000 women) prospective
randomized clinical trials of screening and treatment for SCH
demonstrated no effect of treatment on offspring IQ at age 5 years.
Because treatment for SCH has not resulted in a beneficial effect
on outcomes, routine screening for SCH is not currently
recommended. Targeted screening for women at risk for overt
hypothyroidism is still appropriate.
Don’t use amniotic fluid index to make a diagnosis of
oligohydramnios (in the third trimester).Amniotic fluid volume can
be measured using either the amniotic fluid index (AFI) or the
deepest vertical pocket (DVP). Diagnosis of oligohydramnios based
on an AFI of
-
Dizon-Townson D, Miller C, Sibai B, Spong CY, Thom E, Wendel G
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P, Miodovnik M, O’Sullivan MJ, Conway D, Wapner RJ, Gabbe SG;
Eunice Kennedy Shriver National Institute of Child Health and Human
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RM, Zhao Y, Spong CY, Sibai B, Wendel G Jr, Wenstrom K, Samuels P,
Caritis SN, Sorokin Y, Miodovnik M, O’Sullivan MJ, Conway D, Wapner
RJ; Eunice Kennedy Shriver National Institute of Child Health and
Human Development Maternal-Fetal Medicine Units (NICHD MFMU)
Network. Prothrombin gene G20210A mutation and obstetric
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MJ, Eldor A, Steinman N, Many A, Bar-Am A, Jaffa A, Fait G, Lessing
JB. Increased frequency of genetic thrombophilia in women with
complications of pregnancy. N Engl J Med. 1999 Jan;340(1):9–13.
[published erratum appears in N Engl J Med 1999 Jul
29;341(5):384].
Durnwald CP, Momirova V, Rouse DJ, Caritis SN, Peaceman AM,
Sciscione A, Varner MW, Malone FD, Mercer BM, Thorp JM Jr, Sorokin
Y, Carpenter MW, Lo J, Ramin SM, Harper M, Spong CY; Eunice Kennedy
Shriver National Institute of Child Health and Human Development
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trimester cervical length and risk of preterm birth in women with
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J Matern Fetal Neonatal Med. 2010 Dec;23(12):1360–4. Berghella V,
Odibo AO, To MS, Rust OA, Althuisius SM. Cerclage for short cervix
on ultrasonography: meta-analysis of trials using individual
patient-level data. Obstet Gynecol. 2005;106:181–9.
American College of Obstetricians and Gynecologists Committee on
Genetics. Noninvasive prenatal testing for fetal aneuploidy.
Committee Opinion No. 545. Obstet Gynecol. 2012
Dec;120(6):1532–4.
Society for Maternal-Fetal Medicine Publications Committee,
Berkley E, Chauhan SP, Abuhamad A. Doppler assessment of the fetus
with intrauterine growth restriction. Am J Obstet Gynecol. 2012
Apr;206(4):300–8.
Society for Maternal-Fetal Medicine Publications Committee,
Berghella V. Progesterone and preterm birth prevention: translating
clinical trials data into clinical practice. Am J Obstet Gynecol
2012 May;206(5):376–86.Combs CA, Garite T, Maurel K, Das A, Porto
M; Obstetrix Collaborative Research Network. 17-hydroxyprogesterone
caproate for twin pregnancy: a double-blind, randomized clinical
trial. Am J Obstet Gynecol. 2011 Mar;204(3):221.e1–8.Combs CA,
Garite T, Maurel K, Das A, Porto M; Obstetrix Collaboration
Research Network. Failure of 17-hydroxyprogesterone to reduce
neonatal morbidity or prolong triplet pregnancy: a double-blind,
randomized clinical trial. Am J Obstet Gynecol. 2010
Sep;203(3):248.e1–9.Caritis SN, Rouse DJ, Peaceman AM, Sciscione A,
Momirova V, Spong CY, Iams JD, Wapner RJ, Varner M, Carpenter M, Lo
J, Thorp J, Mercer BM, Sorokin Y, Harper M, Ramin S, Anderson G;
Eunice Kennedy Shriver National Institute of Child Health and Human
Development Maternal-Fetal Medicine Units Network (NICHD MFMU).
Prevention of preterm birth in triplets using 17
alpha-hydroxyprogesterone caproate: a randomized controlled trial.
Obstet Gynecol. 2009 Feb;113(2 Pt 1):285–92.
Iams JD, Goldenberg RL, Meis PJ, Mercer BM, Moawad A, Das A,
Thom E, McNellis D, Copper RL, Johnson F, Roberts JM. The length of
the cervix and the risk of spontaneous premature delivery. National
Institute of Child Health and Human Development Maternal Fetal
Medicine Unit Network. N Engl J Med. 1996 Feb
29;334(9):567-72.Conoscenti G, Meir YJ, D’Ottavio G, Rustico MA,
Pinzano R, Fischer-Tamaro L, Stampalija T, Natale R, Maso G,
Mandruzzato G. Does cervical length at 13–15 weeks’ gestation
predict preterm delivery in an unselected population? Ultrasound
Obstet Gynecol. 2003 Feb;21(2):128-34.Ozdemir I, Demirci F, Yucel
O, Erkorkmaz U. Ultrasonographic cervical length measurement at
10-14 and 20-24 weeks gestation and the risk of preterm delivery.
Eur J Obstet Gynecol Reprod Biol. 2007 Feb;130(2):176-9. Berghella
V, Talucci M, Desai A. Does transvaginal sonographic measurement of
cervical length before 14 weeks predict preterm delivery in
high-risk pregnancies? Ultrasound Obstet Gynecol. 2003
Feb;21(2):140-4.
Rosenstein MG, Cheng YW, Snowden JM, Nicholson JM, Doss AE,
Caughey AB. The risk of stillbirth and infant death stratified by
gestational age in women with gestational diabetes. Am J Obstet
Gynecol. 2012;206:309.e1-7.
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How This List Was CreatedAs a national medical specialty
society, the Society for Maternal-Fetal Medicine relies on the
input of any number of its committees in the development of various
documents. In the case of the items included in this list, the
Publications Committee reviewed the literature and evidence from
SMFM’s published documents for possible topics. For SMFM’s first
set of five recommendations a sub-group of the Committee initially
developed a list of 10 items that the Committee then ranked for the
top five with input and suggestions by the Society’s Executive
Committee. For SMFM’s second set of recommendations, the sub-group
of the Committee developed a list of 12 items that the Committee
then ranked for the top five, again soliciting input and
suggestions by the Society’s Executive Committee. For SMFM’s third
set of five recommendations, the sub-group of the Publications
Committee developed a list of 10 items that the Committee ranked
for the top five, again soliciting input and suggestions by the
Society’s Executive Committee. The final lists have been reviewed
and approved by the Society’s Document Review Committee and
Executive Committee.
SMFM’s disclosure and conflict of interest policy can be found
at www.smfm.org.
Sources
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The mission of the ABIM Foundation is to advance medical
professionalism to improve the health care system. We achieve this
by collaborating with physicians and physician leaders, medical
trainees, health care delivery systems, payers, policymakers,
consumer organizations and patients to foster a shared
understanding of professionalism and how they can adopt the tenets
of professionalism in practice.
The Society for Maternal-Fetal Medicine (SMFM) is a society of
physicians and scientists who are dedicated to the optimization of
pregnancy and perinatal outcomes. SMFM was established in 1977 and
is the membership organization for obstetricians/gynecologists who
have additional formal education and training in maternal-fetal
medicine. There are currently about 2,000 active members of SMFM.
The Society hosts an annual scientific meeting in which new ideas
and research in the area of maternal-fetal medicine are presented.
The Society is also an advocate for improving public policy and
expanding research funding and opportunities in the area of
maternal-fetal medicine.
For more information about SMFM, visit www.smfm.org.
®
About the ABIM Foundation About the Society for Maternal-Fetal
Medicine
For more information or to see other lists of Things Physicians
and Patients Should Question, visit www.choosingwisely.org.
To learn more about the ABIM Foundation, visit
www.abimfoundation.org.
Society for Maternal-Fetal Medicine (SMFM), Habeber E, Sciscione
A. SMFM Consult Activity Restriction in Pregnancy. Contemp Ob Gyn.
2014.
Society for Maternal-Fetal Medicine (SMFM) Publications
Committee. Society for Maternal-Fetal Medicine Consult Series #36:
Prenatal aneuploidy screening using cell-free DNA. Am J Obstet
Gynecol. 2015 Jun;212(6):711-6.
Committee Opinion No. 640: Cell-Free DNA Screening For Fetal
Aneuploidy. Obstet Gynecol. 2015;126(3):e31-7.
Society for Maternal-Fetal Medicine (SMFM), Hughes BL,
Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine Consult
Series #39: Diagnosis and antenatal management of congential
cytomegalovirus (CMV) infection. Am J Obsts Gynecol. 2016 (in
press).
American College of Obstetricians and Gynecologists. Practice
Bulletin #151: Cytomegalovirus, Parvovirus B19, varicella zoster,
and toxoplasmosis in pregnancy. Obstet Gynecol. 2015
Jun;125(6):1510-25.
Society for Maternal-Fetal Medicine (SMFM). Norton ME, Biggio
JR, Kuller JA, Blackwell SC. The role of ultrasound in women who
undergo cell-free DNA screening. Am J Obstet Gynecol. 2017
Mar;216(3):B2-B7.Benn P, Cuckle H, Pergament E. Non-invasive
prenatal testing for aneuploidy: current status and future
prospects. Ultrasound Obstet Gynecol 2013;42:15-33.
Society for Maternal-Fetal Medicine (SMFM). McIntosh J,
Feltovich H, Berghella V, Manuck T. The role of routine cervical
length screening in selected high- and low-risk women for preterm
birth prevention. Am J Obstet Gynecol. 2016 Sep;215(3):B2-7.
Baxter JK, Airoldi J, Berghella V. Short cervical length after
history indicated cerclage: I s a reinforcing cerclage beneficial?
Am J Obstet Gynecol 2005;193:1204-7.
Inherited thrombophilias in pregnancy. ACOG Practice Bulletin
No. 197. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2018;132:e18—34.
Hickey SE, Curry CJ, Toriello HV. ACMG Practice Guideline: lack
of evidence for MTHFR polymorphism testing. Genet Med. 2013
Feb;15(2):153-6.
Baglin T, Gray E, Greaves M, et al. Clinical guidelines for
testing for heritable thrombophilia. Br J Haematol
2010;149:209–220.
Thyroid disease in pregnancy. Practice Bulletin No. 148.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2015; 125:996–1005.
Lazarus JH, Bestwick JP, Channon S, Paradice R, Maina A, Rees R,
et al. Antenatal thyroid screening and childhood cognitive function
[published erratum appears in N Engl J Med 2012;366:1650]. N Engl J
Med 2012;366:493–501.
Society for Maternal-Fetal Medicine. Screening for thyroid
disease during pregnancy. Contemporary OB/GYN; August 2012.
https://www.smfm.org/publications/88-screening-for-thyroid-disease-in-pregnancy
Kehl S, Schelkle A, Thomas A, Puhl A, Meqdad K, Tuschy B, et al.
Single deepest vertical pocket or amniotic fluid index as
evaluation test for predicting adverse pregnancy outcome (SAFE
trial): a multicenter,open-label, randomized controlled trial.
Ultrasound Obstet Gynecol. 2016;47(6):674-9.
Ultrasound in pregnancy. Practice Bulletin No. 175. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2016;128:e241–56.
Antepartum fetal surveillance. Practice Bulletin No. 145.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2014;124:182–92.
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http://www.choosingwisely.orgwww.abimfoundation.org