International Federation of Gynecology and ObstetricsWorking Group on Best Practice on Maternal-Fetal Medicine

Presented byNARENDRA MALHOTRA MD,FICOG,FRCOGCommittee memberPresident Elect ISPATPast President FOGSI,IndiaSec SAFOG

OUR PUBLICATION AT FIGO

ABSTRACT

This is often not the test that is good or badbut the way we use it

FIGO GUD PRACTICE ADVISES

PREMISES

Why good practice advises

• Too many recent developments• Many asumptions for best managements of pregnancy

and child birth• FIGO’s attempt to give a clearity for the applications of

new techniques and clinical options • These issues apply univesally • More important in inndustrializesd and semi

industrialized countries• Authoritative guidance is urgently needed to establish

best practice

FIGO RECOMMENDATIONS

FIGO GUIDELINES PRESENT 8 GOOD PRACTICE ADVISES

• 1.SCREENING FOR CHROMOSOMAL ABNORMALITIES AND NIPD

• 2.PRECONCEPTIONAL FOLIC ACID FOR THE PREVENTION OF NEURAL TUBE DEFECTS

• 3.CERVICAL LENGTH AND PROGESTERONE FOR THE PREDICTION AND PREVENTION OF PRETERM BIRTH

• 4. & 5.MAGNISIUM SULPHATE USE IN OBSTETRICS• 6.ULTRASOUND EXAMINATION IN PREGNANCY• 7.THYROID DISEASE IN PREGNANCY• 8.HYPERGLYCEMIA IN PREGNANCY

1.FIGO RECOMMENDS FORSCREENING FOR CHROMOSOMAL ABNORMALITIES AND N.I.P.T.

• MATERNAL AGE HAS LOW PERFORMANCE AS A SCREENING TOOL FOR FETAL CHROMOSOMAL ABNORMALITIES DETECTION RATE OF 30-50% AND FALSE POSITIVE OF 5-20%(INVASIVE TESTING SHOULD NOT BE CARRIED OUT BY ONLY MATERNAL AGE)

• FIRST LINE SCEENING FOR TRISOMIES 13-18-21 SHOULD BE BY COMBINED TEST( AGE+FETAL NT+FHR+MATERNAL SERUM Bhcg and PAPP-A) the detection rates are 90 % for 21and 95%for 18 and 13 with a falso positive of 5%

Cont….

• Combined test could be improved by using additional USG markers( nasal bone+ductus venosus +tricuspid flow) when all these are added the detection rate is 95% with less than 3% false positive.

• Screening by cfDNA has a detection rate of 99% for 21,97%for 18 and 92% for 13 with a false positive of 0.4%

Cont….

• So as of now the cfDNA should be in combination to the combined test at 11-13 weeks

FIGO recommends the following stratergy for

prenatal diagnosis• The patients with combined test risk over

1:100 can be offered cfDNA or invasive testing

• Combined test risk of 101-2500;pts can be offered the option of cfDNA

• Combined test risk lower than 1 in 2500:there is no need for further testing)

2. FIGO RECOMMENDS PRECONCEPTIONAL FOLIC ACID FOR THE PREVENTION OF NEURAL

TUBE DEFECTS

• All women who plan to become pregnant or women of child bearing age not on contraceptives should utilize 400 ug(0.4 mg) of synthetic folic acid,at least 30 days before conception and continue throughout first trimester

• All women coming for any medical appointment should be advised on the benefits of folic acid

Cont……….

• Health care providers should inform and council women a) benefits of folic acid in pregnancy is not only prevention of NTD but also for IUGR,autism,preterm and cleft palate defect prevention,b)folic acid 0.4 mg(400 ug) can be taken for years without any know adverse effects and c)effects of high doses of folic acid are not known except complicating diagnosis of vit B 12 deficiency,hence the dose of daily folic acid supplimentation should be kept below 1 mg except in women at high risk of NTD

Cont………

• Women with high risk factors for NTD should be advised 4000 ug daily at least 30 days before conception and continued in first trimester

• The high risk factors area)NTD in previous pregnancyb)Partner affected by NTDc)First degree relative affected by NTDd)Prepregnancy diabetese)Pts. on antiepileptic(valproic acid or carbamazepine)f)pts. on folate antagonists(methotrexate,sulfonamides etc)

3.FIGO recommends Cervical length and progesterone for prediction and

prevention of PRETERM birth• Sonographic cervical length measurement should be

performed for all pregnant women at 19-23 weeks of gestation by TVS as a part of the ANATOMICAL SURVEY scan

• Women with short cervix <25 mm diagnosed in mid trimester should be offered daily vaginal micronised progesterone therapy for prevention of preterm birth and neonatal morbidity

• Vaginal micronised progesterone 200 mg soft capsule nightly or 90 mg micronized progesterone gel each morning

Cont………

• Universal cervical length and vag progesterone is a cost effective model for prevention of preterm births

• In cases where TVS is not available ,other devises may be used for screening and measuring cervical length objectively

THESE THREE ADVISES HAVE BEEN ENDORSED BY THE FIGO BOARD AND ALSO PUBLISHED in 2014-2015

MAY 2015 :5 NEW GOOD PRACTICE ADVISES WERE ENDORSED BY FIGO

BOARD in 2015

• PREPARED BY FIGO WORKING GROUP

• AND RELEASED AT VANCOUVER FIGO CONGRESS OCT 2015

THESE ARE

• MAGNISIUM SULPHATE USE IN OBSTETRICS(2)• ULTRASOUND EXAMINATION IN PREGNANCY• THYROID DISEASE IN PREGNANCY• HYPERGLYCEMIA IN PREGNANCY

4.& 5. FIGO RECOMMENDS MAGNISIUM SULPHATE USE IN OBSTETRICS

• intravenous/intramuscular mag sulphate is indiacted during labour and post partum for all women diagnosed with severe p.i.h.

• for elective c.s. in such pts mag sulf is given atleast 2 hrs before the operation

• the dose iv mag sulf 4-6 g diluted in 100 ml ns/dw5 over 15-20 mins with maintainance of 1-2 g per hour……for im mag sulf 10 g can be undiluted 50 % solution divided into each buttocks followed by 4-5 g every 4 hrly

Cont……..

• Mandatory monitoring of respiratory rate,deep tendon reflexes and urinary output ,particularly in oligouric patients…..mag toxicity is treated by 10% 10 ml calcium gluconate

• In women with normal renal functions half time for excretion of magnisium is 4 hours

• There is no association of mag sulf use with congenital birth defects

Cont………..

• Very long term infusion may be related to sustained hypocalcemia in fetus and may result in congenital rickets and adverse bone mineralisation

Neonatologists should be alerted to look for neonatal neurologic depression,resp depression,muscle weakness and hyporeflexia in fetus born to women on mag sulf infusion

5.MAGNISIUM SULPHATE USE IN FETAL NEUROPROTECTION

• For imminent preterm birth (active labour with or without PROM) or elective preterm birth for maternal or fetal indication….antenatal mag sulf should be considered for fetal neuroprotection

• Antenatal mag sulf should be considered from viability to 31 + 6 days gestation

• Mag sulf should be discontinued if delivery in no longer imminent or after max of 24 hours of therapy

Cont…….

• Mag Sulf loading dose 4 g over 30 mins,ideally 4-6 hours before delivery followed by infusion of 1g/hour until delivery occurs .however there may be still benefit even if given less than 4 hours

• There is insufficient evidence of use of a repeat course• Delivery should not be delayed in order to administer

antenatal mag sulf if there is a maternal and fetal indication for emergency

• Maternity care provider should use the standard monitoring protocols same as in PIH/ECLAMSIA

• Neonatologist should be alerted to asses neonate for effects of mag sulf

6. FIGO RECOMMENDS ULTRAOUND EXAMINATION IN PREGNANCY

• ultrasound in pregnancy should be performed by specially qualified operators and undergoing continous medical education and quality assurance programs

• current equipments should have the capability to perform tvs and doppler and these equipment subjected to adequate maintainance

• All pregnant women should be offered at least 2 ultrasound screening exams( 11-13 week+6d and at 18-22 weeks ….but optimally at least one from 20 weeks onwards

Cont………

• Medically indiacted ultrasound in pregnancy is safe,proper councelling and proper report and images

• First trimester ultrasound recoginizes 5 aims and objectives 1.asses viabilty 2.asses gestational age 3.diagnose and characterize multiple gestation 4.anatomical malformation screen for anomalies detectable at this stage 5.measure NT

• First trimester ultrasound should include visualisation of both ovaries

Cont…….

• Mid trimester ultrasound also recognises 5 aims and objectives 1. asses gest age if not yet been done 2.asses fetal biometry 3.conduct anatomical survey to screen for anomalies 4.asses placenta and cord insertion 5.measure cervical length by TVS as a part of risk assesment for preterm births

• Ultrasound and DOPPLER should be liberally used in the third trimester to asses AMNIOTIC FLUID,CERVICAL LENGTH,FETAL GROWTH and FETAL WELLBEING

• Biometric tests (tests to measure size)

• Biometric tests are designed to predict size and growth

AC, EFW

05/01/23 DR.PRASHANT ACHARYA 32

Ask for serial measurements and plot the findings in growth chart – not single USG reading

The anatomical survey in second trimester

At a glance Head Intact cranium  Cavum septi pellucidi  Midline falx  Thalami  Cerebral ventricles  Cerebellum  Cisterna magnaFace Both orbits present  Median facial profile  Mouth present  Upper lip intactNeck Absence of masses (e.g. cystic hygroma)Chest/Heart Normal shape/size of chest and lungs

  Heart activity present  Four-chamber view of heart in normal position  Aortic and pulmonary outflow tracts  No evidence of diaphragmatic hernia

Abdomen Stomach in normal position  Bowel not dilated  Both kidneys present  Cord insertion siteSkeletal No spinal defects or masses (transverse and sagittal)  Arms and hands present, normal relationships  Legs and feet present, normal relationshipsPlacenta  Position No masses present  Accessory lobeUmbilical cord Three-vessel cordGenitalia Male or female

Placenta and cervix

Guidelines for maturity and position

++

++

+ +

• Women with a history of uterine surgery and low anterior placenta or placenta previa are at risk for placental attachment disorders. In these cases, the placenta should be examined for findings of accreta, the most sensitive of which are the presence of multiple irregular placental lacunae that show arterial or mixed flow

• Abnormal appearance of the uterine wall–bladder wall interface is quite specific for accreta, but is seen in few cases. Loss of the echolucent space between an anterior placenta and the uterine wall is neither a sensitive nor a specific marker for placenta accreta

Maternal anatomyGuidelines

• Currently, there is sufficient evidence to recommend routine cervical length measurements with a transvaginal scan at the mid trimester even in an unselected population

• Uterine fibroids and adnexal masses should be documented

Cont……..

• The results of a screening ultrasound in first and second trimester can generate refferal for specialised or focused ultrasound

• In multiple pregnancy choionicity should be optimally determined before 15 weeks

• The use of ultrasound in labour should be encouraged to determine fetal and placental position as well as prior to instrumental delivery

• The use of ultrasound should be encouraged in postpartum period to evaluate non physiologiccal bleeding and infections

Thyroid Disorders in Pregnancy

Thyroid disease is the second most common cause of endocrine dysfunction in women of child bearing age.

Hypothyroidism is more common during pregnancy than hyperthyroidism.

Pearls for Practice

7.FIGO recommends for THYROID diseases in pregnancy

• Screening for thyroid function recommended in first trimester particularly in idodine deficient countries and in symptomatic cases.TSH is superior method of screening ,free T4 and TPO Ab are not recommended for screening.TSH is best done by C.I.A or 3rd generation RIA. NOTE THAT NORMAL THYROID VALUES CHANGE IN EACH TRIMESTER

• Treatment of Hypothyroidism is recommended when TSH levels and >2.5 and >3 in first/second/third trimesters.only treat with L-thyroxine.treating subclinical hypothyrodism is debatable. Women on L thyroxine before pregnancy should increase the dose by 30-50 %

Cont……….

• Treatment of hyperthyroidism due to Grave’s disease is by antithyroid drugs (PROPYLTHIOURACIL-PTU or CARBIMAZOLE/METHIMAZOLE.its not recommended to change the drug during pregnancy.sometimes symptomatic treatment with b-blockers for short time may be needed

• Primary prevention of hypothyroidism is by a healthy diet and iodised fortified salt

Cont……

• If the patient has a thyroid nodule she should be evaluated and treated during pregnancy.thyroid ultrasound scan and FNA.Surgery should be preferably deffered to post partum period

• Follow up and post partum TSH evaluation and reduction of L-thyroxine dose to prepregnant levels

8. FIGO Recommends hyperglycemia in pregnancy

• All pregnant women should be tested for hyperglycemia.universal testing by all member associations

• WHO(2013) and IADPSG(2010) criteria for diagnosis of gestational diabetes must be used

• Diagnosis of HDP should be on properly collected venous plasma samples.in developing countries a plasma caliberated hand held gluocometer is acceptable

• Management of HDP should be in accordance with available national resources and infrastructure

Cont…….

• Nutrition and physical activity councelling is a must and continue after birth also

• Insulin is added if lifestyle and diet modification does not control Hyperglycemia.metformin and or glyburide may be used in 2nd and 3rd trimesters.oral drugs may be first choice in 2nd and 3rd trimester

• Postpartum 8 weeks visit councelling and life style modifications for mother and child is necessary

• Public health measures to increase awareness and acceptance of preconception councelling should be applied for all women planning pregnancy.

Thank you

S

13 – 17 Jan 2016

Kalakriti Grounds, VIP Road